CASE STORY: Special Project: Bioterror and the Physician
Leeanne Frazier, Staff Researcher
What is the likelihood that the avian flu sweeping Asia will be hijacked by individuals and introduced into the West to deposit death and turmoil? How should physicians faced with an epidemic like this respond to patients with symptoms that indicate avian flu infection? Steven E. Schutzer, Bruce Budowle, and Ronald M Atlas offer an approach to addressing the situation in their article, "Biocrimes, Microbial Forensics, and the Physician.1
This article describes a framework designed to facilitate interactions an attending physician might have with law enforcement, public health agencies, and patients during instances of possible biocrime or bioterror. The goal is address the needs of the patient, explain a physician's primary duty, and to create a body of evidence for later use in the identification and prosecution of responsible parties. To better orient this approach to normal practice, it is compared with the more familiar documentation procedures utilized in sexual assault and child abuse cases.
The first step in this framework is determining whether the physician has a legal duty, both locally and nationally, to report a possible incident of biocrime or bioterror to law enforcement and/or a public health agency. The physician should also attempt to obtain the patient's consent to release the information. Part of the physician's role at the front-end is to convey to the patient the import of reporting the information to governmental authorities and the likely consequences of not reporting the incident. However, this initial stage must also take into account a patient's fear of revealing this information publicly due to potential stigma and embarrassment.
Once the consent and reporting requirements are addressed, the largest and most complex work the physician performs in cases of biocrime or bioterror begins. This encompasses the collection and preservation of evidence for later legal and medical use. It is at this point the concept of "microbial forensics" enters the picture. The physician's main concern at this stage is to limit, if not eliminate, any destruction or disposal of evidence by laboratory personnel or patients. This procedure is also central to establishing and securing a verifiable chain of custody. Microbial forensics involves physicians collecting early and often any evidence that could identify the origin of the infection. According to the authors, it includes the full scope of forensic evidence and lab analysis that uses molecular sequencing, microbiological cultures, biochemistry, electron microscopy, crystallography, and mass spectrometry. It is similar to DNA analysis and is implemented by identifying and tracking the genome of the pathogen2 that caused the infection. Despite the similarity, microbial forensic analysis is much more complicated due to the ability of pathogens to mutate and evolve in multiple ways, which is why numerous specimens of the bacteria or virus is essential.
Dr. James Young is a leading physician in microbial forensics.3 Dr. Young was recently appointed the Special Advisor to the Minister, Public Safety and Emergency Preparedness for the Government of Canada. Previously, he served as the Commissioner of Public Security and Chief Coroner for the province of Ontario and directed the response and coordination of the efforts to contain the outbreak of SARS that occurred in Toronto from March-April 2003. This experience enabled him to develop a plan of action that would be equally useful during occurrences of bioterror.
Some of the key factors he identified as crucial to controlling any mass infection included: educating the public and health care workers about steps they could take to reduce the likelihood of infection; controlling and tracking the movement of patient transfers, staff, and visitors; and controlling when and how hospital equipment was used by medical facilities. Another principle component to contain SARS was the stringent quarantine requirements imposed on infected individuals in Ontario.4 Since this strategy successfully contained the SARS outbreak within a three-week period, it could reasonably serve as a model plan of action for future infectious disease outbreaks.5
Dr. Young exemplifies both a physicians traditional role as healer and a larger ethical obligation to inform public entities of biocrime occurrences. While this is not easy to accomplish, physicians must nonetheless strive to maintain balance in these dual areas of ethical responsibility by remaining aware and respectful of them.6
1Schutzer SE, Budowle B, Atlas RM (2005) Biocrimes, Microbial Forensics, and the Physician. PLoS Med 2(12): e337.
3Dr. Young will be offering a presentation on Terrorists, Hurricanes and Viruses: Whats Next? at Stetson University College as part of the lecture series offered by the National Clearinghouse for Science, Technology and the Law. This presentation will be held on March 13, 2006.
4 Based on a presentation given by Dr. Young at the University of Albany, School of Public Health, Center for Public Health Preparedness. The PowerPoint presentation of this lecture is available at: http://www.ualbanycphp.org/SiteCoordinators/10_07_04/Media/sars.pdf (Last accessed on January 26, 2006.)
5SARS: Assessment, Outlook, and Lessons Learned: Hearing Before the Subcomm. on Oversight and Investigation of the House Comm. on Energy and Commerce, 110th Cong. (2003) (statement of James G. Young, M.D., Commissioner of Public Security for the province of Ontario). A copy of this report is available at:
6Note that there is free access to this article at: