A Bitter Pill to Swallow: Nonadherence With Prophylactic Antibiotics During the Anthrax Attacks and the Role of Private Physicians

Bradley D. Stein; Terri L. Tanielian; Gery W. Ryan; Hilary J. Rhodes; Shalanda D. Young; Janice C. Blanchard


Biosecur Bioterror. 2004;2(3) 

In This Article

Abstract and Introduction

To generate recommendations for improving adherence to public health advice during public health crises, we conducted semi-structured interviews with employees at the Brentwood Road Postal Facility and on Capitol Hill to identify key themes associated with decisions to adhere to recommended antibiotic prophylaxis during the 2001 anthrax attacks. Factors used in deciding to adhere to recommended prophylactic antibiotics and concerns about the official response were similar in Brentwood and Capitol Hill employees, and in adherent and nonadherent participants. All participants used multiple sources of information and support as they weighed the risk from anthrax against the advantages and disadvantages of antibiotics. We found that nonadherent participants were commonly following the advice of private physicians, whereas adherent participants commonly described ongoing support from multiple sources when discussing their decisions. Our findings highlight the need for better integration between the public and private health care systems during public health crises and the importance of equipping private physicians for their key role in aiding decision-making during a public health crisis. Special attention also should be given to enhancing support and information from multiple sources throughout the entire period of risk.

On October 15, 2001, a letter containing weapons-grade anthrax spores was opened in the office of Senate Majority Leader Daschle in the Hart Senate Office Building (HSOB). His office and people nearby were quarantined as field tests quickly revealed positive results for anthrax. As investigators began nasal swab testing in order to determine zones of potential exposure, staff were treated with prophylactic antibiotics.[1] On October 17, the entire HSOB was closed, and public health officials advised more than 600 Capitol Hill staffers to begin antibiotics to prevent potential infection.

On October 18, U.S. Postal Service officials reported that the Daschle letter probably had been processed at the Brentwood Road Postal Facility (BPF) in Northeast Washington, DC; however, officials thought it unlikely that spores had escaped from the sealed letter into the facility. Following confirmation on October 21 of inhalation anthrax in a postal worker from BPF, the facility wa closed, and nasal swab testing and antibiotic prophylaxis of BPF postal employees began.[1]

The unfolding of these events was characterized by a great deal of uncertainty; communication with the public and with potentially exposed individuals was often confusing and misleading.[1] Emerging health crises are typically characterized by rapid changes in the available knowledge about the cause of illness and appropriate treatment options; however, the manner in which official communications and response efforts were implemented during the anthrax attacks (e.g., changing spokespersons, messages, etc.) compounded potential anxiety and confusion within affected populations. Many at-risk individuals learned of their possible exposure through the media rather than from employers or other more personal sources. Early reports about the source of the anthrax were wrong, and officials did not recognize the seriousness of the threat nor the degree of contamination to the postal system. As events unfolded and more was learned, there were changes in the recommended clinical treatment protocols and in the way the recommendations were communicated to local private health care providers. These rapid changes resulted in different messages and response efforts (e.g., building closings, use of nasal swabbing, prophylaxis choice and course, etc.) between the HSOB and the BPF. Deciphering and making sense of information became a challenge for both local medical personnel and for the at-risk individuals most directly in need of reassurance and care.

Ultimately, the mailing of several anthrax-contaminated letters resulted in 22 documented cases of anthrax, including 4 inhalation anthrax cases and 2 deaths in the Washington, DC, area. Public health officials instructed more than 10,000 people across the United States deemed to be at high risk of anthrax exposure, including approximately 2,700 individuals affiliated with BPF and 600 affiliated with the HSOB, to take at least 60 days of prophylactic antibiotics.[2] But despite extensive public health outreach efforts to at-risk individuals, rapid mobilization of the public health system, distribution of free medication, and national media attention, nationally only 44% of individuals at high risk of anthrax exposure completed the recommended course of antibiotics.[2] Rates of adherence were similar and somewhat higher among both Brentwood postal workers (64%) and HSOB Staff (58%),[2] but still low enough to be of great concern in the event of a contagious disease. Although anthrax is not contagious, understanding adherence rates during this event can help public health decision-makers build better response systems for future public health crises.

Over $4 billion has now been allocated to states and communities to improve the capacity of the public health system to respond to a bioterrorism attack.[3] The early stages of a public health response to an emerging infectious disease or bioterrorism event will almost certainly involve officials instructing the public to take actions to reduce or mitigate their risk. The success of such a response will likely be determined by the extent to which people follow these actions. But decisions to adhere to health recommendations often involve considerable uncertainty,[4,5] even in routine medical settings. During a bioterrorism event, there may be even greater uncertainty about critical factors that affect an individual's decision, such as the probability of exposure, susceptibility to the disease, the consequences of the disease, the options available to prevent or treat the disease, and the pros and cons of such options.[6] Adherence decisions will also be influenced by organizational and government responses, media coverage, and the response of family, friends, and other trusted individuals (i.e., the social environment in which people are embedded).

Others have begun to explore the reactions and major concerns of people exposed to anthrax and to examine the overall official response, including disparities in the HSOB and BPF response efforts.[1,7,8] There remains a paucity of information, however, regarding peoples' decisions about whether or not to follow actions recommended by public health officials after the anthrax attacks. To obtain such information, we interviewed Brentwood Postal Facility workers and HSOB employees about their perceptions in order to better understand, from the perspectives of those affected, how they made those important decisions. Our goal was to generate suggestions for improving adherence to public health recommendations during a future public health emergency.


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