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For researchers with occupational infections, the taking of a relevant occupational history that leads to prompt, appropriate therapy can be lifesaving.2 A delay in history taking and delayed specific therapy can result in prolonged illness or death.3
Greater attention to safety precautions by researchers and vigilance by research managers will prevent many of these types of exposure. The importance of the occupational history is well documented.4 Could a support system be available that would rapidly provide information regarding occupational exposure to clinicians caring for ill researchers? Some research institutions actively encourage patients to volunteer occupational information to the physician,5 but this will not help if the patient does not know about the exposure or is incapacitated. We need to find or develop systems to ensure that physicians receive the necessary information during the initial evaluation.
Scott Deitchman, M.D., M.P.H.
Rosemary Sokas, M.D., M.O.H.
National Institute for Occupational Safety and Health
Atlanta, GA 30333
sed2{at}cdc.gov
References
To the Editor: The cornerstone of any diagnosis is an accurate, complete medical history. In the case of our patient with glanders, it is interesting to note that all the health care providers involved were aware of the occupational exposure to B. mallei, and yet the connection between the patient's job and his illness was not made until he became critically ill. This case underscores the importance of coupling information about exposure with knowledge of the clinical expression of disease. Before this report, glanders had not been reported for more than 50 years, making a low index of suspicion and even a lack of familiarity among primary care physicians completely understandable. We hope that our report will serve as a useful reminder of the manifestations of this unusual disease.
What other lessons can be learned? We agree that researchers should pay close attention to biosafety precautions and that their managers must oversee their adherence to protocols. Researchers should also be aware of the signs and symptoms of the diseases that they study and take responsibility for notifying their health care providers about their exposure. When patients are too ill to do so, this information could come from medical alert tags (like those worn by some patients with diabetes mellitus) or from patients' supervisors or next of kin. In the case we reported, the patient's supervisor provided us with information about exposure and even detailed antimicrobial-sensitivity data at the time of hospital admission.
A final lesson from this case is the importance of reliable clinical information regarding the unfamiliar infections that may arise from biologic warfare. Access to information on the organisms most likely to be used, their transmissibility, the range of potential clinical manifestations, and the most effective treatments is essential to ensure that the medical response is commensurate with the threat to the patient, health care workers, and the community. As concern about bioterrorism grows, we endorse strongly the ongoing efforts to educate physicians about these infections and to formulate plans for responding to such attacks.
Arjun Srinivasan, M.D.
David Thomas, M.D.
Johns Hopkins Hospital
Baltimore, MD 21287
David DeShazer, Ph.D.
U.S. Army Research Institute for Infectious Diseases
Fort Detrick, MD 21702
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