Recognizing Bioterrorism-Related Acute Illness in Clinical Practice: An Urgent Research Priority

The global history of bioterrorism, combined with rapidly increasing biotechnology capabilities, poses a substantial and growing biosecurity threat. ¹ Individuals affected by the deliberate release of biological agents are likely to present first to emergency departments, acute medicine receiving units, and other frontline healthcare services. ² Physicians’ ability to recognize the clinical presentations of biological weapons—particularly Category A agents (eg, smallpox, anthrax, botulism, plague, tularemia, and viral hemorrhagic fevers)—and to diagnose the associated syndromes is therefore critical, as it enables timely management and early involvement of public health agencies.^3,4 Clinicians across specialties—with particular relevance for emergency medicine, primary care, and general internal medicine, alongside infectious diseases, microbiology, virology, and dermatology—must be able to recognize these manifestations and raise suspicion when they encounter a compatible illness.^5,6

However, physicians’ diagnostic capability in this area remains poorly understood. In 2004, 88.6% of the 377 clinicians who attended a brief educational program on bioterrorism reported feeling confident in recognizing presentations of biological agents, yet their diagnostic accuracy was not formally assessed. ⁷ That same year, a cross-sectional survey of physicians across the Yale New Haven Health System found that 48.8% to 71.0% of the 820 respondents reported being “not confident” in recognizing anthrax, botulism, plague, tularemia, and viral hemorrhagic fevers. ⁸ More recently, in 2021, only 16.5% of 471 senior healthcare students at Giresun University in Turkey reported having sufficient professional knowledge and skills regarding chemical, biological, radiological, and nuclear weapons attacks. ⁹ Also in 2021, a cross-sectional study of clinicians in emergency departments and clinical laboratories in 3 major tertiary care hospitals in Riyadh, Saudi Arabia, examined knowledge and preparedness for bioterrorism events, including some questions on clinical presentations, but did not require participants to assign diagnoses to clinical vignettes. ¹⁰

The most robust assessment to date of physicians’ ability to recognize Category A agents appears to be Cosgrove et al ¹¹ (2005), which used 16 vignettes describing patients presenting with anthrax, botulism, plague, smallpox, or clinically overlapping common conditions. Correct diagnoses of Category A diseases were provided in 46.8% of cases on average, rising to 79.0% after a didactic module on diagnosis and management. To the author’s knowledge, no comparable work has since been conducted in the United States, and none has been undertaken in the United Kingdom.

Given the scale of the threat from biological weapons, the centrality of physicians’ diagnostic skills to an effective response, and the limited evidence base on these skills, further research is urgently needed. Accordingly, the author’s forthcoming work will begin by formally assessing the ability of final-year UK medical students—who are soon to enter practice in the UK National Health Service—to diagnose causes of acute illness using validated clinical vignettes, including presentations of Category A biological agents. Subsequent planned studies will evaluate these abilities among practicing clinicians, particularly those in emergency departments and acute internal medicine, and inform the development of targeted educational interventions to strengthen diagnostic capability and bioterrorism preparedness.