The Journal of the American Dental Association
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J Am Dent Assoc, Vol 137, No 4, 461-467.
© 2006 American Dental Association
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COVER STORY

Dentists’ preparedness for responding to bioterrorism

A survey of Hawaii dentists



Alan R. Katz, MD, MPH, Dawn M. Nekorchuk, MS, Peter S. Holck, PhD, MPH, Lisa A. Hendrickson, MD, MPH, Allison A. Imrie, PhD and Paul V. Effler, MD, MPH


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. The authors conducted a survey of dentists in Hawaii to assess their knowledge of, perceived readiness for and willingness to respond to bioterrorist (BT) events.

Methods. Using a cross-sectional study design to access a random sample (n = 240) of all licensed dentists residing in the state of Hawaii (N = 1,016), the authors mailed study participants an anonymous survey up to three times during June and July 2004. Knowledge-based questions were taken from accredited Internet-based free continuing medical education offerings.

Results. Of 234 deliverable surveys, 133 were returned (response rate of 56.8 percent). Only 2.3 percent of respondents reported having received prior BT preparedness training. A total of 14.5 percent felt able to identify and recognize a BT event, and 9.2 percent indicated they were able to respond effectively to a BT attack. A total of 73.8 percent expressed willingness to provide assistance to the state in the event of a BT attack. Dentists scored a mean of 62 percent correct (5.6 of nine questions) on the objective knowledge–based questions.

Conclusions. A low prevalence of prior training coupled with a high degree of willingness to provide assistance indicates the need for additional BT preparedness training. This should be provided as continuing education offerings to practicing dentists and incorporated into the dental school curriculum.

Clinical Implications. Dentists have the basic knowledge and experience to perform a number of key roles in a BT event; however, additional training must be provided to develop BT preparedness competencies.

Key Words: Bioterrorism; preparedness; Hawaii

The role of dentistry in mass disasters traditionally has been involved primarily with forensic odontology.1 However, it is clear that dentists, with their extensive academic training and practical skills, can make a much greater contribution in both the early detection of and response to a bioterrorist (BT) event.

In June 2002, the American Dental Association (ADA) convened a national workshop to determine the potential role for dentistry in the event of a BT attack. A consensus statement arose from the workshop recognizing the valuable assets that dentists could contribute in response to a BT event.2

The ADA and the U.S. Public Health Service sponsored a second meeting in March 2003 to further delineate specific roles for dental professionals related to the detection and management of a BT event.3 That same month, the ADA published "Dentistry’s Response to Bioterrorism and Other Mass Disasters."4 The objective of this document was to assist local dental societies in formulating a response plan. A key component of the document is the recognition of the critical need for coordination between the local dental societies and the local emergency response agencies to ensure that response activities are well-integrated.4 However, there are varying roles that dentists may play, ranging from forensic activities and treating orofacial injuries to providing triage services, medical care augmentation and public information. Accordingly, the ADA’s document states, "The degree of involvement of dentistry in the response to a bioterrorism attack or other mass disaster will vary according to the interest that the profession has in this activity, its resources and the potential role for dentistry as envisioned by the local emergency response agencies."4

We conducted a survey of dentists in Hawaii to assess their base of objective knowledge about BT, their perceived readiness to respond to a BT-associated event and their willingness to respond to such an event.


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
We obtained a comprehensive list of licensed dentists from the Hawaii State Department of Commerce and Consumer Affairs. We targeted only people whose primary residence was the state of Hawaii. The target population included 1,016 dentists. We calculated the sample size from a construct variable defined as achieving greater than or equal to 80 percent on a set of knowledge-based questions. By expecting 50 percent of respondents to achieve this score (with a 10 percent margin of error) and setting {alpha} = .05, we determined that an estimated sample size of 80 was necessary to achieve a power of 80 percent. We tripled this estimate to ensure adequate sample size in light of anticipated nonresponse rates, leading to a final sample size estimate of 240. We selected survey participants using a random sampling technique with a table of random numbers generated with the Epitable program of Epi Info 6, Version 6.04d (Centers for Disease Control and Prevention [CDC], Atlanta.

We developed a five-page, 25-question survey instrument that included sociodemographic questions, questions regarding objective knowledge, questions regarding perceived knowledge and questions regarding perceived training needs. A final set of questions assessed survey participants’ potential response in the case of a BT event; one question asked about previous BT pre-paredness training; another asked if the respondent would be willing to assist the state in its BT response and control efforts. The survey instrument was reviewed by a panel of public health physician epidemiologists (A.R.K., L.A.H., P.V.E.) and the chief of the Hawaii State Department of Health’s Dental Health Division (a dental epidemiologist). The study was approved by the University of Hawaii Institutional Review Board.

Nine objective knowledge–based questions focused on BT agents, syndromic surveillance and the identification of signs and symptoms of high-risk BT-associated diseases (Table 1Go). They were presented in a multiple-choice answer format with a single correct answer. We considered an absent answer or more than one answer to a single question to be incorrect. We took eight of the nine questions from posttests of the open-access, free Internet-based Accreditation Council for Continuing Medical Education–accredited continuing medical education offerings by the CDC5,6 and WebMD’s Medscape,7–9 and we adapted one question from a CDC anthrax update.10 We selected questions to represent elementary concepts in BT and basic clinical manifestations of BT-related agents, with additional questions related specifically to recognition of smallpox and anthrax and to control measures for smallpox.


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  		TABLE 1 Responses to knowledge-based questions, bioterrorism preparedness survey of Hawaii dentists, 2004.

 
Perceived knowledge–based questions were presented in a Likert scale format, with answers of "strongly agree," "agree," "neutral," "disagree" and "strongly disagree." As these questions had no correct or incorrect answer, we did not include any unanswered questions in the denominator of the response calculations. In question-specific response calculations, we also omitted from the denominator any unanswered descriptive categorical questions (for example, age, sex, work setting) and unanswered yes or no questions relating to previous BT preparedness training or willingness to assist.

Participants defined their work settings by selecting a single best response from among five categories: patient care, administration, public health, academic institution or retired/inactive. If a participant gave more than one response, we recoded his or her answer to a single category. As a key focus of this study was assessing the knowledge base of dentists caring for patients, we selected "patient care" as the overall work setting for respondents who noted any combination of work settings that included this response. As administrative duties are common among all health care professionals, we gave this a secondary ranking (for example, we considered "public health" plus "administration" as "public health" and "academic institution" plus "administration" as "academic institution"). We considered respondents who listed "academic institution" plus "public health" as having an "academic institution" work setting. The "academic institution" work setting reflects greater specificity and encompasses public health.

We mailed the survey to all dentists in the sample with a personalized cover letter and stamped return envelope during the first week of June 2004. One week later, we mailed a postcard to all subjects. The card thanked respondents who had submitted their surveys and served as a reminder to those who had not. By tracking numeric identifiers on each returned survey, we targeted nonrespondents for additional mailings. We sent a second mailing of the survey instrument to nonrespondents three weeks after the initial mailing, and a third and final mailing to non-respondents four weeks after the second mailing.11 We included in the analysis responses received within seven weeks after the third mailing (14 weeks after the initial mailing). We searched local telephone directories for listings of potential participants whose surveys had been returned as "undeliverable" in the hope of locating alternate addresses; when possible, we remailed surveys to the corrected addresses.

Statistical analysis. We calculated descriptive statistics using Epi Info, Version 3.2.2 (CDC). We did comparisons of test scores for two groups nonparametrically using the Wilcoxon-Mann-Whitney test. We also did comparisons of more than two groups (for example, test scores by age group or work setting) nonparametrically using the Kruskal-Wallis test. We considered P values ≤ .05 to be statistically significant. All tests were two-tailed. We performed univariate analyses with StatXact, Version 4.0.1 (Cytel Software, Cambridge, Mass.).


   RESULTS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
Of 240 dentist surveys mailed, six were undeliverable. Of the 234 deliverable surveys, 133 were returned (response rate of 56.8 percent). There were no significant differences between respondents and nonrespondents with respect to sex or island of residence. Not all respondents answered all questions, and some improperly gave more than one response to a question.

A total of 87.8 percent (115 of 131) of respondents were male. The median age of respondents was 50 to 59 years. A total of 90.2 percent (119 of 132) reported that they worked in a patient care setting. This included one dentist whose work setting was listed as patient care and administration. Three dentists listed more than one work setting. In addition to the dentist noted above, one listed public health and administration (whose work setting we reclassified as public health) and one listed public health and academic institution (which we reclassified as the latter).

Perceived knowledge, prior training and willingness to respond. Only 2.3 percent (three of 132) reported having received BT preparedness training. A total of 23.8 percent (31 of 130) reported familiarity with the ADA document "Dentistry’s Response to Bioterrorism and Other Mass Disasters." A total of 14.4 percent (19 of 131) responded that they would be able to identify and recognize a BT event in human populations and 12.3 percent (16 of 130) indicated they would be able to recognize the oral manifestations of BT agents. Only 9.2 percent (12 of 131) strongly cared or agreed that they would be able to effectively respond to a BT attack. A total of 73.8 percent of respondents (96 of 130) expressed willingness to provide assistance in the state’s BT response and control efforts (Table 2Go). There were no significant differences in reported willingness to provide assistance when we compared inactive/retired dentists with active dentists (data not shown).


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  		TABLE 2 Respondents’ test scores* by selected variables, bioterrorism (BT) preparedness survey of Hawaii dentists, 2004.

 
Objective knowledge. Dentists had a mean correct score of 5.6 on the nine questions pertaining to objective knowledge (62 percent) (median = 6; standard deviation = 1.7). Approximately 90 percent of respondents correctly answered questions pertaining to the identification of high-risk BT-associated diseases with potential for person-to-person spread (question no. 1), identifying the deadliest form of anthrax (question no. 3) and identifying infection control measures for smallpox (question no. 7). Less than 50 percent correctly answered questions pertaining to recognizing clinical features that differentiate anthrax from an upper respiratory tract infection (question no. 4), recognizing that smallpox transmission may occur without direct or indirect contact with open lesions (question no. 5), recognizing clinical features that differentiate smallpox from chickenpox (question no. 6), and identifying hand washing as the critical measure in preventing contact transmission of vaccinia virus (question no. 8) (FigureGo).


Figure 1
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  		Figure. Percentage of respondents with correct answers to knowledge-based questions, Bioterrorism Preparedness Survey of Hawaii Dentists, 2004.

 
We found no significant differences in overall test performance that were based on age, sex or work setting. The mean objective-knowledge test score of the three dentists who reported having received previous training in BT preparedness was lower than the mean score of those who reported having received no previous training, but this difference was not statistically significant. Dentists who perceived themselves as being able to identify and recognize a BT event in human populations and those who reported the ability to recognize the oral manifestations of BT agents scored higher than those who perceived themselves to be unable to do so; however, these differences were not statistically significant. Dentists who perceived themselves as being able to respond effectively to a BT event scored lower than dentists who perceived themselves as unable to do so, but neither was this difference statistically significant. There was no difference in knowledge-based scores between dentists willing and unwilling to provide assistance.


   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Less than three percent of respondents had received previous BT preparedness training, and less than 15 percent felt able to identify a BT event in human populations or to recognize the oral manifestations of a BT agent. We found no independent variables predictive of knowledge-based test scores, but this was not unexpected in light of the small percentage of respondents who reported having received BT preparedness training. It is noteworthy that despite low objective-knowledge test scores and the perception of being ill-prepared, more than 70 percent of dentists expressed willingness to provide assistance to the state in response to a BT event. These findings are similar to those reported from an earlier national survey, in which researchers found that while only 21 percent of physicians felt prepared to respond to a BT event, 80 percent were willing to continue to care for patients if there was such an event.12

Less than three percent of respondents had received previous bioterrorism preparedness training.

A key strength of this study was the use of objective knowledge–based questions to assess knowledge, as opposed to sole reliance on self-assessment measurements. Also, we are unaware of other published population-based BT-related surveys that have targeted dentists. A limitation of our study is the low response rate, despite our adherence to many established survey design and implementation recommendations aimed at producing a higher response rate.11,13 However, respondents and nonrespondents were similar with respect to sex and island of residence. In addition, our response rate is slightly higher than the 40 to 51 percent reported for other mail-based surveys targeting dentists.14,15 Another limitation of our study was the knowledge-based assessment instrument. Although we took eight of the nine questions from the posttests of accredited continuing medical education offerings focusing on basic BT-related topics, they may not represent a comprehensive set of questions for adequately measuring objective knowledge in this topic area.

The finding that only three of 132 respondents (2.3 percent) received prior BT preparedness training indicates the clear need for additional BT preparedness training. The ADA16 and the Academy of General Dentistry17 have developed Web site–based educational resources and links to assist the practicing dentist with readily accessible materials. In addition, the ADA and the American Dental Education Association recommended that a core set of competencies related to BT preparedness be incorporated into the curriculum of all dental schools, and that "all dentists should receive at least a basic level of BT training, including training that would enable them to recognize diseases."18 As Jeffcoat19 wrote in a JADA editorial, "All of us, dentists and physicians alike, need a crash course on the specifics of bioterror weapons. ... Learn what can be done for the victim, by you and by others. Learn how each disease is transmitted, and how to protect yourself and others from infection." The New York University College of Dentistry has established itself as the vanguard in this regard by having already incorporated BT preparedness materials into all four years of its curriculum.20


   CONCLUSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
Dentists are acknowledged widely as leaders in preventive health care. They have the knowledge and experience to be able to perform a number of key roles in preparedness for and response to BT if provided with additional training. Possible training may include refreshing a number of skill sets such as ventilation, defibrillation, phlebotomy and pharmacy.19 In any case, basic knowledge of BT agents and their clinical manifestations will be crucial in attaining BT preparedness competency. Training must come from credible, valid and reliable sources and must be coordinated with local emergency response agencies to ensure an integrated response plan. It is reasonable to assume that dentists in Hawaii are similar to dentists in other states with regard to their willingness to provide assistance in the event of a BT attack. Hence, we strongly urge that a high priority be set for providing these professionals with the knowledge and training necessary to improve their ability to respond effectively in such an event.


   FOOTNOTES
 

Dr. Katz is a professor of epidemiology, Department of Public Health Sciences and Epidemiology, John A. Burns School of Medicine, University of Hawaii, Biomedical Sciences Building, Room D104M, 1960 East-West Road, Honolulu, Hawaii 96822, e-mail "katz{at}hawaii.edu". Address reprint requests to Dr. Katz. When this article was written, Ms. Nekorchuk was a master’s degree student in epidemiology, Department of Public Health Sciences and Epidemiology, John A. Burns School of Medicine, University of Hawaii, Honolulu. She now is the bioterrorism preparedness food safety coordinator, Disease Outbreak Control Division, Hawaii State Department of Health, Honolulu.


Dr. Holck is an associate professor of biostatistics, Department of Public Health Sciences and Epidemiology, John A. Burns School of Medicine, University of Hawaii, Honolulu.


Dr. Hendrickson is a medical epidemiologist, Disease Outbreak Control Division, Hawaii State Department of Health, Honolulu.


Dr. Imrie is an assistant professor of epidemiology, Department of Public Health Sciences and Epidemiology, John A. Burns School of Medicine, University of Hawaii, Honolulu.


Dr. Effler is the chief, Disease Outbreak Control Division, and state epidemiologist, Hawaii State Department of Health, Honolulu.


This study was supported financially by the Hawaii State Department of Health through a Centers for Disease Control and Prevention Cooperative Agreement on Public Health Preparedness and Response to Bioterrorism (U90/CCU916969-04).


The authors gratefully acknowledge Dr. Edwin Cadman, John A. Burns School of Medicine, University of Hawaii, for his support and sponsorship of the survey; Ms. Lisa Nakao, Honolulu Emergency Service Department, City and County of Honolulu, for her thoughtful guidance and advice; Dr. Mark Greer, Dental Health Division, Hawaii State Department of Health, for his review of and comments on the survey instrument; and Ms. Sherry Callejo and Mr. Dmitry Krupitsky for their invaluable logistical support.


   REFERENCES
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Vale GL, Noguchi TT. The role of the forensic dentist in mass disasters. Dent Clin North Am 1977;21(1):123–35.[Medline]

  2. Guay AH. Dentistry’s response to bioterrorism: a report of a consensus workshop. JADA 2002;133:1181–7.

  3. American Dental Association. Conference summary: Dentistry’s role in responding to bioterrorism and other catastrophic events, March 27–28, 2003, Washington. Available at: "www.ada.org/prof/resources/topics/topics_bioterrorism_conf.pdf". Accessed Feb. 16, 2006.

  4. American Dental Association. Dentistry’s response to bioterrorism and other mass disasters: A template for dental societies to use in developing a plan for providing assistance in the response to a bioterrorism attack and other mass disasters. September 2003. Available at: "www.ada.org/prof/resources/topics/topics_bioterrorism.pdf". Accessed Feb. 16, 2006.

  5. Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Recomm Rep 2000;49(RR-4):1–14.[Medline]

  6. Centers for Disease Control and Prevention. Vaccinia (smallpox) vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001. MMWR Recomm Rep 2001;50(RR-10):1–25.[Medline]

  7. Friedewald VE. Medscape personal professor: Anthrax. Available at: "www.medscape.com/viewprogram/2718?src=search". Accessed May 28, 2005.

  8. Friedewald VE. Medscape personal professor: Smallpox. Available at: "www.medscape.com/viewprogram/2265?src=search". Accessed May 28, 2005.

  9. Nierengarten MB, Lutwick L, Lutwick S. Syndrome-based surveillance for clinicians on the frontlines of healthcare: Focus on rapid diagnosis and notification. Available at: "www.medscape.com/viewprogram/2427?src=search". Accessed May 28, 2005.

  10. Centers for Disease Control and Prevention. Update: investigation of anthrax associated with intentional exposure and interim public health guidelines, October 2001. MMWR 2001;50:889–93.[Medline]

  11. Dillman DA. Mail and internet surveys: The tailored design method. 2nd ed. New York: John Wiley & Sons; 2000.

  12. Alexander GC, Wynia MK. Ready and willing? Physicians’ sense of preparedness for bioterrorism. Health Aff 2003;22(5):189–97.[Free Full Text]

  13. Field TS, Cadoret CA, Brown ML, et al. Surveying physicians: do components of the ‘Total Design Approach’ to optimizing survey response rates apply to physicians? Med Care 2002;40:596–605.[Medline]

  14. Alonge OK, Narendran S. Opinions about oral cancer prevention and early detection among dentists practicing along the Texas-Mexico border. Oral Dis 2003;9(1):41–5.[Medline]

  15. Roth SF, Heo G, Varnhagen C, Glover KE, Major PW. Occupational stress among Canadian orthodontists. Angle Orthod 2003;73(1): 43–50.[Medline]

  16. American Dental Association. Bioterrorism. Available at: "www.ada.org/prof/resources/topics/bioterrorism.asp". Accessed July 18, 2005.

  17. Academy of General Dentistry. Bioterrorism Webliography. Available at: "www.agd.org/library/webliography/bioterrorism.asp". Accessed July 8, 2005.

  18. Chmar JE, Ranney RR, Guay AH, Haden NK, Valachovic RW. Incorporating bioterrorism training into dental education: report of the ADA-ADEA terrorism and mass casualty curriculum development workshop. J Dent Educ 2004;68:1196–9.[Abstract/Free Full Text]

  19. Jeffcoat MK. Are we ready? Thinking about the unthinkable (editorial). JADA 2002;133:1600, 1602, 1604.

  20. Psoter WJ, Alfano MC, Rekow ED. Meeting a disaster’s medical surge demand: can dentists help? J Calif Dent Assoc 2004;32:694–700.[Medline]





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