BIOSECURITY AND BIOTERRORISM: BIODEFENSE STRATEGY, PRACTICE, AND SCIENCE Volume 2, Number 3, 2004 © Mary Ann Liebert, Inc. 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, and JANICE C. BLANCHARD ABSTRACT 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 Facil- ity 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 recom- mended 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 ad- vantages and disadvantages of antibiotics. We found that nonadherent participants were commonly following the advice of private physicians, whereas adherent participants commonly described ongo- ing 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 dur- ing a public health crisis. Special attention also should be given to enhancing support and informa- tion from multiple sources throughout the entire period of risk. 175 O N OCTOBER 15, 2001, a letter containing weapons- grade anthrax spores was opened in the office of Senate Majority Leader Daschle in the Hart Senate Of- fice Building (HSOB). His office and people nearby were quarantined as field tests quickly revealed positive re- sults for anthrax. As investigators began nasal swab test- ing in order to determine zones of potential exposure, staff were treated with prophylactic antibiotics. 1 On Oc- tober 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 fa- cility. Following confirmation on October 21 of inhala- tion anthrax in a postal worker from BPF, the facility was Bradley D. Stein, MD, PhD, is an Associate Director for Mental and Behavioral Health, Center for Domestic and International Health Security, and a Natural Scientist at RAND Corporation. Terri L. Tanielian, MA, is a Senior Social Research Analyst and an Associate Director for Mental and Behavioral Health, Center for Domestic and International Health Security, RAND Corporation. Gery W. Ryan, PhD, is a Senior Behavioral Scientist, RAND Corporation. Hilary J. Rhodes, MSc, is a doctoral fellow, Pardee RAND Graduate School. Shalanda D. Young, MHA, is a Health Program Fellow, RAND Corporation, and a Public Health Ana- lyst, National Institute of Dental and Craniofacial Research, National Institutes of Health. Janice C. Blanchard, MD, MPH, is a doctoral fellow at the Pardee RAND Graduate School and an assistant professor of emergency medicine at George Washington University Medical Center.