Webcast Transcript

Anthrax: What Every Clinician Should Know, Part 1

(October 18, 2001)

(View the webcast on the cUniversity of North Carolina School of Public Health site.)

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Dr. Baker (moderator):
We’d like to share a little bit more information with you about the issue of reporting. You have just heard about clinical and epidemiological issues related to anthrax. I would like to give you a brief overview of how our nation’s public health agencies operate and then how you as clinicians should relate to them. Each of you is served by both a local and a state governmental public health agency. In some states, the state health department is also responsible for governmental presence at the local level. To help you identify the points of contact for your location, CDC, in partnership with our local and state public health colleagues, has developed a new health department locator system, which can be accessed via the Web at www.phppo.cdc.gov, and by entering your location you will then be directed to the appropriate health official. This resource, we believe, will be especially important as you report suspect cases of anthrax or request information regarding management of specific situations. CDC will also be providing you with alerts and updates through our Health Alert Network, which goes out to over 2,300 hospitals around the country. At the end of this broadcast we will provide information to you on how to link to that network system.

CDC also publishes the Morbidity and Mortality Weekly Report. I would like to show you the copy that is now accessible over our Web site. As you know, this journal publishes—the Journal of the American Medical Association reprints the MMWR to facilitate distribution to you. This week’s issue features 2 important articles: one, a summary of the investigation that Dr. Perkins just described, and secondly, an article on recognition of illness that really relates to the issue of heightened surveillance. Both of these articles are available now at our main Web site, www.cdc.gov.

CDC is also building partnerships with academic institutions for the creation of a national network of CDC Centers for Public Health Preparedness to provide regional and national training information and consultation resources for public health practitioners addressing these challenging problems. We will continue to provide advice through our distance learning courses such as today’s broadcast through the Public Health Training Network, and laboratory training through the National Laboratory Training Network. For further information, again, our Web site has it available to you.

Finally we want to direct your attention to the part of the CDC Web site which has, as you might imagine, received very heavy traffic in recent days. In fact, Dr. Koplan mentioned it earlier. Today there were over a million hits on this part of the Web site, and the address, as he gave you earlier, is emergency.cdc.gov. This site includes a wide range of clinical and public guidance which is being updated on a daily basis with authoritative and scientifically accurate information.

Now let’s turn to your questions. As you might imagine, we will not be able to respond to every question today, but we will do our absolute best to use your questions as a guide in updating our Web site and other information resources. We are considering additional videoconferences of this type and your questions will help us to plan for the future.

For our first question I’d like to turn to Dr. Perkins. You described the Florida investigation for us very well. The question has come in, is in doing that Florida investigation, when did you and your team first suspect that the 2 cases of inhalation anthrax might have been related to an intentional release of the bacteria?

Dr. Perkins:
Thank you, Ed. That’s a good question. I think we need to put the beginning of the investigation in appropriate context. For the last several years we’ve dealt with a very large number of hoax incidents. Generally, they’ve involved letters or packages usually containing a powder and frequently labeled as being anthrax. Up until the time we began the Florida investigation we had never identified a letter or a package that actually contained Bacillus anthracis. Even so, that has changed of course, with the incidents in New York City and Washington D.C. that occurred after the beginning of the Florida investigation. Even so, we approached the Florida single case of inhalational anthrax with an open mind as to whether this could be a naturally occurring case or whether it was the result of intentional exposure. Of course, we had heightened suspicion. This was the first case of reported inhalational anthrax in the United States in more than 25 years. There was the temporal association with the events of 9/11, and we knew going into the investigation that initial interviews conducted by the local and state health departments had revealed no obvious source for environmental or natural exposure for inhalational disease. When we found Bacillus anthracis spores in the index patient’s work place, and then identified a second case of inhalational disease in an employee of the same company who worked in the mailroom, we were quite suspicious. What clenched our suspicion, however, was the directed environmental sampling we did in the work place which revealed multiple sites of contamination, the index patient’s keyboard, and the mailroom, and at that point the investigation became both a combined public health and a criminal investigation.

Dr. Baker (moderator):
Great. Thank you very much. One of the issues that you faced in Florida, and both of you have referred to this previously, has to do with the use of antibiotics in these particular situations. It would be I think very helpful to know what the decision-making process was that you went through in deciding who should be given postexposure antibiotic prophylaxis for prevention of inhalation anthrax in Florida. How did you approach that?

Dr. Perkins:
Well, for the last several years we have worked at CDC and with many of our partners to develop recommendations for postexposure antibiotic prophylaxis. David Stephens has summarized those guidelines and they are also included in today’s MMWR or CDC’s weekly public health report.

Our decisions about who needs antibiotics in these situations are driven primarily by intensive epidemiologic investigations. The purpose of these investigations is to thoroughly describe the circumstances in which suspected exposures or confirmed exposures may have taken place. Those investigations are designed so we can identify everyone that is at risk. As an adjunct to these investigations we are using a number of laboratory tools to help us better define populations that may benefit from antibiotic therapy. Some of the laboratory tools that we have used have included nasal swabs for identification of Bacillus anthracis in the nose. We have also used very targeted environmental sampling in environments we think may be contaminated with anthrax spores, and in some circumstances we’ve actually obtained serology to look for persons that may have been exposed to anthrax.

I think that it is important to note that all of these laboratory strategies—laboratory-based strategies—are really an adjunct to the epidemiologic investigation. There has been some confusion about the use of these tests in this situation and none of these—none of these laboratory-driven techniques are designed to be used in individual patient management decisions. All of them are designed to support the epidemiologic investigation and to be used in combination with it to identify populations that would benefit from antibiotic therapy.

Dr. Baker (moderator):
So it’s not a simple decision, you have to integrate a lot of information together to decide about when to start somebody on prophylaxis?

Dr. Perkins:
Exactly. One of the things that we are finding is that some number of people may be initially started on antibiotics, but as we get more information to help us clarify the circumstances of exposure more carefully, we may actually revise those recommendations, hopefully target a smaller group of people before we commit them to this long-term (but we think very important) course of antibiotic therapy.

Dr. Baker (moderator):
There is a question I think about antibiotic availability. People are certainly aware of the fact that the folks that purchased antibiotics, there are some people that are keeping them in their houses and so forth. But the question really for Florida has to do with what really happened? How are these antibiotics that were given to individuals, where did they come from, how are they supplied in that particular situation?

Dr. Perkins:
Yes, in the Florida situation, as soon as we decided that we needed to treat a targeted group of individuals who were at risk for inhalational disease, we contacted the CDC National Pharmaceutical Stockpile personnel and they mobilized to deliver oral antibiotics and the personnel that were needed to logistically support the delivery of those antibiotics in a very short period of time. Actually, we decided to treat individuals on Sunday evening, October 5, at about 7:00 in the evening. We decided that about 1,000 people could benefit from treatment with antibiotics. We mobilized the National Pharmaceutical Stockpile at that time. At 5:30 the next morning, all of the equipment that was needed to deliver those antibiotics and personnel to support the delivery of those antibiotics were on the ground in Palm Beach County and at the clinic ready to go to work passing out these antibiotics at 9:00 the next morning. So the system worked beautifully. You know, I’m sorry we had to use it, but it worked very well.

Dr. Baker (moderator):
So what you are saying is, it took about 10 hours, a little more than 10 hours, from the time you decided you needed the medicine to having it be on the ground with the people, ready to deliver it in Palm Beach, Florida?

Dr. Perkins:
Yes, and it actually could have happened faster. That timing was designed with the thought in mind that we could not get people in to get the antibiotics before about 9:00 in the morning. So the Stockpile actually has the ability in this circumstance to even deliver earlier than that.

Dr. Baker (moderator):
Right. And as you know, the Stockpile has also been deployed to other sites around the country in very short periods of time just as with the case there.

Dr. Perkins:
Exactly.

Dr. Baker (moderator):
Another question that’s come in has to do with this drug called “cipro,” which seems to now be almost a household word. David, could you say a little bit more about some of the side effects here of ciprofloxacin?

Dr. Stephens:
Sure, Ed. Ciprofloxacin is a fluoroquinolone antibiotic. It has been used for a number of years. It does have some side effects, but they are relatively minor in terms of their—usually minor. These side effects include gastrointestinal complications, which is diarrhea and vomiting. In about 1% of patients there may be some increased CNS irritability, but in general ciprofloxacin is a safe and effective antibiotic and has been used for some time.

Dr. Baker (moderator):
What about other drugs? In your earlier presentation you mentioned doxycycline as a drug that has also been thought about, and there are other drugs that are out there that have been mentioned in this context. Could you say a little bit more about the risk of using tetracyclines and also fluoroquinolones, particularly in children, and say a little bit more about whether these alternatives are really available to us, David?

Dr. Stephens:
I think this is an obvious concern and in—there are some potential complications of ciprofloxacin and doxycycline in children. Those include issues in very young children with dental enamel (with tetracyclines). They also include issues of potential cartilage—interference with ligament and cartilage formation in children receiving ciprofloxacin. However, this must be taken into account in the context of a life-threatening situation such as inhalational anthrax, and those risks must be weighed. It is also important that additional antimicrobial susceptibilities be determined in all new isolates to help us determine other alternative regiments for both prophylaxis and treatment in children.

Dr. Baker (moderator):
Great. Thank you very much.

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