Webcast Transcript

Anthrax: What Every Clinician Should Know, Part 2

(November 1, 2001)

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

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Dr. Caine:
We are going to open this up to more questions from our audience. We will start.

Dr. Valentine Burroughs:
Thank you, Dr. Caine. I’m Dr. Valentine Burroughs, Chairman of the Health Policy Committee for the National Medical Association. My question to you is, what should a clinician do if he or she suspects that a patient has anthrax, and where can they be tested?

Dr. Caine:
I think the key thing is, is that it’s really important to confirm the diagnosis by obtaining a laboratory diagnosis or making appropriate laboratory specimens. Depending on what form of illness you have, whether it’s inhalational or cutaneous or gastrointestinal, you want to take those particular specimens. And also I really would advise, consult an infectious disease specialist if you have it available or consult your local health department officials. They should be well qualified in order to provide the additional information for you. Also I think in terms of exposure circumstances, these are really important factors as you make your decisions in terms of prophylaxis and so if you need additional information, remember: regardless of what your laboratory test shows, if you can document some definite exposure in regard to anthrax, please place them on antimicrobial prophylaxis antibiotics.

Dr. Fernando Daniels III:
Hi, I’m Dr. Fernando Daniels III, the Section Chair for Emergency Medicine at the NMA. Dr. Khan, is the CDC specifically recommending influenza vaccine for the postal workers?

Dr. Khan:
Excellent question, especially as we come up on influenza season in the United States. Dr. Caine has already made the point that we should maybe use the term “nonspecific febrile illness” for anthrax instead of flu because there is no coryza and rhinitis. Back to the vaccine issue, ACIP has a set of recommendations of who to be vaccinated—the elderly, the immunocompromised, people in high-risk groups. However, the recommendations are quite permissive in that any other individuals or groups of individuals who require vaccinations should be vaccinated. Postal workers would fall into those groups. Influenza among postal workers would potentially disrupt services and it’s very appropriate for postal workers to be vaccinated against influenza. However, we should be quite clear that flu vaccine will not prevent anthrax.

Dr. Daniels:
My second question is to Dr. Walks. How are the healthcare systems going to cope with the influx of patients with flu or anthrax symptoms this year?

Dr. Walks:
Well, Dr. Daniels, I think it’s really a follow on through to Dr. Khan’s answer. I think it is important for us to first of all get our hospitals all talking together. Here in Washington, D.C., we have a 10 a.m. conference call. The hospital association put that together, doctors, hospitals, regional health officers all talk to each other every day. As we approach flu season, the two questions are, are we all clear what to do when our emergency rooms get clogged? How are we going to respond to that? I think we are going to give a lot of people their flu shots. I think that’s job one, but then job two is to make sure we understand, as our emergency rooms get crowded, what is our response going to be? We don’t have a test in a healthy person for anthrax. I think that is clear. So that needs to get out to the medical community and into the public. Don’t rush to your ER to ask for your anthrax test; we don’t have one. I think that sort of public education campaign can avoid a lot of clogged ERs.

Dr. Albert Morris:
I’m Dr. Albert Morris, Chairman of the Environmental Task Force for the National Medical Association, and my question is for Dr. Satcher. There have been some influenza vaccine delays this year. How will that affect our flu season?

Dr. Satcher:
Well, there will be a slight delay, but not as much as last year. We have delivered all 79 million plus doses that we expect to have for influenza vaccine. Forty-four million were delivered by the end of October, and we believe the rest will be delivered by the middle of November. So we feel very good about the availability of the vaccine. Now we are assuming the need to be around 79 million dosages. Getting back to Dr. Walks’s point earlier, we don’t believe that the vaccine should be used to help people avoid confusing symptoms with the flu; you’ve heard what the symptoms are and we’re not using it that way. We believe that we should target first people who are over 65 years of age or people who have chronic illnesses or people who work with those people—and healthcare workers especially, because they can both get influenza from patients, but they can also give it if they are working around patients who are elderly or at high risk. So we think we ought to target the high-risk people first and then certainly after November 15^th people between the ages of 50 and 64 are now recommended by the CDC as lower risk, but somebody who should get it. Remember, last year we had 100,000 hospitalizations for influenza and we had 20,000 deaths. So it is very important to be aggressive in immunizing older people and people with chronic diseases.

Dr. Marinelle Payton:
Hi, I’m Marinelle Payton, Chair of the Department of Public Health, School of Allied Health Sciences, Jackson State University. My question is for Dr. Caine. Dr. Caine, given the susceptible populations—children versus elderly, risk versus benefits—are there contraindications in the use of either cipro, doxycycline, or other types of antibiotics?

Dr. Caine:
In the past, at least for cipro and even the tetracyclines, especially in children have had adverse health outcomes. If we look at cipro it causes impacts on the metastasis of the bone formation as young children are growing and it affects their metastasal plate and so it has been contraindicated in children. Also we have seen staining of teeth for the tetracyclines or doxycyclines in children. Also their bones are also dose-related as well. We have certain contraindications for doxycycline in pregnant women, and especially—sometimes they are allowed to be used before six months of gestation but I would never recommend that without making sure that you are talking to the family practitioner, OB or gyn, or the midwife who is taking care of these pregnant mothers and if we can have the susceptibility studies available we can also place them on amoxicillin in those instances if the penicillin susceptibility has been confirmed.

Dr. Morris:
My question again is for Dr. Satcher. Some of our patients are concerned that the treatment of response protocols have changed as this outbreak has progressed. Can you help us understand why this is happening?

Dr. Satcher:
Yes, as we mentioned before I think this is an evolving experience that we are having here. Our first concern I think was understandable and that is, we didn’t know if this organism would be resistant to say penicillin or doxycycline or agents that have been around for a long time so therefore you would expect it to be more resistant. Ciprofloxacin, on the other hand, has been around about—what, 15 years?—not a lot of resistance to ciprofloxacin. You don’t want to take any chance with inhalation anthrax as you’ve heard from Dr. Caine and others. So you go with the big gun at the beginning until you find out for certain that this organism is sensitive to other agents like penicillin and doxycycline. So what we have done is we’ve determined now after all of this experience that all of these different outbreaks, if you will, have been with organisms that are sensitive to doxycycline. As you have heard, there is some concern about penicillin, especially if you are actually treating inhalation anthrax, and the possibility that even if there is not resistance at first, because of penicillinase development you could get resistance later. So in the exposure mode you can use penicillin, amoxicillin, but you want to make sure that if you are treating somebody with inhalation anthrax you go with something that is certain, so you are going to combine ciprofloxacin or doxycycline with one of the big guns like rifampin and others that we talked about. But no—this is an evolving experience, and we are making adjustments that are appropriate for managing any kind of outbreak.

Dr. Daniels:
Dr. Fernando Daniels, III again. My question is for Dr. Perez, in that we are switching from doxycycline to cipro and a lot of citizens are worried about is it as effective as cipro. I would like for you to make a comment on whether doxycycline is as effective as cipro.

Dr. Perez:
I guess I would just reiterate what we’ve heard from our Surgeon General to alleviate those fears as pointed out by Dr. Walks that you go for your big gun first. As we have all learned, first do no harm. So what we are doing is we’re going—alleviating that which has the greatest potential for harm. So we started out with the cipro, the bigger gun, a broader spectrum, to assure that there would be no resistance, but we have found that in all of the strands from Florida, New York, and Washington, all of the strands have been susceptible to doxycycline. Using doxycycline and using it with the regimen of twice a day is as effective as using cipro.

Dr. Walter Royal III:
I’m Dr. Walter Royal III, Department of Medicine at the Neuroscience Institute, Morehouse School of Medicine. My question is for Dr. Khan. Dr. Khan, could you tell us what is the case definition for anthrax?

Dr. Khan:
Yes, I can. The current case definition in the United States for anthrax is divided into 2 categories, confirmed cases and suspect cases. For confirmed cases you require clinically compatible illness that is confirmed by either isolation of Bacillus anthracis or other laboratory evidence based on 2 supportive laboratory tests: PCR, immunohistochemistry, or serology. For a suspected case, the definition is clinically compatible illness with one supportive lab test or a link to an environmental exposure that we are currently studying.

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