Webcast Transcript

Anthrax: What Every Clinician Should Know, Part 1

(October 18, 2001)

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

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Dr. Koplan:
Thank you, Mr. Secretary. I would like to thank everybody who is listening today. I know your days are extremely busy. You are pulled in every direction by clinical responsibilities, administrative responsibilities, the needs of patients in your communities—and the fact that you are taking a little time to sit with us today and learn a bit more about anthrax and share some of your concerns and questions with us we appreciate deeply.

A critical thing for us in public health is the linkage with clinical medicine. The bonds of that are true in every aspect of healthcare now, whether it is getting high immunization rates in a community, whether it is improving mammography screening, whether it is cutting down on tobacco use—nowhere is it more important than this area of bioterrorism. In over 50 years of CDC we have not had a real bioterrorism threat. We do now, and now is a good time for partnership. Now is a must time for partnership between you and us and getting the job done for the well being of the country.

We talk a lot about disease surveillance. Disease surveillance starts with you all. We play a part in it. Local, city, and county health departments, state health departments play a part in it. But really, the grassroots—that where the rubber meets the road in this is in you practicing clinicians’ hospitals, folks in care in the community, emergency room doctors, infectious disease consultants, everybody. It’s the surgeon who sees something for debrevement that looks unusual that needs to be thinking, “Could this be anthrax?” It’s the pediatrician who is seeing a child with an unusual sore on their finger that looks like it might be a brown recluse spider bite, but thinks maybe it’s something else. There is no community that is not potentially part of this. There is a tendency in popular culture to think that this can only happen in big urban settings, but we have seen already that that’s not true. So wherever you are viewing from, wherever you are listening from, this is something that is germane, pertinent, and really important for both us and you to master some of this information. Many of us may have glossed over anthrax in medical school or in our postgraduate training. Well, we’ve learned in the last couple of weeks that we need to be experts in it, and the good news is, there is a pretty discrete body of knowledge to learn and we can all be experts in it in a pretty short period of time and you will be before this broadcast is over.

The role we would like you to play, and I think that you want to play just by virtue of having tuned in on this, is to be able to recognize some of these threats that are presented to us, recognize them quickly, and to play that role in linking what you do to what we do and in stopping these outbreaks in their tracks. There is nothing more important in disease control than limiting the spread of disease. In this case anthrax does not spread person-to-person, but nevertheless, the earlier we detect an initial outbreak, the earlier we can apply control measures and limit other people from becoming ill from it. This link between public health and medicine is one we would like to further. A crucial part of this will be interplay between you in clinical practice and your local health departments and your state health departments. It was exemplary evidence in the Florida outbreak in which an astute clinician played a crucial role in getting appropriate laboratory samples to the state health department in an early diagnosis made of anthrax. I think there has been an underestimate of the quality of care provided in the U.S. and the astuteness of American clinicians, but this is something that this program and our activities here are in an attempt to even further, and to make sure that you are comfortable and confident of what you are doing when it comes to bioterrorist agents and anthrax in particular.

A couple of my colleagues here who are truly expert in this particular disease and its management and the public health aspects of it are going to be giving you considerable details promptly. I would also like to let you know that CDC is posting a variety of information, a variety of sources for health alerts, advisories, updates on a regular basis and it’s appearing on our Emergency Preparedness and Response Web site, which is emergency.cdc.gov. A fair amount of information is accessible there and will continue to be updated in the days and weeks to come.

Dr. Baker (moderator):
Great. Thank you very much, Jeff, and thank you, Secretary Thompson. We understand, Mr. Secretary, that your time is limited today, as is Dr. Koplan’s, so we would like to get a couple of questions that have come in today right now from our viewers. We are only receiving questions by e-mail or by fax. We wondered if you, Mr. Secretary, would have time for one question?

Secretary Thompson:
Absolutely.

Dr. Baker (moderator):
One of the issues that has come in has to do with a question that you are asked very often, and that has to do with our state of preparedness in the country. You have been very supportive of the efforts that are now underway. Could you say a bit more about that issue, please?

Secretary Thompson:
Absolutely, and thank you for asking. First off, we have set aside this huge suite of offices right next to mine for actually planning and for dissemination and taking in of information 24 hours a day, 7 days a week. We also have a telephone line that you can call us for information. We have also hooked up CDC through our Health Alert Network with 37 states and we are in the process of getting the remaining 13 states hooked up. We have gotten 7,000 doctors and professional medical people (nurses and EMTs) that are on alert. They are distributed in 90 medical assistant teams and they can be moved relatively quickly. We have 8 strategically located push packages, each containing 50 tons of medical supplies and we are requesting from Congress an additional 200 tons of 4 more push packages located in other sites around America. We have 6,000 other doctors and medical people on the Commissioned Corps and professional people that could be utilized by the Department of Health and Human Services to send out to a community or a state if they need it and we feel that we can respond. Our problem, of course, is that our state labs are really being overloaded now with all the fears by so many people asking for requests about a lot of stuff that really is not anthrax but people are fearful about it. I think that is about all I want to say at this point and time. I can go into greater detail if anybody wants.

Dr. Baker (moderator):
Great. Thank you. A question for Dr. Koplan: Jeff, the situation is changing from day to day. You are getting regular briefings and you are directly involved in the overall management of CDC’s efforts around the epidemic. Could you update folks a bit on where we stand today?

Dr. Koplan:
Well, basically, we are dealing with focal outbreaks of disease. The initial one was in Florida and you will hear more details about that, but there we are dealing with 2 cases of disease, one other person with evidence of exposure of the disease, and a number of people are under antibiotic prophylaxis.

In New York, we have 3 cases of the disease, and again, focal exposures in certain workplaces and a number of people on antibiotic therapy. It is possible we will have a case or 2 more. They are under consideration and the laboratory work is being analyzed. But keep in mind, I think throughout this that it is a limited number of cases, a very limited number, a limited number of exposures that created a large amount of public and medical interest and certainly a huge amount of public health interest. We are deeply concerned and deeply involved in these, but the amount of morbidity and mortality—all of which is unfortunate and we wish we had none of it—remains circumscribed and indeed the need for action around these outbreaks remains relatively circumscribed. You’ll hear more about the details of those from the participants here.

Dr. Baker (moderator):
Great. Thank you. Mr. Secretary, one last question for you if you have time for one last question.

Secretary Thompson:
Sure.

Dr. Baker (moderator):
As you know from a lot of the work that has gone on from both CDC and members of the Senate and the House, there is concern, as you mentioned earlier, about the state of the local public health infrastructure. You’re now back in your state of Wisconsin as we understand. What are you feeling from communities around your state about local needs that exist either in your home state or in localities around the country?

Secretary Thompson:
Well, I’m just hearing that they are stretched, which we know they are and we want to be helpful. I think the fact that so many people are calling in with requests, and the laboratories are trying to handle them just because of the heightened awareness of everything that is taking place in America right now, that they are stretched pretty thin. What we are trying to do is to buttress that with some additional appropriations through Congress in order to strengthen our local and state public health needs. We feel that even though it was terrifying and a terrible thing for America to go through on September 11, one of the good consequences of that, of course, is the fact that people now are aware of the need and the importance of putting more money into our local and state public health systems. That is why a good share of the 1.5 billion dollar request, outside of the medicine, is going to go for strengthening the local and state health departments.

Dr. Baker (moderator):
Mr. Secretary, we very much appreciate your support and also your willingness to take time with us today. We have one last question for Dr. Koplan and then we will go to a break. Jeff, could you say a little bit more about this issue of vigilance around the country? Practitioners like the ones in this program are clearly in a heightened state of vigilance. People are going to be perhaps needing to look for other unlikely things besides anthrax, and to look in places perhaps a little bit out of the way, not in our big cities—perhaps in rural areas. Could you say a little bit more about the need for increased vigilance, what people need to be looking for, and where does this vigilance need to apply?

Dr. Koplan:
I think—thanks—I think vigilance is a good way to put it. I guess I keep thinking back in my training, and probably most of you folks heard this in your training as well, is the old line for clinicians is, “When you hear hoof beats, think horses, not zebras.” I think unfortunately what we need to do now is yes, still think horses, but in the back of your mind think, “Could there be a zebra in this pack that is going by?” That is where the vigilance comes in, and to think, “Is there anything unusual about this case that doesn’t fit in with other ones? Have I seen a couple or 3 or 4 similar patterns in the last week or month that just don’t fit the bill? Does it seem to be a clustering of something that might be unusual? Should I order that extra laboratory test, as unlikely as it might be?” A blood test, a culture, a patient that doesn’t seem to be getting better on antibiotics that you would have thought would have been appropriate, etc., etc. You will hear more of the clinical details from my colleagues. But it is that vigilance that caused an infectious disease specialist in Palm Beach County to say, “Something doesn’t fit in this patient; I’m going to ask for an anthrax culture and a smear.” He might never have done it before, but something tipped this off, and that indeed is what gave us a big head start on coming to grips with this outbreak.

Dr. Baker (moderator):
Jeff, thank you very much. What we are going to do now is to take time, a brief video, and if you want to send us your e-mails or faxes, you’ve received the information. We want to thank Secretary Thompson and Dr. Koplan for being with us. They have other commitments and will be leaving the program at this point. We will be coming back with the second part of our program in just a moment. Thanks.

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