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.)
Segment 4 of 6
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Dr. Baker (moderator):
What we would like to do now is to turn to our second
expert, Dr. Brad Perkins. Brad, thank you for being with us today.
Brad is with the Meningitis and Special Pathogens Branch here at
CDC. He leads CDC’s group of scientists with technical responsibility
for anthrax. He is board certified in internal medicine and he is
just back from Florida where he led the team that was investigating
the outbreak there. Good to have you with us.
Dr. Brad Perkins:
Thanks very much. It is a pleasure to have an opportunity
to talk with all of you about medicine and public health and give
you an inside glimpse at some of the strategies we are using to
investigate these outbreaks and to help us define the cases and
the approaches we are going to recommend to identify people that
are at risk and get them on appropriate therapy.
On October 4, through the efforts of an astute physician, as Dr.
Koplan has already mentioned, we were notified of a suspected case
of inhalational anthrax. By the next morning, even before the case
was confirmed at CDC and state public health laboratories, we had
teams ready and on route to 2 locations that the case patient (or
the index patient) had visited within the incubation period for
inhalational anthrax, Florida and North Carolina. This slide outlines
the investigative strategy. Early in the investigation the 2 primary
focus areas were the case investigation (that’s the who,
what, when and how did this individual contract
inhalational anthrax) and surveillance. Both of those efforts proceeded
intensively in parallel in both Florida and North Carolina. As those
investigations proceeded, intervention strategies were designed
based on the information that was yielded from those efforts. For
example, in the case investigation, we rapidly ascertained that
there was no clear explanation for natural exposure that could account
for the inhalational anthrax case. In addition, through our surveillance
efforts we found that there was a second case of inhalational anthrax
also employed by the same company as the index patient. Through
selected and epidemiologically driven environmental sampling of
the index patient’s place of employment we identified contamination
with Bacillus anthracis in multiple locations of the building.
Those pieces of combined information that were yielded from case
investigation and surveillance allowed us to design an intervention
strategy that included targeting approximately 1,000 persons that
we felt may be at risk for inhalational anthrax. That intervention
was delivered, those people are on antibiotics, and we have identified
no further cases of inhalational disease. Still, there is an ongoing
public health and criminal investigation to try to completely define
the circumstances of this exposure.
Let me tell you a little bit about anthrax case definitions. These
are epidemiologic case definitions that have some relevance to clinical
medicine, but are primarily designed to help us track the occurrence
of these cases on local, state, and national levels. We are considering
a confirmed case of anthrax to be a person that has a clinically
compatible illness with isolation of Bacillus anthracis from
affected sites or tissues, or two supporting non-culture laboratory
tests. Those nonculture tests may include staining with immunohistochemical
staining techniques, PCR studies identifying DNA of Bacillus
anthracis in clinical tissues or from clinical sites, or serology
that suggests that there has been seroconversion or strong seropositivity
to the anthrax organism.
For a suspected case, we are considering that there needs to be
a clinically compatible illness, and in this situation we don’t
have isolation of Bacillus anthracis, but we have at least
one supportive non-culture laboratory test, or we have an epidemiologic
link to a confirmed environmental exposure. That is, we know this
person was exposed to a letter in which Bacillus anthracis
has been identified or to some other source of environmental contamination
that has been documented.
I want to go over just briefly what we would suggest is an algorithm
for action for clinicians when encountered or when there is a suspected
anthrax case. These steps—these
three steps—must be entertained simultaneously.
First of all, if there is any suspicion of anthrax, the patient
has to undergo appropriate clinical testing. Beyond the clinical
suspicion, the tests that can serve as early confirmatory evidence
of anthrax include Gram stain of affected tissues or sites, culture
(we are in very good shape with culture because this organism grows
extremely well on traditional culture media that’s available in
all clinical laboratories), or biopsy of affected sites, particularly
in the case of cutaneous anthrax.
The treatment of the patient when anthrax is suspected should be
based on the clinical impressions of the physician. It is unlikely
that there will be definitive test results from any of these methods
so that treatment—initial treatment, as Dr. Stephens has
outlined—should be
begun on clinical suspicion. While all of this is going on, just
as the physician in Palm Beach County did, you must notify local
or state public health authorities. That is going to trigger the
larger investigation, the larger public health response that is
necessary for rapid identification of persons that may be at risk
for developmental, inhalational, or other forms of anthrax.
Right now we are experiencing and actively engaged in a number of
investigations that are presenting a variety of challenges to the
public health system. In Florida, we were presented with inhalational
cases first, with no obvious vehicle. In New York City, we were
presented with cutaneous disease with a confirmed vehicle, a letter
that was positive for Bacillus anthracis. And lastly, most
recently in Washington, D.C., we are presented with a situation
where there is no obvious disease, but a very recent exposure with
a confirmed vehicle or letter. This set of experiences is serving
as a basis for us to develop a public health framework to approach
these situations in a systematic and scientifically based manner.
So in closing, I would like to suggest that the clinicians are our
first line of defense for bioterrorism in the United States. We
want you to be suspicious at this time. We want you to consider
testing for Bacillus anthracis, and as those situations arise,
report to your local and state public health authorities so we can
get into the public health investigation and identify people that
may be at risk for development of disease. Thank you.
Dr. Baker (moderator):
Brad, thank you very much.
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