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.)
Segment 5 of 6
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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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