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.)
Dr. Ali Khan:
Again, intervention in these sites has been directed at the workers who have had exposure to the letters or been in facilities with disease, and hopefully one of our moderators, Dr. Ivan Walks, who is the Health Commissioner for D.C., will give you a lot more details along those lines. He has been a great partner as we have done this investigation.
There should be a slide of the Brentwood facility coming up. If not, let me just describe the facility to you. This is a large, almost one million square feet facility, in which the 4 cases of inhalational anthrax occurred. From what you can see on the slide, there are 4 cases, 3 of them marked in triangles on the top left-hand corner of your screen were around the sorting machines which look like little red dots. Then all the way at the bottom right-hand side of your screen should be another triangle for where the fourth case occurred. Now where the sorting machines are and the red dots, that is where the letter destined for the Senator went through. I want to make a couple of points here. Over the last—essentially over my whole career I have dealt with things like Ebola and Rift Valley Fever, and people always ask me, “Is this causing a small-particle aerosol that is going to infect many people by the aerosol route?” I always try to inform people that this type of transmission is a rare event if ever with those diseases. However, what you can see in this Brentwood facility is clearly a small-particle aerosol where at the sorting machine you have the letter going through and then you have people many feet away, essentially yards away, who are getting infected. In the case of the fourth individual it is all the way on the other side of a building that is a million square feet. It has really sort of given us a good respect for small-particle aerosols and how dangerous this weapon can be and what its potential is. It is something we have not recognized previously, although there was theoretical data that would have supported this. This is the first practical demonstration of what anthrax in a powder-concentrated form can do in the population.
The next slide should be a summary of everything we have so far. It should be a summary of the cases in Florida, New York, D.C., New Jersey, and you have already heard those numbers. There are 16 confirmed cases, 10 of them inhalational and, fortunately, only 4 deaths, but as the Surgeon General said, 4 too many.
The next slide is what we would call an epidemic or epidemiologic curve of cases and even though it is outdated I’d like to use it to make one major point to you. That is, I would like people to think of this outbreak in terms of phases. The first letter on this time line you see, or the first set of letters which would be sort of potentially the New York City letters and possibly the Florida letters led to a number of cases, inhalational only among people who had contact with the final powder, but mainly cutaneous cases that occurred among the mailroom workers. That was essentially what we were looking for when we came here and were in the process of following the letter from the Senator’s office, to the Senate mailroom, to the facility that receives mail for the whole capital, back through to Brentwood. So we had surveillance systems in place, but in addition obviously looking for inhalational cases. The surveillance system was looking hard for cutaneous cases based on our experience in Florida and New Jersey. Needless to say, we were all dumbfounded when inhalational anthrax appeared right here in Brentwood. That was unexpected, and I can tell you as part of the investigation before, or essentially simultaneous with identifying that first case that—I was out in Brentwood with a team of epidemiologists. And like the employees in Brentwood, myself and my team of epidemiologists are all taking 60 days of prophylactic antibiotics at this point. Because we didn’t realize what had happened in that facility until the case declared itself and the additional 3 cases declared themselves. Now, we knew how dangerous the material that had passed through the facility was. We see that as the second phase of this investigation where we were able to recognize that you don’t just get inhalational case to the end user and maybe some cutaneous cases among postal workers, but this powder could be dangerous for anybody through the chain, from it being mailed all the way to the end user, and that made us rethink how we targeted people for prophylaxis. It was based on that data that we decided to start prophylaxis for essentially everybody who was getting mail directly from this Brentwood facility. And it’s only now, as we have gotten additional epi data and environmental data and clinical data, that we’ve been able to integrate in that stuff and say okay—maybe we can now narrow that group down to the people where there was true inhalational disease such as in the Brentwood facility or the State Department where there was a case of inhalational disease. That data hopefully will allow us to refine who we are putting on prophylaxis and not try to do that so broadly.
The final phase is this new phase as you heard of individuals such as the cutaneous case in New Jersey and the inhalational case in New York that do not seem to be linked to mail in any way, shape, or form, and it’s too early to say where that phase will lead us, but that is where we are now.
Let me end with some issues and things that we need to pay attention to. Approximately 3 years ago I was detailed to the Bioterrorism Preparedness and Response Program at CDC to help put together (with a number of our colleagues) a strategic plan on how CDC should prepare for bioterrorism. Fortunately, in those 3 years we have made numerous strides. However, we are not there yet. There are a lot of things that we need to really think about, as we are now learning for the first time how these agents work in the community. I’ve put some of those elements up on the slide.
The first element was integrated real-time national surveillance systems that can take into account inhalational disease, take into account cutaneous disease, and also integrate in laboratory values, clinical data, environmental data, so we can move that information out faster to our partners. I think that is the key focus for us. We need to be able to communicate that stuff as fast as possible.
The second element on my slide is trying to define the epidemiology of unnatural phenomena—again, this is an unnatural phenomenon and it’s hard to predict what’s going to happen next. But we need to try to do the best we can using the tools we’ve used in the past and developing new tools to try to protect people, and that’s really where we all come down to.
The third element is improving our diagnostics. We need some enhanced diagnostics to try to make the diagnosis and try to deal with these environmental samples and the capacity to do that. With our laboratory capacity, nationally, not just the CDC, is maxed out trying to respond to these events. We can’t afford not to test. We have to have the ability to say, “Is this B. anthracis or is this not B. anthracis?” All of this should lead to risk reduction measures and education. And I’d like to end on that point, to be thankful again for the opportunity to chat with the physicians in this audience and the physicians on the other side of the camera. The physicians truly are our first line of defense and I know as public health officials we like to see physicians as our sources of our public health data, but as you all know out there (and I’m a doc also), we are not just sources of public health data. We are the ones who take care of the patients—healthcare workers in general—who take care of the patients, and we need to be the ones to educate our community. It can’t be done by one agency alone. It has to be done in conjunction with all of our partners, state and local health departments, and the physicians out there to educate people.
- Page last updated November 20, 2002
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