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11/21/2001

CDC Broadcast Aims to Improve Clinicians' Grasp of Anthrax Issues

Kate Traynor

Officials from the Centers for Disease Control and Prevention (CDC) held a live satellite and Web broadcast on October 18 to bring clinicians up to speed on the diagnosis, treatment, and reporting of anthrax exposure.

The 90-minute program, titled "Anthrax: What Every Clinician Should Know," was sponsored by CDC, the American Hospital Association, and the American Medical Association.

Spreading the word. CDC Director Jeffrey P. Koplan stressed during his presentation that health care professionals throughout the country, from the "grassroots" level up, need to be involved in surveillance for anthrax.

"We've learned in the last couple of weeks that we need to be [anthrax] experts," he said.

Koplan described the anthrax situation on October 18 as "focal outbreaks of disease," with CDC "deeply concerned and deeply involved" in handling the outbreaks. So far, he said, "the need for action around these outbreaks remains relatively circumscribed."

Still, Koplan noted, "there’s no community that’s not potentially targeted" by bioterrorists.

"The earlier we detect an initial outbreak, the earlier we can apply control measures and limit other people from becoming ill," he said.

Recognizing and reporting the disease. CDC Meningitis and Special Pathogens Branch Chief Bradley A. Perkins urged clinicians to act promptly if they suspect a patient has been exposed to anthrax.

"If there is any suspicion of anthrax," Perkins said, "the patient has to undergo appropriate clinical testing." Such tests, he said, could include culturing bacteria and, if cutaneous anthrax is suspected, performing a biopsy.

While tests are being run, Perkins said, clinicians need to notify their state or local public health authorities.

"That is going to trigger the larger investigation, the larger public health response that's necessary for rapid identification of persons that may be at risk for developing inhalational or other forms of anthrax," he said.

David S. Stephens, who is also with CDC’s Meningitis and Special Pathogens Branch, described the clinical features of cutaneous, inhalational, and gastrointestinal anthrax. He also described other diseases with symptoms similar to those of anthrax, which may complicate diagnosis. Portions of Stephens’ presentation, including photographs of anthrax lesions, are available at www.bt.cdc.gov/DocumentsApp/Anthrax/Clinical/ClinicalAnthrax.pdf (PDF).

Federal response coordination. Perkins praised CDC’s quick response to the anthrax outbreak in Florida, the first apparent bioterrorist attack in the nation.

"At about 7:00 in the evening, we decided that about 1000 people could benefit from treatment with antibiotics," Perkins said. "We mobilized the National Pharmaceutical Stockpile at that time.

"By 5:30 the next morning," he continued, "all of the equipment that was needed to deliver the antibiotics and personnel that support the delivery of the antibiotics were on the ground in Palm Beach County and at the clinic, ready to go to work."

In describing CDC’s response plan, Perkins said, "I'm sorry that we had to use it, but it worked very well."

Outbreak-centered focus. Perkins stressed that current clinical and environmental tests for anthrax exposure are interpreted at the epidemiological level, not at the individual patient level.

"None of these laboratory . . . techniques," Perkins said, "are designed to be used in individual patient-management decisions." Instead, he said, the tests are used "to identify populations that would benefit from antibiotic therapy."

Perkins expressed optimism about streamlining the response to future anthrax outbreaks.

"A number of people may be initially started on antibiotics," he noted. "But as we get more information, . . . we may actually revise those recommendations, hopefully targeting smaller groups of people before we commit them to this long-term—but, we think, very important—course of antibiotics."

This optimism soon proved unfounded. Within five days after Perkins made the remark, several cases of inhalational anthrax, two of which resulted in death, were confirmed among postal workers serving New Jersey or Washington, D.C. The finding that inhalational anthrax may have been contracted through exposure to unopened envelopes led CDC to recommend anti-infective prophylaxis to postal workers and other people who may have come into contact with sealed Bacillus anthracis-containing mail.

Antimicrobial regimen. CDC recommends ciprofloxacin or doxycycline prophylaxis after exposure to B. anthracis. After the October 18 broadcast, CDC expanded its prophylaxis recommendations and released guidelines for the treatment of inhalational anthrax (see table).

Because CDC’s anthrax prophylaxis and treatment recommendations change in response to new clinical data, health care professionals should visit the CDC Web site to obtain the most current information on handling the disease.

Vaccination of health care workers. In response to a caller’s question, Perkins said that CDC’s Advisory Committee on Immunization Practices (ACIP) had previously made a "firm recommendation" against routine pre-exposure use of the anthrax vaccine for health care workers and other "first responders."

"Populations that were considered [by ACIP] included emergency first responders, law enforcement officials, [and] persons that would receive suspicious packages in the laboratory," Perkins said.

But he acknowledged that this recommendation may change.

"Over the last month," Perkins said, "we're seeing the clinical cases and the occurrence of risk. I think that, based on that change of risk, . . . we're going to have to re-evaluate the need for vaccination of selected populations."

Emphasis on funding. The broadcast also featured a live-by-telephone appearance from Health and Human Services Secretary Tommy G. Thompson. More than once during the broadcast, Thompson said that responses to anthrax concerns have left state laboratories "stretched thin" and "overwhelmed." He also appealed to clinicians to educate the public and "knock down this fear factor that’s epidemic across America."

But instead of directly addressing anthrax, most of Thompson’s remarks were devoted to the fiscal side of general bioterrorism preparedness.

Thompson reminded viewers that the Bush administration had recently requested a $1.5-billion increase in emergency funding to combat bioterrorism—a "sixfold increase over the current budget."

Thompson said that part of the expected funds will be used to add four national "push packages" to the current eight. Each push package, he said, contains 50 tons of "medical supplies" to be used in response to a chemical or biological attack.

About $90 million of the new funds will go to assist local public health laboratories, which Thompson described as having been "largely underfunded for several years."

The anthrax attacks appear likely to change the laboratories’ fiscal picture. "People now are aware of the need and the importance of putting more money into our local and state public health systems," Thompson said.

Follow-up broadcast. A week after airing its initial program, CDC participated in a follow-up broadcast cosponsored by the National Medical Association.

During the program, Ali S. Khan, deputy chief of CDC’s Anthrax Response Team, described the epidemiological investigation of the anthrax outbreak in the District of Columbia.

"We were all dumbfounded when inhalational anthrax appeared right here in Brentwood," Khan said, referring to an outbreak traced to a mail processing facility in the district. Khan noted that he and his epidemiological team were undergoing 60 days of anti-infective prophylaxis to counter their unexpected exposure to B. anthracis during the investigation at Brentwood.

He called the terrorism-related anthrax outbreak an "unnatural phenomenom" that has challenged the nation’s public health response.

"We’re now learning for the first time how these agents work in the community," Khan said.

Links to both broadcasts are available at www.bt.cdc.gov/VideoArchives.asp.

 

CDC's Recommendations for Prevention and Treatment of Anthrax, As of November 2, 20011-3

Clinical Situation

Initial Therapy

Duration

Postexposure prophylaxis for inhalational anthrax

 

 

Adults, including immunocompromised persons

Ciprofloxacin 500 mg p.o. b.i.d. or
Doxycycline 100 mg p.o. b.i.d.

60 days

Pregnant women

Ciprofloxacin 500 mg p.o. b.i.d.a

60 days; if strain is susceptible to penicillin, may change therapy to amoxicillin 500 mg t.i.d. for 60 days

Childenb

Ciprofloxacin 10–15 mg/kg p.o. q 12 hr, not to exceed 1 g/day or
Doxycycline 100 mg p.o. b.i.d. for children >8 yr and >45 kg; 2.2 mg/kg p.o. b.i.d. for children >8 yr and <45 kg and those <8 yr

60 days; if strain is susceptible to penicillin, may change therapy to amoxicillin 80 mg/kg/day divided into three doses q 8 hr, not to exceed 500 mg per dose

Treatment for inhalational, gastrointestinal, and oropharyngeal anthrax associated with recent bioterrorism attacks

 

 

Adults, including pregnant womenc and immunocompromised persons

Ciprofloxacin 400 mg i.v. q 12 hr or
Doxycycline 100 mg i.v. q 12 hr
Plus
1 or 2 of the following: rifampin, vancomycin, penicillin,d ampicillin,d chloramphenicol, imipenem, clindamycin, clarithromycin

60 days total; administer i.v. initially, then switch to p.o. therapy when clinically appropriate (ciprofloxacin 500 mg p.o. b.i.d. or doxycycline 100 mg b.i.d.)

Childen,b including immunocompromised children

Ciprofloxacin 10–15 mg/kg i.v. q 12 hr, not to exceed 1 g/day or
Doxycycline 100 mg i.v. q 12 hr for children >8 yr and >45 kg; 2.2 mg/kg i.v. q 12 hr for children >8 yr and <45 kg and those <8 yr
Plus
1 or 2 of the following: rifampin, vancomycin, penicillin,d ampicillin,d chloramphenicol, imipenem, clindamycin, clarithromycin

60 days total; administer i.v. initially, then switch to p.o. therapy when clinically appropriate (ciprofloxacin 10-15 mg/kg q 12 hr, not to exceed 1 g/day; or doxycycline 100 mg b.i.d. for children >8 yr and >45 kg, 2.2 mg/kg b.i.d. for children >8 yr and <45 kg and those <8 yr)

Treatment for cutaneous anthrax associated with recent bioterrorism attackse

 

 

Adults, including pregnant womenc and immunocompromised persons

Ciprofloxacin 500 mg p.o. b.i.d. or
Doxycycline 100 mg p.o. b.i.d.

60 days total; after clinical improvement, may change therapy to amoxicillin 500 mg t.i.d.

Childen,b including immunocompromised children

Doxycycline 100 mg p.o. b.i.d. for children >8 yr and >45 kg; 2.2 mg/kg i.v. q 12 hr for children >8 yr and <45 kg and those <8 yr

60 days total; after clinical improvement, may change therapy to amoxicillin 80 mg/kg/day divided into three doses q 8 hr

aDoxycycline should be used with caution in asymptomatic pregnant women and only when there are contraindications to the use of ciprofloxacin or another appropriate anti-infective agent.
bThe risk of adverse effects from fluoroquinolone or tetracycline therapy must be weighed against the potential benefit.
cCiprofloxacin use during pregnancy is unlikely to be linked with a high risk for structural malformations during fetal development, whereas tetracyclines are known to affect fetal development.
dDo not use penicillin or ampicillin as monotherapy.
eUse i.v. therapies if cutaneous anthrax is accompanied by signs of systemic involvement, extensive edema, or lesions on the head or neck.

  1. Centers for Disease Control and Prevention. Update: investigation of anthrax associated with intentional exposure and interim public health guidelines, October 2001. MMWR. 2001; 50:889-93.   
  2. Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR. 2001; 50:909-19.   
  3. Centers for Disease Control and Prevention. Updated recommendations for antimicrobial prophylaxis among asymptomatic pregnant women after exposure to Bacillus anthracis. MMWR. 2001; 50:960.