Doctors recommend steps to take during outbreaks

Recent anthrax cases show need for better communication, they say

War On Terrorism : Anthrax Scare

November 13, 2001|By Frank D. Roylance | Frank D. Roylance,SUN STAFF

In an online edition of the Journal of the American Medical Association yesterday, doctors called for better and faster two-way communication between public health authorities and front-line physicians when infectious outbreaks are suspected.

"Providers need to be able to know who to call, to remember to call, and to be able to receive information" about potential outbreaks, said Dr. Luciana Borio of the Johns Hopkins Center for Civilian Biodefense Studies, lead author of one of the reviews.

State health departments need to be on duty 24 hours a day, seven days a week, Borio added in an interview. And they need the capacity to communicate with doctors immediately by e-mail, fax, pager or other alert network.

"This is not just for anthrax, but for any infectious outbreaks or other bioterrorist threats," she said.

The online edition included two reviews of four area cases in which news media reports had helped doctors diagnose inhalation anthrax.

The first two cases involved two postal workers hospitalized in Virginia, where doctors had been alerted to the threat of anthrax by news reports on the anthrax-laced letter opened days earlier in the office of Senate Majority Leader Tom Daschle.

The others were of two Washington postal workers who turned up sick at area hospitals Oct. 21 and 22, and emergency room doctors made their working diagnosis of inhalation anthrax based on news reports of the cases in Virginia. Both had been previously misdiagnosed by doctors who had not been alerted to watch for anthrax cases.

In an editorial accompanying the case reviews, Dr. Anthony Fauci and Dr. H. Clifford Lane, both of the National Institute of Allergy and Infectious Diseases, said rapid dissemination of information by the Centers for Disease Control and Prevention, along with early diagnosis, have helped improve the nation's defenses against anthrax.

"It is quite clear that with early recognition [of the disease] and rapid, aggressive initiation of appropriate antibiotic treatment, inhalational anthrax is a serious, but nonetheless treatable disease," the editorial said. "The published mortality rates of 86 percent to 97 percent for inhalational anthrax may not be accurate in the year 2001."

The anthrax case reviews were published online, Borio said, to make doctors aware as quickly as possible of what has been learned, what to look for, and how to respond to an illness that was virtually unknown in the United States.

"There is so little that is known about modern-age anthrax," she said.

One thing that has been learned, according to the case reviews, is that inhalation anthrax can be devilishly hard to diagnose in its early stages.

Joseph P. Curseen Jr., 47, suffered gastrointestinal symptoms for six days before he went to the hospital. He blamed food poisoning, according to the JAMA article. Emergency room doctors saw nothing to the contrary in his test results. They treated him for gastroenteritis and sent him home with orders to see his doctor the next day.

His condition quickly worsened. He returned to the hospital the next day, and died there five hours later.

Thomas L. Morris Jr., 55, went first to an outpatient clinic complaining of fever, aches and weakness. He was diagnosed with a viral illness and sent home.

He went to a Washington emergency room five days later and died 13 hours after admission.

"For me, it's striking that these patients were sick enough to seek out medical care, but not to require hospitalization," Borio said. "Based on what we were previously working with in our brains, they did not need immediate hospitalization."

The symptoms of the two Virginia patients, who survived, also didn't match and provided no signs pointing clearly to anthrax, according to the case reviews.

One patient went to a hospital Oct. 19, complaining of chills, mild fever, a cough and difficulty breathing during exertion.

The other arrived a day later, reporting nausea, chills, night sweats, a mild sore throat and a worsening headache.

Doctors suspected the second patient had meningitis. But their thoughts soon shifted to anthrax.

"The Daschle letter was already in the news, and the other patient at [Inova Fairfax Hospital] mentioned a concern about anthrax, " said Dr. Naaz Fatteh, an infectious disease specialist for Kaiser Permanente, who cared for one of the Virginia patients and contributed to the JAMA case review.

"Upon further investigation, we found out he was a postal employee," she said. Chest X-rays revealed abnormalities typical of anthrax, and the presumptive diagnosis shifted.

In their editorial, Lane and Fauci wrote that, though the four anthrax cases in their early stages provided doctors with no clear red flags, they did offer a few consistent clues that can help other doctors diagnose anthrax sooner.

These included:

Rapid heart rates "disproportionate" to body temperature.

Normal or elevated white blood cell counts.

Abnormal chest X-rays or CAT scan images revealing a characteristic widening of the space between the lungs.

Abdominal pain or chest discomfort, noted in three of the four cases.

Those findings should guide doctors as the flu season approaches, they said.

Public health authorities are concerned that many patients with influenza or other respiratory infections will go to doctors or emergency rooms fearing anthrax and demanding antibiotics.

The JAMA editorial encouraged doctors to take careful patient histories to determine if they might have been exposed to anthrax, and then to use chest X-rays or CAT scans to clinch the diagnosis.

That, the editorial said, "should be able to reduce the inevitable widespread use of antibiotics during the upcoming flu season."

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