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Newsmaker: Dr. Anthony Fauci

October 31, 2001 at 12:00 AM EST
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RAY SUAREZ: Joining me now is Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, a part of the National Institutes of Health; he’s the leading infectious disease expert in the federal government. Dr. Fauci, in Kathy Nguyen, we appear to have now a fatality with no direct link to post offices, media outlets, or Capitol Hill. What does this latest death do to change the profile for the investigators?

DR. ANTHONY FAUCI: It may very well change the profile and what we will need as is going on right now is very intensive investigation that the authorities are carrying out, to try and determine as best as one possibly can, what potential pattern is now evolving, namely, is this workplace related. Are there or will there be any other development of disease in the workplace?

If not, what other patterns can be followed, namely, her personal interactions — in order to determine just what is going on here. When you have a single outlier like this, it’s either an outlier of an already existing paradigm, which we have known and experienced for the last few weeks, namely Postal Service related, or if it is not. It might be the sentinel case in a new evolving paradigm perhaps involving other mechanisms of exposure to individuals.

So now is a very intensive time to try and track that down. And that’s how the evolution of investigations in public health matters occur. This is a very intensive time going on.

RAY SUAREZ: She got very sick very quickly.

DR. ANTHONY FAUCI: Correct.

RAY SUAREZ: And wasn’t able to tell investigators about her movements, the things she had done over the last several days. Is it merely daunting, or is there a degree to which we’ll never be able to piece together all of the parts of her life?

DR. ANTHONY FAUCI: That’s always the possibility, but the way one tracks as best as possible is from her friends, associates, get a good feel for the patterns and the roots that she may have gone through — personal things, who she interacts with, who she has social interactions with, where she goes, where she shops. All of that is part of the blanket of the investigation.

Obviously, if this unfortunate woman were alive and would be able to help the investigators to retrace her steps over the previous several days to a week or so, it would be easier, but it’s not impossible. You can do that kind of tracing even under the very difficult situation that we have right now.

RAY SUAREZ: Is it also hard to figure out what to do next? I mean we have seen post offices being scrubbed down and sprayed down and vacuumed. But you can’t do that to the New York City subway system, can you?

DR. ANTHONY FAUCI: Obviously. If there is no definitive association with a contamination, something that tells you that this is where she got infected, then everything is open. You cannot just throw a net out and start treating everybody who she’s come into contact with or even sweeping everything. Right now it’s very clear that you concentrate on her place of employment, where she lives and where she has gone.

If you get no clue – namely you have an isolated person with inhalation anthrax and that’s it – then you really in some respects have to wait to see what happens next. Is there another emerging illness in someone associated with her? Hopefully clues will evolve that will allow health officials to be able to rapidly track just what the source of this illness was.

RAY SUAREZ: Of the ten cases of pulmonary or the inhaled form of anthrax, four have died, six appear to be on their way to recovery.

DR. ANTHONY FAUCI: Right.

RAY SUAREZ: What are some of the things that are telling the tale there? Why are some people dying and some people recovering?

DR. ANTHONY FAUCI: I think what it’s telling us is that the original “conventional” wisdom-that if you get inhalation anthrax, that you are essentially dead, there is no hope even if you treat the people, because usually people present with inhalation anthrax with a advanced stage of disease– what this is telling us now is that is not true, because when people are treated, as we see now, a good number of them are doing quite well. It also tells us something we know about all disease:

There is a considerable biological variability. We call it a bell-shaped curve in biology, where some people rapidly respond well, some people deteriorate, and then there are other people somewhere in the middle.

So this idea that this is a completely and rapidly and inevitably fatal disease has proven not to be the case. I think it’s a combination of two things, among others: One is vigilance and alertness in identifying cases, because of the heightened sense of urgency that we have now in our society, particularly in the epidemiological setting of postal workers and people in the postal system.

That’s the most important thing. The other thing is the institution of treatment early in the course of the disease. Those two things, I think, have contributed greatly to not having the feared 100 percent mortality with inhalation anthrax.

RAY SUAREZ: Spores keep showing up in new places because of the increased attention, showing up in canvas bags, in boxes, sorting machines. Today in Indianapolis they found a sorting machine that had the spores. It was found to have been shipped from the Brentwood facility near Washington. How long do these spores remain a threat? Do they stay potent a long time?

DR. ANTHONY FAUCI: Well, there are two issues important. Spores, we know historically, particularly from our experience with anthrax in animals where animals die and the carcasses decay or are buried, they could stay indefinitely for decades. The critical issue is at what concentration. What is likely we’re seeing, those lines that are connecting is that these contaminations in this facility here, and then when you carefully look and see received equipment, or what have you, from Brentwood– secondary facilities that feed into Brentwood.

It’s not surprising given the fact that these spores have the capability of disseminating and depositing in different place that you’ll detect variable degrees of spores at places that have the potential of contamination because of a connection with the primary facility. Hopefully — and we’re starting to feel this way — is that most of it will be trivial contamination that will not cause disease, and as the time goes by and you have contamination and people don’t get disease, that adds to that credibility of that concept.

But importantly, and what is going on right now, is that authorities are not taking a chance. If you identify contamination, you close the building and you clean it up and then you let workers back when you have shown that there is no more contamination there.

RAY SUAREZ: In the almost detective part of the story, the work that epidemiologists do to try and understand this, it may sound terrible to say, but is there a way in which you need more people to get sick to really understand this?

DR. ANTHONY FAUCI: Unfortunately, at a personal level in the empathy and the feeling for people who get sick, that sounds like a terrible concept. But in the broad picture of epidemiology, that is how the health investigators determine patterns. You see what happens one to the other. So in some respects, the evolution of a pattern, which by its very definition involves people getting sick, determines the direction of where you’re going to go with it and what you’re going to do to prevent further infection.

But if you just have an isolated situation, you have such a potential landscape there that it’s very difficult to definitively do something without casting out such a wide net that it’s almost untenable — as it narrows down with more cases we say, we’re seeing a pattern — and the same way is when Daschle got the letter, and there was the exposure there, there was the rapid evolution of understanding that, wait a minute, there is the post office can now be a problem. And the secondary post offices that interact with the primary can be a problem.

So then you have the pattern and now you jump all over anything that even smacks of something that is danger at risk.

But when you then have a divergence to possibly another paradigm or another set of patterns, it’s very difficult until you see how things evolve. And unfortunately, sometimes that means additional people getting sick to determine just what is going on.

RAY SUAREZ: Flu season is approaching, and we’re told that the pulmonary form of the disease looks like flu, presents flu-like symptoms.

DR. ANTHONY FAUCI: Right.

RAY SUAREZ: How should people who get sick during this coming winter manage themselves?

DR. ANTHONY FAUCI: Sure. Obviously that’s a very appropriate question. There are some differences, but when a person comes into an office during that period of what we call “overlap of symptoms,” where the symptoms are vague — malaise, not feeling well, fever headache, muscle aches, certainly not only flu — influenza — but other viral diseases can present that way. And we know from experience now that anthrax can — particularly the beginning of inhalation anthrax — can present that way.

There are a number of fine tuning things, there are some kits that can help you diagnose influenza — I wouldn’t put major stock on that, because it will become a question of clinical judgment. To me as a clinician and infectious disease person, a lot is going to weigh on what we call the index of suspicion given the circumstances that you’re in.

For example, if you have a pattern that, let’s say, stays confined to the mail service and mail facilities being an important component of your pattern, if someone who’s in Kansas who’s a construction worker or in Iowa who’s a business person comes in with what sounds like ordinary, run- of-the-mill symptoms that are flu-like and there is no indication there was any other disease in that setting, my index of suspicion would be quite low there — not that I would be very cavalier about it and ignore the possibility the person might progressing.

Whereas if we are in Washington, DC, and someone who’s directly or indirectly with the postal system comes in and says I have a flu-like syndrome, boy, my red flags would go up very, very rapidly on that.

RAY SUAREZ: Doctor Fauci, thanks for joining us.

DR. ANTHONY FAUCI: You’re welcome.