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First Response to Anthrax Threats

Susan Dentzer reports on the medical response to anthrax threats at the local level.

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  • DR. VENKAT MANI, Southern Maryland Hospital:



    Like most U.S. physicians, Dr. Venkat Mani had never before seen a case of anthrax, until he was called into the hospital to see a very sick patient on October 22.


    He had a chest x-ray done which showed wide mediastinum. Mediastinum is part of the chest between the two lungs. That is normally of a narrow size, and in him, that was wider, and he had evidence of pneumonia on either side of the lung.


    At that point doctors knew that the patient, Joseph Curseen, was a night- shift worker at a District of Columbia mail processing plant at Brentwood. At least one letter containing the deadly bacteria apparently passed through the facility. Given the results of Curseen's x-ray, doctors suspected that he had inhalational anthrax. They quickly examined some of his blood under a microscope.


    In this case, there were so many organisms on the smear, that we could directly see it. When you have a person with blood infection, and you see the bacteria on the… on the blood smear, the patient will almost never survive. By that stage the bacteria is winning the battle.


    But just one day earlier, things had looked much different well before Curseen's anthrax diagnosis was made here at Southern Maryland Hospital. At that time, Curseen also came to the same facility, driving himself there from his job at Brentwood.


    He was alert, he was not toxic, was complaining of upper abdominal pain, nausea, and history of having had diarrhea. He was clinically noted to be dehydrated so he was given intravenous fluids to correct that.


    Dr. Mani did not treat Curseen on that earlier visit, but says he has reviewed Curseen's medical record. He says it shows no indication that doctors asked Curseen about his occupation or that Curseen told them, and tests performed on Curseen at that time did not indicate a serious problem.


    He had a chest x-ray done, which was normal. He had blood tests done, which were nothing out of the ordinary, and he was felt to have gastroenteritis, and he was sent home. Apparently he was very anxious to go. "Look, I'm quite well." The doctor wrote an order for a pain medication. "I don't need any pain medicine. I'm, you know, getting better with all the fluids you have given." And he… He went home.


    Back at the hospital 24 hours later, Curseen died to the shock of his relatives and the doctors who treated him. His death followed on the heels of another death of a postal worker at Brentwood. Many questions still remain about how health-care providers and public health officials responded to these and other Washington-area anthrax attacks. Dr. Tara O'Toole is a physician and bioterrorism expert at Johns Hopkins University.

  • DR. TARA O’TOOLE, Johns Hopkins University:

    Clearly not all docs were aware of the possibility of anthrax being within their patient population. Clearly, not everyone knew to call the health department or call the right place in the health department. I have heard that some docs who were treating anthrax patients haven't heard from the health departments, even after deaths occurred.


    O'Toole says these lapses illustrate in microcosm just how under-prepared health care providers and public health officials are to cope with bioterrorism.


    Everyone's working their heart out trying to put this together, but there's no system for doing this with maximum or even moderate efficiency. And of course we're learning as we go.


    Dr. Georges Benjamin, who heads Maryland's State Health Department and is coordinating that state's response to the regional attacks, agrees.

  • DR. GEORGES BENJAMIN, Maryland Health Department:

    We have organized chaos, absolutely. And we have to understand that's the way it's going to be. We are learning every moment. We are readjusting what we do. And I think at the end of this, let's be judged on how quickly we were able to readjust and move forward.


    Experts say that fighting any epidemic, whether born of bioterrorism or not, requires a coordinated response among health providers and many levels of government. The heart of the response is communication, so that crucial information about is shared about critical questions– such as who's infected, how they got infected, where they are? Dr. Benjamin says this crisis has added another element: A demand for speed.


    So data that we used to spend hours and days and weeks kind of pondering over and hypothesizing, we're now having to look at that data and make decisions about whether or not there's a blip, right away, every single day.


    And although it has taken a while to gear up, some public health officials say communications among various players in the system are finally working. Dr. Ivan Walks is Washington, DC's top health official and is coordinating the city's response.

  • DR. IVAN WALKS, Health Director, Washington, DC:

    What we also do now is at 10:00 every morning we have a conference call, and it's a pretty big conference call and it takes about an hour and a half. And we have our hospital association and all of our association members, we also have the regional health directors from the Departments of Health in the surrounding counties and we have the emergency preparedness folks on that call as well.


    Walks says that, regrettably, the hospital that treated Curseen, Southern Maryland, was not included on those daily conference calls until after the postal worker's death. If it had been, it might have passed on word about Curseen's early symptoms, as health providers inside Washington's boundaries had already been instructed to do.


    And Southern Maryland was initially outside of our perimeter for that symptom reporting. They didn't get the first memo from us. That's not to say they didn't do exactly what their clinical judgment told them to do, it's just to say that since then we have learned a lesson and we've expanded that perimeter now.


    Doctors also say they're far better prepared now for possible anthrax cases. Dr. William James Howard is medical director at Washington Hospital Center. He says the treatment protocols there changed almost immediately after the postal workers' deaths.

  • DR. WILLIAM JAMES HOWARD, Washington Hospital Center:

    Well, if you said you were from Brentwood, that really raised what we call our index of suspicion very highly. If you came in from Brentwood and you had a fever and those symptoms, we immediately got a chest x-ray; we immediately got a CT scan, a CAT scan of the chest to look for the presenting finding, which is widening of the mediastinum. And we then went on to admit most of these patients and treat them with antibiotics very aggressively.


    But some experts say doctors and hospitals still are not as prepared as they could be. And a key reason, critics say, is that information is flowing too slowly from the Federal Centers for Disease Control in Atlanta. In fact, it took the agency two weeks after the first victim, Bob Stevens, died of inhalational anthrax in Florida to publish even a cursory description of his case in a key CDC publication. And in congressional testimony this week, some providers complained that although they were forwarding information to the CDC, too little intelligence was coming back.

  • DR. DAN HANFLING, Inova Fairfax Hospital:

    What is so ironic is that if this had been a major snowstorm barreling up the eastern coast of the United States, we would've found a lot more information at our fingertips because the mechanism for reporting those sorts of things are in place. But here with an unfolding public health crisis, there was no means for conveying information in a consistent and timely manner.


    The CDC acknowledges early communications problems early on, but points to signs that things are improving, such as far more timely reports on individual cases. Meanwhile, members of Congress are weighing proposals to beef up the ability of public health departments to respond to bioterrorism, a move that many experts say is long overdue.

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