America At War:
Bioterrorism Readiness
With Teresa Sullivan Dolan, M.D.
Clinical Instructor, Department of Emergency Medicine,
Georgetown University Medical Center
Monday, Oct. 22, 2001; 11 a.m. EDT

As flu season begins, how can you tell if you've got a cold or the symptoms of anthrax? Should you stock up on antibiotics? Many Americans are asking these questions as several cases of anthrax infection and exposure have been confirmed in Florida, New York and Washington, D.C. Emergency room workers are on the front lines of public health and safety.

Teresa Sullivan Dolan, M.D., was online Monday, Oct. 22 at 11 a.m. EDT, to answer questions about the anthrax scare and how the medical community is responding.

Dolan is a clinical instructor in the Department of Emergency Medicine at the Georgetown University Medical Center.

A transcript follows.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

Dr. Teresa Sullivan Dolan: Hello, everybody. My name is Teresa Dolan and I am an emergency physician at Georgetown University Hospital. In that last week or two we have been intermittently flooded with calls about anthrax, and have had many patients coming in with concerns. I hope to address any medical questions or issues you might have and alleviate some of your concerns.

Rockville, Md.:
What symptoms are present for skin, pulmonary and ingested anthrax?

Dr. Teresa Sullivan Dolan: Good question! There are three types of anthrax - cutaneous, intestinal and inhalational. The cutaneous form is by far the most common. It enters the skin through small cuts or lesions, and is often on the hands or arms. It starts as a small papule, which looks like a blister, which dries up and becomes a black or very dark scab. Most of the time, this is very easily treated with antibiotics, and all of the confirmed cases (except three) are of the cutaneous, which is very good news.

Dr. Teresa Sullivan Dolan: The intestinal form is very rare in humans and comes from eating insufficiently cooked infected. The symptoms include severe abdominal pain, vomiting blood, and diarrhea among others. There have been no reported cases of intestinal anthrax in any of the current infected patients.

Washington, D.C.: I started this weekend with a cold. I know that one of the symptoms for anthrax is that. What can I do to be sure I have only a regular cold or anything else?

Dr. Teresa Sullivan Dolan: Thanks for this question, because I think this really gets to the heart of the matter. People are very worried about inhalational anthrax, which we hear is very deadly and first appears with just cold. Before these attacks, inhalational anthrax was very rare. Now we have three confirmed cases.

Inhalational anthrax takes about 1-6 days to develop after exposure. It usually starts with generalized flu-like symptoms (fever, fatique, muscle aches, cough and chest discomfort). Eventually shortness of breath, coughing up blood develop, and overwhelming weakness develop. It is usually fatal in 24-48 hours.

As we are heading into cold and flu season, patients will have more concerns about having colds or the flu versus anthrax.

Arlington, Va.: Is there any specific symptom that we can differentiate anthrax from flu? What is the difference between exposure and infection, does it mean that not all exposures turn out to be a disease?

Dr. Teresa Sullivan Dolan: At the moment, the medical authorities and the CDC believe that the only people currently infected exposed are the following:

1. People on the 5-6th floor of the Hart Senate Building between 9am-7pm on October 15,2001 or in the mail room.

2. Members of the various news organizations that may have been exposed (NBC, the Newpaper facility in Florida, etc...).

3. Postal workers at the DC Brentwood Mail facility or at the BWI mail facility.

Everyone else who has cold or flu symptoms is presumed to only have a cold or the flu at this time.

If you have been exposed to anthrax, just like you might be exposed to someone with chicken pox, you might not develop infection. To develop infection you must show signs and symptoms of the disease. At this time, authorities are doing nasal swabs on people in the locations mentioned about to see if they have evidence of the bacteria (exposure) before they get sick (infection).

Arlington, Va.: I have a very simple question: what is the difference between "infection" and "exposure?" And how do you test for "exposure?"

Dr. Teresa Sullivan Dolan: Right now, the testing method the CDC is recommending is nasal swabs to determine if people may have inhaled the bacteria. They are only performing the tests in people working in, or visiting the locations known to have evidence of anthrax.

Washington, D.C.: I work for a news organization. I feel like I have a flu-like cold. How do I know that I don't have anthrax? I don't want to tax the already over-burdened medical and emergency services with nonsense worries.

Dr. Teresa Sullivan Dolan: If you work for a news organization that has been involved with any of the prior exposures, you should discuss the issue either with your supervisor or you companies medical office. Otherwise, any specific questions can be answered by any of the following offices depending on where you are:

DC Department of Health - 202-442-9196
Fairfax County 703-246-3796
Montgomery County 240-777-4200

Poolesville, Md.: Are most primary care physician offices equipped to deal with anthrax detection and treatment, or is the Emergency Room the only place to turn? If people have questions or concerns pertaining to anthrax, should they consult their own doctor first?

Dr. Teresa Sullivan Dolan: Actually, no they aren't. The CDC is trying very hard to keep track of all the data and patient information so they don't miss anyone who contracts the disease. It is best to call one of the numbers that I gave you or your local health department for more information about testing, if you are one of people who may have been exposed.

Washington, D.C.: My wife is pregnant and works in the Senate. I have heard that pregnant women should not take Cipro. Is that true? If so, what is the appropriate treatment for inhalation anthrax and is it as effective?

Dr. Teresa Sullivan Dolan: It is true that cipro is not appropriate treatment for pregnant women or for young children. Penicillin is an appropriate treatment and is not harmful to either mother or child.

Washington, D.C.: Good Morning,
Question regarding cutaneous form. If you're in Washington, work only a block away from warm zone (course all our mail is going through the same postal service), have a cut on your hand (that has been there for a week) and just noticed to small nodules above the cut that weren't previously there -- which were only noticed because they started itching -- should you worry? Advice please. Thanks

Dr. Teresa Sullivan Dolan: Hmmm. Another good question. Many of the calls we have received involve situations like this, or "I visited the Capitol last week and now I have a cold. What should I do?" I must add again, however, that at this time the only confirmed exposures are at those locations that I outlined earlier. The number and concentration of spores necessary to cause infection would be very unlikely to encounter on a street near the Capitol. Many other people would have been infected by now, so I hope that is reassuring. Any symptoms that concern you should be evaluated by your doctor or a physician, because while they may not be anthrax, they might be of other significant medical concern.

Richmond, Va.: If you have had anthrax (cutaneous), do you acquire lasting immunity?

Dr. Teresa Sullivan Dolan: Actually, we don't know. It is very unlikely. Because most forms of cutaneous anthrax don't become "systemic" (spreading to other regions of the body or the blood stream), one would be very unlikely to develop antibodies and, therefore, immunity to the disease. Even the vaccine requires annual booster shots to maintain immunity.

Washington, D.C.: I think what scares people the most about pulmonary anthrax is that once the symptoms progress beyond a certain point, death is inevitable. In other words, once you have clear symptoms of infection, it's already too late to do anything about it, because the bacteria have already released the toxins that destroy lung tissue. Could you elaborate more on this -- is there anything that could be done for someone to keep them alive, i.e. iron lung, lung transplant, etc? At what point is it truly "too late?"

Dr. Teresa Sullivan Dolan: Yes, I think that you are exactly right. This is the biggest fear that people have. Unfortunately, it seems that inhalation anthrax is very fatal once full blown symptoms develop. Antibiotics are given and all medical attempts are made to provide supportive care and keep the patient alive. We really hope for the best for the two individuals with the disease currently, Leroy Richmond and Ernesto Blanco.

Washington, D.C.: If you are infected with anthrax, are successfully treated... can you contract anthrax again or are you immune?

Dr. Teresa Sullivan Dolan: Certainly, if you have cutaneous anthrax, you can get another form because you haven't developed antibodies. There are, unfortunately, very few people that survive either intestinal or inhalational anthrax, so we don't know. Because these are very rare forms and so few people survive, the medical data just isn't available to tell us. Actually, until 3 weeks ago, anthrax had all but disappeared from North America. Most of the cases in the world (not related to bioterrorism) are in developing countries in Asia, Africa, and Central America where medical care and disease reporting capabilites may not be sufficient to determine the incidence of the disease.

Jersey City, N.J.: How long after infection does it take for a blood test to come back positive for anthrax? Is the vaccine effective, and for people exposed is the proper prophylaxis cipro + vaccine or just cipro. Thanks.

Dr. Teresa Sullivan Dolan: Good question! Most of the screening right now is being done with the nasal swabs that I mentioned earlier. This is done to test primarily for exposure, in other words, it is done to look for evidence of the bacteria in the nostrils of exposed patients. If the test is positive, antibiotics are given for 60 days. The choices for antibiotics include cipro, penicillin or doxycycline, although if allergic to any of these there are other options. The results of the nasal swabs are usually available in a day or two.

Minot, N.D.: If a person was vaccinated for smallpox as a child or teenager (in the 1960's)does one still have immunity now?

Dr. Teresa Sullivan Dolan: Smallpox. I still have the scar on my arm from the vaccine, myself. The answer is that the vaccine is thought to last about 30 years. The last vaccines were given in the late 1960's-early 1970's. We really don't think that anyone vaccinated at that time would be immune now. However, if you were to get infected, you would possibly get a milder case of the disease.

Washington, D.C.: Where can one have a nasal swab done if one believes he/she was exposed to anthrax.

Dr. Teresa Sullivan Dolan: Please see the numbers that I listed earlier!

Washington, D.C.: Call me a hypochondriach, but I started yesterday with a very sore throat. I am not coughing and normally would just think it was a cold coming on, but now i'm racking my brain wondering if I could have touched anything. Is it worth going to get antibiotics?

Dr. Teresa Sullivan Dolan: Unless you were in one of the locations that I mentioned earlier, it is extremely unlikely that you have anthrax. If you have any symptoms that concern you, you should contact your doctor.

Washington, D.C.: Is it possible that people were contracting anthrax before Sept. 11th but we weren't being vigilant enough to notice? The perpetrators certainly had the capability before then. I wonder if our new anxiety about terrorism is allowing us to see what would have previously been diagnosed as the flu for what it really is.

Dr. Teresa Sullivan Dolan: Well, while anything is possible, I really doubt it. I have to say that unusual presentations of disease, cause physicians to do a lot of investigating. We have a many good doctors and plenty of technology, which is what allowed the very astute physicians in Florida to pick up the first cases, followed by those in other states. I don't believe at all that this sudden interest in bioterrorism is the reason these cases were caught. We really need to give them a lot of credit - and the CDC and local officials too.

Rockville, Md.: I am amazed at the number of people who are stockpiling Cipro and other antibiotics "just in case." Since anthrax isn't communicable, why are doctors giving out the medication? At some point, won't the Cipro be ineffective? Also, it almost seems like people want to be in possession os the drug as almost a status symbol. This isn't a public health emergency.

Dr. Teresa Sullivan Dolan: Thanks for bringing this up. Everyone wants to protect themselves, absolutely. At the moment, though, we have pretty strick guidelines outlined by the Centers for Disease Control. No one is really to be given antibiotics unless there is a confirmed exposure or potential exposure. Stockpiling antibiotics is a very bad idea. Right now there is a shortage of cipro in certain areas. People that are actually sick with other medical problems might need the antibiotics that someone else is keeping in their bathroom cabinet "just in case" To treat anthrax, 3-4 days of antibiotic are not going cure the disesase. A full 60 day course is what is recommended, an no one should have 60 days of antibiotic stock piled. Additionally people shouldn't be taking any antibiotic without the recommendation of a physician. As with any medication there are side effects and the potential for allergic reactions. Most importantly, the possiblity of encouraging the growth of antibiotic resistant bacteria is of very high concern when antibiotic are used carelessly. As you can tell, this is a pet peave of mine.

Dr. Teresa Sullivan Dolan: Well, thanks everyone for all the great questions and interest. I want to emphasize that if you were in any of the locations that I listed, or have any specific questions involving potential exposure, you need to call one of the numbers that I listed or talk to your doctor. We have no reason to think that any individual citizens have been targeted with anthrax. I find this very reassuring, both for myself and my family and friends. I hope that I have been able to pass this reassurance along to you with some helpful information. And again, feel free to talk to your doctor about any questions or concerns you might have. Take care, everyone!

TSD

washingtonpost.com:

That wraps up today's show. Thanks to everyone who joined the discussion.

Stay tuned to Live Online:

Media Backtalk at Noon EDT
Film: Desson Howe at 12:30 p.m. EDT
Classical Music Forum at 1 p.m. EDT
Post Magazine: Sietsema on Fall Dining Guide at 1 p.m. EDT
Travel Talk at 2 p.m. EDT
Live Online Special Coverage: America At War

Did you know that you can follow more than one Live Online discussion at the same time? Just open another browser window and toggle back and forth between discussions! And, if you miss one, catch up with the Live Online transcripts.

Keep up with the latest in news, sports, politics and entertainment with washingtonpost.com e-mail newsletters.

NEW! Personalize your Post with mywashingtonpost.com. Get customized news, traffic, weather and more.

   |       |