Dr. Craig Smith: Anthrax treatments and bioterrorism preparedness
Dr. Craig Smith is the director of Infectious Disease Services at Phoebe Putney Memorial Hospital in Albany, Georgia, and is a member of the Infectious Diseases Society (ISDA) of America's bioterrorism committee. Dr. Smith was the only biological warfare officer in Saudi Arabia for the United States Army during the Persian Gulf War. He joined the CNN.com chat room from California, where he is attending the 39th annual ISDA meeting.
CNN: Welcome to CNN.com, Dr. Smith. Thank you for being with us today. How quickly is the greater medical community coming up to speed about anthrax? Is it fast enough to prevent more tragic incidents such as the deaths of the two postal workers earlier this week?
SMITH: The medical community has been seeking and receiving information from many sources. The Infectious Disease Society provides information on their Web site, as well as the Centers of Disease Control and the American Hospital Association. What doctors do every day with examining patients and making diagnoses has not changed. All doctors are doing now is learning the specifics of other diseases they have to consider as they see their patients. All of the diseases discussed in bioterrorism are historic diseases about which a lot of knowledge has been accumulated, and treatments are understood. They're just diseases that have not been commonly seen in the U.S. for a number of years.
CHAT PARTICIPANT: Dr. Craig, is there a chance that over-prescription of the drug Cipro might lead to resistant forms of bacteria?
SMITH: Medical care is administered on a patient-by-patient basis. If a specific person needs an antibiotic, it would be given without hesitation. When we discuss resistance from antibiotics, there are many ramifications, so that the larger amount of antibiotics used by a community without doubt, the more resistant infections are seen. At this time, for people who have a credible threat, then the antibiotics must be used. However, we have seen in other circumstances resistance develops when large numbers of people are put on the same antibiotic. So, care must be taken in recommending large numbers of people for Ciprofloxacin treatment without a specific known threat.
CHAT PARTICIPANT: Dr. Smith, we have recently seen a "new" (weapons grade) anthrax. Is it possible that this anthrax is already out of control seeing as how we are a few days behind because of the incubation period?
SMITH: Anthrax is an infectious disease, but is not a contagious disease, which means that there is little or no person-to-person transmission. When someone becomes ill with anthrax, it depends on their initial exposure, and magnitude of the exposure as to how fast and how severely they become ill. The term "weaponized" refers to whether the strain of anthrax has been genetically altered to make it more resistant to antibiotics, which has not been shown in the known current cases, or the term is used to describe the quality of the anthrax spore preparation as far as the purity and dispersability of the anthrax product.
CNN: Is Cipro a drug that most people can take -- as opposed to penicillin, which many people are allergic to?
SMITH: Cipro is a drug in the quinolone family, which is commonly used for respiratory and urinary tract infections, as well as skin and gastro-intestinal type infections. In general, it is tolerated very well, although upset stomach is the most common side effect. Allergic reactions such as rash are less common with Ciprofloxacin than with penicillin. In general, the drug is very well tolerated.
CHAT PARTICIPANT: How are small towns in the U.S. dealing with this? Are they equipped or knowledgeable enough?
SMITH: Small towns are attempting to plan as well as large towns for bioterrorism. Since we don't know who is doing this, and what they have access to, it's difficult to predict what the targets of the future might be. Every local area, whether city, county, or whatever size jurisdiction, has been recommended to develop emergency plans which coordinate the hospitals and the acute care medical system with the public health surveillance system and the law enforcement agencies. These coordinated plans are being further developed and refined throughout the country. Communication between the agencies is essential. Assistance in planning comes from state agencies, professional societies such as the Infectious Disease Society, and the American Hospital Association, as well as federal agencies such as the department of defense.
CNN: Is it true that the outbreaks of anthrax are truly the first 'human study' of an anthrax outbreak, as described by military officials yesterday?
SMITH: The disease anthrax is as old as mankind. The fifth plague in Exodus in the Bible is thought to describe cutaneous anthrax. Wool-sorter's disease seen with goat and sheep-herding has been described for hundreds of years. Anthrax as a biological warfare weapon was studied throughout the twentieth century, both offensively and defensively. There is a large amount of knowledge regarding the care of these diseases. The problem becomes rapid diagnosis, as those tests are still not highly developed, and widely available. Much of our knowledge of a large human inhalation anthrax outbreak comes from the Russian experience in 1979. However, many animal studies have also been performed to test the treatment with vaccines and antibiotics. All questions about anthrax have not been completely answered; however, there is a large amount of knowledge of how to treat and care for patients with anthrax. Outside of the United States, anthrax is seen in many countries on a routine basis.
CHAT PARTICIPANT: I heard today that "experts" are able to narrow down the type of strain of the anthrax to be able to determine where this anthrax came from. Is that correct and if so, how long will that process take?
SMITH: To give the specific site of production for an anthrax bioterrorism product is virtually impossible. To identify the strain is more easy, and has been done in the three known locations. The strain appears to be similar to the Ames strain first isolated in Iowa more than 20 years ago. However, this strain is not used for anthrax research around the world, and is not traceable because of so many locations having access to the strain. The anthrax powder has been analyzed for the recipe used to produce the powder. The exact individual who produced the powder cannot be identified, however, the recipe can be identified as to the source as different state-sponsored offensive biological warfare programs use different recipes. Currently, three countries would be suspected for a source of the production due to the recipe used in preparation of the current product.
CNN: You were the sole biological warfare expert on the ground during the Persian Gulf War in 1991. Describe the military's understanding of biowarfare then versus now.
SMITH: The military since the Gulf War has developed a tremendous knowledge base and system for response to biological warfare. Prior to the Gulf War, biological warfare was thought to be a very low probability. Currently, 15-17 countries have active offensive programs. The military has responded by preparing their medical systems to better respond to biological warfare, and has vaccinated and treated their service members, so they are at less risk of exposure to biological warfare. Much of this effort is organized through the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Dietrich, Maryland.
CNN: Do you have any closing comments to share with us?
SMITH: People traditionally respect their local doctors and health care providers. This should not change with bioterrorism. Doctors are trained to identify patients and make diagnosis on a daily basis. Bioterrorism includes diseases that have not commonly been seen, but doctors have incorporated those diseases into their decision making process. Just as your physician may ask help from a cardiologist if you have a heart attack, there are infectious disease specialists and bioterrorism experts available to help local physicians if these more uncommon diseases occur. There is no health care crisis. Public health and acute care medicine are responding and will continue to respond to the current bioterrorism threat.
CNN: Thank you for joining us
SMITH: Thank you very much for joining us.
Dr. Craig Smith joined the CNN.com chat room by telephone and CNN provided a typist. This is an edited transcript of the interview which took place on Friday, October 26, 2001.
Infectious Diseases Society of America
U.S. Army Medical Research Institute of Infectious Diseases
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