Knowledge as a Defense

While doctors and public health authorities reassure us that the risk of exposure to anthrax is extremely low, many Americans remain anxious.

Warnings about overwhelmed emergency rooms and pledges to increase security seem to be having little effect. When people develop fevers, fatigue and body aches--symptoms shared by the flu and the lethal bacterial infection--they begin to worry: Could this be anthrax? Last week, without a single case identified in the West, Dr. Brian Johnston, director of emergency medical services at White Memorial Medical Center in Los Angeles, said that already people were arriving at the emergency room with concerns they might have anthrax. “They come to the ER with complaints like ‘I opened this envelope and got a funny taste in my mouth.”’

No cases were found, he said. But a sharp increase in the numbers of such patients--the worried well, in many cases--has been reported nationwide.

The unease about such symptoms is understandable--and it’s shared, to some degree, by doctors whose only experience with anthrax is likely to have been in a textbook.

Distinguishing anthrax from other illnesses will be complicated by the winter flu season, because flu, which is very contagious, and anthrax, which is not contagious, get footholds in the respiratory system.

But there are steps patients and doctors can follow to ensure proper treatment, prevent needless panic and avert excess strain on already stressed emergency rooms.

What Patients Can Do

First, consider the symptoms.

Most of the common winter bugs bring low-grade fever, nasal congestion, sore throat and perhaps bronchitis, which usually improve with rest, fluids and maybe some pain and fever reducers. Anthrax is different.

If you wake up feeling as if you’ve been hit by a Mack truck, with a fever, body aches, headache, and dry cough (but not a runny nose), seek a diagnosis from your doctor or local clinic--especially if you suspect you could have come in contact with anthrax at home or work. Development of symptoms typically occurs within a week of exposure, although it could be in as manyuch as 60 days.

If you have reason to believe you’ve been exposed, some experts suggest also calling the health department to make sure public officials are aware of the potential health threat. Immediate action is crucial. Anthrax symptoms worsen precipitously after several hours or a few days, resulting in severe breathing problems, meningitis and shock. Untreated it’s fatal in 90% of cases. Given early enough, antibiotics can be lifesaving.

The flu has a more stable course, usually resolving itself in several days, with symptoms lingering for a couple of weeks. It responds to some antiviral drugs, although the infection, often complicated by pneumonia, kills 20,000 people each year.

It can take professional detective work to distinguish between anthrax and flu.

“First, call your physician. Don’t go to the ER. Don’t call 911,” stressed Dr. Laurene Mascola, chief of the acute communicable disease control unit for L.A. County’s health department.

Your doctor should obtain a detailed health history with information about your recent whereabouts. It’s important that he or she know if you work in a mail facility, government office, newsroom or other location where anthrax powder may have been identified.

Although there is no quick anthrax test, you can request one of the quick flu tests that can determine in about 30 minutes whether your illness is either type A or type B flu.

If it’s flu, your doctor may prescribe an antiviral medication--not an antibiotic, which doesn’t work on viruses and can promote antibiotic resistance.

If your test is negative and your doctor is sufficiently concerned, he or she may order other diagnostic tests. A chest X-ray can show whether your breathing problems stem from pneumonia, in which some areas of the lungs will appear congested.

With anthrax, the chest X-ray will show an enlargement of a structure called the mediastinum, where the spinal cord, heart, blood vessels and lymph nodes come together.

A nasal swab test only shows if you’ve recently been exposed to anthrax spores, not whether the spores took hold, and generally is most useful to epidemiologists trying to help assess exposure from a particular incident. The test’s reliability is still unknown. It’s better to have a blood culture, which takes about a day to show results.

If inhalation anthrax is confirmed, according to federal guidelines revised last week, you’ll be given two or more antibiotics for 60 days. The primary drug will probably be Cipro or doxycycline, taken for 60 days, and your doctor may add to that such drugs as penicillin, ampicillin, vancomycin or clarithromycin.

To reassure yourself and reduce likelihood of symptoms, doctors say your first line of defense is a flu shot. However, with supplies delayed, high-risk patients--the elderly and those chronically ill with diabetes, cancer, heart disease and asthma--are just now getting the few available doses. Healthier people should expect to wait, although you may be able to obtain shots through local drugstores, supermarkets and clinics.

Doctors and public health officials say vaccination will at least reduce the number of people wondering whether they have anthrax. It also should lessen the volume of flu sufferers clogging medical offices and emergency rooms--an especially important factor should anthrax spread beyond confirmed locations in New York, New Jersey, Florida and Washington, D.C.

What Doctors Can Do

The problem of differentiating anthrax from the flu is complicated by doctors’ lack of experience with it. Previously, the only people familiar with it were veterinary students and farmers.

“I think what I learned about anthrax in medical school was how to spell the word,” said Dr. Samuel J. Stratton, medical director of the L.A. County Emergency Medical Services Agency.

Most doctors are relying on the expertise of public health agencies and insights from recent cases.

So far, the East Coast experience has challenged views about how much anthrax it takes to make someone ill. Doctors have become more sensitive to timely treatment of cutaneous anthrax, contracted through a break in the skin. L.A. County health officials are alerting dermatologists that prompt treatment can avert its spread into the bloodstream and spinal cord, said Dr. Jonathan Fielding, the county’s public health director.

Last week, the California Medical Assn. distributed guidelines to doctors on how to respond to possible anthrax exposure. But that guidance could change as assumptions about anthrax evolve.

Dr. Robert Romanoff, a New York City internist, is among those physicians who don’t want to take chances in the absence of more guidance. Although he’s concerned about the consequences of overusing antibiotics, Romanoff said it might be hard to say no to some patients. “If they are really, really sick and ... they’ve been in an endemic area, I might err on the side of putting them on antibiotics right now.”

Dr. Baldeep Singh, an internist in West Los Angeles, said he tacked on his bulletin board a memo from UCLA’s infectious disease chief that tells him how to proceed with suspected anthrax.

“We’ve definitely thought about the issue and educated ourselves as to what’s going to happen,” said Singh. Because anthrax is so tough to differentiate from other respiratory illnesses, “that’s where we’re going to have to use judgment.”

Singh said he’d immediately begin antibiotic treatment for someone who worked in a mail facility where spores were found and admitted that if he became inundated with calls for Cipro from “the general population” during an outbreak, he couldn’t be sure he wouldn’t “break down and prescribe it.”

What the Health System Can and Can’t Do

Although patients may storm doctors’ offices demanding to be tested for anthrax, “the lab capacity is not there to do anthrax testing on everybody who might show up with the flu,” said Stratton, vice chairman of the emergency department at Harbor-UCLA Medical Center.

He says he will follow the evolving recommendations of public health officials on whether to test someone for possible exposure to anthrax.

Currently, officials at the Centers for Disease Control and Prevention do not recommend routine testing to determine whether someone has been exposed to anthrax or to guide decisions about treatment.

As for antibiotics, Stratton said, two stockpiles, each capable of treating 20,000 people, are housed in strategic locations in L.A. County, with four more being added.

Should a pandemic outbreak occur, he said, “I feel pretty confident we’re covered.”

But he expressed concern that patients may not be able to locate Cipro as easily from their local pharmacies should demand continue to exceed supply.

Already, there are questions about how medical facilities will respond to demands for anthrax care.

Just last week, an industrial health clinic turned away three workers who thought they might have been exposed to anthrax. They were referred to an emergency room, where doctors pronounced them healthy, Stratton said.

But if clinics and private doctors turn away potential anthrax cases, “the emergency departments are going to be overwhelmed.”

The consequence could be long waits when quick diagnosis and treatment--as anthrax cases in Washington, D.C., have shown--can mean the difference between life and death.

But if clinics and private doctors turn away potential anthrax cases, “the emergency departments are going to be overwhelmed.”

The consequence could be long waits when quick diagnosis and treatment--as anthrax cases in Washington, D.C., have shown--can mean the difference between life and death.