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Dr. William Hall: Medical impact of bioterrorism

Dr. William Hall is the president of the American College of Physicians-American Society of Internal Medicine, and director of geriatrics at the University of Rochester School of Medicine at Strong Memorial Hospital in Rochester, New York. A recent research project conducted by Dr. Hall concerned viral respiratory tract illness in adults. He joined the chat room from Seattle, Washington.

Dr. William Hall
Dr. William Hall  

CNN: Welcome to Dr. Hall. Thank you for joining us today.

HALL: Hello, I'm William Hall, and I'm a doctor of Internal Medicine, currently the president of the American College of Physicians, and the American Society of Internal Medicine. We're the largest medical specialty organization in the country, comprised of over 100,000 doctors of internal medicine, practicing in virtually every community in America.

CNN: Reports out of New York City say that people are flooding the emergency rooms over fears of anthrax. How are doctors around the country dealing with this mass anxiety?

HALL: The anxiety is very prevalent virtually everywhere in the country, not just New York City. Our members are saying that every office is receiving many phone calls and visits. People are saying they have symptoms of a respiratory tract infection, like stuffy nose or couch, cough, and they're concerned that this could be anthrax. Because of all the media attention on this disease, most people legitimately ask the question, why shouldn't I have an antibiotic, most commonly Cipro, and if I shouldn't take it now, why shouldn't I have a sixty-day supply of it stockpiled? We're trying to educate our physicians and the American public that there is a better and safer way to approach these concerns.

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    First, we point out that the likelihood of those symptoms being related to anthrax is extremely remote. Secondly, taking antibiotics indiscriminately can lead to some very serious personal side effects, such things as serious diarrhea, liver abnormalities, an occasional allergic reaction that could be fatal. In children, there is a possibility of a bad influence on bone development, even. The key here is for every American to have a plan this year for themselves and their families to know what to do when the inevitable respiratory tract infections come. We're suggesting that people need to be sure that they can reach their doctors or their doctor's office, and that the office will take their complaints seriously, and deal with them in the most appropriate fashion. In most cases, this will be reassurance, in some cases a careful history and examination, perhaps leading to an alternative diagnosis, and an established relationship with a health care provider, someone who will be available if the symptoms don't clear up. This is a massive educational program with our members, and we are also making available materials that can be distributed, to help us through this season when anxiety will be at its peak.

    CHAT PARTICIPANT: Why are we not immunizing the public against the threat of anthrax? Is it easier to just treat it after the fact?

    HALL: Remember that none of us have had any real clinical experience with this disease. We have to make these decisions based on relatively few cases over the last 50 years. There is a vaccine, which is in very short supply, and has largely been used for military purposes. Even if we felt it was very effective, it would take a very substantial amount of time to develop adequate supplies so that someone could actually get the vaccine in their local communities. And vaccines also carry inherent risks themselves. At the present time, we know that in the United States there has been one fatal case of this disease, and therefore we feel it doesn't warrant panic. Treatment for many forms of anthrax, particularly the skin form, can be started after the infection begins, with very good results. The inhalation form of the disease may or may not be helped by antibiotics.

    CHAT PARTICIPANT: Is it true that even if there were an outbreak of smallpox in this country, that there is only a 30 percent fatality rate from this, even if gone untreated?

    HALL: The figure of 30 percent for smallpox comes from historical experience in other countries, when smallpox was endemic. At one point in history, everybody probably got smallpox. However, at the present time in our country, virtually nobody under age 35 has been vaccinated. We have no idea whether this lack of natural exposure might influence how serious an epidemic of smallpox might be. We do know that when smallpox has been introduced into populations who have not encountered the virus before, such as what happened during the colonization of the U.S., that smallpox had a much higher fatality rate, certainly exceeding 50 percent.

    CHAT PARTICIPANT: Can a virus such as smallpox be carried or piggybacked with an agent like anthrax?

    HALL: I don't have the technical expertise to know that for sure, but my hunch is that it probably would be distributed in a different way. Smallpox might even be introduced if one could find a volunteer willing to infect him or herself first. Anthrax would not be spread that way.

    CHAT PARTICIPANT: How long does the vaccination for smallpox last ? Can some of us still be okay if we had one long ago?

    HALL: We don't know. We know that there is probably some immunity in those people immunized 20 years ago, but it is clearly not known how effective that will be, and for how many people, at this point. The assumption is that all Americans are very susceptible to smallpox.

    CNN: How are physicians around the country being quickly educated about anthrax and other possible bioweapon risks?

    HALL: There is a remarkable effort going forward, certainly unprecedented in my 30 years in medicine. My own organization is trying to reach every one of our 100,000 members through our publications, and increasingly, our Web site. We are trying to emphasize two very important areas. First, of course, what are the clinical signs and symptoms of these diseases because few of us have ever seen cases? Secondly, how do we best allay fears of our patients and avoid the indiscriminate use of antibiotics that not only will not help them, but also may harm them. Other medical societies are undertaking similar efforts. Finally, the Centers for Disease Control in Atlanta is an extraordinarily effective agency of the government, and they're providing educational materials for all health care providers. Thanks to the Internet, we can distribute these educational materials in a way that would not have been possible even ten years ago. This gives us a certain advantage in being able to deal with this unprecedented occurrence during the last month.

    CHAT PARTICIPANT: What would be realistic policy or procedures for medical offices to have in place in regard to anthrax or smallpox?

    HALL: The first would be a system whereby concerned patients knew they were communicating with a trusted health care provider. Secondly, they need to be reassured that they will get information that will help them both before such an episode would occur, and also, if by chance they felt they'd had exposure. All of this is a great challenge.

    CHAT PARTICIPANT: With the limited effect the recent strains of anthrax have had, how worried should Americans be?

    HALL: I think every American has to become informed, as much as they possibly can be. They need a relationship with a health-care provider. If they do these two things, my sense is that we can get on with our lives without undue fear, and without changing our lives. Those are the ultimate objectives of bioterrorism, not to hurt or maim but to disrupt society.

    CHAT PARTICIPANT: What can be done about people stocking up on unneeded Cipro?

    HALL: At the present time, education is our best and most effective method of dealing with this problem, a partnership between educating both patients and physicians. The vast majority of the stockpiles have been prescribed by a doctor, not purchased over the Internet or in another country. Our strongest tool here is mutual education.

    CHAT PARTICIPANT: Initially we were told that only Cipro was effective against pulmonary anthrax. Now, many medical professionals, who have extensively studied the bacterium, are saying that penicillin and tetracycline are effective against anthrax.

    HALL: We have always known that a number of antibiotics, including the penicillins and tetracyclines, have been effective against naturally occurring anthrax. What we don't know is the potential for bioengineering of the organism. There is some evidence, based on the experience in Iraq, that some groups may have been able to make the anthrax organism resistant to antibiotics. For that reason, the advice has been that if one is going to treat, to start with Cipro, but quickly switch to one of the other two drugs if the organism is found to be susceptible to these drugs.

    CHAT PARTICIPANT: Is there a shortage of flu vaccine? The flu can give the same symptoms as anthrax, can it not?

    HALL: We're advising our physicians to very aggressively administer the flu vaccine this year. The stockpiles are probably adequate at this time to immunize the high risk populations of America, older people, and people with chronic disease. We have government assurances that ample supplies of vaccine will be available in November and December for the rest of the population. That's plenty of time to protect against influenza, which tends to occur mainly in January and February.

    CNN: Do you have any closing comments for us today?

    HALL: We're all learning every day about this new world. We have the best medical system in the world and by having all of our citizens and our physicians working together, we can contain these problems and continue to lead productive lives.

    CNN: Thank you for joining us today, Dr. William Hall.

    HALL: My pleasure.

    Dr. Hall joined the chat room via telephone from Seattle, Washington and provided a typist. The above is an edited transcript of the interview on Friday, October 19, 2001 at 1:30 p.m. EDT.


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