Is anthrax the culprit, or antibiotic used to fight it?
Are we on the cusp of an evolutionary experiment?
It seems the terrorists achieved their goal of creating fear. Americans are rushing to get their hands on ciprofloxacin as a precaution against the anthrax scare that emerged following the terrorist attacks on Sept. 11, 2001.
But ethicists can play a pivotal role in allaying the fears of patients by creating a sense of reassurance — first among health care providers and then within the community.
"We have to reinstill a sense of confidence for people who work in the health care system," emphasizes veteran epidemiologist William Schaffner, MD, chairman of preventive medicine at Vanderbilt University School of Medicine in Nashville, TN.
"Start with the doctors. They are the ones that are going to be more panicked than the nurses," he advises.
Hospitals at front lines of vigilance
Ethicists, hospital epidemiologists, and other key clinicians involved in health care bioterrorism readiness and response must set the tone for a panicky public and an uneasy health care work force, advises Schaffner.
And the government echoes that sentiment by calling for hospitals to be vigilant. Speaking during a White House news conference last month, U.S. Department of Health and Human Services Secretary Tommy Thompson called for the nation’s hospitals to take a prominent role in assisting the government with vigilance against bioterrorism.
Thompson said hospitals needed to help because the Centers for Disease Control and Prevention (CDC) in Atlanta is "stretched."
Jeffrey Koplan, MD, director of the CDC, challenged health care providers to participate in "grass-roots, frontline vigilance." Koplan says it’s up to physicians and emergency department (ED) personnel to stop outbreaks in their tracks through early diagnosis and astuteness.
These pleas for calm come as insurers and pharmacists report dramatic increases in prescriptions for the drug ciprofloxacin, manufactured under the brand name Cipro by West Haven, CT-based Bayer AG.
Many people are stockpiling the medication, but those who take it indiscriminately could create a far more serious situation than the anthrax it fights.
Despite anthrax outbreaks in New York City, Washington, DC, and Boca Raton, FL, as well as New Jersey, only one death is attributed conclusively to the condition at press time. The good news in all the anthrax hysteria is that it is treatable.
Physicians urged not to prescribe
The Chicago-based American Medical Association (AMA) urged its 300,000 members in middle October to resist prescribing ciprofloxacin to patients who are merely worried and have no evidence of anthrax exposure. "We’re getting reports from physicians and [EDs] that are being overwhelmed with anxious patients," says AMA president Richard Corlin. "In the majority of cases, these people should not be on antibiotics."
Indiscriminate use of ciprofloxacin could lead to the emergence of germ-resistant strains of bacteria, experts warn. Ciprofloxacin belongs to the fluoroquinolone class of antibiotics, and is among the last effective treatments for some serious infections. (For a list of biological agents and treatments, see "Treatment of Biological Agent Exposure," below.)
Germs resistant to antibiotics cause or contribute to the deaths of 70,000 hospitalized patients in the United States every year, says Stuart Levy, head of the Center for Adaptation Genetics and Drug Resistance at Tufts University School of Medicine in Boston.
Furthermore, a sudden surge in patients using ciprofloxacin could worsen the problem by encouraging germ-resistant strains of bacteria to emerge, Levy suggests.
"You’re going to see a huge change in the microbiology of the world in which we live, to the detriment of a drug that’s important to many patients," he says. "It’s an experiment in evolution that we’re witnessing."
Pressure over profits
The demand for antibiotics has resulted in round-the-clock production of medicines to keep up with demands from consumers and the government. The attention the drug industry is getting is not without a price, however. Some critics argue that drug companies are unduly profiting from the unfortunate attacks against America.
Bayer, the manufacturer of ciprofloxacin — the only drug approved to treat inhaled anthrax by the U.S. Food and Drug Administration, is being pressured to release its patent on the drug to allow for generic production to meet the increased demand.
The issue of patents will likely face more scrutiny as the government pumps millions of dollars into pharmaceutical research and development. The need for new treatments and vaccines against biological agents will cause pharmaceutical companies to become defense contractors for the government.
The new relationship will test the existing patent system, and ultimately the pricing structure, due to an overly anxious public.
(Editor’s note: Next month, Medical Ethics Advisor will examine the ethics of distributing vaccines and treatments for bioterrorist events.)
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