Dr. Timothy Johnson's Flu Season Advice

B O S T O N, Nov. 6, 2001 -- As the flu season approaches, both the medical establishment and all of us as potential victims of the flu (not to mention of the much more common cold) are increasingly nervous about how we can tell the difference between the anthrax bacterial infection and the viral illnesses called colds and flu.

Obviously the most important reason for being able to tell the difference is to start early antibiotic treatment in the very rare case when it might be anthrax, yet not waste antibiotics for colds and flu.

Unfortunately, the early symptoms for inhalation anthrax and the flu can be similar - fatigue, fever, muscle aches, etc. And we have so little experience with human inhalation anthrax that we have not yet identified any reliable and easy way to differentiate the two in their early stages.

I would suggest the following "plan" for dealing with the many people who might worry that they have anthrax when they develop flu-like symptoms.

First let me stress the importance of all high risk people getting flu shots this year. The largest high risk groups are people with serious chronic diseases, especially of the heart and lungs, and all people over age 50. (We used to use 65 as the cutoff point but we now know that the risk starts going up even at age 50). Other high risk groups include those who live and/or work with people at high risk (e.g., health care or nursing home workers) and emergency personnel who might be exposed.

And if there is enough vaccine available, I personally would recommend anyone who can get a flu shot this year do so - both to actually prevent the disease, and to reduce possible confusion if symptoms arise.

I realize not all public health authorities agree with this idea but I personally think it makes sense as long as we can get enough vaccine for the high risk groups first.

Remember, you can get a flu shot even in December and still expect benefit since the most intense part of the flu season usually occurs in January and February, often even later. Remember also that the flu shot is not 100 percent effective against the flu - and does not protect at all against the common cold - so if you get flu like symptoms after having a flu shot, don't assume it must be anthrax.

If worrisome flu like symptoms do develop, there are several ways to help sort out the anxiety. First and foremost is to realize that at least so far, cases of inhalation anthrax are extremely rare (only four deaths vs. the average 20,000 deaths each year from complications of the flu) and confined to certain geographical locations and to the mail system in those locations - with the exception of the hospital worker in New York who has not yet been directly connected to mail distribution, though this may still turn out to be the case.

In plain English, flu-like symptoms for a postal worker on the East Coast will be treated very differently than the same symptoms for people throughout most of the rest of the country.

When a person with symptoms does fall into a category that has been recognized for higher anthrax risk, I think it makes sense to; 1) start immediate anthrax testing, 2) start antibiotics until test results come back, 3) consider a chest X-ray (which may show suggestive enlargement of lymph nodes in the middle area of the chest known as the mediastinum), and 4) consider rapid testing for other infections that might be causing the symptoms (such as tests for strep throat or influenza viruses).

Again, we cannot and should not be doing all of this for the vast majority of Americans who will develop flu-like symptoms this winter, but such an approach should be considered for anyone possibly connected to high risk areas or occupations.

Obviously what makes anthrax so frightening is that we yet still do not know where it is coming from, or where it might appear next. But I really believe that we will be able to contain any anthrax events to prevent major outbreaks of actual cases - as we have done so far. But it will take a combination of high medical alertness from our public health authorities and common sense concern - vs. hysterical anxiety - from all of us.