http://www.nytimes.com/2002/01/06/health/policy/06ANTH.html
January 6, 2002
Anthrax Missteps Offer Guide to Fight Next Bioterror Battle
By LAWRENCE K. ALTMAN and
GINA KOLATA
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"You say, `Here's the scenario: We have 160 victims, how do we triage
them, where will they go, how will they be handled?' " said Dr. Thom
Mayer, the chairman of the hospital's emergency department.
But just a month later, Inova Fairfax treated real victims of bioterrorism —
two postal workers with inhalation anthrax, who showed up in its emergency room
a day apart. Only then, Dr. Mayer said, did the staff discover that no part of
the elaborate rehearsal had resembled a real attack.
Now, with no new cases since mid-November, health officials inside and outside
the federal government have begun an autopsy of the anthrax outbreak that
killed 5 people, infected at least 13 more and terrified large segments of the
population over two months. What did health officials do right? What went
wrong? What was a matter of luck? And how can they learn from the luck?
While it is too early to glean a set of precise lessons for a future
bioterror attack — particularly since no suspect has yet been charged in this
one — the officials acknowledge that the handling of the outbreak was marked by
a catalog of miscalculations, missteps and misunderstandings about bioterrorism
in general and anthrax in particular. Among them were these:
¶Medical scientists thought they knew anthrax. But they now say they
overestimated the death rate for those infected and had no idea how many spores
a person must inhale to develop the disease.
¶Procedures for communicating about unfolding events proved inadequate to
reassure a frightened public.
¶Federal, state and local governments were unprepared for the close
collaboration required in an investigation that combined the medical and the
criminal.
¶Laboratories were unexpectedly swamped with samples that had to be tested
for anthrax spores.
Underlying the government's response to the outbreak, experts say, was a
misunderstanding of the difference between the goals of terrorism and the goals
of warfare.
As Dr. Craig Smith, an infectious disease expert at Phoebe Putney Memorial
Hospital in Albany, Ga., put it, warfare seeks to conquer territories and
capture cities; terrorism seeks to "hurt a few people and to scare a lot
of people in order to make a point."
That is why the terrorism drills, which assumed that the attacks would involve
a cloud of anthrax pumped into a building or sprayed over a stadium, turned out
to be so far off the mark. Dr. Smith, the only infectious disease expert who
accompanied troops in the Persian Gulf war, is a member of the bioterrorism
task force at the Infectious Diseases Society of America. He said he and his
fellow members were as much to blame as anyone for that misperception.
Another terrorism expert, Jeffrey Hunker, dean of the H. John Heinz III
School of Public Policy and Management at Carnegie Mellon University, said:
"We're coming out of a cold war mentality that says that the big threat we
have to face is the Soviet Union unleashing biological or nuclear weapons. By
saying we were preparing for mass attacks, you are saying we were preparing for
war."
The goal now is to build a system that can respond quickly, and flexibly,
because there is no reason to believe that the next bioterrorism attack will
resemble this one. That, experts say, requires careful thought and
deliberation, not just throwing money at the problem to correct yesterday's
mistakes.
"There is just so much to do that we have not sat down to look at this
outbreak day by day and say, `What did we decide on Day X and what was done and
what might have been done, how could you have been doing it earlier?' "
said Dr. D. A. Henderson, the director of the Office of Public Health
Preparedness and chief adviser on bioterrorism to the health and human services
secretary, Tommy G. Thompson. "We plan to do that and sort it out and figure
out what we might have done differently."
Communication: 'Baffled' Officials, Mixed Messages
In late September, Secretary Thompson told television viewers that the
government was prepared to deal with any kind of bio terrorism attack.
Days later, he announced that Robert Stevens, a photograph editor at a
supermarket tabloid published in Boca Raton, Fla., had inhalation anthrax. It
was, he said, an isolated case. Anthrax happens naturally, he said, and there
was no evidence of terrorism. He hinted that Mr. Stevens might have become
infected by drinking water from a stream, although experts said such a means of
transmission had never been documented.
Yet the doctor who had just diagnosed inhalation anthrax in Mr. Stevens had
a very different view. Dr. Larry M. Bush, an infectious disease expert and
chief of staff at J.F.K Memorial Medical Center in Atlantis, Fla., said that
when he realized what Mr. Stevens had, he knew immediately what it meant.
Mr. Stevens worked in an office, in a state where no anthrax had been
reported in years. And inhalation anthrax was virtually unknown in the United
States; almost all of the very few cases had occurred in workers exposed to
airborne spores — by working with hides of infected animals, for example. Dr.
Bush interviewed Mr. Stevens's wife, who said her husband opened letters all
day, and concluded that the anthrax had come through the postal system. Dr.
Bush said he told local health officials, the federal Centers for Disease
Control and Prevention and the Federal Bureau of Investigation about his
suspicions.
When Dr. Bush heard Mr. Thompson suggest that the infection might have
occurred naturally, he was thunderstruck.
"I thought: `Wow. His first statement is wrong. Why did he say that?'
" Dr. Bush said. "It was a major disservice. He should have said: `We
have a case of anthrax. It is very concerning. I don't have the details, but we
will investigate it as potential bioterrorism.' "
Meanwhile, at the Health and Human Services Department in Washington,
officials were perplexed by Mr. Stevens's illness. Could he have become
infected in some unorthodox way?
Government officials acknowledge that they found it hard to imagine a case
in which a terrorist aimed airborne anthrax at just one person.
"Everything we knew about the disease just did not fit with what was going
on," Dr. Henderson said. "We were totally baffled."
As for health officials' initial response, Dr. Henderson said they often
play down the seriousness of an outbreak to avoid frightening the public. But
he added that he himself was critical of the practice. "It is not
reassuring," he said.
Still, James Adams, a terrorism expert who is a senior associate at the
Center for Strategic and International Studies in Washington, said he could
sympathize with government officials. "It's the worst political
problem," Mr. Adams said. The truth of the matter, he added, is: "We
have no solution. Therefore, we can't bear to tell you about it."
But it was soon becoming impossible to play down the events. Reporters
clamored for information. The requests "just really buried us in a way
that we had not anticipated," Dr. Henderson said.
The Centers for Disease Control and Prevention, the federal agency
responsible for investigating diseases, kept silent.
"Early on we were under the Federal Emergency Management Act and the
decisions were made that C.D.C. should not be a locus of communications, in
part because it was a criminal investigation and we were not really clear what
the appropriate message was to put out," said Dr. Julie L. Gerberding,
acting deputy at the agency's infectious disease center. "Soon thereafter
it became clear that C.D.C. was desperately needed as a spokesperson for this
outbreak, but by that time we were in a reactive state."
Mr. Thompson later held news conferences about the anthrax outbreak,
assisted by government scientists. But his initial remarks left a lasting
impression of overconfidence.
A basic principle of sound public health management is to have scientists
inform and interpret what has happened promptly. But when communication was
most critical early in the outbreak, no government scientist consistently
delivered the clear message many people said was needed.
In describing the general problem, Dr. John F. Eisold, the Capitol
physician, said that "the message was clearly a medical message, and you
have got to have medical people talking about medical facts and not nonmedical
people prescribing antibiotics."
Federal health officials were confused and disorganized. "We felt very
strongly about the need to be available and to communicate, and there was just
no way in the world you could," Dr. Henderson said. "We were just
paralyzed." Meanwhile, the information vacuum was being filled by
"experts" who came forward, some with questionable qualifications.
Another problem was the disease control agency's usual way of working. It
"has traditionally been a very deliberative body, scientific in nature,
that makes good policy decisions agonizingly over time," said Dr. Georges
C. Benjamin, the secretary of the Maryland Health Department and president of
the Association of State and Territorial Health Officials.
Ordinarily, once epidemiologists understand the nature of a particular
microbe and the way it is transmitted, they can develop effective public health
responses. But the rush of new information about anthrax and the postal system meant
that the agency had little time to be deliberative. Dr. Benjamin said that
meant "a new paradigm" for the agency; Dr. Gerberding of the disease
control centers agreed and said the lesson had now been learned.
The Warnings: 'A Weird Disease' and Its Nuances
Anthrax "is a weird disease," Dr. Henderson said.
Before the attacks, he said, he did not appreciate many of its nuances. He
and others writing a primer on anthrax in The Journal of the American Medical
Association in 1999 relied primarily on reports of 18 patients who developed
anthrax in the United States, a limited amount of information on a 1979
outbreak in Sverdlovsk, in the former Soviet Union, and a limited amount of
research in the laboratory and with animals.
Scientists knew that anthrax spores could lie dormant in soil for decades
and then cause disease. They also knew that inhalation anthrax occurred when
spores entered the lungs and were swept into lymph nodes in the mediastinum, in
the middle of the chest, where they germinated and pumped out toxins. But
scientists still had much to learn.
Few scientists had ever considered how dangerous anthrax spores might be if
they were sent through the mail. But in retrospect, it is clear that there were
clues.
In Canada, military scientists investigated the question as a result of a
hoax — a letter said to contain anthrax that forced the government to close a
building in Ottawa last January.
That led Dr. Bill Kournikakis and his team at the Defense Research
Establishment in Alberta to conduct an experiment. They used a harmless microbe
to mimic how spores might disperse in an office or mailroom if an envelope
containing anthrax were opened.
Their conclusion was chilling: a person could inhale a lethal dose of spores
within seconds of opening an envelope. Those who remained in an affected room
for more than 10 minutes could inhale far more than a lethal dose, depending on
their location and the air flow.
In early October, when American epidemiologists linked the spread of anthrax
to the postal system, Dr. Kournikakis said he sent the report to the disease
control centers. But it went unread in the blizzard of e-mail messages that
arrived at the agency, and it was not until three weeks later that officials
learned of the study through other channels.
A similar warning had come in 1999, from William C. Patrick III, a
government germ warfare expert, in a report for a government contractor
exploring what might happen if an anthrax letter was opened. Finely milled
spores, he wrote, could easily contaminate an office.
Medical experts also misjudged the difficulty doctors would have in
diagnosing inhalation anthrax, assuming that a sophisticated surveillance
system was needed to detect an attack. But Dr. Bush, the Florida infectious
disease expert, says he knew immediately what was wrong with Mr. Stevens, the
first patient with inhalation anthrax. He saw Mr. Stevens on the morning of
Oct. 2. By 2 p.m., he was convinced.
"I had four pieces of information, all consistent with anthrax and not consistent
with other organisms on my short list," Dr. Bush said. He called the local
health department, telling officials there that he thought he had a victim of
bioterrorism. And he sent samples of the bacteria to a state reference
laboratory for further tests. By 8:30 the next morning, all three tests had
come back positive.
Medical textbooks say that inhalation anthrax starts with mild, flulike
symptoms that are hard to recognize, and that by the time it progresses to its
severe phase, it is easy to diagnose but virtually impossible to cure. But the
two postal workers who came to the emergency room at Inova Fairfax in October
did not have textbook symptoms. The first patient did not even seem very ill,
but a CT scan of his chest showed telltale signs of anthrax. The second patient
complained of the worst headache of his life. But he did not have the classic
signs of inhalation anthrax — bacteria in his spinal fluid and abnormalities in
a chest scan. Doctors learned he had anthrax only when they examined his blood
and saw the characteristic boxcar-shaped anthrax bacteria.
Both patients recovered with aggressive treatment — another surprise,
considering how deadly the advanced stage of the disease was assumed to be. But
that expectation was based on what scientists knew about the 1979 outbreak in
Sverdlovsk, which was caused by a plume of spores accidentally released from a
bioweapons factory.
Now, Dr. Henderson said, scientists realize they misread scientific papers,
never appreciating that many more Soviets may have had the disease and
survived. It is unclear how effective antibiotics were in Sverdlovsk, he said,
because no one is sure how many people were given antibiotics and for how long
they took them.
The anthrax attacks also pointed to another scientific mystery: how many
spores does it take to infect someone? Could one spore cause a fatal disease?
The two most recent deaths, of two women who were not postal workers — Kathy T.
Nguyen in the Bronx and Ottilie W. Lundgren in Oxford, Conn. — raise the question,
because no spores were found in their homes and the source of their infection
is unknown.
Dr. Henderson and others now say that the outbreak illustrates an important
lesson: the temptation to draw firm conclusions from a small database should be
resisted, even if it is the only information available.
"There is a lot of feeling that we didn't know what we were doing as
scientists in giving advice," he said. "But, sorry, we haven't had a
lot of anthrax around to know just how it's going to behave."
The Collaboration: 'Layers and Levels' of Teamwork
Teamwork is essential in any epidemiologic investigation. But, Dr.
Gerberding of the disease control agency said, "In retrospect, we were
certainly not prepared for layers and levels of collaboration" among a
vast array of government agencies and professional organizations "that
would be required to be efficient and successful" in the anthrax outbreak.
The agency quickly deployed hundreds of workers and created an operations
center, installing banks of telephones so epidemiologists could relay
information from colleagues in the field to top officials at its headquarters
in Atlanta and then on to the National Security Agency, the Central
Intelligence Agency and the White House. Even so, calls from state and local
health officials and departments and doctors across the country flooded the
lines.
And responsibilities for health matters were fragmented. "We were very
much aware that we had no jurisdiction over federal facilities whether it was
the V.A. or the post office," said Dr. Matthew L. Cartter, an official of
the Connecticut Health Department. He urged local, state and federal agencies
to work out a memorandum of understanding to clarify lines of jurisdiction
before another outbreak.
In New York City, the Health Department had prepared itself for inhalation
anthrax in recent years, building liaisons between hospitals and specialists in
infectious disease, pulmonary disease and emergency room care. But health
officials overlooked dermatologists and surgeons, who treated the first anthrax
cases — the skin form. "Very few dermatologists had ever heard of us or
knew how to reach us," said Dr. Marcelle Layton, an assistant commissioner
in the department's communicable disease bureau.
Anthrax also challenged health officials and law enforcement agencies to
work together. And each group had something to learn. For F.B.I. agents, it was
how to obtain evidence without contaminating the scene of a medical
investigation. For epidemiologists, it was how to collect specimens without
disturbing the chain of custody in a criminal case.
"It's a different mind-set, of using epidemiology to reconstruct the
circumstances of the exposure that resulted in disease," said Dr. Bradley
A. Perkins, a top anthrax investigator at the federal disease centers. Law
enforcement officials "immediately recognized the value of that in
prosecuting the criminal case," he said.
The Testing: Samples Deluge the Laboratories
On Oct. 15, a letter stuffed with anthrax spores was opened at the office of
Senator Tom Daschle. The next day, 2,500 people who had potentially been
exposed lined up for nasal swabs. Many were terrified. "People thought
each spore was plutonium," said Dr. Eisold, the Capitol physician.
But although the nasal swabbing continued wherever anthrax spores showed up,
epidemiologists soon discovered that it was of little use in detecting illness.
Its main role was in helping determine where and how far spores had spread.
Soon officials in every state were hit with an avalanche of samples to test
— from nasal swabs, from suspicious letters, from swabs of offices and rooms,
from clothing, from soil. "You could never have prepared for the volume
that you had to process," said Dr. Lou Turner, the director of the North
Carolina Laboratory of Public Health.
The disease control agency regards environmental microbiology as one of its
strengths, Dr. Gerberding said, but it soon learned that the discipline had a
long way to go when it came to anthrax — in particular, sampling the air for
spores, disinfecting an area and monitoring it for spores and particles that
might escape when envelopes are put under mechanical pressure.
The agency believed that it was prepared for a real anthrax outbreak. It had
created a network of laboratories to aid in rapidly detecting microbes.
Although the network worked well, the assumption had been that the labs would
mostly test specimens from sick patients. Instead, most tests were for spores
in the environment — and for hoaxes. The agency had to expand lab space and
open a new lab at its headquarters just to test more than 5,500 specimens for
spores.
Some health officials complained about the data coming back from testing
labs. Does a negative report mean that the laboratory used only a quick
screening test, or that it also performed a culture? Such details are
important, particularly for laboratory reports that will be evaluated by law
enforcement officials and others who would not understand what tests were done,
health officials said.
A new problem has emerged: how to return the variety of items — rugs,
envelopes, china, even a 50-gallon drum — that were tested and found not to be
contaminated.
"We have to figure out how to get rid of all this, which is still
evidence and still in the chain of custody," said Dr. Elizabeth Franko,
the director of the Georgia Public Health Laboratory. "Either law
enforcement needs to come get it, or they need to sign off and say it is trash
and they do not want it back."
The anthrax attack was much less horrific than it might have been. But
medical and terrorism experts say that situation is due in large part to luck.
Considering the size of the postal system, relatively few people were infected.
And unlike smallpox, among other possible terrorist weapons, anthrax is not
spread from person to person.
In deconstructing the response, Dr. Hunker, the terrorism expert, said, it
will be important to investigate what role luck played, to avoid having to rely
on it in the future.
The backbone of the Centers for Disease Control and Prevention's response to
health emergencies is a corps of epidemiologists known as the Epidemic
Intelligence Service. Forensic epidemiology has not been part of their
training. But now it has to be, Dr. Gerberding said.
And experts caution that the anthrax outbreak may not be over.
"We still do not know who put anthrax in the mail, we still do not know
if they used all they had, and we still do not know how to make all the mail
safe," said Dr. John O. Agwunobi, the Florida secretary of health.
"So the question becomes how quickly can we apply what we have learned so
far to the next event."
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