http://www.nytimes.com/2001/11/13/health/13DOCS.html

 

November 13, 2001

THE DOCTOR'S WORLD

When Everything Changed at the C.D.C.

By LAWRENCE K. ALTMAN, M.D.

	(AP) To deal with anthrax, Dr. Jeffrey P. Koplan rallied the federal disease centers' largest epidemiological force.
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	Centers for Disease Control and Prevention Anthrax Medicine and Health Terrorism
	Robin Nelson for The New York Times At the headquarters of the Centers for Disease Control and Prevention in Atlanta, concrete barriers now restrict access, and armed private security guards inspect visitors' cars.

TLANTA — About 3 a.m. on Oct. 12, Dr. Jeffrey P. Koplan, director of the Centers for Disease Control and Prevention, awoke to a call from one of his top epidemiologists, Dr. James M. Hughes, who said, "We've got something reported from the lab, and we need to look at it."

A few minutes later, Dr. Koplan, Dr. Hughes and a pathologist, Dr. Sherif R. Zaki, were peering through a microscope at a specimen of skin from an employee of NBC in Manhattan, who was suspected of having cutaneous anthrax.

It was just what the centers had been on alert for since an anthrax case had been detected in Florida a week earlier. The events that unfolded in these early hours would lead the C.D.C. to embark on the largest epidemiologic investigation in it history, covering more than 50 years.

As the medical detectives met, they had only the bit of skin to test. The question of whether the NBC employee, Erin O'Connor, had anthrax — and thus, whether terrorists might have spread anthrax spores in New York City — now depended on an immunological and chemical test that Dr. Zaki had developed a few years before.

"We knew we were going to be subject to incredible scrutiny," Dr. Koplan recalled, especially since they had no powder, no suspicious letter or other evidence. Nor had they tested a culture, the preferred, but slower, method of determining anthrax.

"But," he said, "we have enough confidence in Dr. Zaki to say, `If he says it, we'll go with it.' "

About 3:30 a.m., after Dr. Zaki had finished explaining his findings, "we walked away convinced," Dr. Koplan said. Ms. O'Connor probably had anthrax. The C.D.C. doctors informed the New York City Health Department's top epidemiologist, Dr. Marcelle Layton.

A few hours later, Dr. Koplan was on the phone with Mayor Rudolph W. Giuliani. "Are you sure it's anthrax?" the mayor asked.

"Well, we have a high degree of probability," Dr. Koplan replied.

"No, no, no, don't give me that stuff," was the mayor's rejoinder. "Is it anthrax or is it not?"

"Yes," Dr. Koplan said.

"Fine, that's all I needed to hear," Mr. Giuliani said.

In the following days, Dr. Koplan pulled together the largest epidemiological force the disease centers had ever marshaled. As the investigators learned about cases at other news media companies and among postal workers, they worked to check out suspected and confirmed cases in New York City, New Jersey and the District of Columbia. The work went on around the clock; some investigators napped briefly on cots set up in offices; others went home only for quick showers. One epidemiologist postponed her wedding to join the investigation.

The effort was huge, but for many doctors, especially in the early stages, it was not enough.

"We needed concrete recommendations about how to handle situations," said Dr. Daniel Ein, a physician in Washington and the former president of the city's medical society. Instead, he said the early stages of the investigation were plagued by confusion and conflicting information.

When he called the disease centers' hot line, he said, he "talked to some fellow who might have had a high school education and he was fumbling around," unable to answer Dr. Ein's questions.

It was days before things were running more smoothly.

Since its creation 50 years ago, the centers' Epidemic Intelligence Service has built a worldwide reputation for solving puzzling cases and outbreaks. Because these medical detectives have learned that early detection is vital to effective control and prevention, they often concentrate on finding cases in the earliest stages, even if it means focusing on just a few cases.

Although an unusually large team of 15 epidemiologists and laboratory scientists was sent out when the initial anthrax case was reported in Florida on Oct. 4, the investigation started in the traditional mode, with the assumption that the disease had natural causes, Dr. Hughes said.

The approach changed abruptly with the early morning call to the New York City Health Department. In part because no one knew how widespread the attack would be, the centers dispatched dozens more scientists to New York, assigned more than 500 of its 4,000 employees in Atlanta to the anthrax outbreak and made plans to enlarge the group if needed. Epidemiologists who had been working on influenza, diabetes and tobacco control suddenly found themselves investigating anthrax.

"It was clear that we were going to have to operate differently" to deal with the immediate and potential threat, Dr. Hughes said.

Within hours of the New York call, Dr. Koplan's team had converted a large room into an operations center and installed telephones and computers.

Partitions separated the staff into different teams, called pods. One pod was set up to communicate with investigators in the field. A second dealt with health officials in the states with confirmed cases. A third communicated with health departments in other states where officials were investigating suspected cases and hoaxes. Conference calls with state health officials were held frequently. More staff members were sent into the field as needed.

At the same time, a fourth pod tried to help laboratories that had been overloaded with requests for testing, helping them obtain supplies and reporting back to them about specimens they had sent to the C.D.C. laboratories.

The agency summoned additional experts on plague and tularemia from its laboratories in Fort Collins, Colo., out of concern that terrorists might launch attacks with these and other infectious agents, Dr. Hughes said.

And additional pods were set up to help with suspected cases in postal workers and in other countries, to deal with public relations and to determine the best ways to detect and treat anthrax.

Meanwhile, the centers were changing in other ways. With the anthrax attack, the C.D.C. imposed the tightest security measures in its history, surrounding buildings with the concrete barriers that have become familiar at government centers around the country.

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