SHEA coverage

Won’t get fooled again? SHEA meeting sheds harsh light on anthrax response

Recipe for chaos: Envelopes, stamps, and anthrax

In a strikingly blunt assessment of the evil effectiveness of last year’s anthrax mailings, public health officials and epidemiologists are warning that the hard lessons learned must not be forgotten if the country is to fare any better against the next bioterrorism attack. That was the consensus in a candid, near-confessional bioterrorism forum in Salt Lake City at the annual conference of the Society for Healthcare Epidemiology of America (SHEA).

"Anybody who was paying any attention in the fall learned that a tablespoon of anthrax powder and a handful of letters could basically shut down the postal system and the U.S. government," said Julie Gerberding, MD, MPH, a top bioterrorism official at the Centers for Disease Control and Prevention (CDC) in Atlanta. "While we may not be dealing with [international] terrorists, we have taught any kook in the United States how easy it is to accomplish this kind of devastating social, if not medical, catastrophe."

An additional tragedy of Sept. 11 and the anthrax aftermath was that epidemiologists and public health officials were caught so off-guard, said Michael Osterholm, PhD, a bioterrorism advisor to the CDC. "Many of us in this room were surprised," Osterholm told SHEA attendees. "This session is an effort to help us understand that in the future we can’t be surprised because, in fact, this will happen again. There is no question about it. It is not a matter of if; it is matter of when, where, and how bad."

Rep. Jim Matheson, (D-UT), a member of the House Science Committee described the complete disruption of government following the Oct. 15th opening of the anthrax-laced letter to Sen. Tom Daschle (D-SD). "Two days later, all of the congressional office buildings were closed for anthrax testing. While most of the House office space was closed briefly, the Hart Senate office building did not open until Jan. 22. The Hart Senate office building houses 50 of the 100 senators."

The anthrax attacks illustrated the lack of communication and clear lines of authority between federal agencies all of all stripes, including the Environmental Protection Agency (EPA) and the Federal Emergency Management Agency (FEMA), he emphasized. "Science Committee hearings revealed that leaders of the EPA, CDC, and FEMA didn’t know who was really in charge or responsible for declaring a building safe for public use," Matheson said. "I’m not trying to point fingers. Sept. 11 revealed the House of Representatives had no evacuation plan in place, either. We all have a lot to learn."

One of the problems the anthrax attacks exposed was how the various missions of federal agencies can put respondents at cross-purposes, he noted. For example, the criminal aspect of the anthrax response required law enforcement agencies to withhold information in order not to compromise their investigation. Conversely, the public health aspect of the bioterrorist attack pressured officials to broadly disclose information to educate and reassure the public, Matheson said.

"We obviously need new skills," Gerberding added, who is acting deputy director of the CDC national center for infectious diseases. "Forensic epidemiology is not a practice that I had ever had any training in. Learning how to work side by side with the FBI and negotiating the differences in our cultures — as well as our commitment to the same purpose — is something that needs to happen. We’re doing dual-training programs, cross-training, and so forth to try and facilitate this in the future. I would encourage that at the local level as well."

Communications grade: D-

The communication between investigating agencies was actually fairly good, in part, due to two-hour daily conference calls, Gerberding said. Problems arose, however, at state and local jurisdictions. "We wanted the governor of the area to be the first to release the news, but we had to negotiate with the federal personnel, who also felt like it was important to be the first ones to know," she said. "It was very difficult for us to keep all of those balls in the air."

Worse still was the communication of the anthrax investigation to the public and press, which at first was virtually stonewalled, then given limited information, then provided daily press briefings and news conferences. "One of the very critical lessons has to do with communication," Gerberding explained. "On the scale of successes, the CDC received about a D- in communication, for a lot of reasons, not all of which were in our capacity to manage. But we went from a system where we had essentially no communication, got the capability of giving some information on a limited basis. . . . Then very soon thereafter, people were desperate, and it was widely recognized that our communication was needed. But by then, we were clearly in a profoundly reactive mode."

The agencies established an emergency operations center and used an "incident-command model," which likely will be the method used in the future, she added. "People in the field of epidemiology and all of the others with expertise in infectious diseases need to be accessible to support the day-to-day operation of these centers," she told SHEA attendees. "That will be your primary role. You will also play a role in making the decisions."

In a fascinating inside look at how the CDC viewed the unfolding situation, Gerberding highlighted key points in the agency’s anthrax investigation. For starters, the CDC’s working anthrax contingency plan wasn’t exactly helpful. "I reviewed the anthrax plans some time after 9/11, and I never looked at it again once we had our first case of anthrax," she stated matter of factly. "It was irrelevant, and in retrospect, humorous because we didn’t exercise the plan and we didn’t practice the scenarios and really play out in tabletop exercises and so forth how that plan would work."

The anthrax situation began to develop rapidly, with the first inhalational cases in Florida followed by cutaneous cases in people who handled mail in New York and New Jersey.

"We had letters with powders, cutaneous cases, and some environmental contamination where they [handled mail] in New York City," Gerberding explained. "We had no inhalational cases in New York. We had two inhalational cases in Florida, but no envelope and no powder. But the people with those diseases had actually either opened or been present when envelopes were opened."

At this point, the CDC developed "dogma" or assumptions to guide the investigation. As she recalled, these included the following four beliefs at the CDC:

1. The powders in New York City would not cause inhalational anthrax.

2. Although they were at risk for cutaneous disease, postal workers who processed the mail between the point at which it was mailed and the point where it was opened were not at risk for inhalational anthrax.

3. Re-aerosolization of anthrax spores would not occur.

4. A fairly large number of spores were necessary to develop inhalational disease.

"Of course, in retrospect, we realized that all four of these facts’ were wrong," she said "That was brought home to bear when the postal workers at Brentwood [post office] died of inhalational anthrax and other cases in the Washington, DC, area were identified."

As a result, CDC’s plans for future bioterror attacks call for establishing a separate team of scientists and experts to conduct research without being directly involved in the ongoing investigation. "They can be reviewing the literature thoughtfully, delving back into prior publications, [and] examining things from a critical perspective without being caught up in the fracas of the day-to-day events," she said.

With their assumptions fading fast, the CDC tried to the trace the letters through the postal system. Investigators began to suspect that there must be at least one other letter containing anthrax. "We knew about the Daschle letter because it had been opened," she said. "But the fact that somebody acquired inhalational anthrax in the state department told us that there must be another letter. We could not account for that case on the basis of the Daschle letter."

Indeed, an FBI search of the bins containing quarantined mail found another anthrax letter, the one that had been mailed to Sen. Patrick Leahy (D-VT). Trying to address the hazards in mail-handling facilities, the CDC did intensive environmental assessments. The level of contamination was dramatic, as evidenced when Gerberding showed a blueprint of a huge postal facility in Hamilton, NJ, that was dotted throughout with positive anthrax cultures.

"The entire facility had cultures positive," she says. "We have to assume that there was wide-spread environmental contamination with no other conclusion that there had been an impressive aerosol of anthrax in that facility. Everybody that worked in there had to have been at risk. This was true in Hamilton, and it was true in the Brentwood facility and in the AMI building in Florida. And it was certainly true in the Hart Building and the Daschle offices."

Meanwhile, the national laboratory response network (LRN), which has a testing facility in every state, was being overwhelmed by false alarms and powder scares. The LRN labs processed some 70,000 specimens in a three-month period, dealing with an unprecedented surge that revealed some problems in separating reports for environmental vs. patient test results.

Even as other aspects of the investigation were coming into some focus, the CDC was soon to face two additional surprising cases. A health care worker in New York City and an elderly Connecticut woman, neither of whom had any clear connection to the previous cases, contracted inhalational anthrax and died. The CDC was initially suspicious that another unidentified letter was out there, but it appears now that the cases were likely the result of cross-contamination in the mail. "We actually had one person in New Jersey who got cutaneous anthrax from what was probably cross-contaminated mail, so we shouldn’t have been completely surprised," Gerberding said. "But the inhalational presentation was shocking to us."

Ultimately, the CDC’s "decision-making" process, which for years has favored a conservative, consensus-building approach, was ill-equipped to deal with bioterror. "We are used to being very deductive and having all of the facts at our disposal before we issue a guideline, which usually takes us two or three years before it ultimately appears," she said. "This is not a good time frame for this type of problem."

In facing future attacks, the CDC will try to reason more inductively and make adaptive decisions, Gerberding noted. Such an approach requires making decisions with whatever information is at hand, knowing full well events may change quickly and require a different course. Clinicians actually do this routinely when they follow a patient through the various manifestations of disease and treatment. "This is a concept that is very difficult for some scientists, but I think it’s very comfortable for clinicians," she said.

The lessons from the anthrax attacks are instructive for future dealings with any manner of agent, Gerberding stressed. She urged SHEA attendees to begin broadening their focus beyond infectious organisms and start preparing for chemical and radiological weapons.

"We have been focusing on biological terrorism here, but we really need to very quickly have an all-hazards mentality," she said. "I think most of us know very little about these [chemical and nuclear] agents, and yet as health care epidemiologists, we will need to know how to do the medical assessment. We will need to be able to say who is safe [and] who isn’t safe. We will need to be able to screen for the dose of radiation. There are a whole number of skills and activities that people in hospitals and in our field will need to be leading."