Public health leaders cite lessons of 2001 anthrax attacks

Sep 1, 2011 (CIDRAP News) – Public health leaders, recalling and reflecting on the anthrax letter attacks of 2001 in a lengthy report released today, say the nation is better prepared to respond to such an emergency than it was 10 years ago, but their confidence is tinged with fear of slipping backward in the current era of budget cutting.

The report, titled "Remember 9/11 and Anthrax: Public Health's Vital Role in National Defense," includes essays from about 35 federal, state, and local public health officials who were involved in responding to the 2001 attacks, plus a chronology of key events and a summary of the anthrax investigation.

The report was prepared by the Trust for America's Health (TFAH), a nonprofit, nonpartisan advocacy group based in Washington, DC.

The report recalls the fear, confusion, and overwhelming workloads that public health agencies faced in the wake of the Sep 11 terrorist attacks and especially the anthrax attacks that surfaced in early October of that year. Envelopes containing Bacillus anthracis spores were mailed to several East Coast media outlets and two US senators' offices, leading to 22 anthrax cases and 5 deaths.

A 7-year investigation led the FBI to conclude that the attacker was Dr. Bruce Ivins of the US Army Medical Research Institute of Infectious Diseases. Ivins committed suicide as the FBI was preparing to formally charge him in 2008, and controversy about the FBI's conclusion has persisted.

In a press release, TFAH says the stories in the report reflect how the 2001 events marked the first time that public health came to be considered central to emergency response and national security on a wide-scale basis, and also show how public health officials were working without adequate resources or training to respond to these types of attacks. A summary of how public health preparedness has evolved in the past 10 years is also included in the report.

Most, if not all, of the contributors to the TFAH report say the public health world is better prepared to respond to a biological weapons attack today than it was in 2001. In particular, they say public health laboratories are better equipped to test potentially dangerous samples, communication systems have improved, there are plans in place to distribute countermeasures, and public health has a much closer relationship with law enforcement and emergency response agencies.

However, another common theme is that these gains could be lost because of budget cuts and resulting personnel losses.

"In 2001, we experienced the unimaginable. In 2011, we know we need to expect the unexpected," writes Lowell Weicker, Jr., former three-term US senator and former Connecticut governor, in the report's introduction. Weicker is president of the TFAH board of directors.

In the past decade, he writes, "We've made smart, strategic investments, and there's been a lot of progress to show for it. We can be proud of the improvements that have been made. Of course, there is a lot left to be done."

The report includes separate sections on federal, state, local, and laboratory responses to the 2001 crisis.

Federal response perspectives
From the federal perspective, the report contains personal details and observations that aren't widely known. Tom Daschle, the former US Senator from South Dakota whose Washington office was targeted in the anthrax attacks, said he remembers a somewhat chaotic environment as the Centers for Disease Control and Prevention (CDC) and other federal agencies struggled to respond.

Daschle described the investigation into the attacks as an arduous, frustrating, and controversial experience. He said confidence in the FBI's assertions is lower than it should be, but he is reasonably satisfied that the agency is correct in its conclusion. "But I must recognize the legitimate concerns and questions posed by many skeptics since the case was officially closed," he said.

Several of the people who contributed their stories credited the CDC for having trained by 2000 a small group of laboratory experts who could isolate and conduct molecular subtyping on Bacillus anthracis, which was critical to the investigation.

By then the CDC had also developed and trained the Laboratory Response Network, allowing others to isolate and identify the pathogen.

Tanja Popovic, MD, PhD, a CDC lab expert, said the experts completed their training just 6 months before the anthrax letters were mailed. "This did not come from luck. This came from the vision of some dedicated people to whom we all owe a lot," she writes.

"We were ready. I was confident, very confident of our microbiology," Popovic said. "And we never missed. I never had to come back and say our lab got it wrong."

Current and former federal officials mentioned the unusual experiences they had working under heavy security conditions that followed the terror attacks. Tracee Treadwell, DVM, MPH, reflected how she and her colleagues at the CDC's main campus in Atlanta met at an alternative site to plan their response the day of the New York City attacks.

Immediately after the Sep 11 attacks, she boarded a small CDC jet that had Federal Aviation Administration clearance to fly the agency's investigators and materials into New York City. During the flight, she saw a black dot moving rapidly toward them, and Treadwell said she feared the CDC plane would be shot down. The fighter plane got so close, she could see the face of the pilot.

"They did a wing wave and moved on. We were the only civilian plane in the sky. They called us CDC-1," Treadwell said in the report.

One gap identified in some accounts, including that of James M. Hughes, MD, former director of the CDC's National Center for Infectious Diseases, was an initial lack of an emergency operations center. He said the need for situational awareness touched many areas, from meeting the demands of the 24-hour news cycle to rapidly providing post-exposure prophylaxis.

He said the biggest threat to the nation's bioterrorism preparedness is complacency, which has led to funding reductions at the state and local levels. "Just in time economy introduces additional preparedness challenges," he writes.

Daniel Jernigan, MD, MPH, who now works as deputy director of the CDC's Influenza Division, headed its epidemiology team in Atlanta that investigated the anthrax cases. He called the investigation "unprecedented" and observed how the multistate effort began to incorporate the incident-command model of response.

"We learned that the outbreak model must persist, but in extraordinary outbreaks, the incident command model is vital too," he said. "We needed better systems to communicate and interact with partners, elected officials, the media, and the public,"

The anthrax experience taught health officials valuable lessons that were useful during the 2009 H1N1 response, Jernigan wrote. "Anthrax taught us the value of having laboratory processes in place, the need for rapid diagnostics, how to communicate uncertainty, and the importance of collaboration with others."

Federal officials also learned the value of regulatory preparedness, he added, noting that response activities involved working with the US Department of Agriculture (USDA) and Food and Drug Administration (FDA) to identify and manage emerging regulatory obstacles.

Public health lab stories
The CDC estimated that the nation's public health labs processed about 350,000 environmental samples and clinical specimens, an extended effort that led to long hours as lab employees juggled the new tasks with their regular workload, the report says. Sara Beatrice, PhD, assistant commissioner of the New York City Public Health Laboratory, wrote that the public health community is well poised to handle potential bioterror threats, but the lack of sustainable funding makes the system vulnerable.

Federal resources drove and supported the response to the attacks, she says. "Unfortunately, these federal grants have consistently been cut so that even service contracts for equipment purchased under the grants can't be maintained."

Jim Pearson, DrPH, BCLD, deputy director for laboratories with the Virginia Department of General Services, writes that the strong lab infrastructure, with reliable lab testing in every state and major city, at the time of the attacks helped save lives and calm hysteria. He recalled an instance in which a public health lab detected B anthracis within 40 minutes of receiving the sample from the hospital, which resulted in the patient returning to the facility for appropriate antibiotic treatment.

Missouri's public health lab handled massive amounts of samples, including some from the CDC, recalls Eric C. Blank, DrPH, senior director of public health systems for the Association of Public Health Laboratories. He says he was surprised at the roles labs played in helping the public work through tragedies and providing a level of comfort to the public.

Given that the lab was considered a potential target, state fire marshals served as security detail, with one officer regularly bringing his Labrador retriever along. "The dog was calming and reassuring—it was something normal during a time that was anything but. We rechristened the dog 'the Lab's lab,' " Blank writes.

Blank said another lesson lab officials learned from the anthrax experience was how to operate in an incident-command setting. Once the flood of samples slowed, federal preparedness funding helped Missouri and other states beef up their emergency response operations to incorporate incident-command principles, he said, adding that the new capabilities helped labs respond to the 2009 H1N1 pandemic.

State officials' struggles
In the section on state responses, George DiFerdinando, Jr, MD, MPH, director of the New Jersey Center for Public Health Preparedness at the University of Medicine and Dentistry of New Jersey, recounts struggles he and his colleagues faced at the time of the anthrax attacks, when he was acting commissioner of the New Jersey Department of Health and Senior Services.

At the end of a conference call, he writes, it was revealed almost casually that the anthrax letters originated somewhere in New Jersey. Officials on the call were assured that anthrax spores in a sealed letter were not a danger. But at the same time, the state health department got calls from two New Jersey physicians reporting persistent skin illnesses in postal workers who worked at the facility where the letters were processed.

A few days later one of the cases was confirmed as cutaneous anthrax, and the postal facility was shut down. It was initially thought that the building could be tested and reopened in 72 hours. But in the end, it took more than 3 years to certify and reopen the building.

After another postal worker developed cutaneous anthrax, state officials decided to propose offering prophylactic antibiotics to the staff. But the CDC disagreed that the workers were at risk and didn’t support the state request for antibiotics from the national stockpile, DiFerdinando writes. So New Jersey officials had to scramble to find ciprofloxacin and a place to deliver it, without the legal support of an emergency health powers act. Since then the state has corrected that deficiency.

"To me, the biggest change the public health world has seen over the past decade has been our incorporation into the law and public safety community," DiFerdinando writes. "However, I'd have to be willfully blind not to see that there are fewer people in public health departments in NJ now than there were on 9/11. Today we might respond with a better trained and equipped work force, but there would be many fewer at the front lines."

John R. Lumpkin, former director of the Illinois Department of Public Health (IDPH) and now a senior vice president at the Robert Wood Johnson Foundation, recalls thousands of "white powder" calls after the attacks, forcing the state lab to go into "overdrive" and run its equipment at full capacity.

The crisis forced state lab improvements that were helpful when West Nile virus reached Illinois in 2002, sickening 71 and killing 4, he says. The crisis also led to a much stronger relationship between the state health department and the Illinois Emergency Management Agency.

Lumpkin remembers the fear and uncertainty of the time, seasoned by satisfaction that IDPH was up to the challenge. "I also look back with regret as I realize that once again our country has forgotten the lessons of the past," he adds. "Health departments across the nation are being ravaged by budget cuts and layoffs."

Local responses recalled
Isaac Weisfuse, MD, MPH, deputy commissioner of the Division of Disease Control in the New York City Department of Health and Mental Hygiene, recalls a difficult day at NBC headquarters at Rockefeller Center, where he had to help respond after an anthrax letter was received. He was "on the firing line for questions on anthrax and many were difficult if not impossible to answer."

Weisfuse said that if a bioterrorist attack occurred now, his agency would be better prepared in three respects:

  • Communication: the department has developed and stockpiled information sheets and frequently asked questions on a variety of emergencies
  • Lab response: the city now has a biosafety-level-3 (BSL-3) lab, a better trained staff, and better computer systems in the lab
  • Countermeasures distribution: the department now has a set of sites for distributing countermeasures and pre-staged equipment, and has trained staff

In Charlotte, N.C., the Mecklenburg County Health Department faced a variety of extra burdens in the wake the anthrax attacks, writes Stephen R. Keener, MD, MPH, the department's medical director.

The county was besieged with "white powder" incidents, he recalls. In addition, the health department had to investigate an apartment where the daughter of Robert Stevens, the American Media photo editor and first anthrax victim, lived, since he had visited there shortly before his illness. Public health investigators looked for clues that might point to a natural anthrax source, but none of the samples grew anthrax. Also, the CDC asked hospitals in the county to review lab cultures over the previous 3 months that could've been Bacillus species and examine records of patients who had undiagnosed illnesses.

Also, the county and state health departments had to run tests at a bank payment processing center in Charlotte that received daily mail deliveries from the Brentwood postal facility in Washington, DC, where several postal workers were sickened by anthrax, Keener writes. Until the samples tested negative, prophylactic antibiotics were offered to the staff. The incident prompted the county to provide funds for an electronic syndromic surveillance system, which was eventually replaced by a statewide system.

Segaran P. Pillai, PhD, MSc, who directed the Florida State Public Health Laboratory in Miami at the time of the attacks, writes that the lab operated 24/7 in the first weeks and processed 14,244 samples over 2 years after the attacks. He is now the chief medical and science adviser for the science and technology directorate of the US Department of Homeland Security.

In particular, the Miami lab operated 24/7 for 2 weeks in 2003 to test 6,500 samples from the America Media Inc. building in Boca Raton, where the first anthrax victim worked, and there was no overtime pay. "Public health staffs are the unsung national heroes who give time and risk their lives to ensure the safety and security of the public," Pillai says.

He writes that the hardest challenge at the time was the lack of resources and personnel to process the large number of samples. Since then, CDC "focus C" grants have provided for trained scientists who can handle highly complex tests on select agents, and also have been used to create more BSL-3 lab space.

Since 2001, 160 labs have joined the CDC's Laboratory Response Network, Pillai says. In addition, primary care and infectious disease doctors and nurses have been trained, and he's confident they can rapidly recognize a disease associated with select agents.

"My biggest concern is that the country is getting complacent and we might be losing focus on the importance of being prepared," he writes.

See also:

Sep 1 TFAH press release

Sep 1 TFAH report "Remembering 9/11 and Anthrax: Public Health's Vital Role in National Defense"

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