A look inside the hunt for a white, powdery killer.
- By Mark PendergrastExcerpted from Inside the Outbreaks by Mark Pendergrast, copyright © 2010. Reprinted by permission of Houghton Mifflin Harcourt Publishing Company. All rights reserved. Mark Pendergrast is the author of, most recently, Uncommon Grounds: A History of Coffee and How It Transformed Our World.
Since its founding in 1951 by Alexander Langmuir as a service/training program, the Epidemic Intelligence Service, working out of the CDC in Atlanta, Georgia, has sent out more than 3,000 officers to combat every imaginable human (and sometimes animal) ailment.
These young people — doctors, veterinarians, dentists, statisticians, nurses, microbiologists, academic epidemiologists, sociologists, anthropologists, and now even lawyers — call themselves "shoeleather epidemiologists." EIS officers have ventured over the globe in search of diseases, sometimes in airplanes or jeeps, on bicycles, aboard fragile boats, on dogsleds, atop elephants and camels.
EIS officers generally have performed their tasks without fanfare or notice. They have saved uncountable lives, preventing uncontrolled spread of disease and diagnosing problems before they escalated.
They even may have saved your life, though you were probably unaware of it. And in October 2001, they became deeply involved with containing the spread of anthrax in the United States.
On October 3, the Florida state laboratory called the CDC about a likely anthrax case. A disoriented, feverish 63-year-old man named Bob Stevens had entered a Boca Raton hospital the day before, and then had a seizure. His spinal fluid had just tested positive for Bacillus anthracis.
The next day the CDC lab confirmed the diagnosis. Stevens, a photo editor at the tabloid the Sun, was suffering from inhalational anthrax, a rare, deadly disease. There had been only 18 such cases in the United States during the 20th century, and the last had occurred 25 years before.
On October 4 a CDC team, led by EIS alum Brad Perkins and including five EIS officers, flew to Boca Raton. There they joined Florida-based EIS officer Marc Traeger.
Coming so soon after the 9/11 terrorist attacks, the unusual inhalational anthrax case caused understandable concern, but the CDC investigators thought it unlikely to be bioterrorism. Why would terrorists pick on one obscure photo editor at an insignificant tabloid?
At 4 p.m. on Friday, Bob Stevens died. In the wake of the 9/11 attacks, the George W. Bush administration tried to control and centralize communication, so CDC director Jeff Koplan was effectively muzzled, while HHS Secretary Tommy Thompson, who knew little about medicine, gave a press conference. He asserted that Stevens may have contracted anthrax by drinking from a North Carolina stream. "We cringed when we heard Thompson’s comments," Traeger said. No one could get inhalational anthrax from contaminated water.
On Saturday CDC’s Sherif Zaki arrived in Florida to perform the autopsy on Stevens, then returned to Atlanta along with all the environmental and clinical samples collected thus far. At 6:25 p.m. on Sunday, October 7, Perkins and the Florida CDC team were eating dinner at a cheap Italian restaurant. "We were feeling pretty good," recalls Josh Jones. "We had worked hard and had found nothing of real concern."
Then Perkins got a call from Zaki on his cell phone. The samples from Stevens’s computer keyboard and mail slot tested positive for anthrax. Bioterrorism, Perkins thought. It had to be an intentional exposure, probably from a letter.
On Friday, October 12, the phone woke New York City epidemiologist and EIS alum Marci Layton around 3 a.m. The biopsy results on 38-year-old Erin O’Connor, assistant to NBC news anchor Tom Brokaw, were positive for anthrax.
By the end of the day, three other media-related cases had been reported to Layton from ABC, CBS, and the New York Post. Over the next few days a total of seven media-related New York City cutaneous anthrax cases were identified.
Only two anthrax letters were found, addressed to Brokaw and the editor of the New York Post. Both tested positive for anthrax, were postmarked on September 18 in Trenton, New Jersey, and contained the same message in handwritten block letters: 09-11-01. THIS IS NEXT. TAKE PENACILIN NOW. DEATH TO AMERICA. DEATH TO ISRAEL. ALLAH IS GREAT.
The EIS officers conducting surveillance for bioterrorism in the city’s emergency rooms reported to the NBC offices at Rockefeller Center, where they were each paired with a mental health counselor. For the next three days they handed out Cipro, took nose swabs (all negative), and tried to allay employee fears. As a member of the Armed Forces Medical Intelligence Center, recent EIS grad Mike Bunning was dispatched to test the thousands of suspicious powder specimens that concerned citizens sent. Public health laboratories across the country were overwhelmed with suspect powder samples.
On Monday morning, October 15, an intern in Senator Tom Daschle’s office in the Hart Senate Office Building in Washington, D.C., opened a letter sealed with tape on all sides that released a puff of fine white powder. He placed the letter on the floor and called security. Daschle himself wasn’t in the building, but 13 of his staff were in the room at the time and were immediately put on Cipro. It wasn’t until 45 minutes later that someone thought to shut down the building’s ventilation system. The letter’s contents tested positive for anthrax, and it appeared to be of a finer consistency than the variety sent to New York — more easily airborne.
By the end of the day the entire building was shut down, as was mail delivery throughout the Capitol. Over the next three days EIS officer Scott Harper and his colleagues gave antibiotics to more than 2,000 people who had been in the building. Twenty-eight nasal swabs tested positive, though no one contracted anthrax.
The Daschle letter featured the now-familiar handwritten capital letters, beginning with: YOU CAN NOT STOP US. WE HAVE THIS ANTHRAX. YOU DIE NOW. It had been postmarked in Trenton, New Jersey, on October 9, which meant that, like the New York media letters, it had traveled through a large postal distribution center in Hamilton, New Jersey.
After hearing about the New York cases, two New Jersey doctors had notified the state health office of possible cutaneous anthrax in Teresa Heller, a postal carrier, and Patrick O’Donnell, who worked in the Hamilton distribution center. On October 18 Heller’s wound biopsy tested positive for anthrax. With two likely cases of cutaneous anthrax in mail handlers, a CDC team led by EIS alum Beth Bell flew up to New Jersey that afternoon, accompanied by EIS officers Jennita Reefhuis and Michelle McConnell. By the time they arrived, the Hamilton facility, which processed approximately 2 million pieces of mail per day, had been closed.
As several postal employees in D.C. and New Jersey contracted the disease and some of them died, it seemed as though the anthrax cases would never end. "It was like getting slammed by an ocean wave," CDC director Jeff Koplan said. "Wham! You just have to keep moving and dive right in."
On November 16 an unopened anthrax letter addressed to Senator Patrick Leahy was found in mail that had been quarantined after the arrival of the Daschle letter. It, too, had been postmarked in Trenton on October 9. Three days after the Leahy letter surfaced, Ottilie Lundgren, a 94-year-old widow who lived alone in rural Oxford, Connecticut, was diagnosed with inhalational anthrax. She died two days later.
Lundgren was the last anthrax victim of the 2001 bioterror spree. A total of 22 people had been infected, half of them with inhalational anthrax, and five inhalational victims had died. Of the 146 then-current EIS officers, 136 helped with at least one part of the investigation. Nearly a third of them went out twice, and some were redeployed four or five times.
EIS alum Larry Altman, a New York Times science reporter, complained of the "distressing lapses in communication with the public" during the anthrax investigation, as did alum Philip Brachman. "You won’t ever prevent hysteria," Brachman said, "but you feed hysteria by not releasing information." In future bioterror events, he advised that "a single and well-informed source" should be the spokesperson.
CDC director Jeff Koplan probably should have been allowed to be that person, but at the onset of the anthrax scare, he was forbidden to make public statements. Tommy Thompson made his life miserable by insisting on personal updates several times a day.
The FBI and most other experts concluded that the perpetrator was probably a U.S. citizen, perhaps an unhinged scientist with the expertise to produce finely milled anthrax spores. (In July 2008 military scientist Bruce Ivins, who worked with anthrax at Fort Detrick, Maryland, committed suicide as the FBI was amassing circumstantial evidence that he had sent the anthrax letters. Some critics remain unconvinced of his guilt.)
In the wake of the anthrax letters, the Bush administration and Congress threw billions of dollars into bioterror preparedness, much of it going to the CDC and to state health departments. Tommy Thompson called for an EIS officer in every state, but some states had weaker public health infrastructure and lacked good supervisors. Instead, EIS alums called career epidemiology field officers (CEFOs) were posted to such states, though they focused primarily on terrorism and emergency response.
The new bioterror money undoubtedly improved preparedness for many potential public health emergencies, but other problems were underfunded, according to EIS alum Barry Levy, editor of the 2003 book Terrorism and Public Health. "These bioterror initiatives have, in general, distorted public health priorities," complained Levy, "and drained human and financial resources away from addressing current public health problems, including tobacco- and alcohol-related diseases, gun-related injuries and deaths, HIV/AIDS, and mental health disorders."