THE ANTHRAX CRISIS
12 Feb 2003
Source: Newsday, October 8, 2002.
The Anthrax Crisis
How a suspected case in NYC threaded its way to diagnosis despite initial CDC uncertainty
by Laurie Garrett, Staff Writer
Second of two parts (click here for first part)
A year ago, the nation's public health "surge capacity" was put to the test.
The culprit, anthrax, wound up infecting only 12 people, killing five of them. Yet, it utterly sapped the capacities of public health operations not only in targeted areas, such as New York City, but throughout the nation.
Last October the deadly white powder was seemingly everywhere.
"It was a national problem," Dr. James Hughes, director of the Centers for Disease Control and Prevention's National Center for Infectious Diseases, said in an interview in his Atlanta office. "All the state public health laboratories were overwhelmed with specimens, hoaxes. It was even true internationally."
Such emergencies call for rapid conversion of hospitals, fire departments, public health offices and, perhaps most vitally, diagnostic laboratories into crisis facilities that can process high volumes of material for a sustained amount of time.
"Surge capacity - imagine!" said Hughes. "If it was exhausted for us here at CDC - literally and figuratively - you can imagine what this means at the local level."
In New York as the anthrax crisis heightened, "there were immediate problems," said Dr. Isaac Weisfuse, the New York City deputy health commissioner. "There was an expectation of instant analysis. Doctors wanted answers now. The volume of material far exceeded our capacity. The NYPD was bringing stuff in at all hours, day and night."
The lab was prepared to handle "swab samples," he said, but wound up facing deliveries of easy chairs, briefcases and newspapers - all suspected of being tainted with anthrax. The health department's three bioterrorism-trained lab workers were toiling around the clock, processing hoaxes - a routine that would continue for four weeks.
New York's anthrax vigil had begun in early October, when the first cases were diagnosed in Florida. Even as fears and hoaxes were sending health department labs all over the country close to maximum capacity, the effect was more pronounced here because Dr. Marcelle Layton, head of the city health department's communicable disease section, had faxed a 13-page anthrax advisory to 65,000 physicians in the city, urging them to report suspected cases.
But Layton had a new concern: She was worried about the case of Erin O'Connor (case 2), assistant to NBC news anchor Tom Brokaw. O'Connor recalled that on Sept. 25 she opened an envelope addressed to Brokaw and noticed it contained a white powder. A few days later she developed an ugly, yet painless sore on her left collarbone.
Though a series of doctors and O'Connor herself felt certain she was the victim of an anthrax attack, neither the New York City Department of Health lab nor the U.S. Army's lab at Fort Detrick in Maryland was able to find any anthrax spores in the envelope or in O'Connor's skin biopsy.
Layton knew that if O'Connor had anthrax, evidence would be hard to find. That's because a tissue biopsy of the sore wasn't taken until several days after she had been placed on antibiotics by another physician. And effective antibiotic use makes it almost impossible to find intact Bacillus anthracis in the tissue of an otherwise healthy individual.
So Layton called Dr. Steven Ostroff, a Hughes deputy who had been the CDC's point man in 1999 during the West Nile virus outbreak. He was in Washington to address Congress about protecting the nation's food supply, and Layton reached him at the Willard hotel. She knew that the only facility in the world capable of finding anthrax in O'Connor's biopsy - if, indeed, it was there - was the CDC lab known as RRAT.
The Rapid Response and Advance Technology lab in Atlanta, where pathologists are affectionately referred to as "The RRATS," was the brainchild of Sherif Zaki, the CDC's top medical examiner. Over the years he had developed innovative techniques to find obscure organisms in human tissue. And last fall he hastily developed a new approach to identify anthrax: Using mice, he created antibodies to attack three specific proteins found on Bacillus anthracis, and chemically labeled the antibodies with dyes. If anthrax were in a sample of tissue, Zaki would see bright magenta, rod-shaped bacilli under his microscope.
Ostroff recalled that Layton "asked me if I could arrange to have specimens tested that were from an NBC employee. She called me directly, because she had already called the CDC lab and they had said, 'We're already overwhelmed with specimens from Florida.' She wanted a top priority test, no delays."
Ostroff agreed to the testing and the samples were sent overnight via Federal Express from Manhattan to Atlanta.
On the afternoon of Oct.11 - even as the three lab workers in New York were processing hundreds of pieces of paper and desk objects found in O'Connor's work area at NBC, and the envelope that she had opened was delivered to Richard Meyer, a CDC lab chief - the O'Connor biopsy sample reached Zaki's lab. His staff set about exposing it to the dyed antibodies, a process that would take several hours.
Submitting it to microscopic analysis would be a tedious process. The sample - initially in a wax block, roughly one inch square - had been sliced into hundreds of paper-thin pieces, each one separately mounted on a glass slide. And every one had to be viewed by Zaki and fellow pathologists Wun-Ju Shieh and Jeannette Guarner. The trio pored over a microscope that allows up to five people to scrutinize a slide at once.
As they began their night's work, they saw healthy blue-stained human cells against a white background. Here and there they spotted isolated fragments of magenta-colored material, but these were not identifiable as anthrax.
At 1 a.m. they reached some slides that bore significant numbers of magenta pieces. That could indicate antibiotic- destroyed anthrax bacteria. Or it might be something else altogether.
Frustrated and exhausted, they were reaching the bottom of their pile of slides when Zaki spotted a single, isolated, fully intact magenta rod standing out against a sea of blue cells. On the same slide, far away, was another.
He was sure it was anthrax. Shieh and Guarner concurred. But they were mystified at finding only two identifiable organisms in the entire sample. They were well aware the Fort Detrick group had examined tissue from the same biopsy, using a different technique, and found nothing.
"But I was sure," Zaki would say later.
Hughes, the CDC infectious disease center director, called Layton at 5 a.m. to report: "It looks like anthrax." An hour later Mayor Rudolph Giuliani was on the phone, demanding to know: Is it anthrax or isn't it?
"We think it is," Hughes said. Giuliani said he didn't like the uncertainty, but he decided to go ahead and make the CDC's pronouncement public.
On that morning, Oct. 12, the NYPD showed up at the city health department lab with a second envelope addressed to Tom Brokaw that O'Connor had received within a week before the first envelope. It had been in one of O'Connor's file drawers.
"They took it to our lab," Weisfuse said, "and the handling of it caused a contamination event at our lab" later that day. Anthrax powder puffed out of the envelope in clouds, spreading across the lab. Two of the three lab workers inhaled it. Unlike their counterparts at the CDC, they had never been offered anthrax vaccines. They immediately began taking the antibiotic ciprofloxicin.
Their noses were swabbed for signs of anthrax, and results of the tests they conducted on their own samples came up positive. No one would develop symptoms. For their bravery, the lab workers would receive awards from the American Society for Microbiology 11 months later.
But on that October day Weisfuse had a problem. Two of his lab technicians were too traumatized to work, and there were hundreds more samples to test. Worse, the lab was contaminated and had to be sealed shut. (It remains shuttered, despite several gas treatments. So far, nobody has determined how to clean the lab sufficiently to guarantee that no deadly spores remain.)
Late that day, Layton called the CDC to report that this second envelope to Brokaw tested positive for anthrax, confirming O'Connor's exposure. Zaki, relieved to have his diagnosis confirmed, fell into his first restful sleep in days.
But for New York City's lab workers, a nightmare had just begun. The bioterrorism-trained trio "was very, very, very upset," Weisfuse said. And specimens kept pouring in to the city health department. "We needed a good Biohazard Level 3 facility" - where scientists wear protective gear and shower and scrub before entering or leaving - "fast."
New York City, where all emergency response agencies had gone through bioterrorism drills for three years, had another urgent problem. The carefully coordinated working relationship between the Department of Health and the fire and police departments' hazardous materials teams were in tatters, because members of the highly trained teams had perished in the World Trade Center on Sept. 11.
"So the police didn't know how to handle samples," Weisfuse said. Entirely new lines of communication and understanding between the health department and NYPD had to be created even as both were in crisis mode.
"Communication is the key," Layton said. "And the issue that always comes up is: Who is in charge? There was no question who was in charge in New York City - it was the mayor."
Because Giuliani took command of all direct communication with the citizens of New York, Layton and her colleagues focused on improving lines of information within the health department and to local physicians and hospitals. They had several distinct advantages, Layton said, from their experience handling West Nile virus.
Amid public anxiety in the summer of 1999, the department learned the importance of a daily flow of honest information, separately tailored for the general public and for physicians. They learned to resist the temptation to issue constant reassurances that everything was under control.
"The press would say to the health commissioner and the mayor, 'Can you assure us?' and they said, 'No, I can't reassure you. I can just give you the information accurately,'" Layton recalled.
Every night until well after Thanksgiving, Layton, exhausted, worked into the wee hours writing clinical and epidemiologic summaries of the day's findings on samples and human cases. These bulletins were faxed every morning to hundreds of hospital emergency rooms, infectious-diseases departments and physicians throughout New York City and the suburbs. It was Layton's conviction that physicians would be the first to spot new anthrax cases and were the most credible voices of calm for the worried public.
This simple exercise, copying the effort used successfully for West Nile virus in 1999, cemented lines of communication between the medical community and the Department of Health. "That's the thing I'm most proud of, those broadcast alerts. Physicians were screaming for them," Layton recalled.
Today, having caught their breath, CDC lab chiefs Meyer and Tanja Popovic have tallied the anthrax laboratory toll. All 50 states wound up inundated with suspicious samples by Thanksgiving, Meyer said. In addition, laboratories in 66 nations requested assistance or advice in processing possible anthrax samples. More than 80,000 specimens were analyzed nationwide, 45,000 of them in Florida, New York, Connecticut and New Jersey.
Meyer's group processed 7,000 additional samples during the fall. "I missed the entire fall," Popovic said. "I never saw it."
By December, when the federal Department of Health and Human Services declared the anthrax episode over, 12 people had contracted the disease, and five had died of inhalational anthrax. Two cases - those of elderly rural Connecticut resident Ottilie Lundgren (case 23) and Bronx resident Kathy Nguyen (case 22), a hospital clerical worker - remain a mystery. Though it was assumed they were exposed to contaminated mail, no culprit envelopes or papers were ever found in their homes.
The credibility of HHS and its scientists suffered from their inability to explain basic aspects of anthrax. For two weeks early in the anthrax scare, they insisted a fatal case of anthrax required inhalation of some 10,000 spores. But the Lundgren and Nguyen cases forced reconsideration, and by the end of the fall many government experts were saying it was possible, at least theoretically, that inhalation of fewer than 10 spores could be lethal. With that, every aspect of cleanup of contaminated sites became excruciatingly complex, as workers and politicians demanded assurance that not a single spore would remain alive in exposed buildings.
One year and billions of dollars later, the nation has upgraded its public health system, labs, computers, scientific research establishment and training of hospital personnel. Surely, the nation has learned many lessons, insiders say.
But is America ready for another mass mailing of anthrax, or a worse contagious-disease attack?
"We have certainly taken some giant steps forward," the CDC director, Dr. Julie Gerberding, said in a recent news conference. But, she added, "we are not satisfied, we are not finished, we have got more expansion and more work to do."
1) ‘Communication is the key. And the issue that always comes up is: Who is in charge? There was no question who was in charge in New York City - it was the mayor.’ - Dr. Marcelle Layton, head of the New York City health department’s communicable disease section
2) ‘There was an expectation of instant analysis. Doctors wanted answers now. The volume of material far exceeded our capacity. The NYPD was bringing stuff in at all hours, day and night.’ - Dr. Isaac Weisfuse, New York City deputy health commissioner.
End of second of two parts (click here for first part)