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26 Feb 2003

Source: Esquire 139 (3), 214-222, March 2003.

What Ever Happened to Anthrax?

Second of Two Parts (click here for first part)

BY SEAN FLYNN (continued)

Wednesday, October 3. Bradley Perkins is an epidemiologist, but he looks like an exceptionally well groomed roadie, big and boyishly rumpled, with a mop of sandy hair swirling over his broad face. At the moment, he is in suburban Atlanta, waiting for his daughter to finish up her piano lesson, when his phone rings. It's David Ashford, one of the doctors on his staff at the Centers for Disease Control and Prevention. David tells him there might be anthrax in Florida.

He listens to David run through the basics, the symptoms, the early test results. His pulse quickens. A classic case, Brad thinks. David tells him where, Palm Beach County, just outside Boca Raton. Another flash. That's where the 9/11 terrorists lived. When he hangs up, it hits him. Everything fits. This is it. Bioterrorism.

He's dreaded this moment for years, knew it was coming, knew no one was ready for it. Brad supervises a team of the CDC's Epidemic Intelligence Service, which was created in 1951 to ferret out biological attacks, to catch the communists if they started spreading plague over the Korean peninsula. It turned out there wasn't much need for that. Using germs and viruses as weapons never became a mainstay of military arsenals, mainly because they proved too unreliable: Contagious viruses spread wildly, and aerosolized bacteria can drift with the wind, not unlike the way mustard gas occasionally blew the wrong way over the trenches of the Western Front. And as technology allowed for more lethal bioagents, the threat of retaliation kept everybody in check: An exchange of Ebola or smallpox was as palatable to the cold-war superpowers as a nuclear shoot-out.

So instead the EIS gradually shifted its focus to naturally occurring epidemics. When Brad Perkins signed on for a two year stint with the EIS in 1989, that's what he worked on. He chased down outbreaks of bacterial meningitis in Nairobi and Brazilian purpuric fever, then spent months unraveling the cause of cat-scratch disease. It was esoteric work, but he was damn good at it.

Twelve years later, Brad is in charge of the team he used to work for. And for the past few years, he's been worrying again about bioterror, about the man-made epidemics the EIS was originally formed to investigate. He's worked through all the tabletop exercises with the military people, the worst-case scenarios of a hundred billion bugs loosed over New York or Los Angeles, the single-point explosion, the massive attacks upon which generals fixate. But what has worried him most are the low-tech terrorists, the jihadists with black-market connections or the antiabortionist doctor who might swipe a few grams of something deadly from a lab. There had been hoaxes for years, usually at women's health clinics, letters sprinkled with talcum powder or cornstarch, with ANTRAX or ATHRACKS scrawled on the envelopes. Perkins always thought that if any of those hoaxes had been real, no one knows what would have happened. How far would the bacteria spread? How many people would it infect? How long before people got sick? How long before they died? How would we treat people?

No one knows. No one's been in a hurry to find out, either. In the late nineties, almost a decade after President George H. W. Bush scared the bejesus out of America with promises of Iraqis gassing troops in the desert, the CDC finally got some money to start stockpiling antibiotics and to organize a network of labs to respond to an attack early. But there was still no cash for research. No real-life models to work from, either, only guesses, and most of those were extrapolated from a twenty-two-year-old accident six thousand miles from home. In the spring of 1979, a worker at a military lab near Sverdlovsk in the former Soviet Union forgot to replace a filter in the exhaust system, and anthrax spores drifted out into the night wind. Because the Soviets never fully acknowledged the accident, the best guess is that at least sixty-six people died and dozens more fell ill, the last of whom developed symptoms more than six weeks after the initial exposure.

That's all we know. That's what Perkins has to go on. One old man's symptoms and twenty-two-year-old ghost stories. He works the phones for a few hours, then goes home to pack for the flight to Florida.

It's a quarter past seven on Wednesday night, thirty-five hours since Larry Bush peered into his microscope, and Jean Malecki is at JFK Medical Center, sorting through the details of Bob Stevens's life.

The final test results still aren't in, but, like Larry Bush, Jean assumes Bob has anthrax. She has to. Her job as public health director is to figure out how he contracted it, find out who else may have been exposed, and contain the damage.

An epidemiological investigation is a process of elimination. To be thorough, investigators have to backtrack, check every place Bob could have inhaled those microscopic spores. After the Sverdlovsk accident -- which Jean is familiar with because it is not difficult to master the entire body of available literature on anthrax outbreaks -- Russians were infected up to almost two months after the initial release. So she'll have to retrace Bob's final sixty days of consciousness, identify any suspect places, then clear each one. She's glad Brad and his CDC team are coming down; she can use the help. She called in the feds yesterday, Tuesday afternoon, right after she called the state's public-health officials.

Jean gets most of her information from Bob's wife, Maureen. She asks questions for three hours, gently probing during Maureen's visits to her husband's bedside. By a quarter past ten, Jean has a pretty good dossier on Bob Stevens (case 5).

He's a Brit, London born, but he's been in the States since 1974. He retired as a commercial artist and went to work for American Media Inc., which owns The National Enquirer and Weekly World News and a handful of other supermarket tabloids. He is a photo editor for The Sun, whose offices are on the third floor of AMI's headquarters, almost seventy thousand square feet of beige cement and smoked glass set behind a stand of trees in an office park in Boca Raton. He opens the occasional package, but mostly he downloads photos on his computer.

It's a forty-five-minute trip from the office to Bob's house in Lantana, thirty-five if traffic on Route AIA is light, and he drives with the sunroof open. In his backyard, there is an orange tree, pineapple plants, pots of herbs that he tends, and, near the pots, a patch of loose dirt where he'd yanked a thicket of weeds. Sometimes Bob will pick fruit from the tree and slice it in half for the juicer, usually without washing it off first. There are feral cats slinking around the neighborhood, which Bob and Maureen feed. If toads get into the kibble, Bob will catch them in a net and take them down to one of the local lakes. He's probably trapped fifty of them.

Jean's thinking that these are all ways, theoretically, that Bob could have been exposed. A dusting of anthrax on the orange tree, spores clinging to a toad, a puff torn loose with the weeds. There are other possibilities, too. John Prince Park, where he'd pedal his bicycle with a friend. Lake Worth Beach, where he'd take his granddaughter, Annalisa, almost every Sunday. The banks of Lake Osborne or the Loxahatchee Wildlife Refuge, where he fished. Bob bought his basmati rice and curry paste and garlic pickles from an Indian store on Dixie Highway, and his noodles from the Fortune Cookie Oriental Supermarket on Forest Hill Boulevard. Both of those places sell goat meat. He'd been to both in the past two months. Both will have to be checked.

Maureen tells Jean that her husband seemed fine a week ago, on Wednesday, September 26. The next morning, at seven o'clock, they left home and started driving north on Interstate 95 toward Charlotte, where their daughter Casey lives. They stopped only for gas in Georgia. Exit 29. Maureen's good with the details.

They got directions at a hotel in North Carolina, found their way to Casey's house at about 5:30. Her puppy, a mutt she rescued back in June, nipped at them. Just playful, nothing serious.

The next morning, Friday, the three of them drove out to a place called Chimney Rock, rode the elevator up to the observation deck at the peak, looked around, came back down. Then they hiked a trail to the bottom of Hickory Nut Falls, where water cascades down a four-hundred-foot cliff. Bob leaned in close to the falls, scooped a handful of water, and drank it. He told Casey, "Tastes minerally."

Bob spent Saturday wandering around downtown Charlotte, walking the puppy in the park behind the apartment, then resting while Maureen and Casey went shopping. He felt tired, not sick. He went to bed a little earlier than normal, just before ten.

It hit him on Sunday, October 1, about 12:30. They were driving to Durham to see Casey's boyfriend, Andrew, a student at Duke, when Bob started shivering, shaking, his face flushed. He lay down for a couple hours in Andrew's fraternity house, then rode in the rear seat back to Charlotte. His appetite disappeared. He slept deep and hard. The next morning, Maureen felt his pillow. It was soaked with sweat.

They were up by 6:00 A.M., on the road to Florida not long after. Bob drove, sipped bottled water, and kept a sweater on the whole trip. They were home by five. Bob skipped his usual beer, drank some hot tea instead, ate a turkey sandwich. He told Maureen he felt awful, took his temperature: 101. He was in bed by eight, but he was fidgety, restless.

At 1:30 Tuesday morning, he woke Maureen with his retching. A few hours later, he was unconscious.

That's what Jean Malecki has to work with, the mundane details of a nice man's life. A million possibilities and not a single clue.

Brad Perkins and his team of CDC investigators are on the ground in Florida by four o'clock Thursday afternoon, October 4. They know for certain what they're dealing with now. The final test on Bob's spinal fluid came back early that morning: positive. He's got inhalational anthrax, the first American case in a generation.

The strategy from here is straightforward: retrace Bob's last steps, collect samples pack everything off to the labs. At the same time, investigators are hunting for other cases. It's unthinkable that Bob was the only one infected. Jean already has the medical examiner poring over old death certificates, looking for any unusual fatalities. She has veterinarians going through their files, too. Nearly three dozen hospitals on the east coast of Florida are put on alert for patients with symptoms like Bob's.

Working from Jean's notes, Brad organizes his staff into three teams. Friday morning, they split up. One goes to the lakes where Bob fished and the park where he rode his bike. Another takes the stores where he bought his spices and noodles. Brad takes the third team to Bob's house. (A separate CDC squad retraces his North Carolina steps.) He's not expecting to find anything there, but he has to check. Maybe Bob has an old coat lined with goat hair in his closet or a mangy sheepskin rug stuffed in a corner of the garage.

Brad spends a few hours at the house, poking around the yard, wiping dust from the walls. It's a total crapshoot. The swabs he's using to collect the samples have never been used in the field before. He doesn't know if they'll pick up any spores that might be lingering on a countertop, doesn't know if they'll kick out false positives in the lab. All he knows is nothing looks suspicious.

By early afternoon, he's driving south to Bob's office in Boca. His gut is telling him that's where he'll find the anthrax. Still, he doesn't want to put on the protective gear. The staff at AMI is edgy enough without men in white biohazard suits tromping around their cubicles. Brad's taking a precautionary course of antibiotics, which should-should-neutralize any low-dose exposure. If he goes into any high-risk areas, like the vent system or the air-conditioning units, he'll put on the full armor.

Brad and his staff talk to Bob's coworkers, ask if he's gotten any suspicious packages. No one remembers anything like that. They ask if Bob has any enemies, if he was into anything weird, if any crackpots have been harassing him. No. Everyone likes Bob.

He goes to the third floor, finds the desk where Bob downloaded photographs on his computer. Like Larry Bush and Jean Malecki, Brad is thinking the spores might have been mailed into the building. Okay, he says to himself, where do I open a letter? He looks at the desk. All right, powder falls out. Where is it going to be undisturbed a week later? He looks at the computer. Dust clings to the screen, gets trapped in the keyboard. He dabs samples from both surfaces. His team moves through the rest of the building, swabbing here, wiping there, picking areas where they think air currents might have carried stray spores. They work down to the first floor, where the mail room is tucked next to the front entrance.

Brad's lost track of how many samples they've collected. Fifty-six so far, he thinks. He has one swab left for the mail room. He has to pick his Spot. He finds the cubbyhole where Bob's mail was deposited, runs the swab inside, then packs it into a sterile container to be shipped to the lab.

Right about then, at four o'clock in the afternoon on Friday, October 5, Bob Stevens dies.

The pieces fell together quickly after Bob died. On Friday night, only hours after his death, a hospital in Miami reported a patient with a stubborn case of pneumonia. His name was Ernesto Blanco (case 7), and he was the seventy-three-year-old mail-room supervisor at American Media. The CDC sent people to swab the inside of Blanco's nose for anthrax spores: Those tests came back positive. So did many of the samples Brad Perkins collected inside AMI, including, most important, the one from the mail room. By Sunday morning, five days after Bob Stevens stumbled into the emergency room, investigators had determined where he'd been infected, who else might have been exposed-anyone who'd set foot inside the AMI building in the previous two months -- and how the germs had been delivered.

Of course, the headlines from Palm Beach unleashed an immediate panic across the country. The U.S. was under attack. Phantom anthrax was everywhere. Jetliners were grounded every time a stewardess spilled the NutraSweet, and hazmat teams were dispatched to sweep up brick dust and talcum power. Yet there was also real anthrax floating about, many millions of deadly spores that might have gone unnoticed if not for Bob Stevens.

In fact, he wasn't necessarily the first casualty. (It's impossible to pinpoint precisely when he was infected.) While Bob lay comatose in Florida, at least five people in New York City were suffering from cutaneous anthrax, with lesions that in one case had been misdiagnosed as spider bites. Once Bob was diagnosed, those cases were reexamined and quickly traced to a handful of letters mailed from Trenton, New Jersey. That, in turn, put Senator Tom Daschle's staff on alert when a nearly identical letter arrived in his office a few days later loaded with a pinch of powder containing millions of anthrax spores that theoretically was capable of killing several hundred, if not several thousand, people. A second letter, addressed to Senator Patrick Leahy, was discovered four weeks later in a pile of quarantined mail at a postal facility. After that, the Senate office buildings were shut down.

Those were apparently the last two anthrax letters, the last bursts of the attack. In New York and Florida and Washington, investigators swabbed the nostrils of thousands of potential victims, searching for spores that might have been trapped on their way into the lungs, trying to determine how far the bacteria had spread. Anyone who was at risk was issued a prophylactic supply of antibiotics in the hope that the germs could be overwhelmed before they took root.

Still, new exposures cropped up well into November. Spores had leaked from the envelopes as they passed through high-speed mail-sorting machines, contaminating equipment and whole buildings and then other pieces of mail that passed through. The last known case, the twenty-second infection and the fifth fatality, was diagnosed in a ninety-four-year-old Connecticut woman (case 23) who is believed to have contracted it from a piece of mail delivered to her house. She died on November 21, seven weeks after Bob Stevens felt the first chills of a fever.

Bob Stevens was an old guy with a bum heart who had a seizure and died. That happens in Florida every hour on the hour. If he'd died at home or if he'd died alone, if he'd been dead before anyone tapped his spinal column, only his relatives and his friends and his undertaker would have noticed. And the death toll could have been much, much worse.

Sixteen months have passed now, and no one knows who killed Bob Stevens and four other people, poisoned seventeen more, and terrorized the country for seven weeks. Or why. Or, by logical extension, how to stop him or her or them the next time. As criminal investigations go, Amerithrax -- that's what the FBI calls the attacks --has been an exercise in impotence.

A few facts have emerged since October 2001. Brad Perkins, for one, learned that the swabs he wiped across the desks in the American Media building actually worked, that the CDC has the tools to collect trace amounts of anthrax should this ever happen again. On the other hand, investigators also learned that swabbing the nostrils of potential victims is not particularly useful: The correlation between having a spore in one's nose and developing symptoms is nonexistent. At best, the swabs can help define the area of exposure.

Public-health officials learned that most of what had been expected to happen in an anthrax attack was wrong. For instance, it was believed that spores couldn't re-aerosolize that is, that once they had settled onto a surface after the initial release, they couldn't float back into the air. Not true, especially if the spores are resting on a mail-sorting machine that's blasted with compressed air as part of its routine maintenance. Curiously, it's both more and less deadly than they thought. On the one hand, they now know that far fewer than eight thousand spores can kill a person. After the ninety-four-year-old woman in Connecticut died (case 23), epidemiologists sifted through her house, even stirring things up with a leaf blower. They found no other spores, which suggests she inhaled a stray cluster clinging to an envelope. On the other hand, they discovered that, properly treated, even inhalational anthrax isn't necessarily fatal, that an early and heavy dose of antibiotics can kill the bacteria. (Assuming the germs aren't engineered to be drug-resistant, that is) Oddly, for a bunch of science geeks, they also had to be reminded of the basic rules of geometry. Initially no one at the CDC suspected postal facilities would be contaminated because the seams of the envelopes had been taped shut, apparently to keep the powder from leaking. Yet an anthrax spore three microns wide can easily slip through paper fibers with fifty-micron gaps between them-and did, causing two postal-worker deaths (cases 15 and 16).

The cops and the doctors have also figured out how Bob Stevens was infected, which, like all the other cases, was through the mail. Letters delivered to the American Media building -- which is still closed, by the way -- were sent along two different routes: one that handled the bulk of the packages and a second that rerouted mail first sent to an outdated address for The National Enquirer. Both were contaminated with spores, which means more than one letter had been sent. Some employees remember seeing a curious letter about Jennifer Lopez -- a marriage proposal folded around a small Star of David -- that might have been the source. Eventually, investigators found anthrax spores in eighty separate areas of AMI.

Most important, it has been determined that the anthrax in each of the mailings was from the same batch and apparently did not increase in potency from New York to Washington. Technically, as one CDC official puts it, "the isolates are indistinguishable from each other," which in the context of terrorist bioattacks means they're identical. That isolate, meanwhile, is from a strain of anthrax routinely used in American research labs, including military ones.

None of this information, though, is going to be of any practical use if another round of letters is injected into the postal system. "Usually we can explain epidemiologically what happens in a disease outbreak," says Stephen Ostroff, a CDC epidemiologist who investigated the New York infections. "You know, we can say it was the tacos, and we can go back into the plant and pinpoint how the tacos got contaminated. And if we think it's bad tacos, we can get rid of the tacos. Here, unless we shut down the entire U. S. mail system, we can't stop it."

Or unless the bad guy, or bad guys, is caught. On the face of it, that shouldn't be terribly difficult. Given the particular strain of anthrax that was used, there are only a few dozen people with both the access and the expertise to refine the spores into the powder that killed five people. Still, after nearly a year and a half, the feds don't have enough to arrest, let alone convict, anyone.

There have been suspects, of course, a few characters dragged out for public flogging, the most notorious of whom was Steven Hatfill, a researcher who worked for a time at a military lab. In August, Attorney General John Ashcroft publicly called him a "person of interest" in the Amerithrax case, which apparently means only that Hatfill was a convenient distraction during fruitless months of sleuthing. The feds made quite a spectacle of him, searching his house and his girlfriend's, too, wading through ponds, even leaking an improbable tale about bloodhounds woofing and pawing when they sniffed around a restaurant where Hatfill had eaten. Yet they seem to have found no evidence -- no equipment, no matching handwriting samples, not even a stray anthrax spore. The media scrutiny was so intense that Hatfill held two press conferences to declare he was innocent of a crime for which he was never charged.

The main thing the anthrax attacks of 2001 demonstrated was how wholly unprepared the country is to respond. Emergency rooms can report suspicious infections and antibiotics can be stockpiled and epidemiologists can backtrack to the source of infection, but once an epidemic is loosed, finding the mad scientist responsible isn't going to save anyone. A criminal investigation would be useful only for intelligence -- figuring out who has access to bioweapons and the will to use them -- and vengeance. But people are still going to die.

At the moment, smallpox is the dreaded bioagent of choice, a virus that was supposed to have been eradicated a generation ago. Except several vials were kept for research purposes, and a few tons were grown as part of clandestine weapons programs in the former Soviet Union. It is hardly the only menace, though. The world's bioweapons engineers have tinkered with bugs most people have never heard of (tularemia and Marburg, for instance) or believed were eradicated ages ago (bubonic plague) or, at the very least, thought were confined to distant shores (Ebola). There are no effective defenses against most of them, either. A few billion filoviruses dumped in the New York City subways could eliminate half the Manhattan populace, and quite gruesomely. Then it would spread. Even a more sophisticated strain of anthrax, one that antibiotics couldn't kill, would be a disaster of epic proportions.

October 2001 could have been -- should have been -- far more deadly and far more terrifying than it actually was. If Bob Stevens had died alone or if he'd died at home, Larry Bush never would have looked through a microscope at a drop of his spinal fluid. If Bush hadn't done his job so well -- if he hadn't recognized an esoteric microbe so wildly out of context; if he hadn't trusted his instincts Bob could easily have been misdiagnosed. Then the dominoes would have begun to fall: Without Bob Stevens, the Florida attack goes undetected until dozens, maybe hundreds, of AMI workers fall ill. Meanwhile, the New York cases remain mysterious lesions and spider bites, which means the anthrax-laden letters are found later, if ever. So when similar letters arrive in Washington, perhaps they're not taken quite so seriously. And even if they are, the spores would by then have had almost a month to circulate through the postal system, cross-contaminating mail and infecting workers. Five deaths were a fraction of the potential toll.

"Can you imagine if Tom Brokaw died of inhalational anthrax?" Bush says now. "Imagine if Senator Daschle died of inhalational anthrax. And they were sent enough to kill them. What message does that send? Not only can we knock down your buildings, not only can we kill thousands, we can kill your senators. With a letter. We can pick and choose."

He leaves that thought to linger. "You know," he says, "some guy, the general public, you open your mail, you die, no one knows why -- who cares?"

His family cares. And his friends and his undertaker. Then it's too late for everyone else.

End of Second of Two Parts (click here for first part)