HOW EXPERTS MISSED ANTHRAX CASE
07 Dec 2002
Source: Washington Post, November 19, 2001
How the Experts Missed Anthrax
Brentwood Cases Defied Assumptions About Risks
By Steve Twomey and Justin Blum, Washington Post Staff Writers
His name was Leroy Richmond, and he was lethargic but coherent and calm. He had been waiting in Inova Fairfax Hospital's emergency room for a while, triage having put him at low risk because his symptoms were only labored breathing, slight fever and such. Cecele Murphy, the attending physician, entered exam room 8 and began chatting with Richmond as she watched his vitals on a monitor. It was late Friday afternoon, Oct. 19.
Where do you work?
It was a place Murphy did not know; Brentwood bore no notoriety yet. The patient said it was a post office and he handled Express, none of which was remarkable to the doctor. Richmond went on: Almost all of the Express Mail goes to the federal government. Half of that, he said, goes to the Senate.
"Bells and whistles went off," Murphy said.
Four days earlier, bioterrorism had been inflicted on a Senate building, via letter. No one was known to be sick, and no one was thought to be at risk beyond Capitol Hill. Yet here was a listless, 57-year-old postal worker who toiled miles from the Hart Senate Office Building, where the bioterror missive had been opened.
Murphy ordered a chest X-ray. It showed mild abnormalities. She ordered a CAT scan, a more potent investigatory tool. And there, the hints of inhalation anthrax: enlarged lymph nodes in the lungs. She reached for a phone -- "almost within seconds" -- and dialed across the Potomac River.
In an extraordinary week in a year with many of them, Murphy's call to the D.C. Department of Health that night was the pivot point. It began the transformation of an unsettling but seemingly contained health problem on the Hill into a medical emergency affecting thousands of people well beyond it.
More importantly, it was the first serious crack in the medical foundation that underlay the official response to the only outbreak of bioterrorism in U.S. history, according to interviews, statements and congressional testimony. It meant the federal government might be wrong.
Until then, the Centers for Disease Control and Prevention had assured nervous postal officials that based on previous mail of the terror campaign and the CDC's knowledge of anthrax, not enough spores could escape sealed letters or packages to cause the most serious form of the disease, inhalation. Only certain Capitol Hill workers needed to take antibiotics because only people present when a letter is opened face a potentially deadly threat, the CDC believed, not those who handled a letter as it navigated the postal system.
But now, Richmond was sick with what, indeed, turned out to be inhalation anthrax. "It was becoming clear," said Ivan C.A. Walks, the District's health director, "that what were sound CDC recommendations based on prior knowledge and science had left the Brentwood workers unprotected."
Richmond would live because of Murphy and the Inova team. But by Monday, Oct. 22, two postal workers were dead of anthrax; the Brentwood Road NE processing facility was closed; 2,000 Brentwood workers were being urged to take antibiotics to ward off illness; and complaints were rising that officials had acted less swiftly to defend the blue-collar, often minority workers of the Postal Service than they had the white-collar, mainly white world of Capitol Hill.
A close examination of the events of that week suggests that Brentwood workers were not victims of such a double standard. So confident was government that the workers faced little risk that high-ranking health and law enforcement officials had a news conference inside Brentwood on Oct. 18 -- and had to begin taking antibiotics themselves after illnesses and tests revealed that the facility was a hot spot of anthrax spores.
Rather, local and federal officials were trying to contain a disease that was not well known, being spread in a way never seen. CDC and Postal Service officials say they did the best they could with what they knew, and numerous outsiders agree, including national unions representing postal workers.
"There was not a neglect on the part of the CDC of the postal workers of our community," Walks told the Senate Governmental Affairs Committee, which is examining the events. The CDC's assessment of the risks to Brentwood was based on "the best science," he said, science later found "not to be compatible with this form of anthrax."
Even so, others wonder whether the CDC reacted quickly enough as evidence mounted that the best science might be flawed, and whether the CDC assumed too much. Sen. Joseph I. Lieberman (D-Conn.), chairman of the Governmental Affairs Committee, said Brentwood should have been shut Oct. 18, three days before it was. And Tara O'Toole, deputy director of the Center for Civilian Biodefense Studies at Johns Hopkins University, said the tragedy illustrated the need for a system within government to gather information better and anticipate all possibilities.
Whether a faster response would have saved those who died cannot be known. But during a Governmental Affairs hearing, Sen. Max Cleland (D-Ga.) said federal health officials "didn't quite know exactly what [they] were dealing with, except Brentwood became the place to pay the price."
Assurances of Safety
In his truck, Clarence Raynor usually listens to WTOP as he ferries mail from Brentwood to neighborhood post offices and back, and on the afternoon of Oct. 15, the all-news station told him that a letter that might have anthrax spores had arrived in the Hart offices of Senate Majority Leader Thomas A. Daschle (D-S.D.). Raynor, though a postal worker for only four years, knew the arteries of delivery in the city, and he knew that the Daschle letter must have passed through Brentwood. "If he's contaminated," Raynor thought, meaning Daschle, "we're contaminated."
Not that Raynor, 48, is an expert in how bacteria can penetrate or float. But he knew what sorting machines do to a piece of mail. "It is shaken, bounced around, pulled at, tugged at, beat up. . . . It is not just sitting still." And he knew how the machines were cleaned, how dust and scraps were blown. "They do it with pressurized air. It's like an air hose at a service station." In the Brentwood break room, though, there was only chatter about the Daschle letter, not agitation about it, Raynor said. "It's more or less a wait-and-see game."
As he worked his routes that day, officials at an Army facility in central Maryland, working with extreme caution, were examining powder samples from the Daschle letter, received from the FBI and U.S. Capitol Police. By that evening, the agency -- the U.S. Army Medical Research and Materiel Command at Fort Detrick -- was able to report early findings in conference calls.
The Daschle contents seemed to be anthrax spores. And one more thing. Fort Detrick "had been somewhat surprised by the nature of it . . . that it was a fine powder, that it easily went into the air," said Mitchell L. Cohen, director of the CDC's division of bacterial and mycotic diseases, who participated in one of the conference calls as the CDC's liaison to the FBI. The smaller and more floatable the spores, the more likely they will be inhaled.
During the hours that followed, conflicting terms would be used publicly to describe the powder, including "weaponized" and "garden variety," and an impression was created that the Daschle attack was more dangerous than ones discovered earlier involving NBC News and American Media Inc., the publishing company in Florida where the anthrax scourge first arose.
Actually, at the time of Fort Detrick's analysis, no one knew whether the Daschle spores were more dangerous than the others. No letter has ever been found in Florida, and the letter opened in the office of NBC News anchor Tom Brokaw did not have enough material to show how fine its particles were. Still another letter, sent to the New York Post, did have enough powder to analyze -- but no one had done so because it lay undetected in the newspaper's mail system. Law enforcement would not have it for days.
"This was the first material that we had actually seen," Cohen said of the Daschle letter.
Despite that, the CDC reasoned that the spores of the Daschle, Brokaw and Florida letters had the same properties and, therefore, posed an equal danger. The perpetrator would have created a batch of spores and divided it among the letters, Cohen said, adding that he knew of no discussions between the FBI and CDC about whether the criminal might have changed the nature of the weapon. Steven Wiersma, state epidemiologist for the Florida Department of Health, said he also assumed that the letters contained spores with the same properties.
Apparently, they did not.
After authorities found the New York Post letter, which was mailed the same day -- Sept. 18 -- as the Brokaw letter, they determined that its spores were not as fine as those in the Daschle letter, senior law enforcement officials said. The material in all the letters was the same genetically, but not in size or refinement. That difference is suggested by the eventual health toll: Only two postal workers in the paths of the Brokaw and Post letters became sick, both with the milder cutaneous anthrax, but seven became sick after the Daschle letter was mailed, six with inhalation anthrax.
On Oct. 15, though, no postal worker was known to be ill. And that was crucial to the CDC. Only people in the Florida and New York destination offices had gotten some version of anthrax, suggesting that however fine the powders being sent, however floatable the Daschle material was, spores were not leaking en route, at least not enough to cause inhalation anthrax. Bolstering the CDC's analysis, the Daschle letter was heavily taped. So were the Brokaw and Post letters, postal inspectors say now, as if the perpetrator wanted to ensure that his spores reached their targets and did not fall out flaps or corners.
The CDC had no studies to prove that sealed letters were trustworthy vessels. But Ronald M. Atlas, the president-elect of the American Society for Microbiology and a professor of biology at the University of Louisville, said he would have assumed what the CDC did, that powder could not escape a sealed envelope. Likewise, E.J. Rice, vice president for development at the Institute of Paper Science and Technology in Atlanta, said that if the CDC had called him then and asked whether spores could pass through envelope paper, he would have said, "We don't think there's much chance of that happening."
Rice would not say that now. The institute has since run tests of paper, he said, and saw gaps "that are in the order of 10 microns in size," bigger than the anthrax spores in the Daschle letter. The gaps do not always go all the way through, he said, but "I think there's a reasonable probability that some micro-size material could find its way through some paper."
Later, Sen. Fred D. Thompson (R-Tenn.) told Army and CDC officials that given the "billions of dollars" spent on research and preparedness, "you would think" the possibility that anthrax spores could escape a letter "would have occurred to somebody."
As health and government officials met and telephoned in the wake of the Daschle letter, hundreds of Capitol Hill workers were lining up for antibiotics, including many who had been nowhere near the Hart Building when the Daschle letter was opened. Nothing like that was happening at Brentwood. Neither people nor equipment was being checked to see whether the facility was contaminated. Hundreds of postal employees kept moving the mail.
"We hadn't heard anything," worker Helen Molinos said. "We assumed everything was all right."
Evidence Adds Up
The same day the Daschle letter arrived, and 1,000 miles south, officials announced that anthrax spores had been detected at a mail facility in Boca Raton, Fla., through which a letter to American Media Inc. might have gone. By then, many of the mail facility's workers had been taking precautionary antibiotics for three days.
Then, on Wednesday, Oct. 17, spores were found in a mailroom at the Dirksen Senate Office Building, through which the Daschle letter had gone. And the next day, a case of cutaneous anthrax was detected involving a letter carrier at a postal facility near Trenton, N.J., through which the Brokaw letter had gone.
All those problems might have arisen from other, still-unfound terrorist letters, letters that were not sealed tightly or were accidentally slashed in processing, shedding spores in postal facilities. Just Friday, the FBI announced that a search of Capitol Hill mail impounded after Oct. 15 had uncovered what appeared to be another terrorist letter, addressed to Sen. Patrick J. Leahy (D-Vt.).
But the evidence of contamination and illness that was mounting immediately after the Daschle letter arrived also raised the possibility that the "sealed envelope theory," as a government investigator called it, "didn't hold water." Spores might have seeped out of the Florida, Brokaw and Daschle letters no matter how well they were taped, perhaps directly through the paper. They might have reached postal machines, people and other mail.
"Once the traces were found in the Dirksen mailroom, shouldn't that have set off an alarm that something unusual was happening, that maybe it was possible for this stuff -- the anthrax -- to get out of the packages or the envelopes, and not just endanger people once the package was opened?" Lieberman asked at a hearing.
Replied Maj. Gen. John S. Parker, the commander of Fort Detrick: "The fact that the spores did, in fact, pass through porous areas in that [Daschle] envelope and create an aerosol that caused harm in this particular case was maybe a fact too far for most of us, sir."
By Wednesday, Oct. 17, postal officials were increasingly worried, despite CDC assurances. Postal authorities had been giving information to their workers about the nature of anthrax and how to be safe in handling mail, but there was anxiety on the Brentwood work floor.
"We weren't experiencing a high absentee rate at Brentwood, but people wanted to know what we knew, and people wanted to know what we were finding out in real time," said Deborah K. Willhite, a Postal Service vice president. "We wanted to make sure the facility was not contaminated."
That day, the Postal Service called the D.C. Department of Health and the CDC in Atlanta and asked whether Brentwood workers should be given nasal swabs, to detect whether they had been exposed to anthrax spores. Rima Khabbaz, a CDC infectious disease specialist assigned to the Washington outbreak, said the answer was no.
Spores might have been leaking from envelopes, Khabbaz said in an interview, but it was unlikely that the totals reached 8,000. That is the number that decades-old studies with monkeys had suggested was the threshold for inhalation anthrax. (The current outbreak has raised the possibility that the threshold is not that high.) At worst, the CDC thought, postal workers might get cutaneous anthrax, which is easily treated. The side effects of giving them precautionary antibiotics might be worse than the disease.
"In all instances, we try to balance the risks and benefits of a public health action," Cohen said.
Whatever the CDC's beliefs, the Postal Service decided to act anyway. On Thursday, Oct. 18, Daryl Louder, a battalion chief and program manager for the hazardous materials response team of the Fairfax County fire department, got a call from a Postal Service doctor. The service had already hired a company to do lab tests for anthrax spores at Brentwood, but the results would take time. The doctor wondered whether Fairfax could do a faster check, however tentative, to see just how bad things might be.
That evening, two Fairfax workers in protective gear took samples at Brentwood, as the unprotected employees of the 24-hour plant went about their jobs, some noting the contrast. The quick results were negative. But by nature, field tests are rough and, Louder said, about 10,000 spores are needed to get a positive.
By this point, Joseph P. Curseen Jr. and Thomas L. Morris Jr., both Brentwood workers, were feeling the symptoms of the disease that would kill them. And the next afternoon, Leroy Richmond walked into the emergency room at Inova Fairfax.
No More Doubts
At 7 a.m. Sunday, Oct. 21, Khabbaz called Walks at home on his cell phone. "Ivan, it's confirmed," Walks recalled her saying. "He has inhalation anthrax."
Although Richmond's illness had been suspected since Friday night, Brentwood had stayed open as his case was analyzed and as the Health Department prepared for what was eventually set in motion: mass testing and preventive drugs. Walks's deputy, Larry Siegel, said the CDC was "justifiably suspicious" that the Inova case was inhalation anthrax, and it was "astounded, really" when it was confirmed.
That afternoon, Brentwood postal worker Terrance Braxton was home watching the Redskins beat Carolina for their first win. There was a news break: A co-worker had anthrax. Braxton was stunned. They weren't safe after all.
Morris died that evening.
Curseen died the next day.