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12 Feb 2003

Source: Newsday, October 7, 2002.

Questions Linger a Year After Anthrax Mailings

Unknown dominates probe

by Laurie Garrett, Staff Writer

First of Two Parts (click here for second part) -- It came into the building in a letter. Somewhere along the way, Ernesto Blanco (case 7), an American Media company mail room clerk, handled it. The letter was opened near a stack of reams of paper for the 68,000-square-foot building's copy machines. Eventually, photo editor Robert Stevens (case 5) held the envelope, unwittingly sprinkling its contents onto his computer keyboard. It spread all over the three-story Boca Raton, Fla., office building as those reams of paper were inserted into copy machines that shuffled the pages about. Or so the Federal Bureau of Investigation would conclude a year later.

It was there, but nobody could have imagined its presence at the time. And nobody would, until Stevens was taking his final breaths and Blanco was lying in an intensive care unit, fighting for his life. Anthrax.

On Oct. 4, 2001, the world learned that Stevens was dying of acute inhalational anthrax disease, and with his death the following day a chain of events unfolded that would permanently imprint the word "bioterrorism" into the consciousness of Americans. It would shake up the country's public health system as nothing ever had. And it would test the resolves of thousands of health workers, the largest group of whom would be scouring the nation's capital and New York City in search of clues and answers.

A year later, those dogged disease detectives have scaled many obstacles, but still face a long list of unsolved mysteries. How two of the five anthrax victims -- including Bronx resident Kathy Nguyen (case 22) -- contracted the disease remains unknown. The FBI still is searching for the culprit or group responsible for the deadly mailings.

And officials at the federal and local levels still are struggling to reshape America's public health system, trying to mend the enormous holes in the nation's safety net that were revealed last fall. What became clear in the past year is the extent to which the public health system was overwhelmed by just seven known anthrax-laced envelopes.

On Oct. 2, 2001, Stevens, 63, was admitted to a West Palm Beach, Fla., hospital. He was in a terrible state. The American Media photo editor had been on a fishing vacation with his wife, traveling about the South, when he came down with what he thought was the flu, in North Carolina.

That was five days earlier, during which time his condition had worsened considerably. By Oct. 2, Stevens was nauseated and making little sense. He had no idea where he was, what year it was, or who was the president of the United States. Blood tests revealed a war was under way, with millions of white blood cells doing battle with some unknown invader.

While the nearby Jacksonville, Fla., public health laboratory tried to identify that mysterious invader in Stevens' blood, the hospital put him on massive doses of antibiotics. But the anthrax bacteria had long since made their way into Stevens' spinal cord and brain, triggering meningitis. As he lay in intensive care, the bacteria released three powerful toxins into his blood. It would be months before scientists, spurred by the urgency of the anthrax crisis, would study how these toxins kill.

One way, they learned, was by disabling Stevens' immune system, allowing the other two to wreak havoc inside cells all over Stevens' body.

Months later, scientists and clinicians would realize that giving antibiotics to patients as far gone as Stevens only worsens matters, as the drugs kill some anthrax bacteria, which break open, releasing their deadly toxins. The sudden toxic surge flooded Stevens' brain, causing a grand mal epileptic seizure. Were it not for a machine that pumped oxygen into his airways, Stevens would have died immediately.

By Oct. 3, the toxins began killing cells in Stevens' heart. He suffered a heart attack and then went into a coma. He never regained consciousness.

Months earlier, the federal Centers for Disease Control and Prevention in Atlanta had begun a poorly funded effort to upgrade the nation's public health laboratories in hopes of improving local capacity to diagnose rare infections, such as anthrax. A tiny cadre within the CDC, the Army and a handful of other institutions had long feared the potential use of biological weapons and was appalled to learn that most American health labs couldn't run reliable tests for a long list of likely germ weapons.

The gold standard for such lab work was set by CDC lab chiefs Richard Meyer and Tanja Popovic, who had trained several dozen local laboratory staffers before the Sept. 11 terrorist attacks. Yet nationwide, fewer than 100 health laboratories -- out of thousands -- had completed laboratory response network training and equipment upgrades, Meyer said.

Fortunately, one such trainee was Phillip Lee of Jacksonville, the man who grew anthrax from Robert Stevens' blood samples. Lee used the special stains and fluids Popovic had taught him would reveal the presence of anthrax in a fluid sample.

Peering through a microscope at a thousand-fold magnification, he saw Stevens' cerebrospinal fluid swarming with long thin rods, stained a deep purple, and lined up end to end to form chains -- classic attributes of anthrax bacilli. When he called Popovic on Oct. 3 to tell her what he found, the CDC scientist knew the result was solid -- America had anthrax on its hands.

The world's top DNA-PCR (DNA fingerprinting) lab and anthrax diagnostics facility is a two-tiered facility at the CDC. Meyer ran the first tier -- a section that conducted the primary screenings of samples, processing them both for anthrax DNA and as legally certified criminal evidence.

In a higher-security building, Popovic directed the lab that confirmed infection by growing living anthrax bacilli from a sample. Fortunately, Popovic's lab was housed in a brand-new building, completed just weeks before Sept. 11. A few months before, the dangerous work would have been performed in a World War II-era facility in which contamination could not have been easily prevented. By the time she received the fateful call from Jacksonville, Popovic and her tiny staff were working in a state-of-the-art facility, housed under security so strict that its innermost core could be entered only by a handful of people.

Meyer's DNA analysis could give a tentative answer within an hour or two, but Popovic's confirmation couldn't come any faster than the rate at which anthrax grows -- at least seven hours.

Back in Florida on Oct. 3, Lee's anthrax diagnosis was more a matter of puzzlement than anything else. Nobody then could anticipate the national chain of events that would unfold shortly. Lee didn't know that another patient -- mail clerk Blanco -- also was suffering from anthrax, or that the Florida cases were part of a bioterrorism event that had already led to skin infections in New York newsrooms -- infections that wouldn't be properly diagnosed for several more days.

On Thursday night, Oct. 4, the CDC's chief of meningitis and special pathogens, Dr. Brad Perkins, had just nestled in for his daughter's piano recital when his cell phone rang. The CDC caller told Perkins that a Florida man was hospitalized with inhalational anthrax. Fourteen hours later, Perkins was in Florida leading a CDC investigation to determine how Stevens got infected with a remarkably rare microbe. His first stop was the hospital where Stevens remained unconscious and was running a fever of 104 degrees.

"He was intubated, critically ill, unable to speak," Perkins recalled. "But I did not expect him to die that day. And actually the family was very hopeful that he was going to survive."

In Washington, Health and Human Services Secretary Tommy Thompson officially had announced the ailing Stevens' anthrax case to a nation whose nerves were still very much on edge from the Sept. 11 attacks. He said of Stevens' infection that it "appears that this is just an isolated case" and "there's no evidence of terrorism."

Proceeding on a scientific mission, Perkins took his team to the American Media building, where Stevens had worked for The Sun supermarket tabloid. As they met with editors who knew Stevens, the phone rang. It was the hospital, informing American Media that the photo editor had just died of anthrax poisoning.

"That was a fairly dramatic moment because we were sitting in a room with people who had known him," Perkins said. "This was a universally loved guy. Everyone was just in utter disbelief."

Stevens' Oct. 5 death brought grim urgency to a CDC investigation that spanned four states through which he had recently traveled. And it brought the world's media, numerous state and federal agencies and the White House into the picture.

Thompson once again faced the media, saying the anthrax case was probably of natural origin, based on something Stevens picked up from drinking from a South Carolina stream. Anthrax is not a water-borne organism, however, and the secretary's comment would haunt his department, undermining its credibility for months.

Thompson, a former governor with no scientific or medical training, issued orders that all information to the public and media come from his office, barring government scientists and health experts from providing expert advice or information.

In Florida, meanwhile, Perkins' job was to stay focused on leading a solid, scientific investigation.

He and his small staff meticulously scoured Stevens' home and office, as well as the American Media mail room, swabbing for anthrax spores.

In Atlanta, the CDC was eager to have autopsy results on Stevens, but nobody in Florida wanted to perform the procedure. Pathologist Sherif Zaki, the CDC's top medical examiner, flew to West Palm Beach on Saturday, Oct. 6, and headed straight for the morgue. He found the staff of the medical examiner's office understandably frightened, Zaki said, but willing to assist once he had explained safety procedures.

When they opened Stevens' chest, Zaki recalled, the team found "evidence of anthrax in literally every organ we touched," especially the man's disease-fighting lymph nodes. Those were so saturated with the toxins that they actually disintegrated as Zaki's probes touched them.

The next day, Perkins got word from the CDC's anthrax laboratory that swabs collected from Stevens' computer keyboard and the mail room tested positive for Bacillus anthracis. That finding triggered the FBI's criminal investigation. He also got CDC laboratory confirmation that there was a second case of the disease -- in someone who worked in the same building as Stevens -- and learned about Ernesto Blanco, fighting for his life in another hospital.

At that point, Perkins said, he decided to place thousands of American Media employees and recent visitors on ciprofloxacin antibiotics as a precaution. In coming days television footage of long lines of anxious Floridians queued up to get nasal swabs and pills would spark public anxiety and a demand for antibiotics. Within two weeks the nation's entire supply of ciprofloxacin would be sold out, with none available for treatment of genuine, and often serious, ailments for which it is normally used, such as children's ear infections.

In Atlanta, the CDC was deluged with calls asking who should be given antibiotics. In what doses? What are the symptoms of anthrax? Is the powder in my Alaska office a hoax or the real thing? The agency was in danger of being overwhelmed. And because of the directives from Thompson, most of the queries had to go unanswered.

"We needed information," John Auerbach, executive director of the Boston Board of Health, said recently. "Every kind of government report that we needed was delayed. We were getting information from journalists, for God's sake, not the CDC. There simply wasn't a good, accurate, timely internal communication system."

"We made a decision at CDC that the people who needed information in order to effectively respond should be our priority," Dr. Julie Gerberding recalled. Last fall she was the deputy director of the CDC's National Center for Infectious Diseases. Ten months later, her boss, Dr. Jeffrey Koplan, would be forced to resign and Gerberding would be named CDC director. Few could get information from the CDC for days, Gerberding would later concede, not even America's physicians, most municipal health directors or even members of Congress.

With the exception of New York City, where then-Mayor Rudolph Giuliani personally handled all public announcements related to terrorism, the nation's public health messengers were late in communicating. Public health officials learned that their communications systems -- computers, phones, faxes, video systems -- were woefully out of date. Their ranks of skilled speakers and information officers were thin, and their ability to control panic minimal.

A year later, the CDC has built the Health Alert Network, reaching every public health department, no matter how small or remote, in America. But that was a mere skeleton last October. "As events wore on, it became clear the CDC needed to be the primary source of scientific information," Gerberding said in an interview months later. "But once it was obvious to all that we needed to take the lead, we were in a reactive mode. And we are still catching up."

Within hours of the collapse of the World Trade Center, Dr. Kevin Yeskey, director of the CDC's Bioterrorism Response Program, had issued an alert to health departments nationwide "calling for enhanced surveillance, meaning, 'Please be vigilant for anything that might be suggestive of a bioterrorism event,'" Yeskey said. As word of the Florida case spread, health providers and public health officials all over America started remembering that alert, and anxiously sought information from Atlanta.

"I said, 'Let's set up an Ops Center here,'" Yeskey recalled. He sat down with a sheet of paper and drew a pyramid, with CDC director Koplan at the top and Infectious Diseases Director Dr. James Hughes and Gerberding just below. He drew a military-style chain-of-command map that connected Koplan to the field investigators then dispersed over the states tracing Stevens' movements and suspected additional anthrax cases.

Yeskey, a former military officer, marched into Gerberding's office, his chart in hand, and said, "We need a Special Ops Center. This is what it would look like. Field A responds to command leader A here in Atlanta, and Field B ... "

Gerberding stared at the piece of paper and thought it was a crazy idea. Slightly amused, she listened as Yeskey spun a web of desks and phones and chains of command. But under prior bioterrorism preparedness guidelines, she knew some sort of operational center was necessary, so she gave Yeskey the green light to implement what, in the back of her mind, remained a whacky concept.

Within 24 hours, Yeskey's team had transformed the CDC's auditorium into a command center, with portable walls erected according to the chart he had mapped out. In each space were CDC officers, drawn from their normal duties to handle emergency coordination. One desk was Florida. One desk soon would be New York City. As events unfolded, Washington, D.C., and other hot spots around the country got desks, staffed 24 hours a day by high-ranking CDC scientists whose job was to coordinate all the information and logistics in a given field location.

At another desk was a medical team that did nothing but answer questions from physicians. If doctors called in with suspected anthrax cases, that team had a list of questions and symptoms to walk the person through, aimed at winnowing out cases that obviously were not anthrax.

By mid-October, the Ops Center was a noisy beehive, coordinating activities all over the world -- indeed, a global liaison desk was added. Never in the history of the CDC had such a system been used. Of course, Hughes said, "Never in the history of the CDC have we dealt on so many fronts at the same time," even during serious epidemics.

A year later, the CDC is building a multimillion-dollar Special Ops center in Atlanta, and encouraging local health departments all across America to erect mini-versions of such communications and command centers. Looking back on October 2001, health officials shake their heads in wonder that Yeskey's primitive pyramid had somehow gotten them through the chaos of the anthrax crisis.

End of First of Two Parts (click here for second part)