Managing terror: Public health officials learn lessons from bioterrorism attacks - Health Policy Update

Physician Executive, March, 2002 by Georges C. Benjamin

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In early October 2001, a 63-year-old man presented to a Florida emergency department with fever and confusion.

During his evaluation, a widened medinistium and gram positive bacilli in his cerebral spinal fluid were found. Further testing revealed he had inhalation anthrax.

He died three days later.

This was the index case of an outbreak of anthrax caused by bioterrorism. At its conclusion, 18 people became ill and thousands potentially exposed. Eleven cases of inhalation anthrax and seven cases of cutaneous anthrax were diagnosed.

There were five deaths, all from inhalation anthrax. Over 33,000 people in four regions of the country required prophylactic antibiotics; a small subset elected to receive anthrax vaccine under an investigational protocol as an additional protective measure.

Epidemiologic and criminal legal investigations identified five letters filled with "weaponized" anthrax spores as the vectors of this attack.

What we thought we knew

Prior to this attack, the nation experienced several anthrax hoaxes delivered through the mail. Many of the envelopes contained powdery substances that were not infectious or toxic.

Based on this experience and limited clinical understanding of the pathophysiology of anthrax, bioterrorism planners developed several common beliefs that were ultimately proven incorrect. These included:

* Anthrax is easy to grow but hard to weaponize. This put the focus on state sponsored terrorism.

* A letter had to be opened in order to expose people.

* Weaponized anthrax stays put and exposure is a local event. So reaerosolization probably will not occur.

* Cross contamination is not a significant problem.

* Inhalation anthrax is 90 percent fatal.

Instead, here's what did turn out to be true.

* One variant of the anthrax was lightweight, almost gaseous.

* The letters turned out to be "leaky," especially when put through the violent processes of a postal service mailroom.

* The leaks resulted in illness and cross contamination of other pieces of mail and equipment.

* It was also discovered that early diagnosis and aggressive therapy of inhalation anthrax can reduce the mortality to less than 60 percent.

The response

In the past, the health care system responded to single disasters such as hurricanes, floods and fires confined to limited sections of the country.

These anthrax cases represented a new kind of disaster requiring partnerships across disciplines that had historically not worked together well. The partnerships also had to span the entire country.

Responders included:

* Fire and emergency medical hazardous-materials teams

* Epidemiologists

* Laboratory technicians

* Pharmacists

* Mental health workers

* Law enforcement

* The military

In unprecedented numbers working incredible hours in six states and the District of Columbia, public health officials ran from Florida to New York to Washington, D.C. and back to test, diagnose and treat thousands who may have come into contact with letters laced with anthrax.

In addition, no state or territory was unaffected because of the number of copycat hoaxes and threats these letters produced.

Massive supplies of antibiotics were bought and contracts rapidly let to perform environmental tests on postal facilities in both government buildings and private businesses that may have received anthrax-tainted letters.

State and local health departments established clinics to dispense antibiotics and the nation's public health laboratories went on 24-hour shifts to test thousands of clinical and environmental samples.

"This is probably as major a deployment of people and tasks and commitment by us ... in our fifty-year history," said Jeff Koplan, director of the Centers for Disease Control and Prevention in Atlanta.

Lessons learned

For several years, the public health community issued warnings about the need to improve its infrastructure in order to respond to biological threats.

The most important lesson learned from the anthrax attacks was reaffirmation that the public health system is an essential component in homeland security. Public health preparedness activities are now accelerated nationwide in response to these attacks.

Public education

Another clear lesson is the need for enhanced public education.

Giving the public a better understanding of the difference between viruses and bacteria and how we treat them is extremely important. The goal is to ensure a clear understanding of the therapeutic options among antibiotics, antivirals and vaccines.

This is important because follow-up surveys with individuals received antibiotics show that as many as 60 percent did not comply with antibiotic therapy as prescribed.

Educational activities should be culturally appropriate and in the language of the recipient. Messages should be consistent, clear and accurate.

The need for adequate communications emerged early in the crisis. Having pre-designated and expandable conference call capacity was essential. In addition, having accurate telephone, beeper and fax numbers, as well as e-mail addresses for essential personnel, ensured rapid communication.