Laboratory response to anthrax bioterrorism, New York City, 2001 - Bioterrorism-Related Anthrax

Emerging Infectious Diseases, Oct, 2002 by Michael B. Heller, Michel L. Bunning, Martin E.B. France, Debra M. Niemeyer, Leonard Peruski, Tim Naimi, Phillip M. Talboy, Patrick H. Murray, Harald W. Pietz, John Kornblum, William Oleszko, Sara T. Beatrice

In October 2001, the greater New York City Metropolitan Area was the scene of a bioterrorism attack. The scale of the public response to this attack was not foreseen and threatened to overwhelm the Bioterrorism Response Laboratory's (BTRL) ability to process and test environmental samples. In a joint effort with the Centers for Disease Control and Prevention and the cooperation of the Department of Defense, a massive effort was launched to maintain and sustain the laboratory response and return test results in a timely fashion. This effort was largely successful. The development and expansion of the facility are described, as are the special needs of a BTRL. The establishment of a Laboratory Bioterrorism Command Center and protocols for sample intake, processing, reporting, security, testing, staffing, and quality control are also described.

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Laboratories across the United States have been preparing for the past 5 years for the possibility of civilian populations being the target of bioterrorism (1). The New York City (NYC) Department of Health (DOH) laboratory response plans for bioterrorism changed forever after October 12, 2001, with the knowledge that letters laden with Bacillus anthracis spores had been sent through the U. S. Postal Service (2). The original conception of the laboratory's role in bioterrorism response was not yet fully validated, nor was the need for extensive environmental testing fully appreciated or anticipated. The number of personnel with specialized training was another key factor.

The most probable scenario envisioned a sharp increase in hospital admissions caused by one of the recognized bioterrorism agents (3). By the time the symptoms and bioterrorism agent were diagnosed, the disease was likely to be well established within the local population. Thus, laboratory response would center primarily on human clinical sampling. The scope of required environmental sampling was not fully anticipated and was generally considered to be secondary to the original epidemiologic investigation. Such samples would predominantly consist of evidence obtained from the putative source of the exposure.

Although this was the operational scenario, the actual laboratory workload during this event was evenly divided between environmental and clinical samples. However, the amount of labor and materials associated with processing environmental samples for analysis far exceeded that of the clinical samples.

Background: Laboratory Structure before October 2001

Before October 12, the NYC Public Health Laboratory (PHL) processed one or two suspected bioterrorism environmental samples per month, utilizing a small Biosafety Level 2 (BSL-2) room with two dedicated personnel. In the year before the attack, the PHL received approximately 10 samples, all of which were hoaxes. The laboratory was set up according to Centers for Disease Control and Prevention (CDC) protocols, and staff were trained by CDC on methods for isolating and identifying bioterrorism agents.

The bioterrorism laboratory consisted of a 400-square-foot area designed at BSL-2 as described in Biosafety in Microbiological and Biomedical Laboratories (4). Entrance to the laboratory was controlled by proximity card access and monitored 24 hours a day by video cameras. The space contained a biosafety cabinet, a fluorescence/phase-contrast microscope, incubators, freezers and refrigerators, a Wallach/Perkin Elmer Victor Time Resolved Fluorescence instrument (The Perkin-Elmer Corp., Norwalk, CN), computers, and necessary laboratory supplies. This configuration provided a comfortable and controlled access space for sample preparation and analysis. Because of the low sample volume, each sample was treated uniquely, and a generalized method for handling numbers of environmental specimens was not considered necessary.

Before October 12, all specimens submitted to NYC BTRL were tested for four priority bioterrorism agents: B. anthracis (anthrax), Francisella tularensis (tularemia), Yersinia pestis (plague), and Brucella species (brucellosis). Protocols defined and validated by CDC were used to isolate and identify these agents (5). All specimens tested during that time were culture negative for the four priority bioterrorism agents according to the validated protocols.

October 12: First Letter Tested Positive

Before B. anthracis was identified in letter C from media outlet 1, two other letters (A and B) were received and tested by BTRL. Letter A came from media outlet 1, and letter B came from media outlet 2. Letters A and B were tested for the four priority bioterrorism agents and were negative. At the time, the negative result for letter A was somewhat surprising because the patient diagnosed with cutaneous anthrax was employed by media outlet 1. When letter C later arrived at BTRL, it was tested and found to contain a powdery substance that was positively identified as spores of B. anthracis. The discrepancy involving the positive results of letters A and C was soon resolved when it was determined that letter C was actually received before letter A at media outlet 1 but was inadvertently placed in a corporate "hate-mail" file and was thus recovered after letter A.