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Managing terror: Public health officials learn lessons from bioterrorism attacks. (Health Policy Update).


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.

Risk communication remained a significant challenge. For almost four weeks following the first anthrax attacks, the health care community and the general public received conflicting messages from a number of sources.

The media frequently turned to any available source for information to answer questions about anthrax, terrorism and health-related issues. There needed to be a single, accurate message from credible sources to allay fears and prevent panic.

The need for a national medical spokesperson emerged. In addition, the need to rapidly address inaccurate information and respond to the changing understanding of science was essential.

Public health professionals must be better trained to address media inquiries, educate the public and develop information resources to support communication needs.

Professional education

The medical community responded with a thirst for new information.

The public health goal was to raise the clinical index of suspicion across the nation, increase the understanding of diagnostic and therapeutic options and let practitioners know where to call for administrative or clinical help.

New systems are needed for the rapid dissemination of new knowledge to the practicing community. Systems under development include rapid fax, e-mail and beeper systems.

Teleconferencing was used to share important information on both anthrax and small pox. Computer education through the Web can be used in the future as an additional tool.

Additional training about the full range of threat agents (36 in all) is needed.

Training must occur in the area of health security. This includes working in a unified command, handling suspicious packages or mail and securing the workplace and high-risk communications.

Controlling access and laboratory support

A better understanding of the location of high-risk agents at both the state and federal government level is needed. The importance of biosecurity of these agents cannot be overstated.

Clinical labs need to ensure they can identify or have a process to refer suspected clinical material. Public health laboratories need to be prepared to be a reference lab for threat agents as well as a primary laboratory for a broad range of clinical and environmental specimens.

Issues such as transportation of specimens, maintaining a chain of custody and safe disposal of agents are vitally important.

The public health laboratory network, built with the first round of bioterrorism funding in 1999, worked well. However there is a need for expanded capacity since most labs were overwhelmed. Medical managers should ensure they are aware of where to send clinical specimens in their state for the full range of threat agents.

Disease surveillance and follow-up

The ability to share information and communicate clinical and epidemiological results immediately is crucial to the ability to respond to any health threat. New and enhanced tools for disease surveillance are essential.

Passive and active surveillance for disease was useful to access background disease states. Surveillance using syndromes was useful to access background disease burden. But the importance of recognizing individual cases by individual practitioners is crucial.


The need for a clear delineation of command and control is essential.

Linkages should be strengthened among a broad range of non-medical professionals such as environmentalists, disaster preparedness experts, firefighters and law enforcement personnel, as well as medical professionals.

Access to a core group of specialists in every state should be accomplished by surveying the practicing community. There are many practitioners that have seen these threat agents before in clinical settings. They should be identified now and consulted when an event occurs.

Legal challenges

Most public health laws were written in the early 1900s. Consequently, there is a national effort to update the legal basis for public health in a national disaster.

The Model Emergency Health Powers Act drafted by the Center for Law and the Public's Health at Georgetown University/Johns Hopkins University is a model law that is being used as a menu for states to evaluate their public health authority.

Many states will be addressing this issue during their next legislative sessions.

The frantic, almost frenetic effort to tackle the outbreak of anthrax tapped the resources of thousands of public health professionals. While many believe the system responded well, a steep learning curve and an inadequate public health infrastructure became significant management problems. Many people question how the system would cope if the anthrax attacks had been more expansive.

Preparing to manage this new form of disaster is a national priority.

Georges Benjamin, MD, FACP, is the Secretary of the Department of Health and Mental Hygiene in Baltimore, Md. He can be reached by calling 410/767-6505 or via email at

Additional reading

1. connolly, Ceci. "Public Health system Is on War Footing." The Washington Post, Saturday, October 27, 2001.

2. Stolberg, Sheryl Gay and Miller, Judith. "Bioterror Role and Uneasy Fit for Disease centers." The New York Times, Sunday, November 11, 2001.
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Author:Benjamin, Georges C.
Publication:Physician Executive
Geographic Code:1USA
Date:Mar 1, 2002
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