Dear Governor Ridge:
Today marks the six-month anniversary of the opening of a letter containing anthrax toSenator Tom Daschle. The anthrax threat to postal workers and congressional staff in Washington,D.C., to media professionals in Florida and New York, and to two individuals in New York andConnecticut required a comprehensive, investigative response from various local, state and federalagencies. The unprecedented anthrax exposure prompted responding agencies to marshal untestedresources. Given the newness of the situation, policymakers and public health experts must analyzethe response, identify its strengths and weaknesses, and use the findings to inform future responsesto similar threats and to circumvent tragedy.
I asked several public health experts to lend their expertise to this cause and provide a writtencritique of the local, state and federal agencies' response to the anthrax attacks. I asked them tocomment on any aspect of the response as they saw fit, with an eye toward identifying strengths andweaknesses that could prove useful in the future. I also asked them to touch on, if they could, theinteractions between responding agencies, including the Centers for Disease Control (CDC), theFederal Bureau of Investigation and the U.S. Army Medical Research Institute on InfectiousDiseases.
Three of the experts provided critiques. They raise several points that highly concern me.For example, one expert feels the CDC failed to recognize that “a tape-sealed letter could leak(anthrax) spores." Another expert believes the Federal Bureau of Investigation wrongly reassured theCDC that the anthrax had limited potential to spread. I am not in a position to verify these experts’contentions, but I hope everyone in the public health community who dealt with last fall’s anthraxoutbreak will consider these responses, analyze their relevance, and make any necessary changes tosecure public safety in the event of another bioterrorism attack. Five people died in last fall’s anthraxoutbreak. We have an obligation to them, to their families, and to the public to prevent any futureloss of life.
Please let me know how your office processes these responses and ensures that the relevantagencies correct any applicable shortcomings. Thank you for your work to protect the public. Pleasecall Jill Gerber of my staff at 202/224-6522 if you have any questions.
Sincerely,
Chuck Grassley Ranking Member Attachments: Critiques from Public Health Experts
MMWR, 2001, Nov. 9, 50(44);987-990 Interim Guidelines for Investigation ofand Response to Bacillus Anthracis Exposures
MMWR, 2001, Dec. 7; 50(48):1077-1079. Update: Investigation of Bioterrorism-Related Anthrax ---Connecticut, 2001 Use of Onsite Technologies for Rapidly Assessing Environmental Bacillusanthracis Contamination on Surfaces in Buildings
MMWR, 2001, Dec. 21; 50(50):1129-1133. Evaluation of Bacillus anthracis Contamination Insidethe Brentwood Mail Processing and Distribution Center ---District of Columbia, October 2001MMWR, 2002, Jan. 25; 51(03):59 Evaluation of Postexposure Antibiotic Prophylaxis to PreventAnthrax
Nicas M, Neuhaus J, Spear RC, 2000, Risk-based selection of respirators against infectious aerosols:application to anthrax spores. J Occup Environ Med Jul;42(7):737-748Ross, JM, 1957, The pathogenesis of anthrax following the administration of spores by the respiratoryroute. J Pathol Bacteriol 73,485-494
Shafazand S, Doyle R, Ruoss S, Weinacker A and Raffin, TA, 1999, Inhalational Anthrax:Epidemiology, Diagnosis, and Management, Chest 116:1369-1376.
Ronner U, Husmark U, Henriksson A, 1990, Adhesion of bacillus spores in relation tohydrophobicity. J Appl Bacteriol 1990 Oct;69(4):550-6
Titball RW, Manchee RJ, 1987,Factors affecting the germination of spores of Bacillus anthracis. J.Appl Bacteriol 1987 Mar;62(3):269-73
3/13/02
Senator Charles Grassley Ranking Member United States Senate Committee on Finance Washington, D.C. 20510-6200
Dear Senator Grassley,
Thank you for requesting my analysis on the handling of last Fall'sbioterror crisis. I will direct my comments to the official response and itsrelevance to future threats.
The anthrax mailings revealed a lack of integration among the variousagencies that were called upon to defend against the threat. Specifically,the FBI led the investigation, and acting with strict criminal protocol,conducted experiments using the USAMRIID lab, but excluded CDC scientistsfrom directly examining the envelopes.
Nor did the Army perform the appropriate tests right away; in fact DNAtracers to check seepage from the envelopes, and quantitative tests todetermine airborne potential, were not conducted until late October, whenseveral people had already gotten sick and two had died.
The CDC, in turn, spread faulty information to the local health agenciesand the US Postal Service based on epidemiological speculation. Not seeingthe evidence, and being wrongly reassured by the FBI, the CDC guessed thatthe anthrax had limited potential to spread. Then when the two postal workersdied in Brentwood, the CDC overreacted, not by closing facilities, but byadministering antibiotics to 30,000 postal, media, and government workers whowere anywhere near where the anthrax had been found. This overuse ofantibiotics (only eighteen people actually acquired anthrax overall), causedneedless expense (millions of dollars), and side effects from the medication(diarrhea, insomnia, rashes).
The antibiotic authorized for use, Cipro ($300 for a month's supply), isten times more expensive than generic equivalents (doxycycline - $30 for amonth's supply) that have been tested and found to be equally effectiveagainst the anthrax bacillus. Examination of the anthrax itself revealed nodrug resistance to any of these antibiotics, yet the more expensive Ciprocontinued to be used.
The FBI only showed photos of the anthrax letters to the CDC's scientistsand epidemiologists. No one from the CDC examined the actual envelopes thatwere sent to Tom Brokaw, Senators Daschle and Leahy, and the NY Post. TheArmy Infectious Disease lab, which has the same top level D clearance as theCDC lab, had control of the letters. But the Army lab is oriented tobiowarfare whereas the CDC targets public health. According to CDC's DeputyDirector for Infectious Disease, Julie Gerberding, the Army worked directlywith the FBI, and the CDC was informed of the results by conference callsorganized by the National Security Council. At first the Army downplayed therisk to postal workers and the media, and the CDC relayed this reassurance.On October 15th, the letter to Senator Daschle was received in his officeand opened by his assistant. According to Dr. Gerberding, Army scientists didnote that the anthrax in the Daschle letter had "a high concentration ofspores, and that the powder would poof, indicating it was easily aerosolizedand could float around in a more dangerous way." Yet the FBI continued torelay that the letter had been well sealed, only a risk to the person whoopened it, (though only Daschle's assistant had seen it unopened), andtherefore none of the other agencies including the CDC and the Postal Serviceexpected the anthrax to escape the envelope.
It was only after workers got sick that the CDC began closing governmentbuildings and postal facilities, and under pressure from the media began tohand out antibiotics to everyone who was in a contaminated building. Theinitial underreaction was followed by a costly overreaction. This anthrax wasdeadlier than expected, but it was still not contagious and the mail was aninefficient way to spread it. In the end, many more people probably got sickfrom taking Cipro than from anthrax.
Had the FBI integrated its team with the Army and the CDC, had this teamworked together with state and local agencies, the reaction to the anthraxcould have been earlier, more appropriate, and more to scale.
Deborah K. Willhite, Senior Vice President of the Postal Service forGovernment Relations, in a letter to you dated November 14th, wrote that thePostal Service "received critical information through the media, not fromother agencies. The different focuses of various law enforcement and healthorganizations resulted in parties speaking different languages. And, absentan established protocol, lines of authority could be unclear."
Even after a postal task force was organized, the CDC only provided guestexperts, and was no direct imput to the Postal Service from the FBI.
Here in New York, state and city health departments relied on theguidance and the presence of the CDC. Resources were marshaled to test largenumbers of the population, without knowing whether this would be necessary ornot. Labs were readied to perform nasal swab testing of all who might beexposed to anthrax, and blood cultures on those who might already be sickwith inhalation anthrax. (the blood cultures could help distinguish anthraxfrom flu). At first, nasal swabs were felt to be adequate screening, untilthe CDC reversed itself in late October and indicated that the test wasuseful for epidemiological purposes only. But the NY State epidemiologist,Dr. Perry Smith, told me that nasal swabs did in fact have clinical value ifit detected the presence of anthrax - whereupon treatment could potentiallyprevent the onset of the disease.
The confusion about testing; who to test, how to test, how many to test,typified the lack of knowledge and the lack of communication between the CDCand the local agencies it was asked to inform. This problem would have beenless significant if the CDC had seen the anthrax and been better able to makepredictions about its potential for spread.
Going forward, if a team of experts in public health is integrated with ateam of nose-to-the-ground law enforcement agents, the result could be atight web of educated defenders. In fact, Dr. Mitchell Cohen, the CDC'sDirector of Bacterial Diseases and liason to the FBI, admitted to me thatthese "different cultures are not used to working together," but that apartnership is crucial to fight bioterror. He said, "we will be going to FBIheadquarters. Our different approaches can complement each other. We look atinformation in different ways, Scientists collect data, develop hypotheses,and test them. Law enforcement examines the data for patterns to developleads. One side might find what the other side is missing."
Now that 11 billion dollars has been budgeted to protect the publicagainst future threats of bioterror, consideration must be given to where themoney will be spent. Antibiotics, vaccines, and beefing up state and localhealth care agencies are considered primary targets for the funding. But thereal protection against bioterror, the safety net that can be built ofepidemiologists, scientists, and co-operating federal agencies, has still notbeen established. And massive stores of antibiotics and vaccines areperishable, if not used within a few years, they will have to be discardedRecently, truckloads of antibiotics were sent to Salt Lake City to coverthe Olympics. Given how difficult it is to spread anthrax, those antibioticswere due to be wasted, and now, after they expire in two years, discarded.
Bioterror money is better spent in integrating agencies and in making sure anatrocity the magnitude of crop dusting a stadium doesn't happen. A moreeffective public defense against bioterror attack would be public educationrather than antibiotics. Conferences and lectures could be given informingdoctors and the public about tools of bioterror. A relevant medical data basethat could be drawn from in the event of an impending attack would be worththe money spent. Accurate information about smallpox, other viruses, anthrax,plague, could go a long way towards calming fears and preparing a defense.I believe large scale purchases of antibiotics should be avoided. For onething, antibiotics convey the message that bioterror may be in the offing.
For another, since a bacteria cannot possibly spread to thousands of peopleovernight, such a display of drugs is purposeless. Mass stores of antibioticswithout the doctors ready to prescribe them for a disease that doesn'tcurrently exist is a significant waste of funds. As was evidenced last Fallwith the anthrax scare, public perception of a potential catastrophe caneasily necessitate an additional expenditure just to combat hysteria.
Money is better spent on scientists, epidemiologists, and liaisonservices between federal and local agencies. The best return for the moneywould be in establishing a framework of expertise that could be mobilized butcould also be used to reassure the public. But integrating agencies requiresa spirit of co-operation. More than that there must be a structure, adesignated bioterror agency under the auspices of the Office of HomelandSecurity with power over all the other agencies on issues of bioterror.
Though the FBI controls its turf and is not used to co-operating excepton its own terms, still, I believe interagency liaison and the formation of abioterror agency would be a good place to start when considering how to spendthe money that's been allocated. A good epidemiologist or public healthoriented microbiologist working in conjunction with an on-the-scene FBI agentmight know exactly when a particular group of citizens is at risk. Asuspected pathogen of bioterror could be subject to meticulous measurementsto quantify its risk of spread. Vectors such as envelopes could bescrutinized with DNA probes to make exact predictions. Found spores could besent right away to spore specialty labs. The information acquired fromcareful CDC supervised experiments could then be spread responsibly to statesand counties perceived to be in danger.
Just assigning millions of dollars to a particular region will by nomeans assure that the response there is effective or integrated. Whereas aresponse team of high priced scientists would be worth the money spent.
Respectfully submitted,
Marc K. Siegel, MD Asst. Professor of Medicine NYU Medical School
Feb. 26, 2002 Senator Chuck Grassley U.S. Senate
135 Hart Senate Building Washington, D.C. 20510
Dear Senator Grassley:
I am responding to your request of January 25 to critique the response by government agencies tothe anthrax bioterrorism event that began in September 2001. As a former epidemiologist on the staffof the Centers for Disease Control and Prevention (CDC) for thirty-two years, I was in charge of theanthrax activities during the 1950s, 1960s, and 1970s and am acquainted with anthrax as well as withthe responsibilities that CDC has been given related to bioterrorism. I am also well acquainted withthe Epidemic Intelligence Service (EIS) that I directed for 11 years while at CDC. My comments arebased on information from CDC's Morbidity and Mortality Weekly Report (MMWR), reports fromvarious media sources, and by attending meetings both in Atlanta and in Washington, D.C. I feel thatI can respond to your queries with objectivity.
Several years ago CDC had been given responsibility for developing a response plan for bioterrorismto be implemented at all levels of government i.e. federal, state, and local which in my judgment theycarefully accomplished. It was previously acknowledge that CDC would be the lead federal agencyin directing the public health response to a bioterroristic event. This was not what happened. Therewere problems with the release of information for the public and is conducting some of the fieldinvestigations. Whereas, CDC's normal actions would include daily public briefings reporting thecurrent data developed from the investigations, it was reported that all briefings would come fromWashington. One result of the inability of CDC to put out daily briefings was that state healthdepartments were unable to obtain up to date information about the investigations. When informationwas released from Washington, it was not always correct information due to nonfamiliarity withanthrax and with all the investigations in progress. When CDC wished to investigate certainpotentially contaminated environments, they were told to stand aside, as others (the FBI) would bein charge of that activity. In determining the degree of environmental contamination of variousbuildings, CDC's expertise was not found useful, which resulted in confusion and inappropriatestatements.
These are examples that I am aware of, when CDC's leadership was subverted. Initially datadeveloped by other agencies were not shared with CDC, and yet CDC was supposed to makerecommendations for control and prevention. If there is a criminal element to a bioterroristic event,then the Federal Bureau of Investigation (FBI) will be involved which is appropriate. It is obviousthat the FBI needs to work with a certain amount of secrecy in order to conduct the criminalinvestigation in the manner in which they have expertise. However, CDC is sensitive to their publichealth responsibilities to keep the public aware of what is being done to try to determine the causationfactors in a bioterroristic event and to help alleviate the fear and hysteria that is associated with suchan event. But when they are not able to provide daily briefings, those who look to CDC forinformation will be frustrated, as was the case in this event. From what I observed, the relationshipbetween CDC and the U.S. Army Medical Research Institute on Infectious Diseases wascollaborative, cordial, and very important.
CDC, with its primary mission to control and prevent disease, with a dedicated, competent,experienced staff that is ready to travel on a moments notice must be given the authority to operateas it always has in times of emergency. To put dampers on its actions, can only lead to problems, andI suggest this is what led to some of the problems that occurred during the recent bioterroristic event.I was concerned over several problems within CDC. It appeared that there was no one person atCDC who was directing all of CDC's activities. Though they held daily meetings within CDC, no oneperson was fully knowledgeable about all of the activities in progress nor the results of various fieldand laboratory investigations. CDC did place some of their staff as liaison persons in cities of majorinvolvement, but these persons were not always adequately informed of the current investigation data.
Use of a retrospective scope is dangerous. We must not forget that this is the first such majorbioterroristic event to occur in the United States. No matter how carefully plans are developed forhandling bioterroristic events, once an event has occurred, and the plan is implemented, problems willbe identified. Each bioterroristic event will differ from a previous such event and it is not possibleto foresee what will happen. Thus flexibility has to be part of any plan directed at reacting to abioterrorist event.
It has been said that CDC did not advise the postal service early enough about the dangers ofprocessing contaminated mail. Since this was the first known actual use of the mail to distribute B.anthracis, who would have thought that the environment in post offices could become contaminatedfrom processing these letters. Also, CDC was not in charge of culturing the environments of the postoffice and of the government buildings so they did not immediately have all the necessary data uponwhich recommendations should be made. Some of the results reported by other agencies were ofculture results from unproven field kits, whose sensitivity and specificity had not been determined.The current bioterroristic event has clearly pointed out the significant need CDC has for additionalresources. It has been reported that some new monies have been made available to CDC so that itwill now be possible for the Epidemic Intelligence Service to be expanded in order that there may beEIS officers located in every state health department and in some of the larger municipal healthdepartments. EIS officers represent the first line of involvement in investigating bioterroristic events.
It is important that the support staff for the EIS officers also be expanded and given permanent status.The fabric of CDC needs to be strengthened and expanded. The original buildings are old and needrefurbishing. They have been forced to rent additional facilities throughout northeast Atlanta and thisleads to inefficiency in operation as a team. CDC has developed plans to upgrade their currentfacilities and to build additional offices and laboratories on their current two primary sites, but thisoverdue development should be expedited so that it can be completed within five and not ten orfifteen years. The current facilities are an embarrassment and inhibiting especially when CDC is beinggiven important new bioterrorism prevention responsibilities. If the government is serious aboutstrengthening our ability to adequately respond to such events, there needs to be better support forthe prevention activities and this should be given immediate and primary attention.
Education and training are an important aspect of bioterrorism preparedness and to this end CDC hasdeveloped plans for constructing a cutting edge training center on their primary campus in Atlanta.This facility should be given the highest possible priority so that training both within the facility aswell as for developing and implementing a full range of distant learning activities can provide as soonas possible.
Once the physical facilities and program strengthening actions have been taken, it will be apparentthat the practice of prevention in general will be strengthened. Not only will we improve our abilityto handle a bioterroristic event but many public health prevention programs will also be strengthened.It is also necessary that CDC have the necessary authority and financial support to conduct researchappropriate to their mission, which is control and prevention of disease whether it is related tobioterrorism or natural phenomenon. This includes operational research, which is exceedinglyimportant for the vitality of their activities.
It is unfortunate that it takes this type of an event to empha the additional needs of support forCDC but let us not dwell upon the traumatic nature of the bioterroristic event but on the opportunityto have learned what deficiencies there are in the system so that corrections can be made prior to thenext bioterroristic event. No matter what we as a country or what specific agencies do, we cannotprevent bioterroristic events but we can certainly reduce the quantitation of that event by beingprepared to respond. This is the responsibility of CDC and I do hope that the resources will be madeavailable to them so that they can operate in the manner in which they are well suited to function inthese critically important emergency situations as well as during normal times.
I hope you find these comments useful.
Sincerely,
Philip S. Brachman, M.D.
Professor, Emory University PSB/mjc
