"Lethal Weapon Was Used in This Attack": How the 2001 Washington Anthrax Outbreak Was Neutralized

Dr. Ali Khan, former director of the Bureau of Medical Training and Response at the US Centers for Disease Control and Prevention, has been involved in curbing the spread of this deadly infection. He told about his experience in the book "The Next Pandemic", which is dedicated to the fight against the most dangerous diseases on the planet. With the permission of the publishing house "MYTH", Lifehacker publishes an excerpt from the chapter "The Highest Form of Murder".

When I arrived in Washington on the morning of October 16, the Capitol building was surrounded by police tape and FBI agents were crawling inside. There is confusion at the beginning of a major outbreak of any disease, but here the case was compounded by the confusion of criminal investigations, duplication of work by local and federal authorities trying to figure out what was happening, and fear of a third world war caused by the 9/11 attacks.

We first met with the Chief Justice, then with Sherri Adams, the head of the Emergency and Medical Services Division of the District of Columbia Department of Health. Dr. Adams said she is a municipal employee and therefore the Capitol and other federal buildings do not come under her jurisdiction. This was the first hint of bureaucratic intricacies that we would have to break through in order to do anything. We also met with Dr. John Isold, a Capitol physician who played a key role in the medical care of members and staff of Congress, as well as representatives from the Federal Emergency Management Agency and the Environmental Protection Agency.

The Centers for Disease Control and Prevention team was led by Dr. Rima Habbaz of Viral Diseases ("True American" of Anglo-Saxon descent) - an excellent leader with amazingly developed critical thinking. Among other things, she had to deal with political intrigues and communicate with the media. I was the operational leader of the crew - the guy in the engine room who keeps the ship moving forward.

We treated these letters as an attack, however, despite the uncertainty of the situation, we had no choice - we had to make decisions on which life and death depended. We all experienced extreme stress, and that is why it was necessary to keep a bright mind. I have not slept in two days and I think I would not sleep even if I tried. I was completely consumed by the urge to understand what the hell was going on.

In this attack, lethal weapons were used, and in the midst of the chaos I described above, it was necessary to calmly figure out who faced this threat, who might face it in the future, and who had already suffered from the consequences. In addition, we had to formulate precautions, since anthrax spores could be all over the place.

Anthrax is a deadly weapon.

A teaspoon of powder in a mail envelope can contain billions of spores, although it takes only 5,000 to 50,000 pathogen spores to kill half of the people they affect (and for some, a dozen spores are enough). It is not the anthrax bacilli themselves that kill a person, but the toxins that they release as they multiply - these substances cause a drop in blood pressure and the appearance of carbuncles, in which the pathogen settles.

You can get infected if spores are inhaled or if they get on the skin. When anthrax spores get on the skin, black painless spots appear at the contact points, which people often confuse with spider bites (the English name for anthrax - anthrax - comes from the ancient Greek word ἄνθραξ - "coal", that is, "black as coal"). You can also get infected by eating infected meat - this is often the case in Africa. In addition, in recent years in the United States, the disease has often affected musicians who play traditional drums. These tools are covered with the skins of African animals, and it is the skins that are infected. A man beats drums - spores fly into the air. In Europe, there are cases of infection after the injection of infected heroin.

We found that 67 people worked in the immediate vicinity of room 216, where the 4th Grade return address, Greendale School, was opened, with a total of 301 people on the fifth and sixth floors. The incubation period for anthrax is from one to seven days, regardless of whether the infection occurred through inhalation or through the skin, but it can stretch to 60 days, so prevention has to be carried out for two months.

We did not know how many people were in the building at the time of the incident.

Since the ventilation system worked for some time, pathogens scattered everywhere: analyzes showed the presence of thousands, if not millions, of disputes in offices, corridors, and stairwells.

We took washes from furniture on all floors and immediately sent them off for inspection. However, the priority was not furniture, but people.

Biological material for analysis had to be obtained from each employee, so there were long queues of people waiting for a nasal swab. We ran 150 tests on Monday, 1,350 on Tuesday, 2,000 on Wednesday. We then sent all samples to the National Institutes of Health, the Walter Reed National Medical Center, the Armed Forces Pathology Institute, Fort Detrick and the Analytical Services in Norcross, Georgia. A total of 7,000 samples of human biomaterial were collected.

At the same time, we formed an epidemiology team, a clinical team, a surveillance team, an environmental health team, an intervention team, as well as a team to conduct press conferences, write press releases and other public relations. Our temporary headquarters were located directly in the Capitol building, and when the number of the team increased, we moved to offices in the US Botanical Garden, which was very conveniently closed for renovations.

The field and headquarters structure was rather primitive at the time, as our preparedness and response program had yet to define what an emergency operations center should look like. Previously, we mainly reacted situationally, but now we developed the idea of creating a coordination center by analogy with those that coordinate the actions of firefighters and police in the event of a fire. We built a clear organizational structure that oversaw finance, planning, operations and logistics. The head of the center was subordinate to the director of the Centers for Disease Control and Prevention, and subsequently a special scientific unit appeared.

By 1 am on October 16, the first laboratory tests revealed anthrax. As a result, almost all samples from room 216 will contain her spores.

We immediately prescribed antibiotic therapy for 227 people. The test result would be positive in 20 of the 30 employees working in the immediate vicinity of the incoming mail and in adjacent premises, in a couple of people from the neighboring office and in six from the rapid response team, but given the ability of anthrax spores to travel in any direction, it was necessary to check everything, not just the priority and obvious.

The Centers for Disease Control and Prevention promptly instituted enhanced passive disease monitoring in emergency rooms (we chose this term because the commonly accepted notion of “surveillance” had a slightly different meaning to colleagues at the FBI). We constantly asked: “Do you have any alarming symptoms? Perhaps a fever of unknown origin? Labored breathing? Our colleague, Scott Harper, went looking for new and earlier cases of meningitis (inflammation of the lining of the brain) and lung infections that could indicate anthrax. The disease could manifest itself in different ways, but if it turns out that the victim worked in the Capitol, that is what you need.

Later, staff from the National Institute for Occupational Safety and Health will be brought in to help environmental teams comb the building and collect many samples in the ventilation system. The spores will be found in 7 of the 26 buildings near Capitol Hill, and the EPA will spend $ 27 million to clean them up.

Then the actual forensic phase of the investigation began. Only it was based not on the usual principle "follow the money", but on the principle "follow the mail."

After examining the time stamps, the FBI worked with the US Postal Service to trace the path that the letter addressed to Tom Dashle made, down to the cells in the mail room and machines for unpacking letters. All stages of the movement of this letter were established from Trenton, where it was received on October 9, to the P Street Post Office in Washington, where the letter arrived on October 12; he was then taken to the Dirksen building post office serving the Hart building, whereupon the letter reached room 216.

Meanwhile, reports were coming in from the Naval Hospital in Bethesda and the National Institutes of Health. There were more and more positive results, and in each case there was strong and rapid growth. There was a hell of a lot of controversy. Since the very first tests were whipped up with Tetracore forensic kits, we sent these samples to the Centers for Disease Control and Prevention for confirmation. We also consulted with leading anthrax experts in Atlanta, most notably Arnie Kaufman, on what to do with all the information we received. Ironically, two years before the incident, the Centers for Disease Control and Prevention was about to close the anthrax program - it was saved by the fact that funding was allocated at the last moment as part of the response to the bioterrorist threat.

I briefed congressional staff on the state of affairs and met with medical officials from Maryland and Virginia. There were a lot of telephone conversations - by the way, the cell phone in the Capitol catches disgustingly.

At the Capitol, we collected 1,081 environmental samples. Using high efficiency air filters (HEPA filters), we vacuumed the Hart Building and the Ford Building, where the controversy showed up on a machine sorting mail for the US House of Representatives. We replaced filters in the ventilation system and removed all correspondence. Soon there were more positive results: the infection was found in the Dirksen building, where all mail for the US Senate was processed, as well as in three offices in the Longworth House building.

On October 17, Speaker Dennis Hastert closed the House of Representatives for five days. The Hart building had already been closed.

Mail delivery to the White House was suspended and nine judges left the Supreme Court for the first time since it opened in 1935.

On October 18, anthrax spores were discovered in the White House post office. Tests have also confirmed another infection - a New York Post news assistant was diagnosed with cutaneous anthrax on the middle finger of his right hand.

On October 19, a scraping was taken from a Washington police car. The anthrax test was positive.

The Laboratory Response Network has tested over 125,000 environmental samples alone - over a million laboratory tests have been performed.

On October 25, the Senate passed the Patriot Act. The Act passed by George W. Bush in response to the 9/11 attacks (full title is the Act of Rallying and Strengthening America by Providing the Appropriate Means Required to Suppress and Disrupt Terrorism). The document significantly expanded the powers of law enforcement agencies: for example, the special services received the right to wiretap citizens' telephone conversations without court sanction, read e-mails, track purchases on the Internet, and so on.

By that time, 10 Epidemic Investigation Service personnel had joined us, and the Centers for Disease Control and Prevention teams were working with information networks in New York, with newspapers and on two cases in Florida. We looked at emergency room admissions for unexplained deaths. We looked for sepsis, respiratory and gastrointestinal diseases, undefined infections, neurological diseases, even a rash because anthrax is a black rash on the skin.

We were in the thick fog of war, almost like the heroes of CSI: Crime Scene when mixed with 24 Hours (a TV series with Kiefer Sutherland, where the clock is constantly ticking). If a person breathes well with spores, the incubation period can take as little as two days. We were constantly under the pressure of conflicting demands and bureaucracy, we wanted to understand who was in charge here and who was interfering with his own business, who was interfering and who was helping, and at the same time we had to act. If we take the wrong step, people will die.

Brentwood

On October 19, Leroy Richmond, 56, approached the emergency room at Inova Fairfax Hospital in Falls Church, Virginia. It was difficult for him to breathe. The doctor assumed that he had pneumonia and was ready to prescribe antibiotics and send him home, but the patient turned out to be stubborn and said that he worked at the post office. The Brentwood Post Office handled all mail sent to Capitol Hill.

Virginia officials were alerted to what was happening, and we sent Scott Harper there to investigate. Mr. Richmond was asleep in the hospital room. In three days he lost about 3 kilograms, convulsions appeared, but there were no skin lesions.

The leukocyte count was elevated, and the chest X-ray was relatively normal. Fortunately, the doctor who received Leroy Richmond turned out to be discerning and prescribed the patient a computed tomography, which revealed a symptom of anthrax - an expansion of the mediastinum, the area between the lungs. Tomography showed a slight enlargement of the liver, mediastinal lymphadenopathy (enlarged lymph nodes in the center of the chest), infiltrative changes in the lungs and unilateral effusion in the chest - fluid in one lung. Swollen lymph nodes suggested that Leroy might have lymphoma. Initially there was no fever, but it appeared that evening, and the next day the blood culture was positive for anthrax. There was no bacterial growth in the nasal swab. The ER doctor gave Richmond IV ciprofloxacin and then added a couple more antibiotics.

A day earlier, another Brentwood Post Office employee, 55-year-old Thomas Morris Jr., had come to the Kaiser Permanente Clinic expressing specific concerns about anthrax.

And although Morris at that time was only mildly ill, he was much less fortunate.

The therapist called the health department and heard that anthrax posed no threat to postal workers. The patient was sent home and advised to take paracetamol for cold symptoms, and if the condition worsened, come again. Three days later, Morris called 911. Breathing was severely labored. Morris said he contracted anthrax. He died a few hours later.

The day after the mayor announced the anthrax case in Brentwood, another post office employee, Joseph Kersin Jr., drove to MedStar Hospital Center in Clinton, Maryland. The day before, he passed out during mass, but refused an ambulance because he wanted to take the sacrament, and in the evening he went to work. He returned home early in the morning, complaining of pain in the upper abdomen, nausea and diarrhea. The X-ray result looked normal and the patient was diagnosed with stomach flu. He was prescribed medication for diarrhea, after which he declared that he was feeling well and went home. Nobody asked where he works. He died the next day.

We hit Brentwood, just like CSI does, and started collecting swabs, swabs, and vacuum filtration. The 37,000-square-meter Post Office located at 900 Brentwood Road, northeastern Washington DC, employs 1,700 people to handle mail for Congress and federal agencies. Meanwhile, a similar story was played out in New Jersey with the employees of the Trenton Post Office. State medical authorities discovered the first case a day earlier. The post office was closed, and employees were sent for preventive maintenance.

Curiously, we have not previously seen cases of infection in post offices, although all letters - even those arriving in Florida - went through the US Postal Service. This reinforced the mistaken belief that only the people who opened the letters were at risk.

And here's what we found.

When you seal an envelope, there are always unsealed spots on the top sides. In the compartment, the envelope goes through a sorting machine, which flattens it in front of a postcode reader. In Brentwood, sorting machines processed up to 30,000 letters per hour, applying tens of atmospheres to each envelope. Due to such a strong and fast compression, the spores flew well to the sides.

In addition, machines were cleaned daily with compressed air, and spores could fly up to 10 meters.

We ended up closing the post office in Brentwood for more than two years and costing nearly $ 320 million to clean up the anthrax.

Dr. Ali Khan and colleagues have fought the spread of Ebola, SARS and other dire diseases, and after Hurricane Katrina helped rebuild New Orleans' medical infrastructure. The Next Pandemic is full of stories about his adventures, but the author also reflects on the huge difference between baseless panic caused by high-profile headlines and a real threat that requires the most serious consideration. The book will be of interest to everyone who loves medical stories and wants to learn more about the everyday life of epidemiologists.