September 11th Attack and the Intentional Release of Anthrax Q&A: CDC and Public Health Respond
Trust for America’s Health and the Robert Wood Johnson Foundation recently issued a new report, Remembering 9/11 and Anthrax: Public Health’s Vital Role in National Defense. NewPublicHealth will continue to run excerpts from the report throughout the months of September and October. The following reflects portions of interviews with and reports by past and present Centers for Disease Control and Prevention (CDC) leaders and subject matter experts.
A tragedy is often marked in the lives of those who have experienced it as “life before,” or “life after.” The CDC does the same as it reflects on the decade after the terrorist attack of September 11 and the intentional release of anthrax that followed. Before the September attack, CDC was doing what CDC does: work with state and local public health departments and partners across borders to find and tackle the problems that can plague individuals, communities and the world. And then disaster struck.
CDC responds to the Sept.11, 2001, attacks
Our first thoughts were, “how can we help?”
Within hours of the morning attack, CDC sent a small cadre of its public health experts from different disciplines to New York City by private jet.
CDC had previously established a unique FAA-issued priority flight designation that allowed people and materiel to be flown to New York City despite the closure of airspace over the United States.
There were many unknowns that first day, but the team’s primary mission was to support the city health department. CDC expected to help in organizing for mass casualties and conducting immediate biological surveillance for infectious disease illnesses from the possible release of biologic agents.
The team arrived before nightfall and integrated with the New York City Health Department. Concerned about the possibility that hospitals could be overwhelmed with the injured, the NYC health director and CDC’s team-lead agreed that CDC should send up more than a dozen Epidemic Intelligence Service (EIS) officers. In addition, the first emergency mobilization of the National Pharmaceutical Stockpile, arrived that night in New York City.
At the request of the New York City Department of Health, CDC’s Strategic National Stockpile delivered a 50-ton package of pharmaceuticals and medical supplies to Ground Zero in New York City within seven hours of the federal decision to deploy. In addition, ventilators and their ancillary supplies and other critical medical supplies necessary for the treatment of burn and blast injuries were sent. Along with that, thousands of respirators and other personal protective equipment for response personnel were delivered to New York in the 24 hours after the attack.
CDC deploys officers to emergency departments
CDC sent epidemiologists, occupational health specialists, industrial hygienists and other professionals to support the city’s response. Officers were deployed to emergency departments to identify unusual disease symptoms or outbreak clusters. Their job would be disease and injury surveillance to help identify the types and amount of medical resources needed.
The expectation was that large numbers of people had been injured by the crash and collapse of the buildings. When the sad realization was that hospitals would not be receiving injured survivors because most victims had perished, the CDC team’s attention was also directed to occupational health. Eye injuries and respiratory distress ranked high. Soon attention turned to environmental health concerns such as air quality, food and water safety, and rodent control. Days later, more EIS investigators were deployed both to New York City and to Washington, D.C. to help establish a disease surveillance system.
CDC responds to the anthrax attacks
The nation as a whole was still reeling from the terrorist attack of September 11th when public health officials identified a case of inhalation anthrax in a Florida resident, the first such case since 1976 in the United States. As the Department of Health and Human Services’ lead agency for bioterrorism response, CDC had a much more central role for the federal government in the anthrax attack response compared to the terrorist attack on September 11th.
In 1998, CDC had begun to earnestly develop a strategic plan for addressing bioterrorism. Public health was the lead for increased vigilance and preparedness for unexplained illnesses and injuries. There were five components to the plan: preparedness and prevention, surveillance and early detection, diagnosis, response, and communication. These required integrated training and research. CDC was making incremental progress to define, develop and implement a set of public health capacities at the local, state and federal level to respond to deliberate biologic or chemical attacks on the health of U.S. citizens. Importantly, CDC established a national repository of emergency drugs and medical equipment, which later became the Strategic National Stockpile.
Ready or not, the Florida anthrax event thrust public health and bioterrorism to the front of the line. A CDC trained laboratorian in the Florida Health Department isolated Bacillus anthracis from a patient and alerted his health director and CDC according to protocol. The national Laboratory Response Network was created specifically to ensure the nation had sentinel experts who could correctly identify unusual bacteria from patient specimens and sound the alarm. It worked.CDC and public health as a whole had limited science or past bioterrorism experience to draw upon beyond basic laboratory and epidemiologic understanding. There was great uncertainty about what the nation was dealing with and the magnitude of the event. The days and weeks that followed saw a quick escalation along the East Coast. On October 4, anthrax was confirmed in the first patient and a second patient from the same media company reported being ill. Three days later, a Sunday, CDC confirmed B. anthracis from the office keyboard of the first patient —there was no doubt it was intentional because the organism would not naturally be found in an office setting.
Public health leads
In the weeks that followed, cases accumulated in New York, New Jersey, Washington, D.C. and Connecticut. CDC deployed teams of epidemiologists, occupational health experts, industrial hygienists and environmental health professionals in response. In addition, it gathered nearly a third of its workforce at the headquarters to aid in the response. The response was staged in an old auditorium at the Atlanta headquarters set up on metal tables marked by paper signs, according to their mission: epidemiology and surveillance response, environmental response, lab response, interventions and information sharing.
The anthrax cases in Florida provided a good example of how CDC worked with state and local officials. After the first case resulted in death, CDC moved quickly to confirm the case of the second victim early on the evening of October 7. The CDC, HHS, FBI, DOJ, Florida Governor’s Office, Florida Public Health Department, and a local public health department quickly formulated a plan that got the word out overnight to the affected employees that they needed to come to the clinic for medicine and testing that very next morning. CDC shipped medicine to Florida overnight so it was there when the people arrived in the morning. And CDC and Florida officials issued a joint release at 11 p.m. on October 7 notifying the media and public of the second case. It was a good example of local, state, and federal officials working together to get out a message, send medicine and mobilize people to come get treatment — literally overnight on a Sunday evening.
Current threats to bioterrorism preparedness
A potential threat may be the misguided belief that preparedness is a thing, something you create once and simply take off the shelf when you need it. Being prepared is an ongoing process and a collective mindset among all public officials and citizenry to the degree they are willing to invest time, resources and attention.
Our society is interconnected and accessible from anywhere across the globe. New technology and ill purpose can wreak havoc without notice.
Preparedness means good public health with an ability to deal with day-to-day disease threats, including detecting and responding to unusual diseases, having the capacity to diagnose rare illnesses, the laboratory acumen to know what you have, and the insight to know what it means to our citizenry’s health. Collectively, these things and the means to respond swiftly are the foundation of preparedness against acts of bioterrorism.
National emergency preparedness requires a coordinated effort involving every level of government as well as the private sector, non-govern mental organizations and individual citizens. The best public health strategy to protect the health of civilians against biological terrorism is a strengthened public health system including public health laboratory capacity, increased surveillance and outbreak investigation capacity and education and training at the local, state and federal level.
>>View the rest of the Remembering 9/11 and Anthrax: Public Health’s Vital Role in National Defense excerpts and more preparedness coverage on NewPublicHealth here.