Anthrax in D.C.: Dan Hanfling and Georges Benjamin Remember the Events of 2001

Oct 18, 2011, 2:30 PM, Posted by NewPublicHealth

Trust for America’s Health and the Robert Wood Johnson Foundation have issued a new report, Remembering 9/11 and Anthrax: Public Health’s Vital Role in National Defense. NewPublicHealth continues to run excerpts.

This week marks the anniversary of when four Washington, D.C., postal workers were hospitalized with inhalational anthrax in October 2001. The following includes excerpts of recollections of these events from Dan Hanfling, MD, special advisor on Emergency Preparedness and Disaster Response to the Inova Health System and Georges C. Benjamin, MD, FACP., FACEP. (E), American Public Health Association executive director and Joan H. Tisch Distinguished Fellow in Public Health at Hunter College.

Public Health Response to Terrorism and Bioterrorism: Inventing the Wheel

Hanfling Dr. Dan Hanfling, Inova Health System

Dan Hanfling

On October 15, a letter containing anthrax was opened in the office of Senator Tom Daschle, located in the Hart Senate Office Building. A few days later, on October 19, the first of what would become hundreds of patients with concerns of anthrax exposure came to our emergency department seeking care. The patient’s chief complaint was that he thought he might have been exposed to anthrax.

The Emergency Department physician on duty that evening, Dr. Cecile Murphy, did what all great clinicians do – she listened to the patient. When he diagnosed himself with anthrax, he did so because he knew his body and something didn’t feel right – his chest felt strange.

The patient said he delivered mail from the Brentwood postal facility. Dr. Murphy asked where the bulk of the mail eventually ended up. The patient answered that most of it goes to the Senate. In hindsight it seems pretty apparent what was going on.

So Dr. Murphy pursued the case further. She did an x-ray which just didn’t look right, and then followed that up with a chest CT Scan. Sure enough, it was clear as day that the patient was suffering from inhalation anthrax.

The first call Dr. Murphy made was to the D.C. Department of Health.

At the time, there was limited guidance on the management of a bioterrorist attack. Treatment protocols for anthrax were tucked away in journal articles sitting in the hospital library. And no effective means for managing the multitudinous information that was beginning to ripple across the healthcare community was in place.

In short, we were inventing the wheel. This wasn’t reinventing the wheel, because virtually no clinicians in the United States had faced this before.

We realized there was no cavalry coming to sort things out, and that we would have to manage most of this ourselves.

We created our own treatment protocols and put together an ad-hoc communication information management system that reached all Northern Virginia hospitals. We made clinical decisions on the management of the anthrax cases by committee and involved infectious disease and intensive care doctors. While I helped to contribute to a number of these early discussions, I turned my attention to creating the systems needed to manage the ongoing bioresponse event – essentially to invent the wheel. Along with colleagues in emergency medicine from across northern Virginia, we created the Northern Virginia Emergency Response Coalition (NVERC), one of the first health care coalitions in the country, and the model for much of what HHS/ASPR has encouraged in the years since these awful attacks. In October 2002, the NVERC was formally re-established as the Northern Virginia Hospital Alliance, governed by the CEOs of the northern Virginia hospitals who comprise its Board of Directors. In the 10 years since the attacks, this group has never failed to have a quorum of participants, which demonstrates the absolute commitment to emergency preparedness by the healthcare system leadership in our community.

We have evolved these efforts into a much stronger community of emergency responders in the decade since the attacks, coordinating closely with, not only our public health colleagues, but those in public safety and emergency management.

September and October 2001 was a frenzied and chaotic time in the history of our country. These successive attacks stretched thin all aspects of the public health system.

As an emergency physician who was deep in the trenches in the fall of 2001, I can tell you that the entire public health community was dealing with a world that was turned upside down. It was clear to me that emergency physicians and nurses were now on the frontlines of the public health response in this new age of catastrophe, terror and fear.

In short, emergency physicians and nurses have become the operational lynchpin of our new focus on public health emergency preparedness. While the emergency department has long comprised a significant portion of the public health safety net, providing equal access to all who seek care, we now find ourselves in the added role of community protector. And it doesn’t stop at the emergency room threshold. In fact, hospital staff have become the ‘new first responders’ or what has now been termed ‘first receivers.’ We are all essential personnel in the continued struggle to keep our communities safe and healthy.

Public Health, Always Be Prepared

Dr. Georges Benjamin, American Public Health Association

Georges C. Benjamin

In October, I learned through the beltway rumor mill about a confirmed case of anthrax in Washington, D.C. So, I picked up the phone and called District of Columbia health officer, Dr. Ivan Walks, and offered our help. I perceived it was his problem, but quickly learned otherwise.

The victim was a Maryland resident who was hospitalized in Virginia who worked in Washington, D.C. Clearly this case eclipsed borders and the entire metropolitan area needed a coordinated, consistent and coherent response. The victim was Thomas L. Morris Jr., a postal worker whose job was to carry mail from the Brentwood Facility in Washington, D.C. to Baltimore Washington International Airport (BWI). At the time, Brentwood hadn’t been clearly established as the site where he was exposed so we had to quickly determine where he got infected. If he was exposed at the airport, people all over the country and possibly the world could have been exposed.

Working through the night, we began piecing it together. We determined that the victim primarily carried mail to an air cargo facility on the outskirts of BWI and consequently could not have contract anthrax in the airport. This was a great relief, but it also raised other concerns. If Brentwood was the most likely place of exposure, that would mean not only were other workers and residents at significant risk, but so were other members of the Washington metropolitan region.

We received calls from bankers and others whose employees wouldn’t go near the mail even to process checks. They needed to know if the mail was safe. Unfortunately, we didn’t have a good answer for them, so we ended up conducting a state-wide testing program for business mail rooms to define our risks and reassure the public. Like other public health agencies we tested all kinds of things, from personal mailboxes to powders that turned out to be from donuts.

It was incredibly difficult to allay public fears because there were few reliable rapid tests for anthrax in the environment. In some cases we were inventing new testing methods based on the best science we had. We simply didn’t have a lot of experience with environmental testing under these conditions and no experience with mass exposure to anthrax. We got through it, but with a lot of ingenuity and teamwork.

Ten years ago, public health workers answered our nation’s call to action. Before that, preparedness had not always been considered central to our jobs. Some feel that the added responsibilities undermine our other important work. But in the 21st century, it’s clear that preparedness is an integral and important part of public health. It is not an either or thing. At the end of the day, preparing for any threat makes us better prepared for all threats, whether it’s bioterrorism or a flu pandemic.

We learned a lot from these attacks. There is no question that the old Boy Scout motto “be prepared” is still very relevant today, and we are much better prepared for bioterrorism, pandemics and basically any public health emergency. However, I do worry that our short-sighted zeal for financial solvency is putting our health preparedness and safety at risk. Simply trading our long-term health future for short-term fiscal stability isn’t a reasonable trade off.

>>Read the full pieces from Hanfling and Benjamin, and more stories on preparedness here.

This commentary originally appeared on the RWJF New Public Health blog.