Webcast Transcript

Anthrax: What Every Clinician Should Know, Part 2

(November 1, 2001)

(View the webcast on the University of North Carolina School of Public Health site.)

Segment 4 of 10
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Dr. Caine:
Thank you, Dr. Satcher. Now let’s meet our first guest on our panel of experts. We are pleased to have Dr. Ali Khan, Deputy Chief of CDC’s Anthrax Response Team from Washington, D.C., from the Centers for Disease Control. Dr. Khan will now provide an epidemiologic update.

Dr. Ali Khan:
Thank you, Virginia, and let me start by thanking the National Medical Association for this wonderful opportunity and privilege to give the updated epidemiologic information in this investigation. As you just heard from our Surgeon General, this story starts approximately a month ago when there was recognition of an unprecedented attack of bioterrorism in the United States through the U.S. Postal Service. You will see in front of you our first slide, which is a Gram stain of the cerebral spinal fluid of the first individual, a 63-year-old gentleman who was a photo editor at the American Media Company, who had onset September 30—fever, altered mental status—and was admitted on the 2^nd of the month with the Gram stain that you see in front of you, quite classic and alarming, that it’s clear that these are the Bacillus species in the Gram stain. Positive blood cultures, positive CSF cultures. CDC was notified the following day, confirmation occurred 2 days later, and was finally confirmed with an autopsy that is consistent with inhalational anthrax on the 6^th of the month. Next slide, please.

Those are the details of that first individual I just discussed. Now while the epidemiologic investigation was ongoing and the environmental assessment was ongoing of this Florida case, we heard of a case of cutaneous anthrax in New York City, and that would be the following slide that shows the lesion on the first index case in that city.

The next slide gives some details of this individual. She was a 38-year-old, female, NBC TV anchor assistant. She became sick on September 25 with a skin lesion, central necrosis, a painless lesion, and Dr. Sherif Zaki of the Centers for Disease Control and Prevention, based on an immunohistochemical staining of a skin biopsy, was able to document a Bacillus anthracis infection on the 12^th of last month. This woman had handled a suspicious letter with powder in it. Next slide, please.

At this point, there is a multi-state investigation underway that involves Palm Beach County, Florida, which was the initial area; New York City; Washington, D.C.; and Trenton, New Jersey. What I’d like to do on the following slide and before I launch into a complete description of what confirmed and suspect cases is, let me just make clear what the case definition is for the audience that we are using. And that case definition for confirmed cases would be a clinically compatible illness confirmed by isolation of B. anthracis or other laboratory evidence based on two or more supportive tests. For suspected cases, the case definition is clinically compatible illness with one supportive lab test or a link back to a confirmed epidemiologic exposure. Now using that as a frame of reference on what we are calling confirmed cases and what we are calling suspect cases, I’d like to go through the investigation in the 4 states and try to put together for you what we think is happening in the country from these letters.

The first investigation is in Florida where there have been 2 inhalational cases. The first one, as you heard from Dr. Satcher, and that gentleman died. Of the exposures that were checked in that AMI building, only one nasal swab was positive out of 1000 such swabs that were taken. From an environmental standpoint, the work site was deemed to be contaminated based on testing. Some post offices that sent letters to that building were also deemed to have evidence of Bacillus anthracis spores along a mail stream of the letters, ending up eventually in the AMI building. Clean-up is underway there.

For intervention, there was prophylaxis for company employees and postal workers. I will try to make that point as I go through that we have been very careful to try and do targeted prophylaxis of individuals and not go to a scheme that has us prophylaxing hundreds of thousands of people, potentially giving the side effects that would be associated with that management strategy.

The next slide is the New York City investigation, and, unfortunately, these have not been updated. So let me give you the updated numbers on these slides. Needless to say we chose trying to provide updated educational materials over sparkling new slides. In New York City there were 6 cutaneous cases and 1 death, and that death was from a newly diagnosed inhalational case that you just heard about from Dr. Perez. Of those individuals, 4 worked for media companies, all who had cutaneous disease. We have not yet defined exposure for the woman with inhalational death. Some of the work sites have been deemed to be contaminated and clean-up is underway in those areas. Again, for intervention, we are only doing targeted prophylaxis for those individuals who were exposed to letters.

The next slide is a description of the New Jersey investigation, and again here is an update. Of the cases in New Jersey, there are now 5 cutaneous cases, 2 inhalational cases; all except for 1 was a mail handler, and this is an individual who has cutaneous disease. We have not yet determined the mode of exposure for that individual. From an environmental standpoint, again, there was evidence of contamination at a number of mail-processing facilities. The investigation is ongoing in this facility and clean-up is underway. And again, from an intervention standpoint, there was prophylaxis for a defined group of people who had contact with the facility.

Let me finish up the investigations with the District of Columbia where I have the most experience. But before I get to that, let me talk about letters, which seems to be the next slide. In these 3 states, and the one I’m about to talk about in the District of Columbia, there were 2 letters identified in New York City, one to NBC and one to the New York Post. These were all postmarked 9/18, mailed from New Jersey to media companies, and that is potentially the link back to New Jersey, and I’ll elaborate on that in a couple of minutes. There was B. anthracis in those letters in a powder form. The District of Columbia also received a letter into the Hart Building (the Senate Hart Building) that was postmarked September 9^th, and that was mailed from New Jersey to a senator’s office and there was Bacillus anthracis powder identified within that facility.

In the District of Columbia, which should be on the next slide, there should be a description of cases for the audience. All the cases in the District of Columbia are mail handlers; 5 of them had inhalational disease and there were 2 deaths among those mail handlers. Also in the Hart Building, where a letter was opened on the 15^th, there were a number of people exposed on 2 floors. There were 28 positive nasal swabs from those individuals, including all 13 people who were on the floor where the envelope was opened, and we have made recommendations there to prophylax that whole floor, the 5^th and 6^th floors where this event occurred and the first responders to this event. We also had the opportunity there to do an extensive environmental assessment to follow back the chain of the letter through the capital post offices to the Brentwood facility and then eventually back to New Jersey. A number of these facilities were contaminated. At this point, we know that the Brentwood Post Office had evidence of contamination. We know there was evidence of contamination of multiple buildings within the capital. We fortunately know that within the mail—from letters that went from Brentwood to other parts of the city which may have touched the letter that went to the senator, we have been very encouraged by the fact that of about 40 or 50 post offices that received such letters, there have been only 3 post offices that have a single swab with scant growth on it. So that was very encouraging. However, we have gotten a lot of data at this point from the federal mailrooms. At this point, depending on whether you count confirmed or preliminary data, there are half a dozen to a dozen such facility mailrooms that have had evidence of contamination, suggesting that there was extensive targeting of multiple federal facilities for receipt of such letters, although there is no clear recognition or identification of the letters themselves. The epi supports that with all this contamination in the mailrooms.

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