New York Times, October 16, 2001

Fifty years ago, the federal government set up an elite corps of medical detectives to counter a threat it hoped never to face. Now, with the emergence of anthrax, that corps, the Epidemic Intelligence Service, is facing the challenge of that mission: tracing the cause and stemming the spread of a disease that that may have been deliberately introduced - in other words, a biological attack.

Summoned to action immediately after the destruction of the World Trade Center on Sept. 11, the Epidemic Intelligence Service has been working with the F.B.I. and state and local health departments to conduct its effort on two fronts. One is directed at detecting any communicable agent that might have been released. After anthrax was detected in Florida, the epidemic service, which is based at the Centers for Disease Control and Prevention in Atlanta, set out to determine how the patient contracted the disease. The information is crucial in assessing the potential harm to other people.

The second front is informing the public of the anthrax cases, the steps the C.D.C. is taking to combat the threat to public health, and what people can do. Much of the detection effort went well, though there were disturbing glitches like a power failure at the C.D.C. that delayed the detection of anthrax in an NBC employee in Manhattan. (The failure was caused by a short in a cable that was awaiting repairs.)

But there is ample evidence of distressing lapses in communication with the public that, if the illness had been more widespread, could have made the bad situation even worse. The lapses were not entirely the fault of the C.D.C., which is the federal agency charged with controlling communicable diseases in this country and coordinating an early warning system for bioterrorism.

The lapses underscore the need for the government to heed the advice of the epidemic service's first director, Dr. Alexander D. Langmuir. He advocated a system to monitor disease and rapidly disseminate information, as a prime defense against biological warfare. But many experts have criticized the C.D.C. for remaining largely silent about the anthrax threat instead of providing more detailed information sooner to people who may have been exposed as well as to doctors and the public.

C.D.C. spokesmen have said they were restricted in disclosing information because of provisions of the Federal Emergency Response Act and because the F.B.I. was conducting a criminal investigation. That was so, said the C.D.C. director, Dr. Jeffrey P. Koplan, even though the centers and the F.B.I. are conducting parallel public health and criminal investigations, and the centers are not under the bureau's direction.

"If anything, we are under the direction of the Florida state health department, with whom we are there assisting," Dr. Koplan said in an interview. The only other known bioterrorism act the epidemic service ever investigated was in 1984 in Oregon, where followers of Bhagwan Shree Rajneesh deliberately contaminated restaurant salad bars, leading to 751 cases of salmonella poisoning. That case was hardly a model of timely communication of health threats to the public. The C.D.C. delayed publishing a scientific report of the outbreak for 13 years, saying it did not want to aid in creating copycat episodes. On Oct. 4, when Tommy G. Thompson, the secretary of health and human services (the C.D.C.'s parent agency), disclosed the first anthrax case, he said it appeared to be an isolated case in Florida, possibly linked to natural exposure to anthrax in the environment.

Last week, when the most pressing health problem was the degree to which the country was vulnerable to anthrax, the C.D.C.'s Morbidity and Mortality Weekly Report, the bulletin that doctors and health workers look to for information about communicable diseases, devoted only two paragraphs to the anthrax situation, providing only sketchy details of the first two cases and a description of anthrax symptoms. As a former editor of the report, I know that it can quickly transmit needed health information. But this time, its current editor, Dr. John W. Ward, said the report "was out of the loop."

Even the little that the bulletin was able to publish "was an achievement," he said. At times, C.D.C. spokesmen have issued puzzling statements and have said they did not have access to information about developments in New York and Florida. In response to my questions, they have asked me to explain the science, saying they did not understand it or had not been informed. Underlying the silence is a mind- set that has developed in recent years among scientists who have become accustomed to obeying embargoes imposed by journals that prohibit public discussion about scientific findings until publication. Even though journals waive embargoes for information of an urgent public health nature, some researchers still hesitate to discuss their work, for fear that the journals will then refuse to publish it. In this vacuum, journalists and the outside experts they consulted could only speculate about what might be going on.

The resulting news reports were often conflicting and occasionally inaccurate. Communication from the C.D.C. is particularly important because anthrax in humans is rare in this country, with just 236 cases of all types reported between 1955 and 1999. Most doctors have never seen a case, and look to the C.D.C. for guidance. Anthrax is one of the most difficult infections to trace and has often challenged the ingenuity of medical detectives in past generations who sought the source of cases. For instance, anthrax cases among World War I aviators were traced to a natural source, helmets lined with wool from infected sheep. And when a man developed cutaneous anthrax in Philadelphia years ago, epidemiologists learned its source only after they tore apart his newly purchased wool coat and found Bacillus anthracis in one sleeve.

When Florida health officials called the C.D.C. to report that Robert Stevens, 63, had apparently developed inhalation anthrax, the centers deployed 15 epidemiologists and other scientists. In confirming the case and seeking its source, the Epidemic Intelligence Service has relied on traditional Sherlock Holmes-style sleuthing and the skills of colleagues in the laboratory, who use the latest genetic and other laboratory tests, Dr. Koplan said. Mr. Stevens had traveled with his wife to visit a daughter and go hiking in North Carolina, but became ill on the drive back to Florida. So while some epidemiologists examined Mr. Stevens and talked with his doctors about the evolution of his symptoms, others fanned across Florida and North Carolina, joining colleagues from those states seeking clues to where he might have acquired the illness.

In the investigation's initial stages, the epidemiologists could assume nothing, and the patient himself was unable to communicate - he was in a coma when he arrived at the hospital in Atlantis, Fla., and died without regaining consciousness. So health workers had to interview his wife and family to reconstruct what he did during the preceding two weeks. Where did the Stevenses stop, eat and sleep on the trip? Was he exposed to a sick animal? Goat hair? Mr. Stevens worked as a photo editor for The Sun, a tabloid sold in supermarkets and published by American Media Inc. in Boca Raton, Fla. Epidemiologists went there and to his home in nearby Lantana, where they asked what Mr. Stevens did in his spare time. Did he garden? Did he spent a lot of time outdoors? If so, where? With whom? They also collected samples of dust, soil and vents seeking a possible source of anthrax-contaminated materials.

While these investigators focused on possible natural causes, others looked at the more ominous possibility: that Mr. Stevens was the victim of an organized anthrax attack. They visited all hospitals in the area to talk with infection-control workers and other doctors, reviewing medical, microbiology and X-ray records of patients treated for meningitis, severe respiratory failure, septicemia, unexplained fevers and diseases like tularemia that can produce symptoms similar to those of anthrax. Might any have been been anthrax, but misidentified as something else? Inhalation anthrax produces swollen lymph nodes in the mediastinum, an area between the back of the lungs and the spine. The swelling can show up on an X-ray. Did a radiologist miss the finding? In all their work, the epidemiologists "found nothing that was suspicious," said Dr. James M. Hughes, a top C.D.C. expert who oversaw the investigation from Atlanta. Mr. Stevens's co-workers were given a phone number to call if they developed any symptoms. Epidemiologists also set up a system to monitor any unexplained pulmonary illness in hospitals serving the area.

Meanwhile, C.D.C. workers sought advice from Dr. Philip S. Brachman, an expert in anthrax epidemiology and a former director of the Epidemic Intelligence Service who now works at the Emory School of Public Health, next to the centers' campus. Dr. Brachman said he reviewed his records from his days as an officer with the epidemic service in the late 1950's and early 1960's, when he investigated anthrax cases that developed among workers exposed to contaminated goat hair and wool at three mills in North Carolina and one in South Carolina. The mills are now closed, but given how long anthrax spores can live in the environment, Dr. Brachman wondered if Mr. Stevens could have contracted the disease in one of the cities where the mills had been. Had the mills been renovated for a new use? Was one a motel? If so, had Mr. Stevens stayed there?

But when Dr. Brachman asked the epidemic service officers these questions, he was frustrated. "They say, `We cannot say,' Dr. Brachman said. "They have strict orders." Dr. Brachman is among the health leaders who have criticized the C.D.C. for not making an investigator regularly available to reporters. He said: "The media is an extremely important part of the public health team in providing education. If you turn them off, what is the media going to do?"

On Oct. 7, the investigation took a new twist when anthrax was identified in a swab of Mr. Stevens's co- worker Ernesto Blanco, 73. Because anthrax is not contagious, the finding immediately heightened suspicions of a bioterrorist attack. Mr. Blanco developed a fever, severe pneumonia involving at least two lobes of his lungs, and bloody fluid in the pleural lining. He needed a mechanical respirator to help him breathe. B. anthracis has not been identified in cultures of the fluid and sputum. His symptoms are atypical for inhalation anthrax, and there may be no way of knowing if his symptoms were caused by anthrax, Dr. Hughes said. Blood tests taken over the next few weeks to detect antibodies to anthrax and other infectious agents may help clarify the diagnosis.

Meanwhile, Mr. Blanco is recovering. Epidemiologists talked to Mr. Blanco to learn everything he did for the preceding two to three weeks. Was he an avid gardener like Mr. Stevens? Did they share a garden plot? Had they bought fertilizer or bone meal from the same distributor? What, if anything, did Mr. Blanco and Mr. Stevens do together outside work? Because Mr. Stevens and Mr. Blanco were co-workers, epidemiologists asked about recent construction or renovation at American Media. Could someone have dug up soil that contained spores from a cow that died of anthrax many years ago? They swabbed dust in cracks, under the desks and from ventilation ducts and filters. Anthrax spores were found on Mr. Stevens's keyboard. Spores also were detected in samples from work surfaces in the mailroom at American Media, the C.D.C. said. The exercise was repeated several times, after anthrax was identified in other people. Anthrax was cultured from the nose of Stephanie Dailey, 36, who worked with Mr. Blanco in the mailroom.

Then attention turned to New York City when Erin M. O'Connor, an assistant to Tom Brokaw at NBC headquarters, developed cutaneous anthrax after opening two envelopes, one containing powder and the other a granular substance. The initial skin lesions from anthrax can resemble an insect bite, and a doctor who examined Ms. O'Connor initially thought she might have been bitten by a brown recluse spider, Dr. Hughes said.

Luckily, however, an infectious disease specialist who had worked in areas of the world where anthrax is endemic suspected it was the cause of the sore on her skin and a dermatologist then took a biopsy of the lesions and sent a sample to the C.D.C. Special staining and immunologic tests performed at the centers identified anthrax as the cause of the skin lesion, but the organisms have not grown in the laboratory, presumably because the antibiotics Ms. O'Connor had already been taking destroyed them, Dr. Hughes said.

Tests on Ms. O'Connor's biopsy were among thousands of others that C.D.C. and state and local health laboratories have performed in the search for the source of the anthrax. Cultures from swabs of noses and environmental sources may grow several microbes. So scientists may have to repeat the tests before they can confirm anthrax. Newer laboratory techniques based on DNA, like the polymerase chain reaction, have allowed more rapid detection of microbes. But such successes have also created overly optimistic expectations. When it is necessary to grow microbes in the laboratory, the process cannot be speeded up, Dr. Koplan said.

In recent years, many public health leaders have warned that the country was ill prepared to detect anthrax and other diseases that only a few American doctors have seen. Yet the quick detection of anthrax in New York and Florida suggests that doctors may be better prepared than expected to respond to the threat, Dr. Koplan said. Dr. Martin E. Hugh-Jones, an anthrax expert at Louisiana State University, said: "Official agencies have learned they must talk to each other. We've for years been trying to get doctors to understand what to look for. Now everyone knows."