Docs Still at Front Line in Detecting Bioterrorism

VIDEO: Tommy Thompson: U.S. Still Vulnerable to Anthrax

Some individual clinician will be the key player the next time there's a covert bioterrorism attack, like the anthrax episode a decade ago.

Despite a marked increase in resources aimed at detecting and foiling bioterrorism, "it's going to be a practitioner who diagnoses the next covert attempt," according to Dr. Larry Bush of JFK Medical Center in Atlantis, Fla.

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Bush should know. He made the initial diagnosis of anthrax inhalation after a confused and feverish Robert Stevens walked into the emergency ward on Oct. 2, 2001 -- a diagnosis that kicked state and federal health agencies into high alert and probably saved dozens, if not hundreds, of lives.

Behold the Zebra

"What I saw was a man who -- according to his wife -- drove home 24 hours earlier from North Carolina and now was comatose, on a ventilator, and had meningitis," Bush told MedPage Today.

He and colleagues took spinal fluid from the comatose Stevens and Bush noted a preponderance of white cells, indicating inflammation, as well as the telltale boxcar shape of bacillus cells.

"A bacillus that causes meningitis is very rare," Bush said, and Steven had none of the usual precursors of more common infections, such as head trauma.

Of course, he also had none of the common precursors of inhalational anthrax, such as working with hides or in a lab that deals with the pathogen, and for many doctors that would have been that.

The medical school adage about horses and zebras would have kicked in and the incredibly rare diagnosis of anthrax -- 18 cases in the U.S. in the previous century -- would have been dismissed as a zebra.

But Bush took a different view. "In the worst case, this is anthrax," he thought. "And if it's anthrax, it's bioterrorism until proven different."

He notified health authorities and the rest is history.

Anthrax Timeline

The story as it unfolded:

In September and October 2001, envelopes containing Bacillus anthracis were mailed to two senators -- Patrick Leahy and Thomas Daschle -- and to media outlets in New York City and Boca Raton, Fla.

On Oct. 2, Bush made his famous diagnosis. At the time there were already several undiagnosed cases of cutaneous anthrax.

On Oct. 5, Stevens died and a second employee of the same company, in hospital since Sept. 30 with pneumonia, was diagnosed with inhalational anthrax.

Events began to build from Oct. 9 through 19 -- a period that saw several more diagnoses of cutaneous anthrax, after people handled some of the suspect envelopes. Several postal workers were diagnosed in New Jersey and 28 people were found to have been exposed to anthrax after an envelope was opened in Senator Daschle's Hart Senate Office Building office.

On Oct. 19, the CDC linked the four confirmed cases of anthrax to "intentional delivery of B. anthracis spores through mailed letters or packages" and over the next four days, four postal workers in a District of Columbia male processing plant were admitted to hospital with inhalational anthrax. Two later died.

Over the next few days, the CDC recommended antibiotic prophylaxis for thousands of people who had potentially been exposed either in the mail plants or in government buildings.

On Oct. 31, a 61-year-old female hospital stockroom worker in New York City died from inhalational anthrax, although how she was exposed remains a mystery.

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