On October 4, 2001, the threat of biological terrorism became a reality when the Centers for Disease Control and Preventio% (CDC) and Florida health ofneals reported the first case of inhalational anthrax. In Washington, DC, we were still recovering from the attack on the Pentagon when we were once again forced to confront the reality of terrorism in our back yard. Many lives were changed in the national capital area as millions of Bacillus anthracis spores were released into the Hart Senate Office Building on October 16, 2001, after a US Senate staff member opened a letter laden with the organism. Several days later, four postal workers from the Brentwood Mail Processing and Distribution Center in the District of Columbia were hospitalized and diagnosed with inhalational anthrax. Two of these workers later died from the exposure. Physicians, especially those in uniform, began to address the reality of anthrax and the many unknowns that accompanied this diagnosis.
Prior to these events, B. anthracis was something against which deploying military forces, farmers, and veterinarians were immunized. Beyond the military, few imagined the possibility of B. anffa-acis as a weapon, and even fewarweare repared for this attack on American soil. In the medical community it was rapidly recognized we were unprepared to address this new problem fully. Normally we rely on data, carefully and scientifically collected, of which there are little. There was no clinical trial to look to, no previous mass exposure to learn from, and no algorithm to follow. How would we deal with the hundreds of patients who came to our offices asking if they had anthrax? What could we tell them? There is little reassurance in "I don't know," especially when coming from a physician's mouth.
What did we know about B. anthracisl It is a spore-forming bacterium that occurs most frequently as an epizootic or enzootic disease in herbivores that acquire the spores from direct contact with contaminated soil. Humans become infected, usually with the cutaneous form, after direct exposure with an infected animal or animal product. The inhalational form is very rare. Importantly, no case of human-to-human transmission has ever been documented.
We had to rely on the CDC and infectious disease experts to give guidance as we began dealing with the wave of patients. Without prior real life experiences, there were no definite answers. Flexibility from both physicians and patients became a requirement as recommendations were initially presented and then evolved as more information was gathered.
Many lessons were learned from the experience with B. anthracis, which the US Postal Service is still eradicating from the Brentwood Mail facility. First, a chain of command and decision-making responsibility must be clarified early on in an emergency. This is something that is achieved easily in the military, where chains of command are ever present, and this was rapidly appreciated by civilian providers.
Second, make use of ail of the resources available including expert advisors, but realize that they may not make decisions for you. Third, acknowledge that this is an evolving process that requires flexibility as more information is gathered from the initial experiences. This was seen as the recommendations for prophylaxis and treatment evolved into multiple options from a simple 60 days of ciprofloxacin, to ciprofloxacin plus immunization, to the sole pediatrie case that required multiple antibiotics in the initial phase followed by a prolonged course of amoxicillin.
Fourth, keep ongoing data logs about the various exposures, screening tools used, treatment options, and outcomes. These data will be invaluable if we have to face B. anthracis in future acts of bioterrorism or biological warfare. Finally, be prepared for anything. We now must consider other possible tools of an enemy who lacks a face. What will we confront next? Are we ready?
Following our experience with anthrax we have learned many lessons, but we also learned how strong our country can be. As a military resident preparing for graduation and future service. I feel that anxiety that besets any physician who is entering into a transition period. I also feel prepared to care for my patients and, along with many other pediatricians in training, I will keep these lessons close at hand to be used as a tool for challenges in the months and years to come.