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December  2003                                                    Volume 5 - Number 3

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FEMA Update...

Summary of Public Health Response to Anthrax Incidents of 2001 (GAO)

By Anupa Gandhi

The 2001 anthrax incidents revealed the benefits of strategic response planning and uncovered areas for improvement at the local and federal levels. The local and federal response lacked effective communication, coordination, and a trained workforce. Since then, the CDC has worked to improve federal response by developing effective communication and clinical tools.

In October 2001, an American Media, Inc. employee in Florida contracted inhalational anthrax. It was the first case of anthrax in the U.S. in two decades. The FBI confirmed the existence of only four mailed letters containing infectious spores, but by December 2001, the Environmental Protection Agency (EPA) confirmed that over sixty locations had been contaminated, one third of which were U.S. postal facilities. Although these incidents were limited to epicenters on the east coast, the implication that mail processing facilities caused cross-contamination was national.

At the time of the incidents, the existing public health response model placed responsibility at the local level to minimize cost. The rationale was that people would consult their local physicians, who would then report suspicious disease patterns to the state health department. As a result, disease trends would be identified and public health officials would determine whether a national response was needed. The anthrax incidents tested this model and the local and federal responders.

Locally, lack of communication, coordination, and surge capacity limited overall effectiveness. Previous emergency incidents, training drills, and disease outbreaks like West Nile virus helped local response support coordination with law enforcement, plan across multiple sites, and implement surveillance methods. But the anthrax incidents showed that although prophylaxis clinics could be set up quickly, there was no efficient method of testing and administering to patients. Despite effective communication between public health officials and first responders, information flow with medical personnel and clinicians was problematic and lacked timeliness. Communication was further hindered when some public health officials lacked security clearance due to an ongoing criminal investigation. Lastly, reports to the media were often inconsistent.

Although the epicenters of the incidents had engaged in limited response planning, they had not anticipated the extent of the anthrax events and they lacked coordination among a wide range of public and private entities such as first responders, environmental agencies, and postal workers. The response capacity of the local workforce and labs was strained and would not have sustained a more extensive crisis in spite of the Center for Disease Control (CDC) and Department of Defense (DOD) providing resource assistance and transfer employees. These employees had to be trained in their new duties, again wasting time.

At the federal level, the CDC had already implemented bioterrorism-planning initiatives. In the late 90s, the CDC assumed national responsibility for the public’s health in the face of an attack, and collaborated with local officials and other federal agencies including the FBI, FEMA, FDA, National Domestic Preparedness Office, NIH, DOD, and Office of Emergency Preparedness. Unfortunately, these collaborations were not formalized when the anthrax incidents occurred. The CDC was also developing diagnostic and epidemiological standards for state health departments, and organizing research for vaccines and drugs. During the events, the CDC effectively supported the local response with clinical and lab resources, surveillance, decontamination, and prophylaxis. Yet, the CDC did not own a nationwide list of outside experts and, therefore, had trouble disseminating rapid and accurate guidance. The CDC also had difficulty providing timely information to the media and the public. Their spokespersons, considered the most authoritative, were not visible and had trouble conveying information with the caveat of uncertainty. The CDC has since organized a team of analysts who exclusively review information. They will not be part of the daily response, as the CDC had trouble managing that role in addition to the flow of information. The CDC’s epidemiological and clinical resources were also spread thin because labs were overwhelmed by samples, ineffective treatments, and few clinicians could diagnose anthrax. A plan, implemented in November 2000, aimed to educate clinicians on anthrax recognition, but few people had been trained when the incidents occurred. Current measures aim to restructure the Office of the Director, create and operate an emergency operations center, enhance communication infrastructure, create a database of biological agents, and solidify partnerships with other federal agencies.

The anthrax incidents illustrated the need for effective communication and mitigation. The local response benefited from past experience, but was equipped to handle a bio-terrorism crisis of only moderate extent. At the federal level, the CDC’s initiatives were minimally implemented and ineffective during the attack. As a result, communication was problematic and inconsistent, workers were strained, and the need for a strong nationwide public health infrastructure became apparent.