Bioterrorism: CDC’s Public Health Response

Statement of 
Mitchell L. Cohen, M.D.
Director
Division of Bacterial and Mycotic Diseases
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Department of Health and Human Services

Testimony
Before the Committee on Governmental Affairs and Subcommittee on International Security, Proliferation and Federal Services
United States Senate

Good morning, Mr. Chairman and Members of the Committee.  I am Dr. Mitchell L. Cohen, Director, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC).  Thank you for the invitation to update you on CDC’s public health response to the threat of bioterrorism.  I will update you on CDC’s response to recent anthrax exposures, and I will discuss the status of implementing the overall goals of our bioterrorism preparedness program.
                As has been highlighted recently, increased vigilance and preparedness for unexplained illnesses and injuries are an essential part of the public health effort to protect the American people against bioterrorism.  Prior to the September 11 attack on the United States, CDC was making substantial progress toward defining, developing, and implementing a nationwide public health response network to increase the capacity of public health officials at all levels–federal, state, and local–to prepare for and respond to deliberate attacks on the health of our citizens.  The events of September 11 were a defining moment for all of us, and since then we have dramatically increased our levels of preparedness and are implementing plans to increase it even further.

Recent Anthrax Exposures
                As you are aware, many facilities in communities around the country have received anthrax threat letters.  Most were received as empty envelopes; some have contained powdery substances.  However, in some cases, actual anthrax exposures have occurred.  On Wednesday, October 3, the Florida Department of Health notified CDC of a positive anthrax laboratory test result in a Florida resident who had recently visited North Carolina.  Samples were sent overnight to CDC for confirmatory testing, and CDC dispatched two investigative teams–to Florida and North Carolina–on October 4.  By Sunday, October 7, test results confirmed that a second person–a coworker of the first individual–had been exposed to anthrax and that traces of the bacteria had been found in their workplace.  A decision was made to close the building, and additional CDC staff were sent to help the state and local public health department manage notification, health evaluations of other coworkers, and provision of prophylactic antibiotics after the National Pharmaceutical Stockpile was deployed. 
                As CDC was continuing to receive clinical specimens and environmental samples from Florida, we became aware of a possible case of cutaneous anthrax in New York City.  This person, an NBC employee in Rockefeller Plaza, had opened envelopes containing powder on September 18 and 25 and subsequently developed a skin lesion.  A biopsy of the lesion yielded evidence of anthrax.  The diagnosis was confirmed by immunohistochemistry on a skin biopsy specimen in CDC’s laboratory in the early morning of October 12.  The New York City Department of Health and CDC immediately implemented appropriate public health actions, including restricting access to two floors of 30 Rockefeller Plaza and evaluating workers for the need for prophylactic therapy.  CDC sent additional personnel to New York, joining the more than 30 epidemiologists and other CDC staff assisting with worker injury and enhanced syndrome surveillance following the September 11 terrorist attack.  Laboratory studies on the powder from the September 25 letter were negative for the organism causing anthrax.  Subsequent investigation identified the letter that had arrived on September 18, which was found to be contaminated with Bacillus anthracis, the organism that causes anthrax.
                On October 15, CDC was notified of a possible anthrax exposure on Capitol Hill.  A letter, which has now been confirmed to have contained B. anthracis, was opened by a Senate staff member.  This person took appropriate action, notifying emergency personnel, and public health measures were promptly implemented.  Certain areas of the office building were closed, and employees were screened by history for exposure and started on antibiotic prophylaxis after a nasal swab was obtained to assess the extent of the exposure zone.  CDC has sent over 70 epidemiologists, laboratorians, environmental health experts, industrial hygienists, and other public health professionals to Washington, DC, to assist local, state, and federal authorities in the investigation. 
                Environmental specimens have tested positive from the initial area of exposure as well as several other locations in Congressional office buildings.  In addition, mail rooms in the U.S. Capitol complex have had positive environmental samples.  Environmental specimens have also tested positive from mail facilities servicing the Departments of State and Justice, the CIA, the Walter Reed Army Institute of Research, and the U.S. Supreme Court.
                                Late Friday evening, October 19, enhanced regional surveillance activities–a collaborative effort between the Washington, DC, Department of Health (DCDOH), the Maryland Department of Health and Mental Hygiene, and the Virginia Department of Health–identified a patient with an acute respiratory illness who was an employee of the U.S. Postal Service’s Washington, DC, Processing and Distribution Center (the Brentwood facility).  The patient’s illness progressed, and on Sunday, October 21, the illness was confirmed as inhalational anthrax.  Between October 20 and 22, three additional postal workers at the Brentwood facility were hospitalized for what was determined to be inhalation anthrax.  On Thursday, October 25, a mail handler for diplomatic pouch mail at an off-site mail facility servicing the Department of State was hospitalized and subsequently confirmed as having inhalational anthrax.  Two of these five workers have died. 
                On Saturday, October 20, CDC and DCDOH initiated an investigation of the Brentwood facility, based on the clinical presentation of illness in the index case.  Although no specific exposure event was identified, the contaminated tightly sealed letter that was mailed to the Senator's office was processed at this facility on October 12 before entering the Capitol mail distribution system.  The Brentwood facility was closed on October 21, and antibiotic prophylaxis was recommended to employees working there.  In addition, business visitors to nonpublic operations areas of this facility also were offered antibiotics.  Subsequently, antibiotic therapy has been recommended to all mail handlers in facilities receiving mail directly from the Brentwood facility pending results of ongoing epidemiologic and environmental investigation.  
                The first patient also worked at a second postal facility.  On October 21, this facility also was closed.  Antimicrobial prophylaxis also was recommended for workers at this facility pending further epidemiologic and environmental testing.
                As of this morning–October 30–2 cases of inhalational anthrax have been identified in Florida, 5 cases of inhalational anthrax have been identified in Washington, DC, 1 case of inhalational anthrax and 6 cases of cutaneous anthrax have been identified in New York City, and 2 cases of inhalational anthrax and 4 cases of cutaneous anthrax have been identified in New Jersey.
                CDC is working with U.S. Postal Service employees and managers on strategies to protect workers in mail-handling and processing facilities from exposure to anthrax.  These strategies include administrative controls to limit the number of workers potentially exposed, engineering and house-keeping controls to prevent exposure, and personal protective equipment for workers handling mail.
                The best defense against such biologic threats continues to be accurate information regarding how to recognize a potential threat and knowledge of appropriate actions.  In the Morbidity and Mortality Weekly Report (MMWR) and in multiple health advisories distributed via the Health Alert Network, CDC has issued several updates on the investigations as well as interim guidelines for health departments with recommended procedures for handling such incidents.  These guidelines include advice to the public and state and local health officials dealing with suspicious incidents, as well as guidance to clinical laboratory personnel in recognizing Bacillus anthracis in a clinical specimen.  The guidelines also outline post-exposure prophylaxis and anthrax treatment recommendations.  In persons exposed to Bacillus anthracis, disease can be prevented with antibiotic treatment.  Early antibiotic treatment of all forms of anthrax is essential.  The Bacillus anthracis strains in this outbreak are susceptible to doxycycline and fluoroquinolones.  Ciprofloxacin or doxycycline is recommended as the antibiotic for initial use for prophylaxis.  Copies of the October 26, 2001, MMWR, which addresses these issues, have been provided to the Committee.
                This is the first bioterrorism-related anthrax attack in the United States, and the public health ramifications of this attack continue to evolve.  In collaboration with state and local health and law enforcement officials, CDC and the FBI are continuing to conduct investigations related to anthrax exposures.  During this heightened surveillance, cases of illness that may reasonably resemble symptoms of anthrax will be thoroughly reviewed.  The public health and medical communities  continue to be on a heightened level of disease monitoring to ensure that any potential exposure is recognized and that appropriate medical evaluations are given.  This is an example of the disease monitoring system in action, and that system is working.

Public Health Leadership
                The Department of Health and Human Services’ (DHHS) anti-bioterrorism efforts are focused on improving the nation's public health surveillance network to quickly detect and identify the biological agent that has been released; strengthening the capacities for medical response, especially at the local level; expanding the stockpile of pharmaceuticals for use if needed; expanding research on disease agents that might be released, rapid methods for identifying biological agents, and improved treatments and vaccines; and preventing bioterrorism by regulation of the shipment of hazardous biological agents or toxins.
                As the nation’s disease prevention and control agency, it is CDC’s responsibility on behalf of DHHS to provide national leadership in the public health and medical communities in a concerted effort to detect, diagnose, respond to, and prevent illnesses, including those that occur as a result of a deliberate release of biological agents.  This task is an integral part of CDC’s overall mission to monitor and protect the health of the U.S. population.
                In 1998, CDC issued Preventing Emerging Infectious Diseases: A Strategy for the 21st Century, which describes CDC’s plan for combating today’s emerging diseases and preventing those of tomorrow.  It focuses on four goals, each of which has direct relevance to preparedness for bioterrorism:  disease surveillance and outbreak response; applied research to identify risk factors for disease and to develop diagnostic tests, drugs, vaccines, and surveillance tools; infrastructure and training; and disease prevention and control.  This plan was developed with input from state and local health departments, disease experts, and partner organizations such as the American Society for Microbiology, the Association of Public Health Laboratories, the Council of State and Territorial Epidemiologists, and the Infectious Disease Society of America.  It emphasizes the need to be prepared for the unexpected – whether it is a naturally occurring influenza pandemic or the deliberate release of anthrax by a terrorist.  It is within the context of these overall goals that CDC has begun to address preparing our nation’s public health infrastructure to respond to acts of biological terrorism.  Copies of this CDC plan have been provided previously to the Committee.  In addition, CDC presented in March a report to the Senate entitled Public Health's Infrastructure: A Status Report.  Recommendations in this report complement the strategies outlined for emerging infectious diseases and preparedness and response to bioterrorism.  These recommendations include training of the public health workforce, strengthening of data and communications systems, and improving the public health systems at the state and local level.

CDC’s Strategic Plan for Bioterrorism
                CDC outlined necessary steps for strengthening public health and healthcare capacity to protect the nation against bioterrorist threats in its April 21, 2001, MMWR release of Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response - Recommendations of the CDC Strategic Planning Workgroup.  This report reinforces the work  CDC has been contributing to this effort since 1998 and lays a framework from which to enhance public health infrastructure.  In keeping with the message of this report, five key focus areas have been identified which provide the foundation for local, state, and federal planning efforts: Preparedness and Prevention, Detection and Surveillance, Diagnosis and Characterization of Biological and Chemical Agents, Response, and Communication.  These areas capture the goals of CDC’s  Bioterrorism Preparedness and Response Program for general bioterrorism preparedness.