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Testimony
Before the Committee on Governmental Affairs and the Subcommittee
on International Security, Proliferation and Federal Services
United States Senate
Senator Joseph I. Lieberman, Chairman
District of Columbia Government Coordination
and Preparation for Bioterrorism
Terrorism Through the Mail: Protecting Postal Workers and the
Public
Statement of
Ivan C.A. Walks, M.D.
Chief Health Officer of the District of Columbia
Director, District of Columbia Department of Health
Good morning Chairman Lieberman and members of the Full Committee
on Governmental Affairs and the Subcommittee on International
Security, Proliferation and Federal Service.
My name is Dr. Ivan C.A. Walks. I am the Chief Health
Officer of the District of Columbia and the Director of the
District’s Department of Health (DOH).
I welcome this opportunity to testify before you today.
Acknowledgement of Deaths
On behalf Mayor Anthony Williams let me first say that all
of us here in the District of Columbia share the grief of the
United States Postal Service over the loss of two of our neighbors
and fellow public servants. These deaths are tragic, especially
because they were deaths due to deliberate acts of terror. Our
hearts and prayers go out to these two families. They are victims
of evil.
Context
The use of an infectious disease as a weapon, places the providers
of healthcare in the role of first responders. Our doctors, nurses
and other providers have become our first line of defense. With
anthrax, we are facing a significant challenge that we as a nation
and as a society have never faced before. We are facing the
results of a deliberate terrorist act or acts of one or more
individuals who are determined to deliberately harm and disrupt
the lives of our citizens and of our society.
The enemy can choose its time, and place, and method. As such, we
must predict and prepare. As we try to predict when, where and
how, we must ensure we are appropriately resourced. The good news
is that the United States of America has the world’s greatest
laboratories, with the world’s greatest scientists. The bad news
is that our public health infrastructure has been neglected.
It is critically important to emphasize that we can we can only
fight the terrorists by devoting the necessary resources now to
training and equipping medical and public health personnel and by
developing and delivering educational material to the public.
As a nation, we will need to develop a heightened awareness
of potential threats to the public health and institute plans to
mitigate them. At the request of Senator Frist who has worked
closely with the DOH a budget of $30 million to support our
infrastructure needs here in the District was presented. Our needs
reflect those of state and local public health departments across
the country.
The District of Columbia Experience
For the past five years, the District of Columbia Department of
Health has been planning for a bioterrorism event. On September 11th,
we activated our enhanced biosurveillance protocol. This means
that we monitored daily emergency room presenting symptom logs.
Our epidemiologists analyzed that data in order to look for
unusual clusters of suspicious illnesses. Further, on September 26th,
I sent an alert to all regional health care providers to move them
from diagnosis reporting to a symptom based reporting construct.
That alert notified hospitals and health care providers of
warning signs and symptoms that might indicate an Anthrax
infection. We also submitted a biochem disaster “day one”
contingency plan to the Executive Office of the Mayor.
On Monday, October 15th, we learned from the television
news that an envelope potentially containing Anthrax had been
opened in Senator Daschle’s office in the Hart Senate Office
Building. The FBI
later confirmed that the letter’s contents had tested positive
for Anthrax.
Sherry Adams, RN who directs the District of Columbia Department
of Health’s Office of Emergency Health and Medical Services (OEHMS)
confirmed that report with the Office of the Attending Physician.
As the incident was believed confined to the U.S. Capitol
complex, I called and spoke with John Eisold, MD, the Attending
Physician. I assured him that our Department of Health was
available to assist him. He thanked me for the call and assured me
that he had the resources he needed
Because of our bioterrorism planning, the OEHMS staff of seven
assessed the potential impact in the community beyond the Capital
complex. We recognized our need for assistance. We called the
Centers for Disease Control and Prevention (CDC) Bioterrorism
office in Atlanta, Ga. and asked them to send a Technical Support
Team to assist in epidemiological monitoring, surveillance, and
community outreach. We
also asked for a National Pharmaceutical Stockpile Advance Team to
give technical assistance. Finally,
we requested a USPHS officer from the Office of Emergency
Preparedness to act as a liaison.
The federal government approved all three requests.
At 4:30am on the 16th of October, Mrs. Adams was
notified by Dr. Tracy Treadwell of the CDC that “a virulent
form” of Anthrax had been confirmed. The CDC technical
assistance team arrived in our Department of Health offices prior
to 8am on the 16th. We briefed them about our
Department of Health’s needs and concerns. Shortly thereafter,
the CDC deployed part of their team to work with Dr. Eisold at
Capital Hill.
Other members of the CDC team remained to work with us at the DOH;
assessing our biosurveillance protocols and activities in order to
insure the safety of District residents and visitors. On Tuesday
the 16th, I again made contact with the Office of the
Attending Physician to discuss concerns raised by some of our
District area hospitals. Those issues included patient complaints
about long wait times for medications and insistence that they be
treated at local area hospitals.
While on Capital Hill, the CDC team recommended that the
District’s Department of Health be involved in all further
discussions regarding the Anthrax attack. Upon their return to the
Department of Health, The CDC team briefed us about the events of
the day.
On Wednesday October 17th, the Department of Health established an
Anthrax hotline for questions, concerns and clinical reports. Dr.
Scott Lillibridge called the DOH and invited us to a joint
taskforce meeting at the Office of the Secretary of the Senate.
Dr. Larry Siegel represented the Department of Health at
both the meeting and a joint press conference led by Senator Frist.
Discussions at that Wednesday meeting included concerns about the
path of the Anthrax letter through the mail delivery system. The
CDC concerns and recommendations at that time were based on
existing knowledge and science which indicated that anthrax spores
could not escape a sealed envelope in sufficient quantity to
infect an individual with Inhalation Anthrax.
Given the experience of the mail handlers in New York, CDC
scientists were more concerned over exposure to cutaneous anthrax,
a far less serious, and readily treatable condition.
On Thursday October 18th, the District’s Department
of Health received a call from Dr. David Reed, the National
Medical Director of the US Postal Service. We discussed concerns
with Dr. Reed about Anthrax contamination at the Brentwood
facility. Again, there was a recommendation by the CDC that
consistent with the available science, environmental or employee
testing at the Brentwood facility was not indicated at that time.
The US Postal Service decided to go ahead and begin environmental
tests for Anthrax contamination using a private contractor.
On Thursday, both Dr. Siegel and I attended the joint
taskforce meeting at the Office of the Secretary of the Senate.
It is important to note that, through Friday there was no CDC or
any other prediction that anyone outside of the Hart building
could be at risk for Inhalation Anthrax. In order to try to
pinpoint the Hart Building areas of exposure, the Office of the
Capitol Physician obtained nasal swabs from Senators and staff.
These people were initially placed on up to 10 days of
antibiotics pending further analysis of the information.
As test results became known, a discrete area of potential
exposure was defined, and individuals in that area received a full
course of antibiotic therapy.
As new areas of potential exposure were identified,
additional people were included for prophylactic therapy.
The Emergence of Illness at Brentwood
On Friday night October 19th, the DOH call
center was notified by the Inova Fairfax Hospital that they were
treating a Brentwood Postal Worker who had a clinical presentation
consistent with Inhalation Anthrax. This turned out to be the
index case. Both the DOH and the CDC followed this gentleman’s
case closely. Dr. Siegel and I spent the day Saturday with the
joint taskforce at the US Capital. Under Senator Frist’s
leadership, we conferred with both DHHS Secretary Thompson and
Governor Ridge.
As the day wore on further test results from Inova Fairfax
supported the initial suspicions of Inhalation Anthrax. Working
closely with the CDC and other components of the Commissioned
Corps of the Public Health Service, we updated and finalized our
“day one” plan. It
was becoming clear that what were sound CDC recommendations based
on prior knowledge and science had left the Brentwood workers
unprotected.
By Saturday night, we were following a second suspicious case. At
approximately 7am Sunday morning, CDC confirmed Inhalation Anthrax
in the first Inova patient. I activated our response plan.
On October 21st and 22nd, two additional
postal workers, also associated with the Brentwood Postal Facility
were hospitalized with clinical presentations suspicious for
inhalation anthrax and subsequently died.
Inhalation Anthrax was later confirmed as the cause of both
deaths.
Our initial plan included the use of the DC General Health Campus.
However, with over 50,000 people expected next door at RFK Stadium
for a Sunday concert, the DOH working closely with the US Public
Health Service, the Office of Emergency Preparedness, the CDC and
the Postal Service, immediately established the Anthrax Evaluation
and Dispensing Unit at – One Judiciary Square to evaluate and
dispense prophylactic antibiotics to postal workers, other mail in
bulk handlers and other individuals who may have been exposed to
Anthrax at the Brentwood postal facility in Washington DC.
Using the existing facilities and equipment, we created a model
process for intake and screening, informational briefings,
medication dispensing, outpatient tracking, and crisis counseling.
At the news conference announcing the opening of the Anthrax Unit,
Georges Benjamin, MD the Maryland Secretary of Health and
Virginia’s Health Commissioner E. Anne Peterson, MD joined us.
The strength of our response has been our coordination with the
Centers for Disease Control and other appropriate MD, VA, and
federal public health officials.
The DOH has been working hand-in-hand with the Centers for Disease
Control, the U.S. Public Health Service, and the U.S. Postal
Service to define the epidemiological perimeter of this event, to
establish treatment modalities that are appropriate to the disease
and its presentation in subject populations, and to identify means
to limit the spread of the problem.
Services
The Evaluation and Dispensing Unit provides the following
services:
General written information about Anthrax and its treatment
Informational briefing from a physician
Consultation with a pharmacist
“Sick Call” interview with a physician (for all clients who
may have symptoms compatible with Anthrax)
Interview with a mental health professional available for all
clients
Emergency medical services available
Dispensing of antibiotics
Operations
Intake – All clients complete a General Information form and an
Anthrax Heath and Medical Questionnaire. Health professionals
review Questionnaire and determine if the client has checked
“Yes” on any of the screening questions. If the client has
Flu-like symptoms (possibly compatible with Anthrax) they are
referred to the “Sick Call” area to see a physician after
they pick up their prophylactic antibiotics. If the client is
taking any other medications and /or dietary supplements; has a
history of epilepsy, liver or kidney disease; or drinks dairy,
caffeine or products containing high levels of calcium; or is
pregnant or breast feeding, the client has a consultation with a
pharmacist. If the client does not check “Yes” on any question
on the Anthrax Health and Medical Questionnaire, they go directly
to “Express Dispensing” line and receive their medication from
a pharmacist.
On that first day, we began taking nasal swabs of potentially
affected employees to establish an epidemiological perimeter, and
we dispensed 10-day supplies of the antibiotic, Cipro™, to all
people who came in for treatment. The support of Senator Frist was
invaluable. In fact the Senator and his wife toured the operation
on Sunday. On Monday we moved to DC General. Over the course of
Sunday and Monday, we tested with nasal swabs and treated with
antibiotics over 3,000 Brentwood workers.
On Tuesday the CDC advised that nasal swab testing of all workers
was no longer indicated to identify the area of exposure, since
the confirmed cases made it evident that individuals at the
Brentwood Postal Facility were exposed.
Nasal swabs are of absolutely no value in guiding the
treatment of individual patients. It is important to note that they are used only to pinpoint
the area of contamination. And
as has been reported, Brentwood has a large open area, and cases
occurred in different areas of the building.
Although there have been a handful of suspected Inhalation Anthrax
infections REPORTED in the Washington Metro area, the number of
case actually CONFIRMED is limited to 5: the two postal workers
who tragically died, plus three other individuals who are proving
every day that Inhalation Anthrax caught early and treated
appropriately, can be managed. All three continue to do well.
Based upon further CDC analysis and recommendations, the at risk
treatment cohort was expanded early last week to include
individuals who work at mail handling facilities that receive mail
in bulk from the Brentwood facility – the “downstream”
facilities.
The expansion of the treatment cohort was validated by the finding
that among the five confirmed positives, one is a mail handler
from the State Department Annex #32 remote facility in Virginia
that receives mail in bulk from Brentwood.
The Difference Between Protocols Used At the Capitol and at
Brentwood
Unlike what several people are assuming, the basic
protocols used at the Capitol and at Brentwood are the same.
After a confirmed Anthrax incident:
Individuals in suspected areas of exposure have been placed on
limited treatment while an area is either confirmed or cleared.
If an area is confirmed, treatment is extended to the full
period.
Individuals in confirmed areas of exposure receive the full course
of therapy.
Each situation is different.
The decision to TREAT, and HOW TO TREAT, is based on the
unique information at a specific location.
While we do not want to under-treat individuals, we also
must be cautious not to over-treat, since there is the potential
for long-term negative effects as a result of the use of these
drugs. Over-prescription
runs the risk of creating strains resistant to our medications.
We are working with a disease that has been relatively unknown,
with treatment that has been rarely necessary.
As new information and new science becomes available to us,
we continue to adjust our approach accordingly.
Contamination Concerns and Public Safety
We need to be vigilant, but not afraid.
Each of us needs to be part of our new awareness: being
vigilant for ourselves, and for others as well. Our recommendation
to USPS is that they deploy technologies that will sanitize the
mail.
The positive news is that the anthrax we are facing is sensitive
to a full range of antibiotics.
If you suspect that you may have been exposed, and are
experiencing what you think are symptoms, you should see your
health provider at once. You
should not wait.
The unfortunate thing is that many of the symptoms of pulmonary
anthrax are similar to the symptoms of the flu.
It will be a challenge for us as we enter the flu season,
to distinguish between these two.
However, the typical runny nose and watery eyes of the flu
are usually absent in Inhalation Anthrax.
This is a new challenge. And we continue to gather more
information, and learn more science, and be more effective with
this new challenge. We
are in daily contact with the CDC, the U.S. Public Health Service,
HHS, the U.S. Postal Service, the Metropolitan Washington Council
of Governments, the Secretary of Health of Maryland and Virginia
Commissioner of Health. The
D.C. Department of Health has maintained daily contact directly
with the FBI and daily contact with other federal agencies.
Currently, the D.C. Department of Health is hosting approximately
85 CDC personnel. We
are providing computers, communications, logistics,
transportation, food, office space, office supplies, and
laboratory support, supplies, and equipment. We hold two meetings a day – one in the morning and one in
the evening – to ensure a smoothly operating process and to
monitor the treatment cohort and epidemiological evidence.
A daily medical conference call is held between Regional
Health Officers, the DOH and all regional hospitals in DC, MD, and
VA, including military medical facilities to share information on
people who have come into area hospitals seeking treatment and
testing for Anthrax exposure. This group also shares information on the status of patients
who are in the hospital with either confirmed or potential
diagnoses of inhalation or cutaneous Anthrax.
Additionally, our surveillance people are in daily contact with
their counterparts at the county and state level in MD and VA to
ensure consistent treatment regimens and to share and evaluate
medical information. Based on current data, new recommendations
from CDC are being released today that will further refine their
treating and testing protocols.
It is fair to say that the science is an evolving body of
knowledge, and the pace of change is fairly rapid.
Having said that let me say that there are some fairly
straightforward things that everyone should do to protect
themselves (irrespective of whether they work handling mail).
First, wash your hands with soap and water frequently
during the day, but especially after handling mail.
We need to start with the basics before adopting more
elaborate and expensive work practice controls.
Second, we need to ensure that people can recognize suspicious
mail and know what to do with it both prior to and after opening
such mail. Obviously,
steering clear of hazardous mail will minimize the risk of
exposure. Further,
knowing what to do and what not to do will minimize the risks
after exposure. This
will require a continued and aggressive public education campaign
on the part of the U.S. Postal Service and state and local
departments of health, nationwide.
Third, until the U.S. Postal Service can deploy technology to
irradiate and sanitize the mail, people who are actively employed
in handling mail might consider using a High-Efficiency
Particulate Air (HEPA) filter mask approved by the CDC’s
National Institute of Occupational Safety and Health.
HEPA filters can remove 99.97 percent of particles 0.3
microns in size. For reference, the period at the end of a
sentence is about 500 microns in diameter.
Finally, the U.S. Postal Service clearly needs to implement some
sort of technology that can sanitize the mail as it is being
processed. This
technology exists. I
would urge Congress to make funding available to the Postal
Service in a supplemental appropriation, if need be, to allow it
to obtain and deploy such technology as soon as possible.
Going Forward
Our “day one” plan has proven to be effective. In any future
bioterrorism event we would follow protocols we have developed and
continue to refine during this incident. Of course, our future
actions will be informed by the lessons we learn in the handling
of the current situation.
I would like to close by making three vital observations.
They are, if you will, the lessons I have already learned
over the last 10 days.
Access to Information
Local public health officers across the nation cannot make sound
medical judgments without access to the broadest range of
accurate, timely, unfiltered information.
There have been occasions over the past 10 days when I have
felt “out of the loop” of critical information.
For example, I learned about the ultimate characterization
of the Anthrax spores from the media several days after the Postal
Service was notified. Public health officers – especially those in major
population centers – should have background checks and receive
security clearances so that they can fully participate in
briefings as appropriate.
Coordinated Decision-making
One of the reasons we have been successful in our efforts in
Washington, D.C. is that we have had an excellent cooperative,
collaborative relationship with our federal and regional partners.
However, some areas have not been completely smooth.
Picking up on these differences, the press and some public have
accordingly questioned whether some people received favorable
medical treatment. This
is an issue of perception rather than medical fact.
The consequences are not measured in morbidity and
mortality, but it public apprehension and anger.
Coordinated “Real Time” Public Information
Likewise, the value of coordinated timely public information has
become abundantly clear. Message coordination across agencies and
distances can slow decision-making and information dissemination. If the aim of the terrorist is to instill fear, then
the inability of government to sing from the same sheet of music
only helps the terrorist attain his goal.
We need to ensure, that we are coordinated in our message
and factual information.
The best way to instill and preserve public confidence is with
accurate, timely, and informative public information delivered in
a confident and compassionate manner, coupled with a treatment
plan that is medically sound and competently executed.
We will never be able to undo the events of September 11 or
the deaths related to Anthrax.
It is a different day. We now live in a different world. As
terrorists try to cripple America by infecting us with fear, I
offer a public health prescription.
Lets use the public confidence lessons learned in California
related to earthquakes, in the Midwest related to tornadoes and in
the Southeast related to hurricanes. These are real threats we
have learned to endure while living normal lives. Basic emergency
preparedness and public education is key. Lets not be afraid to
both inform and involve the public.
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