A Seminal Event: A Review of Recounting the Anthrax Attacks

It has been almost 18 years since the anthrax attacks in which 22 people were deliberately infected with the deadly bacteria to which 5 people succumbed. To many of those who do not work in the field, this event has likely faded from memory. In lectures to medical students a few years ago, anthrax was described as some sort of “panic” that occured post-9/11 with little appreciation that it was an actual attack. Given this context, a new book by an FBI agent (and PhD scientist) who worked the case is a welcome retelling of the events from a law enforcement and forensic vantage point. R. Scott Decker’s Recounting the Anthrax Attacks: Terror, the Amerithrax Task Force, and the Evolution of Forensics in the FBI is an easily accessible book that recaptures the environment of 2001 and details the birth of microbial forensics.

Decker does an excellent job recounting the ups and downs of the investigation . However, for someone familiar with the investigation I was disappointed to see several key elements not discussed. For example, Decker describes in detail the wrongful pursuit of Steven Hatfill and mentions a civil lawsuit regardings leaks but does not mention the fact that the https://www.theatlantic.com/magazine/archive/2010/05/the-wrong-man/308019/ on television and that taxpayers had to oay him millions of dollars for their (literal) dogged pursuit of him. Decker also gives just brief mention to the National Academies report on the forensic scientific approach used to reach their conclusion regarding the ultimate identity of the anthrax mailer, which I believe strongly delimits what the microbial forensics was able to conclude. No where does Decker mention the baffling approach the government took to defending itself in the lawsuit filed by the widow of the first victim in which they stated, in a court filing, that the identified anthrax mailer “did not have the specialized equipment” needed to commit the attack. (For more on the merits of the case I refer you to this PBS Frontline piece).

Despite what I think are serious omissions, I do think that the book is compelling reading as it underscores the threat of biological weapons, provides a great deal of information on how the investigation progressed, discusses how the government had to develop the wherewithal for such an unprecedented attack, and shows the birth of microbial forensics. The book also revisits tantalizing coincidences such as 9/11 hijackers renting an apartment from the first victim’s colleague’s wife as well as the activities, the tracing of the repositories that held the Ames attack strain, the legal travails of an anthrax vaccine manufacturer, and numerous other incidents that are important to understanding the complexity of a bio-attack. For these I think it is recommended reading for those in the field and who have an interest in this topic.

The NYC Subway: Plague & Anthrax, but not Urine, Free

I often tell people that bacteria are everywhere, because they are. They lurk in almost every niche of the planet, including all the niches in and on our bodies. Some are found in more abundance in certain environments such as fresh water, salt water, on reptiles, in the soil, etc. 

So, when a study reported all the myriad microbes found in the NYC subway, I wasn't surprised as it as a perfect Petri dish for many different microbes because many people traverse it, it is littered with discarded food and often has puddles of liquid (which could be rain water on a good day, urine or some other substance on a bad day). Plus, rodents abound. 

The controversial part of the study, which detailed many different microbes being present, was the researchers detection of the bacteria that cause plague and anthrax in the subway. Such a finding immediately grabbed headlines. I also didn't find this to be too surprising because it is well known that both Bacillus anthracis and Yersinia pestis are widely distributed in the enviroment--though Y.pestis tends to stay west of the "plague line".  

The study was back in the headlines earlier this week when the research time clarified their findings, which now exclude the detection of the plague and anthrax bacilli in the subway. 

I would caution people--and rats--to not breath too deep a sigh of relief in the subway as, though not at risk for plague or anthrax, the smell of urine might do you in. 

Anthrax Guest Starring on House of Cards

On one of the episodes in the 2nd season of House of Cards there is a white powder incident at the US Capital, causing a lockdown. In the episode, the lockdown lasts for hours while the powder is tested and ultimately revealed to be a mixture containing flour (wheat) and talcum powder. It was stated that pesticide on the wheat caused a false positive on initial tests, requiring the longer lock down of the area while confirmatory tests were performed.. There were several references to anthrax, which was actually released from an envelope in the Capital in 2001, in the dialogue. 

White powder incidents abounded after the events of 2001 and still continue to this day--witness the Super Bowl's corn starch incident. What is often overlooked is the amount of law enforcement, public health, and clinical resources that are absorbed--and diverted from other functions--in the response to these incidents. Much like a bomb threat, a white powder incident can't be ignored as both anthrax and ricin have been sent in the mail. 

Treating Anthrax in 2014

It's been almost 13 years since the anthrax attacks of 2001 and, not suprisingly, medical care has advanced during that time. Accordingly, the CDC has released new guidelines for the treatment of anthrax. 

Several important highlights include:

• Attention to the coagulation defects that occur with anthrax with the goal of keeping fibrinogen levels above 100 and avoiding pharmacological thromboprophylaxis
• Emphasis on the drainage of pleural effusions--a procedure linked to improved outcome
• Carryover of the recommendation for 60 days of post-exposure prophylaxis
• Delineation of anthrax with possible meningitis from anthrax without possible meningitis
  • In cases where meningitis is a possibility the recommendation to use 3 drugs with high CNS penetration, 1 of which should be a protein synthesis inhibitor (ciprofloxacin, meropenem, and linezolid)
  • In cases where meningitis has been ruled out the recommendation to use 2 drugs, 1 of which should be a protein synthesis inhibitor (ciprofloxacin + linezolid)
• Use of an anti-toxin therapy such as raxibacumab (or anthrax immune globulin--not FDA approved)

Overall, the guidelines are highly evidence-based and consistent with standard infectious disease and critical care practice. Hopefully, when followed the 45% mortality rate experienced in 2001 would be significantly diminished (in the cases that have occurred in the US since 2001, no patient has died).