Anthrax Response in DC: Very Intense

Rima Khabbaz, M.D., led the CDC field team to the nation's capital during the public health response to the anthrax attacks of 2001. "I would characterize that time as very intense, we were acutely aware that we were dealing with an intentional attack, and focused on doing all we could to try and mitigate the consequences and save lives," she explained. "A few of us from CDC arrived in DC just hours after anthrax was confirmed in the letter that was opened in Senator Daschle's office. By the end of the first week the team grew to close to 100 staff, and more than double that at the peak of the response."

How they did it was a feat of agility and flexibility—there was no guidebook for responding to a bioterrorist event that affects politicians, postal workers, and media. "Public health had identified anthrax as a potential agent so we had some expertise, but there were gaps in our scientific knowledge. What happens in nature and what happened in an intentional release can be very different," Khabbaz noted.

Requests seemed endless

While Khabbaz and her team tried to understand the layout of the Hart Building and respond to the many concerns from congressional members and staff, the requests for briefings seemed endless. "Recognizing that we were dealing with very important people, I wanted to be responsive to all, but at some point all I would have been doing is talk on the phone or go to meetings. I learned quickly to delegate even some high-profile meetings. We had to answer questions about exposures and make decisions on prophylaxis."

A confusing element of this response was the question of who had authority where in the District, including for example at the Capitol and in the different Federal facilities. "We worked very closely with the Washington, D.C., health department but they did not have jurisdiction at the Capitol. Straightening that out was important," she said.

When the outbreak investigation took them to the Brentwood mail facility, the environmental sampling took on a whole new meaning. "People can easily understand where to swab in an office if a letter is opened, but understanding how mail moves in an oversized open warehouse on machinery that could sort envelopes at incredible speed was something else. It was difficult for people to imagine. We had our investigators all over that facility, mapping out the logistics," she explained. "We needed to be able to follow the path of the letters."

Investigators used swabs, HEPA vacuum filtration and air sampling. Sampling was used to determine the presence and extent of contamination. The investigators also sampled postal facilities that received mail from the Brentwood facility.

Controversy and regret

A point of controversy and regret was the perception that postal workers and people working at the Capitol were being responded to differently. "We started prophylaxis with Ciprofloxacin first because we did not know whether the anthrax from the envelopes was susceptible to Doxycycline. As soon as we confirmed that Doxycycline was effective, we switched to using it because we had it in the Strategic National Stockpile. The message that they were equally effective did not get through clearly," Khabbaz shared.

"It is so important that people understand the steps that are being taken and why we recommend what we do. I'm glad CDC has a new approach to communicating to people in a crisis. To this day, I feel angry and very sad that people lost their lives from this attack, but I believe our providing timely prophylaxis to a large number of exposed people likely prevented more illnesses and deaths," she said.

Khabbaz understatedly calls the experience she had in the anthrax response "very intense." That means something coming from a professional who has also responded to outbreaks of Nipah, Ebola, West Nile, SARS, and monkeypox.