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Anthrax I: Florida Discovered Intentional Attack, Ties to Mail, Report Says By Mike Nartker Florida Health Department epidemiologist Marc Traeger outlined how the department investigated the first two intentional anthrax cases in the United States as he presented a report — written by Florida Health official Steven Wiersma — at an Atlanta conference of the U.S. Epidemic Intelligence Service, part of the Centers for Disease Control and Prevention. The investigation, which started as an exploration into a bizarre outbreak of a little-seen disease, progressed into a criminal investigation of the first intentional anthrax biological weapons attack in the United States and provided the first connection between the attacks and the mail, according to the report. The initial case for the Florida investigation — which would later be revealed as the beginning of an anthrax outbreak in four states and Washington that would kill five people — was Robert Stevens, a 63-year old male who worked for American Media Inc. in Palm Beach County, Fla., according to the report. Stevens became ill on Sept. 30, 2001, with an unexplained disease that included symptoms of fever, vomiting and an altered mental state. Stevens entered the hospital on Oct. 2. Doctors discovered he had an increased white blood cell count, and a chest X-ray showed increased perhiliar density — an enlargement in the dense area of the chest between the lungs. Tests conducted on a sample of Steven’s spinal fluid indicated the presence of long, rod-shaped bacteria, which confirmed he had contracted anthrax. Once doctors determined Stevens had contracted anthrax, they attempted to discover whether he had contracted it naturally or through an intentional exposure, where he had probably contracted the disease and whether others were at risk, the report said. In an attempt to find a source for the infection, state health officials investigated AMI, recreation and travel destinations that Stevens had recently visited, as well as retail businesses that he had recently patronized. The Florida Health Department investigated area hospital intensive care units and contacted medical examiners in an attempt to discover other unexplained deaths that were consistent with anthrax. The investigation into hospital emergency rooms, intensive care units and medical examiners was later expanded into neighboring counties. The Florida Health Department conducted a statewide veterinary investigation to determine whether there were anthrax-infected animals. The epidemiological investigation also was expanded into North Carolina, where Stevens was known to have traveled before contracting the disease, the report said. While investigators examined Stevens’ death, a second AMI employee, 73-year old Ernesto Blanco, contracted the disease, according to the report (see GSN, Feb. 25). Blanco first exhibited signs of a respiratory illness on Sept. 28 and checked into the hospital on Oct. 1. According to the report, doctors discovered a more moderate form of the disease with no sign of mediastinal lymphadenopathy — enlargement of the lymph nodes between the lungs, which probably had caused the increased perhiliar density in Stevens’ chest X-ray. Bring in the Feds On Oct. 7, investigators discovered the presence of anthrax spores in AMI headquarters through spores found on a computer keyboard used by Stevens and through a nasal swab taken from Blanco, according to the report. From this evidence, Florida health officials determined that the source of both men’s anthrax infections was the AMI building and that the disease had been spread through an intentional release. Once that determination was made, the FBI took a leadership role in the now-criminal investigation, the report said. Authorities closed and secured AMI headquarters and took numerous swabs and air and vacuum samples to discover the prevalence and pervasiveness of anthrax spores. The CDC National Institute for Occupational Safety and Health and the CDC National Center for Environmental Health were also consulted, according to the report. A Florida environmental team assisted federal health officials in processing samples taken from the AMI building, but they were unable to go inside. Also on Oct. 7, federal and state health officials began intervention planning to determine the extent and level of anthrax exposure, the report said. The potential exposed group was defined as anyone who had spent longer than an hour in the AMI building in the last 60 days. Officials then distributed a questionnaire and conducted nasal swabs and blood tests on those in the exposed group to assess the level of exposure. Several other suspect cases; including two other AMI employees and several non-AMI workers were also hospitalized, according to the report, but preliminary testing ruled out anthrax in their cases. AMI Results On Oct. 10, investigators received the results of tests conducted on the AMI building and employees. Out of 1,051 nasal cultures taken, only one returned positive. About 75 percent of the environmental cultures taken from the AMI mailroom — 10 out of 14 — also came back positive for anthrax. The positive nasal culture was taken from a 36-year-old female AMI employee, who showed no symptoms of anthrax infection, according to the report (see GSN, Oct. 11). The woman handled AMI mail and opened a letter that contained powder around Sept. 25, the report said. Cultures from the woman’s office also came back positive for anthrax. On Sept. 19, Stevens had been observed viewing a suspicious letter that contained a fine white powder and a Star of David, the report said. Authorities made the connection between the AMI infections and exposures and the mail through Stevens and the AMI female employee’s handling of suspicious mail, as well as Blanco’s position as an AMI mail distributor, according to the report. Initial evidence suggested there could have been multiple suspicious letters that caused the anthrax infections, the report said. Mail Becomes Focus Once officials made the connection between the AMI infections and exposures and suspicious letters, the investigation began to focus on the postal service and express mail, according to the report (see GSN, Oct. 25, 2001). Further anthrax exposures and deaths in New York, Washington, New Jersey and Connecticut would later confirm the link between anthrax and the mail. Officials provided post-exposure protocol to postal workers, who handled mail, and waste handlers, who might have come into contact with disposed suspicious letters. The environmental testing of the AMI building determined that positive anthrax tests in the environment did not pose a direct risk and that it was not possible to quantify the level of risk of anthrax through such tests, the report said. Environmental testing also helped to rule out waste management staff and housekeeping workers as risk groups for anthrax exposure. The investigation did discover two issues that were later revealed to be specific to the Florida anthrax infections, according to the report. No letter was ever found that could be directly linked to the infections, unlike the anthrax-tainted letters sent to media organizations in New York and to congressional members in Washington. One reason for this could have been that there were multiple letters involved, the report said. There also were no cases of Palm Beach county postal workers being infected, unlike anthrax infections and deaths in Washington and New Jersey. This could have been because the powdered anthrax used in the Florida attacks had different physical properties and a different quantity than the powder used in later attacks, the report said (see GSN, Oct. 25, 2001). The report also speculated that no postal workers were infected during the Florida anthrax outbreak because the powder was sent in a different type of letter — with different packaging than the one used in the later attacks — and because of different environmental conditions.
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