http://www.dallasnews.com/national/STORY.e9891915b4.b0.af.0.a4.a4811.html

Sunday | October 14, 2001

Dallas News

More anthrax exposures reported in Florida, NY CDC says data incomplete; Nevada letter tests positive 10/14/2001 By BROOKS EGERTON / The Dallas Morning News America's anthrax scare widened from New York to Nevada on Saturday, and a Florida tabloid publishing firm said that five more of its employees had tested positive for exposure to the potentially deadly bacteria. But the U.S. Centers for Disease Control and Prevention stressed that the company's announcement was based on incomplete data and "doesn't imply that they're at a higher risk of developing disease." Nevada's governor said a picture sent to a Microsoft office in Reno was confirmed to have been contaminated with anthrax, though no one who handled it was ill. And NBC confirmed that a second aide to anchor Tom Brokaw was being treated for possible symptoms of an anthrax skin infection. Both women handled a threatening letter sent to Mr. Brokaw and are responding well to antibiotics while testing continues, network spokeswoman Barbara Levin said. No one has become seriously ill except the first known victim, a photo editor at American Media Inc. in Boca Raton, Fla. His death Oct. 5, after inhaling anthrax and contracting the most dangerous form of infection, has made him another symbol of the fear that has hit the United States since suicide hijackers killed thousands of people Sept. 11. Some federal authorities suspect the anthrax cases could be linked to the hijackers or their accomplices, saying that Osama bin Laden's organization has trained terrorists in the use of biological and chemical weapons. Still, no evidence of a connection has emerged. Whatever the case, people are jittery. Major news organizations, other businesses and some state agencies started screening or even refusing mail Friday after learning of the NBC aide's infection. Some New Yorkers have gone to emergency rooms to be tested for symptoms such as sore throats and fever, which can be the early signs of anything from a cold to inhalation anthrax. Anthrax panic has also hit the aviation world. Eighty passengers were held aboard a United Airlines jet in San Francisco for three hours Saturday after a man accidentally spilled confetti from a greeting card. Another passenger had accused him of dispersing a powder into the plane's ventilation system, prompting an FBI investigation and a visit by a local hazardous-materials team. On Friday, two private planes were forced to land in Austin and Tulsa after an air-traffic controller overheard the word "anthrax" on a cockpit radio frequency. Later, the FBI cleared the pilots of suspicion. And a US Airways jet made an unscheduled landing Saturday in Indianapolis after a flight attendant found a white powder in a trash bin. Tests later determined that it was not hazardous; it was believed to be a common packing material, an Indiana official told The Associated Press. A substance in one threatening letter sent to NBC had been described as a white powder, but it has since tested negative, too. Officials said the source of the aide's infection appears to have been another letter containing another substance. It was postmarked in Trenton, N.J., and mailed earlier than the first, officials said. Anthrax itself is microscopic, CDC spokeswoman Lisa Swenarski stressed, so there's no way to confirm its presence without laboratory analysis. Bacteria could be mixed with any number of visible materials or none at all, she said. Getting anthrax into an easily inhalable, aerosol form would require considerable sophistication, terrorism experts say. And, Ms. Swenarski observed, "Fear is a public health problem in this situation, too." She confirmed that the CDC had told American Media about preliminary test results pointing to possible exposure of five employees. Asked why the company was notified, she responded: "People are really craving information" and may want to begin taking antibiotics in case they have been infected. "The results are not final," Ms. Swenarski said. "The blood work is uninterpretable at this point." Company officials told various news organizations Saturday that the five employees had anthrax antibodies in their blood. But no one knows how or when they developed them, the CDC said, acknowledging that such antibodies are not common in the general public. After photo editor Bob Stevens died, tests confirmed that two co-workers had been exposed to anthrax, meaning that spores had been found in their noses. But neither they nor anyone else at the company has become sick, Ms. Swenarski said. Authorities had initially said after Mr. Stevens died that they had found no sign of exposure in his co-workers. That's because the first check for trouble is a nasal swab, which Ms. Swenarski said "is not a diagnostic tool." Instead, she said, it's a quick way to search for leads as part of a wider investigation. "A negative swab does NOT rule out a possible exposure," a CDC bulletin cautions. "Rapid diagnostic tests ... are available only at national reference laboratories," according to the 1999 report, "Anthrax as a Biological Weapon." It was prepared by a national group of health experts and published in the Journal of the American Medical Association. Ms. Swenarski agreed Saturday that "very few labs can do very sophisticated testing." But such testing isn't necessarily required to detect anthrax, or at least to get a strong enough suspicion to start treatment. One of Mr. Stevens' doctors diagnosed him simply by examining his spinal fluid under a microscope, according to news reports. But even aggressive treatment could not save him. Testing has also caused confusion in Nevada. A third anthrax test came back positive on the pornographic contents of an envelope sent from Malaysia to a Microsoft office, Gov. Kenny Guinn said Saturday. Two earlier tries produced conflicting results. The CDC will now try to sort things out, Ms. Swenarski said. But she said she did not know what tests would be done. Mr. Guinn said the envelope did not appear to contain powder or other materials that might be inhaled. Those who handled it have not tested positive for anthrax exposure, officials said. The Associated Press contributed to this report.

-- meg davis (meg9999@aol.com), October 14, 2001

Answers

Points of clarification: the headlines saying things like "### New Cases" are very misleading. The confirmed "case count" in any meaningful medical sense remains, for the moment, ONE systemic anthrax in Florida (meningitis, pneumonia; fatal) and ONE cutaneous anthrax in NYC (non-fatal). That's it.

What the headlines are calling "cases" are really results of special surveillance techniques to help the investigators understand who-when- where; unfortunately, the message being received by most people is that more people are sick than actually are. It doesn't even confirm how many people are actually exposed, just gives some rough ideas as to the scope of the exposures in each building. (See below.)

Also, the public (and many physicians) are getting a repeated message from the press reports that there are reliable "screening tests" for anthrax: the nasopharyngeal swabs -- basically a Q-tip up the nose; or a serologic blood test. In fact these tests are *research tools* and simply don't tell people what the suppose they are saying.

Background: in the 1950s, when some of the core studies on anthrax were being done in animal-hide factory workers, it was discovered that something like 6 or 7% of the workers had hundreds -- I think the median was around 500 -- of anthrax spores in their noses, but were not at all ill. Those exposure data were a reminder that it takes many thousands or tens of thousands of spores, of the "proper" small size, to cause systemic illness. And many more workers were clearly being exposed than had spores found in their noses.

In the current investigations in NYC and in Florida, and who knows where else as the days roll by, the NP swabs and serologic blood tests don't indicate anything clincally useful about *illness*. Obviously, with evidence of exposure by NP swab, people must be given antibiotic preventive therapy. But it even *might* be that those people with spores in their noses are not at risk -- i.e. the spores only got as far as their noses; and the number of spores is apparently below the likely threshold needed for disease (this is unprovable of course since they are getting antibiotics).

Conversely, *not* finding spores in someone's nose doesn't by itself tell you whether that person is at risk and could go on to develop disease soon. These are epidemiologic research tools, providing useful information to figure out the sequence of events, but not clinical tools.

None of this explanation is meant to disparage the seriousness of what's happening; but the press reports are, unintentionally in this case I think, making the daily case count sound much worse than it is...

So far anyhow. Stay tuned. This mess isn't yet "the next shoe to drop" in my opinion, merely the sound of a footfall, coming closer...

Sure hope I'm wrong.

-- Andre Weltman, M.D. (aweltman@state.pa.us), October 14, 2001.