The Anthrax Letters: The Attacks That Shocked America (7 page)

The working group recommended that patients with “clinically evident” inhalation anthrax receive an intravenous dose of 400 milligrams of Cipro every 12 hours—800 milligrams a day. The amount is consistent with guidelines for treating other infections. The Bayer Corporation, the company that manufactures the drug, recommends daily doses that total 800 milligrams for infections of the urinary tract, respiratory tract, bones, joints, and other locations. For severe and complicated cases, the manufacturer’s advisory allows for a daily total of 1,200 milligrams, but no more. A cardinal understanding in pharmacological medicine is that the higher the dose, the greater the risk of adverse reactions.

Over the years Dr. Omenaca had prescribed Cipro many times at the advised dose levels. Like other doctors, he had never seen a case of anthrax, but he knew that Cipro was considered the initial antibiotic of choice. He reacted quickly:

How much was that “highest dose?” Omenaca smiled faintly, seeming to find incredulous what he was about to say, “Seven hundred and fifty milligrams, three times a day.” That’s 2,250 milligrams a day! Nearly twice the recommended level for even the most severe infections. Why did he do it?

Omenaca knew that the medical information on human inhalation anthrax exposure was sparse and tentative. As would later become evident, many assumptions about anthrax turned out to be wrong. The available data reflected uncertainty. For example, the
JAMA’s
working group article on anthrax cited findings that “the LD50 (lethal dose sufficient to kill 50 percent of persons exposed to it) is 2,500 to 55,000 inhaled anthrax spores.” A cluster of 55,000 spores is microscopically tiny—smaller than the eye of an ant. But when compared with the low-end estimate of 2,500 spores, the difference between low and high seems large.

Uncertainty also shadowed information about deaths from anthrax. The handful of known inhalation cases in the United States, just 18 in the 20th century, had a mortality rate of 89 percent. Still, according to the
JAMA
article, “the majority of cases occurred before the development of critical-care units and, in some cases, before the advent of antibiotics.” Similarly, in 1979, when germs escaped from a Soviet military facility in Sverdlovsk, 68 of 79 inhalation anthrax victims reportedly died. But here, too, the utility of the data is unclear because, according to the article, “the reliability of the diagnosis in the survivors is questionable.”

Dr. Omenaca learned these facts, and more, in succeeding days as he immersed himself in the literature on anthrax. Absent from his readings was any suggestion that Cipro be administered in the amounts Ernie was receiving. Moreover, it was not even clear that Ernie had anthrax: no
Bacillus anthracis
in his blood culture, no widened mediastinum visible on his chest X ray. But every day massive quantities of Cipro nearly three times the recommended dosage—continued to trickle into his system. Dr. Omenaca would not back off.

On Friday, October 5, now aware of Ernie’s hospitalization, state and federal public health officials became interested. They arranged for swabs of his nasal passages to be taken and sent for analysis to the Centers for Disease Control and Prevention in Atlanta. During the next few days, Ernie’s condition worsened. His blood pressure fell, and, to assist his faltering breathing, he needed high concentrations of oxygen, delivered through a mechanical respirator. On October 7 the report came back from the CDC that one of the swabs had picked up anthrax spores. The finding was tantalizing but not proof that Ernie had anthrax. The presence of spores did not confirm the presence of the disease any more than finding a cold virus in someone necessarily means the person has a cold.

Still, the finding was suggestive. Until then, “my suspicion that it was anthrax was low,” Omenaca said. Even if Ernie had the disease, finding anthrax spores at that point was odd. “Usually after 24 hours of antibiotics you get negative testing,” Omenaca said. “But he grew out one colony from the four swabs.” A colony of anthrax bacteria had grown from one of the samples placed on plates containing blood agar and other nutrient media. The CDC then confirmed, through PCR (polymerase chain reaction) testing, that the bacteria were anthrax.

PCR was developed in 1985 by Kerry Mullis, a scientist then with Cetus, a California biotechnology company. The discovery earned him a Nobel Prize in 1993. Mullis subsequently gave up science in favor of surfing and recreational drugs. But he bequeathed a procedure that has become an essential tool of laboratory science. PCR enables multiple copies of a piece of DNA to be made quickly and repeatedly. In just 1 hour a tiny snippet of DNA that had been exposed to special DNA primers can generate a billion copies. To identify anthrax, a DNA segment known to be part of the anthrax genome is prompted to find a complementary segment of DNA in the suspected organism. If copies are successfully generated, or “amplified,” the presence of anthrax DNA in the suspected bug is confirmed. In such a manner the CDC was able to establish that the bacterial sample from Ernesto Blanco contained anthrax DNA.

As of Thursday, October 4, Robert Stevens was known to have contracted anthrax. The diagnosis was confirmed by other tests because the Florida laboratory in Jacksonville was not equipped for PCR testing. Subsequently, the CDC did conduct PCR on Stevens’s samples. Not surprisingly, the test was positive for anthrax, just as the PCR on Ernie Blanco’s sample was positive. The difference was that the bacteria from Stevens were grown from his blood and cerebrospinal fluid. The spores from Blanco had been obtained by a nasal swab. Again, confirming the
presence
of anthrax spores did not necessarily mean
infection
. Rather, the patient’s symptoms and the bacteria’s location in the body are key determinants.

Yet another suggestive indicator about Ernie’s disease came from CDC testing on the bloody fluid in Ernie’s chest. Here, too, PCR testing was positive for anthrax DNA. The anthrax DNA could conceivably have come from an earlier exposure that had never caused disease. But to Dr. Omenaca the test results seemed increasingly persuasive:

The CDC’s refusal to call Ernie’s illness “anthrax” frustrated his family. “Dr. Omenaca was telling us one thing, and the Centers for Disease Control were telling us another,” said Maria Orth, Ernie’s stepdaughter. “They just kept saying pneumonia, pneumonia. And I thought: What? With the security guard posted outside Ernie’s room? With the intensive care unit and everything? With the FBI investigating?”

What she did not know was that back in Atlanta, CDC officials were having a running debate. “There were lots of discussions about whether Mr. Blanco was a case or not,” recalled Stephen A. Morse, associate director of CDC’s program on bioterrorism preparedness and response. “It all hinged on the fact that they could not culture anthrax from him.” Would CDC officials remain rigidly attached to their central tenet—the ability to culture, or grow, the bacteria from a patient’s sample? In fact, 2 weeks later the CDC announced that Ernie had anthrax. “What happened was they had to change the case definition of anthrax,” Morse said. Whether or not a person has a particular disease is determined by specific indicators, including symptoms and test results. With the benefit of experience, the criteria for a determination—or a “definition”—may be revised. Morse explained:

Nonculture tests could include cell wall and capsular staining, PCR, or demonstration of the presence of antibodies to anthrax. If an illness were “clinically compatible” with anthrax but only one test was positive, the CDC would consider the patient a “suspected case.”

While CDC was arguing about case definition, Ernie was fighting for his life. “I felt physically, and in my soul, that I was leaving this world,” he said later. The family summoned a priest to give him last rites. During the following days Ernie remained conscious but confused. After Daniel Rotstein had called Omenaca, the doctor asked Ernie, “Do you know Mr. Rotstein?”

“No,” Ernie replied.

“But you work with him,” the doctor said.

“Everybody’s asking me that question. I don’t know him.”

A few days later Omenaca asked Ernie the same question. “Of course I know him,” Ernie said. “I know him for 10 years. We see each other every day. We work in the same building.”

After 4 or 5 days on the massive doses of Cipro and repeated thorocentesis—drainage of bloody fluid from his chest—Ernie’s condition began to improve. On October 23, twenty-two days after he entered the hospital, Ernesto Blanco went home. Weak but on the mend, he continued to take oral Cipro for weeks and to see Dr. Omenaca and other doctors several times a week. In March 2002, Ernie returned to work at AMI on a reduced schedule. Relaxed and happy to tell his story, he said, “Now I feel all right, good. It looks to me I’m perfect.”

In the midst of Ernie’s darkest days, Omenaca had been in touch with Dr. Aileen Marty. A Navy commander, she is a specialist on emerging infections—previously unknown or rare diseases that are appearing more frequently in the human population. On his behalf, she spoke with several experts on anthrax, including Dr. Arthur Friedlander, one of the author’s of the
JAMA
article. She conferred repeatedly with Omenaca, encouraging him about the treatment he was giving Ernie. “Dr. Omenaca is a wonderful doc, a brilliant clinician,” she said afterward. “I told him he was doing the right thing by Mr. Blanco.”

On the evening of Thursday, October 4, hours after the announcement at JFK Medical Center that a patient there had anthrax, Dr. Larry Bush got a call from the emergency department. By then everyone at the hospital knew that Bush had been the first to suspect that Bob Stevens had anthrax. “We have a woman down here,” the voice said. “She has some pneumonia, and she’s concerned about anthrax.”

“You know what, guys?” he responded. “You can’t call me for every cough you get because everybody thinks they have anthrax.”

“But that’s not it. She really has a story to tell you.”

“Okay.”

He recounted the experience: “So I go down there. I meet Martha Moffett. She’s got a cough. She’s got a little fever.” He looks at her chest X ray and examines her.

“Do you have a headache?” he asked.

“No.”

“Any neck pains?”

“No.” Martha said later, “I was scared, but I began to feel better when I could answer ‘no’ to almost all his questions.”

“Martha, I think you have a little pneumonia, but I don’t think you have anthrax. They’ll give you some antibiotics, and you can go home and follow up with your doctor.” Then he added: “I’m curious. Why would you think you got anthrax?”

“Well, because of Bob Stevens. I work with him. I’m the librarian at the AMI building.”

“Well, why would you think that anything happened in your building?”

“Maybe because of all the stuff we published about Osama bin Laden,” she said.

“Martha, do you really think Osama bin Laden reads your tabloids?”

“I don’t know, but we’ve been real hard on him, and you never know.”

In the next couple of days, Martha Moffett’s symptoms subsided, but she remained unsettled. She recalled: