In the wake of the attack of anthrax letters in October, 2001, Charlotte-Mecklenburg County (North Carolina), like many other jurisdictions, was besieged with so-called “white powder incidents,” in which anxious citizens reported unnecessary testing of a variety of granular compounds such as salt, sugar, ash-tray sand and tile grout. In addition to these incidents, however, Charlotte-Mecklenburg experienced two potential actual brushes with anthrax.

On Thursday, October 4, the Mecklenburg County Health Department was notified that Robert Stevens, a photo editor at American Media, Incorporated in Boca Raton, FL who was stricken with inhalation anthrax the previous week, had died. He had spent five of his last seven days in North Carolina; visiting his daughter in Charlotte, sightseeing in the Chimney Rock area, and traveling to Durham, North Carolina. At this point, the hypothesis was that Mr. Stevens had acquired anthrax from a naturally occurring source.

Staff from the Health Department visited Mr. Stevens’ daughter’s apartment, looking for clues that might point to such a natural source — pet food and accessories, HVAC filter, vacuum cleaner filter, sinks and plumbing, etc. Staff also visited two restaurants in Charlotte where Mr. Stevens and his family dined. Later that evening, to the amazement of curious neighbors, military personnel in full protective gear entered the apartment again to obtain specimens for culture. Fortunately, none of the cultures grew.

The following week, hospitals in Mecklenburg County and several other counties in North Carolina were asked by the Centers for Disease Control and Prevention (CDC) to review results of laboratory cultures that could have been Bacillus species, records of inpatients with undiagnosed illnesses during the prior three months and records of patients who were directly admitted to ICUs. This process, which took approximately two weeks, revealed no evidence of other anthrax diagnoses in North Carolina, and when the first anthrax letters were discovered, the focus of the investigation shifted from epidemiology to law enforcement.

At least two of the letters postmarked 10/09/2001,were processed at the Brentwood mail facility in Washington, D.C. On October 21, one of the postal workers became ill, and that worker and another died the next day from inhalation anthrax. Two other workers became ill and survived. Postal workers and public health officials feared for their safety, and the Brentwood facility was closed. In addition, letters that had been processed at Brentwood were believed to be the source of contamination of other government and postal service buildings where anthrax was detected.

Later in the week, the Mecklenburg County Health Department received a telephone call with concerns from the headquarters of a North Carolina based bank. The bank maintained a bill processing center in Charlotte, where approximately 300 employees processed envelopes containing payments to the bank. This facility received a daily shipment by courier of bag mail containing up to100 letters directly from Brentwood. Bank executives, having heard about the Brentwood employee’s illness, were legitimately concerned about the health and safety of their workers.

Health Department officials and Charlotte Fire Department’s HazMat team, supported by law enforcement, responded to the site within an hour and were given a tour by managers. In consultation with colleagues at the North Carolina Division of Public Health (NC DPH) and CDC, environmental samples were collected from some of the letters, the letter-opening machinery, and an air filter in the main work room. The samples were submitted to CDC for testing.

When the deaths of the two Brentwood employees were reported the next day, CDC and NCDPH made the recommendation to offer prophylactic antibiotics to the bank facility employees. The Health Department quickly gathered its inventory of ciprofloxacin and Doxycycline (used in the Sexually Transmitted Disease Clinic), and borrowed an additional supply from a partner hospital. Important information sheets about ciprofloxacin and Doxycycline were developed by the Health Department’s pharmacist. Health Department nurses were mobilized to distribute a 10-day supply of antibiotics to second and third shift workers that evening and through the night under a prescription order from the medical director. At the same time, NC DPH requested additional antibiotics from the CDC Vendor Managed Inventory, which was delivered early the next morning. By the time the first shift arrived, a sufficient supply of antibiotics was available to distribute10-day supplies to the remainder of the workers. The duration of the response was approximately36 hours.

Subsequently, all environmental laboratory tests for anthrax revealed no anthrax, and it was not necessary to distribute any more antibiotics. To our knowledge, none of the employees of the facility became ill, nor suffered any untoward reactions to the antibiotics.

These two incidents were the impetus for Mecklenburg County Board of Commissioners to allocate local funding to create a county electronic active surveillance system for communicable diseases which utilized a pre-existing emergency department syndromic disease surveillance system and a school absentee reporting database. This system was replaced by a statewide syndromic surveillance system several years later. The incidents also pointed out the need for enhancements in local public health department capability and capacity to respond to all types of public health emergencies, and launched the Department into the modern era of public health preparedness.

By Stephen R. Keener, M.D. M.P.H., Medical Director, Mecklenburg County Health Department, North Carolina

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