When the first case of intentional anthrax occurred, I was the North Carolina State Epidemiologist. I received the phone call from the Centers for Disease Control and Prevention (CDC) as soon as there was suspicion of terrorist activity and the potential for further exposure/cases of inhalational anthrax. Coincidentally, the NC Governor’s Terrorism Task Force was meeting that day.

We, at public health, shared the development with members of the task force including Federal Bureau of Investigation (FBI) agents before they heard of it through their own channels. This further established the lead role of public health for this event in NC.

Based on what we knew about anthrax at the time and the travel history of the index case, it was believed that the exposure occurred in North Carolina. Therefore, the state was at the center of this public health emergency. I was tasked with leading the public health response along with the State Health Officer, Dr. Leah Devlin.

Our history of natural disasters (floods and hurricanes mostly) provided a strong base of experience for organizing the State Emergency Response Team (SERT) and partnering with local responders. Consequently, the framework for organizing the response was similar to other emergencies.

Of course, it differed dramatically in scale with the whole state potentially at risk and with the fear of the unknown. In a hurricane, we can see it coming, track the flooding and devastation and then organize the clean up and recovery efforts. With anthrax, we did not know who the enemy was, if they were going to attack again and we couldn’t see the weapon. This meant that FEAR ruled the day and public communications were critical. During the response we established a “battle rhythm” of regular communications with1), our local response partners; 2), our national response partners; and 3), the media to keep the public appropriately informed.

The attack created many challenges for the public health and emergency response system throughout government. In addition to communication, there was a lack of public health infrastructure. One area where this was keenly acute was in the lack of electronic systems for public health surveillance. Since the attacks, North Carolina has made tremendous progress in this regard. Instead of having to wake hospital infection control staff in the middle of the night to pull charts and track down lab results, we now have a near real time electronic emergency department surveillance and reporting system in every hospital that allows us to do public health surveillance much more efficiently.

Ultimately it became known that North Carolina was not the site of the powder drop. However, we made incredible public health improvements in the decade since the attacks.

Major Accomplishments in North Carolina since 2001 (a portion of this was reproduced in the full report).

Steve Cline, Assistant Secretary for Health Information Technology, North Carolina Department of Health and Human Services Office of Health Information Technology, North Carolina Department of Health and Human Services

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