Federal Bureau of Investigation (FBI) offices in five U.S. cities have received warnings of an imminent bioterrorist attack. Each threat indicated that a "shower of anthrax would rain on U.S. cities," unless certain demands were met immediately. One of these calls was in Northeast, a large city on the Eastern Seaboard with a metropolitan population of 2 million. The threats were credible, but no information was relayed to city officials in Northeast or elsewhere.
On the evening of November 1, a professional football game is being played in Northeast's outdoor stadium before an audience of 74,000. The evening sky is overcast, the temperature mild, a breeze blows from west to east. During the first quarter of the game, an unmarked truck drives along an elevated highway a mile upwind of the stadium. As it passes the stadium, the truck releases an aerosol of powdered anthrax over 30 seconds, creating an invisible, odorless anthrax cloud more than a third of a mile in breadth. The wind blows the cloud across the stadium parking lots, into and around the stadium, and onward for miles over the neighboring business and residential districts. After the anthrax release, the truck continues driving and is more than 100 miles away from the city by the time the game is finished. The anthrax release is detected by no one.
Approximately 16,000 of the 74,000 fans are infected by the anthrax cloud; another 4,000 in the business and residential districts downwind of the stadium also are infected. After the game, the fans disperse to their homes in the greater Northeast metropolitan area; some return to homes in neighboring states. A few are from other countries. The driver of the truck and his associates leave the country by plane that night. They will be many time zones away by the time the first symptoms of anthrax appear 2 days later.
Two days after the game, hundreds of people in and around Northeast become ill with fever, cough, and (in some cases) shortness of breath and chest pain. Some of the sick self-administer over-the-counter cold remedies; some seek phone advice from physicians and nurses; others are seen in clinics, doctors' offices, and emergency departments throughout the city.
Influenza cases had been seen in Northeast 2 weeks before the game. Healthcare providers seeing the new patients recommend bed rest and fluids for presumed flu. Specimens are sent to confirm influenza. A few of the sickest patients get chest radiographs to exclude pneumonia. Only in retrospect, after the source of illness is clear, will the widened mediastinum seen on a number of chest radiographs be recognized for the signal it carries. A few patients are hospitalized; some have blood cultures drawn. The 400 ill persons in the region are receiving care from so many different sources that the health emergency is not detected.
By November 4, nurses and physicians note the increased volume of serious upper respiratory illness, and some contact the city health department for treatment recommendations and a regional flu update. Blood cultures from the earliest patients grow gram-positive bacilli in seven laboratories around the city. The laboratories identify these as Bacillus species. No further identification is requested, and none is pursued.
By the evening of November 4, patients with the earliest symptoms are dying. The illness has been rapidly fatal, killing previously healthy young adults within 24 to 48 hours. Members of the medical community, now alarmed by these unexpected and unexplained deaths, urgently contact the state and city health departments. Health department officials contact the Centers for Disease Control and Prevention (CDC). By midnight November 4, 1,200 people around the city have fallen ill, 80 of whom have died.
Word that previously healthy persons are dying of a rapidly fatal illness spreads quickly among health-care providers in the state, and is featured on local and national morning news shows. News media interview families of the deceased, physicians, and city health officials. Expert consultants appear on television to discuss potential diagnoses, including the new Spanish flu, Hong Kong bird flu, and many other infectious and noninfectious diseases. A rapid survey of city emergency departments and health clinics finds that persons of all ages and from all sectors of the city continue to come down with similar illness. The numbers have doubled since the previous day, inundating many health-care facilities.
The mayor convenes an emergency meeting of leading medical experts and health officials as reporters gather outside city hall. The assembled experts debate possible causes and responses to the illness. Many express great concern that a virulent strain of influenza or another highly contagious disease may be present. Isolation of all persons with fever, cough, or chest pain; expanded laboratory analyses; and rapid epidemiologic investigation are recommended. Blood and tissue specimens are sent to CDC for urgent analysis. CDC investigators are en route. During a news conference, the mayor describes the city's response to what appears to be a serious influenza outbreak, appeals for public calm, and is surprised by questions about the possibility of bioterrorism.
By noon November 5, intensive-care units and isolation beds across the city are full. Even patients receiving the most advanced medical care are dying. Patients are febrile, hypotensive, and seem to be in septic shock; some have meningitis. Still, there is no diagnosis. At some locations, the shock of rapid and unexplained deaths has created an atmosphere of desperation and confusion among hospital and clinic staff.
The recommended isolation protocols quickly fall apart as hospital and clinic staffs struggle to cope with the surge of patients. Fears of a contagious disease prompt hospital staff to don protective positive-pressure hoods; the news shows physicians working in this gear and explains that there are only two dozen or so such hoods available per hospital.
In the early evening of November 5, a university laboratory makes a preliminary diagnosis of anthrax from the blood culture of a young patient who died. The laboratory immediately notifies city and state health departments, which in turn notify CDC and FBI. The specimen is transferred to the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID), where within hours experts report that rapid diagnostic tests support the preliminary diagnosis of anthrax.
The mayor of Northeast consults with officials from the city and state health departments, CDC, FBI, and USAMRIID. The working assumptions are that the disease in Northeast is anthrax and that it is the result of a bioterrorist attack. Widespread exposure to an anthrax aerosol is feared.
The mayor is outraged to learn that the FBI had not informed her of the credible anthrax threat to Northeast. She is also shocked that it has taken more than 80 deaths and hundreds of illnesses before anyone from the medical community came up with the diagnosis. She is informed that an anthrax vaccine exists, but it is unclear whether any will be made available for civilian use in Northeast. No one can yet estimate the probable scale of the epidemic or whether there has been a single or multiple attacks. CDC is seeking news of similar syndromes in other locations around the country. The mayor's medical advisors recommend that quinolone antibiotics be used for initial treatment of the sick. They also advise the same antibiotics for those exposed to anthrax but not yet sick, even though identifying the exposed will take time and requires more information. All that is known is that many (but not all) of the dying had been at the football game on November 1.
The mayor also is told that to prevent death, antibiotics must be given before symptoms occur, or at the latest, in the earliest hours after symptoms begin. Patients with serious symptoms are likely to die, no matter what anyone does. Available information suggests that the local supply of needed antibiotics will soon be exhausted; many local pharmacies were already emptied of antibiotics as the initial news of a lethal epidemic spread through the city. Given this shortage of antibiotics, one senior advisor asks the mayor to consider a triage plan that uses all available antibiotics to protect the exposed who are not yet sick. In this plan, antibiotics would be kept from those already sick and thus likely to die, regardless of treatment. The mayor requests immediate federal assistance in obtaining and distributing large supplies of antibiotics. Antibiotic shipments from other states are also urgently requested.
State officials notify hospitals around the city of the anthrax epidemic and warn them to prepare for a new surge of patients in the wake of the mayor's forthcoming TV address. Recommendations for the care of infected patients are sent to hospitals and clinics around the region.
