Researchers Examine Deaths of Two Postal Workers from Inhalational Anthrax

Study Says Improved Communication and Disease Detection Needed

The Center for Civilian Biodefense Studies at the Johns Hopkins Bloomberg School of Public Health and the National Institutes of Health (NIH) have published a case study examining the deaths of two Washington, D.C., postal workers who died from inhalational anthrax as the result of the bioterrorism attack. Both postal employees worked at the Brentwood facility, which processed an anthrax-laden letter mailed to Senator Tom Daschle on October 9, 2001. The report, which appears in the November 12, 2001, online edition of the Journal of the American Medical Association (JAMA), illustrates the difficulty doctors and clinicians face in distinguishing the symptoms of anthrax from a number of other common illnesses. The report also emphasizes the need for better communication of epidemiological information to front-line medical providers and the need for rapid diagnostic tests for anthrax and other dangerous pathogens that could be used as biological weapons.

"The symptoms of anthrax look like many other common diseases. None of the doctors who treated these patients suspected anthrax until they heard reports of other sick postal workers from the news media," says the study's lead author, Luciana Borio, MD, a fellow at the Johns Hopkins Center for Civilian Biodefense Studies and the Critical Care Medicine Department, Clinical Center, at NIH. "These cases emphasize the importance of developing more rapid lines of communications between medicine and public health. Clinicians need information to make a proper diagnosis and provide timely treatment for their patients," adds Dr. Borio.

According to the report, a 47-year-old male postal worker developed "flu-like" symptoms on October 16, which he attributed to food poisoning. A few days later, he sought medical attention in an emergency room, where he received intravenous fluids and anti-nausea medications. He was sent home after his symptoms improved.

On October 22, the man eventually collapsed at home and was taken to the hospital. Doctors then suspected the man had inhalational anthrax after learning from media reports of two other postal workers hospitalized with the disease. The patient was treated with multiple antibiotics, but died five hours later.

The second postal worker began feeling ill on October 17. The 55-year-old male visited a primary care doctor complaining of weakness, muscle aches, and fever. The man was diagnosed with a viral infection, but the symptoms persisted. By October 21, the postal worker was admitted to the hospital. Once again, doctors suspected inhalational anthrax after hearing media reports of similar cases. Doctors treated the man with antibiotics, but he died after 13 hours. The next day, his blood culture came back positive for Bacillus anthracis.

"These cases also demonstrate the urgent need for better disease detection capacities in the public health and clinical communities. This should be a priority in our strategy to improve response to biological attacks and other outbreaks," explains Dr. Borio.

It is important to note that the nasal swab of the first postal worker to die from inhalational anthrax was negative, underscoring that the nasal swab cannot be used as a clinical diagnostic test.

"Our report demonstrates the need for rapid diagnostic tests to distinguish an early anthrax infection from other diseases with similar symptoms. More research is needed in this area and should be a high priority on a national research agenda to respond to threats of bioterrorism," says co-author Thomas Inglesby, MD, deputy director of the Center for Civilian Biodefense Studies and assistant professor of infectious diseases at the Johns Hopkins School of Medicine.

Dr. Borio says that the rapid release of this information to the medical community was only possible because of the collaboration of several groups, such as the doctors and nurses from Greater Southeast Community Hospital, Southern Maryland Hospital Center, the medical examiners for the State of Maryland and the District of Columbia, the expedient review of JAMA, and the patient's families, who gave her permission to publish the manuscript in JAMA.

"Hopefully, this case report will help other front line health care providers who may be dealing with anthrax patients in the future," adds Dr. Borio.

Research for the article was conducted by Luciana Borio, MD; Dennis Frank, MD; Venkat Mani, MD; Carlos Chiriboga, MD; Michael Pollanen, MD, PhD; Mary Ripple, MD; Syed Ali, MD; Constance DiAngelo, MD, MS; Jacqueline Lee, MD; Jonathan Arden, MD; Jack Titus, MD; David Fowler, MD; Tara O'Toole, MD, MPH; Henry Masur, MD; John Bartlett, MD; and Thomas Inglesby, MD.

The case study may be viewed by visiting www.jama.ama-assn.org.