DAY SEVENTY-TWO:Nov. 21:
There was good news today. Quite a bit of it, actually.The estimates of numbers of dead incinerated in the World Trade Center was revised downwards again, now standing at around 3,200. That is a marked decline from the September 11 estimate that 40,000 people had perished, and considerably less than the reckoning of September 13 that 20,000 had died in the catastrophe. As time has elapsed, and more communities have come forward with names of the missing the toll has been revised downwards several times. It is remarkable that so many people managed to escape with their lives. Undoubtedly this was possible thanks to the comradely behavior of those inside, who by all accounts heroically assisted one another in reaching safety. One pair of men, for example, carried a wheelchair-bound woman down 60 floors of stairs. It is also a testimony to the bravery and planning of the Port Authority security personnel, most of who gave their lives to guide others to safety.
Down at Ground Zero, which is where the original Dutch settlers made their New Amsterdam homes in the 17th century, the bowels of the community are now revealed, streets torn open to fix damaged phone, cable, water and sewer lines. Some of the pipes are astoundingly ancient, encased in rust and crud. This is the infrastructure built nearly 150 years ago in response to rounds of cholera in old New York. Now the city has a chance to pull the deteriorated infrastructure out, replacing it with state-of the-art systems of waste disposal, drinking water, electricity and, of course, the newer systems of cable, computer lines and phones. Manhattan could well end up with the strongest such infrastructure in any city in the world.
And there is good reason to believe that billionaire Mayor-elect Bloomberg will take on the reconstruction effort with vigor and positive intent. His recently announced transition committee is packed with the most respected leaders of the business and political communities, most of them - remarkably - liberal Democrats. Among them is National Basketball Association Commissioner David Stern. (Today Stern's wife, Dianne, called to ask that I be the keynote speaker for NBA All Stars weekend in February. As an avid basketball fan this is greeted with a rousing, "Yes!")
And tonight thousands of children are huddling in the chilly night air, watching the helium inflation of gigantic balloon renditions of their favorite cartoon characters, from Homer Simpson to Scooby Doo. It's a night of preparation for the Macy's Thanksgiving Day Parade.
But there was plenty of bad news today to counterbalance the positivism.
I was in a conference call with HHS Sec. Tommy Thompson at 1:45 this afternoon when he said, "Oh, I'm being slipped a piece of paper here...I regret to say that the 94-year-old Connecticut woman suffering from inhalational anthrax has died."
The mysterious Connecticut case is forcing investigators to rethink some of the most basic scientific assumptions about anthrax, in terms of how people become infected, what dose is required to cause disease and how long the microbes incubate. The scope of the scientific mystery is so vast that it could affect recommendations regarding how long postal workers who are now on antibiotic prophylaxis should be considered at risk, for how much longer people might be expected to contract illness based on mailings posted in September and whether or not America's elderly may be especially vulnerable to trace amounts of anthrax spores in the mail.
It has become something of a mantra among public health leaders: inhalational anthrax requires a dose of some 10,000 spores, which are picked up in the lungs by macrophages cells that carry the deadly microbes to nearby lymph nodes. There, the bacilli divide and multiply, eventually flooding the bloodstream where they release toxins that cause death. The time from initial inhalation of the deadly microbes to onset of illness is usually 3 to 7 days, but can extend out as far as 50 days, in rare cases.
Based on that mantra the U.S. Department of Health and Human Services and local health departments heaved sighs of relief last week when 60 days had elapsed since the presumed dates of the anthrax-laced mailings to various political and media targets. The last case, however, reported on October 25 posed an enormous mystery, involving 61-year-old Kathy Nguyen, a hospital clerk and resident of the Bronx. How did she get infected?
And now, let's face it, the Connecticut case throws the ultimate monkey wrench into the works. This woman lived in a tiny hamlet in rural Connecticut, rarely left her farm home except to attend church and received on occasional pieces of mail which were collected by friends and relatives who brought them to her home.
It's time to rethink the mantra.
Two mail-associated clusters have been responsible for all other cases of inhalational anthrax in the Northeast (excluding the two Florida cases). The first was mailed on September 18 to NBC News, passing through New Jersey postal stations. The second was posted on October 9, and sent to central postal distribution centers in new Jersey and Washington D.C. Seven of the nine Northeastern inhalational anthrax cases and all identified cutaneous infections can be traced to those mailings, or to cross-contamination of the New Jersey and Washington DC postal centers.
Neither Nguyen, nor the Connecticut case can, as of now, be connected to those postal cross-contaminations.
Further, both cases have occurred well outside of the usual timeline for anthrax exposure and illness, though Nguyen's infection did occur within the far range of the 50-day window. Still more mysterious, because neither woman was thought to be a direct target of anthrax mailings, and no spores have been found in Nguyen's home or office, it is assumed that the numbers of spores they inhaled were small--certainly well below the presumed 10,000 necessary to cause an inhalational disease. (CDC tests of the Oxford, Connecticut home of the most recent case were underway yesterday, and results of spore samplings are expected this weekend.)
"We wish we knew more about anthrax than we do," Dr. James Hughes, Director of the CDC's National Center for Infectious Diseases, said in an interview yesterday. "As with a number of diseases there's a lot about anthrax that isn't known. This current experience highlights research needs."
To begin with, the lethal dose for anthrax may be far lower, particularly in peoples over 70 years of age.
"I can't give you a number, a lower level," of spores that might cause disease, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases said in a press conference yesterday. "That would have to be done experimentally."
Experiments were done, decades ago, at the U.S. Army's research facility in Ft. Detrick, MD. Using monkeys, in a variety of anthrax studies, the Army determined that a mean of 8,000 to 10,000 spores had to be inhaled to kill half the exposed animals. But exactly what those monkey studies mean for humans--especially elderly humans--isn't clear. Worse yet, says Louisianna State University in Baton Rouge anthrax research Dr. Martin Hugh-Jones, the raw data gathered by the Army isn't available to civilian scientists, and some of it may be lost. Without the raw data it's hard to know whether the Army tested monkeys that would have been the equivalent of 70 or more human years in age, or whether they used spores that were of the same refined consistency as those mailed to the offices of Senators Patrick Leahy and Tom Daschle.
Nevertheless, "It has not gone unnoticed that the age range of these individuals," who have contracted inhalational anthrax is high, Fauci continued. None are under 40 years of age; nine of them are 55 or older. "It is conceivable as one gets older that the natural defenses may reach a critical threshold which brings out susceptibility or a defect in the ability to clear spores that come into the lungs."
It's becoming increasingly clear that everybody is guessing about the anthrax dose question. And that has ramifications for timing, incubation. Numerous old studies of clinical anthrax show that incubation time is determined by dose, Hughes said. So the CDC may have underestimated just how far from the time of exposure symptoms could occur, simply because the mantra called for a dose of 10,000 spores. Duke University's Terry Dixon wrote in a 1999 study of anthrax in the New England Journal of Medicine that, "Longer incubation periods may be associated with smaller inocula."
Thus, it could be possible that the Connecticut case is still linked to the mailings of September, and postal cross-contamination, CDC Director Dr. Jeffrey Koplan said yesterday. If the Connecticut case is, indeed, found to be linked to the mail, Fauci said, it might be necessary to consider guidelines for how elderly Americans handle their mail. And it may be necessary to revisit recommendations for postal workers who are now taking antibiotics because of possible exposure. Well after their 60-day medication, Koplan said, "we will be watching them" to be sure that none develop disease. Ingested antibiotics cannot reach spores that hide inside cells or in cavities in the lungs.
Another factor that can affect the incubation time for anthrax is the status of the spores, themselves. Newly produced spores are surrounded by a balloon-like structure called an exosporium. Weapons-grade spores have been treated in a manner that removes that exosporium, making it easier for the spores to enter the lung, hide from the human immune system and lurk inside the body, undetected, for days or weeks at a time. Such spores may not be readily spotted and absorbed by macrophages, and therefore not transported to the lymph nodes rapidly to cause disease. That would lead to a far longer incubation time for disease. The spores found in the letters posted to Sens. Tom Daschle and Tom Leahy were analyzed at Ft. Detrick, but Army officials told Newsday that the FBI has prohibited them from revealing whether or not the exosporium is intact on those spores.
It is, of course, possible that the Connecticut case, as well as Nguyen's death, have no relationship to the mailings. Local investigators say the Oxford, CT woman was frequently visited by friends and neighbors, prompting Hugh-Jones to hypothesize a completely different route of infection--one that could only be successful if the assumed dose necessary to cause disease was quite minute: "I would put forward an idea; if she had a visitor--it's likely to be a relative--well, everyone gets hugs. If this visitor had a contaminated sweater or coat on, Granny gives a hug, Granny gets a snort-full. And for Nguyen, same thing. A snoot-full on the subway off the contaminated clothing of a fellow passenger. It's a wild idea, but when logic breaks down you're only left with imagination."
So, the anthrax saga continues, and the mystery widens. Partly in response we received a memo today at Newsday, informing us that:
"effective today, November 21st, Newsday's mail center in Melville will be opening all first class envelopes delivered to Two Park and Kew Gardens. Under the new procedure, all envelopes will be opened over a black tabletop and checked for foreign substances. If any foreign substances are found, the envelope and its contents will not be forwarded.
The FBI continues to insist that the culprit responsible for this horror is a lone wolf, a sort of biology Ted Kzcyienski. For weeks, however, I have been chasing rumors of an anthrax vaccine factory in Kabul, controlled by the Taliban. Now that the Taliban has fled the city reporters have managed to gain entry to the site. And the news is disturbing: The new procedures will delay the receipt of all first class mail by 24 to 48 hours.
I encourage you to request all outside correspondence be sent to you via fax or email. This will insure its timely receipt and reduce the volume of mail being handled through the Mail Center.
NOTE: The company considers all mail directed to Newsday to be business mail, and will open all mail in accordance with the procedures we have established to ensure everyone's safety. Please do not use Newsday's address to receive personal mail, as we are unable to treat such mail differently than business mail."
Does the FBI have serious leads? Time will tell.Well, tomorrow is Thanksgiving. Eat turkey. KABUL, Afghanistan (AP) -- At an Agriculture Ministry laboratoryoutside Kabul, scientists worked with anthrax. If Osama bin Laden'sal-Qaida network wanted to get its hands on the deadly substance,this laboratory, now badly damaged by U.S. bombing, could have beena source.The now defeated Taliban regime has long denied being involvedin chemical or biological weapons research, but it seems to havetaken an interest in the work being done at the lab, according toscientists there and it was repeatedly hit by U.S. bombers.The lab, in a two-story mountainside building, was frequentlyvisited by a Taliban official during the past five years, accordingto scientists interviewed there Tuesday.They did not say whether Mullah Qari Abdullah showed a specificinterest in anthrax, and the scientists insisted their work wasaimed purely at developing animal vaccines.Ali and his colleague, Dr. Abdul Wakil, did not say whether anyof their research was transferred to al-Qaida or used in weaponsexperiments. But they acknowledged that the lab's activities meantthe Taliban had access to anthrax.The scientists, long-time workers at the lab, showed a largecontainer, which they said held concentrated anthrax, spores.was studying chemical, biological and even nuclear weapons. It'snot clear whether any was ever produced. Be well. Stay safe. Stand defiant
Laurie Garrett
