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Abstract

In August of 2005, Hurricane Katrina struck the Gulf Coast killing nearly 2,000 people and causing approximately 100 billion dollars in damage. The disaster was ranked as one of the deadliest in United States history, with New Orleans suffering a great bulk of the damage. Eventually about 80% of the city became flooded which caused a series of public health issues. The damage of this natural disaster was shocking but even more shocking was how the response from local, state and federal public health and emergency response agencies was mishandled. Not only was the public health response criticized but it seems that New Orleans was not adequately prepared to handle such an event. Three areas will be discussed in this paper: the roles and responsibilities of the local, state and federal public health authorities and how these roles were unmet; how these agencies should have worked together before and after the disaster; and how these agencies could have better handled the problems that arose during and after the event. This paper will target specifically how to improve leadership among public health authorities during a disaster such as Hurricane Katrina, recommendations for timely decision making during such a disaster, and how to make improvements to infrastructure and preparedness before a disaster.

The mishandling of the Hurricane Katrina disaster

Hurricane Katrina struck the Gulf Coast in August of 2005 and with it brought devastating damage to the region. The city of New Orleans was hit particularly hard and was the result of much of the monetary damage as well as human loss of life. Katrina exposed serious flaws in the United States’ disaster response capabilities (Howitt et al., 2006).

In the American disaster response schema, the initial responsibility for disaster response rests with local authorities (Howitt et al., 2006). This “bottom-up” approach makes sense in most emergencies because local governments are closer to disaster sites and therefore can provide quicker response as well as intimate knowledge of the area (Howitt et al., 2006). Aid from state or federal sources is generally provided in such instances where localized resources have been exhausted (Howitt et al., 2006). There are generally more specialized resources at the state and federal levels, but these resources are further away and their response time is longer, which is decidedly important in disaster response (Howitt et al., 2006).

Some of the other criticisms of the mishandling of Hurricane Katrina were cited as unqualified crisis managers and weak elected officials, inadequate preparedness plans, failure to make investments into infrastructure (particularly in the case of New Orleans) and poor and/or late decision making (Howitt et al., 2006).

“Crisis” emergencies like Hurricane Katrina are distinguished from routine emergencies by their novelty (Howitt et al., 2006). In other words, the “crisis” emergency presents something that the planners have not adequately planned for. According to Howitt et al., (2006), it is inevitable that at some point a community will be presented with this type of crisis disaster. These crisis disasters require different capabilities, for example: responders must identify the novel elements of the disaster. In the Hurricane Katrina disaster these novelties were: the need for assistance in the evacuation of people from their homes and from the city of New Orleans, the failing of the levees which resulted in significant flooding to the city, the unexpected use of the city’s convention center for sheltering refugees (which included providing food and law and order), and restoring water and power (Howitt et al., 2006).

Even though Hurricane Katrina was a local disaster, federal disaster relief was needed because of the magnitude of the disaster. No local municipality or state can afford to keep all the assets that are necessary in an emergency like Katrina in reserves, so turning to federal assistance was necessary (Howitt et al., 2006). As Howitt et al., (2006, p. 219) points out, the coordination of federal, state, and local agencies “demands skillful coordination of aid workers, equipment, and organizations across professions, agencies, jurisdictions, levels of government, and the public and private sectors.” No easy task. And many or most of the public health officials and organizations that were part of the post-Katrina response had little or no prior experience working together (Howitt et al., 2006).

This fact was at the center of the debacle of the post-recovery response from Hurricane Katrina; and illustrates the point quite clearly the need for such training to occur in disaster preparedness whereby individuals at the local, state, and federal levels that may be called to work together in the event of a large scale disaster need to have real-life training as such.

In fact, one could argue the point that the disaster response for Hurricane Katrina put NIMS – the National Incident Management System – that was created in 2002, to the test. Unfortunately, it was a failed effort which further points to the need for additional training on the management of this type of disaster. The purpose of NIMS, ideally, is to establish a clear division of labor and assignment of functional responsibility; and to clearly define the chain-of-command (Howitt et al., 2006). But in the disaster response post-Hurricane Katrina, the NIMS system was not effective in any of these areas. It is this writer’s opinion that the problem is one of management-style. The NIMS style opts for a “military-type” command system; even the terminology of “command system” and “chain-of-command” give the whole federal disaster response system a military feel. The military is quite capable in war-time efforts, but is not the most effective of systems in peace-keeping efforts. With NIMS on showcase in post-Katrina response we got a military-style effort; what we needed was a peace-keeping or humanitarian effort.

In the case of Katrina, there was noticeable friction between local and state officials, with the city officials and mayor on one side, and the state and governor on the other side. And both local and state officials criticized the federal response, most notably FEMA (Howitt et al., 2006).

Rosenbaum (2006, p. 437) writes: “(Katrina) exposed every public policy failure essential to community and population health. After the levees broke, we watched every single system associated with the life of a city fail: the electric grid, the water system, the sewer system, the transportation system, the telephone system, the police force, the fire department, the hospitals, even the system for disposing of corpses.” In fact, the devastation to New Orleans (and other areas) infrastructure was so great that more than one million people were homeless even as of December 2005, four months after the disaster struck (Rosenbaum, 2006).

When Hurricane Katrina struck, first responders were as unprepared for the disaster as they had been on 9/11 (Shughart, 2006). But why, and who was to blame? Why was FEMA delayed in their arrival? Why were no police or National Guard units in place to prevent looting (Shughart, 2006)? According to Shughart (2006, p. 32), “the fiasco was predictable because politicians and bureaucrats have relatively weak incentives to prepare for emergencies and to promptly mobilize the resources necessary to alleviate hardship when catastrophe strikes.”

While I agree with Shughart in that Government is certainly full of shortcomings, I’m not sure we can simply say “oh well, that’s Government for you” and forget about it. When a disaster the size of Katrina occurs and the response is as impotent as it was, I think we must address why it occurred and look for some solutions. It may not make the next big disaster go perfectly, but hopefully we can make some improvements when the inevitable occurs again.

And it isn’t as if public officials didn’t have ample warning about Katrina. On August 27, 2005 – two days before Hurricane Katrina struck the Gulf Coast – Louisiana State University’s Center for the Study of the Public Health Impacts of Hurricanes predicted that New Orleans would flood as the result of Hurricane Katrina (Shughart, 2006). With this warning in hand, city officials should have evacuated the city, but they did not. In fact, another study two years prior to Hurricane Katrina found that a category 3 hurricane, which Katrina was, would flood the city (Shughart, 2006). So there was enough evidence to suggest that city officials should have put the city on alert and began evacuation procedures, but they did not.

The Army Corps of Engineers, who were responsible for both building and monitoring the levees around New Orleans, warned state and local officials that soil erosion had caused some stretches of the flood barrier to sink as much as three feet, and these areas must be repaired (Shughart, 2006). However, the levees were not repaired. Why did city or state officials not address the levees, knowing it was simply a matter of time before a category 3 storm would hit the city? When the storm reached New Orleans, the levees failed as predicted, and about 80% of the city was under water, 20 feet deep in some places (Shughart, 2006).

The best answer for why the levees were not repaired was because citizens of New Orleans did not voice their concerns loudly enough to politicians. That is not to say that it is the residents of New Orleans fault, but rather politicians will typically only address those issues that are likely to get them reelected (Shughart, 2006). Since citizens were not talking about levee repairs for the most part, city officials and politicians ignored it, choosing to spend money in other areas (Shughart, 2006). For politicians, money spent on infrastructure and repair is wasted money, because no one really sees it, it deteriorates over time, and the public isn’t generally aware of it (Shughart, 2006). So politicians generally ignore these types of infrastructure necessities, hoping that when a problem occurs, it will “happen on someone else’s watch” (Shughart, 2006).

Another issue regarding the levees was that they were overseen by four different governing boards, made up of gubernatorial and local political appointees, each with their own autonomy to some extent (Shughart, 2006). And in the city of New Orleans, there are independent water and sewer boards that run and maintain the pumps and canals needed for draining low-lying areas (Shughart, 2006). This fragmentation clearly had foreseeable consequences, for it seems that though the Army Corps of Engineers recommended repairs to the levees, it was unclear exactly who was responsible for the repairs (Shughart, 2006). The city thought the repairs should come from the governing boards responsible for the levees, and those boards thought the cost should be footed by the city of New Orleans. And it seems that past repairs to the levee system had been done rather haphazardly – repaired well in some areas using appropriate materials, repaired poorly in other areas using cheap or ineffective materials or erecting levees that were not sufficiently high enough (Shughart, 2006).

The Orleans Levee District (one such governing board) focused more on developing its prominence in the region and acquiring more political power in order to build parks, marinas, walking paths, and a commuter airport near Lake Pontchartrain in an order to make considerable profits (Shughart, 2006). And during this development of the area, very little money was put into levee repair by this governing board, instead opting for money-making developments. Lake Pontchartrain area was one of the hardest hit by Hurricane Katrina. Most of these developments by the Orleans Levee District board were destroyed (Shughart, 2006).

To address the fragmentation of government that we saw in the Hurricane Katrina example, it is essential that in situations such as these that one governing board be over the entire flood levee system. Or at least have a governing board that has the power and authority to enforce the “local” boards with regards to repairs. And this governing board should not be compromised by having real estate development interests and money-making schemes as its first priority.

But the failures of the Katrina response were not merely inadequate preparations. Both the mayor of New Orleans and the governor of Louisiana were heavily criticized regarding their actions or rather inactions for the first few days when Hurricane Katrina hit (Shughart, 2006). Mayor Nagin chose to “wait-out” the disaster in a local high-end hotel rather than being at Louisiana’s emergency operations facility in Baton Rouge (Shughart, 2006). Shughart (2006) also criticizes Governor Kathleen Babineaux Blanco for allowing the mayor to determine whether or not New Orleans should be under mandatory evacuation. It would seem that perhaps Governor Blanco was not confident enough to make such a decision, perhaps fearing the move would hurt the local and/or state’s economy. But she had ample evidence that Katrina was a severe enough hurricane that significant damage was likely to be done to the area, especially in light of New Orleans’ inadequate levee protection. Though the mayor should have called for the evacuation of the city, so should have the governor stepped in and done so when the mayor failed to do so. Both are to blame for the inadequate response in my opinion.

Once Hurricane Katrina struck New Orleans, communications between the mayor and the governor and between the governor and other public health officials were cut-off (Shughart, 2006). The governor was able to notify the president of the need for additional assistance the day that Katrina struck the city, but did not give a detailed list of what was needed until three days later (Shughart, 2006). Apparently this was due to her lack of communications with the mayor and other public health officials in the city. And then it was several days later before President Bush actually sent any aid (Shughart, 2006). So from the time the storm hit New Orleans to the time that aid actually arrived, about 5 days had passed (Shughart, 2006).

One way that this could have been avoided was to have all of the necessary players, the mayor, the governor, and other city and state officials at the command center, rather than having them separated in different parts of the city and state. In fact, this one of the main tenets of the NIMS system: the Incident Command Post (ICD). So why the ICD was not used in this case by officials is still unclear.

President Bush was also criticized for his lackluster response (Shughart, 2006). The President kept speaking engagements and continued his vacation even after learning of what was happening in New Orleans (Shughart, 2006). Looting and rioting were problems in the flooded streets of New Orleans, particularly since a significant portion of the police force had deserted the city (Shughart, 2006). It wasn’t until several days later that President Bush suggested to the governor that she allow federal National Guard units to impose martial law on the city. However, the governor refused (Shughart, 2006). Many accused the president of racism since the majority of those left behind and homeless in New Orleans were poor and black. But Shughart (2006) contends that the lackluster response from President Bush more likely had to do with motivation. President Bush was already in his second term with no re-election to worry about, and in an area of the country that is loyal to the Republican Party (Shughart, 2006).

I agree with Shughart’s contention about President Bush to some extent. But to say that a sitting president could care less about what happens during his second term because there is no re-election value I think it a bit off. Someone doesn’t reach the level of president without being an ego-maniac to some extent, and presidents always care about their legacy. This writer’s opinion is that President Bush waited to respond because both the mayor and the governor were democrats. President Bush wanted to see them fail and struggle to some extent so he could rush in and “save the city” from the inept democratic leadership. Unfortunately for President Bush, his own response along with his FEMA appointee, Michael Brown, were equally inept.

Perhaps no one, not even the mayor or governor or president took more blame than did FEMA (Shughart, 2006). According to Shughart (2006) the cause of FEMA’s inept response to Hurricane Katrina was the result of their reorganization after 9-11 into the newly formed Department of Homeland Security, where their role in disaster preparedness was diminished and they were forced to utilize their resources to “prevent another 9-11-style attack.” This left them ill-prepared to handle a natural disaster the size of Hurricane Katrina.

But it wasn’t only that FEMA was not accustomed to the role that it was cast into during the Katrina recovery, other criticisms were leveled at the then FEMA director, Michael Brown, who by his own acknowledgement was probably not the man for the job, despite President Bush’s infamous supportive statement of “Brownie you are doing a heck of a job!” (Hsu and Glasser, 2005). President Bush’s transparent self-interest statement of Brown aside, it was quite clear that as FEMA director, Brown, a lawyer with no real background in disaster management or public health, was in over his head; some even calling him “clueless” (Hsu and Glasser, 2005 & CNN, 2006). Brown resigned his post shortly after Katrina (Hsu and Glasser, 2005).

Despite the poor leadership of FEMA, a more central issue is at hand in my opinion. We can replace all the FEMA directors we want, but the real issue is the role that FEMA has been cast into as part of the Department of Homeland Security. Acts of terrorism in this country, both foreign and domestic, have been quite rare. The amount of money that is being allocated to combat terrorism are funds that are misappropriated in my opinion. Perhaps even some republicans agreed for one of their recommendations to the Department of Homeland Security was to increase FEMA’s budget by 10% in 2007 (CNN, 2006). Additionally, an organization like FEMA must be allowed to do what it does best, disaster preparedness, not trying to thwart terror attacks – that is what the CIA and or/FBI should be doing.

What is perhaps most interesting about the ineptness of the local, state, and federal government responses was how well by comparison private companies like Wal Mart were able to offer assistance to victims of Katrina (Shughart, 2006). According to Shughart (2006, p. 42), “Wal Mart frequently beat FEMA by days in getting trucks filled with emergency supplies to relief workers and citizens.” Both Home Depot and Fed Ex also leant support in similar efficient style in the aftermath of the disaster (Shughart, 2006).

So what does this say about our Governmental preparedness to handle disasters when private companies are able to outperform them? Is it simply inevitable that the more talented of individuals will find themselves employed in the private sector because their talents are better appreciated and more rewarded there? Government would need to increase salary amounts or provide other types of incentives such as easy-qualifying home loans or student loan repayment in order to attract more talented individuals into the Government positions. Or is it less of a reflection of government personnel and more a reflection of poor infrastructure? Private sector tends to shoot for top performance due to profitability, whereas government wants standardization, control, and an acceptable level of performance.

Recommendations

In summary, there were several factors that led to the mishandling of the Katrina response, both in terms of pre-event planning and post-recovery response. First, it is conceivable that if the necessary infrastructure repairs had been put into place, most notably in the levee repairs and they had been performed to an adequate level, that the devastation of Hurricane Katrina and the havoc it brought about on New Orleans would have been much less severe. In my opinion, despite the poor leadership of the mayor, the governor, the president, and FEMA, those repairs alone may have saved countless lives and dollars. But the disaster did shed light on other issues of leadership and governmental structure that are lessons that we can learn from and hopefully use to prepare for the next inevitable disaster.

Second, fragmentation of government will always likely be an issue, but we must work to ensure that in situations such as infrastructure repair to something so important as levees, that only one governing body has the ultimate authority and responsibility for maintenance.

Third, I believe we need to restructure our disaster response into something less “military-style” as NIMS is, and opt for something that is more focused on a humanitarian effort. Perhaps lessons can be learned from how Wal Mart and other private sector businesses outperformed the military-styled NIMS system. And fourth, FEMA must be removed from the Department of Homeland Security and given back its primary role of disaster preparedness.

References:

CNN. (2006, February 14). Report: Katrina response a ‘failure of leadership.’ Retrieved from

http://www.cnn.com/2006/POLITICS/02/13/katrina.congress/index.html

Howitt, A & Leonard, H. (2005). Katrina and the Core Challenges of Disaster Response.
The Fletcher Forum of World Affairs, 30(1), 215-221.

Hsu, S. & Glasser, S. (2005, September 6). FEMA Director Singled Out by Response
Critics. Washington Post. Retrieved from

http://www.washingtonpost.com/wp-dyn/content/article/2005/09/05/AR2005090501590.html

Rosenbaum, S. (2006). US Health Policy in the Aftermath of Hurricane Katrina. American
Medical Association, 295(4), 437-440.

Shughart II, W. (2006). Katrinanomics: The politics and economics of Disaster Relief.
Public Choice, 127(1), 31-53.

**The following is a fictitious scenario that I created for one of my public health courses:

Outbreak Scenario

On October 12th, 2009 at 9:32am, a group calling themselves “The Movement” contacted members of the local media in Phoenix to tell them that a bioterrorism “bomb” had been released at the Arizona Cardinals stadium in Glendale during a football game on October 11th, which had several thousand fans in attendance. The group claimed that it had released anthrax (a category A agent) in an aerosolized manner. The group expressed that they are an anti-immigration group that is angered by Phoenix’s lax immigration standards. The media then immediately contacted the Phoenix Police Department and notified both the Maricopa County Health Department and the Arizona (state) Department of Health.

On October 12th at 10:04am, officials at the state and county health departments held a teleconference call where it was determined that the local hospitals should be contacted to notify physicians and epidemiologists to be on the look-out for cases of inhalation anthrax. Physicians were asked to confirm their diagnosis of anthrax via a blood culture test and to submit the blood culture to the state lab for confirmation. Physicians would then be notified by the state lab if there was a confirmation of the diagnosis. However, since inhalation anthrax is a fast progressing disease, physicians were instructed to begin administering antibiotics for any suspected cases of anthrax even before blood test confirmation. The public health officials also contacted the National Pharmaceutical Stockpile and asked that shipments of ciprofloxacin and Biothrax be readied in the event that there was a shortage of needed antibiotics.

The police were also contacted and notified that a HAZMAT team was assembled and was being sent to the stadium for decontamination. The HAZMAT team arrived to the stadium at 12:12pm on October 12th and decontamination procedures were initiated. The clean-up of the stadium and the surrounding area took approximately 10 hours, and some residents surrounding the stadium were evacuated during the decontamination process to protect them from possible exposure. The Arizona Cardinals stadium is a dome, but has an open roof, so it was not initially clear if the aerosolized spores of anthrax were contained within the stadium or had traveled to the surrounding areas outside of the stadium.

The HAZMAT team worked in cooperation with the local police department, fire department, and the Federal Bureau of Investigation who had also been called-in due to the terrorist nature of this event.

Residents were allowed to return to their homes after the HAZMAT team determined that there were no exposure risks outside of the stadium. However, the stadium remained closed for a week to ensure that all areas of the very large stadium had been thoroughly decontaminated and to allow the local police department and the FBI to conduct investigations.

At 12:30pm on October 12th the county health department received a call from Dr. Marquez at Phoenix Baptist Hospital indicating that a patient had reported to their ER room with symptoms that are suspicious for inhalation anthrax and the patient notified hospital staff that he had been at the game on the 11th. Dr. Marquez ordered a blood test and confirmation was confirmed on October 14th at the state lab. This patient was the first index case.

Shortly thereafter, at 12:44pm on October 12th, the county health department received another call, this time from Dr. Wongduan at St. Joseph’s Medical Center indicating that he had heard about the news report regarding the possible bioterrorist attack yesterday at the Cardinals game, and he had a patient that has symptoms that are concerning for inhalation anthrax. He wanted to report the case to the health department before lab confirmation. This case was also lab confirmed via a blood culture on October 14th.

The health departments received a total of 8 calls on October 12th from hospitals and dozens of calls from concerned citizens that had attended the game. The public health officials told those concerned citizens to report to an ER room at a local hospital and await instructions from hospital staff. The hospitals were instructed to begin administering antibiotics for any patients that presented with symptoms concerning for inhalation anthrax. A total of 10 patients that presented with symptoms on October 12th were confirmed via blood test on October 14th.

After learning of the advisement from the public health officials, some hospitals recalled patients that were initially diagnosed on the evening of the 11th and early morning on the 12th that presented to the hospital with flu-like symptoms. It is felt that these patients may have been misdiagnosed and were possibly exposed to the inhalation anthrax. However, none of these patients were confirmed as having anthrax.

Since inhalation anthrax is a fast-developing disease, it was necessary to start confirmed cases of inhalation anthrax on ciprofloxacin, along with another antibiotic such as penicillin or doxycycline given intravenously. Public health officials decided to recommend to doctors not to use the Biothrax vaccine, due to its controversial nature, unless they felt it necessary in a particular case and then the physician should discuss the possible side-effects with the patient before administering it. Exposed individuals also underwent decontamination procedures at hospitals to include removing any contaminated clothing from the patient and to have the patient shower with soap and water for about 20 minutes. Bleach solution was not recommended unless the exposed individual could not be decontaminated with soap and water for some reason, and then if necessary, the diluted bleach solution to be used after the soap and water shower, and then rinsed off after a 10 to 15-minute period. Isolation or quarantine was deemed unnecessary since anthrax is non-communicable, so only standard precautions applied.

Over the course of one week, from the exposure date of October 11th, a total of 112 people were confirmed via blood culture as having inhalation anthrax. Public health authorities had feared that there might be considerably higher numbers given the aerosolized manner of the substance. It is unclear as to why more people were not infected, perhaps when the police investigation is concluded more will be understood about how the terrorists released the substance. However, police and FBI investigations revealed that all of the infected individuals were seated in one section of the stadium, so other areas of the stadium were apparently not affected. It is unclear at this time if this was intentional by the terrorists or if the aerosolized spores somehow deviated from the planned attack area.

Of the 112 laboratory confirmed cases, 10 of them reached second stage development of inhalation anthrax, which was confirmed by a chest x-ray, presumably because these individuals did not report to a hospital ER room in a timely manner. Of these 10 individuals, 9 died of inhalation anthrax. This resulted in a total mortality rate of 8%, however, of the victims that reached the second stage of symptoms for inhalation anthrax there was a 90% mortality rate. All exposed patients are currently receiving treatment and will continue to receive treatment for up to 60 days. Currently all other patients are responding well to the treatment.

Conclusion

On October 12th, 2009 a terrorist group calling themselves “The Movement” contacted local media in Phoenix, Arizona to notify them that aerosolized anthrax had been released at the Arizona Cardinals football stadium in Glendale on October 11th. The media immediately contacted public health officials and the Phoenix Police Department. Public health officials then contacted local hospitals to notify them to be on the look-out for suspected cases of inhalation anthrax and to test all suspicious patients with a blood test. Infected patients were decontaminated and started on antibiotics which included a combination of ciprofloxacin and either penicillin or doxycycline. A HAZMAT team was also sent to the Arizona Cardinals stadium to close down and decontaminate the entire area. The decontamination of the surrounding neighborhoods was completed within 10 hours and residents were allowed to return to their homes. The stadium and adjacent facilities were closed for one week to ensure a thorough decontamination of the area.

Laboratory confirmed cases of inhalation anthrax were totaled at 112. Public health officials expected this number to be much higher, but it was determined by the Phoenix Police Department along with the FBI that only one section of the stadium was exposed to the aerosolized anthrax. Of the 112 confirmed laboratory cases of inhalation anthrax, 10 of them reached “second stage” symptoms, which resulted in a total of 9 deaths from this terrorist action. There have been no further cases identified since October 18th, 7 days after the exposure date. However, public health officials will continue to provide surveillance for up to 60 days. The Phoenix Police Department’s investigation into the terrorist actions is ongoing as is that of the Federal Bureau of Investigation.

Background

Anthrax is a naturally-occurring bacterium which lives in soil and can remain alive for years as a spore, which can then be passed to humans that handle infected livestock or eat contaminated, undercooked meat (Null, 2003). Anthrax occurs in three forms: pulmonary, cutaneous, and gastrointestinal (Heymann, 2008). Cutaneous anthrax is the most common, accounting for greater than 95% of cases affecting humans (Heymann, 2008).

Symptoms of cutaneous anthrax typically begin with itching of the affected site, followed by a lesion developing into a depressed black eschar, this last phase taking approximately 2 to 6 days (Heymann, 2008). The eschar is then surrounded by moderate to severe edema, which is quite extensive; there is usually little to no pain (Heymann, 2008). However, there is often considerable swelling around the site of the sore and bouts of shivering and chills in the affected individual are common (Null, 2003).

Common sites of infection include the hands, forearms, head and neck; this is because these are exposed parts of the body and cutaneous anthrax requires a pre-existing cut or break in the skin for it to enter into the body (Heymann, 2008). If left untreated, the disease may spread to the lymph nodes and into the bloodstream, though this is fairly rare (Heymann, 2008; Null, 2003). The fatality rate for cutaneous anthrax is between 5 to 20% if untreated, however, with treatment fatality is rare (Heymann, 2008).

If anthrax were to be used as a bioweapon, it would most likely be aerosolized which would result in inhalation anthrax (Null, 2003).  Early symptoms of inhalation (also known as pulmonary anthrax) are a mild cough, headache, fever, and general malaise, which makes them virtually indistinguishable from symptoms of influenza, unless a blood test is done (Null, 2003). However, within 3 to 4 days, symptoms progress to respiratory distress, enlargement of the mediastinum, immune system failure, shock, and death within 48 hours after the release of the toxin (Heymann, 2008; Moore, 2001). For untreated cases, fatality is 100% and may occur in as many as 95% of treated cases if therapy is begun more than 48 hours after the onset of symptoms (Cieslak et al., 1999).

Gastrointestinal anthrax is not common in developed countries, but is seen in poor or developing countries, usually by way of eating contaminated meat (Heymann, 2008). The consumption of tainted meat usually takes the form of gastrointestinal anthrax, though oropharyngeal may also develop (Heymann, 2008). With oropharyngeal anthrax the lesion is in the mouth cavity, on the tongue, mucosa, tonsils, or pharynx wall (Heymann, 2008). Early symptoms of oropharyngeal anthrax include sore throat and extensive edema in the throat that may lead to blockage of the trachea (Heymann, 2008). The lesion of gastrointestinal anthrax is typically found in the intestinal tract and is ulcerative and massively edematous, which leads to hemorrhaging and obstruction of the gastrointestinal tract (Heymann, 2008). The incubation period for both gastrointestinal and oropharyngeal anthrax is approximately 3 to 7 days (Heymann, 2008). It is not always fatal, but even with treatment, this form of anthrax has a high fatality rate (Heymann, 2008).

Naturally occurring cases of anthrax may come about from environmental disasters, like tsunamis or floods which can cause erosion of burial sites of infected animals, which in turn can lead to contact of the disease by humans (Null, 2003). Any contact with an infected animal, including touching the hair or skin of the animal as well as handling bones of a deceased animal that was infected can result in a human becoming infected with anthrax (Cieslak et al., 1999). Biting flies that have bitten a diseased animal and then bite a human can also infect the human, as well as touching contaminated soil (Heymann, 2008). Inhalation anthrax occurs primarily in industrial or factory settings where animal hides are processed and there is poor ventilation, which results in ingestion of the anthrax spores (Heymann, 2008).

The incubation period for anthrax is generally 1 to 7 days, though incubation periods of up to 60 days is possible (Heymann, 2008). Person to person transmission is exceptionally rare and has only been documented with cutaneous anthrax (Heymann, 2008).

Anthrax has also been both used and studied as part of some countries bioweapons programs, perhaps most notoriously by the Japanese Imperial Army during the 1930’s and 1940’s, through the infamous Unit 731; and by the Soviets during the cold war era (Miller et al., 2001).  Anthrax has also been used as a bioweapon by domestic terrorists, most recently and perhaps most notably in October of 2001, which infected and killed a number of Americans (Null, 2003). According to military and counterterrorism experts anthrax is near or at the top of any list of most likely bioweapon (Cieslak et al., 1999; Moore, 2001). Given the relatively short incubation period, and rapid progression of disease, identification of the exposed population within 24 to 48 hours and employment of therapeutic and prophylactic strategies are likely to present a challenge (Cieslak et al., 1999).

There is a vaccine for anthrax, Biothrax (also known as AVA, which stands for Anthrax Vaccine Adsorbed), though it is not made available to the general public, it is recommended for lab workers and workers that handle potentially contaminated raw materials who may come into contact with anthrax through their job duties (Heymann, 2008). The vaccine was also administered to American military troops prior to their campaign in Iraq, as a precautionary measure against Saddam Hussein’s army which it was feared might use anthrax as a bioweapon against American soldiers (Null, 2003).

The vaccine is effective in preventing cutaneous and inhalation anthrax and is designed for preventing exposure to anthrax, though it can be administered as an “after-the-event” treatment in the case of a biological weapons attack, for example, and would be combined with antibiotic therapy, of which ciprofloxacin is considered the first line treatment though doxycycline or amoxicillin maybe used in some cases (Heymann, 2008). However, ciprofloxacin and doxycycline have side effects which may be more severe than other antibiotics which also may work against anthrax, like penicillin (Null, 2003).

Prevention control for naturally acquired anthrax includes vaccinating livestock, properly disposing of dead livestock by burning them, ensuring proper ventilation systems in factories and labs, and educating employees that might come into contact with anthrax about safe practices such as wearing protective masks and clothing (Heymann, 2008).
Anthrax is essentially non-contagious, so quarantine of humans is unnecessary and standard preventive measures when handling the patient such as wearing disposable gloves, changing bedding soiled with lesion fluid, disinfecting clothing, and washing hands regularly would be applicable (Heymann, 2008).

Assumptions

On October 12th, 2009 a group calling themselves “The Movement” contacted members of the local media in Phoenix to tell them that a bioterrorism “bomb” had been released at the Arizona Cardinals stadium in Glendale during a football game on October 11th, which had several thousand fans in attendance. The group claimed that it had released  anthrax (a category A agent) in an aerosolized manner, though this has yet to be confirmed.

Of great concern to the county and state health departments is the high number of citizens in Phoenix that might be affected due to the amount of residents potentially exposed at the football game. Shortly after receiving the call from The Movement, physicians at hospitals in Phoenix began reporting patients that were beginning to show early symptoms of what might be inhalation anthrax. The disease progression is expected to have a normalized progression and those patients reporting to local hospitals are being tested for inhalation anthrax and will receive “after-the-event” vaccinations and antibiotic therapy as well as decontamination if the tests are positive. The local and state health departments are currently working with the media to release a message to those in attendance at the game to report immediately to an ER room at a hospital to get tested for possible inhalation anthrax exposure.

References:

Cieslak et al., T.J. & Eitzen, E.M. (1999). Clinical and Epidemiologic Principles of Anthrax.  Emerging Infectious Diseases, 5(4), 552-555.

Heymann, D.L. (2008). Control of Communicable Diseases Manual (19th ed.). Baltimore: United Book Press.

Miller et al., J., Engelberg, S., and Broad, W. (2001). Germs: Biological Weapons and America’s Secret War. New York: Simon & Schuster.

Moore, P. (2001). Killer Germs: Rogue Diseases of the Twenty-First Century. London: Carlton Books.

Null, G. (2003). Germs, Biological Warfare, Vaccinations: What You Need to Know. New York: Seven Stories Press.