Anthrax Bioterrorism: Lessons Learned and Future Directions

n September 11, 2001, the United States experienced the worst terrorist attack in its history. As the nation sought to deal with this tragedy, it would face a second wave of terrorism—this time, in the form of a biological attack. The suspicion of anthrax in a patient by an astute infectious disease clinician along with capable clinical and public health laboratory staff in Florida would lead to the discovery that Bacillus anthracis spores had been intentionally distributed through the postal system, causing 22 cases of anthrax, including 5 deaths, and forever changing the realm of public health. In this issue of Emerging Infectious Diseases, numerous individuals involved in the public health aspect of the anthrax investigation document their experiences. Articles describe the epidemiologic and laboratory investigations, applied research findings, environmental assessment and remediation experiences, workplace safety issues, prophylaxis and clinical care information, international aspects, and collaborations between law enforcement and public health officials. The articles also highlight the widespread efforts made to identify the source of exposure and prevent illness among those exposed. While many of the individuals involved in this effort are acknowledged in these articles, many others are not, including the large numbers of medical, public health, law enforcement, and emergency response personnel throughout the country and the world who dealt with the numerous hoaxes perpetrated in the weeks following the attack. We recognize and thank them for their heroic efforts. This issue also provides an opportunity to review the valuable lessons we have learned from these experiences. Foremost among them is the knowledge that we cannot afford to be complacent. Throughout the Department of Health and Human Services (DHHS) as well as across other federal, state, and local agencies, we remain alert for the first evidence of a disease outbreak. Multiple systems are now in place, both in the United States and internationally, to detect initial cases. On the local level, clinicians and laboratorians play a key role in this process. Activities such as monitoring emergency room visits, pharmacy requests, calls to emergency response and poison control centers, and animal disease registries for unusual occurrences are also expanding. These lessons have also led us at the Centers for Disease Control and Prevention (CDC) to change the way we operate. Changes have been made within our programs, among our staff and partners, and in our coordination with other federal agencies. Many of these changes have been based on valuable input provided by public and private sector experts during numerous consultations. Terrorism response capacity is being integrated into existing infrastructures, further strengthening the foundation of public health. The anthrax cases highlighted the importance of the “golden triangle” of response between clinicians and clinical microbiologists, the health-care delivery system, and public health officials. Steps have been taken to strengthen these and other critical linkages, including those between professionals in the human, veterinary, and public health communities and between the public health, law enforcement, and emergency response systems. DHHS has made available through CDC more than $918 million for state and local health departments to enhance their terrorism preparedness programs. These funds are intended to strengthen capacity to respond to bioterrorism, other infectious disease emergencies, and other urgent public health threats. Existing programs that proved invaluable during the events of last fall, such as the Laboratory Response Network for Bioterrorism (LRN) and the National Pharmaceutical Stockpile (NPS), both described in this issue in the article by Perkins et al., have also been strengthened. During the anthrax attacks, laboratories within the LRN tested more than 125,000 clinical specimens and approximately 1 million environmental specimens. The number of these specialty laboratories participating in this network has now increased to more than 100, with at least one in each state, enabling widespread testing for microbes that might be used in a terrorist attack to cause illnesses such as anthrax, tularemia, plague, and botulism. New facilities have been opened, and improvements in others are in progress or planned for the near future. The NPS has also been O