Connecticut-based EIS Officer Hot on the Trail of Anthrax

Dr. Kevin Griffith, a CDC Epidemic Intelligence Service (EIS) officer on assignment at the Connecticut Department of Public Health, never thought he would be adding bioterrorism surveillance and anthrax detective work to his pubic health skill sets.

Griffith, a 33-year-old MD with an interest in environmental issues, had already built up an impressive record of medical service to underserved populations before coming to CDC. During medical school and residency, he volunteered as a doctor on the Navajo and Apache reservations in New Mexico and served on medical missions to Ecuador and Guatemala.

After the September 11 terrorism attacks, Griffith answered CDC's call for volunteers to travel to New York in the largest EIS deployment ever.

"I had never been to New York City before. Coming into the city, seeing the smoke hovering over Manhattan, was a surreal experience," Griffith said. "As we got closer to the public health operations center, all the streets were blocked off from traffic and police were on every corner."

He spent the next three weeks monitoring for symptoms of bioterorrism in the emergency room of Brooklyn's Lutheran Medical Center. One day after his 12-hour shift, Griffith took a one-hour train to Manhattan to deliver his surveillance data to the public health operations center. It was the Monday after the attacks, the first day many commuters returned to work in Manhattan.

"It was about 8 a.m. and I was coming back from Brooklyn. While making a transfer, I came around the corner inside the subway station and saw a mass of people coming toward me. I remember they were being led by a police officer who was carrying a young girl who had been knocked over. There had been a bomb threat," recalled Griffith, whose communication skills as a family doctor helped him to calm some of the people he encountered.

"People were very panicked – they couldn't deal with the added stress. It's an example of how far the population had been pushed," he said.

Griffith's New York assignment was completed on September 29 and, after a quick CDC debriefing in Atlanta, he returned to Hartford. Three days later, the first anthrax case was reported in Florida. Connecticut and other state health departments across the country were immediately bombarded with public inquiries about anthrax.

"We fielded hundreds of calls in the first couple of days. Being a physician, I was asked to respond to physician calls," Griffith said. "Doctors were inundated with people wanting nasal swabs and they wanted advice on how to screen people correctly."

When inhalational anthrax was confirmed in a 94-year-old woman from Oxford, Connecticut on November 19, Griffith was the first public health official deployed to the hospital. He spoke to her physician and reviewed her medical chart, but was unable to interview the woman since she was already in intensive care. Instead, Griffith and a local FBI agent questioned the woman's niece and other close contacts. The woman died on November 21.

"We were trying to reconstruct the last 60 days of her life before she developed the illness. We categorized her exposures by whether they were mail or non-mail related. We looked for ways she could have been exposed to anthrax, but we couldn't find any evidence that she received any of those letters. So, our investigation switched from looking for a direct source to a cross-contaminated source," Griffith said.

Unlike the anthrax case in New York that involved a Bronx woman who worked at a hospital and traveled by subway, the Connecticut woman spent most of her time at home.

The Connecticut Department of Public Health led the investigation with support from EIS and other CDC staff – forming teams to focus on environmental sampling, epidemiologic investigation, surveillance, post-exposure prophylaxis and clinical case follow up. More than 24 CDC and 30 Connecticut DPH people took part in the investigation.

Team members quickly became experts on U.S. Postal Service operations and processes. They found traces of anthrax contamination at the regional postal facility that processed the woman's mail. Though four machines were contaminated with anthrax, there was not evidence of the widespread contamination that had been seen in facilities in New Jersey and Washington, D.C.

Griffith supported the mail investigation by calling bulk-mailing organizations that sent mail through New Jersey to Connecticut from October 9 to 17 to look for evidence of cross-contaminated bulk mail sent to the woman's home or zip code.

"In collaboration with U.S. Postal Service and the Postal Inspectors, we learned of a letter to a nearby address that had passed through the same machine in New Jersey approximately 20 seconds after the Leahy letter was processed," Griffith recalled, noting that investigators used trace forward analysis that allowed them to know the timing of the letter by the sequential numbering of the letters as they were processed.

Since the team also had initiated widespread surveillance of death certificates, and veterinarian, laboratory and hospital admissions records, they quickly were able to compare data. By coincidence, the address where the contaminated letter was sent was next door to one of the death certificates.

"According to our surveillance records, a person next door to where the letter was sent had been found dead in his home the same week our patient developed anthrax. There were no autopsy records and no family to talk to about the death. We contacted the health commissioner, governor and FBI and decided to go to the home where the letter was received while the medical examiner performed an autopsy that night," said Griffith, who was part of the team that made the midnight trip to the residence.

After waking the recipients of the letter, the team swabbed mailboxes and returned the following day for the letter, which tested positive for anthrax.

"Fortunately, the people were not infected and the autopsy turned up negative for anthrax," said Griffith.

In addition, Griffith coordinated post-exposure prophylaxis for the 16 local residents who had contact with the woman and needed antibiotics in case they had also been exposed. He also helped administer questionnaires to postal workers and the 16 local contacts.

While the state has no definitive answer as to how the woman was exposed, evidence suggests it might have been from cross-contaminated mail.

Before September 11, Griffith was investigating a tuberculosis outbreak in a correctional facility and preparing to begin a surveillance project on Lyme disease. He expressed amazement at the breadth of experiences he has had over such a short time period.

He said state epidemiologist Dr. Jim Hadler and the state's Epidemiology Program Coordinator Dr. Matt Cartter (EIS '83), who was Connecticut's first EIS officer, have provided him with a "great training experience" – one that has helped him decide on a career in public health. Griffith plans to combine his interests in public health and the environment. Eventually, he hopes to teach. Whatever challenges lie ahead, he knows the EIS has prepared him well.