Spotlight falls on anthrax case

A case of inhalation anthrax discovered in a small Connecticut hospital in November gave Ramin Ahmadi, M.D., M.P.H. ’97, the scare of his life—and he was 7,000 miles away.

Ahmadi, program director for internal medicine at the 160-bed Griffin Hospital in Derby, Conn., was spending a lonely evening in the small city of Maizuro, Japan, where he’d just arrived to teach a course on health and human rights at the local hospital. Ahmadi had settled down on the sofa with a book and an Asahi beer. He was half watching the news in Japanese when Patrick Charmel, M.P.H. ’83, his boss from back home, appeared on the screen. “I wondered,” said Ahmadi, “if I was having visual hallucinations.”

Charmel, the president and CEO of Griffin Hospital, was on every channel. Searching for a program in English, Ahmadi switched to CNN and soon had an explanation: a 94-year-old woman from the rural town of Oxford, Conn., had been diagnosed with anthrax. She was a patient at the community hospital where Ahmadi worked.

Back in Derby, Charmel and Kenneth J. Dobuler, M.D. ’76, HS ’79, chair of medicine at Griffin, were caught in what Dobuler described as a media maelstrom. The calls from journalists began minutes after word got out on Tuesday, November 20, that a patient at Griffin had inhalation anthrax, and attention intensified when she died the next day. Television satellite trucks encircled the hospital.

When Ottilie Lundgren had arrived at the hospital the Friday before, she seemed to have a mild illness and was admitted largely because she lived alone. Her case looked more complicated by the next morning, a Saturday, when four blood cultures were found to contain sporulating gram-positive bacteria. When Lydia Barakat, M.D., FW ’00, heard about the lab results that morning, she drove to the hospital to have a look. Barakat, who had trained at Yale in infectious diseases the year before, recalls telling the laboratory technician: “This looks exactly like anthrax, but what are the odds?” She didn’t think it was a likely diagnosis for an elderly woman living in a rural town in Connecticut.

She did take the possibility seriously enough to ask Lundgren if she’d opened any powdery mail; Lundgren remembered none. Barakat prescribed three antibiotics, including Cipro. By Monday, with more test results in, Barakat felt pretty sure she was seeing anthrax. Lundgren was getting sicker. Still, the treatment had begun early. “I had hope,” Barakat said.

When State Epidemiologist James L. Hadler, M.D., M.P.H. ’82, heard about the case that Monday morning, he was incorrectly told that only one blood culture had come back positive for the bacillus. “I was a little bit skeptical,” said Hadler, an assistant clinical professor of epidemiology and public health at Yale. He suspected the positive culture might have resulted from contamination on Lundgren’s skin when the blood was drawn.

Since early October, when letters containing anthrax were sent to prominent politicians and journalists, the state health department lab had been working seven days a week on “powder incidents.” “We were already in full anthrax mode without having had a single case of anthrax,” said Hadler. “Since early October, my job had been 100 percent anthrax.” Suspicious substances had included nondairy creamer and powdered sugar.

Despite his skepticism, Hadler arranged for immediate transportation of the organism to the state laboratory, which was able to do confirmatory tests not done in hospitals (a phage test and a direct fluorescence antibody test). By Tuesday morning it seemed clear that Lundgren had anthrax. Hadler called the state health commissioner, the FBI and the Centers for Disease Control and Prevention (CDC). In the next 24 hours the CDC sent a dozen advisors to Hartford, since no one knew if Lundgren would prove to be a lone victim or the first of many.

The CDC wanted to get final confirmation, based on a polymerase chain reaction test. When Hadler tried to send Lundgren’s blood on the next flight from Connecticut to Atlanta, the airline balked. Hadler says there’s no way to get anthrax from bacillus in blood, even if it spills, but the CDC had to send its own plane. Meanwhile, staff from the FBI, the state police and the state Department of Environmental Protection drove to Oxford and cordoned off Lundgren’s house.

Back at Griffin Hospital, Charmel knew he needed to talk to Griffin employees before the story became public. More than 300 of the 1,100 hospital staff members attended a meeting that afternoon. Charmel told them about the case, urged them not to tell anyone the patient’s name if they knew it and reassured them that anthrax could not be spread from one person to another.

At about the same time, word of the case reached the media: Gov. John G. Rowland had announced a 5 p.m. press conference on a Connecticut anthrax case, and “about two minutes after that went out on the [news] wire,” Charmel said, “the phone began to ring off the hook.” He had a plan for responding. “The conventional wisdom is to pick a single hospital spokesman,” said Charmel. “My gut told me that wasn’t right in this situation.” The press, he said, “wanted to talk to clinicians. The public needed to see and hear from credible experts, to be reassured that everything possible was being done for the patient and that they were getting accurate information.” The panel that answered reporters’ questions included Charmel, Dobuler, Barakat and Stephanie Wain, M.D., FW ’89, chair of pathology and laboratory medicine at Griffin. (Ironically, Dobuler is a rarity among American physicians in having seen anthrax outside a textbook. As a Yale medical student, he spent three months studying infectious disease in Iran, where cutaneous anthrax is common among shepherds. Seeing anthrax then was interesting, he said, “but clearly irrelevant to my future.”)

Charmel’s media panel held news conferences and answered reporters’ questions nonstop until 1 a.m. A Washington Post reporter even managed to get Dobuler’s pager number. On the whole, Dobuler said, “the press did a remarkably credible job given the frenzy.” Although the hospital refused to name the patient, it didn’t take long for reporters driving around Oxford to locate a house surrounded by yellow tape and monitored by people in white suits.

Lundgren died Wednesday morning—“a very sweet lady who was beloved by her family … murdered,” said Dobuler. She was the fifth American since early October to be killed by anthrax. Although investigators never found anthrax spores in her house, Hadler said investigators are now “pretty sure” that Lundgren was exposed to contaminated mail. Spores were later found on four mail-sorting machines in the Wallingford, Conn., distribution center, including the bin that contained mail for Lundgren’s route.

Hadler says the case seems to disprove animal studies suggesting that thousands of spores are needed to cause an infection. “In theory,” he said, “one spore, in the right place at the right time, can do it. She seems to have had a low-dose exposure.”

The day that Lundgren died, Ahmadi returned to teaching his course at the Japanese hospital to find himself an object of interest. Physicians, residents, interns—even the cleaning woman—had seen his supervisor on television and were asking about Griffin Hospital by name.

Traveling halfway around the world, said Ahmadi, “you think you are getting away from New Haven and Griffin and Yale and your usual surroundings. You think you are somewhere very far away. Then you are reminded that you’re part of a little global village. It’s kind of unsettling.”