With the opening of a letter in the office of US Senator Tom Daschle on October 15, the stage was set for one of the most alarming and potentially dangerous public health crises in the nation's Capitola crisis that would force Kaiser Permanente's Mid-Atlantic States (KPMA) Region onto the medical forefront of a new era of bioterrorism.

Prior to October 2001, no case of inhalational anthrax had been seen in the United States in more than 25 years, and only 18 cases had been treated in the entire 20th century.^a So when the threat of mass bioterrorism became all too real in the aftermath of the events of September 11, infectious disease clinicians all over the country scrambled to review what was known about a disease that virtually no one had seen.

Fortunately, the seven infectious disease physicians and
the rest of the staff of the Permanente Medical Group of KP's Mid-Atlantic Region had a head start. The region already had a detailed Bioterrorism Readiness Plan in place, thanks to the painstaking preparations for the much-feared Y2K "bug" of 18 months earlier. They also had a Disaster Planning Task Force up and ready to lead and coordinate responses and had well-tested plans for an Emergency Operations Center (EOC), should the need arise. Immediately, they set about updating the existing bioterrorism clinical practice guidelines and researching all potential infectious agents in addition to anthrax.

The need arose suddenly and dramatically on the weekend of October 20-21. The Washington area was already in a panic due to the confirmed release of anthrax spores from the Daschle letter, an event which precipitated the closing and testing of most Congressional offices and epidemiological screening of thousands of Capitol Hill staffers. But while scores of Capitol Hill people tested positive for exposure to anthrax and were put on antibiotics, until Sunday, October 21, no one in the Washington area had actually been confirmed by blood cultures to have inhalational anthrax infection. Now, suddenly, three cases of inhalational anthrax infection, including one fatality, were confirmed by the Centers for Disease Control and Prevention (CDC)all KP members. All three were also employees associated with the US Postal Service's big central processing and distribution facility on the District's Brentwood Road, NE. By Monday, a fourth Brentwood worker, not a KP member, also died of inhalational anthrax.

The next 10-12 days was an extraordinary time for the physicians and staff of KPMA. The crisis tested the region's clinical expertise, its ability to coordinate, integrate, distribute, and utilize massive amounts of constantly changing information, its capacity to respond to soaring demands for access and advice, and its ability to communicate and cooperate with a patchwork of community hospitals, other health care organizations, local and state public health authorities, public safety authorities, and the CDC. Recognizing that there were limits to what the region's own physicians could handle, Regional Medical Director Adrian Long, MD, put out a call for volunteer physicians from other KP Regions. The response was immediate: two Infectious Disease docs and 12 Internal Medicine docs were on site within days to help cover routine appointments, to provide support to advice nurses and do telephone consults from the EOC.

By the time the immediate crisis abated in early November, a total of 40 members had been admitted to hospitals to rule out anthrax. Only three of thosethe original three, including the member who diedwere confirmed to have inhalational anthrax infections. But the actual level of anthrax-related patient activity may be better reflected by the nearly 1000 entries made in PACE (the region's electronic medical record) under the "HAZMAT" notation that was added a few days after the crisis broke.

KPMAS's extraordinary handling of the crisis has been widely reported, and applauded, in both professional journals (including a JAMA article, dated November 28, 2001, mostly authored by MAPMG physicians) and the mass media, including NPR, all the major national dailies, and several TV news/talk shows.

The article on page 57 (Capitol Hill Hearing Testimony...) provides a close-up look at the crisis from the perspective of the infectious disease physician, Dr Susan Bersoff-Matcha, who treated the two surviving members. It is based on testimony she delivered to the House Committee on Veterans Affairs on November 14, 2001.

Complementing Dr Bersoff-Matcha's testimony, a brief companion article by Steven Black, MD, Co-Director of Kaiser Permanente's Vaccine Study Center in Oakland, California, provides an expert point of view on the question of whether Americans should be mass-immunized for smallpox in anticipation of another bioterrorist crisis.

Dr Lee Jacobs, a Permanente Journal editor and infectious disease physician, who did volunteer service in the Mid-Atlantic Region during the crisis, gives an additional perspective on the KPMA response to this challenge and how KP was uniquely capable of meeting this challenge.

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