New York City's first case of inhalation anthrax last week killed a female hospital worker, shut down 30-bed Manhattan Eye, Ear and Throat Hospital and further challenged the nation's already taxed public health system.
Setting aside concerns that they might be a terrorist target, New York hospitals stepped up their state of alert and focused even more intently on distinguishing early symptoms of the deadly disease from the everyday aches and pains of a terrified public. And, as in the days immediately following the attack on the World Trade Center, hospital officials hadn't begun to assess the economic or emotional toll on their own operations.
"We need to be very cognizant (of the dangers), but we were before," said Susan Waltman, senior vice president and general counsel at the Greater New York Hospital Association. "Every case adds a level of knowledge that improves our ability to understand."
Kathy Nguyen, 61, a supply room worker at Manhattan Eye, Ear and Throat Hospital-known locally as MEETH-died from anthrax last week in Lenox Hill Hospital, three days after she was admitted. She was already much too ill to help criminal and health investigators determine the source of her infection.
The city's medical examiner ruled her death a homicide, but by week's end that was about the only thing officials could say with any certainty. Nguyen worked in the basement supply room at the low-profile, primarily outpatient facility on the wealthy Upper East Side. Her case bewildered criminal and medical investigators searching for evidence that might link it to the random scattering of anthrax outbreaks in New York, New Jersey, the District of Columbia and Florida. Until she fell victim, the investigation was focused on media and government offices and the U.S. Postal Service.
Now, all bets are off.
By all accounts, Nguyen was a gentle Vietnamese immigrant who led a solitary life. Although the supply room where she worked is near the mailroom, health officials came up empty when they scoured that room and the rest of the hospital for traces of the bacteria. Tests of her Bronx apartment and her clothes similarly came back negative, despite earlier indications to the contrary. Also, tests of a co-worker with a skin lesion that had been thought to be the less-serious cutaneous anthrax came back negative late last week.
Erring on the side of caution, city health officials distributed antibiotics to more than 1,100 people, including more than 300 workers and patients who spent at least an hour in the hospital since Oct. 11. Nasal swabs were given to 28 employees who worked in the basement area near Nguyen. They all came back negative for anthrax.
Hospital already was shaky
Despite the negatives in all the testing performed, city Health Commissioner Neal Cohen, M.D., said late last week that it would be at least "a couple of days" before health officials even considered reopening the hospital.
Whether the not-for-profit hospital has the wherewithal to bounce back from the loss of revenue after last week's shutdown remains a question. In 1999 it was a hair's breadth away from closing and selling itself off as real estate when the state attorney general's office weighed in, saying the specialty hospital was too valuable a public health asset to lose. That year the hospital lost $16.8 million on $27 million in revenue, the most recent financial data available from its Internal Revenue Service filings. The following year 652-bed Lenox Hill, also on the Upper East Side, acquired it.
In 2000 MEETH discharged 1,458 inpatients and 7,385 outpatients, according to filings with the state health department. Through July of this year, it discharged 798 inpatients and 6,313 outpatients.
Lenox Hill officials did not respond to requests for comment.
"We are all hopeful that the source is quickly identified because it is unsettling for everyone," Waltman said. "(Based on the negative tests) the hospitals might believe they are not a target, but on the other hand, it begs the question: Where did this occur?"
Although the latest case hit one of its own, New York hospitals took the scare in stride, a measure of how much they have been through since Sept. 11. The city's health department continued to pump out regular alerts apprising clinicians of guidelines as they developed. Doctors were advised that there were some occupational risks associated with the disease and to give more thorough work-ups to those patients. Earlier in the month, New York Mayor Rudolph Giuliani advised people to get flu shots to minimize confusion because symptoms of the viral infection have similarities to the early onset of pulmonary anthrax.
"In a situation like this, anyone who said they weren't concerned would not be truthful," said Myrna Manners, a spokeswoman for 2,112-bed New York-Presbyterian Hospital. The closest hospital neighbor to both Lenox Hill and MEETH, New York-Presbyterian provided some anthrax screening for MEETH patients in the first hours after the newest case was announced. Manners said that at least one pattern is developing: With each new confirmed case, the number of people visiting or calling emergency rooms increases. Then it dies down until the next scare.
"It's a new situation that none of us have ever faced before, but we have an excellent healthcare system here in New York City. We're all working together to do the best we can," she said.
Labor gets involved
At week's end, Local 1199 of the Service Employees International Union, the state's politically powerful healthcare union-which counted Nguyen as a member-briefed some 3,000 delegates representing its 220,000 members on anthrax and bioterrorism. The event was meant to allay fears and give frontline healthcare workers a chance to ask questions of public health officials and infectious disease experts.
The healthcare union has taken a leadership role in the wake of the Sept. 11 terrorist attack, which has economically devastated several New York hospitals. With the union's three-year contract with New York hospitals set to expire Oct. 31, Local 1199 President Dennis Rivera volunteered to extend the existing contract until March 31, 2002.
The friendly relations between hospitals and the union also were reflected in the fact that the GNYHA helped to coordinate the briefing, which was attended by several state officials, including New York Gov. George Pataki.
"Your courage in the face of the death of Kathy Nguyen is something that inspires all of us," Pataki told the workers.
Delegates attending the briefing at the massive Jacob Javits Center left with a binder of information about anthrax and bioterrorism. The union set up three Web sites with even more facts.
Rivera said after the briefing that the delegates would form teams with hospital managers "to deal with this awful reality. Mind you, we had a member of our family die."
New Jersey turmoil
The situation last week in New Jersey was difficult as well. Health officials confirmed the first case of cutaneous anthrax in a woman whose occupation was not directly linked to the Trenton-area mail-delivery system, where several anthrax-laced letters apparently originated. By week's end state health officials were tracking two cases of pulmonary anthrax and five cases of the skin version. Two of the cases involved postal workers who lived in Pennsylvania and Delaware, expanding state surveillance to hospitals in those states. There were no deaths attributed to anthrax in New Jersey or those states.
The crippling of the central New Jersey mail-delivery system threw a wrench into operations at the Princeton-based New Jersey Hospital Association. With the local post office closed last week, the NJHA was communicating with hospitals primarily by fax and e-mail.
"From an association perspective, we're somewhat handcuffed," said Ron Czajkowski, a spokesman for the NJHA. At midweek, NJHA workers were to be found licking the stamps for hundreds of credit-union checks and then driving those checks to an out-of-area post office.
The association also was reaching out to members to help coordinate anthrax surveillance testing conducted by the state health department. Getting an accurate assessment of what hospitals are doing is frustratingly difficult, Czajkowski said.
The crisis prompted the trade association to convene its first bioterrorism task force late last week. As many as 60 hospital representatives attended the meeting.
"The sense is that the public is certainly nervous and rightly so, but at the same time we really need to have a clear understanding of the facts and the role hospitals need to play," said Sean Hopkins, the NJHA's senior vice president of health economics. "I think the mood was an extremely focused interest in learning as much as we can. We are trying to be more prepared tomorrow than we were today, which obviously was more prepared than we were yesterday."
With the help of a team of 17 from the federal Centers for Disease Control and Prevention, state health officials implemented a surveillance plan that took investigators outside the laboratory in search of new cases, said Marilyn Riley, a spokeswoman for the Department of Health and Senior Services. Health officials maintained daily contact with 26 hospitals in central New Jersey and with a select few, but expanding number of, hospitals in Pennsylvania and Delaware. The sentinel hospitals provided daily reviews of people admitted to intensive-care units and visiting emergency rooms, as well as results of microbiology laboratory tests, she said.
Anthrax testing on rise
Hospitals outside the anthrax hot spots also were feeling the impact of the scare. Shore Health System on Maryland's bucolic eastern coast, some 70 miles from Washington and Baltimore, saw a spike in people coming into the ER asking for anthrax tests, said Patti Willis, a spokeswoman for the two-hospital system, based in Easton, Md. Following CDC recommendations, ER staff were forgoing nasal swabs in favor of blood or wound cultures to detect the bacteria. The hospital has performed about two dozen such tests. All have come back negative, she said.
"Before the story broke, we never had anybody ask about anthrax," Willis said. "The new speculation about the routes of transmission and cross contamination is raising the level of anxiety here as well as elsewhere."
In light of the newest cases, Willis said healthcare workers are advising, "Don't hesitate to come in because you feel silly" about being cautious.
Willis said the system has implemented elements of its disaster plan, although it had not gone as far as setting up a command center. The bioterrorism task force is meeting at least once a week to discuss the news and adjust procedures when necessary. The system also inspected its supply of decontamination suits for frontline healthcare workers-if it ever comes to that-and bolstered its stock of emergency supplies, she said. There's been an economic impact even for a small healthcare system like Shore Health, she added.
"We haven't captured it yet, but just in terms of (staff) time, it's staggering," Willis said.
While Americans in the heartland may be concerned about further terrorist attacks, the healthcare systems in cities like Dallas were far less preoccupied with the anthrax scare than East Coast hospitals.
"It's really been to some extent a blip on the radar screen in terms of medical resources," said Paul Pepe, M.D., chairman of emergency medicine at 708-bed Parkland Health and Hospital System, a public hospital in Dallas. Granted, the city's hazardous materials team, which typically makes 100 calls per year, has made 75 in the past couple of weeks, but emergency resources have barely been tapped, he said.
Pointing to a biohazard sentinel event system that was set up in the city more than five years ago, Pepe said he feels secure that Dallas is prepared for such emergencies. "We've considered anthrax a threat for the last five to 10 years," he said.