Anthrax: A Possible Case History
Thomas V. Inglesby
Johns Hopkins School of Medicine, Baltimore, Maryland, USA

Federal Bureau of Investigation (FBI) offices in five U.S. cities have received warnings of an imminent bioterrorist attack. Each threat indicated that a "shower of anthrax would rain on U.S. cities," unless certain demands were met immediately. One of these calls was in Northeast, a large city on the Eastern Seaboard with a metropolitan population of 2 million. The threats were credible, but no information was relayed to city officials in Northeast or elsewhere.

On the evening of November 1, a professional football game is being played in Northeast's outdoor stadium before an audience of 74,000. The evening sky is overcast, the temperature mild, a breeze blows from west to east. During the first quarter of the game, an unmarked truck drives along an elevated highway a mile upwind of the stadium. As it passes the stadium, the truck releases an aerosol of powdered anthrax over 30 seconds, creating an invisible, odorless anthrax cloud more than a third of a mile in breadth. The wind blows the cloud across the stadium parking lots, into and around the stadium, and onward for miles over the neighboring business and residential districts. After the anthrax release, the truck continues driving and is more than 100 miles away from the city by the time the game is finished. The anthrax release is detected by no one.

Approximately 16,000 of the 74,000 fans are infected by the anthrax cloud; another 4,000 in the business and residential districts downwind of the stadium also are infected. After the game, the fans disperse to their homes in the greater Northeast metropolitan area; some return to homes in neighboring states. A few are from other countries. The driver of the truck and his associates leave the country by plane that night. They will be many time zones away by the time the first symptoms of anthrax appear 2 days later.

Two days after the game, hundreds of people in and around Northeast become ill with fever, cough, and (in some cases) shortness of breath and chest pain. Some of the sick self-administer over-the-counter cold remedies; some seek phone advice from physicians and nurses; others are seen in clinics, doctors' offices, and emergency departments throughout the city.