Introduction

On October 2, 2001 a sixty-three-year-old Florida man who worked as a photo editor at a media publishing company was admitted to an emergency department complaining of nausea, vomiting, and fever. His symptoms began four days earlier on a recreational trip to North Carolina. The man died shortly thereafter. An astute clinician quickly made the surprising diagnosis of inhalational anthrax, which is a serious and deadly disease. The diagnosis was surprising because inhalational anthrax is extremely rare; only 18 cases were reported in the United States between 1900 and 1978. Public health officials at first believed that the Florida case was an isolated, rare event that might have gone unnoticed except for the heightened state of public health vigilance and alert following the catastrophic events of September 11, 2001. However, when a second case occurred in a seventy-three-year-old man who worked at the same Florida media publishing company and delivered mail to the first man, the coincidence seemed remarkable. Employees of the media publishing company reported seeing a suspicious letter on or about September 19, 2001, although that letter was never found. Public health officials theorized that a letter contaminated with deadly finely milled anthrax spores was the source of the disease. Thus began the 2001 anthrax outbreak in the United States caused by the intentional release of anthrax spores, an act of bioterrorism.