In Philadelphia 30 Years Ago, an Eruption of Illness and Fear

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In Philadelphia 30 Years Ago, an Eruption of Illness and Fear

by LAWRENCE K. ALTMAN, The New York Times

August 1, 2006

The Doctor's World

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In late July 1976, American Legionnaires returning from a state

convention in Philadelphia began to fall ill with mysterious

symptoms: pneumonia and fevers topping 107 degrees.

By early August, news organizations across the country were

reporting that 6 to 14 of the men in Pennsylvania had died. Others

were in hospitals fighting for their lives. No laboratory tests

could determine the cause of their illness, which quickly became

known as Legionnaires' disease. No one knew the health status of the

10,000 other convention participants.

As the news began to break, 30 years ago this week, Americans were

primed for the threat of an epidemic. The Ford administration was

making plans to vaccinate every American against a new strain of

influenza, known as swine flu, after repeated warnings from

government officials that a devastating epidemic could strike

without warning. Crichton's " Andromeda Strain " had become a

best seller. And some scientists were calling for a moratorium on

laboratory efforts to genetically engineer microbes for fear they

might create a monster germ.

These factors made the unexpected attack on American veterans, which

occurred shortly after the country's bicentennial celebration, front-

page news.

When I first heard about the mysterious cases from news agency

bulletins on Aug. 2, I initially viewed them with some skepticism. A

few months earlier, Dr. Leonard Bachman, the Pennsylvania health

secretary, issued a news release saying that a staff member, Dr.

Buford S. Washington, had discovered an often fatal new disease,

pantosomatitis, that was spreading throughout the eastern United

States. Looking into the claim, I found there was no documented case

and no such disease.

Disease outbreaks were familiar territory for me. Before coming to

The New York Times, I'd been an Epidemic Intelligence Service

officer at the Communicable Disease Center, now the Centers for

Disease Control and Prevention, in Atlanta. If the Legionnaires'

outbreak had occurred a decade sooner, I might have been one of the

investigators sent to Pennsylvania.

Health officials there urged the public not to panic, and some

initially denied that the cluster of cases was an outbreak of an

infectious disease. But behind the scenes, the same officials were

bracing themselves for a medical catastrophe.

" We thought we might be faced with an unprecedented condition in

modern medicine, one for which we had no really effective

antibiotics, drugs or therapy, " Dr. Bachman told me in 1976. Because

there was no way to predict how many more Legionnaires would fall

ill, Dr. Bachman said he had contemplated seizing control of all

hospitals in the state and imposing quarantines.

It took six months to determine that the illness had been caused by

a bacterium, Legionella pneumophilia, which we now know usually

succumbs to the timely prescription of proper antibiotics. The

bacterium, which in this case was apparently spread from the hotel's

air-conditioning system, is a cause of pneumonia and other illnesses

worldwide.

The investigation that solved the mystery took an array of

surprising twists and turns. It revealed the strengths and

weaknesses of the nation's health system in response to an outbreak

from an unknown agent.

Some lessons learned from the outbreak improved investigations of

later outbreaks like avian flu, SARS and the deliberate release of

anthrax spores in the postal system shortly after the Sept. 11

attacks. But many authorities have not learned other important

lessons, like the need for more effective communication.

Intense news coverage of the Legionnaires' outbreak continued for

weeks, providing one of the rare opportunities for the public to see

how medical detectives work and how scientists make discoveries.

The epic challenged the widespread notion that medicine was all-

knowing, able to lick almost any problem, and that antibiotics and

vaccines had turned once lethal infectious diseases into minor

threats.

The news coverage also marked a turning point in journalism's

efforts to hold officials accountable for their response to

epidemics that can threaten the lives of thousands of people, as

well as tourism, international trade and world economies. News about

the outbreak led to the temporary closing of the Bellevue-Stratford

Hotel, a Philadelphia landmark that was the headquarters of the

American Legion convention and a focus of suspicion about the spread

of the bacterium.

The C.D.C. sent 20 epidemiologists — the largest squad of medical

detectives to investigate an outbreak in the federal agency's

history — to Pennsylvania where they joined scores of state health

workers.

The sleuths fanned across the state to review the medical records of

all the ill Legionnaires and to study the autopsy findings in the

fatal cases. Epidemiologists also checked every hospital to identify

new cases and interview patients' families and doctors, in part to

determine whether one or more Legionnaires might have taken the

illness to Philadelphia.

On Aug. 2, when news agencies began issuing dispatches, a quick look

convinced me that the Legionnaires' cases were real, not another

false alarm. Late that evening, I finished my first article about

the still-unnamed mysterious disease.

Then I drove to burg, listening to the radio to keep me awake

but unable to escape the repetitious news accounts about the

outbreak, the speculation that the illness was swine flu and the

safety concerns about visiting Philadelphia.

The Times handled the story more cautiously than radio and

television. My article, on Page 12, was not even included in the

news summary.

Over the next few days, the toll of the illness rose. The final

count was 221 cases, including 34 deaths.

As a physician, I wanted to see the patients who were recovering or

fighting to stay alive and to learn what leads were being developed

from the interviews.

In Chambersburg, Pa., I joined Dr. B. Thacker, then a rookie

in the C.D.C. epidemiology program. We interviewed a Legionnaire,

A. Payne, 48, whose temperature rose to 107.4 degrees before

he was put in a cooling blanket.

We felt safe entering his room because we followed standard

precautions, wearing yellow masks, white gowns and gloves. In

introducing us, Dr. Thacker told Mr. Payne that he " was part of the

medical team investigating this weird disease. "

Dr. Thacker, who later became the head of the epidemiology program,

asked Mr. Payne a number of questions related to the onset of his

illness, how he had felt since, where he had stayed in Philadelphia

and what convention events he had attended. Then Dr. Thacker sent

the information to colleagues in burg.

Two weeks later, I interviewed another hospital patient who had

driven with four Legionnaires from their home in Saltillo, Pa., to

Philadelphia where they had stayed at the same hotel and were

together for nearly all the convention events. But no one could

figure out why only that patient had developed the disease.

The anecdote illustrates the kinds of dead ends that

epidemiologists, like criminal detectives, encounter and that

scientific journals rarely publish. They and other factors create a

false impression that investigations and discoveries are simpler

than they really are.

A week into the investigation, health officials were relieved as a

second outbreak failed to develop among those attending an

international religious meeting in Philadelphia and no spread of the

ailment occurred from Legionnaires' patients to their families and

friends.

Tests also excluded all forms of influenza as a cause of the

outbreak. " All of us can breathe a sigh of relief it was not the

flu, " said Dr. J. Sencer, then the C.D.C. director.

If not influenza, what was the illness? Earlier tests had ruled out

poisoning from 17 metals. But experts in a variety of specialties

who were not connected with the outbreak had called or written to me

and health officials to suggest a number of toxins.

Stumped, health officials re-examined the possibility of other

toxins or poison gases. One poison, nickel carbonyl, was a long shot

that health officials took seriously, only to be embarrassed by

flaws in the collection of the tissues for testing. The initial

nickel findings were ruled invalid because of probable contamination

from the use of metal instruments in autopsies. Pathologists were

then ordered to use plastic knives.

Reports of the lapses in investigation technique jarred public

confidence about the ability of health departments to detect

outbreaks from hazardous chemicals. The flaws also led to a

Congressional hearing in the fall on the medical investigation,

causing federal and state health officials further embarrassment.

By winter, many of the authorities said the outbreak's cause was

definitely not a bacterium and that it would never be known. But the

doubters overlooked the importance that human factors like

compulsiveness, embarrassment and public pressure can play in

solving scientific riddles and making discoveries.

At Christmastime in 1976, Dr. ph McDade, a C.D.C. laboratory

scientist who had tested specimens from the outbreak, was harshly

criticized at a party for his agency's failure to solve the mystery.

Dr. McDade said his usual custom at that time of year was to " tidy

up loose ends, " so when he went to his laboratory " to put to rest

some hunches about something " he had seen in the specimens, the

insult lurked in the background.

Within a month, Dr. McDade had identified the culprit and showed

that Legionnaires' was a newly recognized old disease. The bacterium

had been isolated at least twice before by different groups of

researchers at the Walter Army Institute of Research in

Washington starting in 1947. Each group believed it was dealing with

a bacterium that affected animals, not humans.

Dr. McDade's discovery quickly led scientists to document a number

of earlier outbreaks in Pontiac, Mich.; Washington; and elsewhere.

Legionnaires' disease now accounts for an estimated 18,000 hospital

admissions in this country each year, and C.D.C. scientists have

said that doctors miss the diagnosis in many more patients. Most

outbreaks and cases have been traced to contaminated water in places

like shower heads, air-conditioning systems and medical respiratory

devices. The largest outbreak, in Spain in 2001, affected nearly 700

people.

The Legionnaire bacterium can produce two forms of illness that

begin with flulike symptoms. One, Legionnaires' disease, goes on to

produce pneumonia and systemic illness. The other, Pontiac fever,

produces only a mild illness. Why the same bacterium causes two

distinct illness patterns is not known.

Seamless teamwork between epidemiologists and laboratory scientists

can be a potent weapon in solving disease outbreaks caused by known

and unknown agents. But the teamwork in the Pennsylvania outbreak

was porous, as lapses in investigation technique showed.

From the start, the investigation encountered a number of problems,

some beyond their control. One was that the American Legion had no

registration list of conventioneers, leaving no easy way to contact

attendees to check on their health.

In investigating outbreaks, epidemiologists often develop

questionnaires, in part to make statistical comparisons between

those who become ill and those who do not.

Another aim is to determine the priority in performing laboratory

tests to determine the cause of an illness. But the longer the delay

in starting this medical sleuthing, the fuzzier people's recall of

events becomes. A problem was that health officials could have

learned of the outbreak earlier than they did. For example, a

physician in Pennsylvania called health officials on July 30, a

Friday afternoon, to report a Legionnaire with possible typhoid

fever. It was too late in the day, call back on Monday, a nurse said.

The episode illustrated that many health departments did not provide

the type of 24/7 coverage for calls and emergencies that hospitals

and doctors did. Now more health departments provide such coverage.

Still another problem was that Philadelphia health officials learned

belatedly about an earlier outbreak of 19 cases of an illness

similar to Legionnaires' disease, including three deaths. It

affected members of the Independent Order of Odd Fellows in 1974

after they had visited the Bellevue-Stratford. The cluster was not

reported until after news of the Legionnaires' outbreak in 1976.

However, there were widespread complaints about a number of issues

over which health officials had some control. One was the lack of

coordination between investigators from federal, state and local

health departments and determining which was in charge.

Doctors who cooperated in providing information and specimens from

Legionnaires' patients said they had received little feedback from

health officials. For example, some doctors said antibiotics were

effective in their patients and urged wider use of them in the

outbreak. But health officials gave no advice, largely because they

could not scientifically evaluate the effectiveness of the

antibiotics among the patients quickly enough.

The issue of providing such evaluations of therapy during an

outbreak remains an important problem; many doctors and others

lodged the same complaint against the C.D.C. in the anthrax outbreak

in 2001. Some critics said they learned more about the outbreak from

news organizations than from the agency.

In the case of Legionnaires', persistent pressure from the news

media, a number of health officials said later, helped hold them

accountable and to spur scientists to do what they rarely had done

in other unsolved cases and outbreaks — taking a crucial second look

that solved the Legionnaires' outbreak.

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