Anthrax Exposure Response Guidelines 

To:        Emergency Department Physicians, Infectious Disease Physicians
From:    James L. Hadler, MD, MPH, State Epidemiologist
Date:     October 15,2001 - with update in 2nd paragraph
Re:        Anthrax Exposure Response Guidelines

Currently, police and health departments are referring individuals concerned about possible anthrax exposure to see a health care provider. The purpose of this communication is to provide guidance to those performing medical evaluation and response in these situations. These guidelines are based on guidance given by the CDC to state health departments, the "Consensus Statement on Anthrax as a Biologic Weapon: Medical and Public Health Management" (JAMA 1999, VoI281:l735-45, http://jama.ama-assn.org/) and on our current experience with anthrax threats. They are based on the principles used by the Epidemiology Program staff when responding to questions from many of you.

• People with "powder" incidents should report them to the local police and FBI (203- 777-6311) as soon as possible. Any true exposure is likely to be the result of criminal activity. Any scenario in which testing of powder and/or prophylaxis of a potentially exposed individual is being considered should be reported to a law enforcement agency. The Department of Public Health Laboratory will only accept specimens of powder or letters or other substances for testing for anthrax when submitted by the CT State Police Office of Emergency Services (1-800-842-0200), the Department of Environmental Protection HAZMAT {Hazardous Materials team {860-424-3338)} or the FBI.
• Specific guidelines for handling suspicious packages or letters and scenes where there is a suspicious powder are given in the CDC Health Alert which is included at the end of this document and can also be found at: http://www.btcdc.gov/DocumentsApp/Anthrax/10122001Handle/10122001Handle.asp

• Much as we do with rabies, it is important to assess the nature of possible exposure to anthrax of any concerned person before deciding on a course of action. Factors that need to be assessed include credibility of the exposure and whether the exposure might result in inhalational anthrax or cutaneous anthrax.

Credibility

The potential that an exposure really is anthrax is higher when:

• There is a distinct threatening message with the powder or substance

• The substance is brown or sandy-brown rather than stark white. Of note, the positive NBC letter is reported to have had brownish sand-Iike material in it.

• If a suspicious letter or package is involved (see the CDC Health Alert for details).

Situations with lower credibility that the exposure is anthrax include scenes in which a white powder is found without a note, where one might expect someone to have spilled sugar, flour, etc.; or a situation in which a white powder comes in an envelope with expected mail that is easy to trace to the sending source.

• lnhalational anthrax generally requires a large dose of invisibly fine powder -particles 1-5 microns in size, a size necessary to get into the alveoli. It is technologically very difficult to get anthrax into a form where it can be inhaled. Reaerosolization of particles on clothing and on surfaces into particles of this size is nearly impossible. Thus, visible settled powders and letters or boxes that are opened and contain powders are usually not serious threats for inhalational anthrax. Thus, the immediate risk to people "exposed" in these situations is small. lnhalational anthrax would be of concern if: a) a person got a face full of fine powder with heavy contamination of eyes, nose and throat; b) there was a real concern of aerosolization based on warning that an air handling system is contaminated or warning that a biological agent was released in a public space.

• Cutaneous anthrax appears to require lower doses and is the most plausible form of anthrax that could be caused by letters and packages that did not have obvious aerosolizing devices -all one needs is spores rubbed into the skin or cuts in the skin. Given its characteristic physical picture and very good prognosis when recognized and treated, potential exposures can readily be managed by observation and treatment as clinically needed.

Risk-based Medical Management of Possible Exposures

Low-credibility exposure situations and situations with possible cutaneous exposure

• If no clear-cut exposure (e.g., patient was in New York, now has cold symptoms and is worried), provide reassurance to the patient about the rarity of infection without known exposures. We do not recommend collecting a nasal swab or blood for a serologic test to try to confirm that there is no evidence of exposure to anthrax.

• If the only potential exposure to a powder/suspicious substance is cutaneous (the usual situation with finding powder on a surface, opening a letter with powder in it), provide advice on what to look for (red spot -> papule -> vesicle -> black center over several days to a week), reassure them that cutaneous anthrax can be readily diagnosed and easily treated. We do not recommend collecting a nasal swab or blood for serology in the absence of a skin lesion. This situation is analogous to the rabies situation of having a provoked bite from an animal that is highly unlikely to have rabies - e.g., squirrel that bites finger.

High-credibility exposure situations

• If situation suggests real potential for inhalational exposure (e.g., got a face and nose full of powder from highly suspicious situation), consider starting preventive therapy until exposure ruled out. (This situation is analogous to starting rabies prevention prior to getting a test result back if there is an animal bite to the face from a plausible source of exposure -where time is of the essence and you don't really have the leeway to wait for test results). A nasal swab might be helpful if the powder was not available for testing.

• If situation suggests real potential for cutaneous exposure (e.g., hand contact with brownish powder or letter in envelope with threatening note), provide reassurance and counseling about the signs and symptoms of cutaneous anthrax and wait to start preventive treatment until culture of powder complete. This is analogous to waiting to start rabies treatment pending testing for plausible rabies exposure - e.g., unprovoked stray cat bite on hand -when you have time to sort the situation out.

• In general, use of nasal swabs to rule anthrax exposure in or out is discouraged. Their use in recent investigations by CDC has been for epidemiologic purposes only - to try to find out who was at highest risk of exposure in situations where there is a known exposure event. The results have been used to guide further investigation and to determine which groups of people (not which individuals) should be given preventive therapy. Their sensitivity and specificity and clinical value are all unknown.

• The one exception to discouraging their use is in the situation where there is a highly credible exposure potential and there is no discrete environmental source to test (e.g., the person who got a "blast" of powder in the face - and the powder was cleaned up before there was any police /FBI involvement and was subsequently irretrievable.

If you have any questions about the medical management of persons concerned about exposure to anthrax, please feel free to contact the Department of Public Health Epidemiology and Emerging Infections Program weekdays (8:30-4:30) at 860-509-7994 or 7995. For assistance on nights and weekends, call the DPH Emergency number 860-509-8000 and ask for the Infectious Disease epidemiologist on call. If our experience with anthrax exposures changes and there is a need to modify this guidance, we will do so.

This is an official

Distributed via Health Alert Network
October 12,2001, 21:00 EDT (9:00 PM EDT)

HOW TO HANDLE ANTHRAX AND OTHER BIOLOGICAL AGENT THREATS

Many facilities in communities around the country have received anthrax threat letters. Most were empty envelopes; some have contained powdery substances. The purpose of these guidelines is to recommend procedures for handling such incidents.

DO NOT PANIC

1. Anthrax organisms can cause infection in the skin, gastrointestinal system, or the lungs. To do, so the organism must be rubbed into abraded skin, swallowed, or inhaled as a fine, aerosolized mist. Disease can be prevented after exposure to the anthrax spores by early treatment with the appropriate antibiotics. Anthrax is not spread from one person to another person.
2. For anthrax to be effective as a covert agent, it must be aerosolized into very small particles. This is difficult to do, and requires a great deal of technical skill and special equipment. If these small particles are inhaled, life-threatening lung infection can occur, but prompt recognition and treatment are effective.

SUSPICIOUS UNOPENED LETTER OR PACKAGE MARKED WITH THREATENING MESSAGE SUCH AS "ANTHRAX":

1. Do not shake or empty the contents of any suspicious envelope or package.
2. PLACE the envelope or package in a plastic bag or some other type of container to prevent leakage of contents.
3. If you do not have any container, then COVER the envelope or package with anything (e.g., clothing, paper, trash can, etc.) and do not remove this cover.
4. Then LEAVE the room and CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away).
5. WASH your hands with soap and water to prevent spreading any powder to your face.
6. What to do next...

• If you are at HOME, then report the incident to local police.
• If you are at WORK, then report the incident to local police, and notify your building security official or an available supervisor.

7. LIST all people who were in the room or area when this suspicious letter or package was recognized. Give this list to both the local public health authorities and law enforcement officials for follow-up investigations and advice.

ENVELOPE WITH POWDER AND POWDER SPILLS OUT ONTO SURFACE:

1. DO NOT try to CLEAN UP the powder. COVER the spilled contents immediately with anything (e.g., clothing, paper, trashcan, etc.) and do not remove this cover!
2. Then LEAVE the room and CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away).
3. WASH your hands with soap and water to prevent spreading any powder to your face.
4. What to do next...

• If you are at HOME, then report the incident to local police.
• If you are at WORK, then report the incident to local police, and notify your building security official or an available supervisor.

5. REMOVE heavily contaminated clothing as soon as possible and place in a plastic bag, or some other container that can be sealed. This clothing bag should be given to the emergency responders for proper handling.
6. SHOWER with soap and water as soon as possible. Do Not Use Bleach Or Other Disinfectant On Your Skin.
7. If possible, list all people who were in the room or area, especially those who had actual contact with the powder. Give this list to both the local public health authorities so that proper instructions can be given for medical follow-up, and to law enforcement officials for further investigation.

QUESTION OF ROOM CONTAMINATION BY AEROSOLIZATION:

For example: small device triggered, warning that air-handling system is contaminated, or warning that a biological agent released in a public space.

1. Turn off local fans or ventilation units in the area.
2. LEAVE area immediately
3. CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away).
4. What to do next.

• If you are at HOME, then dial "911" to report the incident to local police and the local FBI field office.
• If you are at WORK, then dial "911" to report the incident to local police and the local FBI field office, and notify your building security official or an available supervisor.

5. SHUT down air handling system in the building, if possible.
6. If possible, list all people who were in the room or area. Give this list to both the local public health authorities so that proper instructions can be given for medical follow-up, and to law enforcement officials for further investigation.

HOW TO IDENTIFY SUSPICIOUS PACKAGES AND LETTERS

Some characteristics of suspicious packages and letters include the following. ..

• Excessive postage
• Handwritten or poorly typed addresses
• Incorrect titles
• Title, but no name
• Misspellings of common words
• Oily stains, discolorations or odor
• No return address
• Excessive weight
• Lopsided or uneven envelope
• Protruding wires or aluminium foil
• Excessive security material such as masking tape, string, etc.
• Visual distractions
• Ticking sound
• Marked with restrictive endorsements, such as "Personal" or "Confidential"
• Shows a city or state in the postmark that does not match the return address