CDC Press Releases

This page contains the latest CDC press releases on the anthrax attacks.

November 30, 2001

CDC Update

 

Update: Investigation of Bioterrorism-Related Inhalational Anthrax ---Connecticut, 2001

 

Since October 3, 2001, CDC and state and local public health authorities have been investigating cases of bioterrorism-related anthrax (1--5). As of November 28, a total of 23 cases have been identified; 11 were confirmed as inhalational anthrax, and 12 (seven confirmed and five suspected) were cutaneous. Epidemiologic investigations to identify the source of exposure to Bacillus anthracis continue for a case of inhalational anthrax in a hospital stockroom worker in New York City (NYC) and, most recently, a case of inhalational anthrax in an elderly woman in Connecticut (CT). Antimicrobial prophylaxis is continuing in persons exposed to B. anthracis, and surveillance to detect new cases of bioterrorism-related anthrax is ongoing. This report summarizes the findings of the case investigation in CT.

 

On November 16, a 94-yearold woman who resided in Oxford, CT (2000 population: 9821), presented to a local hospital with fever, cough, weakness, and muscle aches of approximately 3 days' duration. She had no history of chills, headache, rhinorrhea, vomiting, diarrhea, or abdominal or chest pain. She had a medical history of chronic obstructive pulmonary disease, hypertension, and renal insufficiency. On admission, the patient had a temperature of 102.3 F (39.1 C) with an elevated heart rate and room air oxygen saturation of 93%. Physical examination was otherwise unremarkable. Initial chest radiograph had no evidence of pulmonary infiltrate, pleural effusion, or widened mediastinum. Her white blood cell count was 8,100 cells/mm3 (78% neutrophils, 15% lymphocytes). Hematocrit, platelet count, and electrolytes were normal. Blood and urine cultures were obtained and the patient was admitted for dehydration and possible urinary tract infection.

 

On November 17, gram positive rods were noted on microscopic evaluation of the blood culture and gram negative rods were isolated from the urine. Antibiotic therapy was initiated for possible sepsis with vancomycin and ceftazidime, and changed to ampicillin/sulbactam and oral ciprofloxacin later that day. On November 18, the patient had progressive respiratory distress and confusion. Repeat chest radiograph revealed a left-sided pleural effusion and possible infiltrate but no mediastinal widening. A chest CT was not performed. Thoracentesis performed the following day obtained 800 ml of serosanguinous fluid with 4,224 red blood cells and 1,463 white blood cells. On November 19, the patient was transferred to the intensive care unit and required mechanical ventilation and vasopressor support. Clindamycin was added to her antibiotic regimen, and ciprofloxacin was changed to intravenous administration. The patient's condition deteriorated, and she died on November 21.

 

On November 19, the Connecticut Department of Public Health (CDPH) was notified by the hospital of the positive blood culture results. On November 20, the isolate was identified as B. anthracis at the CDPH laboratory with confirmation at CDC the following day. The B. anthracis isolate was indistinguishable by molecular typing and antibiotic susceptibility patterns when compared with the strain from recently identified cases of bioterrorism-related anthrax. An autopsy revealed hemorrhagic mediastinal lymphadenitis with positive immunohistochemical staining for B. anthracis on spleen and mediastinal lymph node tissue.

 

The patient lived alone in a rural area of CT and was homebound except when provided transportation by friends and family. Interviews with family members and others were conducted to construct a time line of the patient's activities during the 60-day period preceding her illness. The time line was used to guide environmental sample collection. As of November 27, none of the environmental samples from the patient's home, local businesses, and other areas that she frequented has yielded B. anthracis. In addition, nasal swabs from friends and relatives who may have had common exposures with the patient were negative for B. anthracis. These persons were started on ciprofloxacin or doxycycline for postexposure prophylaxis. The decision whether or not a full 60-day course is necessary will be made after further investigation into the potential source of exposure.

On November 20, environmental testing was conducted at the local post office and regional mail distribution facility involved in delivery of the patient's mail. In addition, sampling was performed on mail recovered from the patient's home, area mailboxes, and the mail carrier vehicle. As of November 27, none of the samples have yielded B. anthracis. Nasal swabs also were taken from 460 postal employees in the two facilities; all are negative for B. anthracis. Mail flow investigations have identified several letters that were delivered to the area serviced by the patient's local post office and that had previously passed through the mail facility in Trenton, NJ, shortly after the B. anthracis contaminated letters addressed to two U.S. Senators. However, no such letters are known to have been received by this patient. On November 21, approximately 900 postal employees at two facilities in CT were started on either ciprofloxacin or doxycycline, pending the results of further investigation.

 

Surveillance for new and possibly undiagnosed anthrax cases is being intensified by contacting hospitals, laboratories, physicians, and by reviewing death certificates. Environmental and case investigations to identify a source of B. anthracis exposure are ongoing.

 

Reported by: H Quentzel, MD, S Spear, MD, L Barakat, MD, Griffin Hospital; N Lustig, MPH, Pomperaug Health District, Oxford; K Spargo, MPH, Naugatuck Valley Health District, Shelton; M Cartter, MD, J Garcia, MD, DM Barden, MT (HHS), DR Mayo, ScD, KA Kelley, DrPH, J Hadler, MD, State Epidemiologist, Connecticut Dept of Public Health. EIS officers, CDC.

 

Editorial Note:

The source of exposure to B. anthracis for the 94-year-old CT resident remains unknown. The genetic characteristics of B. anthracis isolated from this patient links this case with the previous bioterrorism-related cases of anthrax. However, this patient differed from most previously identified cases in both epidemiologic characteristics and potential sources of exposure. The patient in CT had limited activity outside her home, had not visited a media company or postal facility, and had an onset of symptoms at least 3 weeks later than previously reported patients. In addition, one notable clinical finding was the absence of a pulmonary infiltrate, pleural effusion, or mediastinal widening on the admission chest radiograph.

 

Epidemiologic findings indicate that recent cases of inhalational anthrax most likely occurred from aerosols generated from opening a letter containing B. anthracis powder or from aerosols generated in processing a sealed letter containing B. anthracis powder at a postal facility. The most recent case in CT and a case of inhalational anthrax in the 61-year-old hospital stockroom worker in NYC did not have either exposure identified. Possible sources of B. anthracis under investigation include exposures inside and outside the home and mail that passed through contaminated mail facilities. The investigation by public health and law enforcement authorities to find the source of exposure continues and surveillance for new cases of bioterrorism-related anthrax is ongoing.

 

Clinicians and laboratorians should remain alert for symptoms or findings that might indicate anthrax (6).

 

November 30, 2001

CDC Update

 

Adverse Events Associated with Anthrax Prophylaxis Among Postal Employees --- New Jersey, New York City, and the District of Columbia Metropolitan Area, 2001

 

Antimicrobial prophylaxis to prevent inhalational anthrax has been recommended for persons potentially exposed to Bacillus anthracis as a result of the recent bioterrorist attacks (1). During October 26--November 6, 2001, an epidemiologic evaluation to detect adverse events associated with antimicrobial prophylaxis was conducted among 8,424 postal employees who had been offered antimicrobial prophylaxis for 60 days in New Jersey (NJ), New York City (NYC), and one postal facility in the District of Columbia (DC). This report summarizes preliminary results of that evaluation, which found that few employees receiving antimicrobial prophylaxis sought medical attention for symptoms that may have been associated with anaphylaxis. Persons with exposures to B. anthracis related to the bioterrorist attacks should complete the full 60-day course of antimicrobial prophylaxis.

 

In NJ, NYC, and DC, a questionnaire was administered on days 7 to 10 after postal employees received prophylaxis (when they returned for medication refills). In NYC and DC, the questionnaire was self-administered by postal employees; in NJ, nurses interviewed postal workers and administered the questionnaire. Information was collected about the type of antimicrobial used, the occurrence of adverse events, medical attention sought for adverse events related to antimicrobial prophylaxis, and discontinuation of prophylaxis. Persons who reported hospitalization or sought medical attention for symptoms that may have been associated with anaphylaxis (i.e., difficulty breathing; throat tightness and difficulty swallowing; swelling of lips, tongue, or face; and rash, hives, and itchy skin) are being followed up closely by contacting patients and clinicians to confirm or exclude possible hospitalizations and life-threatening adverse events.

 

Of the 8,424 postal employees offered antimicrobial prophylaxis, 5,819 (69%) completed or were administered the questionnaire to evaluate the occurrence of adverse events. A total of 3,863 (66%) had initiated antimicrobial prophylaxis*; of these, 3,428 (89%) reported using ciprofloxacin for antimicrobial prophylaxis; 435 (11%) used other antimicrobials (when ciprofloxacin was contraindicated), including doxycycline (6%) and amoxicillin (1%) (Table 1). Of the 3,428 persons on ciprofloxacin, 666 (19%) reported severe nausea, vomiting, diarrhea, or abdominal pain; 484 (14%) reported fainting, light-headedness, or dizziness; 250 (7%) reported heartburn or acid reflux; and 216 (6%) reported rashes, hives, or itchy skin. Of those persons taking ciprofloxacin, 287 (8%) discontinued the medication; 116 (3%) discontinued the medication because of adverse events, 27 (1%) discontinued because of fear of possible adverse events, and 28 (1%) stopped taking the drug because they "did not think it was needed." For the 3,863 persons on any medication for antimicrobial prophylaxis, 83 (2%) sought medical attention for symptoms that may have been associated with anaphylaxis. Among the 33 persons who sought medical attention for these symptoms in NJ and NYC, none was hospitalized and none of the symptoms was attributed to antimicrobial prophylaxis by clinicians who evaluated these persons. Follow-up of persons in DC who sought medical attention for symptoms that may have been associated with anaphylaxis is ongoing.

 

Reported by: R Brechner, MD, State Epidemiologist, Maryland Dept of Health and Hygiene. G DiFerdinando, MD, E Bresnitz, MD, State Epidemiologist, New Jersey Dept of Health and Senior Svcs. New York City Dept of Health; SH Factor, MD, TD Matte, MD, Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York. L Siegel, MD, S Adams, I Walks, MD, J Davies-Coles, PhD, M Richardson, MD, District of Columbia Dept of Health. E Peterson, MD, R Stroube, MD, State Epidemiologist, Virginia Dept of Health. National Center for Infectious Diseases; and EIS officers, CDC.

 

Editorial Note:

Among persons with exposures to B. anthracis related to the recent bioterrorist attacks, completion of a full 60-day course of antimicrobial prophylaxis is essential for preventing anthrax (1). Activities to promote adherence among postal employees in NJ, NYC, and DC include messages (e.g., posters at the worksite) to promote adherence, small group discussions with postal employees to identify and resolve barriers to adherence, and reminder devices (e.g., pocket calendars). In addition, a key component of promoting adherence is monitoring adverse events that might deter patients from taking antimicrobial prophylaxis. Information from these monitoring systems can be used to reassure workers of antimicrobial prophylaxis and to guide management of workers with potentially serious adverse events.

 

Although adverse events were commonly reported by postal employees who participated in this evaluation and included gastrointestinal and dermatologic reactions, only 2% of persons surveyed sought medical care for symptoms that may have been associated with anaphylaxis. Overall rates of adverse events (regardless of attributability) in NJ, NYC, and DC are similar to the frequency of adverse events among other persons on antimicrobial prophylaxis for exposures to B. anthracis related to these bioterrorist attacks (2) and among persons on ciprofloxacin therapy for any indication (3,4). The higher rates of adverse events in NJ compared with NYC and DC (p=0.001), may be explained by the different mode of administration of the questionnaires (nurse versus self-administered). Discontinuation of therapy caused by adverse events was similar to other groups previously studied (5). Both active and passive monitoring of adverse events and promotion and assessment of adherence to prophylaxis will continue for the duration of the recommended postexposure prophylaxis.

 

References

  1. CDC. Update: investigation of anthrax associated with intentional exposure and interim public health guidelines, October 2001. MMWR 2001;50:889--93.
  2. CDC. Update: investigation of bioterrorist-related anthrax and adverse events from antimicrobial prophylaxis. MMWR 2001;50:973--6.
  3. Segev S, Yaniv I, Haverstock D, Reinhart M. Safety of long-term therapy with ciprofloxacin: data of controlled clinical trials and review. Clin Infect Dis 1999;28:229--308.
  4. Food and Drug Administration. Medical review. Available at <http://www.fda.gov/cder/foi/nda/2000/19-537S038_cipro.htm>. Accessed November 2001.
  5. Halkin H. Adverse effects of the fluoroquinolones. Rev Infect Dis 1988;10(suppl 1):S258--S261.

* The proportion of surveyed postal employees who had initiated prophylaxis varied across sites: 1,643 (99%) in DC, 434 (99%) in NJ, and 1,786 (48%) in NY. In NY, antimicrobial prophylaxis was recommended for approximately 1,800 postal employees who were at increased risk for anthrax and made available to another 2,600 postal employees at lower risk for anthrax.


Table 1

 

November 16, 2001

CDC Update

 

Investigation of Bioterrorism-Related Anthrax, 2001

 

This report updates the investigation of bioterrorism-related anthrax and the provision of antimicrobial prophylaxis to exposed persons and highlights CDC assistance to other countries investigating cases of bioterrorism-related anthrax. Since November 7, 2001, CDC and state and local public health agencies have identified no new cases of bioterrorism-related anthrax. As of November 14, a total of 22 cases of anthrax has met the CDC case definition (1); 10 were confirmed inhalational anthrax, and 12 (seven confirmed and five suspected) were cutaneous anthrax. Investigation of a case of inhalational anthrax in a hospital stock room worker aged 61 years in New York City (NYC) found no evidence of anthrax contamination at the work site or home; the source of exposure is unknown. Environmental clean-up of contaminated facilities continues, and surveillance for new cases of bioterrorism-related anthrax is ongoing in Delaware (DE), District of Columbia (DC), Florida (FL), Maryland (MD), New Jersey (NJ), NYC, Pennsylvania (PA), Virginia (VA), and other states.

 

Use of Antimicrobial Prophylaxis

A 60-day course of antibiotics to prevent inhalational anthrax has been recommended for persons potentially exposed to Bacillus anthracis aerosols in FL, NJ, NYC, VA, and DC. These recommendations are for persons at risk for inhalational anthrax by 1) the presence of an inhalational case at a facility (e.g., media company in FL), 2) environmental specimens positive for B. anthracis in facilities along the path of a contaminated letter in which aerosolization might have occurred (e.g., postal facilities in NYC), and 3) exposure to an air space known to be contaminated with aerosolized B. anthracis from an opened letter (e.g., Senate office building in DC). These persons should receive a full 60-day course of antimicrobial prophylaxis. Specific recommendations by site include:

In addition, a 60-day course of antimicrobial prophylaxis is recommended for other workers with specified risks for inhalational anthrax. In some areas, local health authorities facilitated access to a 60-day course of antimicrobial prophylaxis for persons who handled mail in facilities from which B. anthracis was isolated but did not have exposures for which antimicrobial prophylaxis is recommended (2). These persons may choose or may be directed by local health authorities to discontinue antimicrobial prophylaxis before completing a 60-day course.

 

CDC Assistance to Other Countries

CDC has assisted authorities in other countries investigating cases of bioterrorism-related anthrax. During October 12--November 13, CDC received 111 requests from 66 countries. Of these, 47 (42%) requests were laboratory related; 43 (39%) were general requests for bioterrorism information; 13 (12%) were for environmental or occupational health guidelines; and eight (7%) were about developing bioterrorism preparedness plans. The largest proportion of requests were from Central and South America (26%). Of the 66 countries, 15 (23%) received laboratory assistance, including testing or arrangements for testing of suspected isolates at a CDC-supported laboratory or a reference laboratory in another country. Forty-two (64%) countries received telephone or email consultation regarding specific tests for suspected B. anthracis isolates. CDC has confirmed two isolates from outside the United States as B. anthracis. These isolates were recovered from the outer surface of letters or packages sent in State Department pouches to the U.S. Embassy in Peru. These items were processed at the U.S. State Department mail sorting facility where a case of inhalational anthrax had occurred (1). No cases of bioterrorism-related anthrax have been confirmed in U.S. Embassy employees or in persons from other countries. Requests for information regarding bioterrorism-related issues outside the United States should be directed to the International Team of CDC's Emergency Operations Center (telephone, [770] 488-7100, e-mail, eocinternational@cdc.gov).

 

Reported by: J Malecki, MD, Palm Beach County Health Dept, West Palm Beach; S Wiersma, MD, State Epidemiologist, Florida Dept of Health. New York City Dept of Health. E Bresnitz, MD, State Epidemiologist, G DiFerdinando, MD, New Jersey Dept of Health and Senior Svcs. P Lurie, MD, K Nalluswami, MD, Pennsylvania Dept of Health. L Hathcock, PhD, State Epidemiologist, Delaware Div of Public Health. L Siegel, MD, S Adams, I Walks, MD, J Davies-Coles, PhD, M Richardson, MD, District of Columbia Dept of Health. R Brechner, MD, State Epidemiologist, Maryland Dept of Health and Hygiene. R Stroube, MD, State Epidemiologist, Virginia Dept of Health. J Burans, US Naval Research Center Detachment, Lima, Peru. US Dept of Defense. EIS officers, CDC.

 

Editorial Note:

Since the previous report, all patients with bioterrorism-related anthrax who were hospitalized have been discharged and continue to recover; no new cases have been reported. The source of these bioterrorist attacks has not been identified, and additional cases might occur. Public health authorities, health-care providers, and laboratorians should remain vigilant for cases of anthrax.

 

Antimicrobial prophylaxis is indicated to prevent inhalational anthrax after a confirmed or suspected aerosol exposure. Persons recommended to receive prophylaxis should complete the 60-day regimen. Public health programs should work with health-care providers and patients to promote completion of antimicrobial prophylaxis and to monitor the occurrence of adverse events (1).

 

CDC continues to respond to inquiries about anthrax and bioterrorism. The CDC Public Response Hotline was established to provide the public with information about anthrax and other biologic and chemical agents. During November 1--12, CDC received approximately 4,400 calls through the hotline and to the Emergency Operations Center. The hotline is available in English (888-246-2675) and Spanish (888-246-2857). CDC also receives requests for information by e-mail through the Health Alert Network (<healthalert@cdc.gov>), MMWR (<http://www.cdc/gov/mmwr/contact.html>), and other public health communications systems.

 

November 2, 2001

CDC Update: Current case count and transcript available on-line

CDC confirmed cases of anthrax

Summary of Local, State, and Federal Confirmed Human Cases and Exposures

Case Status

Florida

New York City

New Jersey

Washington, DC

Total
Confirmed

2

5

5

5

17
Cutaneous

0

4

3

0

 
Inhalational

2

1

2

5

 
 

 

 

 

 

 

Suspect

0

3

2

0

5
Cutaneous

0

3

2

0

 
Inhalational

0

0

0

0

 
 

 

 

 

 

 
Total Cases

 

 

 

 

22

There have been 4 deaths associated with inhalational anthrax.

CDC confirmed cases are based on a rigorous case definition which was published in CDC’s Morbidity and Mortality Weekly Report (MMWR) on October 19, 2001.  The MMWR is available on-line at:  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5041a1.htm. 

 

 

October 31, 2001

CDC Health Advisory

Use of Ciprofloxacin or Doxycycline for Postexposure Prophylaxis for Prevention of Inhalational Anthrax

Interim recommendations, MMWR 50(no 41):893 Oct 19,2001, for postexposure prophylaxis to prevent inhalational anthrax after exposure to B. anthracis spores recommend ciprofloxacin or doxycycline as initial therapy in situations associated with the current bioterrorist attack in the United States.

Effectivness: There is no evidence which demonstrates that ciprofloxacin is more or less effective than doxycycline for postexposure prophylaxis for prevention of infection with B. anthracis

Resistance: Widespread use of any antibiotic will promote resistance. Many common pathogens are already resistant to tetracyclines such as doxycycline. However, ciprofloxacin resistance is not yet common in these same organisms. To preserve the effectiveness of ciprofloxacin against other infections, use of doxycycline for prevention of B. anthracis infection is reasonable. Ciprofloxacin is an effective antimicrobial for a variety of other bacterial infections. Thus, the wide use of this drug in thousands of individuals may lead to increased resistance of other bacterial pathogens to ciprofloxacin and other fluroquinolones, and limit the usefulness of these agents.

Side Effects: On the basis of side-effect profiles, the history of reactions, or the clinical setting, either doxycycline or ciprofloxacin may be preferable for an individual patient.

 

October 30, 2001
CDC Update: CDC confirmed cases of anthrax

 

Summary of Local, State, and Federal Confirmed Human Cases and Exposures

Case Status

Florida

New York City

New Jersey

Washington, DC

Total
Confirmed

2

4

5

5

16
Cutaneous

0

3

3

0

 
Inhalational

2

1

2

5

 
 

 

 

 

 

 

Suspect

0

3

1

0

4
Cutaneous

0

3

1

0

 
Inhalational

0

0

0

0

 

 

CDC confirmed cases are based on a rigorous case definition which was published in CDC’s Morbidity and Mortality Weekly Report (MMWR) on October 19, 2001.  The MMWR is available on-line at:  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5041a1.htm. 

 

CDC defines a confirmed case of anthrax as 1) a clinically compatible case of cutaneous, inhalational, or gastrointestinal illness that is laboratory confirmed by isolation of B. anthracis from an affected tissue or site or 2) other laboratory evidence of B. anthracis infection based on at least two supportive laboratory tests.  CDC defines a suspect case as 1) a clinically compatible case of illness without isolation of B. anthracis and no alternative diagnosis, but with laboratory evidence of B. anthracis by one supportive laboratory test or 2) a clinically compatible case of anthrax epidemiologically linked to a confirmed environmental exposure, but without corroborative laboratory evidence of B. anthracis infection.

 

New York case confirmed

 

A case of inhalational anthrax has been confirmed by the New York City Department of Health. The individual works in the stockroom of a hospital in Manhattan and occasionally works in the hospital’s mailroom.  Diagnostic tests have confirmed this case of inhalational anthrax. 

 

Additional information about the case is available from the New York City Department of Health web site at http://www.nyc.gov/html/doh/html/public/press01/pr1001029.html, or by contacting the Department of Health’s Media Relations Office at (212) 295-5335.

 

Mail handling tips for the home or office

 

While it is not possible to eliminate the risk of anthrax, the risk to the general public is low and can be further reduced by being alert for suspicious packages and by handwashing after opening the mail. Heightened public health surveillance continues and has been intensified so that anthrax can be promptly recognized and treated.

 

While the risk is considered to be very low to individuals from possible contamination in the mail, people should continue to be alert for suspicious mail.

 

Mail might be considered suspicious if it is:

 

    • Sent by someone you don’t know
    • Addressed to someone no longer at your address
    • Handwritten with no return address or one that you cannot confirm as legitimate
    • Lopsided or lumpy in appearance.
    • Sealed with excessive amounts of tape.
    • Marked with restrictive endorsements such as personal or confidential.
    • Has excessive postage.

 

Dos and Don’ts for suspicious letters:

            Don’t -

    • Shake or empty the contents.
    • Carry the package or envelope, show it to others, or allow others to examine it.

 

Do -

    • Put the package or envelope on a stable surface; do not sniff, touch, taste, or look closely at it or any contents that may have spilled.
    • Alert others in the area about the suspicious package or envelope. Leave the area, close any doors, and take actions to prevent others from entering the area. If possible, shut off the ventilation system.
    • Wash hands with soap and water to prevent spreading potentially infectious material to face or skin. Seek additional instructions for exposed or potentially exposed persons.
    • If at work, notify a supervisor, a security officer, or a law enforcement official. If at home, contact the local law enforcement agency.
    • If possible, create a list of persons who were in the room or area when this suspicious letter or package was recognized and a list of persons who may have handled this package or letter. Give the list to both the local public health authorities and law enforcement officials.

 

Cutaneous anthrax is a boil-like skin lesion that eventually forms an ulcer with a black center or crust (similar in appearance to some spider bites).

 

The cutaneous form of anthrax responds well to antibiotics if treatment is started soon after symptoms appear, such as in this case.

           

Individuals should, especially in areas that have been directly affected, review and be familiar with advice provided to all postal patrons by the US Postal Service and follow that advice.

October 27, 2001
CDC Health Advisory: Updated Recommendations for Handling Suspicious Packages or Envelopes

Previous CDC recommendations for handling suspicious packages or envelopes were published as part of CDC Health Advisories on October 12 and 14, 2001. These recommendations were part of guidelines for handling anthrax and other biological agent threats. The following are updated CDC interim recommendations:

Handling of Suspicious Packages or Envelopes

· Do not shake or empty the contents of a suspicious package or envelope.

· Do not carry the package or envelope, show it to others, or allow others to examine it.

· Put the package or envelope on a stable surface; do not sniff, touch, taste, or look closely at it or any contents that may have spilled.

· Alert others in the area about the suspicious package or envelope. Leave the area, close any doors, and take actions to prevent others from entering the area. If possible, shut off the ventilation system.

· Wash hands with soap and water to prevent spreading potentially infectious material to face or skin. Seek additional instructions for exposed or potentially exposed persons.

· If at work, notify a supervisor, a security officer, or a law enforcement official. If at home, contact the local law enforcement agency.

· If possible, create a list of persons who were in the room or area when this suspicious letter or package was recognized and a list of persons who also may have handled this package or letter. Give the list to both the local public health authorities and law enforcement officials.

These recommendations were published on October 25, 2001, in “Update: Investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy.” MMWR 2001; 50: 909-919.

October 23, 2001
CDC Update: CDC summary of confirmed cases of anthrax and background information

CDC-confirmed cases of anthrax

Based on a rigorous case definition, CDC is reporting 11 confirmed cases of anthrax: 2 in Florida, 3 in New York, 2 in New Jersey, and 4 in Washington, D.C. (in collaboration with MD and VA).  These cases include the two deaths recently reported in Washington, D.C.  Both cases were proven, through laboratory testing, to be cases of inhalation anthrax. One additional case has been reported by the New York City Department of Health.  CDC is conducting additional tests to fully confirm this 12th case.

CDC defines a confirmed case of anthrax as 1) a clinically compatible case of cutaneous, inhalational, or gastrointestinal illness that is laboratory confirmed by isolation of B. anthracis from an affected tissue or site or 2) other laboratory evidence of B. anthracis infection based on at least two supportive laboratory tests.

Background

·         Anthrax is NOT contagious from one person to another. Family members and contacts of persons who work in or visited sites where exposure occurred are not at risk and antibiotic therapy is not recommended for them. Other members of the community are not at risk. Public health officials, together with the FBI, are continuing the investigation.
 

·         Inhalation anthrax is the most serious and rare form of human anthrax. It occurs when a person breathes a large number of anthrax spores that are in the air. Initial symptoms may resemble the common cold (including fever, muscle aches, and fatigue). After several days, symptoms may progress to severe breathing problems and shock. If left untreated, inhalation anthrax can be fatal.
 

·         Cutaneous (skin) anthrax is different from inhalation anthrax. A cutaneous infection due to anthrax can occur if the spores are in contact with an area of skin that is not intact, such as a cut or sore. Cutaneous anthrax is marked by a boil-like lesion that eventually forms an ulcer with a black center. The cutaneous forms respond well to antibiotics if treatment is started soon after symptoms appear.

For people with suspected anthrax disease, laboratory testing is essential to diagnosis. Tests may include:

·         Cultures of blood and spinal fluid (should be done before antibiotic treatment has been initiated)

·         Cultures of tissue of fluids from affected areas.

·         Microscopic examination of tissue.

·         PCR (polymerase chain reaction) test that amplifies trace amounts of DNA to document that the anthrax bacteria is present.

Antibiotics are an effective treatment if the disease is diagnosed early on; but anthrax can be fatal if left untreated.

The Centers for Disease Control and Prevention continues to work with state and local health departments, law enforcement officials, and other federal agencies to investigate incidents of possible anthrax exposures around the United States. In Atlanta, CDC officials continue to work out of a 24-hour Operations Center. The Operations Center staff is also responding to hundreds of calls each day from the public. CDC has dispatched more than three dozen employees to Florida, New York City, or Washington, D.C. More than 50 CDC laboratories have processed hundreds of specimens.

October 21, 2001
CDC Health Update

CDC Update: CDC case definition of anthrax and summary of confirmed cases

CDC case definition of anthrax

CDC defines a confirmed case of anthrax as 1) a clinically compatible case of cutaneous, inhalational, or gastrointestinal illness that is laboratory confirmed by isolation of B. anthracis from an affected tissue or site or 2) other laboratory evidence of B. anthracis infection based on at least two supportive laboratory tests.

October 21, 2001 - Summary of confirmed cases

Based on this definition, CDC is reporting eight confirmed cases of anthrax: two in Florida, three in New York, two in New Jersey, and one case in Washington, D.C. (in collaboration with public health officials in Maryland and Virginia).

One additional unconfirmed case is under investigation.

October 18, 2001
CDC Health Advisory

HAND-HELD IMMUNOASSAYS FOR DETECTION OF Bacillus anthracis SPORES

Hand-held assays (sometimes referred to as “Smart Tickets”) are sold commercially for the rapid detection of Bacillus anthracis. These assays are intended only for the screening of environmental samples. First responder and law enforcement communities are using these as instant screening devices and should forward any positive samples to authorities for more sensitive and specialized confirmatory testing. The results of these assays should not be used to make decisions about patient management or prophylaxis. The utility and validity of these assays are unknown.

At this time, CDC does not have enough scientific data to recommend the use of these assays. The analytical sensitivity of these assays is limited by the technology, and data provided by manufacturers indicate that a minimum of 10,000 spores is required to generate a positive signal. This number of spores would suggest a heavy contamination of the area (sample). Therefore a negative result does not rule out a lower level of contamination. Data collected from field use also indicate specificity problems with some of these assays. Some positive results have been obtained with spores of the non-anthrax Bacillus bacteria that may be found in the environment.

For these reasons, CDC has been asked to evaluate the sensitivity and specificity of the commercially available rapid, hand-held assays for B. anthracis. When this study is completed, results will be made available. Conclusions from this study are not expected in the near future.

October 18, 2001
Official CDC HEALTH ALERT
Distributed Via Health Alert Network

Recommendations for visitors or employees who were in the Hart Senate building on 10/15/01

People who were on the 5 th or 6 th floor, SE wing, of the Hart Senate Building, Washington, D.C., between 9am-12pm on October 15, 2001, should receive 60 days of prophylaxis for possible anthrax exposure because it is believed that these individuals were potentially exposed to the bacteria. These individuals should not be given nasal swabs as a preliminary test for exposure to anthrax. Nasal swabs are primarily being used for epidemiological investigation, not for individual diagnosis, prophylaxis, or treatment.

The Capitol Physician’s Office has offered to provide the appropriate drug for anyone (staff or visitors) who was in this area on October 15, 2001, during the specified time. The D. C. Department of Health has set up a call center at (202) 442-9196 for treatment information as well as general inquiries. These guidelines may change over the next few days and we will update them as needed based on continuing results. Individuals who were in the specified area of the Hart Senate Building on October 15 between 9am-12pm and are presently in another state/county should contact their state/county health department or CDC for information on treatment.

Studies are ongoing in the capital area to assess whether additional people will need prophylaxis. At the current time there is no indication that additional people who visited other areas of the Hart Senate Building or the capital need to be on prophylaxis or to have nasal swabs.

October 17, 2001
Update: Anthrax antibiotic treatments and CDC disease detective status

Treatments for anthrax

The Food and Drug Administration (FDA) www.fda.gov has approved three antibiotics to treat anthrax:

· Penicillin

· Doxycycline

· Ciprofloxacin

CDC Disease Detectives status

The Centers for Disease Control and Prevention continues to work with state and local health departments, law enforcement officials, and other federal agencies to investigate incidents of possible anthrax exposures around the United States. In Atlanta, CDC officials continue to work out of a 24 hour Operations Center. The Operations Center includes approximately 50 work stations equipped with state of the art information systems, phone lines, and fax machines. The Operations Center is also responding to hundreds of calls each day from the public. CDC has dispatched more than three dozen employees to either Florida, New York City, or Washington, D.C. More than 50 CDC laboratories have processed hundreds of specimens.

October 16, 2001
CDC Update: Facts about anthrax testing and on-going investigations in Florida, Nevada, New York, and Washington, D.C.

Anthrax Disease

For people with suspected anthrax disease, laboratory testing is essential to diagnosis. Tests may include:

·         Cultures of blood and spinal fluid (should be done before antibiotic treatment has been initiated)

·         Cultures of tissue or fluids from affected areas

·         Microscopic examination of tissue

·         PCR (polymerase chain reaction) test that amplifies trace amounts of DNA to document that the anthrax bacteria is present.

Exposure to Anthrax Bacteria (Bacillus anthracis)

Persons with an exposure or contact with an item or environment known, or suspected to be contaminated with Bacillus anthracis — regardless of laboratory tests results — should be considered for antibiotic (prophylaxis) treatment. Exposure or contact, not lab test results, is the basis for initiating such treatment.

Tests that might be conducted during an anthrax exposure investigation

·         Culture of nasal swabs are used to detect anthrax spores that may be resting in the nose. Nasal swabs can occasionally document exposure, but can not rule-out exposure to anthrax. In other words, a negative nasal swab test does not mean that exposure has not occurred. Nasal swabs are used during investigations of known or suspected anthrax exposures because they may provide clues to help investigators assess the exposure circumstances.

·         Antibody tests can be used to measure reactions in the blood of persons with anthrax infection and others who have received anthrax vaccine. Antibody testing also helps investigators make estimates of the number of exposures in a population affected by the investigation, but is not validated as a diagnostic tool for anthrax disease. For this reason, antibody tests are not available in most laboratories.

Two sequential tests are usually necessary to interpret the antibody test information. Therefore, persons who are tested as part of an investigation of anthrax exposure may be asked to return for a second test. This second test is compared with the first test to measure any changes in the antibody level over time. Results from the second antibody test can help investigators to interpret the significance of the initial test, and help assess the exposure (e.g., location in a building or number of persons exposed).

Testing work environments and suspicious letters or packages

Law enforcement officials and public health officials work together to investigate envelopes and packages suspected of containing anthrax or other biological agents. Powder and other specimens collected from these sources usually are analyzed through the Public Health Laboratory Network, which includes the Laboratory Response Network (LRN).

Powders

Lab testing of powders or other materials suspected of harboring the anthrax bacteria is often an important component of an investigation. Tests may include:

·         Cultures of suspected materials.

·         Microscopic examination of a sample of a suspect material.

·         Evaluation of the characteristics of the suspect agent’s growth properties.

·         PCR (polymerase chain reaction) test that amplifies trace amounts of DNA to document that the bacteria is present.

·         DFA (direct fluorescent assay) to detect key bacterial proteins.

·         Other specialized tests to confirm the identification of the bacteria.

Environment (where exposure may have occurred)

During the course of an investigation important information may be obtained from sampling the environment where the exposure may have occurred. Testing of the environment is useful for detecting trace amounts of anthrax spores. Specimens obtained may include:

·         Samples of the air

·         Swabs of material on various surfaces

These samples are processed in the laboratory to promote growth of any spores, if present. If suspicious bacteria grow, additional testing — like that conducted on suspect powders (see “Powders”) — also may be performed.

Where are specimens sent?

The specimens are sent to various laboratories. Local clinical laboratory testing is confirmed at state and large metropolitan public health laboratories. The LRN is a collaborative partnership and multilevel system linking state and local public health laboratories with advanced capacity laboratories—including clinical, military, veterinary, agricultural, water, and food-testing laboratories—to rapidly identify threat agents, including anthrax. The Centers for Disease Control and Prevention (CDC) conducts highly specialized testing for anthrax as well.

Clean-up of contaminated areas

The U.S. Environmental Protection Agency (EPA) www.epa.gov, with help from 16 federal agencies and departments, including CDC, is responsible for environmental and cleanup issues. Federal agencies, in conjunction with local and state agencies, will determine the best approach to the cleanup.

Update: On-going anthrax investigations

NEVADA
Test results sent to CDC on the initial samples from Nevada are negative. However, additional samples have been sent and will be tested.

FLORIDA
The Palm Beach County Control and Prevention have confirmed that the 73-year-old male employee of American Media Inc., hospitalized since the beginning of October, has been diagnosed as a probable case of anthrax disease. The diagnosis cannot be confirmed according to the strictest diagnostic criteria (requires isolation of the bacteria from a clinical specimen such as blood, lung samples, or spinal fluid). However, the overall picture of clinical symptoms combined with positive results on laboratory tests suggest to the Health Department, Florida Department of Health, and the Centers for Disease health officials that this individual has anthrax disease.

Also, a minuscule amount of anthrax spores has been found in a small, non-public mail processing area of the Boca Raton Main post office. There is no indication that these spores pose a health risk to workers or visitors. As an extraordinary precaution, health officials are asking employees to leave this small portion of the building. The affected area will be cleaned tonight — after the post office closes. The post office will be open again for business in the morning.

In Florida, there are 2 cases of anthrax and 1 exposure.

For more information on this investigation, contact the Palm Beach County Health Department, (561) 712–6488/6400

NEW YORK
Preliminary tests indicate cutaneous (skin) anthrax disease in an infant. The child’s mother, an ABC employee, took the child with her to the ABC building on West 66th Street in Manhattan on September 28. While it is not certain that the child came into contact with anthrax bacteria at the ABC building, it is currently the focus of the investigation. The child was started on a course of antibiotics and is doing well. The New York City Health Department is not aware of any other individuals with symptoms of cutaneous anthrax who work in, or visited, the ABC building. The infant’s doctor notified the Health Department on October 12 that the symptoms might be suggestive of a cutaneous anthrax infection. On October 13, a skin biopsy was CDC for testing and the Health Department received the results on October 15.

In New York, there are 2 cases of anthrax and 3 exposures.

For more information on this investigation, contact the New York City Health Department, (212) 295-5335 or online at: www.ci.nyc.ny.us/html/doh/home.html

WASHINGTON
CDC and health officials in the District of Columbia are conducting an public health investigation related to possible anthrax exposure on Capitol Hill. CDC has sent a team of investigators to assist with the investigation.

NATIONALLY
There are numerous reports of potential anthrax cases throughout the United States. The initial assessment of these incidents is made at the state level. CDC is providing technical assistance to the states on “How to handle anthrax and other biological agent threats.”

October 12, 2001
CDC Update: Public Health Message Regarding Anthrax
 

•Preliminary testing done at CDC along with clinical diagnosis indicates that an employee who works on the third floor at 30 Rockefeller Plaza has developed cutaneous anthrax, a bacterial infection of the skin. The source of the anthrax exposure is still being investigated, but it is possible that it may have occurred when an envelope was opened on September 25, 2001 that may have contained material contaminated with the spore-form of anthrax. The employee developed a skin infection and was seen by an infectious disease specialist who suspected cutaneous anthrax. The patient has been treated with antibiotics and is doing well.

•Although test results are normally not released to the public until there is confirmation, these preliminary results are being released given the current circumstances.

•Anthrax is not contagious from one person to another.

•Cutaneous (skin) anthrax is different from inhalation anthrax, which is the type of anthrax that resulted in the death of one person in Palm Beach County, Florida. A cutaneous infection due to anthrax can occur if the spores are in contact with an area of skin that is not intact, such as a cut or sore. Cutaneous anthrax is marked by a boil-like lesion that eventually forms an ulcer with a black center. The cutaneous form responds well to antibiotics if treatment is started soon after symptoms appear, such as in this case.

•Selected areas of 30 Rockefeller Plaza have been closed, and environmental samples are being taken.

•The risk of exposure is greatest for the few people who handled the letter after it was opened, or those in the immediate area at the time the envelope was opened. Nevertheless, as a precaution, all people who worked on the third floor will be given antibiotics.

•CDC is supplementing a New York City Health Department team of epidemiologists investigating the case. CDC has provided personnel and is supporting New York with laboratory assistance and antibiotics, if needed.

•For more information regarding public health actions being taken in New York City, press can contact the NY City Health Department by calling 212-295-5335/5336. The public can call 1-877-817-7621 or visit nyc.gov/health.

October 8, 2001
CDC Update: Ongoing Investigation of Anthrax in Florida

Today public health officials in Palm Beach County Health Department began to evaluate and offer prophylactic treatment to persons who might have been exposed to Bacillus anthracis (the bacteria that causes anthrax) while working or visiting America Media Inc. (AMI) in Boca Raton, Florida.

Persons known to have been in the AMI building for at least one hour since August 1, 2001, will be contacted if they have not already been evaluated. Those who are not currently in Florida might seek care in other jurisdictions. Contact your local or State health department if this happens in your jurisdiction, so that the information can be relayed to CDC and the Palm Beach County Health Department.

For the prophylactic antibiotic treatment regimens recommended for persons potentially exposed to B. anthracis at AMI, contact the CDC. Additional information about prophylactic treatment for anthrax can be found at www.bt.cdc.gov

Federal agencies and public health officials are continuing to investigate anthrax in Florida.

No additional cases of anthrax have been identified.

Reminder: symptoms of inhalational anthrax include fever, muscle aches, and fatigue that rapidly progress to severe systemic illness. Workers and visitors associated with the AMI worksite in Florida who develop such symptoms should be thoroughly evaluated to exclude anthrax and be reported to the state health dep