Anthrax Protocols

Washington Hospital Center

Department of Emergency Medicine and Section of Infectious Disease

Mark Smith; MD, Chris Wuerker, MD; Dan Lucey, MD

 

	Known Significant Exposure	Possible Exposure	No Known Exposure
Symptomatic	likely admit ŧ	likely admit ŧ	usual ER management*
Asymptomatic	60 day prophylaxis	interim prophylaxis t	no prophylaxis

 

Ŧ             Interim prophylaxis if discharged

*              Be alert for next index case

t               Includes new suspicious powder exposures under investigation

 

Risk Classification (see attached list for specific locations)

Known Significant Exposure: 

Known exposure to those areas designated by CDC / DC DOH (department of Health) to have clinically significant anthrax contamination (known source for inhalational case or heavy environmental contamination [likely due to direct handling of letter/package containing anthrax).  Does not include areas with ‘trace’ environment contamination (likely due to low grade cross contamination of mail).

Possible Exposure: 

Exposure to potentially contaminated environment where test results or formal guidelines are incomplete (includes areas with ‘trace positive’ environmental surveys for which CDC guidelines are pending).

NOTE:  DC DOH guidelines published 11/5/01 recommend 60 days prophylaxis for persons exposed to ‘trace positive’ environments pending further CDC input.

No Known Exposure: 

All other areas including customer areas of post offices (including Brentwood) and environmentally test negative facilities

Symptoms & Signs of Inhalational Anthrax

Recent Experience (from CDC, ID Society of America, 10/28/01)

Symptoms:           Fever - 6/8 patients

                                Fatigue – 6/8 patients

Sweats/chills – 5/8 patients

                                Cough – 5/8 patients

                                Nausea/vomiting/abd pain - 5/8 patients

                                Chest pain - 3/8 patients

                                Headache  - 3/8 patients

                                Sore throat - 1/8 patients

Signs:                    Chest CT (mediastinal disease) – 4/6 patients

                                Pleural effusions on CXR - 5/8 patients

                                WBC – normal to high normal (increased neutrophils)

                                Hemoconcentration (Hgb>16)

Coryza, rhinitis and purulent sputum were absent in the reviewed cases.

Admission Criteria: 

Patients with ‘hard’ signs / symptoms consistent with anthrax (fever, toxicity, leukocytosis, pleural effusions, CT findings) or constellation of concerning ‘soft’ symptoms should be admitted for IV antibiotics and observation.

Example:  Brentwood postal worker with 2 day history of fever, chills, cough and fatigue but without coryza or rhinitis.  Patient is febrile but exam otherwise unremarkable

 CXR, CT, and WBC are normal. Patient admitted to hospital for observation and Rx.

 

 

Known Significant Exposure Zones   (“Hot Zones”)

Full 60 day Antibiotic Prophylaxis

These sites tested environmentally positive for anthrax to a significant level

National Capital Region

• Brentwood Mail Distribution Center: non-public work area
• State Dept – Remote Mail Facility: SA32
• Hart Building 5th & 6th floors SE wing - October 12, 9 A – 7 P
• Hart Building SW freight elevator - October 11 and after
• Ford mail handling room - October 11 and after
• Dirksen mail handling room - October 11 and after

Outside National Capital Region

New York City

• NBC (letter postmarked 9/18/01 from Trenton, NJ)
• CBS - office and anteroom of Dan Rather
• New York Post (letter postmarked 9/18/01 from Trenton, NJ)
• US Postal Service - Morgan Processing Center, New York City
• US Postal Service - Regional Mail Center, Hamilton, NJ

Florida

• US Post Office – 2 in Boca Raton, FL
• US Post Office – Lake Worth, FL
• American Media, Inc., Boca Raton, FL – index case

 Possible Exposure Zones: Interim Prophylaxis

(Zones Under Investigation or Awaiting Final Recommendations)

For Mail Handlers and People Visiting Back Mailrooms of US Postal Service / Governmental / and Private Building Mailrooms (does not apply to customers of those mailrooms)

Private / Governmental / US Postal Service mail handlers that

1. Directly receive mail from Brentwood Postal facility AND
2. Use automated ‘machine’ sorting equipment AND
3. Are in Zip codes 200XX AND
4. Worked in back mailroom since October 11, 2001

Treatment should be based on environmental testing of specific facility

• Results pending:  interim prophylaxis pending results
• Results negative:discontinue prophylaxis
• Results positive:  continue interim prophylaxis pending final CDC / DC DOH guidelines on management of exposure in trace positive environments  (“interim” may last up to 60 days)

Environmentally “Positive” Post Offices Awaiting Final Recommendations:

• SW Post Office (1/20 positive environmental samples)
• Friendship Heights PO (1/32 positive)
• 20th St. PO – 1/9 pending
• Farragut PO – 1/10 pending
• BWI airmail facility (1st flr 1/14 pending; 2nd flr – no results)
• Dulles Airport mail facility (1/11 positive)
• Post offices in PG and Montgomery Counties

Environmentally “Positive” Federal Mailrooms Awaiting Final Recommendations:

• White House – remote mail facility
• Dept of Agriculture (unspecified building)
• State Dept – in house mailroom
• Supreme Court- in house and remote mail facility
• CIA – mail processing building

Others Sites Testing “Positive” and Awaiting Final Recommendations:

• Longworth Building (House of Representatives)
• Offices of Mr. Balducci (rm 1740) – Oct 12~17
• Offices of Mr. Pence (rm 1605) – Oct 11~17
• Offices of Mr. Holt (rm 1630) – Oct 11~ 17
• Ford Building Police Room (rm 167) – HazMat change out room
• Walter Reed Army Research Annex (Silver Spring, MD) – mail room

Management of patient with an exposure to a suspicious powder

• associated  with a credible threat package or letter
• Treatment must be based on verification of significant exposure to anthrax
• The source must be evaluated by an appropriate public safety agency with specific testing completed if indicated
• Nasal swabbing of patients may be indicated for certain circumstances
• Patients should be started on interim prophylaxis pending results of testing of suspicious source

No Known Exposure: No Prophylaxis

All buildings and post offices not on above list are not considered to be a possible exposure risk and people working at such facilities do not need antibiotic prophylaxis

 

This includes all office buildings that are not in zip codes 200XX

 

This includes all office buildings that are in zip code 200XX but do not use automated sorting equipment

 

Buildings fitting into any of these categories do not need to be environmentally tested.

 

Treatment Protocols

Known Significant ‘Hot Zone’ Exposure / Acutely Symptomatic:

Evaluation, Rx, Likely Admit

1. CBC
2. CXR
3. Blood Culture
4. BHCG
5. Low Threshold for Chest CT without IV contrast  (change in recommendation)
6. Very-likely admission to hospital (A-medicine)
7. ID consultation (House or Kaiser)
8. If admit: Penicillin 4 million units IV q4h + Ciprofloxacin 400 mg IV  both should be given before the patient leaves the ED  (if patient is pregnant, do not use ciprofloxacin unless directed by ID consultant)

• If toxic: add Clindamycin 900mg IV q8h
• LP if indicated (perform soon after antibiotics administered)
• If anthrax meningitis: add Rifampin 300 mg IV q12h
• STAT Dermatology Consultation for any skin lesions
• Complete Anthrax logs (see below)
• If highly suspicious for inhalational anthrax or meningitis, page ‘Anthrax MD on call’ (see key numbers at end)

9. If discharge:  place patient on Doxycyline 100 mg 6 pack to go and 14 day prescription (see alternative drugs below) pending further investigation of event

• Follow-up with designated public health facility.  Patient will be called with results and further advice
• Provide patient with instruction sheets (drug and follow up)

Known Significant ‘Hot Zone’ Exposure / Asymptomatic:

Rx x 60 days / no nasal swab

• No nasal swab
• Doxycycline 100 mg BID (alternative: Cipro 500 BID or (if pregnant) Amoxicillin 500 TID) 
• Dispense 6-pack (to start Rx immediately) + prescription for 14 days (additional antibiotic to be provided by Public Health at follow up)
• Confirm patient’s home and work telephone (write on chart on Clin 1)
• Follow-up with designated public health facility (ID) Service
• Provide patient with instruction sheets (drug and follow up)

Possible Exposure:  Investigational Zone / Acutely Symptomatic:

work-up, Rx, likely admission

• Management as per ‘Known Significant Exposure / Symptomatic’

Possible Exposure:  Investigational Zone / Asymptomatic:

Rx x 17 days /no swab

• No nasal swab except for special circumstance (e.g., patients sent by HazMat or Protective Service after exposure to suspicious material)
• Doxycycline 100 mg BID (alternative: Cipro 500 BID or (if pregnant) Amoxicillin 500 TID
• Dispense 6-pack (+ prescription for 14 days if no public health facility has as yet been identified for follow-up care)
• Obtain patient’s home and work telephone # and write on chart on Clin 1
• Indicate to patient criteria for stopping antibiotics versus continuing for a full 60 day course (i.e., further investigation)
• Follow-up with designated public health facility or WHC Anthrax Service
• Provide patient with Anthrax instruction sheet (kept with Anthrax log books)

 

For asymptomatic patients that present during the hours when a central public health screening/treatment site is open for management of that particular hot zone or zone under investigation exposure, send patient to that facility; otherwise initiate Rx at WHC

 Follow Up for Asymptomatic Patients

US Postal Service (DC/MD/VA) / Private Employees

 

DC POH Anthrax Hotline 202-442-9196

Treatment Site:    

DC General Hospital Building #3

1600 Massachusetts Ave., SE

Washington DC

Nov 6 ~ 9:  10:00am to 2:00pm            ONLY                   

 

PG County Anthrax Hotline 301-583-1818

Treatment Site:    

PG Health Dept Building

1701 McCormick Drive, Largo, MD

301-883-7832

Mon ~ Fri: 1pm to 5pm

 

Montgomery County Anthrax Hotline 240-777-4200

Treatment Site:    

Health and Human Services Building

2000 Dennis Avenue, Wheaton, MD

Mon ~ Fri: 12pm to 7pm

Sat/Sun: 10am to 2pm

 

Fairfax County Anthrax Hotline 703-246-3796

Treatment Site:    

Government Center

1200 Government Center Parkway, Fairfax, VA

Mon ~ Fri: 9am to 10pm

 

Federal Employees (Office of Emergency Preparedness / CDC)

Treatment Site:    

Occupational Health Clinic / 2nd Floor / Eastern section

Humphrey Building

900 Independence Ave., SW

Nov 6 ~ 9: 10:00am to 5:00pm ONLY

 

Senate / House Congressional Personnel

Attending Physician to Congress Anthrax Hotline 202-225-5421

Treatment Site:

Rayburn Health Unit

Rayburn Building Rm B-344

Mon ~ Fri: 8:30am to 5pm

 

US Capital Health Unit

US Capital Rm S-153

Mon ~ Fri: 8:30am to 5pm 

Supplemental Information

Results of nasal swab surveillance from DC POH:

                3/3110 positive (not confirmed)

CDC Update: Summary of Confirmed Cases of Anthrax, Nov.4, 2001    

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					22

 

There have been 4 deaths associated with inhalational anthrax.    

Confirmed Cases of Inhalational Anthrax (dates approximate)

1. 10/5/01:  FL: American Media, Inc, Boca Raton, FL - photo editor – died
2. 10/21/01:  DC: US Postal Worker - Brentwood, DC – mail handler - died
3. 10/22/01:  MD: US Postal Worker – Brentwood, DC – mail handler - died
4. 10/23/01:  FL:  American Media, Inc, Boca Ratan, FL – mail handler (d/c)
5. 10/20/01(?):  VA:  US Postal Worker – Brentwood, DC – mail handler
6. 10/20/01(?):  VA:  US Postal Worker – Brentwood, DC – mail handler
7. 10/26/01:  VA:  State Dept Remote Mail Facility – Sterling, VA – mail handler (Winchester)
8. NJ: ?
9. NJ: ?
10. 10/30/01: NY: EET Hospital, non-mail hospital worker – died

CDC Anthrax Case Definition:

Confirmed case of anthrax:  (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; (2) other laboratory evidence of B. anthracis infection base on at least two supportive laboratory tests.

Suspect case of anthrax: (1) a clinically compatible case of illness without isolation of

B. athracis and no alternative diagnosis, but with laboratory evidence of B. anthracis by one supportive laboratory test; (2) a clinically compatible case of anthrax epidemiologically linked to a confirmed environmental exposure but without corroborative laboratory evidence of B. anthracis infection. 

GOVERNMENT OF THE DISTRICT OF COLUMBIA

DEPARTMENT OF HEALTH

Current CDC Recommendations for Treatment of Persons Potentially Exposed to Anthrax in Mail-handling Facilities

If you are …	And you …	Treatment Recommendations
Someone who handled mail in or visited the back (i.e., non-customer) areas of the Brentwood or State Department Annex #32 postal facilities	Have been on prophylactic Cipro™ or another prescribed antibiotic	Continue taking the medication you have been prescribed for the full 60 day course
Someone who handled mail in any U.S. Postal Service or private mail facility that has tested positive for the presence of Anthrax	Are in the middle of your initial supply of antibiotics	Continue taking the medication you have been prescribed for the full 60 day course
Someone who handled mail in any U.S. Postal Service or private mail facility that has tested negative for the presence of Anthrax	Have been on prophylactic Cipro™ or another prescribed antibiotic	You do not need to be on antibiotics, and you should stop taking them unless you have some other condition for which they are prescribed
A postal customer	Never entered the back areas of any postal facility	You do not need to be on antibiotics, and you should stop taking them unless you have some other condition for which they are prescribed
Someone who handles mail in a non-governmental mailroom which has a zip code beginning with ‘200’ and which uses automated or mechanized sorting equipment	Have been on prophylactic Cipro™ or another prescribed antibiotic	Continue taking the medication until environmental testing of your facility indicates whether Anthrax was actually present.  If the facility tests negative for the presence of Anthrax, discontinue the antibiotics.
Not in any of the above categories	Are taking antibiotics as a “precaution” against Anthrax	You do not need to be on antibiotics, and you should stop taking them unless you have some other condition for which they are prescribed

Environmental Assessment of Washington Area Sites

Receiving Mail directly from the Brentwood Mail Distribution and Processing Center, Conducted by CDC

6:45 PM

Number of  Postal Facility Sites*	Testing status of Sites
43	Post Office Facilities with confirmed negative environmental testing results to date
4	Post Office facilities with confirmed positive environmental testing results to date
0	Post Office Facilities tested, results pending

 *Site 44, Dulles Terminal, not tested by CDC, removed from total count

 

Number of D.C. Government Sites	Testing status of Sites
8	District of Columbia Government sites with confirmed negative environmental testing results to date
0	District of Columbia Government sites tested, results pending

 

Environmental testing performed by collecting wipe specimens using moistened sterile swabs.

Environmental Assessment of Washington Area Sites

Receiving Mail directly from the Brentwood Mail Distribution and Processing Center, Conducted by CDC

6:45 PM

	Post Office Facilities tested to date	Results of testing
1	“V” Street Annex	Negative
2	CFS	Negative
3	Customs House	Negative
4	Brookland	Negative
5	Anacostia	Negative
6	Frederick Douglass	Negative
7	Fort Davis	Negative
8	River Terrace	Negative
9	Benning Rd NE	Negative
10	Northeast	Negative
11	Southwest	One Positive sample
12	L’Enfant Plaza	Negative
13	Southeast	Negative
14	Congress Heights	Negative
15	Lamond Riggs	Negative
16	Bright Wood	Negative
17	Columbia Heights	Negative
18	Chillum Place Annex	Negative
19	Georgetown	Negative
20	Cleveland Park	Negative
21	Calvert	Negative
22	Palisades	Negative
23	Randle	Negative
24	Friendship	One Positive Sample
25	Ward Place	Negative
26	National Capital	Negative
27	Ledroit Park	Negative
28	BWI/AMF	Negative
29	National Airport	Negative
30	Washington Square	Negative
31	Farragut	Negative
32	20th Street	Negative
33	Dulles	One Positive Sample
34	McPherson	Negative
35	Watergate	Negative
36	Temple Heights	Negative
37	Martin L. King	Negative
38	T Street	Negative
39	Northwest	Negative
40	Woodridge	Negative
41	Mid City	Negative
42	Kalorama	Negative
43	Columbia Heights Finance Center	Negative
44*	Dulles Terminal*	Not to be tested by CDC*
45	Bolling	Negative
46	Pentagon	Two positive samples out of 17
47	Ben Franklin	Negative
48	Tech World	Negative

 

District of Columbia Government Offices

49	DC City Council 1350 Penn Ave. NW	Negative
50	Office of Property Management 441 4th St. NW	Negative
51	Reeves Building, 2000 14th St. NW	Negative
52	DC Public Library 901 G St. NW	Negative
53	Metropolitan Police Dept. 300 Indiana Ave. NW	Negative
54	Dept. of Banking & Financial Inst. 1400 L St	Negative
55	DC Public School Mailroom, 825 N. Capitol St., 7th Floor	Negative
56	DC Public School Mailroom, Adams Place	Negative