Actions to Be Taken Following Identification of a Letter, Package, or Other Item
Which Could Potentially Contain or Be Contaminated With a Hazardous Substance

Initial Actions if at Home:

• Do not shake or empty the contents of any 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 down on a stable surface; do not sniff, touch, taste, or look closely at it or at 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.
  
• Contact the local law enforcement agency.
  
• Create a list of persons who were in the room or area when the suspicious letter or package was recognized and a list of persons who also may have handled the package or letter. Give these lists to both the local public health authorities and law enforcement officials.
  

Initial Actions if at Work:

• Do not shake or empty the contents of any 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 down on a stable surface; do not sniff, touch, taste, or look closely at it or at 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.
  
• Notify a supervisor, a security officer, or a local law enforcement official. (Ensure local law enforcement officials are contacted.)
  
• If possible, create a list of persons who were in the room or area when the suspicious letter or package was recognized and a list of persons who also may have handled the package or letter. Give these lists to both the local public health authorities and law enforcement officials.

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Environmental Specimen Collection and Transport
(Includes any sample NOT from clinical sources)
Missouri Dept of Health and Senior Services (800) 392-0272 (24 hours)
State Public Health Laboratory (573) 751-3334 or 751-0633

For further information, see the State Public Health Laboratory Web Site:
www.dhss.state.mo.us/Lab/index.htm

Remember that these samples may be highly infective! Extreme caution should be taken in collecting, preparing for shipment, and transporting any material suspected of being contaminated with a biological agent.

NOTE: Environmental samples can be no larger then 12 inches by 36 inches (including packaging). For larger samples, consult the Missouri State Public Health Laboratory (MSPHL) before submitting.

Samples may include paper, water, dry swab samples from air vents or other surfaces, powders, soil or other environmental samples. Only liquid samples need to be kept cold. All other samples can be transported at room temperature.

In individual situations environmental specimens received in the MSPHL must be accompanied by paper documentation which includes the following:

1. Agency name and telephone number and a contact person for the submitting law enforcement organization along with chain of custody papers.
   
2. Paper documentation that the sample has been "prescreened" by a FBI-certified bomb or explosives technician and a certified HAZMAT team.

The sample being submitted should only be the suspect material. Additional items from the area that are suspected of being exposed should be bagged up and held until testing is complete. For example, if a suspicious package/letter is received in a post office, only the suspicious package/letter should be brought to the MSPHL for testing. All accompanying pieces of mail and the mail bag or letter tray should be bagged in plastic until testing of the suspicious items is completed. Arrangements for where and how that material will be held are the responsibility of the investigating officials.

The specimen must be transported in a container that MSPHL personnel are able to open within a safety cabinet. This would include plastic bags or other devices that can be easily opened. This does not include sealed plastic buckets, etc.

The MSPHL is unable to accommodate used HAZMAT gear or other collection gear. If the HAZMAT team has collected the specimen they should package their gear in a separate container from the specimen. Disposal of HAZMAT gear is the responsibility of the HAZMAT team.

Reporting:
All reporting times are the minimum time. Any individual specimen could take longer.

For environmental specimens, negatives could be reported in 24 hours if there is no suspicious growth. However, any suspicious growth would need to be investigated and could delay the reporting of negative results.

A culture specimen could be reported "presumptive positive" in 24-48 hours with complete identification and positive confirmation at 72 hours.

General Guidance for Managing Persons Who Have
Had Exposure to an Unknown Powdery Substance

1. Persons exposed to an unknown powdery substance should wash their hands with soap and water to prevent spreading potentially infectious material to face or skin.
   
   1. If the initial evaluation of the incident finds evidence of significant risk of exposure to anthrax, exposed persons should, as soon as practical, remove contaminated clothing and store in labeled plastic bags (handling the clothing as little as possible to avoid agitation), and shower thoroughly with soap and water.
      
   2. If the initial evaluation of the incident does not find evidence of significant risk of exposure to anthrax, then the individual may, when they go home, shower with soap and water, and wash their clothing in the normal manner using laundry detergent.
2. Asymptomatic persons exposed to an unknown powdery substance should not be started on prophylactic medications unless there is specific evidence that the substance contains anthrax spores. If law enforcement personnel evaluate the incident and believe it to represent a credible threat, the substance will be tested and, if positive, appropriate prophylaxis can quickly be instituted. Only if there is specific evidence that anthrax spores may be present would prophylaxis prior to receiving positive laboratory results be considered.
   
3. If evaluation of the incident by law enforcement personnel indicates the absence of any credible risk, and no environmental testing is done, prophylactic antibiotics would not be indicated.
   
4. If an exposed person begins to demonstrate signs/symptoms consistent with those seen in early anthrax (e.g., fever or evidence of systemic disease), and no environmental laboratory results are available, then a decision must be made as to whether to begin treatment for anthrax. This decision must take into account the signs/symptoms, their onset in relation to the time of exposure, and the probability (as best can be determined) that the substance might contain anthrax spores. Clinicians caring for such patients should consult with infectious disease specialists, and with public health officials. If it is concluded that the initiation of treatment is indicated, then the recommended treatment regimen for anthrax disease (which differs from the prophylaxis regimen) should be used, and treatment should begin immediately (a delay of antibiotic treatment for patients with anthrax infection may substantially lessen the chances for survival). If, as a result of laboratory testing, it is subsequently found that the individual was not exposed to, and does not have, anthrax, the treatment regimen can be discontinued or modified as necessary.
   
5. If the substance is found to contain anthrax spores, all individuals potentially exposed to aerosolized spores should be offered prophylactic antibiotics as quickly as possible. Public health officials will be involved in investigating the extent of the exposure, and will provide recommendations as to which specific persons should be offered prophylaxis. All persons receiving prophylaxis should be provided education on anthrax disease and its signs/symptoms. They should be told to contact a medical provider immediately if they develop signs/symptoms consistent with early anthrax. Persons with exposure to anthrax spores who develop such signs/symptoms should immediately be started on an anthrax treatment regimen.
6. Recommendations for anthrax prophylaxis and treatment regimens are available in Health Alert #27 (http://www.dhss.state.mo.us/BT_Response/HealthAlert27.pdf). Additional recommendations may be made once drug sensitivities have been determined.
7. No screening test is available for the detection of anthrax infection in an asymptomatic person. Nasal swab cultures should not be used to diagnose cases of anthrax or to evaluate whether a person has been exposed. Nasal swab cultures may, in some instances, be utilized by public health researchers conducting an investigation of an anthrax attack.

Summary of the Clinical Features of Anthrax
The symptoms and incubation period of human anthrax are determined by the route of transmission of the organism. There are three clinical forms of anthrax: inhalational, cutaneous, and gastrointestinal. The inhalational and cutaneous forms would most likely be seen following a successful terrorist attack, and are described in the following sections taken from the CDC publication entitled Epidemiology and Prevention of Vaccine-Preventable Diseases (The Pink Book) (http://www.cdc.gov/nip/publications/pink/anthrax.pdf).

Inhalational Anthrax
Originally known as woolsorter's disease, inhalational anthrax results from inhalation of Bacillus anthracis spores. This form of anthrax is generally expected to be the most common following an intentional release of B. anthracis. The incubation period for inhalational anthrax for humans appears to be 1-7 days, but may be as long as 43 days. [Note that some animal data has suggested that the upper limit of the incubation period might be longer, and this possibility has been considered in the development of the current anthrax prophylaxis recommendations.] The median incubation period for the first 10 bioterrorism-related inhalational anthrax cases in 2001 was 4 days, with a range of 4-6 days. It is noted that the incubation period for inhalational anthrax may be inversely related to the dose of B. anthracis. Data from studies of laboratory animals suggest that B. anthracis spores continue to vegetate in the host for several weeks after inhalation, and antibiotics can prolong the incubation period for developing disease.

Early diagnosis of inhalational anthrax is difficult and requires a high index of suspicion. Initial symptoms can include a nonproductive cough, myalgia, fatigue, and fever. Profound, often drenching sweat was a prominent feature of the first 10 bioterrorism-related cases in 2001. A brief period of improvement has been reported following the prodromal symptoms, but was not seen in the 2001 cases. Rapid deterioration then occurs, with high fever, dyspnea, cyanosis, and shock. Chest x-ray often shows pleural effusion and mediastinial widening due to lymphadenopathy. Meningitis, often hemorrhagic, occurs in up to half of patients with inhalational anthrax. Prior to the bioterrorist attacks in 2001, the case-fatality estimates without antibiotics were 85-97%. With antibiotics, the case-fatality rate was estimated to be 75%. For inhalational anthrax cases in 2001, the case-fatality rate with intensive therapy was 45% (5 of 11 cases). Death sometimes occurs within hours of onset.

Initial symptoms of an influenza-like illness (ILI) could be similar to early symptoms of inhalational anthrax. ILI is a nonspecific respiratory illness characterized by fatigue, fever, cough, and other symptoms. Most cases of ILI are not caused by influenza, but by other viruses, such as rhinovirus and adenovirus. Nasal congestion and rhinorrhea (runny nose) are common with ILI, but uncommon with inhalational anthrax. Shortness of breath is common with inhalational anthrax but uncommon with ILI. Most persons with inhalational anthrax have abnormalities on chest x-ray, whereas most persons with ILI do not have abnormal chest x-rays (although primary influenza pneumonia or secondary bacterial pneumonia may occur in persons with influenza).

Cutaneous Anthrax
Most (>95%) naturally occurring B. anthracis infections are cutaneous and occur when the bacterium enters a cut or abrasion on the skin (e.g., when handling B. anthracis-contaminated animals, animal products, or other objects). The reported incubation period for cutaneous anthrax ranges from 0.5 to 12 days. Skin infection begins as a small papule that may be pruritic, progresses to a vesicle in 1-2 days, and erodes leaving a necrotic ulcer (eschar) with a characteristic black center. Secondary vesicles around the primary lesions may develop. The lesion is usually painless. Other symptoms may include swelling of adjacent lymph nodes, fever, malaise, and headache. The diagnosis of cutaneous anthrax is suggested by the presence of the eschar, the presence of edema out of proportion to the size of the lesion, and the lack of pain during the initial phases of the infection. The case-fatality rate for cutaneous anthrax is 5-20% without antibiotic treatment and <1% with antibiotic treatment.

Additional Information on Anthrax
Anthrax (Missouri Department of Health and Senior Services)
http://www.dhss.state.mo.us/BT_Response/MedicalProfessionals.htm#_Anthrax

Anthrax (Centers for Disease Control and Prevention)
http://www.bt.cdc.gov/agent/anthrax/index.asp

Inglesby TV, O'Toole T, Henderson DA, et al. Anthrax as a Biological Weapon, 2002: Updated Recommendations for Management. JAMA 2002; 287(17): 2236-2252.
http://jama.ama-assn.org/cgi/content/full/287/17/2236

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