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Anthrax Assessment and Treatment

Thursday, October 25, 2001
MSG 2001-085
MEMORANDUM FOR: 
Human Resources Directors
Subject: 
Anthrax Assessment and Treatment

Continued Anthrax Assessment/Treatment for Executive Branch Employees

Through our health clinic, the Department of Health and Human Services will continue to provide assessment for those executive branch employees concerned about exposure to anthrax.

Currently, the following recommendations are in place:

  1. Anyone who worked in or passed through the 5th and 6th floors of the Southeast wing of the Senate Hart Office Building on Monday, October 15. CDC recommends that anyone fitting these criteria begin the full 60-day course of antibiotics as a precautionary measure.
  2. Anyone who has been in the non-public, mail operations area at the U.S. Postal Service's Washington DC Processing and Distribution Center at 900 Brentwood Road, NE, Washington DC (US Postal Brentwood Facility) since October 11, 2001, should receive prophylactic treatment for potential exposure to anthrax. As an added precaution, people who have worked since October 11, 2001 in the non-public mail operations area at postal facilities that directly receive mail packed in bulk from the Brentwood facility should also receive prophylactic treatment. This includes federal government mail facilities that receive and process mail from the Brentwood facility.
  3. The Capitol Physician's Office indicates that they have already tested and treated all appropriate persons at the Ford Building. If the Capitol Physician's Office has not contacted you, they do not recommend testing or treatment.
  4. CDC is recommending, as a precautionary measure, that all mailroom facilities undergo environmental testing.

CDC, the Capitol Physician's Office, and the DC Department of Public Health continue to assess treatment needs as the investigation continues.

Assessment and prophylactic treatment are available through the Department of Health and Human Services at:

    HHS Health Clinic
    200 Independence Ave., SW
    2nd Floor
    Washington, DC 20201

On Friday, October 26 and Saturday, October 27 the hours of operation will be between 8:30 a.m. and 6 p.m. Any future hours will be determined based on need.

Additionally, anyone fitting these treatment guidelines can appear at DC General Hospital for assessment and, where appropriate, receive prophylaxis, between 9AM and 10PM, Friday, Saturday or Sunday, with their IDs. Appointments are not possible. If there are issues that arise at DC General please call 202-698-7314.

If any of your employee health supervisors have questions, please call 202/690-7439.

Official CDC Health Advisory: CDC Interim Recommendations for Protecting Mail Handlers from Cutaneous and Inhalational Anthrax Associated with Intentional Distribution of Bacillus anthracis through the Mail

As of October 24, 2001, the Centers for Disease Control and Prevention (CDC) is aware of several cases of inhalational anthrax among postal workers and mail handlers, including two fatal cases, as well as additional cases of cutaneous anthrax. These cases have been associated with exposure to mail contaminated with Bacillus anthracis. This document provides interim recommendations for protecting workers involved in mail sorting, distribution, and handling.

A program to reduce skin or respiratory exposures to B. anthracis spores may decrease the risk of the anthrax disease in mail handlers. These interim recommendations are based on the currently available information regarding ways to avoid infection and the effectiveness of various prevention strategies. These recommendations will be updated as new information becomes available.

A hierarchy of measures should be used to control potential exposures to B. anthracis. These include, in hierarchical order, engineering controls to capture B. anthracis spores at potential points of release, housekeeping measures to reduce the spread of B. anthracis spores, and personal protective equipment to prevent worker exposure. The selection of these measures may be made after conducting a site-specific evaluation of the potential risk for B. anthracis exposure in each mail-handling facility. These recommendations should be incorporated into a comprehensive safety and health program for protecting mail handlers.

A major source of dust in mail handling facilities occurs during the operation and maintenance of high-speed mail handling machines. The "blowdown" of these machines in the maintenance operation can aerosolize particles in the size range of B. anthracis spores. Additionally, pinch roller operations should be evaluated for their potential to force dust-containing spores from envelopes.

The following recommendations are provided for workers potentially exposed to B. anthracis spores while handling or processing mail. These recommendations do not address instances where a known exposure has occurred. Mail facilities should develop an emergency plan to contain the hazards and activate the plan when a known or suspected exposure to B. anthracis occurs.

Engineering Controls in Mail Facilities

  • Use an industrial vacuum cleaner equipped with a High-Efficiency Particulate Air (HEPA) filter as the first choice for cleaning high-speed mail-sorting equipment. If blowdown/blow-off must be used, first vacuum to remove as much dust as possible.
  • Install engineering controls such as HEPA-filtered exhaust hoods for high-speed mail handling equipment and for other areas where dust is generated by processing mail. Local ventilation at pinch roller areas should be specifically considered.
  • Install air curtains (using laminar air flow) to isolate areas where large amounts of mail are processed.
  • Install HEPA filters in the building's HVAC systems to eliminate re-circulation of aerosolized spores.

Housekeeping Controls

  • Avoid dry sweeping and dusting.
  • Use wet cleaning and vacuuming.
  • Use HEPA vacuum cleaners.

Personal Protective Equipment for Workers Handling Mail

Personal protective equipment for workers handling mail must be selected based upon the exposure risk and the type of disease to be prevented (inhalational vs. cutaneous anthrax).

Preventing Inhalational Anthrax

The engineering control measures described above are the first step toward preventing inhalational anthrax. In addition, respiratory protective equipment may be needed to protect persons working with or near machinery that may generate airborne particles, or at other sites where airborne particles may be generated. Hand sorting of mail is likely to generate lower levels of airborne particles than machine sorting, but hand sorting may still present a risk for exposure.

Respirators Considered For Prevention of Inhalational Exposures to B. anthracis

  • A NIOSH-approved respirator at least as protective as a half mask respirator equipped with N100, P100, or R100 filters (disposable or elastomeric) should be used by any person who works with or near equipment or machinery known or suspected to generate aerosolized particles (e.g., electronic sorters) if dust levels cannot be or have not yet been adequately controlled by engineering controls. N100, R100, and P100 filters are at least 99.97% efficient at filtering out particles 0.3 microns in size when the respirator is properly fitted. Anthrax spores typically range from 2 to 6 microns in diameter.
  • Half-mask respirators with P100 filters must be used in conditions where oil mist from machinery or high humidity is present.
  • Fitted N95 respirators can be used by workers sorting mail in other areas, such as workers who hand-sort mail.
  • Alternative respirators (such as powered air-purifying respirators with loose-fitting hoods) may be required for workers with facial hair (beards and or large moustaches) because facial hair interferes with the fit of protective respirators.

The need for respiratory protection for workers in other areas should be determined by an on-site risk evaluation.

When respirators are worn, a respiratory protection program that complies with the provisions of OSHA [29 CFR 1910.134] should be in place. This includes medical clearance for wearing a respirator and a respirator fit-test to ensure that the respirator fits properly. Without fit testing, persons unknowingly may have poor face seals, allowing aerosols to leak around the mask and be inhaled. (See December 11, 1998 MMWR, available at http://www.cdc.gov/mmwr/PDF/wk/mm4748.pdf. Workers who cannot be fitted properly with a half-mask respirator based on a fit test may require the use of alternate respirators such as full face piece negative-pressure respirators equipped with P100 filter respirators, powered air-purifying respirators (PAPRs) equipped with HEPA or supplied-air respirators.

Preventing Cutaneous Anthrax

  • Protective gloves should be available to all workers handling mail (e.g., envelopes, packages). Different gloves or layers of gloves may be needed depending on the task, the dexterity required, and the type of protection needed. Gloves chosen should be appropriate to the task (e.g., leather gloves may be needed for operations where gloves can easily be torn). In some cases, workers may need to wear cotton gloves under impermeable gloves for comfort and to prevent dermatitis. Skin rashes and other dermatological conditions are a potential hazard of wearing gloves.
  • Gloves should be provided in a range of sizes to ensure proper fit.
  • For workers involved in situations where a gloved hand presents a hazard (e.g., close to moving machine parts), the risk for potential injury resulting from glove use should be measured against the risk for potential exposure to B. anthracis.
  • The choice of glove material (e.g., nitrile, vinyl) should be based on safety, fit, durability, and comfort. Gloves can be worn under heavier gloves (e.g., leather, heavy cotton) if more protection against hand injury is needed. Latex gloves should be avoided because of the risk of developing skin sensitivity or allergy.
  • Sterile gloves (e.g., surgical gloves) are not necessary.
  • Care must be taken to avoid touching skin, eyes, or other mucous membranes since contaminated gloves may transfer B. anthracis spores to other body sites.
  • Gloves should be discarded if they are visibly torn.
  • Long-sleeved clothing should be worn to protect exposed skin, and gloves should be pulled over the ends of the sleeves.
  • Hands should be thoroughly washed with soap and water when gloves are removed, before eating, and when replacing torn or worn gloves. Soap and water will wash away most spores that may have contacted the skin, and disinfectant solutions are not needed. Do not rely on alcohol-based hand cleaners, as these cleaners will not remove spores as well as soap and water will.
  • Used or torn gloves can be discarded in regular trash.

The use of disposable aprons or goggles by persons working with or near equipment or machinery known or suspected to generate aerosolized particles may provide an extra margin of protection. As with gloves, used aprons and goggles can be discarded in regular trash. If a suspicious piece of mail is recognized and handled, the worker's protective gear should be handled as potentially contaminated material (See "Guideline For Hand washing And Hospital Environmental Control," 1985, available at http://www.cdc.gov/ncidod/hip/guide/handwash.htm.

Mail facility health and safety plans also should consider personal protective needs for maintenance workers who may clean or repair mail sorting machines, and for custodial workers who must clean potential spills.

CDC Interim Recommendations Related to US Postal Service (USPS) Workers and Mail Handlers Who May Have Had Exposure to Anthrax

NOTE:

The duration of the treatment to prevent inhalation anthrax is 60 days. People deemed to have significant risk of exposure initially would receive 10 days of treatment. Many people who initiate treatment will not need a full 60-day course if the investigation does not show exposure. If the investigation does show exposure, a full 60-day course of antibiotics will be required. The additional medication needed to complete the full 60 days will be provided.

In these guidelines, business visitors are defined as temporary postal workers, vendors, contractors, and people who deposited bulk mail.

Washington, DC Facilities

(For further information regarding testing protocols, please see the information distributed via the Health Alert Network on October 24, 2001, attached as Addendum 1)

Brentwood Facility

  • OEP and the DC Department of Health will provide appropriate antibiotics for 10 days for all USPS workers at the Brentwood facility and all business visitors to the employee work area from October 12th through October 22
  • Complete targeted environmental sampling
  • Recommend Brentwood remain closed until further environmental sampling results are available, decontamination is complete, and facility is considered safe.
  • USPS worker surveillance through occupational health support and state and local public health.
  • Continued disease surveillance in hospital system.
  • Recommend use of appropriate protective equipment when facility reopens.

Facilities Directly Served By Brentwood (includes postal, government and private facilities)

  • OEP and the DC Department of Health will provide appropriate antibiotics for 10 days for all USPS workers and mail handlers at the facilities and all business visitors to the employee work areas from October 12th through October 22.
  • Complete targeted environmental sampling
  • USPS worker surveillance through occupational health support and state and local public health.
  • Continued disease surveillance in hospital system.
  • Recommend use of appropriate protective equipment.

Anne Arundel Facility

  • OEP and the DC Department of Health will provide appropriate antibiotics for 10 days for all USPS workers at the facilities.
  • Complete targeted environmental sampling
  • Recommend Anne Arundel remains closed until further environmental sampling results are available, decontamination is complete, and facility is considered safe.
  • USPS worker surveillance through occupational health support and state and local public health.
  • Continued disease surveillance in hospital system.
  • Recommend use of appropriate protective equipment.

P Street

  • OEP and the DC Department of Health will provide appropriate antibiotics for 10 days for all USPS workers at the facilities.
  • Complete targeted environmental sampling
  • Recommend P Street remains closed until further environmental sampling results are available, decontamination is complete, and facility is considered safe.
  • USPS worker surveillance through occupational health support and state and local public health
  • Continued disease surveillance in hospital system.
  • Recommend use of appropriate protective equipment.

New Jersey Facilities

Hamilton Township, NJ, Facility

  • Work with state/local health authorities and USPS officials to provide appropriate antibiotics for 10 days for all USPS workers at the Hamilton facility and all business visitors to the employee work area from September 18 through October 19.
  • Complete targeted environmental sampling.
  • Recommend Hamilton remain closed until further environmental sampling results are available, decontamination is complete, and facility is considered safe.
  • USPS worker surveillance through occupational health support and state and local public health.
  • Implement disease surveillance in hospital system.
  • Recommend use of appropriate protective equipment when facility reopens.

Hub & Spoke Facility in Carteret, NJ

  • Work with state/local health authorities and USPS officials to provide appropriate antibiotics for 10 days for all USPS workers at the Carteret facility.
  • Conduct targeted environmental sampling.
  • USPS worker surveillance through occupational health support and state and local public health.
  • Implement disease surveillance in hospital system.
  • Recommend use of appropriate protective equipment.

West Trenton Post Office

  • Work with state/local health authorities and USPS officials to provide appropriate antibiotics for 10 days for all USPS workers at the West Trenton facility.
  • Complete targeted environmental sampling
  • Recommend West Trenton facility remains closed until further environmental sampling results are available, necessary decontamination (if any) is complete, and facility is considered safe.
  • USPS worker surveillance through occupational health support and state and local public health.
  • Continued disease surveillance in hospital system.
  • Recommend use of appropriate protective equipment.

Florida

  • No current recognized risk for anthrax due to the duration since the American Media Incorporated (AMI)-associated cases occurred in Palm Beach County.
  • Antibiotics are not recommended; however, they could be provided on request of postal workers associated with delivery of mail to AMI. Details have yet to be worked out with state and local health authorities.
  • Continue USPS worker surveillance through occupational health support and state and local public health.
  • Continued disease surveillance in hospital system.

New York

  • No current recognized risk for anthrax due to the duration since the contaminated letters were received at media outlets in New York City.
  • Antibiotics are not recommended; however, they could be provided on request of postal workers. Details have yet to be worked out with state and local health authorities.
  • Continue USPS worker surveillance through occupational health support and state and local public health.
  • Continued disease surveillance in hospital system.

ADDENDUM 1

Released via Health Alert Network (HAN) on 10/24/01:

Official CDC Health Advisory: CDC Statement Regarding the Washington DC Processing and Distribution Center, and Postal and Mailroom Facilities Who Directly Receive and Distribute Mail from this Center

The Centers for Disease Control and Prevention (CDC) recommends that all people who have been in the non-public, mail operations area at the U.S. Postal Service's Washington DC Processing and Distribution Center at 900 Brentwood Road, NE, Washington DC (US Postal Brentwood Facility) since October 11, 2001, receive prophylactic treatment for potential exposure to anthrax. This facility has been closed. As an added precaution, people who have worked since October 11, 2001, in the non-public, mail operations area at postal facilities that directly receive mail from the Brentwood facility should also receive prophylactic treatment. There are no reported or documented cases of anthrax or contamination in these additional facilities, and CDC recommends they remain open. The U.S. Postal Service, in conjunction with the Health Departments of the District of Columbia, Maryland, and Virginia, and CDC, is identifying and contacting these facilities.

Visitors at the Brentwood facility who should receive prophylactic treatment are defined as vendors, contractors, and persons who handle mail in the mailroom bulk mail acceptance unit. It is not necessary for customers who entered any U.S. Postal facility to purchase stamps or conduct other postal business to receive prophylactic treatment.

Only the persons described above who are currently located in the metropolitan DC area or surrounding areas of Maryland and Virginia should seek these services from the DC General Hospital, 1900 Massachusetts Avenue from 9:00 A.M. - 10 P.M. Those located outside the metropolitan DC area should seek these services from their state or local health department or private physician. DC General Hospital is accessible by METRO (Orange and Blue Lines/Armory Stadium Station).

CDC's investigation is ongoing. Future modifications to these recommendations may occur on the basis of new epidemiologic and laboratory information.