Biological Threat Evaluation Guidelines for Health Care Providers

Many facilities nationwide are receiving anthrax threat letters. As a result, hospital emergency departments and health care providers are seeing many patients seeking testing/treatment due to contact with suspicious substances. The purpose of these guidelines is to recommend procedures for handling such patients.

Anthrax is an immediately reportable disease as required by N.J.A.C. 8:57. Any suspected or confirmed case of anthrax should be reported immediately by telephone to the Local Health Department (where the patient resides) and by the Health Officer to the State Department of Health and Senior Services (DHSS), normal business hours at 609-588-7500, off hours at 609-392-2020. Be prepared to provide clinical and laboratory information that supports the diagnosis for appropriate investigation and control recommendations.

• DO NOT isolate the patient. There is no need to evacuate the Emergency Department or your office. Anthrax is not spread from person to person.
  
• Provide support and understanding to prevent panic.
  
• Reinforce to patients the rarity of infection without known, confirmed culture-positive exposure.
  
• If exposed skin may have come in contact with an unknown substance/powder, recommend washing with soap and water only.
  
• Record the individual's name, address, contact numbers and a brief description of perceived potential exposure. Forward to your local health department for follow-up.
  

• Reassure the patient about the low risk of infection without known, confirmed culture-positive exposure.
  
• Refrain from use of nasal swabs for diagnosis of exposure. Nasal swabs and blood serum tests are used as epidemiological tools to characterize an outbreak when there is a known confirmed biologic agent in an environmental sample. Nasal swabs are not diagnostic tools for anthrax in asymptomatic people.
  
• In addition, serologic studies that measure antibody titers to Bacillus anthracis are used as epidemiolgic tools, and prior to the recent anthrax cases, have been used in the context of testing immunologic response to receipt of anthrax vaccine. These serologic tests are not indicated for screening or initial diagnostic purposes.

1. Reassure patient about the low risk of infection even with exposure to a known
   confirmed, culture-positive environmental sample.
   
2. Prescribe antibiotic prophylaxis as recommended by public health authorities, as follows:

   Post-exposure Prophylaxis (PEP) Recommendations:
   
   

   	Initial therapy	Duration
   Adults (including pregnant women 1,2 and immunocompromised)	Ciprofloxacin 500 mg po BID OR Doxycycline 100 mg po BID	60 days
   Children 1,3	Ciprofloxacin 15-20 mg/kg po Q12 hrs 4 OR Doxycycline 5: >8 yrs and >45 kg: 100 mg po BID >8 yrs and < 45 kg: 2.2 mg/kg po BID <8 yrs: 2.2 mg/kg po BID	60 Days

   
   See table "Additional Antibiotic Recommendations" at end for comments
   
   

3. Public health authorities should interview the patient to determine individual risk
   assessment. If this was not done, inform the patient that you will be forwarding his/her contact information to the appropriate authorities.
   
4. Decontaminating the patient, other than by washing with soap and water, IS NOT indicated or recommended.

   Please note: Samples for a suspected case should be referred to a licensed clinical microbiology laboratory in New Jersey competent in the isolation of and the ability to rule out B. anthracis. The DHSS Public Health & Environmental Laboratories (PHEL) is available for consultation 24 hours a day: daytime phone (9am - 5pm) at 609-984-0488, after hours (Nextel number) 609-209-9004.

1. Confirm/rule out the diagnosis by obtaining the appropriate laboratory specimens based
   on the clinical form of anthrax that is suspected (inhalation, gastrointestinal, or cutaneous)
   
   • Inhalation - blood, CSF (if meningeal signs are present); chest X-ray
     
   • Gastrointestinal - vomitus, stool and/or blood
     
   • Cutaneous - vesicular fluid and blood
     
2. Send laboratory samples to a New Jersey licensed microbiology laboratory. Initial testing for B. anthracis include Gram stain and cultures.
3. In a suspected case of anthrax, you must notify your local health department and local law enforcement officials immediately.
   
4. Even in the presence of gastrointestinal or respiratory symptoms, physicians should first consider other diagnoses and treat accordingly.

1. Confirm/rule out the diagnosis by obtaining the appropriate laboratory specimens based on the clinical form of anthrax that is suspected (inhalation, gastrointestinal, or cutaneous)
   
   • Inhalation - blood, CSF (if meningeal signs are present); chest X-ray
     
   • Gastrointestinal - vomitus, stool and/or blood
     
   • Cutaneous - vesicular fluid and blood
     
2. Send laboratory specimens to the NJ PHEL in accordance with NJ PHEL protocols.
   
3. In a suspected case of anthrax, you must notify your local health department and local law enforcement officials immediately.
   
4. Begin antibiotic therapy for these persons

• DO NOT PANIC
  
• DO NOT shake or empty the contents of any suspicious package. DO NOT try to clean up powders or fluids
  
• Place the envelope or package in a plastic bag or other container to prevent leakage of contents. If no container is available, cover the package with anything (clothing, garbage can, paper, etc.) and do not remove this cover.
  
• LEAVE the room and CLOSE the door and ask everyone to leave, and prevent others from entering.
  
• WASH hands carefully with soap and water to prevent powder from spreading to face or skin.
  
• CALL local police, notify your building security official and contact DHSS at 609-538-6030.
  
• If possible, list all people who were in the room where the suspicious material was recognized. Provide this list to local police and local health department officials for follow-up investigations.
  
• Remove heavily contaminated clothing and seal in a plastic bag, and give to local police.
  
• The bag should be labeled clearly with the owner's name, contact telephone number and inventory of the bag's contents. The local police will bring the bag to the PHEL in Trenton for testing.
  
• For incidents involving possibly contaminated material, the environment in direct contact with the letter or its contents should be decontaminated with a solution of one part household bleach to 10 parts water, following a crime scene investigation. Personal affects may be decontaminated similarly.
  
• Shower with lots of soap and water as soon as possible. Do not use bleach or disinfectant on your skin.

Table: Additional Antibiotic Recommendations

* Signs and Symptoms of Clinical Anthrax

Cutaneous: a skin lesion that evolves over 2 to 6 days from a papule, to a vesicle, to a depressed black eschar

Inhalation: a brief prodrome (1-3 days) resembling a viral respiratory illness (including fever, malaise, mild cough or chest pain), followed by respiratory distress (hypoxia and syspnea) and shock with radiographic evidence of mediastinal widening

Intestinal: severe abdominal distress followed by fever and signs of septicemia

Oropharyngeal: mucosal lesion in the oral cavity or oropharynx, cervical adenopathy and edema, and fever

For more information, please visit the DHSS website at www.state.nj.us/health.