Anthrax Information

Current recommendations from PMHS (12/6/01, watch this space for updates) are as follows.

Per Dr. Alan Hodgdon:

Date sent: Fri, 02 Nov 2001 16:06:04 -0500 From: "Hodgdon MD, Alan" <AHODGDON@mercy.pmhs.org> Subject: Anthrax update To: "'emap@list.pitt.edu'" <emap@list.pitt.edu> Send reply to: emap@list.pitt.edu

Hi all, Just so we are on the same page on this, I have put this note up at MPH. I have been in several meetings with the Post Office about this lately, including one today when the main Postal facility was tested for anthrax. You can read the stuff from the CDC, and Allegheny County Health Department and they mirror this for patients without verified exposure to anthrax.

Anthrax Notes:

1. The nurses have a yellow binder that contains anthrax information and a patient handout. This is kept up to date, so if you have a suspicious case, consult the yellow binder.

2. No one is to be placed on antibiotics for prophylaxis or treatment of anthrax, without a discussion of the case with the Allegheny County Health Department. This goes for nasal swabs as well. To date, there have been no reported cases in Allegheny County, so don't treat a disease that is not here.

3. The procedure in place at the Post Office is the Postal Inspector tests the suspect parcel for anthrax. This would have the highest concentration of organisms/spores to test. This is much better than testing individuals. If the suspect parcel is positive for anthrax, there is time to treat the exposed employee and all of the rest of the exposed parties. If you begin routine testing or prophylaxis, you can just plan on seeing all of the Postal Service employees over the next few days. Be careful!

4. I would adopt the above strategy for non-Postal patients as well. Test the suspicious object that caused the exposure, not the patient.

5. Questions call me (412-512-6642) or Gaye.

Thanks,

alan

... \\from the EMAP list -- Emergency Medicine Assn. of Pittsburgh//

Bottom Line:  if patients have no symptoms, there is no need for testing for any clinical reasons.  They may need treatment however, and see the JAMA article and PA Health Alert #16 to choose an appropriate antibiotic.  Clinical testing is only for patient that YOU suspect may have clinical infection with anthrax -- or for epidemiologists to use in evaluating a known exposure.  Nasal swabs, blood cultures, blood titres, etc. have no role in screening.  Despite what a few rogue physicians are saying, the CDC and various state health departments agree:  asymptomatic patients don't need testing.  

Why?  Same reason we don't want these people to come to the ED.  If we are overloaded taking care of people who just need hand-holding, we can't take care of people who are really sick.  And if we send nasal swabs on everyone, the labs will be overloaded, their techs will be overworked and fatigued, more likely to make mistakes, and it'll slow down our lab results for people who really are sick.   Here is what our County Health Department says:

NEWSFAX Release: Thursday, October 18, 2001 
Contact: Guillermo Cole, Public Information Officer 
Phone: 412-578-8004 FAX: 412-578-8325 E-mail: gcole@achd.net

HEALTH DEPT. ANNOUNCES ANTHRAX TESTING AND TREATMENT GUIDELINES

In response to growing public concerns about anthrax in suspicious-looking mail, the Allegheny County Health Department today announced its policy for testing environmental samples as well as recommendations for the testing and treatment of humans for possible anthrax exposure.

Numerous samples of suspicious powders and other materials collected by hazmat crews and local law enforcement officials will be tested for anthrax only if there has been a credible threat of exposure through inhalation, skin contact or ingestion. No human testing is recommended unless a sample from the environment tests positive.

"We strongly discourage anyone from seeking testing or treatment from a doctor or hospital emergency department unless they are sick or there is a positive sample from their environment," said County Health Director Dr. Bruce W. Dixon. "Testing or treating someone when no credible threat of anthrax exposure exists makes no sense. It would needlessly subject them to possible side effects and could lead to antibiotic resistance, which means that in the future when they might really need treatment the drug may be ineffective."

Doctors, hospitals and laboratories throughout the nation are on a heightened state of surveillance for unusual disease occurrences and patterns. No anthrax cases have been reported locally.

For additional information about anthrax, please call the Allegheny County Health Department at 412-687-ACHD.  Visit our Web site at: www.county.allegheny.pa.us/achd

J. David Piposzar, MPH, Environmental Health Administrator Allegheny County Health Department, 3333 Forbes Avenue Pittsburgh, PA 15213 phone: 412-578-8365 fax: 412-578-8325, e-mail: dpiposzar@achd.net

bulletIf an asymptomatic patient presents to the ED:
Note:  there is NO clinical screening test for asymptomatic patients, screening tests are ONLY used by the health department for epidemiologic reasons but not as a clinical test!
If there is no known exposure:  no testing, no treatment, reassure and give the patient this handout and this handout and this handout and discharge.
If there is potential exposure and has not been reported to authorities yet:  call the County Health Department at: 412-578-8060 (working hours) 412-687-ACHD (after hours, weekends, holidays).  Unless the health department says otherwise,  no testing, no treatment, reassure and give the patient this handout and this handout and this handout and discharge.
bulletIf an ED patient may be contaminated with anthrax spores, place patient in Mercy or MPH ED decontamination room for showering, close off room as per Disaster Plan, and call 9-1-1 or Medic Command at (412) 647-5858.
bulletIf you answer a call about possible exposure:  
1. Patients who might be contaminated with anthrax spores should NOT come to the ED, but should call 9-1-1 and follow the dispatcher's advice.
2. People should NEVER bring suspicious materials or parcels to the ED -- employers should call 9-1-1 and have the police and HazMat teams deal with them appropriately, individuals with concerns about materials in their possession should call the County Health Department at: 412-578-8060 (working hours) 412-687-ACHD (after hours, weekends, holidays). If someone shows up at an ED with a suspect parcel, leave it outside the doors and call 9-1-1.
3. People who suspect they were exposed to anthrax but who are asymptomatic should NOT have any testing done UNLESS the County Health Department confirms there was sufficient risk of exposure to anthrax to justify it: 412-578-8060 (working hours) 412-687-ACHD (after hours, weekends, holidays). 
bulletIf you clinically suspect anthrax and will be treating for clinical anthrax (NOT if the patient is worried about anthrax; see the JAMA article, below, for a description of known clinical syndromes):
       1. Send  one nasal culture, swabbed from both nares; enter in computer under "miscellaneous" and on second line, enter "r/o organism screen" and "r/o anthrax."
       2. No need to send throat culture unless patient has bad sore throat and you think it might be high-yield.
       3. Culture any skin lesions.
       4. NO blood cultures or other blood tests unless patient is sick enough that they are otherwise clinically indicated.  There is evidence that blood cultures can be an extremely valuable tool in possible cutaneous anthrax. (See PA Dept. of Health Bulletin #15).  Please obtain blood cultures if you suspect cutaneous anthrax.
       5. Leave a message on the Infection Control answering machine (412-232-7798) about the patient so they can follow up on this (if questions, someone from Infection Control is on call 24 hours a day, available through the Mercy Operator at 412-232-8111).
bulletAny time you are admitting with possible anthrax, or have a very strong suspicion even for a patient being discharged, you should alert the Allegheny County Health Department (412-578-8060) (working hours) 412-687-ACHD (after hours, weekends, holidays) as well as Infection Control (412-232-7798).
bulletPatients with potential occupational exposure, including Post Office: give them Ocunet followup as with all work-related problems.
bulletAll cultures are done at the micro lab at Mercy main, and if positive, are forwarded to the Allegheny County Health Department and if needed to the State Public Health Lab, operated by the Pennsylvania Department of Health.  
bulletIf an employer demands that "you have to send our employees' blood to the CDC" politely refuse and refer them to the County Health Department if they have problems with this > 412-578-8060 (working hours) > 412-687-ACHD (after hours, weekends, holidays).

Links to Additional Anthrax Information

bulletPA Department of Health Update #11
bulletPA Department of Health Update #12
bulletPA Department of Health Update #14 
bulletPA Department of Health Update #15
bulletPA Department of Health Update #16 (with anthrax susceptibilities)
bulletPA Department of Health Update #17 consists of the relevant portions of the 
Oct 26 CDC MMWR with many details of the current anthrax outbreak.  However, as distributed it is a 1.5 MB Word file with an ugly rendition of the original, so I have taken the liberty of downloading the original PDF file from the CDC site and excerpted the 75K relevant portions.
bullet PA Department of Health Update #18
bullet PA Department of Health Update #22 -- (note that only alerts, and portions of alerts, relevant to emergency medicine are posted here):

CORRECTION: Laboratory Specimens for Anthrax PCR: In Health Alert #20 (November 2, 2001) we recommended collecting whole blood for PCR in a red top tube. Instead, a lavender-topped tube (with EDTA) should be used. The relevant section should read:

If the patient is a suspicious case of cutaneous anthrax and is febrile or hospitalized, please also collect: a. Blood for buffy coat Gram stain and culture: b. Send to routine hospital laboratory, if suspicious Bacillus species is identified, contact your local health department, if any, and the PADOH immediately at 877-PA-HEALTH. c. Whole blood for PCR: (lavender top tube)

bullet PA Department of Health Update #21
bullet PA Department of Health Update #23
bulletMercy Infection Control anthrax handout  good patient handout
bulletAllegheny County Health Department Anthrax Information excellent patient handout
bulletAllegheny Co. EMS Anthrax Information
(note that Knox Walk has approved posting here; useful primarily as background briefing material for EMS and ED personnel)
bulletJAMA Consensus article on Anthrax (excellent medical reference):
  link to JAMA web site to read online;
 local PDF file of above to print or in case link is broken
bulletCDC MMWR link: "Bioterrorism Alleging Use of Anthrax and Interim Guidelines for Management"
bullet CDC MMWR excerpt Oct 19: Update: Investigation of Anthrax Associated with Intentional Exposure and Interim Public Health Guidelines, October 2001
bullet CDC MMWR excerpt Oct. 26: Update: Investigation of Bioterrorism-Related Anthrax and Interim Guidelines for Exposure Management and Antimicrobial Therapy, October 2001 
bulletCDC Health Advisory: How to Handle Anthrax and Other Biological Agent Threats;
bulletlocal PDF file of above in case link is broken  excellent patient handout
bulletUS Postal Service information on suspicious packages (note:  for local Postal Inspectors contact the California Avenue post office at 412-359-7900.)
bulletCDC MMWR December 7 issue with Anthrax bioterrorism update