How Physicians Can Help
Antibiotics and Anthrax - Consumer Report

Bioterrorism Signs and Symptoms - Oct. 10, 2001
Official CDC Health Advisory - Oct. 12, 2001
Anthrax Recommendations as of 10/17

Bioterrorism Readiness

For over 125 years the Dallas County Medical Society has been the voice of physicians in Dallas County. Today, nearly 6000 physicians strong, we strive to represent and aid physicians on issues affecting their practice as well as their patients - from organizing physicians to respond to potential bioterrorist attacks and offering sources for volunteerism, to voicing concerns regarding potential anti-trust situations in health care and sounding alarms on managed care injustices.

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Antibiotics & Anthrax - Consumer Report

Consumer Reports health experts have prepared a report about safe, effective and appropriate use of antibiotics; as well as the availability of, and risks associated with, vaccinations for anthrax and smallpox. Click here to view thBe report.

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Bioterrorism Signs and Symptoms

DCMS ALERT

Page 1 of 1 October 10, 2001

Because of the reported anthrax cases in Florida, DCMS has received numerous calls inquiring about symptoms and detection. Symptoms or diagnostic results of likely bioterrorism candidates include:

• Fever, fatigue, malaise, myalgias, mild chest pain, and a nonproductive cough followed by severe respiratory distress with dyspnea, diaphoresis, stridor, and cyanosis, with a widened mediastinum on chest x-ray (indicative of Anthrax).
• Dysphagia, dry mouth, diplopia, dysarthria, dysphonia, and symmetric descending paralysis (could mean Botulism).
• High fever, chills, headache, malaise, myalgias, and cough with gram-negative, safety pin-shaped organisms and hemoptysis in patients (suggests Plague).
• Lesions simultaneously progressing from macules to papules to pustular vesicles (characterizes Smallpox).

As with any notifiable condition, quick and prompt action must occur. Be suspicious of any unusual symptoms and err on the side of caution. Report suspected outbreaks to the Dallas County Health Department at 214-819-2004 for communicable diseases. After hours, page Dallas County Epidemiologist Assefa Nega Tulu, MD, at 214-528-6125.

For more information:

• JAMA has published a series of articles by the Working Group on Civilian Biodefense that outlined recommendations following the use of five biological weapons: small pox, anthrax, plague, botulinum toxin, and tularemia. They are available free at www.jama.com.
• www.hopkins-biodefense.org
• www.bt.cdc.gov
• www.texmed.org/has/bioterrorism.asp

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Official CDC Health Advisory

Distributed via Health Alert Network October 12, 2001, 21:00 EDT (9:00 PM EDT)

HOW TO HANDLE ANTHRAX & OTHER BIOLOGICAL AGENT THREATS

What to do:

• If you receive a suspicious unopened letter or packaged marked with a threatening message.
• If an envelope with powder and powder spills out onto surface.
• If you are concerned that a room has been contaminated by aerosolization.
• How to identify suspicious packages and letters.

Anthrax organisms can cause infection in the skin, gastrointestinal system, or the lungs. Although life-threatening if not treated, prompt recognition and treatment are effective.

Many facilities in communities around the country have received anthrax threat letters. Most were empty envelopes; some have contained powdery substances. The purpose of these guidelines is to recommend procedures for handling such incidents.

DO NOT PANIC
For anthrax to be effective as a covert agent, it must be aerosolized into very small particles. This is difficult to do, and requires a great deal of technical skill and special equipment.

• To be infected, the organism must be rubbed into abraded skin, swallowed, or inhaled as a fine, aerosolized mist.
• Disease can be prevented after exposure to the anthrax spores by early treatment with the appropriate antibiotics.
• Anthrax is not spread from one person to another person.

Back to "What to do" list

If you receive a suspicious unopened letter or packaged marked with a threatening message:

1. Do not shake or empty the contents of any suspicious envelope or package.
2. PLACE the envelope or package in a sealed plastic bag or some other type of container to prevent leakage of contents.
3. If you do not have any container, then COVER the envelope or package with anything (e.g., clothing, paper, trash can, etc.) and do not remove this cover.
4. Then LEAVE the room and CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away).
5. WASH your hands with soap and water to prevent spreading any powder to your face.
6. Call '911' to report the incident to local police and notify any building security official or available supervisor.
7. LIST all people who were in the room or area when this suspicious letter or package was recognized. Give this list to both the local public health authorities and law enforcement officials for follow-up investigations and advice.

Back to "What to do" list

If an envelope with powder and powder spills out onto surface:

1. DO NOT try to CLEAN UP the powder. COVER the spilled contents immediately with anything (e.g., clothing, paper, trash can, etc.) and do not remove this cover!
2. Then LEAVE the room and CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away).
3. WASH your hands with soap and water to prevent spreading any powder to your face.
4. Call '911' to report the incident to local police and notify any building security official or available supervisor.
5. REMOVE heavily contaminated clothing as soon as possible and place in a plastic bag, or some other container that can be sealed. This clothing bag should be given to the emergency responders for proper handling.
6. SHOWER with soap and water as soon as possible. Do Not Use Bleach Or Other Disinfectant On Your Skin.
7. If possible, list all people who were in the room or area, especially those who had actual contact with the powder. Give this list to both the local public health authorities so that proper instructions can be given for medical follow-up, and to law enforcement officials for further investigation.

Back to "What to do" list

If you are concerned that a room has been contaminated by aerosolization (for example, if you receive a warning that the air handling system is contaminated, or that a biological agent was released in a public space):

1. Turn off local fans or ventilation units in the area.
2. LEAVE area immediately.
3. CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away).
4. Dial '911' to report the incident to local police and local FBI field office.
5. SHUT down air handling system in the building, if possible.
6. If possible, list all people who were in the room or area. Give this list to both the local public health authorities so that proper instructions can be given for medical follow-up, and to law enforcement officials for further investigation.

Back to "What to do" list

HOW TO IDENTIFY SUSPICIOUS PACKAGES AND LETTERS

Some characteristics of suspicious packages and letters include the following:

• Excessive postage
• Handwritten or poorly typed addresses
• Incorrect titles
• Title, but no name
• Misspellings of common words
• Oily stains, discolorations or odor
• No return address
• Excessive weight
• Lopsided or uneven envelope
• Protruding wires or aluminum foil
• Excessive security material such as masking tape, string, etc.
• Visual distractions
• Ticking sound
• Marked with restrictive endorsements, such as "Personal" or "Confidential"
• Shows a city or state in the postmark that does not match the return address

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Anthrax Recommendations as of October 17, 2001
Dallas County Medical Society Board of Health

Advice for the Public

An anthrax infection begins with fever, a flu-like illness and possibly a painless blister or jet-black scab on the skin. In this initial stage, anthrax infection is still curable with a wide range of antibiotics. From the start of the fever, there are at least 4 days and possibly a week to begin antibiotics and expect a successful outcome. You cannot catch anthrax from another person who is sick with it.

Follow these guidelines if you are worried about getting anthrax.

When to call your doctor:

1. If you are ill with fever. (If you don't have a thermometer, go buy one. Fever is a reading above 100.5 degrees.)
2. If you have a new skin rash with a painless blister that quickly turns into a coal-black scab surrounded by severe swelling.
3. For public health advice, call your local health department (in Dallas County call the Dallas County Health Department, Dallas County Health and Human Services, at 214-819-2004)

What to do if you find a suspicious substance:

1. If it is associated with a threat, cover or contain it in a sealed plastic bag, wash your hands, and report it to the police by calling 911.
2. If it is not associated with a threat, it almost certainly will not contain anthrax and need not be reported. Use good judgment.
3. Never take a suspicious substance to a doctor's office or hospital.

When to take antibiotics:

1. Take antibiotics only if a physician prescribes them for a suspected anthrax infection or if you have been exposed to a substance proven by laboratory tests to contain anthrax. Remember that after a true exposure to anthrax or development of symptoms you have several days to start antibiotics.
2. Do not stockpile antibiotics. This could do more harm than good. Taking unnecessary antibiotics could cause germs to become resistant to antibiotics, interfere with lab tests to detect anthrax exposure, or produce serious side effects.
3. You cannot get an anthrax vaccine at this time. The human vaccine for anthrax is in short supply and is not available for civilians. If it were available in the future, it would take several doses over weeks to provide protection and has substantial side effects.

Advice for Physicians

1. Anthrax infection has three forms:
   Cutaneous anthrax - The skin lesion starts as a 1-cm papule, sometimes pruritic at first, that quickly forms a vesicle and then a painless, nonpruritic coal-black eschar surrounded by marked edema. It is almost always accompanied by fever and regional lymphadenopathy. It is always curable with antibiotics if treated early. Untreated, the mortality rate is 5-30%.
   Inhalation anthrax - A prodrome of fever, flu-like symptoms lasting 2-3 days, an asymptomatic interval lasting 2-3 days, and then a sudden septic episode that is fatal in 24 hours. The final stage may be accompanied by meningitis, abdominal pain, sepsis and chest wall edema. Antibiotics can cure most cases if given before the final stage. Untreated, the mortality rate approaches 100%.
   Gastrointestinal anthrax - High fever, abdominal pain, diarrhea, gastrointestinal hemorrhage, etc. (usually fatal but never seen in the U.S.)
   
2. The current CDC recommendation is not to perform nasal swabs for culture except for people exposed to a culture-proven source of B. anthracis, and this will be done by the health department.
   
3. If a patient brings in a suspicious substance, immediately contain it in a sealed plastic bag, wash your hands, and call the police. If they believe it represents a credible threat, they will take it to the level 3 laboratory at the Dallas County Health Department, Dallas County Health and Human Services (DCHHS) for testing and culture. Hospital laboratories should not process such environmental samples.
   
4. For asymptomatic people worried about anthrax exposure, prescribe antibiotics only for indicated infections or if a patient has been exposed to a substance culture-proven to contain anthrax. Samples from a suspected environmental exposure should be cultured for anthrax first, and decisions made on treating people as the results are obtained (usually within 24 hours). Remember that after an anthrax exposure, you have several days to start antibiotics.
   
5. If you have a patient ill with signs and symptoms compatible with anthrax, treat with antibiotics for 60 days. Whereas intravenous penicillin has classically been the drug of choice, the fluoroquinolones (ciprofloxacin, levofloxacin and ofloxacin) are currently the first-line choice because the potential for penicillin resistance of biowarfare-engineered strains. Once antibiotic-susceptibility test results are available, one may be able to change to less expensive alternatives such as amoxicillin and doxycycline. Most wild strains of B. anthracis, are sensitive to most mainline antibiotics except trimethoprim-sulfamethoxazole and second/third generation cephalosporins; however, biowarfare strains are likely to be resistant to penicillins, tetracyclines and possibly other agents. Fluoroquinolones and tetracyclines are normally contraindicated in children and pregnant women; however, illness with anthrax outweighs these contraindications and these antibiotics could be used.
   
6. Anthrax infection is not spread person to person. Quarantine or facemasks are not required, and standard universal precautions are sufficient for patient care.
   
7. Contact Information:
   • To report illness compatible with anthrax, call the Dallas County Health Department, DCHHS at 214-819-2004.
   • For asymptomatic patients exposed to suspicious substances involving a threat, alert the Dallas Police Department by calling 911.
   • DO NOT SEND ASYMPTOMATIC PATIENTS OR SUSPICIOUS SUBSTANCES TO A HOSPITAL.
     
8. The human vaccine for anthrax is in short supply and not available for civilians. If it were available in the future, three doses (given at 0, 2, and 4 weeks post exposure) provides protection in 83% of recipients, and six doses over 12 months provides protection in 100% of recipients. The current vaccine has substantial side effects.

Advice for the Police and Fire Departments

1. Initiate investigation of " powder or suspicious substances" using established police protocols.
   
2. In case of a credible threat, contain the suspicious substance in a plastic bag and take it to the Level 3 laboratory at the Dallas County Health Department, DCHHS for testing for anthrax, etc. DO NOT TAKE OR SEND SUSPICIOUS SUBSTANCES TO A HOSPITAL.
   
3. For anthrax related threats judged to be serious, respond with full Haz-Mat gear. For calls not considered serious threats or if overwhelmed by large numbers of calls where Haz-Mat gear is impractical, a particulate respirator (a standard hospital "TB mask," efficient for particles < 1 micron in size) and rubber gloves are sufficient to protect against inhalation anthrax and most cutaneous anthrax. Cutaneous anthrax is always curable with antibiotic treatment. "Splash suits" to protect clothing from spores would also be desirable, but less vital.
   
4. For citizens exposed to substances of unknown composition, record names, addresses and telephone numbers for later follow-up by the Dallas County Health Department, DCHHS. Do not refer healthy people to the hospital to be tested for anthrax. If a suspicious substance is proven to contain anthrax by testing at the Dallas County Health Department, DCHHS laboratory, follow-up of potentially exposed citizens will be directed by the health department with assistance from police and fire departments.

The Role of the Dallas County Health Department Laboratory

1. All environmental specimens suspected of containing anthrax spores are tested at the Dallas County Health Department, DCHHS's Level 3 laboratory, and results are reported to the patients or their physicians and police department in a timely manner. Reporting includes:
   
   a) results of gram stain, spore stain and other rapid tests within 6 hours of receipt,
   b) results of culture within 24 hours, and
   c) definitive identification within 48 hours.
   
   This schedule of reporting is necessary to ensure timely treatment in case an anthrax exposure occurs. CDC and TDH are contacted for advice on the choice of tests and to confirm testing results.
   
   
2. A computerized records management system will be used to ensure accurate documentation of laboratory results and notification of patients and physicians. This will be critical if the number of specimens increases substantially.
   
   
3. If the volume of anthrax cultures or other bioterrorist-related testing overwhelms available laboratory personnel and resources, the Parkland laboratory can assist by assuming selected routine functions such as TB cultures. Otherwise, the county will ensure adequate resources to satisfy the laboratory and public consultative needs related to bioterrorist-related issues.