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HomeMy WebLinkAboutAnthrax - 11/1/2001CO_D lS o m �) \ b1 < M m.Az GI D SAL'^ m � o Z G V = `_ z0 z o 1 ly G o -n a 4' ,(Oj 0) V, p y n �<m OU o - ZZ - �. Q l ^' ..- A O f 1 o m � � p�� � �� J�Q, '^C, a.. 91 o >a C 'l m .Dco z z v m z cn m a X° q \/ w 7§t o o» �r \^ o §)k` k \ VJ�� � 0 0 / - §; qm & ;q w » G }§ 27§ © Emm �0UU r / \ j 3 w G (§ m Gm y $ y / ) /10 R Of \ f D z w I f z 0 0 m z k m m T 0 m � JANE SWIFT GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617)983-6200 08/19/2002 �i AUG 2 5 2002 Submitted By: SCOTT LEITE MANSFIELD BOARD OF HEALTH 6 PARK ROW MANSFIELD, MA 02048 RE: Environmental Specimen submitted for anthrax determination Report Date: 08/19/2002 Submitter ID: 1436 Date Received: 08/16/2002 Sample ENVELOPE FROM POST OFFICE PICKED UP BY CHRYSLER CREDIT CORP. AND BROUGHT BACK TO Description: THEIR FACILITY @ 89 FORBES BLVD. Location Name: CHRYSLER CREDIT CORP. 89 FORBES BLVD. MANSFIELD, MA 02048 Laboratory 02B-0168 Number: Tracking SLI-3239 Number: Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS FOUND Please let us know if you would like this sample returned by calling (617) 983-6291. If we do not hear from you within 15 days, we shall assume that you have no further need for it and it will be discarded. For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at (617) 983-6626. Sincerely, IN — for Ralph J. Timpen Assistant Commissioner Department of Public Health State Laboratory Institute 08/27/2002 TUE 12:09 FAX 508 261 7425 TOWN OR MANSFIELD Z001 TX REPORT TRANSMISSION OIi TX/RX NO 0666 DEPT. ID 3652 CONNECTION TEL 915082619798 SUB -ADDRESS CONNECTION ID ST. TIME 08/27 12:08 USAGE T 00'40 PGS. 2 RESULT OR TOWN OF MANSFIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 FAX COVER SHEET TOWN OF MANSFIELD BOARD OF Hi~ALTH Date: 0 a- Time: From: Town of Mansfield Phone: 508-261-7366 Board of Health Fax; ' 508-261-7343 Six Park Row Mansfield, MA 02048 To: _Y , (3,-r r �5o s a61-y )x3y Type of Forml�nq 'r' � r t Message: No of pages: (Incl. cover sheet) J The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 62130 (617) 983-6200 JANE SWIFT GOVERNOR R6BERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER December 04, 2001 Submitted By: CHIEF BACKLUND MANSFIELD FIRE DEPARTMENT 10 PLYMOUTH STREET MANSFIELD, MA 02048 RE: Environmental Specimen submitted for anthrax determination SubmitterID: MANSFIELD30-1 Date Received: 10/30/2001 Sample FINE WHITE POWDER FROM AN OPENED ROLL OF PENNIES FROM AN UNKNOWN LOCATION Description: WHICH SPRAYED INTO THE AIR. Location Name: MANSFIELD CO-OP BANK —_ 80 NORTH MAIN ST- MANSFIELD, MA 02048 Laboratory bIB-1519 Number: Tracking SLI-1414 Number: Test Methods: GROSS EXAMINATION Test Results: NO EXTRANEOUS MATERIALS OBSERVED For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at (617) 983-6626. Sincerely, '. for Ralph J. Timperi Assistant Commissioner Department of Public Health State Laboratory Institute )QVVVL-� 1L/11/LUV1 1UL` lU:GI PAA UVV GVi �xGV iVva va uannva aua.v �VVi TRANSMISSION OK TX/RX NO DEPT. ID CONNECTION TEL SUB -ADDRESS CONNECTION ID ST. TIME USAGE T PGS. RESULT •x.N:•x. TX REPORT 0202 3652 95082619798 12/11 10:26 00'43 2 OK TOWN OF MANSFIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 FAX COVER SHEET TOWN OF MANSFIELD BOARD OF HEALTH Dater_ aTI01 Time: 9:wo From: Town of Mansfield Board of Health' Six Park Row (� Mansfield, MA f 02048 To: l I . � ! no, e Phone: 508-261-7366 Fax: 508-261-7343 Type of Form No of pages: 0— Message: (Incl, cover sheet) The Commonwealth of Massachusetts _ Executive Office of Health and Human Services Department of Public Health a State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 ° (617)983-6200 JANE SWIFT GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER December 04, 2001 Submitted By: SCOTT LEITE MANSFIELD HEALTH DEPARTMENT 6 PARK ROW MANSFIELD, MA 02048 RE: Environmental Specimen submitted for anthrax determination Submitter ID: 2091 Date Received: 11/07/2001 Sample Description: WHITE POWDER ON FED EX BOX Location Name: NORTH ATLANTIC INTERNET INC. 800 SOUTH MAIN ST. LOWER LEVEL MANSFIELD, MA Laboratory Number: OIB-1886 Tracking Number: SLI-2365 Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS FOUND For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at (617) 983-6626. Sincerely, for Ralph J. Timperi Assistant Commissioner Department of Public Health State Laboratory Institute The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health up, State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617)983-6200 JANE SWIFT - GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER - December 03, 2001 Submitted By: SCOTT LEITE HEALTH AGENT 6 PARK ROW MANSFIELD, MA 02048 RE: Environmental Specimen submitted for anthrax determination Submitter ID: 2124 , Date Received: 11/10/2001 Sample Description: WHITE POWDER RESIDUE BAG CONTAINING RAW MATERIAL UPHOLSTERY FABRIC. Location Name: ROBERT ALLEN FABRIC 55 CABOT BLVD. MANSFIELD, MA 02048 Laboratory Number: OIB-2046 Tracking Number: SLI-2510 Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS FOUND For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at (617) 983-6626. Sincerely, � l!Q for Ralph J. Timperi Assistant Commissioner Department of Public Health State Laboratory Institute JANE SWIFT GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617)983-6200 i December 04, 2001 Submitted By: CHIEF ROBERT BELLA VANCE MANSFIELD FIRE DEPARTMENT 10 PLYMOUTH STREET MANSFIELD, MA 02048 RE: Environmental Specimen submitted for anthrax determination Submitter ID: Date Received: 10/16/2001 Sample GROUND CREW AT MANSFIELD HIGH SCHOOL FOUND PACKAGE AT THE SCHOOL'S Description: LOADING DOCK. Location Name: MANSFIELD HIGH SCHOOL MANSFIELD, MA 02048 Laboratory OIB-0188 Number: Tracking Number: SLI-1127 Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS FOUND For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at (617) 983-6626. Sincerely, for Ralph Assistant Commissioner Department of Public Health State Laboratory Institute 16) TOWN OF MANSFIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 FAX COVER SHEET TOWN OF MANSFIELD BOARD OF HEALTH Date: Ia! '% JO/ Time: From: Town of Mansfield Phone: 508-261-7366 Board of Health Fax: 508-261-7343 Six Park Row (�Mansfield, MA 02048 To: Type of Form No of pages: Message: (Incl. cover sheet) jury ii,-iaaa 12/07/2001 FRI 11:06 FAX 508 261 7425 TO{YN OF MANSFIELD M TX REPORT xw TRANSMISSION OK TX/RX NO 0199 DEPT. ID 3652 CONNECTION TEL 95082619798 SUB -ADDRESS CONNECTION ID ST. TIME 12/07 11:04 USAGE T 01'16 PCs. 4 RESULT OK TOWN OF MANSFIELD; MASSACHUSETTS Six Park Row, Mansfield, MA 02048 FAX COVER SHEET TOWN OF MANSFIELD BOARD OF HEALTH Date: /c,��U/ _ Time: % b.A Q�,, From: Town of Mansfield Phone: 508-261-7366 Board of Health-, Fax: 508-261-7343 Six Park Row Mansfield, MA 02048 To: S/, rk Type of Form No of pages: Message: (Incl. cover sheet) 150�k y0kr' _�cXr1oS r4S r0yn Page I of 1 BLT Infortnation System The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 1T„ U11State Laboratory Institute 'jI305 South Street, Jamaica Plain, MA 021301' �Qll �l f ?QQI (617) 983-6200 I L JANE SWIFT ; 3y GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER Submitted By: CHIEF EDWARD SLINEY JR, November 15, 2001 MANSFIELD FIRE DEPT. 10 PLYMOUTH ST. MANSFIELD, MA, 02048 RE: Environmental Specimen submitted for anthrax determination Submitter ID: 2136 Date Received: 11/12/2001 CHEN COUNTER. Description: ENVELOPE, BAG INITIALLY USED BY OWNER, AND GLOVES INCLUDED- LocaSample GRANULES tion Name: RESIDENCE 78 WARE ST. MANSFIELD, MA, 02048 Laboratory OIB-2071 Number: Tracking SLI-2537 Number; Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS FOUND If you have any questions, please call (617) 983-6626. Sincerely, for Ralph J. Timperi Assistant Commissioner Department of Public Health State Laboratory Institute The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617) 983-6200 ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER November 19, 2001 Submitted By: SCOTT LEITE HEALTH AGENT 6 PARK ROW MANSFIELD, MA 02048 RE: Environmental Specimen submitted for anthrax determination Submitter ID: 2172 Date Received: 11/16/2001 i iC� tU7 `I i' I1rU V ,9 %00t Sample Description: WHITE POWDERY SUBSTANCE FOUND ON TABLE AND FLOOR IN THIRD FLOOR CAFETERIA.' Location Name: TYCO HEALTHCARE KENDALL 5 HAMPSHIRE ST MANSFIELD, MA 02048 Laboratory OIB-2170 Number: Tracking Number: SLI-2619 Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS FOUND For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at (617) 983-6626. Sincere y, for Ralph J. Timperi Assistant Commissioner Department of Public Health State Laboratory Institute BLT Information System Page I of I The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617) 983-6200 JANE SWIFT GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER Submitted MANSFIELD POST November 07, 2001 MANSFIELD FIRE DEPT. 10 PLYMOUTH STREET MANSFIELD, MA, 02048 RE: Environmental Specimen submitted for anthrax determination SubmitterID: Date Received: 10/16/2001 7 i' �' '�i III I Z0 I !1' Sample MANSFIELD POST OFFICE - WHITE GRANULAR POWDER INSIDE ZIP -LOCK BAG Description: FOUND IN POST OFFICE. Location Name: MANSFIELD POST OFFICE MANSFIELD, MA, Laboratory OIB-0178 Number: Tracking Number: SLI-0881 Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS POUND If you have any questions, please call (617) 983-6626. Sincerely, �-&ckt.� �) Ralph J. Timperi Assistant Commissioner Department of Public Health State Laboratory Institute The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617) 983.6200 ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER Submitted By: CHIEF EDWARD SLINEY MANSFIELD FIRE DEPT. 10 PLYMOUTH STREET MANSFIELD, MA 02048 RE: Environmental Specimen submitted for anthrax determination Submitter ID: 2255 Date Received: 11/27/2001 Sample Description: JACKET Location Name: ROBERT ALLEN FABRICS 260 FORBES BLVD. MANSFIELD, MA 02048 Laboratory Number: OIB-2157 Tracking Number: SLI-2740 Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS FOUND For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at (617) 983-6626. Sincerely, for Ralph J. Timperi Assistant Commissioner Department of Public Health State Laboratory Institute ii 0EG' ?001 %I December 03, 2001 The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617)983-6200 JANE SWIFT GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER November 30, 2001 Submitted By: CHIEF EDWARD SLINEY MANSFIELD FIRE DEPARTMENT 10 PLYMOUTH STREET MANSFIELD, MA 02048 RE: Environmental Specimen submitted for anthrax determination Submitter ID: Date Received: .11/02/2001 Sample Description: EDDIE BAUER CATALOG Location Name: RESIDENCE 1315 REBECCA RD. NORTH DIGHTON, MA Laboratory Number: 0113-1709 Tracking Number: SLI-2218 Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS FOUND For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at (617) 983-6626. for Ralphl 7. TunpanO� t Assistant Commissioner Department of Public Health State Laboratory Institute The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617)983-6200 JANE SWIFT GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER November 30, 2001 Submitted By: ROBERT BELLAVANCE MANSFIELD FIRE DEPARTMENT 10 PLYMOUTH STREET MANSFIELD, MA 02048 RE: Environmental Specimen submitted for anthrax determination Submitter ID: 2059 Date Received: 11/02/2001 Sample Description: PLASTIC MILITARY STYLE CANTEEN -FOUND ON HOMEOWNERS LAWN Location Name: RESIDENCE 22 DONALD ALLEN DR MANSFIELD, MA Laboratory Number: OIB-1711 Tracking Number: SLI-2220 Test Methods: GROSS EXAMINATION Test Results: NO EXTRANEOUS MATERIALS OBSERVED For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at�(617) 983-6626. Sincerely, for Ralph J. Timperi Assistant Commissioner Department of Public Health State Laboratory Institute , i ;! The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617) 983-6200 JANE SWIFT GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER Submitted By: CHIEF ROBERT BELLAVANCE MANSFIELD FIRE DEPARTMENT 10 PLYMOUTH STREET MANSFIELD, MA 02048 RE: Environmental Specimen submitted for anthrax determination Submitter ID: i November 30, 2001 Date Received: 11/02/2001 Sample Description: UNKNOWN POWDER FOUND ON TAPE, POWDER FOUND ON GROUND IN FRONT OF SUPERMARKET Location Name: SUPERMARKET GROUND 65 COPELAND STREET MANSFIELD, MA Laboratory OIB-1651 Number: Tracking Number: SLI-2219 Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS FOUND For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at (617) 983-6626. Sincerely, for Ralph J. Timperi Assistant Commissioner Department of Public Health State Laboratory Institute 12/05/2001 WED 10:47 FAX 508 261 7425 TOWN OF MANSFIELD 121001 WWI TX REPORT *r TRANSMISSION OK TX/RX NO 0190 DEPT. ID 3652 CONNECTION TEL 95082619798 SUB -ADDRESS CONNECTION ID ST. TIME 12/05 10:45 USAGE T 02'19 PGS. 8 RESULT OK TOWN OF MANSFIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 FAX COVER SHEET TOWN OF MANSFIELD BOARD OF HEALTH " Date: Time: 9 : -6— () 0_, From: Town of Mansfield Phone: 508-261-7366 Board of Health` Fax: ' 508-261-7343 Six Park Row Mansfield, MA 02048 70: rye ! �f V. r Type of Form F� Y T No of pages: Message: (Incl. cover sheet) 0rr)I TOWN OF MANSFIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 FAX COVER SHEET TOWN OF MANSFIELD BOARD OF HEALTH Date: S Time: From: Town of Mansfield Phone: 508-261-7366 Board of Health Fax: ' 508-261-7343 Six Park Row Mansfield, MA 02048 To: CA r�s-z Sli n-1 U Sad �/ - 9-� Type of Form Y TT No of pages: Message: (Incl. cover sheet) July 17, 1998 TOWN OF MANSFIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 FAX COVER SHEET TOWN OF MANSFIELD BOARD OF HEALTH Date: 0 01 Time: �/ •"�%�� From: Town of Mansfield Phone: 508-261-7366 Board of Health Fax: 508-261-7343 Six Park Row Mansfield, M 02048 To: Type of Form Message: No of pages: �— (Incl. cover sheet) July 17, 1998 �� S� 11/21/2001 WED 10:56 FAX 508 261 7425 TOWN OF MANSFIELD Q001 Ww TX REPORT �W TRANSMISSION OK TX/RX NO 0175 CONNECTION TEL 95082619798 SUB -ADDRESS CONNECTION ID ST. TIME 11/21 10:55 USAGE T 00'38 PGS. 2 RESULT OK TOWN OF MANS.FIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 FAX COVER SHEET TOWN OF MANSFIELD BOARD OF HEALTH Dater 0 I Time:�sa From: Town of Mansfield Phone: 508-261-7366 Board of Health Fax: 508-261-7343 Six Park Row Mansfield02048 To: Type of Form No of pages: .�? -- Message: (Incl. cover sheet) a� u R� '� � au d• � •„rp � O y F H ;a tia � a U o Q U uD � .i p) NCG UJ lV @ Z C7 C Q o © N � G1 UC(13 No r-n.0'coA cNa �y O E J 63 Q V N E E 0 G U a ,n �3 0 � m T•d 0661.-T92(60S) pTai,}su(-W JO UMOI E9S:60 TO b0 oaa L&, \Pc, A, 121 JANE SWIFT GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619 CLINICAL ADVISORY To: Healthcare Providers, Facilities, and Local Health Departments From: Howard K. Koh, MD, MPH Commissioner Date: October 17, 2001 Re: Information and Resources Regarding Anthrax 1oNum III OCT 2 g 2001 Incidents of anthrax and anthrax exposure have occurred in several locations around the United States. Thus far, there have been no cases of anthrax or anthrax exposure identified in Massachusetts, despite intensified surveillance. The Massachusetts Department of Public Health (MDPH) wants to make you aware of existing and upcoming resource materials on the MDPH website www.state,ma.us/dph. In addition to earlier clinical and general advisories; posted today is guidance adapted from material from by the US Centers for Disease Control and Prevention providing clinical information for local health departments, health care providers and laboratories (see "Guidelines for Responding to Concerns About Anthrax" posted under "Provider Information" on the website). These detailed guidelines (too extensive to fax) deal with the management of exposures and possible exposures to anthrax and the laboratory procedures related to the diagnosis of infection due to Bacillus anthraces. They may be helpful in providing background information for counseling patients and coordinating clinical and laboratory activities. It should be noted that concern is highest for circumstances of recognized risk, i.e. situations where mail or other materials arrive in the context of a verbal or written threat or contain powder or other suspicious material. In order to protect the public and avoid increased anxiety and unnecessary treatment, it is important to assess risk in the most objective fashion. If someone has received a letter, package, or object Rom an unknown party containing powder or other suspicious material and/or it is accompanied by a written or verbal threat, he or she should be instructed to call their local law enforcement officials or 911 and follow instructions as outlined in the guidelines. If there is no threat or exposure to suspicious material, patients and the public should be reassured they are at little or no real risk of getting anthrax infection. The MDPH reiterates earlier guidance that antibiotics should only be prescribed and taken for valid clinical indications. Should there be evidence of anthrax exposure or concern about anthrax exposure warranting action, the MDPH will provide clear guidelines for patient management for that particular circumstance. In the absence of such exposure or possible exposure, antibiotics are not indicated for anthrax prophylaxis. Also, to reiterate, nasal swab cultures for anthrax are used solely for epidemiologic follow-up of known exposures. The MDPH has an information line for the public and for healthcare providers at 1-866-627- 1968. This line provides information and technical assistance. Consultation with an MDPH epidemiologist for healthcare providers is available through that number, if you have questions about anthrax exposures or other issues. - The Commonwealth of Massachusetts ' Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619 JANE SWIFT GOVERNOR - ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH - COMMISSIONER COMMONWEALTH OF MASSACHUSETTS ADVISORY To: Local Public Safety Agencies Local Boards of Health and Health Departments From: James P. Jajuga, Secretary Stephen P. McGrail, Director Executive Office of Public Safety Massachusetts Emergency Management Agency Howard K. Koh, MD, MPH Stephen P. Coan Commissioner of Public Health State Fire Marshall Re: Guidelines for Responding to Concerns about Anthrax Exposure The purpose of this advisory is to provide guidance to local agencies that are the first line of response when handling calls from the public reporting possible exposure to anthrax from a package, letter, or other object. Rule #1— Urge calm. Anthrax does not present an immediate threat of injury. Exposure to anthrax does not necessarily mean infection. Anthrax is not spread from one person to another person. If it is determined that there is exposure, infection can be prevented. • All reported incidents have and will be investigated. To date, no anthrax has been found in Massachusetts. Rule #2 - Absent any known cases of anthrax, credible threats, or information regarding specific targets anywhere in the Commonwealth, it is essential to exercise judgment in dealing with suspicious mail and packages. To protect the public and avoid increased anxiety and unnecessary treatment, it is essential that health risk be assessed in the most objective fashion. Letters or package that come from a known source and conform to the following standards are . likely to present little or no risk of exposure to anthrax. THERE IS NO NEED TO CONTACT HEALTH OR LAW ENFORCEMENT OFFICIALS. . • Sender (company or individual) is recognizable and known. • Envelope or package is typical and has standard postage markings. • Return address is indicated — addressee could be contacted to verify contents. • Not accompanied by written or verbal threats. • Contains no powdery substance. The US Postal Service has advised that characteristics which ought to trigger suspicion include letters or packages that: • . Have any powdery substance on the outside • Are unexpected or from someone unfamiliar • Are addressed to someone no longer at your address or with your organization • Have no return address, or have one that can't be verified as legitimate • Are of unusual weight, given their size, or are lopsided or oddly shaped • Have an unusual amount of tape on them Are marked with restrictive endorsements, such as "Personal" or "Confidential", • Have strange odors or stains Rule #3 -Help determine the level of health risk. • If a letter, package or object is of known origin (i.e. it is a usual or expected item from a known business or individual), is not accompanied by any written or verbal threat, and some particulate matter (ie: powder) is found in or around it, the health risk is low. NOTIFY YOUR LOCAL FIRE DEPARTMENT, THERE IS NO NEED TO CONTACT HEALTH OR LAW ENFORCEMENT OFFICIALS. If there is a question, the MDPH . information line is available at 1-866-627-7968. • IF A LETTER, PACKAGE OR OBJECT CONTAINS A POWDERY SUBSTANCE AND IS ACCOMPANIED BY A WRITTEN OR VERBAL THREAT IMMEDIATELY NOTIFY YOUR LOCAL FIRE DEPARTMENT AND FBI FIELD OFFICE (617) 742- 5533 AND ADVISE THE PUBLIC OF THE FOLLOWING: l . Do not shake or empty the contents of any suspicious envelope or package; do not try to clean up powders or fluids. 2. Place the envelope or package in a plastic bag or some other type of container to prevent leakage of contents. MINIMIZE HANDLING OF SUSPECTED PACKAGE. 3. If you do not have any container, then cover the envelope or package with anything (e.g., clothing, paper, trashcan, etc.) and do not remove this cover. 4. 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 or skin. 6. If you are at home call 911. If you are at work, then follow appropriate procedures at your workplace. 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. 8. If clothing becomes contaminated, carefully remove clothes and keep in a plastic bag and await further instructions from public safety and/or public health officials. 9. If you have been subjected to exposure to a suspect material; shower with soap and water as soon as possible. Do not use bleach or disinfectant on your skin. 10. Do not bring or transport suspicious or contaminated material to any facility (ie: the police station, fire station, health department office, hospital, clinic, or doctor's office). Await instructions from public safety and/or health officials. Rule #4 — Stay in communication with your local public safety, emergency management and public health officials, and familiarize yourself with the state resources available to answer questions and concerns about bioterrorism and health. For information about public health, bioterrorism or emergency preparedness contact the following: Massachusetts Department of Public Health http://www.state.ma.us/dph/ Massachusetts Emergency Management Agency http://www.state.ma.us/mema/ Massachusetts Department of Fire Services http://vvww.state.ma.us/dfs/ The Federal Bureau of Investigation littp://www.fbi.gov US Postal Service http://www.USPS.com The US Centers for Disease Control and Prevention http://www.cdc.gov/ The American Red Cross http://www.redeross.org/services/disaster/keepsafe/unexpected.html Guidelines for Responding to Concerns about Anthrax October 17, 2001 The Massachusetts Department of Public Health (MDPH) in conjunction with the US Centers for Disease Control and Prevention (CDC), offer the following guidelines for use in responding to questions about anthrax threats, unknown contamination of items or management of individuals concerned about potential exposure. 1. Advice to the Public — Remain Calm • Anthrax does not present an immediate threat of injury. • Exposure to anthrax does not necessarily mean infection. • Anthrax is not spread from one person to another person. • If it is determined that there is exposure, infection can be prevented. • All reported incidents have and will be investigated. • To date, no anthrax has been found in Massachusetts. • If a letter, package, or object is of known origin (i.e. it is a usual or expected item from a known business or individual), conforms with the characteristics of normal mail, is not accompanied by any written or verbal threats, and contains no powdery substance, there is little or no health risk. There is no need to contact health or law enforcement officials. • If a letter, package or object is of known origin (i.e. it is a usual or expected item from a known business or individual), is not accompanied by any written or verbal threat, and some particulate matter is found in or around it, the health risk is low. There is no need to contact health or law enforcement officials. If there is a question, the MDPH information line is available at 1-866-627- 7968. • If a letter, package or object contains a powdery substance and/or a written or verbal threat the following is advised: 1. Do not shake or empty the contents of any suspicious envelope or package; do not try to clean up powders or fluids. 2. Place the envelope or package in a 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, trashcan, etc.) and do not remove this cover. 4. 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 or skin. 6. If you are at home, then report the incident to local law enforcement or call 911. If you are at work, then notify your building security official or an available supervisor. 7. If possible, 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. 8. If clothing or articles of clothing become contaminated with powder, carefully remove the clothes and keep them in a plastic bag until you are notified of results of testing. 9. If you have body or clothing exposure to a suspect material, then shower with soap and water as soon as possible. Do not use bleach or disinfectant on your skin. 10. Do not transport suspicious or contaminated material to the police, fire, or health department yourself. 11. Do not bring suspicious or contaminated material to the hospital, clinic, or doctor's office. II. Advice to Healthcare Providers and Local Health Officials Anthrax organisms can cause infection in the skin, gastrointestinal system, or the lungs. To do so the organism must be rubbed into abraded (open) skin, swallowed, or inhaled as a fine, aerosolized mist. Anthrax is not spread from one person to another and does not present an immediate threat of injury. . Exposure does not mean infection and the consequences of infection only occur after a several day incubation period. Disease can be prevented after exposure to the anthrax spores by early treatment with the appropriate antibiotics 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. If these small particles are inhaled, life -threatening lung infection can occur, but prompt recognition and treatment are effective. Direct exposure to visible powder is most likely to result in cutaneous anthrax if it causes infection at all. Signs and Symptoms of Anthrax Infection Inhalational Anthrax: A brief prodrome resembling a viral respiratory illness followed by development of hypoxia and dyspnea, with radiographic evidence of mediastinal widening. This, the most lethal, form of anthrax results from inspiration of 8,000-40,000 spores of B. anthracis. The incubation of inhalational anthrax among humans is unclear, but it is reported to range between 1 and 7 days possibly ranging up to 60 days. Host factors, dose of exposure and chemoprophylaxis may play a role. Initial symptoms include sore throat, mild fever, muscle aches and malaise. These may progress to respiratory failure and shock. Meningitis frequently develops. Case -fatality estimates for inhalational anthrax are based on incomplete information regarding exposed populations and infected populations in the few case series and studies that have been published. However, case -fatality is extremely high, even with all possible supportive care including appropriate antibiotics. Records of industrially acquired inhalational anthrax in the United Kingdom before antibiotics were available reveal that 97% of cases were fatal, With antibiotic treatment the fatality rate is estimated to be at least 75%. Estimates of the impact of the delay in post -exposure prophylaxis or treatment on survival are not known. Gastrointestinal Anthrax: Severe abdominal distress followed by fever and signs of septicemia. This form of anthrax usually follows the consumption of raw or undercooked contaminated meat and is considered to have an incubation period of 1-7 days. An oropharyngeal and an abdominal form of the disease have been described in this category. Involvement of the pharynx is usually characterized by lesions at the base of the tongue, sore throat, dysphagia, fever, and regional lymphadenopathy. Lower bowel inflammation usually causes nausea, loss of appetite, vomiting and fever, followed by abdominal pain, vomiting blood, and bloody diarrhea. The case -fatality rate is estimated to be 25-60%, the effect of early antibiotic treatment on that case -fatality rate is not defined. Cutaneous Anthrax: A skin lesion evolving from a papule, through a vesicular stage, to a depressed black eschar. This is the most common naturally occurring type of infection (>95°/n) and usually occurs after skin contact with contaminated meat, wool, hides, or leather from infected animals. Incubation period ranges from 1-12 days. Skin infection begins as a small papule, progresses to a vesicle in 1-2 days followed by a necrotic ulcer. The lesion is usually painless, but patients also may have fever, malaise, headache and regional lymphadenopathy. The case fatality rate for cutaneous anthrax is 20% without, and less than 1 % with, antibiotic treatment. Recommended Patient Evaluation Protocols A. Asymptomatic patient WITHOUT known exposure Provide reassurance to the patient about the rarity of infection without known exposure. Post -exposure prophylaxis (PEP) and diagnostic testing are NOT indicated. Discourage use of nasal swabs for diagnosis of exposure. (Nasal swabs and blood serum tests are used as an epidemiological tool to characterize an outbreak when there is a known biologic agent.) B. Asymptomatic patient WITH potential exposure • Conduct an individual risk assessment and refer to appropriate clinician for post -exposure prophylaxis, if medically appropriate. • If indicated by risk assessment, contact local law enforcement. • Refer to healthcare provider for possible PEP, Decisions about immediate PEP versus waiting for testing results depend on the situation. If you have questions, consult with an MDPH epidemiologist by calling 617-983-6800. • Decontamination procedures, other than by washing with soap and water, are NOT routinely recommended. • In this case, diagnostic testing is not indicated. C. Patients with symptoms compatible with anthrax but with no known exposure: • Evaluate for anthrax and other diagnoses as appropriate. • Call 617-983-6800 to report any suspect case of anthrax. D. Patients with symptoms compatible with anthrax with potential exposure: • Confirm the diagnosis by obtaining the appropriate laboratory specimens based on the clinical form of anthrax that is suspected (inhalational, gastrointestinal, or cutaneous). - Inhalational Anthrax: blood, CSF (if meningeal signs are present); chest X-ray looking for widened mediastinum - Gastrointestinal Anthrax: blood - Cutaneous Anthrax: vesicular fluid and blood • Treat presumptively (consult infectious disease specialist as indicated). • Call 617-983-6800 to report this patient to MDPH. Post -Exposure Prophylaxis (PEP) Recommendations Initial therapy- 1 line antibiotics Duration Adults (including pregnant Ciprofloxacin 500 mg po BID 60 days women 1,2 and Or immmunocompromised) Doxycycline 100 mg po BID Children ' Ciprofloxacin 15-20 mg/kg po Ql2 hrs 60 days Or Doxycyclines: >8 yrs and >45 kg: 100 mg po BID >8 yrs and <45 kg: 2.2 mg/kg po BID 5 8 yrs: 2.2 mg/kg po BID " If susceptibility testing indicates susceptibility, therapy should be changed to oral amoxicillin for post -exposure prophylaxis to continue for 60 days. 2 Tetracyclines are not recommended during pregnancy, although,their use may be indicated for life -threatening illness. Adverse affects on developing teeth and bones are dose related, therefore, doxycycline might be used for a short course of therapy (7-14 days) prior to the 6 h month of gestation. Consult physician after the 6'h month of gestation for recommendations. 3 Use of tetracyclines and fluoroquinolones in children has adverse effects. These risks must be weighed carefully against the risk for developing life -threatening disease. If release of B. anthracis is confirmed, children should be treated initially with cprofloxacin or doxycycline as prophylaxis but therapy should be changed to oral amoxicillin 80 mg/kg of body mass per day divided every 8 hours (not to exceed 500 mg three times daily) as soon as penicillin susceptibility of the organism has been confirmed. ° Ciprofloxacin dose should not exceed I gram/day in children. - e In 1991, the American Academy of Pediatrics amended their recommendation to allow treatment of young children with tetracyclines for serious infections, such as Rocky Mountain spotted fever, for which doxycycline may be indicated. Doxycycline is preferred for its twice -a -day dosing and low incidence of gastrointestinal side effects. MA State DepaNnenl of Heats Fax N 61'/-983 6813 Page 1 of 1 - The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617) 983-6200 JANE SWIFT 7 A �7 Ad GOVERNOR Clinical vlSoly ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER TO: Healthcare Providers, Facilities, and Local Health Departments FROM: Alfred DeMaria, Jr., M.D. Assistant Commissioner Director, Bureau of Communicable Disease Control State Epidemiologist DATE: October 11, 2001 RE: 1. Nasal swab cultures for anthrax, 2. Antibiotic prescriptions The Massachusetts Department of Public Health, prompted by reports from hospital emergency rooms and physician's offices about people seeking nasal swab testing for anthrax and antibiotics used to treat anthrax is advising the public that such requests are unnecessary in the absence of a known anthrax exposure. Nasal swab testing is not a reliable way to diagnose exposure to anthrax. Test results for a nasal swab specimen can neither rule -out nor diagnose anthrax, This testing has been used in Florida only for research purposes as part of the ongoing epidemiologic and criminal investigation. The public is advised not to seek these tests. MDPH is also advising against the use of prophylactic antibiotics. Inappropriate use of antibiotics will lead to increased antibiotic resistance among microorganisms causing common bacterial infections and may result in serious adverse effects, including allergic reactions and interactions with other medications. Stockpiling of antibiotics is also strongly discouraged because it could lead to inappropriate patient decisions to self medicate, incomplete courses of antibiotics that might select for resistant organisms, the eventual use of expired medications and to the depletion of national supplies for medically indicated uses. Antibiotics should be selected according to the specific infection of concern. Iat Vat 44443 PM Emergency Response Planning REGIONAL INFORMATION MEETING A Forum for Public Health, Emergency Management, and Public Safety Personnel AGENDA 2:00 p.m. Welcome 2:10 - 3:00 Massachusetts Department of Public Health j, a n 1 U, cw� • overview of Recent Eventsi»gun • Clinical and Sampling Issues 3 -7 P� 3:00 - 3:30 Massachusetts Emergency Management Agency �` US Y'nq/ 11�Q W�� • MEMA Structure • Comprehensive Emergency Management (CEM) Plans and Terrorism Annexes UrYJ�,� 3:30 - 3:40 Break S Lz r 3:40 - 4:00 Massachusetts Department of Fire Services • The HazMat Response G n\j 0,\ 4:00 - 5:00 Question and Answer Panel rv-\ U i Yzz> �-7 WQ�� t , �'-V, Anthrax Questions and Answers Q. What is anthrax? A. Anthrax is an infectious disease caused by the spore -forming bacterium Bacillus anthracis The bacteria can infect all warm-blooded animals including man. Q. How common is anthrax and who can get it? A. Anthrax is most common in agricultural regions where it occurs in animals. These include South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, and the Middle East. In humans, the disease is usually caused by an occupational exposure to infected animals or their products. Anthrax has not been reported in Massachusetts in over 30 years. Q. How is anthrax spread? A. B. anthracis spores can live in the soil for decades. A person may become infected with anthrax by inhaling anthrax spores from soil or by handling wool or hair from infected animals (which cancauseskin exposures). Infection of the intestinal tract can occur by eating undercooked meat from diseased animals. Q. Whatare the symptoms of anthrax? A.The symptoms vary depending upon the type of exposure. Cutaneous: Most anthrax infections occur when the bacterium enters a cut or abrasion on the skin, such as when handling contaminated wool, hides, leather or hair products (especially goat hair) of infected animals. A boil -like lesion appears which eventually forms an ulcer with a black center. A swelling of the lymph glands may also occur. Inhalation: Initial symptoms may resemble influenza. After several days, the symptoms may progress to severe breathing problems and pneumonia. Inhalation anthrax usually results in death in 1-2 days after onset of the acute symptoms. Intestinal: The intestinal disease form of anthrax may follow the consumption of contaminated meat and is characterized by an acute inflammation of the intestinal tract. Initial signs of nausea, loss of appetite, vomiting, fever are followed by abdominal pain, vomiting of blood, and severe diarrhea. Q. How soon after being infected do symptoms appear? A. Symptoms of disease usually occur within seven days with most cases occurring within 48 hours. Low doses of exposure can cause longer incubation periods for inhalation anthrax (up to 60 days). Q. Can anthrax be spread from person -to -person? A. There are no reports of the disease spreading from person to person. Q. How is anthrax diagnosed? A. Anthrax is diagnosed by isolating the bacteria from blood, skin lesions, or respiratory secretions. Q. What is the treatment for anthrax? A. Penicillin or ciprofloxacin are the preferred drugs, but erythromycin, tetracycline, or chloramphenicol can also be used. To be effective, treatment should be initiated early. If left untreated, the disease can be fatal. Q. Is there a vaccine to prevent anthrax? A. The anthrax vaccine licensed for human use in the United States is a cell -free filtrate vaccine, which means parts of dead bacteria are used as opposed to live bacteria. The vaccine is available for people in high -risk occupations such as military personnel or people who handle animal hides. Anthrax vaccine is not routinely recommended for the general population. For information on terrorism preparedness for you and your family, please visit http://www.redcross.ora/services/disaster/keepsafe/unexpected html Guidelines for Local Health, Police and Fire Officials Triage of Materials for Biologic Agent Screening State Laboratory Institute October 26, 2001 These guidelines are for use by local Massachusetts health, fire, and police officials to assist in the management of requests related to anthrax contamination wariness received from individuals, businesses and government agencies in Massachusetts. These guidelines are based on current information available from the U.S. Centers for Disease Control and Prevention, other federal agencies, and the State Laboratory Institute. They will be reviewed and updated on a daily basis. Unless material is described as "Category 1" (see below), the State Laboratory Institute encourages fire departments, police departments and boards of health to discuss specimen triage with a staff person in the Epidemiology Program (617-983-6800) prior to making a decision to send samples to the Lab for analysis. Questions and comments related to this guideline can be directed to the Director's Office at 617-983-6201. Description of Material Number Samples Testing Triage Protocol Submitted as of Priority October 25 Category 1. U.S. Mail with either a suspicious Emergency transport - alert powder, a threat letter, or both. 12 High Lab by telephone, 617-522- 3700. Category 2. Mail (other than Category 1) with suspicious characteristics identified at a U.S. 50 High Postal facility. Call for Lab assistance in triage. Regular hours: 617- Category 3. Powders, particulate matter, or various liquid or solid material on surfaces of 983-6800. Evenings and floors, walls, furniture, clothing, appliances, or --450 Low weekends: 617-522-3700. food. Category 4. Clothing, household items, business Do not submit. Clothing products, or other such objects. can be washed as regular —605 N/A laundry. Clean other items with a conventional household cleaner. Daily Update : October 26, 2001 There has been no evidence of anthrax contamination in Massachusetts found. Of over 1,000 re _ n environmental samples, all have been negative. In addition, there has been no evidence of human anthrax exposure or disease. Specimens from twelve persons have been screened to rule out anthrax. Exposure to anthrax -contaminated mail is the only risk factor that has been identified at this time for anthrax infection related to deliberate acts. There are 13 reported cases, 11 of which are CDC -confirmed cases of anthrax: 2 in Florida, 3 in New York, 2 in New Jersey, and 4 in Washington, D.C. Other suspect cases are under investigation. W C/) 4-1 U) � O CD U O N O co U) o c c�=S -6.o cILo 4-- o�[L c w O o'2 �o E0 O E J N C a>o C E p a�ifj") .c E Q � U O U) L o C F- w �- �D r � n � � i � � 5 s-e s s rrw.�tr' FA iw U P. t* '� O i F E~ N U U O N s o Co C CD 2 = Co cC G O . co = co p Z'0cNo n. o -a 00 ca ca o a) " m 0 Co � 2 E- -0 �0E��� O U cu E rO E W� > o � U U X M -� I- W The safest, easiest way to remove protective gloves 20 Grasp the palm of your right glove with your left hand. (It doesn't matter which glove is removed first: consis- tency is the key. If you reverse the hands in one step, be sure to reverse them in all j 1 Keep in mind that the outside of your gloves is con - laminated and the inside is clean. Throuahout the procedure, contaminated should touch only contaminated areas and noncontaminated touch only noncontaminated areas. 1 �1 Slowly pull off the right glove, inside out. i f•. 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O � - � E O S "ay >td O w0 2-8 ° Uq Obi (D • % y S+R+ '4 N O p "rl �rop�y �i'i N oC) "?i 000 o 1� V �i � CD � y, � � V ' O. 00 �o m oo Ow 00C �o of i'.y°y CD N 00 �o 00ID CD c+ �! i- �i•'-t .�4 sr ,'`4';vyv N oa ry CD- H CD ,''• , -" o N Vp §s Vl t"r 1-F 11F-�t�y <'D E STATE LABORATORY TESTING TIMELINE • Test begins within 2 hours of receipt of suspect material. • First test is gross examination of object in a biological safety cabinet to locate suspect material. • Second test is a gram stain. • Third test is to culture suspect material; monitored at 12, 18 , 24 and 48 hours for growth. If no growth after 48 hours a final report is issued as not positive. Laboratory notifies local health department and submitter (usually Fire Department). • If biologically dangerous growth is detected at any stage, Laboratory Director contacts submitter, at which point other high order agencies (FBI, medical care providers, and others) will be immediately contacted and local board of health kept informed. State Laboratory telephone number for initial assessment is 617-983-6800 After hours same number, dial 0 and ask for epidemiologist on call. State Laboratory telephone number for test results 617-983-6626. EMERGENCY MANAGEMENT GUIDELINES FOR BUSINESS AND INDUSTRY 1. Establish planning team. 2. Analyze capabilities and hazards. 3. Develop plan. 4. Implement the plan. 5. Train and exercise plan. Lantranting the tear at Hiaterrorism rage IOrc = The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington, Street. Boston, MA 02108-4619 JAW SWH`7 GOVERNOR ROBERT A, GnTENS SECRETARY tbWACOMWSSIONEN MPH Confronting the Fear of Bioterrorism Howard K. Koh, MD, MPH Commissioner of Public Health The Commonwealth of Massachusetts [Published in the Op Ed section of the "Boston Sunday Globe", October 21, 2001, page E-71 The recent diagnosis of isolated cases of anthrax In Florida, Washington, DC, and New York has heightened public anxiety regarding the possibility of bloterrorism. Questions and concerns abound. How should we face the challenge of possible threats of bloterrorism and the associated fear? Quite simply, we can help protect our families and communities by staying informed and putting risks in proper perspective. We must fight fear with facts. Massachusetts has a long history of confronting infectious disease emergencies, and, over the past five years, our capacity to respond specifically to bloterrorism has Increased dramatically. Our disease tracking system can detect unusual health events or patterns of illness that may be associated with bioterrorism. Electronic communication systems are strengthening linkages between state, federal, and local health officials. Any indication of a possible health threat automatically triggers coordinated action and intervention by state and federal authorities. In addition, our State Laboratory Institute is able to conduct rapid testing for any potentially threatening biological agents, and cooperates fully with federal, state, and local law enforcement and public safety officials in bloterrorism investigations. Information and assistance is available for first responders, hospitals, and local boards of health — 24 hours a day, 7 days a week - and training is being accelerated for clinicians and laboratory staff in the identification and diagnosis of diseases that may be caused by bloterrorism agents. In light of recent events, we are intensifying our public information efforts in order to help people keep Informed and healthy. The public should be aware that: Anthrax is extremely rare and not contagious. Not all anthrax exposure leads to infection. According to the US Centers for Disease Control and Prevention (CDC), nasal swabs and blood tests are appropriate only when confirming a case of known exposure. Unless there is a known exposure, the use of antibiotics is not recommended - Individuals should not hoard them. The federal government currently maintains a large stockpile of antibiotics that can be rapidly mobilized in the unlikely event of Widespread exposure to anthrax or other biological agents. • Vaccination against smallpox is not recommended. There have been no cases of smallpox in the world in over twenty years, and there can be serious side effects associated with the vaccine. However, in the unlikely event of exposure to the public, the CDC can swiftly mobilize a sufficient supply of vaccine to control the consequences of a release. • Neither the CDC nor the Massachusetts Department of Public Health recommends the purchase or use of gas masks by the public. To be completely effective, gas masks would have to be wom all the time. httpJ/www.state.ma.us/dph/topics/bioterrorism/KohOpEd.hbn 10/25/2001 Gantranting the tear at diaterrarism rage t ar t Because they are difficult to fit property and can be unhealthy to wear for extended periods of time, their use could do more harm than good. The Massachusetts Department of Public Health and its partners in the public health system are committed to protecting people from bioterrorism. We are maximizing our vigilance by constantly upgrading and improving our emergency preparedness systems. We are working in unprecedented fashion with our colleagues in healthcare, law enforcement, and public safety to protect the health of families and communities. The cornerstones of our public health system are prevention and emergency response. This is a time for us all to work together - with our family, friends, and neighbors — to learn the facts and fight fear, the most infectious terrorist weapon of all. With this resolve, people everywhere will be able to lead healthy lives in healthy communities, not only today, but for many years to come. For information about public health, bioterrorism or emergency preparedness contact the following websites: The Massachusetts Department of Public Health - The US Centers for Disease Control and Prevention - The American Red Cross - http://www.redcross.Qmlm Please note: All files in PDF format require Adobe Acrobat Reader. DPH Homepaoe I What's New I Programs I Search DPH I Commissioner I Publications/Statistics I Directory I For Providers I In The Press I Related WWW Sites I Employment I Contact Us I Privacy Policy hdpl/www.state.ma.us/dph/topics/bioterrarism/KohOpEd.htm In/25/2001 Guidelines for Local Health, Police and Fire Officials Triage of Materials for Biologic Agent Screening State Laboratory Institute October 26, 2001 These guidelines are for use by local Massachusetts health, fire, and police officials to assist in the management of requests related to anthrax contamination wariness received from individuals, businesses and government agencies in Massachusetts. These guidelines are based on current information available from the U.S. Centers for Disease Control and Prevention, other federal agencies, and the State Laboratory Institute. They will be reviewed and updated on a daily basis. Unless material is described as "Category I" (see below), the State Laboratory Institute encourages fire departments, police departments and boards of health to discuss specimen triage with a staff person in the Epidemiology Program (617-983-6800) prior to making a decision to send samples to the Lab for analysis. Questions and comments related to this guideline can be directed to the Director's Office at 617-983-6201. Description of Material Number Samples Testing Triage Protocol Submitted as of Priority October 25 Category 1. U.S. Mail with either a suspicious Emergency transport - alert powder, a threat letter, or both. 12 High Lab by telephone, 617-522- 3700. Category 2. Mail (other than Category 1) with suspicious characteristics identified at a U.S. 50 High Postal facility. Call for Lab assistance in triage. Regular hours: 617- Category 3. Powders, particulate matter, or various liquid or solid material on surfaces of 983-6800. Evenings and floors, walls, furniture, clothing, appliances, or -450 Low weekends: 617-522-3700. food. Category 4. Clothing, household items, business Do not submit. Clothing products, or other such objects. can be washed as regular —605 N/A laundry. Clean other items with a conventional household cleaner. Daily Update : October 26, 2001 There has been no evidence of anthrax contamination in Massachusetts found. Of over 1,000 environmental samples, all have been negative. In addition, there has been no evidence of human anthrax exposure or disease. Specimens from twelve persons have been screened to rule out anthrax. Exposure to anthrax -contaminated mail is the only risk factor that has been identified at this time for anthrax infection related to deliberate acts. There are 13 reported cases, I I of which are CDC -confirmed cases of anthrax: 2 in Florida, 3 in New York, 2 in New Jersey, and 4 in Washington, D.C. Other suspect cases are under investigation. - The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health r' 250 Washington Street, Boston, MA 02108-4619 JANE SWIFT----- ---"�' GOVERNORI��t ROBERT P. GITTENS SECRETARY Eft HOWARD K. KOH, MD, MPH 0 "r �� � � � � 200I COMMISSIONER iLi u CLINICAL ADVISORY To: Healthcare Providers, Facilities, and Local Health Departments From: Howard K. Koh, MD, MPH Commissioner Date: October 17, 2001 Re: Information and Resources Regarding Anthrax Incidents of anthrax and anthrax exposure have occurred in several locations around the United States. Thus far, there have been no cases of anthrax or anthrax exposure identified in Massachusetts, despite intensified surveillance. The Massachusetts Department of Public Health (MDPH) wants to make you aware of existing and upcoming resource materials on the MDPH website www.state.ma.us/dph. In addition to earlier clinical and general advisories, posted today is guidance adapted from material from by the US Centers for Disease Control and Prevention providing clinical information for local health departments, health care providers and laboratories (see "Guidelines for Responding to Concerns About Anthrax" posted under "Provider Information" on the website). These detailed guidelines (too extensive to fax) deal with the management of exposures and possible exposures to anthrax and the laboratory procedures related to the diagnosis of infection due to Bacillus anthracis. They may be helpful in providing background information for counseling patients and coordinating clinical and laboratory activities. It should be noted that concern is highest for circumstances of recognized risk, i.e. situations where mail or other materials arrive in the context of a verbal or written threat or contain powder or other suspicious material. In order to protect the public and avoid increased anxiety and unnecessary treatment, it is important to assess risk in the most objective fashion. If someone has received a letter, package, or object from an unknown party containing powder or other suspicious material and/or it is accompanied by a written or verbal threat, he or she should be instructed to call their local law enforcement officials or 911 and follow instructions as outlined in the guidelines. If there is no threat or exposure to suspicious material, patients and the public should be reassured they are at little or no real risk of getting anthrax infection. The MDPH reiterates earlier guidance that antibiotics should only be prescribed and taken for valid clinical indications. Should there be evidence of anthrax exposure or concern about anthrax exposure warranting action, the MDPH will provide clear guidelines for patient management for that particular circumstance. In the absence of such exposure or possible exposure, antibiotics are not indicated for anthrax prophylaxis. Also, to reiterate, nasal swab cultures for anthrax are used solely for epidemiologic follow-up of known exposures. The MDPH has an information line for the public and for healthcare providers at 1-866-627- 7968. This line provides information and technical assistance. Consultation with an MDPH epidemiologist for healthcare providers is available through that number, if you have questions about anthrax exposures or other issues. - The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619 JANE SWIFT GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER COMMONWEALTH OF MASSACHUSETTS ADVISORY To: Local Public Safety Agencies Local Boards of Health and Health Departments From: James P. Jajuga, Secretary Stephen P. McGrail, Director Executive Office of Public Safety Massachusetts Emergency Management Agency Howard K. Koh, MD, MPH Stephen P. Coan Commissioner of Public Health State Fire Marshall Re: Guidelines for Responding to Concerns about Anthrax Exposure The purpose of this advisory is to provide guidance to local agencies that are the first line of response when handling calls from the public reporting possible exposure to anthrax from a package, letter, or other object. Rule #1— Urge calm. Anthrax does not present an immediate threat of injury. • Exposure to anthrax does not necessarily mean infection. • Anthrax is not spread from one person to another person. • If it is determined that there is exposure, infection can be prevented. • All reported incidents have and will be investigated. • To date, no anthrax has been found in Massachusetts. Rule #2 — Absent any known cases of anthrax, credible threats, or information regarding specific targets anywhere in the Commonwealth, it is essential to exercise judgment in dealing with suspicious mail and packages. To protect the public and avoid increased anxiety and unnecessary treatment, it is essential that health risk be assessed in the most objective fashion. Letters or package that come from a known source and conform to the following standards are likely to present little or no risk of exposure to anthrax. THERE IS NO NEED TO CONTACT HEALTH OR LAW ENFORCEMENT OFFICIALS. • Sender (company or individual) is recognizable and known. • Envelope or package is typical and has standard postage markings. • Return address is indicated — addressee could be contacted to verify contents. • Not accompanied by written or verbal threats. • Contains no powdery substance. The US Postal Service has advised that characteristics which ought to trigger suspicion include letters or packages that: • Have any powdery substance on the outside • Are unexpected or from someone unfamiliar • Are addressed to someone no longer at your address or with your organization • Have no return address, or have one that can't be verified as legitimate • Are of unusual weight, given their size, or are lopsided or oddly shaped • Have an unusual amount of tape on them • Are marked with restrictive endorsements, such as "Personal" or "Confidential" • Have strange odors or stains Rule #3 — Help determine the level of health risk. If a letter, package or object is of known origin (i.e. it is a usual or expected item from a known business or individual), is not accompanied by any written or verbal threat, and some particulate matter (ie: powder) is found in or around it, the health risk is low. NOTIFY YOUR LOCAL FIRE DEPARTMENT. THERE IS NO NEED TO CONTACT HEALTH OR LAW ENFORCEMENT OFFICIALS. If there is a question, the MDPH information line is available at 1-866-627-7968. =1L�1 CONTAINS A AND IS ACCOMPANIED BY A WRITTEN OR VERBAL THREAT IMMEDIATELY NOTIFY YOUR LOCAL FIRE DEPARTMENT AND FBI FIELD OFFICE (617) 742- 5533 AND ADVISE THE PUBLIC OF THE FOLLOWING: 1. Do not shake or empty the contents of any suspicious envelope or package; do not try to clean up powders or fluids. 2. Place the envelope or package in a plastic bag or some other type of container to prevent leakage of contents. MINIMIZE HANDLING OF SUSPECTED PACKAGE. 3. If you do not have any container, then cover the envelope or package with anything (e.g., clothing, paper, trashcan, etc.) and do not remove this cover. 4. 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 or skin. 6. If you are at home call 911. If you are at work, then follow appropriate procedures at your workplace. 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. 8. If clothing becomes contaminated, carefully remove clothes and keep in a plastic bag and await further instructions from public safety and/or public health officials. 9. If you have been subjected to exposure to a suspect material, shower with soap and water as soon as possible. Do not use bleach or disinfectant on your skin. 10. Do not bring or transport suspicious or contaminated material to any facility (ie: the police station, fire station, health department office, hospital, clinic, or doctor's office). Await instructions from public safety and/or health officials. Rule #4 — Stay in communication with your local public safety, emergency management and public health officials, and familiarize yourself with the state resources available to answer questions and concerns about bioterrorism and health. For information about public health, bioterrorism or emergency preparedness contact the following: Massachusetts Department of Public Health littp://www.state.ma.us/dplil Massachusetts Emergency Management Agency http://www.state.ma.us/mema/ Massachusetts Department of Fire Services http://www.state.ma.us/dfs/ The Federal Bureau of Investigation http://www.fbi.gov US Postal Service http://www.USPS.com The US Centers for Disease Control and Prevention http://www.cdc.gov/ The American Red Cross http•//www redcross org/services/disaster/keepsafe/unexpected.htmi Guidelines for Responding to Concerns about Anthrax October 17, 2001 The Massachusetts Department of Public Health (MDPH) in conjunction with the US Centers for Disease Control and Prevention (CDC), offer the following guidelines for use in responding to questions about anthrax threats, unknown contamination of items or management of individuals concerned about potential exposure. I. Advice to the Public — Remain Calm • Anthrax does not present an immediate threat of injury. • Exposure to anthrax does not necessarily mean infection. • Anthrax is not spread from one person to another person. • If it is determined that there is exposure, infection can be prevented. • All reported incidents have and will be investigated. • To date, no anthrax has been found in Massachusetts. • If a letter, package, or object is of known origin (i.e. it is a usual or expected item from a known business or individual), conforms with the characteristics of normal mail, is not accompanied by any written or verbal threats, and contains no powdery substance, there is little or no health risk. There is no need to contact health or law enforcement officials. If a letter, package or object is of known origin (i.e. it is a usual or expected item from a known business or individual), is not accompanied by any written or verbal threat, and some particulate matter is found in or around it, the health risk is low. There is no need to contact health or law enforcement officials. If there is a question, the MDPH information line is available at 1-866-627- 7968. • If a letter, package or object contains a powdery substance and/or a written or verbal threat the following is advised: 1. Do not shake or empty the contents of any suspicious envelope or package; do not try to clean up powders or fluids. 2. Place the envelope or package in a 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, trashcan, etc,) and do not remove this cover. 4. 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 or skin. 6. If you are at home, then report the incident to local law enforcement or call 911. If you are at work, then notify your building security official or an available supervisor. 7. If possible, 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. 8. If clothing or articles of clothing become contaminated with powder, carefully remove the clothes and keep them in a plastic bag until you are notified of results of testing. 9. If you have body or clothing exposure to a suspect material, then shower with soap and water as soon as possible. Do not use bleach or disinfectant on your skin. 10. Do not transport suspicious or contaminated material to the police, fire, or health department yourself. 11. Do not bring suspicious or contaminated material to the hospital, clinic, or doctor's office. II. Advice to Healthcare Providers and Local Health Officials Anthrax organisms can cause infection in the skin, gastrointestinal system, or the lungs. To do so the organism must be rubbed into abraded (open) skin, swallowed, or inhaled as a fine, aerosolized mist. Anthrax is not spread from one person to another and does not present an immediate threat of injury. Exposure does not mean infection and the consequences of infection only occur after a several day incubation period. Disease can be prevented after exposure to the anthrax spores by early treatment with the appropriate antibiotics 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. If these small particles are inhaled, life -threatening lung infection can occur, but prompt recognition and treatment are effective. Direct exposure to visible powder is most likely to result in cutaneous anthrax if it causes infection at all. Signs and Symptoms of Anthrax Infection Inhalational Anthrax: A brief prodrome resembling a viral respiratory illness followed by development of hypoxia and dyspnea, with radiographic evidence of mediastinal widening. This, the most lethal, form of anthrax results from inspiration of 8,000-40,000 spores of B. anthracis. The incubation of inhalational anthrax among humans is unclear, but it is reported to range between I and 7 days possibly ranging up to 60 days. Host factors, dose of exposure and chemoprophylaxis may play a role. Initial symptoms include sore throat, mild fever, muscle aches and malaise. These may progress to respiratory failure and shock. Meningitis frequently develops. Case -fatality estimates for inhalational anthrax are based on incomplete information regarding exposed populations and infected populations in the few case series and studies that have been published. However, case -fatality is extremely high, even with all possible supportive care including appropriate antibiotics. Records of industrially acquired inhalational anthrax in the United Kingdom before antibiotics were available reveal that 97% of cases were fatal. With antibiotic treatment the fatality rate is estimated to be at least 75%. Estimates of the impact of the delay in post -exposure prophylaxis or treatment on survival are not known. Gastrointestinal Anthrax: Severe abdominal distress followed by fever and signs of septicemia. This form of anthrax usually follows the consumption of raw or undercooked contaminated meat and is considered to have an incubation period of 1-7 days. An oropharyngeal and an abdominal form of the disease have been described in this category. Involvement of the pharynx is usually characterized by lesions at the base of the tongue, sore throat, dysphagia, fever, and regional lymphadenopathy. Lower bowel inflammation usually causes nausea, loss of appetite, vomiting and fever, followed by abdominal pain, vomiting blood, and bloody diarrhea. The case -fatality rate is estimated to be 25-60%, the effect of early antibiotic treatment on that case -fatality rate is not defined. Cutaneous Anthrax: A skin lesion evolving from a papule, through a vesicular stage, to a depressed black eschar. This is the most common naturally occurring type of infection (>95%) and usually occurs after skin contact with contaminated meat, wool, hides, or leather from infected animals. Incubation period ranges from 1-12 days. Skin infection begins as a small papule, progresses to a vesicle in 1-2 days followed by a necrotic ulcer. The lesion is usually painless, but patients also may have fever, malaise, headache and regional lymphadenopathy. The case fatality rate for cutaneous anthrax is 20% without, and less than 1% with, antibiotic treatment. Recommended Patient Evaluation Protocols A. Asymptomatic patient WITHOUT known exposure Provide reassurance to the patient about the rarity of infection without known exposure. Post -exposure prophylaxis (PEP) and diagnostic testing are NOT indicated. Discourage use of nasal swabs for diagnosis of exposure. (Nasal swabs and blood serum tests are used as an epidemiological tool to characterize an outbreak when there is a known biologic agent.) B. Asymptomatic patient WITH potential exposure • Conduct an individual risk assessment and refer to appropriate clinician for post -exposure prophylaxis, if medically appropriate. • If indicated by risk assessment, contact local law enforcement. • Refer to healthcare provider for possible PEP. Decisions about immediate PEP versus waiting for testing results depend on the situation. If you have questions, consult with an MDPH epidemiologist by calling 617-983-6800. • Decontamination procedures, other than by washing with soap and water, are NOT routinely recommended. • In this case, diagnostic testing is not indicated. C. Patients with symptoms compatible with anthrax but with no known exposure: • Evaluate for anthrax and other diagnoses as appropriate. • Call 617-983-6800 to report any suspect case of anthrax. D. Patients with symptoms compatible with anthrax with potential exposure: • Confirm the diagnosis by obtaining the appropriate laboratory specimens based on the clinical form of anthrax that is suspected (inhalational, gastrointestinal, or cutaneous). Inhalational Anthrax: blood, CSF (if meningeal signs are present); chest X-ray looking for widened mediastinum - Gastrointestinal Anthrax: blood - Cutaneous Anthrax: vesicular fluid and blood • Treat presumptively (consult infectious disease specialist as indicated). • Call 617-983-6800 to report this patient to MDPH. Post -Exposure Prophylaxis (PEP) Recommendations Initial therapy- Is line antibiotics Duration Adults (including pregnant Ciprofloxacin 500 mg po BID 60 days women',z and Or immmunocompromised) Doxycycline 100 mg po BID Children Ciprofloxacin 15-20 mg/kg po Q12 hrs 60 days Or Doxycyclines: >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 If susceptibility testing indicates susceptibility, therapy should be changed to oral amoxicillin for post -exposure ropliylaxis to continue for 60 days. Tetracyclines are not recommended during pregnancy, although their use may be indicated for life -threatening illness. Adverse affects on developing teeth and bones are dose related, therefore, doxycycline might be used for a short course of therapy (7-14 days) prior to the 6`h month of gestation. Consult physician after the 6ffi month of gestation for recommendations. 3 Use of tetracyclines and fluoroquinolones in children has adverse effects. These risks must be weighed carefully against the risk for developing life -threatening disease. If a release of R anthraces is confirmed, children should be treated initially with Cprofloxacin or doxycycline as prophylaxis but therapy should be changed to oral amoxicillin 80 mg/kg of body mass per day divided every 8 hours (not to exceed 500 mg three times daily) as soon as penicillin susceptibility of the organism has been confirmed. 4 Ciprofloxacin dose should not exceed I gram/day in children. - s In 1991, the American Academy of Pediatrics amended their recommendation to allow treatment of young children with tetracyclines for serious infections, such as Rocky Mountain spotted fever, for which doxycycline may be indicated. Doxycycline is preferred for its twice -a -day dosing and low incidence of gastrointestinal side effects. JANE SWIFT GOVERNOR ROBERT P. GITTENS SECRETARY HOWARD K. KOH, MD, MPH COMMISSIONER Submitted By: I The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health State Laboratory Institute 305 South Street, Jamaica Plain, MA 02130 (617) 983-6200 SCOTT LEITE HEALTH AGENT 6 PARK ROW MA RE: Environmental Specimen submitted for anthrax determination Submitter ID: Date Received: 02/15/2002 Sample Description: GRAY POWDER STUCK TO OUTSIDE OF ENVELOPE Location Name: MANSFIELD POST OFFICE 12 GILES PLACE MANSFIELD, MA 02048 Laboratory Number: 0213-0008 Tracking Number: SLI-3087 Test Methods: CULTURE Test Results: NO BACILLUS ANTHRACIS FOUND For questions about this report, please call (617) 983-6800. For technical questions, please call the laboratory at (617) 983-6626, Sincerely, A*-c2 /oq-`' for Ralph J. Timperi Assistant Commissioner Department of Public Health State Laboratory Institute 02/20/2002 WED 12:39 FAX 508 261 7425 TOWN OF MANSFIELD 0001 TX REPORT TRANSMISSION OK TX/RX NO 0290 DEPT. ID 3652 CONNECTION TEL 95082619798 SUB -ADDRESS CONNECTION ID ST. TIME 02/20 12:38 USAGE T 00,36 PGS. 2 RESULT OK TOWN OF MANSFIELD, MASSACHUSETTS Six Park Row, Mansfield, MA 02048 FAX COVER SHEET TOWN OF MANSFIELD BOARD OF HEALTH Date: d c'� Time: From: Town of Mansfield Phone: 508-261-7366 Board of Health Fax: ' 508-261-7343 Six Park Row Mansfield, MA 02048 To:— I 0 (� 9 Type of Form No of pages:, Message; (Incl. cover sheet) A 3 I'd 06EL-192(809) pTaljsuew 3o umol eZT:TT 20 91 qaA t j \ / } � �/ Sm - f. \e o .\� \ 2 o \ ) Q \ \/\ . a / a \$/ ¥ 2em s K-j ¥k °.Q t:fme a co + a) 0. § CD _» 2 � � 2 / \ 7 )� 3 . 2 G )\ t 2 \ Z ££ § � 42 � ! 7/ 2 oot ,es 999 z, XVA WRT e& \! 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