EPI UPDATE

Please print out this material and share with epidemiology staff, county health department directors, administrators, medical directors, nursing directors, environmental health directors and others with an interest in information of this type. Thank you.

The Bureau of Epidemiology is available 24 hours a day, 7 days a week for consultation at our main number (SunCom 205-4401 or 850/245-4401) PLEASE NOTE: Consultation after 5 p.m. & on weekends is intended for emergencies.

The Department of Health has a home on the World Wide Web at http://www.doh.state.fl.us

For information on diseases and conditions of public health importance go to MyFlorida.com, click on Health and Human Services, then Consumers--Diseases and Conditions.

In this issue:

"The Bureau of Epidemiology developed the following guidelines for county health departments and other constituents in response to requests for information regarding the proper handling of suspicious packages".

Individuals around the state and nation have received letters alleged to contain anthrax. While no single recommendation can cover all circumstances, the following recommendations should apply to most situations:

Letters or packages that may possibly contain anthrax or another hazardous substance are of concern to both public health and law enforcement agencies.

Individuals who are concerned that they may have been exposed to anthrax or another unknown agent should be assured that the Department of Health takes these threats seriously and that while hundreds of such threats have been received in the United States none have contained an infectious agent such as anthrax.

The typical response should be:

1. The letter or package should be left alone and the individual in contact with the letter should leave the vicinity and contact law enforcement. Others should also leave the immediate vicinity of the letter.
2. The letter or package should be collected by law enforcement for forensic evidence. Testing can be conducted at the state laboratory in Tampa, Jacksonville, or Miami. The Department of Agriculture laboratory in Kissimmee is also a resource. The result of the testing will be available in time to determine what, if any, treatment should be implemented.
3. The individual (s) who open or have contact with the letter or package that contains an unknown substance should thoroughly wash their hands with soap and water. Persons who have more extensive contact with an unknown substance should shower and place their clothing in a sealed plastic bag. Do not remove clothing from the bag until the results are available to guide cleaning requirements.
4. There is no need for any decontamination of individuals who have not had direct contact with the letter or package that contains an unknown substance.
5. Testing of individuals exposed to an unknown substance for an infectious agent by use of nasal swabs or blood test is not appropriate.
6. Prophylactic antibiotic treatment should be based on the results of the laboratory testing of the letter or package that contains an unknown substance. There is no need to start antibiotics prior to the analysis of the letter or package.
7. Contact information of all individuals that may have been exposed should be collected ASAP. These individuals should be reassured that they will be contacted as soon as results are known.

Questions concerning the handling of individuals exposed to threatening letters or packages that may contain anthrax or other biological agents should be directed to the local county health department. The Department of Heath, Bureau of Epidemiology, is available 24 hours a day, 7 days a week for consultation at the main number (850-245-4401 or SunCom 205-4401).

The CDC published interim guidelines for the management of bioterrorism alleging the use of anthrax in the February 05, 1999 issue of the MMWR.

A copy can be obtained at the following www site. http://www.cdc.gov/mmwr/PDF/wk/mm4804.pdf

October 10, 2001

"Dr. Ellery Gray, Director of the Office of Emergency Operations, developed the following materials for law enforcement officials".

Effective immediately the following operational procedures will be implemented to deal with suspicious objects, i.e. envelopes or substances that are deemed LESS THAN CREDIBLE THREATS BY THE FBI.

FBI must state that the item does not exhibit a criminal intent and they determine that it is non-threatening.

Local law enforcement authorities then make a decision:

• Does the item or substance pose criminal intent or is it a public safety issue?
• If NO then the item is returned to the owner.

If the answer is YES, they proceed as follows:

• If it is only suspected of being of evidentiary nature then it is handled in law enforcement channels.

If the answer is YES and they suspect it is of a biological or chemical nature they proceed as follows:

• Notify local Hazmat or Fire department and Bomb Squad
• Determine it does not contain a bomb
• Have Hazmat determine it is not chemical
• If suspected to be biological have Hazmat double bag and seal
• Then call local health department

Local Health Department:

• Evaluate the risk and make recommendations.
• Have local law enforcement initiate a chain of custody form.
• Notify the State Department of Health Office of Emergency Operations of their decisions.
• Notify the department of Health state laboratory that they are getting ready to send the item or sample.
• Determine method of transportation, hand deliver in double bag or over-package and send by courier service.
• After testing is completed, notify local law enforcement of results.

Upon receiving notification that an item, substance or sample needs testing, determine which State Laboratory will be designated to receive it and advise the local health department to send it to designated State Health Department Laboratory.

• Receiving laboratory will sign chain of custody form.
• Process the material for testing.
• Render a report to the county health department which sent the material.
• Local Health Department will notify local law enforcement of the testing results.

There have numerous requests for Law Enforcement and Fire Departments for information and for assistance in picking up suspicious packages or letters. Most unopened packages or Letters are safe to handle as they have already been handled extensively by the postal system prior to your arrival on the scene. There has been a lot of panic among the population due to lack of adequate information. There may be instances in which you may be assigned to pick up a package or letter. Please use your training to take charge of these situations and put them in their proper perspective. There are three (3) basic types of situations that you might be called upon to address:

1. Unopened Package or Letter
2. Opened Package or Letter With a Substance Inside
3. Suspicious Package or Letter With a Contraption Inside

• Use common sense!
• Do not open the package.
• Throw it away with the regular household garbage, or;
• If you feel that the package or letter is of sufficient suspicion and merits a thorough investigation by the appropriate agency;
• Put on some hand protection such as rubber gloves and a particle mask like the ones you have seen surgeons wear.
• Carefully put the letter or package in an appropriate sized plastic bag (like a zip-lock bag or evidence bag),
• Seal the bag,
• Place the sealed bag inside of a second bag and seal that one too.
• Place the properly sealed package in the trunk of your vehicle or in an appropriate container inside of your vehicle.
• Remove your mask and gloves and dispose of them properly.
• Wash your hands with soap and water.
• Call your contact number to find the location that you need to transport the package to.
• If you feel ill
• Get some fresh air
• Call Fire-Rescue

Opened Package or Letter With a Substance Inside

If you respond to an incident in which someone inadvertently opened a suspicious letter or package containing a substance such as a dust, powder, cream or liquid, you may do the following things.

• Be careful not to breathe or touch the substance.
• Leave the letter or package where it is and exit the room.
• Close the door to the room.
• Wash your hands with soap, water and a little squirt of bleach.
• If you inhaled the substance, blow your nose and save the tissue in a plastic bag.
• If you get the substance on your clothing, change your clothes and bag the used clothing in a plastic bag.
• Call the appropriate agency (Fire Rescue, Haz-Mat, Safety Officer etc… or refer to your protocols for this type of scenario).
• Wait for assistance
• If you feel ill
• Get some fresh air
• Call Fire-Rescue

Suspicious Package or Letter With a Contraption Inside

If you receive and inadvertently open a suspicious letter or package and find a contraption and/or wires, batteries etc. Do the following:

• Leave the letter or package where it is and exit the room.
• Close the door to the room.
• Evacuate the area.
• Call the bomb squad and/or Fire Rescue
• Call FBI and the Postal authorities.
• Wait for assistance
• If you feel ill
• Get some fresh air
• Call Fire-Rescue

October 9, 2001

"The DOH Bureau of Laboratories and Bureau of Epidemiology will be conducting a joint surveillance project with clinical laboratories across the state. The following letter is being mailed to laboratory directors".

Dear Laboratory Director,

Due to the recent confirmation of a single case of human anthrax diagnosed in West Palm Beach on October 4, the Florida Department of Health and the Centers for Disease Control and Prevention is instituting active laboratory-based surveillance for Bacillus anthracis.

The Florida Department of Health is requesting that all Florida laboratories submit cultures that may be suspicious for Bacillus species. Cultures that should be submitted to the Florida Department of Health Bureau of Laboratories include only those that meet all of the following three criteria:

1. Bacillus species isolated from culture, non-hemolytic, non-motile.
2. Collected since September 11, 2001
3. Collected from a sterile site such as blood, cerebrospinal fluid, or pleural fluid. (Please do not report cultures since September 11, 2001 collected from sputum.)

Isolates may be shipped to the Florida Department of Health Jacksonville, Miami or Tampa Branch Laboratories. The submitting laboratory should contact the Bureau of Laboratories prior to shipping for further instructions. Contact persons are as follows: Phil Lee, Jacksonville (904)-791-1712, Dr. Segaran Pillai, Miami (305) 324-2407, Dr. Phil Amuso, Tampa (813) 974-4002. Results should be available within 48h upon receipt in the laboratory.

Please contact the Bureau of Laboratories with any questions regarding laboratory testing for anthrax. Detailed laboratory protocols can also be found on the following CDC website. http://www.bt.cdc.gov/agent/anthrax/anthracis20010417.pdf

For other anthrax related questions please call 1-800-342-3557.

We greatly appreciate your assistance with this matter.

Sincerely,

Ming Chan, Ph.D.
Chief, Bureau of Laboratories

Steven Wiersma, M.D., M.P.H
Chief, Bureau of Epidemiology and State Epidemiologist