EPI UPDATE

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In this issue:

1. Guidelines for Surveillance of Cutaneous Anthrax
2. Public Health Update: Cleanup of Boca Raton Main Post office

1. Epi Update – Urgent Interim Guidelines for Surveillance.

October 15, 2001

For all Emergency Department healthcare personnel, public healthcare facilities, urgent care clinics, primary care physicians and all other healthcare providers who might see cutaneous skin lesions in their practice:

The Florida Department of Health in conjunction with the Centers for Disease Control and Prevention recommend expanded surveillance for the cutaneous form of anthrax. This is a result of the report of a case of cutaneous anthrax in New York City in conjunction with a single confirmed case of inhalation anthrax in an employee who worked in the American Media, Inc. building in Boca Raton, Florida.

Cutaneous Anthrax Surveillance:

Cutaneous (skin) anthrax is different from inhalation anthrax, which is the type of anthrax that resulted in the death of one person in Palm Beach County, Florida. A cutaneous infection due to anthrax can occur if the bacterial spores are inoculated into skin cuts or wounds. Lesions of cutaneous anthrax are marked by edema and blisters (vesicles, typically filled with clear fluid) that eventually rupture to form an ulcer with a black center (eschar). The cutaneous form responds well to antibiotics even when started late in the course.

Current public concern about anthrax will result in an increase in the number of patients with common skin diseases presenting to hospitals and clinics.

• There is no evidence of the cutaneous form of anthrax being present in the State of Florida at this time.

Please see "Cutaneous Anthrax Information Sheet" and "Diagnostic Flow Sheet" for more detailed diagnosis and treatment recommendations if you suspect a case of cutaneous anthrax in your practice. If anthrax is suspected it is very important to obtain appropriate diagnostic specimens prior to starting antibiotic treatment as the lesion may become sterile as quickly as six hours after initiating therapy.

Notification Procedure:

If a suspect skin lesion is culture positive for Bacillus anthracis, or you have a skin lesion that you feel to be highly suspicious despite a negative culture, Please notify your county health department or the Florida Department of Health at 850-245-4401.

Thank you for your willingness to collaborate with us in this important public health issue.

Cutaneous Anthrax Information Sheet

Cutaneous anthrax occurs when anthrax spores enter the skin surface through a cut or other break in the skin. Cutaneous anthrax is rare in the US, with only 2 cases reported in the last 10 years. Historically most patients with this condition have had contact with animal products contaminated with anthrax spores. Cutaneous anthrax resulting from a deliberate act designed to infect another person is considered possible, and of particular concern in light of a recently reported case of cutaneous anthrax in New York City.

What does cutaneous anthrax look like?

Cutaneous anthrax appears as a small papule or vesicle 2 or 3 days after spores have infected the skin. Over the next day the initial lesion expands and vesicles form in and around a central papule, accompanied by a significant degree of edema. During the next several days the vesicles disappear as the central papule ulcerates. The final stage is a black eschar, which forms as the ulcer dries and typically occurs within one week.

Where are lesions of cutaneous anthrax likely to appear?

The most common areas are the head, neck and extremities. While it is uncommon for other sites to be affected, cutaneous anthrax lesions can occur in any area where anthrax spores come in contact with a break in the skin.

Are there other signs of cutaneous anthrax?

Fever, muscle aches, lymphadenopathy, local erythema and edema are often present.

How is the diagnosis of cutaneous anthrax made?

Please use attached flow sheet for instructions regarding the management of skin lesions considered suspicious for cutaneous anthrax.

A skin lesion with the typical appearance of cutaneous anthrax combined with laboratory isolation of B. anthracis is diagnostic. Patients with cutaneous anthrax may present with a black eschar, and have no memory of a preceding vesicular or ulcerative lesion. Patients may alternatively present with a vesicular or ulcerative lesion that changes into a black eschar within a few days. Without strong evidence of exposure, patients with a new skin lesion that is non-vesicular and non-ulcerative should be considered very unlikely to have cutaneous anthrax.

Culture of vesicular lesions, ulcerative lesions, or the border of a black eschar due to anthrax should reveal the organism. Gram stain is diagnostic in approximately 50% of cases. Blood cultures can be useful in diagnosis and should be drawn if fever is present. Anthrax serology, or paired sera 14 days apart, can support the diagnosis, but is not available except in a limited number of reference laboratories. Biopsy of a cutaneous anthrax lesion is contraindicated due to concern that trauma from tissue sampling may disseminate the bacteria hematogenously.

How do I distinguish cutaneous anthrax from other skin lesions?

Cutaneous anthrax has a characteristic progression from papule, to a vesicular lesion with surrounding edema, to an ulcerative area, to a black eschar. Secondary vesicular lesions around the primary ulcer may be apparent. This typical evolution occurs over approximately one week. Close follow-up with frequent examination of the suspected area for this pattern is crucial to the diagnosis.

Will presumptive treatment of cutaneous anthrax hinder diagnostic testing?

Yes. Antibiotic therapy will limit the yield of gram stain and culture, so these tests should be performed prior to treatment. Cutaneous anthrax progresses slowly, allowing time for diagnostic testing prior to initiation of treatment in most cases.

Close clinical follow-up should continue after antibiotics are begun. The characteristic progression of anthrax skin lesions is observed even with appropriate therapy. Clinically-compatible skin findings combined with laboratory evidence of B. anthracis confirms the diagnosis.

How urgently should cutaneous anthrax be treated?

The typically slow progression of cutaneous anthrax allows time for gram stain and culture of the suspected area. Antibiotic treatment is recommended after a swab for gram stain and culture is taken. Patients with a black eschar should begin antibiotics after culturing the margin of the suspected lesion with a moist swab.

Special consideration should also be given to secondary skin and soft tissue infections that may occur in conjunction with cutaneous anthrax.

Who should I notify if I suspect strongly that a patient has cutaneous anthrax?

Please see the attached flow sheet for instructions regarding the reporting of suspected cases of cutaneous anthrax.

Patients with a vesicular lesion, ulcerative lesion, or black eschar thought to be caused by anthrax should have a swab of the lesion sent for gram stain and culture. A sterile swab moistened with saline is most effective, although a dry swab will suffice. If the patient has a black eschar, the border of the area should be sample preferentially.

If a bacillus species is found on gram stain or culture, the isolate should be sent to the Florida State Public Health Laboratory. Laboratory capacity for identification of B. anthracis is available through the National Laboratory Response Network that can be accessed through the state public health laboratory. Please notify your county health department or the Florida Department of Health at 850-245-4401 when you suspect any patient has cutaneous anthrax. After hours and on weekends, please contact the Epidemiologist on call at 850-245-4401.

If I suspect that a patient has cutaneous anthrax, should they be hospitalized?

Decisions regarding hospitalization are best left to the clinician’s judgment. In general, cutaneous anthrax does not result in a severe illness requiring hospitalization unless left untreated for a few days.

What precautions should be taken when treating or examining a patient with cutaneous anthrax?

Standard precautions apply to the management of patients with cutaneous anthrax. Open wounds should be kept clean and dry with a standard dressing applied. Human-to-human transmission of cutaneous anthrax is considered extremely unlikely.

What is the treatment for cutaneous anthrax?

Antibiotics are listed in order of preference:

Adult males and non-pregnant adult females (ages 18-65):

• Ciprofloxacin 500 mg orally twice a day for 14 days OR

• Doxycycline 100 mg orally twice a day for 14 days OR

• Amoxicillin 500 mg orally three times a day for 14 days

Pregnant adult females:

• Amoxicillin 500 mg orally three times a day for 14 days

Adults age > 65:

• Doxycycline 100 mg orally twice a day for 14 days OR

• Ciprofloxacin 500 mg orally twice a day for 14 days OR

• Amoxicillin 500 mg orally three times a day for 14 days

** In older adults, the potential CNS side effects of ciprofloxacin should also be considered when selecting an antibiotic for prophylaxis.

Children > 9:

• Amoxicillin 500 mg orally three times a day for 14 days OR

• Ciprofloxacin 500 mg orally twice a day for 14 days OR

• Doxycycline 100 mg orally twice a day for 14 days

Children < 9:

Amoxicillin 80 mg/kg/day orally, divided into three doses a day for 14 days

* Drug-drug interactions and individual patient allergies should be considered when selecting an antibiotic for prophylaxis.

For More Information:

http://www.bt.cdc.gov/Agent/Anthrax/Anthrax.asp

http://www.nbc-med.org/SiteContent/HomePage/WhatsNew/MedAspects/Ch-22electrv699.pdf

2. Public Health Update: Cleanup of Boca Raton Main Post Office

October 15, 2001

A miniscule amount of anthrax spores have been found in a small, non-public mail processing area of the Boca Raton Main Post Office located at 2800 North Military Trail, Boca Raton, Florida. There is no indication that these spores pose a health risk to workers or visitors. As an extraordinary precaution, health officials are asking employees to leave this small portion of the building. Personnel from the Environmental Protection Agency will clean the affected area tonight—after the post office closes. Cleaning of the area will be completed by 4AM on Tuesday, October 6, 2001. The post office will be open again for business in the morning. Postal employees who worked in this building can meet with health officials at the Boca Raton Main Post Office today to address any questions or concerns they may have. The important thing for employees to know is that those who have any potential risk for anthrax disease were identified and placed on antibiotics last week. The nasal swabs obtained from those same individuals at the post office have all tested negative for anthrax exposure. These individuals should complete the 15 day course of antibiotics that they were given.

Health officials do not recommend any further testing or antibiotic treatment for other Boca Raton postal employees, visitors to this facility, or individuals and companies who have received mail from this facility.