EPI UPDATE

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In this issue:

1. CDC Update: CDC summary of confirmed cases of anthrax and background information

October 23, 2001/3:00 PM, ET
This is an official CDC Health Update
Distributed via Health Alert Network

CDC-confirmed cases of anthrax:

Based on a rigorous case definition, CDC is reporting 11 confirmed cases of anthrax: 2 in Florida, 3 in New York, 2 in New Jersey, and 4 in Washington, D.C. (in collaboration with MD and VA). These cases include the two deaths recently reported in Washington, D.C. Both cases were proven, through laboratory testing, to be cases of inhalation anthrax. One additional case has been reported by the New York City Department of Health. CDC is conducting additional tests to fully confirm this 12th case.  CDC defines a confirmed case of anthrax as 1) a clinically compatible case of cutaneous, inhalational, or gastrointestinal illness that is laboratory confirmed by isolation of B. anthracis from an affected tissue or site or 2) other laboratory evidence of B. anthracis infection based on at least two supportive laboratory tests.

Background

• Anthrax is NOT contagious from one person to another. Family members and contacts of persons who work in or visited sites where exposure occurred are not at risk and antibiotic therapy is not recommended for them. Other members of the community are not at risk. Public health officials, together with the FBI, are continuing the investigation.

• Inhalation anthrax is the most serious and rare form of human anthrax. It occurs when a person breathes a large number of anthrax spores that are in the air. Initial symptoms may resemble the common cold (including fever, muscle aches, and fatigue). After several days, symptoms may progress to severe breathing problems and shock. If left untreated, inhalation anthrax can be fatal.

• Cutaneous (skin) anthrax is different from inhalation anthrax. A cutaneous infection due to anthrax can occur if the spores are in contact with an area of skin that is not intact, such as a cut or sore. Cutaneous anthrax is marked by a boil-like lesion that eventually forms an ulcer with a black center. The cutaneous forms respond well to antibiotics if treatment is started soon after symptoms appear.

• For people with suspected anthrax disease, laboratory testing is essential to diagnosis. Tests may include:

  • Cultures of blood and spinal fluid (should be done before antibiotic treatment has been initiated)

  • Cultures of tissue of fluids from affected areas.

  • Microscopic examination of tissue.

  • PCR (polymerase chain reaction) test that amplifies trace amounts of DNA to document that the anthrax bacteria is present.

• Antibiotics are an effective treatment if the disease is diagnosed early on; but anthrax can be fatal if left untreated.

• The Centers for Disease Control and Prevention continues to work with state and local health departments, law enforcement officials, and other federal agencies to investigate incidents of possible anthrax exposures around the United States. In Atlanta, CDC officials continue to work out of a 24-hour Operations Center. The Operations Center staff is also responding to hundreds of calls each day from the public. CDC has dispatched more than three dozen employees to Florida, New York City, or Washington, D.C. More than 50 CDC laboratories have processed hundreds of specimens.

2. Antimicrobial Susceptibility of Bacillus anthracis: Isolates Associated with Intentional Distribution in Florida, New Jersey, New York, Pennsylvania, Virginia, and Washington, D.C., September - October, 2001

This is an official CDC Health Advisory
Distributed via the Health Alert Network
October 22, 2001, 21:12 EDT (9:12 PM EDT)

The antimicrobial susceptibility patterns of eleven Bacillus anthracis isolates associated with intentional exposures on the east coast have been determined. The susceptibility patterns of all the isolates were similar and are described below. CDC will be issuing updated treatment recommendations for anthrax and will disseminate them as soon as they are completed.

Ciprofloxacin <0.06 ug/ml (susceptible)
Tetracycline = 0.06 ug/ml (susceptible)
Doxycycline <0.03 ug/ml (susceptible)

Penicillin <0.06 ug/ml - 0.12ug/ml ("susceptible" but see below)
Amoxicillin < 0.03 ug/ml ("susceptible" but see below)

Erythromycin = 1 ug/ml (intermediate)
Azithromycin =2 ug/ml (borderline susceptible)
Clarithromycin =0.25 ug/ml (susceptible)

Rifampin = 0.5 ug/ml (susceptible)
Clindamycin <0.5 ug/ml (susceptible)
Vancomycin = 1-2 ug/ml (susceptible)
Chloramphenicol = 4 ug/ml (susceptible)
Ceftriaxone = 16 -32 ug/ml (intermediate or resistant)

• The penicillin MICs were <0.06 to 0.12 ug/ml, which, using the NCCLS staphylococcal breakpoint for penicillin, would be considered susceptible (resistance is defined as >0.25 ug/ml).

• All of the B. anthracis isolates were also susceptible to ciprofloxacin (MIC< 0.06 ug/ml), chloramphenicol (MIC = 4 ug/ml), tetracycline (MIC=0.06 ug/ml), doxycycline (MIC=0.06 ug/ml), rifampin (MIC<0.5 ug/ml), and vancomycin (MIC 1-2 ug/ml).

• Although there are no amoxicillin breakpoints defined for staphylococci by NCCLS, the amoxicillin results (MIC <0.03 ug/ml) were considered susceptible for B. anthracis. However, the erythromycin MICs of all eleven strains of B. anthracis would be categorized as intermediate (MIC= 1 ug/ml ). The MICs to clarithromycin (MIC=0.25 ug/ml) and azithromycin (MIC=2 ug/ml) are susceptible (but azithromycin MICs are at the susceptible breakpoint). Using the NCCLS ceftriaxone breakpoints designated for gram-negative organisms (since there are no breakpoints specifically for ceftriaxone for staphylococci) all isolates would be considered as intermediate (MIC =16 ug/ml) or resistant (MIC=32 ug/ml). These MICs suggest the presence of a cephalosporinase in the isolates. Additional studies are in progress to define the beta-lactamases of B. anthracis.

Conclusions

• The current B. anthracis strains associated with the intentional exposures are susceptible to ciprofloxacin and doxycycline, the two drugs approved for post-exposure prophylaxis to B. anthracis and recommended as part of initial therapy of inhalational or cutaneous anthrax.

• The current strains also are susceptible to chloramphenicol, clindamycin, rifampin, vancomycin, and clarithromycin, but limited or no data exists regarding the use of these agents in the treatment or prophylaxis of B. anthracis infections.

• Cephalosporins should not be used for post-exposure prophylaxis or treatment of B. anthracis infections.

• The likelihood of a beta-lactamase induction event that would increase penicillin MICs is significantly higher in infections where high concentrations of organisms are present. Thus, treatment of known B. anthracis infections with a penicillin type drug alone (i.e., penicillin G, ampicillin, etc.) in the setting where high concentrations of organisms are present is a concern.

• The likelihood of a beta-lactamase induction event that would increase penicillin MICs is lower when only small numbers of vegetative cells are present, such as during post exposure prophylaxis. Thus, amoxicillin or penicillin VK may be an option for post-exposure prophylaxis where ciprofloxacin or doxycycline are contraindicated.

• Additional studies are in progress to assess the susceptibility of the penicillinase activity observed in these strains to beta-lactamase inhibitors.

• Clinical experience is limited, but combination therapy with two or more antimicrobials may be appropriate in patients with severe infection.

"The Florida Department of Health has developed the attached official documents to help inform physicians and responders of testing procedures and follow up for clinical and environmental samples".

This is an official CDC Health Advisory
Distributed via Health Alert Network
October 22, 2001, 12:00 EDT (12:00 PM EDT)

NIOSH personnel and other investigators at risk for exposure to Bacillus anthracis, the organism causing anthrax, should wear protective personal equipment (PPE), including respiratory devices, protective clothing, and gloves. The items described below are similar to those used by emergency personnel responding to incidents involving letters or packages. Responders need to use greater levels of protection in responding to incidents involving unknown conditions or those involving aerosol-generating devices.

Powered Air-Purifying Respirator with Full Facepiece and High-Energy Particulate Air (HEPA) Filters

• The constant flow of clean air into the facepieces is an important feature of this respirator because contaminated air cannot enter gaps in the face to facepiece seal. These respirators also give wearers needed mobility and field of vision.

• Use respirators in accordance with a respiratory-protection program that complies with the OSHA respiratory-protection standard (29 CFR1910.134).

• Respiratory facepieces for NIOSH investigators will be assigned on the basis of results of quantitative fit testing.

• Wearing a properly functioning, powered, air-purifying respirator with a full facepiece that is assigned to the wearer on the basis of quantitative fit testing will reduce inhalation exposures to 2 % or less of what they would be without wearing this type of respirator.

Disposable Protective Clothing with Integral Hood and Booties

• Wearing protective clothing not only protects the skin but can eliminate the likelihood of transferring contaminated dust to places away from the work site.

• Wear disposable rubber shoe coverings with ridged soles made of slip-resistant material over the booties of the disposable suit to reduce likelihood of slipping on wet or dusty surfaces.

• Decontaminate all PPE immediately after leaving a potentially contaminated area.

• Remove and discard protective clothing before removing the respirator.

Disposable Gloves

• Disposable gloves made of light-weight nitrile or vinyl protect hands from contact with potentially contaminated dusts with compromising needed dexterity.

• A thin cotton glove can be worn inside a disposable glove to protect against dermatitis, which can occur from prolonged exposure of the skin to moisture in gloves caused by perspiration.

5. CDC Recommendations on Antibiotic Prophylaxis: for Workers and Visitors to the Washington, D.C. Processing and Distribution Center, 900 Brentwood Road and the Mail Handling Center, Cargo Road, Anne Arundel County, Maryland

This is an official CDC Health Alert
Distributed Via Health Alert Network
October 23, 2001 02:27 EDT (2:27 AM EDT)

All employees of and visitors to the Washington, D.C. Processing and Distribution Center, 900 Brentwood Road and the Mail Handling Center, Cargo Road, Anne Arundel County, near the Baltimore-Washington International Airport since October 10th should begin antibiotic prophylaxis for possible exposure to B. anthracis (anthrax). It is believed that these individuals could have been exposed to the bacterium.

• These individuals should receive antibiotic prophylaxis for 10 days, with continuation determined by the Washington, D.C. Health Department and the Maryland and Virginia State Health Departments.

• These individuals should not be tested for exposure to B. anthracis with nasal swabs. Nasal swabs are used primarily for epidemiologic investigation and not for individual diagnosis, prophylaxis, or treatment.

• Nasal swabs are also not recommended for testing people at potential risk who are currently away from the Washington, D.C. area. Again, such tests are not used to determine the need for prophylaxis among people who are potentially exposed.

The Deputy Postmaster General is currently contacting employees about beginning prophylaxis. People who meet the criteria for potential risk and are currently away from the Washington, D.C. metropolitan area should contact their local or state health department to receive prophylaxis. CDC requests that state health departments do the following:

• Facilitate access to antibiotic prophylaxis if they are contacted.

• Initiate a system for recording the names of and tracking those individuals for follow-up purposes in the event they develop signs or symptoms consistent with anthrax.

• Contact CDC at (770) 488-7100 and request the State Liaison Desk to report names and contact information of people determined to be at potential risk who are currently away from the Washington, D.C. metropolitan area. CDC's investigation is ongoing. Future modifications to these recommendations may occur on the basis of epidemiologic and laboratory information. Additional modifications and any new information will be posted.

You have received this message based upon the information contained within our emergency notification data base. If you have a different or additional e-mail or fax address that you would like us to use please notify us as soon as possible by e-mail at healthalert@cdc.gov.

October 24, 2001

Contact: April Crowley, 850-245-4111

TALLAHASSEE—The Florida Department of Health (DOH), in cooperation with Home Access Health Corporation (HAHC), has developed and implemented a statewide toll-free hotline number for the collection and reporting of dead bird sightings, and for disseminating educational information on West Nile (WN) virus.

HAHC, based out of Hoffman Estates, Illinois, will staff the hotline with live operators from 8:00 AM to 12:00 AM, Eastern Standard Time, Monday through Friday. An electronic recording will also be available for all incoming calls that are not answered by a live operator.

The toll-free number is 1-800-871-9703. Selections available to callers include:

• Reporting dead birds;
• Educational information on West Nile virus;
• West Nile fever symptoms; and
• Referral to a health department staff member.

West Nile virus is a mosquito-borne illness first reported in the United States in 1999. It is maintained in wild birds (it has been found in more than 50 species), and can infect humans, horses and other mammals. Infected mosquitoes transmit the virus from birds to humans. There is no human-to-human or animal-to-human transmission.