A Publication by the Bureau of Epidemiology
November 2, 2001
"The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow."
--Foege WH et al. Int. J of Epidemiology 1976; 5:29-37.
Steven T. Wiersma, MD, MPH—Bureau Chief and State Epidemiologist
Don Ward, Surveillance Section Administrator, Epi Update Managing Editor
Samuel Crane, MPH, Special Projects Surveillance Coordinator, Epi Update Editor
Bureau of Epidemiology Frequent Contributors:
Kathryn Snavely, MPH
Reportable Disease Manager
Jodi Baldy, MPH,
Biological Scientist IV
Ursula E. Bauer, PhD,
Chronic Disease Epidemiologist
Lisa Conti, DVM, MPH,
State Public Health Veterinarian
Dolly Katz, PhD, MPH, SE Florida
Roger Sanderson, RN, MA, SW Florida
Carina Blackmore, MS Vet. Med., PhD, NE Florida
Zuber Mulla, PhD MSPH,
Central Florida Carina Blackmore, MS Vet. Med., PhD,
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.
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In this issue:
1. CDC Updates
Updated (October 30,2001) CDC Health Alert Network Notice--Updated Information on Recognizing and Handling Suspicious Mail. This is an official CDC Health Advisory.
This information supplements CDC's recommendations for recognizing and handling suspicious packages or envelopes that were published as a CDC Health Advisory on October 27, 2001, and replaces information about identifying suspicious packages that was published as a Health Advisory on October 12, 2001.
Letters containing Bacillus anthracis (anthrax) have been received by mail in several areas in the United States. In some instances, anthrax exposures have occurred, with several persons becoming infected. To prevent such exposures and subsequent infection, all persons should learn how to recognize a suspicious package or envelope and take appropriate steps to protect themselves and others.
Identifying Suspicious Packages and Envelopes
Some characteristics of suspicious packages and envelopes include the following:
Other suspicious signs
If a package or envelope appears suspicious, DO NOT OPEN IT.
Handling of Suspicious Packages or Envelopes
If possible, create a list of persons who were in the room or area when this suspicious letter or package was recognized and a list of persons who also may have handled this package or letter. Give this list to both the local public health authorities and law enforcement officials.
Updated (October 30,2001) CDC Interim Recommendations for Protecting Workers from Exposure to Bacillus anthracis in Work Sites Where Mail Is Handled or Processed (Updated from CDC Health Advisory 45 issued 10/24/01) This is an official CDC Health Advisory.
These interim recommendations are intended to assist personnel responsible for occupational health and safety in developing a comprehensive program to reduce potential cutaneous or inhalational exposures to Bacillus anthracis spores among workers, including maintenance and custodial workers, in work sites where mail is handled or processed. Such work sites include post offices, mail distribution/handling centers, bulk mail centers, air mail facilities, priority mail processing centers, public and private mailrooms, and other settings in which workers are responsible for the handling and processing of mail. These interim recommendations are based on the limited information available on ways to avoid infection and the effectiveness of various prevention strategies and will be updated as new information becomes available. These recommendations do not address instances where a known or suspected exposure has occurred. Workers should be trained in how to recognize and handle a suspicious piece of mail (<http://www.bt.cdc.gov>). In addition, each work site should develop an emergency plan describing appropriate actions to be taken when a known or suspected exposure to B. anthracis occurs.
These recommendations are divided into the following hierarchical categories describing measures that should be implemented in mail-handling/processing sites to prevent potential exposures to B. anthracis spores:
1. Engineering controls
2. Administrative controls
3. Housekeeping controls
4. Personal protective equipment for workers
These measures should be selected on the basis of an initial evaluation of the work site. This evaluation should focus on determining which processes, operations, jobs, or tasks would be most likely to result in an exposure should a contaminated envelope or package enter the work site. Many of these measures (e.g., administrative controls, use of HEPA filter-equipped vacuums, wet-cleaning, use of protective gloves) can be implemented immediately; implementation of others will require additional time and efforts.
Engineering Controls in Mail-handling/processing Sites--B. anthracis spores can be aerosolized during the operation and maintenance of high-speed, mail-sorting machines, potentially exposing workers and possibly entering heating, ventilation, or air-conditioning (HVAC) systems. Engineering controls can provide the best means of preventing worker exposure to potential aerosolized particles, thereby reducing the risk for inhalational anthrax, the most severe form of the disease. In settings where such machinery is in use, the following engineering controls should be considered:
Note: Machinery should not be cleaned using compressed air (i.e., "blowdown/blowoff").
Administrative Controls in Mail-handling/processing Sites-- Strategies should be developed to limit the number of persons working at or near sites where aerosolized particles may be generated (e.g.,mail-sorting machinery, places where mailbags are unloaded or emptied). In addition, restrictions should be in place to limit the number of persons (including support staff and non-employees, e.g., contractors, business visitors) entering areas where aerosolized particles may be generated. This includes contractors, business visitors, and support staff.
Housekeeping Controls in Mail-handling/processing Sites-- Dry sweeping and dusting should be avoided. Instead, areas should be wet-cleaned and vacuumed with HEPA-equipped vacuum cleaners.
Personal Protective Equipment for Workers in Mail-handling/processing Sites--Personal protective equipment for workers in mail-handling/processing work sites must be selected on the basis of the potential for cutaneous or inhalational exposure to B. anthracis spores. Handling packages or envelopes may result in cutaneous exposure. In addition, because certain machinery (e.g., electronic mail sorters) can generate aerosolized particles, persons who operate, maintain, or work near such machinery may be exposed through inhalation. Persons who hand sort mail or work at other sites where airborne particles may be generated (e.g., where mailbags are unloaded or emptied) may also be exposed through inhalation.
Recommendations for Workers Who Handle Mail:
to protect exposed skin.
Additional Recommendations for Workers Who May Be Exposed through Inhalation:
In work sites where respirators are worn, a respiratory-protection program that complies with the provisions of OSHA [29 CFR 1910.134] should be in place. Such a program includes provisions for obtaining medical clearance for wearing a respirator and conducting a respirator fit-test to ensure that the respirator fits properly. Without fit testing, persons unknowingly may have poor face seals, allowing aerosols to leak around the mask and be inhaled. (See December 11, 1998, MMWR, available at http://www.cdc.gov/mmwr/preview/mmwrhtml/00055954.htm
2. Influenza Virus Surveillance Summary Update
(Week ending October 20, 2001-Week 42)
Carina Blackmore, MS, Vet.Med, PhD. Bureau of Epidemiology
National report: During week 42 (October 14-20, 2001), none of the specimens tested by the World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories across the United States were positive for influenza. Since September 30, a total of 1,936 specimens for influenza viruses have been tested and 11 (1%) were positive. Of the 11 isolates identified, 4 were influenza A (H3N2) viruses, 6 were unsubtyped influenza A viruses, and 1 was an influenza B virus. Influenza A isolates have been identified in Alaska, Arizona, New York, and Texas. The influenza B isolate was identified in Texas. The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) overall was 1.5%, which is less than the national baseline of 1.9%. The proportion of deaths attributed to pneumonia and influenza as reported by the vital statistics offices of 122 U.S. cities was 6.4% during week 42. This percentage is below the epidemic threshold of 6.9% for this time. Thirteen state and territorial health departments (Alaska, Florida, Indiana, Kansas, Kentucky, Minnesota, Missouri, New Mexico, New York, Ohio, Pennsylvania, West Virginia, and Wyoming) reported sporadic influenza activity and 36 reported no influenza activity.
Florida: Data from Florida suggests low levels of influenza activity. Overall, one percent of patients seeking care by physicians in the influenza sentinel surveillance met the case definition for ILI (> 100 F + cough and or sore throat) during week 42. Influenza-like illness activity was detected in 11 counties from Duval to Miami Dade. Higher flu activity than expected for this time of year (>2%) was reported by physicians in Broward, Palm Beach and Sarasota Counties. Between September 4 and October 16, influenza A (H2N3) was isolated from 4 patients residing in Collier and Palm Beach counties.