Between November 9, 1998 and February 5, 1999, Erie County Emergency Services responded to 12 reports of malicious anthrax contamination. Although each of these incidents subsequently turned out to be a hoax, the series of threats took a tremendous toll on local emergency resources and often resulted in massive emergency responses. This page contains information on anthrax and the recent anthrax scares in Western New York. In an effort to better educate emergency services providers, we have developed this page to serve as an informational and educational resource. We hope you find this information helpful. For additional information, contact the Erie County Medical Center (ECMC) Office of Prehospital Care at (716) 898-3580.
The Western New York anthrax experience:
November 09, 1998 - Queen of Martyrs Church (Cheektowaga)
January 15, 1999 - United States Attorney's Office (Buffalo)
Lessons learned during recent anthrax threats:
How should we respond to anthrax threats in the future?
Sample anthrax response protocols:
Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. The bacteria exists primarily as a zoonotic infection of herbivores including sheep, goats, cattle and horses but may infect humans. Anthrax spores can survive for long periods of time (years to decades) in soil and other suitable environments. Three forms of anthrax infection can affect humans; cutaneous anthrax, gastrointestinal anthrax and inhalation anthrax.
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Cutaneous anthrax is the most common form world-wide and results from direct contact of non-intact skin with infected animal hides, wool and hair. Clinically, it begins as a raised itchy bump that resembles an insect bite but within 1-2 days develops into a small vesicle and then a necrotic ulcer with a black eschar. Untreated, cutaneous anthrax has a 21% mortality rate. With appropriate antimicrobial therapy deaths from cutaneous anthrax are rare.
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The gastrointestinal form of anthrax is contracted primarily through ingestion of contaminated, poorly cooked animal meat. Clinically, gastrointestinal anthrax presents with diffuse abdominal pain, nausea & vomiting, hematemesis, severe ascites and diarrhea. Untreated, gastrointestinal anthrax carries a 50% mortality rate.
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Inhalation anthrax occurs following exposure to anthrax spores (usually 8,000 to 10,000) that become aerosolized and inhaled. Early symptoms of inhalational anthrax mimic the flu and include malaise, fever, cough and chest discomfort (prodromal phase). After a brief period of recovery, patients with inhalation anthrax will develop severe respiratory distress, cyanosis, stridor and hemoptysis. Untreated or treated too late, inhalation anthrax is almost certainly fatal. Anthrax infection has an incubation period of approximately seven days or less.
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Since anthrax is readily available and can be easily and cheaply manufactured and weaponized, it has great appeal to terrorists. Iraq, Russia and as many as ten nations have the capability to load anthrax spores into weapons. Several other countries are known to be developing biologic weapons programs. It is estimated that an attack on a major US city could cost up to $26.2 billion per 100,000 victims to mitigate. Recognizing the ability to use anthrax as a terrorist weapon, the seriousness with which threats must be taken and the chaos that ensues following a threat, many individuals have recently issued threats of anthrax contamination. It can safely be assumed that emergency services providers will continue to face hoaxes and need to be prepared to respond to actual or perceived threats of anthrax contamination.
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Anthrax bacteria is very susceptible to common antibiotics such as Doxycycline or Ciprofloxacine. Therefore, if discovered and treated early (prodromal phase), most victims will survive anthrax infection. However, if not recognized or treated too late, it is often impossible to reverse the effects of anthrax infection. Anthrax causes death in humans by creating anthrax toxin in the blood stream. Although it may be possible to kill the anthrax bacteria late in the disease course, toxin levels often will already be at irreversable lethal levels.
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To date there are no reports of any form of anthrax disease spreading from human to human and quarantine is not recommended. Additionally, there are no reports of individuals contracting anthrax by handling clothing known to be contaminated with anthrax spores.
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An anthrax vaccine does exist and is indicated for individuals who come in contact in the workplace with imported animal hides, furs, bone meat, wool and animal hair; and for individuals who otherwise might reasonably be expected to come into contact with anthrax spores. Anthrax vaccine is also indicated in conjunction with antibiotic therapy for post-exposure anthrax treatment. The anthrax vaccine for humans is a cell-free filtrate vaccine (i.e., uses dead bacteria as opposed to live bacteria) and is intended for men and women from 18 to 65 years of age. To date, data on the use of the vaccine in children, the elderly and pregnant women is unknown and therefore should be avoided in this population. Vaccination requires three initial subcutaneous injections given two weeks apart followed by three additional subcutaneous injections given 6, 12 and 18 months. Annual booster injections of the vaccine are required to maintain immunity. The anthrax vaccine is produced by Michigan Biologic Products Institute exclusively under contract to the Department of Defense. Consequently, only small quantities are made available as needed for civilian use.
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The Western New York anthrax experience:
Over the course of a four month period, from late 1998 through early 1999, Erie County Emergency Services responded to twelve threats of anthrax contamination. Interestingly, threats were made to a variety of different organizations; churches, schools, supermarkets, town municipal buildings, federal office buildings and health care facilities. Threats ranged from phone calls proclaiming anthrax contamination of the building to threat letters delivered through the U.S. Postal Service as well as by hand. Initial response to these events was large, costly, time consuming and often overwhelmed local emergency resources. However, as time progressed and responders gained familiarity with dealing with this form of bioterrorism, responses were scaled back, mitigated more quickly and at less of a financial cost to taxpayers. Below is a brief summary of some of the early anthrax incidents in Western New York. We have outlined each of these incidents specifically to demonstrate the differences in how each event was handled and to illustrate the progression towards a "scaled back" yet safe response.
November 09, 1998 - Queen of Martyrs Church (Cheektowaga):
At approximately 1:00 PM, a church secretary opens a letter stating that "you have been exposed to anthrax". The secretary shares the letter with fellow co-workers and eventually notifies the local police department. The first police officer arrives on-scene, enters the building and examines the letter. The police officer then contacts the town disaster coordinator via telephone to ask advise on how to handle this threat. The town disaster coordinator advises the police officer to seal the building, not allowing anyone in or out (including himself) until such time that a game plan can be implemented. In the mean time, one employee has already left for home. The local fire department is sent to ensure that the scene is contained and Erie County Emergency Services is contacted for assistance. Responders from Erie County Emergency Services including EMS, Fire and Hazmat are dispatched to an emergency operations center (EOC) established at the county training facility. The Erie County Medical Center Specialized Medical Assistance Response Team (SMART) along with a number of state and federal agencies (including the FBI) are also dispatched to the EOC. At the busy EOC, information on anthrax is gathered and analyzed, options are discussed and a plan to decontaminate all six victims is agreed upon. The county hazardous materials team is alerted and mobilized and antibiotics are sent from the medical center to the on-scene physicians who will ultimately treat the patients.
Several hours into the incident and under the dark of night, operational personnel are moved from the EOC to the scene of the incident. Streets quickly become congested with emergency vehicles including mobile command posts, decontamination trailers, hazmat support units, ambulances, police and fire apparatus. And of course, an extremely large media contingent soon arrives complete with satellite up link trucks and mobile production vans.
Hazardous material team members don level-A personal protective equipment to initiate the time-consuming task of double showering the victims. An initial shower inside the building consists of decontamination with a 0.5% chlorine solution. Clothing and personal belongings are bagged and left inside the building to be dealt with at a later time. All waste water is collected and subsequently placed in 55 gallon overpack drums. After the initial shower, patients were then placed in tyvek clothing, moved to a mobile decontamination facility and showered and decontaminated a second time before being moved to another building for consultation with the SMART physicians.
Medical treatment consisted of obtaining vital signs, administering oral antibiotics, providing a prescription for additional antibiotics, discussing anthrax infection and scheduling a follow up appointment. Simultaneously, the FBI collected the threat letter and began the process of having the letter sent to the FBI lab in Atlanta for analysis.
With the incident winding down, the building was sealed pending the results of lab testing. Police officers were assigned the task of guarding the building until such time that lab tests were obtained, several days later. Thankfully, test results indicated that no anthrax was present in the letter and patients were subsequently advised to discontinue antibiotic therapy.
January 15, 1999 - United States Attorney's Office (Buffalo):
At approximately 11:00 AM, an employee of the US Attorney's Office opens a letter containing a red substance smeared on the letter. Identical to a letter sent to the US Attorney's Office in Rochester days before, the letter stated that "you have been exposed to anthrax". After notifying local police and fire agencies, a massive mobilization of resources begins. Again federal, state, county and city resources are deployed. This time, to an EOC established in the Statler Towers one block down from the affected office building. Two city blocks were virtually shut down for the several hours it took to mitigate this incident.
Four employees who came in contact with the letter are quarantined in an office on an upper floor of the building. All other employees (approximately 100) are detained in their present locations within the building. Again, emergency responders meet, obtain information, analyze the situation and agree to decontaminate the four individuals who came into contact with the threat letter. Buffalo Fire Department's hazardous materials team along with members of the SMART team proceed to a first floor garage in the federal building (location of the incident) and set up a staging and treatment area for the victims. Again, level-A personal protective equipment is utilized by hazardous materials team members who go up to the floor where the victims are quarantined and subsequently shower and decontaminate them with a 0.5% chlorine solution. Once showered, the victims are clothed in tyvek and moved to the treatment are in the garage of the building. As in the previous incident, victims are treated with oral antibiotics and released from the scene. Again, personal belongings are secured in the "hot zone" pending determination of the presence or absence of anthrax. The office where the letter was opened is sealed and the remaining occupants of the building are debriefed and sent home for the weekend. Again the FBI collects the threat letter and sends it to Atlanta for analysis. This time however, cultures are taken from the letter and sent to the Erie County Medical Center for more rapid analysis. Four days later, it is determined that no anthrax was present and the patients are advised to discontinue antibiotic therapy.
January 20, 1999 - Iroquois Middle School (Elma):
Unlike the previous two incidents that affected a small number of victims, the Iroquois Middle School incident affected over 800 individuals, the majority of which were children. Besides being faced with the prospect of treating and decontaminating 800 people, this incident also brought with it the the need to "psychologically treat" up to 1500 parents. Clearly the magnitude of this incident would require us to rethink how we would handle the incident.
At approximately 9:00 am, the Iroquois Middle School office opened a letter stating that there was "anthrax in the building". Unlike previous threat letters, this letter did not specifically proclaim to contain anthrax. The school quickly contacted the fire department and the county sheriff's office while simultaneously implementing a plan to keep students in their classrooms. Upon arrival, the sheriff's deputy entered the building to investigate first-hand the threat letter. Shortly thereafter, the chief of the Elma Fire company arrived on scene, established incident command, made contact with the school via cellular phone and instructed the janitorial staff to shut down the ventilation system. The fire chief also quickly secured the scene to prohibit anyone from entering or leaving the building and requested a mutual-aid response from the county department of emergency services.
Again, a massive mobilization of federal, state, county and local authorities converged on the scene. A command post was established in an adjacent school and the tedious process of information gathering and analysis was begun. Based on the current limited knowledge of anthrax and the actions taken in previous incidents, an initial plan to decontaminate and treat (with antibiotics) all 800 individuals was agreed upon. Hazmat teams were alerted, 1000 tyvek suits were ordered from a local supply company, and the process of planning the actual massive decontamination was initiated. The logistics involved with decontaminating 800 people were staggering. It would take many hours, require numerous hazmat team members in level-A PPE, mounds of "contaminated" clothing and personal belongings not to mention the huge amount of waste water runoff. At one point, consideration was given to using the school swimming pool for decontamination. This option was discarded however due to the large amount of chlorine required among other concerns.
While planning for the mass decon continued. Parents began to gather in mass at the school. Additionally, media began to gather and broadcast erroneous reports. It quickly became clear that efforts to brief the parents and media needed to occur quickly and regularly, a task that in hindsight could have been done better. FBI agents, physicians, county disaster coordinators, school officials and the incident commander undertook the task of briefing the parents and media. Having representatives from a variety of specialties proved beneficial during the joint briefings which often raised more questions than were answered.
At the same time, physicians from SMART began to make arrangements to have medical supplies including antibiotics delivered to the scene. The Erie County Medical Center print shop began printing hundreds of pre-filled-out prescriptions and the ECMC laboratory began to prepare to analyze the numerous cultures that were anticipated. Anticipating the need to treat and counsel the hundreds of patients, additional SMART members including numerous physicians and nurses were dispatched to the scene.
While the situation continued to escalate, advice from the FBI, USAMRID and the National Centers For Disease Control began to filter in. Hazmat specialists from the FBI began to discuss something we had not previously considered, that being the credibility of the threat. Based on prior events in Western New York and throughout the nation, and through a threat assessment analysis, the FBI felt that the chance of anthrax being present in the school was negligible. Based on this threat assessment, the FBI was recommending that no decontamination or treatment of the victims be done. Although everyone in the EOC agreed that we were most likely dealing with a hoax (there has never been a case of actual anthrax used as a weapon in the United States), most everyone agreed that we needed to err on the side of caution. It was felt that failure to do everything we could (i.e., decontamination and treatment with antibiotics) would lead to outrage and criticism by parents. Also, the fear existed that if indeed anthrax was present and we failed to treat patients early, we might ultimately be faced with the death of 800 individuals; something we later could not defend. With this in mind, it was agreed to continue on course and prepare to decontaminate and treat all of the victims.
Having heard the FBI's recommendation, and facing a concern of providing antibiotics to young children who have unknown allergy histories, physicians from SMART began lengthy and detailed discussions with individuals from the National Centers For Disease Control. These discussions ultimately would be the basis for changing the way this and future anthrax incidents would be handled.
Fortunately, the CDC was able to put us in direct contact with researchers and world experts on anthrax and bioterrorism. Initial recommendations from the CDC seemed to echo the FBI's "do nothing" stance. But now, for the first time, we began to hear detailed scientific evidence that challenged the beliefs that we previously had concerning anthrax. Suddenly, we were questioning our decision to decontaminate and treat all 800 victims. A 1:30 pm telephone conference was set up so that representatives from all disciplines could speak directly with these world anthrax experts. At 1:30 pm, a two hour long phone conference began.
Perhaps the largest fear that was alleviated during the conference call was our fear of committing these victims to certain death in the event that anthrax was present in the building. Up to this point, everything we had read or been taught clearly stated that failure to treat victims early equated to certain death of the victim once signs and symptoms of the illness manifested. Physicians from the CDC began to discuss the existence of a prodromal phase of anthrax infection. Apparently, anthrax disease progresses in two distinct phases, an early prodromal phase and a later dromal phase. During the prodromal phase, patients experience flu-like symptoms (cough, fever, chills, sore chest, etc.). However, anthrax toxins are at low levels in the blood. Too low to cause death. If antibiotics are administered during this early phase, the anthrax bacteria can be killed and the production of anthrax toxins halted. Ultimately, it is anthrax toxin, not the bacteria itself, that causes death. The prodromal phase lasts anywhere from two to six days after infection with anthrax. Clearly we now had a window to work within and knew what specific signs and symptoms might occur providing early warning of anthrax infection.
Another concern that was laid to rest was the concern of cross contaminating family members if indeed anthrax was present on the clothing of the students. Other experts who had closely monitored the wool industry spoke to the fact that no one has ever been contaminated by handling clothing that was known to be contaminated with anthrax spores. Additionally, anthrax spores are easily killed during clothes washing with normal detergent. Yet other experts spoke to the fact that anthrax does not remain aerosolized for long in the air (due to the weight of the molecules as they combine with dust and other particles) and is not easy to re-aerosolized. Also, electrostatic properties of anthrax tend to cause the anthrax spores to repel from clothing and the human body. We were also advised that showering with shampoo, soap and water would remove any anthrax spores present. With this data in hand, we were now confident that releasing the students and allowing them to return home was not going to jeopardize contaminating their family members.
Still wanting to err on the side of caution, and upon the recommendation of the FBI bioterrorism experts, it was decided to conclude the threat assessment analysis by searching the building for anything that would give credibility to the threat. Hazardous material team members in level-A PPE were ordered to search the entire building, room by room, searching for anything that might indicate the presence of anthrax. Team members searched for powders, liquids, and devices that could have been used to distribute aerosolized particles. Special attention was given to the inspection of the building's ventilation system.
As could be expected, the search continued at a very slow pace. Entry teams were limited in the time they could spend inside the level-A suits and frequent rotation of teams was needed. Ultimately it was decided to have the personnel in the building search their respective class rooms and areas of the building. After all, who would know better if something suspicious was out of place than the building's normal occupants. Once it was verified that the entire building was searched and nothing was found to add credibility to the threat, is was agreed upon by all parties that the threat be considered minimal.
Simultaneously to the search of the building, SMART prepared discharge instruction sheets for the students to take home to their parents. The instruction sheets outlined the events of the day, recommended that the children shower with shampoo, soap and water upon returning home, instructed the parents to wash their children's clothing and advised parents to observe their children for any of the signs or symptoms of anthrax infection for the next seven days. Plans were to place anyone exhibiting these signs or symptoms over the next seven days on oral antibiotics as a precaution. The school nurse was designated as a central contact point for reporting of any perceived signs or symptoms over the next seven day period. Instruction sheets were quickly duplicated and distributed to each student prior to dismissal. To create an end point for the incident and make a decision as to the presence or absence of anthrax, numerous cultures were obtain from both the environment within the building (e.g., ventilation system) as well as from the nares of adult victims. All swabs were sent to the ECMC laboratory for culturing and analysis. Additionally, as in the past, the FBI collected and sent the threat letter and collected cultures to Atlanta for analysis. Now all that remained were the logistics of dismissal and incident termination. By 7:30 pm, all students were released and the incident termination phase began.
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Lessons learned during recent anthrax threats:
- Perhaps the most important lesson learned during our recent anthrax ordeals was the necessity to perform a threat assessment and base our decisions at a given incident on that assessment. The FBI clearly has the expertise to provide us with a threat assessment that can then be coupled with medical advise to determine the best course of action. In cases where the threat is perceived to be low or negligible, mitigation may simply consist of hand washing, normal showering and clothes laundering at home and monitoring of potential victims for signs and symptoms of illness. Should the threat assessment indicate a credible or high probability that anthrax contamination has occurred, perhaps immediate oral antibiotics and more stringent decontamination might be considered. In any case, threat assessment must begin immediately upon receipt of the threat and progress quickly.
- Another very important lesson learned during the recent anthrax ordeals was the fact that anthrax infection progresses in two distinct phases. Knowing that a prodromal phases exists and that treatment is effective even if begun during the prodromal phase clearly will influence whether antibiotics are given prophylactically. This is especially important when dealing with large numbers of patients or with a pediatric population in which allergy histories are yet unknown.
- Simply stated, time is on your side. When dealing with a biological agent, time exists to gather & analyze data, perform threat assessment analysis and develop reasonable mitigation plans. There is no need to panic or rush to a decision as anthrax infection takes days to onset.
- Usually we're dealing with a hoax. Think about it! If a terrorist really wants to create chaos and gain recognition he/she is not going to boast about releasing anthrax before it has the chance to harm or kill its intended targets. Usually the terrorist will claim responsibility after the damage is done. If we are warned of an anthrax release prior to the onset of numerous sudden deaths we have an advantage in the ability to intervene.
- CDC, FBI and other agencies state that the main concern to rescuers is to protect them from an inhalation hazard. Therefore, Level-C PPE incorporating a HEPA mask is considered adequate to provide protection from biological agents. Alternatively, supplied air respirators may also be used to provide respiratory protection since most fire companys already posess SCBA. A secondary concern to rescuers it to protect skin surfaces from contacting biological agents. Most firefighter turnout gear or tyvek suits will provide adequate skin protection. And remember, intact skin is a great barrier to bacteria. Washing exposed skin with soap and water will more than likely provide adequate decontamination should biological agents contact the skin.
- Anthrax is easily decontaminated with a 0.5% chlorine solution or by simply washing with soap and water. Simple hand washing and showering go a long way in eliminating the threat of anthrax cross contamination.
- Anthrax in a powder form is non-volatile and does not easily aerosolize. In order to be an inhalation threat, anthrax must be aerosolized. In incidents that involve letters stating that the letter itself contains anthrax, the inhalation threat can immediately be deemed small. If a threat indicates that an air handling system is involved, a thorough building search should verify the existence of air-duct tampering or the presence of an aerosolizing device.
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How should we respond to anthrax threats in the future?
Since the three incidents discussed above, and at the time of this writing, nine more incidents have taken place. Each incident, although slightly different, shared several common elements. A police, fire and EMS response was required every time. Some degree of quarantine/control over victims was required until a game plan could be established. Each incident required that a threat assessment be conducted; and each incident required that decisions be made as to decontamination and treatment of victims based on the threat assessment performed.
Clearly we are getting better at handling these threats in a quick, safe and cost effective manner. No longer do we deploy massive resources to each incident. The trend now it to treat the threat in proportion to its credibility. Responses have been scaled back and a small strike-team of knowledgeable and capable individuals will be deployed to assess future threats. Should a threat be deemed credible, then yes, a larger scale response might be in order; but no longer will we "over-do-it" and satisfy the goals of the terrorist wanna-be.
Education is perhaps the most important factor in influencing the outcome of future incidents. Hence this article. If first responders are properly trained in how to react, know who to contact and know what to do while waiting for help, future incidents will be a mere nuisance. If we fail as a system to learn from our previous experiences, each future incident will require us to re-live the learning curve all over again; and we will be right back to square one.
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Sample anthrax response protocols:
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