Mid-America Regional Public Health Leadership Institute Year 9 Fellows
Sarah Burkholder, BSN, MPH, Manager of Nursing
Services, Elkhart Co. Health Dept., Indiana
Robert Clark,
AB, Health Planner, Indiana State Department of Health
Sandy Cummings, MSW, Chronic Disease Coordinator, Marion
Co. Health Department, Indiana
Kristin Everett, BS, Health
Educator, St. Joseph Co. Health Department, Indiana
Kathleen
Koehler, BS, Nursing Supervisor, LaPorte County Health Department,
Indiana
Susan Meece-Hinh, BS, Project Manager, Indiana
University Department of Public Health
Kristine Conyers,
MSN, Mentor, Administrator, Howard Co. Health Department,
Indiana
Adapted from Leadership in Public Health 2002;6(1):31-38
The Mid-America County Health Department recently was one of several agencies responding to a biological terrorist threat to the staff of a neighborhood health care clinic. Twelve agencies worked together to assess and contain the threat. Federal, state and local government levels were involved in the immediate response and the subsequent data collection and limited data and situational analysis. A letter opened by a clerical staff person in a Thinking About Parenthood clinic included a message indicating that the envelope contained anthrax. Through the course of the next five hours, 43 individuals were considered to be exposed and, therefore, were decontaminated. A data collection database was developed and initial data was collected. Two labs determined that the substance was not anthrax. This case study outlines the lines of communication, the time frames for a single episode response and the breadth of organizations whose expertise is needed. Additionally, it poses the question, "how do we adequately assess the indicators of biological terrorism so the threat can be minimized?"
The threat of bioterrorism is a relatively new phenomenon to most institutions. A bioterrorism event, real or a hoax, requires smooth coordination between law enforcement agencies, fire departments and health authorities to ensure adequate handling of a crime scene, protection of the health of exposed or potentially exposed individuals, prevention of additional exposures and a response to public concerns. On October 30, 1998, at 12:30 pm, the office manager of a Thinking About Parenthood clinic received a letter stating that she had been exposed to anthrax. At least 12 agencies and several additional individuals were involved in the event. As a result, all 43 individuals in the clinic were considered contaminated and were decontaminated. Five hours later, 31 individuals were transported to local emergency rooms and received oral chemoprophylaxis. Some underwent a second decontamination as required by hospital policy. Both the state lab and the FBI lab tested the substance. Within 26 hours of the event, the FBI lab revealed the substance in question was not anthrax. Nineteen hours later, the state lab also confirmed the substance was not anthrax. An epidemiological assessment of the event was critical for identification of the suspected biological agent, appropriate isolation, decontamination and medical prophylaxis of exposed individuals. It was crucial that first responders to the event know how to evaluate exposures and manage exposed and potentially-exposed individuals appropriately. It was equally important that agencies that respond to a bioterrorism event know where to obtain confirmative identification and information on potential agents. Finally, clear communication between all agencies and facilities involved was paramount.
The Mid-America County Health Department (MCHD) case study describes a bioterrorist act alleging the use of anthrax. Anthrax is an acute infectious disease caused by the bacterium Bacillus anthracis. Naturally occurring anthrax disease occurs when humans come in contact with anthrax-infected animals or anthrax contaminated animal products. Three types of anthrax infection can occur in humans: inhalational, cutaneous and gastrointestinal. The most deadly type of bioterrorist act would be the release of aerosolized anthrax, resulting in inhalational disease. Inhalational anthrax is almost always fatal if not promptly treated. The MCHD incident occurred on October 30, 1998. Between October 30 and December 23, 1998, the CDC received numerous reports of alleged anthrax exposures. All proved to be hoaxes. Bioterrorism hoaxes reported to the CDC in 1999 totaled over 200. The following case study outlines the response of the public health and safety agencies in Mid-America County to this threat.
The Mid-America County Health Department (MCHD) is the local health entity that services Circle City and all of Mid-America County. On a beautiful fall Friday in 1998, the agency responded to the first real anthrax scare in this state. On that afternoon, a letter with a note saying "You have just been exposed to anthrax and will die within 24-48 hours" was opened by the office manager of the Thinking About Parenthood clinic on the city's east side. This Thinking About Parenthood is the only such clinic in Mid-America County that performs abortions. The letter was placed in a biohazard bag by another office worker, which is what workers at abortion clinics are trained to do when they receive suspicious packages.
The letter was opened at 12:30 p.m. and at 12:45 p.m. the clinic physician reported the incident to a desk sergeant at the Police Departments East Precinct. The 9-1-1 system was purposely not used to limit the number of people aware of the incident. By 1:00 p.m., two police officers arrived in the parking lot of the Thinking About Parenthood clinic. The Fire Department was also called although it is unclear from accounts which agency was called first. Fire fighters and police officers subsequently entered the Thinking About Parenthood office where the letter was opened. The emergency response crew began to arrive in the parking lot by 1:15 p.m. and by 1:30 p.m. there was a full response including the Fire Department Hazardous Material Team, the MCHD Hazardous Material Team, the Police Department, the FBI, the Mid-America County Department of Public Safety and staff from the Mid-America County Emergency Management Agency.
In accordance with established Mid-America County Hazardous Materials Emergency Plan, the Health Department Water Quality and Hazardous Materials Management (WQHMM) was immediately contacted by the Fire Department to provide technical advice regarding appropriate response. An emergency plan for handling bioterrorism threats did not exist. The Thinking About Parenthood clinic physician placed a call to a colleague trained in infectious disease, as there was not a Thinking About Parenthood protocol for who alternatively should be alerted. This colleague then placed a call to Dr. Marcia Welby at the Mid-America County Health Department. Within a few minutes, the MCHD Hazardous Materials team leaders also place a phone call to Dr. Welby of MCHD. Dr. Welby gave instructions to have the exposed individuals decontaminated inside the clinic and instructed on how to gather the necessary materials. Dr. Welby also contacted the Director of the MCHD and detailed a senior agency representative to the incident site to provide communications support and media management functions. Consistent with the Emergency Plan, the WQHMM also contacted the Poison Center, which notified area hospitals regarding the potential agent and the number of people potentially exposed. The Poison Center also indicated to the hospitals that all exposed individuals were contained at the clinic and would be decontaminated prior to being transported. Hospitals were made aware that they would potentially be asked to care for patients.
At the request of the Incident Commander (dictated by the Emergency Plan), the WQHMM Supervisor called the exposed individuals inside the clinic to assess the potential for exposure of those people. The person who opened the letter stated that it was likely that the substance inside the envelope did become airborne when she opened it. Based on this information and the fact that the ventilation system may have circulated the substance throughout the building, all persons in the clinic were considered potentially exposed.
The Incident Commander also asked Health Department staff to locate an individual who had left the clinic and instruct her on decontamination procedures and handling of potentially contaminated clothing and personal belongings. The Health Department subsequently located the individual and arranged for an ambulance to transport her to the hospital.
At the incident site, the WQHMM Supervisor advised the Incident Commander on:
At approximately 2:30 p.m., Dr. Welby requested the state lab to handle the letter/specimen. They agreed to do so and to answer questions for the press. At 3:00 p.m. Dr. Welby received a phone call from the clinic physician who questioned the process for decontamination. Dr. Welby called the CDC to seek consultation on appropriate therapy for anthrax exposure. The State Department of Health sought consultation from a researcher at the Northern University with clinical experience in treating and diagnosing anthrax. The Medical Director of the Communicable Disease Division at the state department of health was out of town on Friday but was left messages on the situation. The state health commissioner was apprised of the incident at about 4:30 p.m.
At 4:15 p.m., the FBI left the scene to take the letter to the state lab. Immediately upon arrival, the lab physician cultured the material on the letter into BHI (brain heart infusion) broth and cooked meat tubes. The CDC contacted the epidemiology office of the State Department of Health.
Decontamination on site began at 5:00 p.m. and was completed within 45 minutes. A total of 43 individuals were decontaminated at the incident scene; 31 were transported to hospitals for repeat decontamination, clinical assessment and prophylaxis. The 12 people whom were not forwarded to area hospitals were deemed to have a low level of exposure and included the first responding police officers and responders whom for various reasons had broken the protective barrier.
The Director of MCHD and Dr. Welby assumed direct responsibility for the clinical management of exposed individuals in the Emergency Department of the county's public hospital. A hospital, which was almost directly across the street, received two of the individuals sent for repeat decontamination. Two other hospitals also received individuals and were contacted with clinical management instructions. An inter-hospital medical liaison was established.
Decontamination procedures were repeated, individuals were evaluated, prophylaxis was initiated and information on the disease was provided. All exposed individuals were subsequently released from the hospital that evening. Emergency department personnel had been requested to ask each patient where she was in relation to the envelope and to document the response. Emergency room doctors had been requested to fax the chart note to the MCHD for data entry and analysis by staff nurse epidemiologists. Electronic reporting directly from emergency departments was not possible in this community.
On the following day arrangements were made with the FBI to transport a portion of the specimen to USAMRIID (US Army Military Research Institute for Infections Disease) in Maryland to expedite laboratory determination. The specimen was taken by the FBI to the airport at approximately 2:00 p.m. Epi spreadsheets were designed to capture and analyze key demographic, exposure and clinical information; and information collection was initiated. A protocol for what data should be collected was non-existent and, therefore, discussion on what should be collected was held prior to designing the spreadsheets. A desktop PC using Microsoft Access was used. At this time, patient contact protocols were also developed for use in both test-negative and test-positive scenarios. Additionally, Dr. Welby spent most of the afternoon trying to get an accurate list of exposed individuals along with their phone numbers and addresses.
Results negative for anthrax were telephoned to the Health Department by the FBI at approximately 8 p.m. Exposed individuals were notified of laboratory findings immediately, and this preceded announcement of results to the media, an operation which was closely coordinated with the FBI. Exposed individuals that the Health Department were unable to locate immediately by telephone were located through field investigation the following day. The WQHZMM Supervisor worked with receiving hospitals to ensure the appropriate handling of personal belongings and the return of belongings after the substance was determined not to be anthrax. Data collection and entry was discontinued.
On Sunday morning the state lab announced that the specimen was not anthrax.
Epilogue: Several months following this incident Dr. Huge Tilmale, working with the Centers for Disease Control and Prevention, visited the Circle City to interview key players to determine how actions could be performed differently in the future. One interview was conducted with Dr. Aaron Foot, Director of Public Safety, and the Incident Commander. His assessment was that there was an over-reaction in the Circle City. Although he stated that all threats should be taken seriously, learning how to rule out non-threats was a priority for follow-up action for his department. All key players who were interviewed had a different perspective of what should be the priority for follow-up action, i.e. the state health commissioner noted rapid identification of organisms, while the county health director wanted epidemiologic infrastructure building.
Within a few months following this accident, a consortium of several city departments published it's first draft of a plan on responding to biological terrorism in Mid-America.
No one thought it would ever happen.
The biological terrorism threat experienced by Mid-America nearly a year and a half ago sounded an alarm for public health practitioners across the country. Biological weapons are easier than ever to manufacture and disseminate and their use is considered inevitable by emergency management personnel. It is widely believed that the effects of biological threats will be seen in hospital emergency rooms long before there is any warning. The ability to recognize symptoms and to understand how to report them will be essential to contain the impact. A strong public health infrastructure must be utilized to initiate an epidemiological investigation, to communicate among front line personnel and to identify the nature and potential impact of the biological agent. It is this infrastructure that we must build today to save lives tomorrow.
AnthraxReady case study last revised March 2, 2004 (epowell)