Special Report: Anthrax in America

Anthrax places focus on bioterrorism response, keeping employees safe

Occupational health professionals must address fears

Editor’s note: As this issue of Occupational Health Management went to press, public health officials and management teams at government agencies had just recently begun their response to something many had feared but had hoped would never happen: The intentional spread of an infectious agent in America.

While much of the focus has been placed on Washington, DC, and especially on Congress and the U.S. Postal Service, employees at several media organizations have also been affected. Even the venerable U.S. Supreme Court was forced to close — for the first time in decades, and companies who regularly picked up bulk mail packages at specific post offices were also placed on alert.

With such a fast-breaking and fast-moving story, it is difficult even for daily publications to stay on top of changing developments. But we felt it was imperative to address this issue as soon as humanly possible and to explore, as a service to our readers, some of the implications this new reality holds for occupational health professionals.

They told us the mail had to go through in rain, snow, and sleet, but they never said nothing bout no anthrax!" These words, spoken by an unidentified postal worker to a CNN reporter, seemed to put it all in perspective: Workers all across America are not only shocked, but they’re more than a little scared.

The facts of the anthrax attacks, as they currently stand, hardly qualify as an epidemic. A total of 32 workers have been exposed to anthrax; 13 have been infected, and, tragically, four have died.

But no one is sure when new exposures will stop springing up — whether other tainted envelopes are still out there — or how many employees are at risk. That is what’s driving the fear, and sometimes resentment, among postal workers, and causing concern among workers across the country. That is why thousands of postal workers are now being tested and/or prophylactically treated, and why occupational health professionals across the country are having to address the mental health ramifications of the attack.

Learning as we go?

Unfortunately, whatever protocols had been in place prior to the event have proven less than adequate, and the responses have shifted as new information emerged. For instance, the Centers for Disease Control and Prevention (CDC) in Atlanta believed at first that sealed envelopes containing anthrax posed no threat to postal workers, but two deaths proved that belief tragically wrong. Initially, Bayer-AG’s Cipro (ciprofloxacin) was designated the drug of choice,’ leading to a mini-run on the drug in pharmacies, especially along the East Coast. Now, however, doxycyline is being recommended, because it is more readily tolerated. And it was most recently announced that workers on the front line, such as laboratory staff and perhaps postal workers, will now be given the anthrax vaccine.

As to this last action, it will take quite awhile to provide these workers with significant protection against anthrax; the administration of the vaccine involves a series of shots over a period of 18 months. "As with most series, you gain more antibody with each exposure," explains Jan Schwarz-Miller, MD, MPH, director of occupational medicine for Atlantic Health System in northern New Jersey. "It will probably not make a big dent in what’s currently going on."

Public health officials admit as much. What they’re seeking to do, they say, is provide protection for workers who may be under an ongoing threat from such attacks — a sobering fact that can’t do much for their peace of mind.

Although standards and protocols may of necessity change from time to time to reflect new knowledge, this has not stopped leading agencies from issuing guidelines to help protect workers. For example, the CDC issued a health advisory on Oct. 24 for protecting mail handlers from both cutaneous and inhalational anthrax.

The advisory addresses engineering controls, housekeeping controls, and protective equipment. The engineering controls include using vacuum cleaners with HEPA filters; HEPA-filtered exhaust hoods for mail-handling equipment; HEPA filters in HVAC (heating, ventilation, and air conditioning) systems; and installation of air curtains. The housekeeping controls include avoiding dry sweeping and dusting. The protective equipment section is most extensive, addressing the prevention of both inhalation anthrax (i.e., using NIOSH-approved respirators) and cutaneous anthrax (the type of protective gloves that should be used, the type of clothing recommended, and guidelines for washing and skin and eye care). (The complete CDC advisory may be found on the web: www.bt.cdc.gov/DocumentsApp/45.pdf.)

The United States Postal Service web site (www.usps.com) has a wealth of information on its web site, including a regularly updated fact sheet on infections and exposures, and a summary of its own new safety measures. In addition, it has posted a detailed advisory from the General Services Administration on how to respond to an anthrax threat in a mail center.

How we should respond

What does all this mean for occupational health professionals who are either directly or indirectly affected by recent events? "In terms of mail and packages, they need to follow the guidelines published by most departments of health, the CDC, and the post office," advises Schwarz-Miller. "I think at this point you certainly see specific areas of risk, such as government workers, the media, and postal workers, but we don’t know if that’s going to change. It would be wise to be cautious, but not fearful."

Speaking of fear, how can occupational health professionals calm the fears of employees? "At our site, I put together an e-mail with the director of public safety and security about how to handle packages," says Schwarz-Miller. "We’ve provided additional training — an inservice to educate employees so they know how anthrax is spread. We also created a bulletin for employees about anthrax, and we continue to work on ways to educate people."

She sees this type of employee education as a crucial role for occupation health professionals. "It can be very reassuring for people outside of the sectors we’ve seen affected to realize we’re talking about a very limited group, yet at the same time giving them enough information to make them feel empowered," Schwarz-Miller asserts.

Her health system also created its own response protocol, which will hopefully not only add a layer of protection but help workers and staff feel more secure. "Being in New Jersey, it’s not surprising that in our hospitals, people have come in with powders that concerned them. They’re worried about letters or packages they received weeks ago," notes Schwarz-Miller. "We work very closely with our [emergency department (ED)], and we’ve put together a fairly structured protocol on what to say to people who find something that concerns them." This protocol, currently in draft form, is very similar to what the CDC has put up on its site, she says, but it is customized to the specific facility.

Of course, even a proactive approach such as this won’t make every employee feel calm and secure. "We absolutely encourage employees who are having bad feelings to seek help," Schwarz-Miller notes. "And this can be from the World Trade Center attacks or the anthrax attacks. If I’m seeing an employee for another medical issue who has recently felt more depressed and out of control — and the anthrax situation certainly will increase those fears — I absolutely will refer them to our EAP [Employee Assistance Program]."

While there’s a wealth of information available on how to protect employees from infection and how to treat them if they become infected, hospital-based occupational health professionals must also concern themselves with the health and safety of first responders and others who may come in contact with these patients.

What sort of precautions should be taken? "There are, of course, isolation standards, which we always use," says Schwarz-Miller. "Most of these were developed in response to HIV. The other concerns are respiratory and droplet and contact. Unless it’s cutaneous, anthrax is not passed by any of those routes. There’s a tiny, tiny, tiny risk, so we do use contact precautions. Thank goodness we do not need to worry about person to person spread."

What if we were faced with an outbreak of something more contagious? "That’s a totally different story," Schwarz-Miller says. "Then, it depends on how it’s transmitted. A worst-case scenario would be something like smallpox, simply because we only have a certain number of negative pressure rooms. The number we have is more than adequate for what we consider to be a standard situation, but in an epidemic there would have to be huge cohorting [among providers]."

What’s most important for the occupational medicine physician, she says, is to have a well-structured system in place to deal with any such emergency. "I believe our setup is ideal because we are divided into public safety and occupational safety departments," she says. "The public safety department deals more with emergency response, such as fires. Occupational health deals more with environmental issues and OSHA [Occupational Safety and Health Administration], and they report to me, as does infection control."

To successfully deal with a bioterrorism event, Schwarz-Miller says, a hospital needs an integrated working team. "The ED, the pharmacy, the lab, and infection controls must all be at the table," she asserts. "Everyone must be involved."

In short, she says, your role must go far beyond the standard definition of occupational health. "Your employees are people who are potentially at risk, yet most of us — including our nurses — have never seen a lot of these diseases. Therefore, you’ve got to get a very coordinated, cohesive group of experts and the people who will be on the front line brought to the table. Make sure everyone is comfortable with his or her role, has resources he or she needs, and feels reassured — and is ready," she concludes.

[For more information, contact: Jan Schwarz-Miller, MD, MPH, director of occupational medicine, Atlantic Health System, Morristown Memorial Hospital, 100 Madison Ave., P.O. Box 94, Morristown, NJ 07962. Telephone: (973) 971-5440. Fax: (973) 290-7978. E-mail: jan.Schwarz-miller@ahsys.org.]