NY anthrax death puts hospitals on greater alert

Mail handlers wear gloves, raise awareness

A case of inhalational anthrax that killed a New York hospital worker and shut down an outpatient hospital triggered a new look at just what protections are necessary to protect employees from the current bioterrorism threat. Should mailroom workers wear gloves? What about respirators? Who else might need protective equipment? Though anthrax isn’t spread from person-to-person contact, public health experts struggled to understand the distribution of spores.

While clear answers to the anthrax threat proved elusive, hospitals have responded based on the perceived risk at their facility. Hospitals served by postal facilities that have been contaminated by anthrax implemented special procedures, such as offering gloves and masks or N95 respirators to mailroom workers. Employee health professionals at other hospitals around the country urged restraint and sought to calm fears.

Jeffrey Koplan, MD, MPH, director of the Centers for Disease Control and Prevention (CDC) in Atlanta, deemed the risk of transmission of anthrax to mail recipients from contaminated facilities as "very, very small."

"The risk isn’t zero as the mail passes through these facilities," Koplan said at a press briefing. "It’s very, very small, but we can’t say it’s zero because of the contamination that has occurred in some of the facilities. Yet the risk to individual recipients, whether it’s in the workplace or at home, is extremely small."

Even so, Koplan acknowledged that a higher level of awareness is warranted. "I’ll admit I look at [mail] with greater scrutiny than I’ve ever looked at it before," he said. "If there were something there that . . . didn’t have a return address, and it was handwritten, and had any of these [suspicious] characteristics, I sure would call local law enforcement and wash my hands fast, and get that thing covered up."

The CDC is recommending that all personnel who handle mail wear nonlatex gloves. Those working near machinery that could aerosolize particles (such as electronic mail sorters), or those emptying large bags of mail or hand-sorting mail could be at risk for inhalation anthrax and should wear N95 respirators. The U.S. Postal Service announced it purchased 86 million pairs of gloves made of vinyl and nitrile and 4 million N95 respirators. (See "CDC advice: Be alert when opening mail" in this issue.)

"Certainly, if individuals are in a setting and they’re concerned, those measures could help protect them," says CDC spokesman Tom Skinner.

In addition, the New York City Health Department has requested that all health care providers in the city who are seeing patients with flu-like illnesses get several pieces of information. The checklist includes taking down a thorough employment history, including whether the patient handles mail, and asking about any exposure to suspicious letters or powders in the last one to two weeks. Hospitals also are urged to review their policies for handling mail and review employee health and absenteeism data since Oct. 1, especially among employees who work in or near the mailroom. Any staff with suspicious lesions should be evaluated for testing.

A 61-year-old stockroom employee of the Manhattan Eye, Ear and Throat Hospital in New York City died of severe respiratory symptoms brought on by inhalational anthrax. The woman, who worked near the mailroom in the basement of the hospital and occasionally handled mail, developed chills and muscle aches on Oct. 25. On Oct. 28, she was hospitalized with symptoms of severe breathing difficulty and fluid in her lungs. Despite receiving a combination therapy of three antibiotics, she died three days later.

Initial tests of the mailroom and hospital building did not detect any anthrax spores, and CDC investigators were unsure where the woman’s exposure occurred. Investigators were considering the possibility that the hospital worker may have been exposed to cross-contamination from another undetected letter.

"It is going to be a painstaking investigation, tracing back," says Eric K. Noji, MD, MPH, chief of the epidemiology, surveillance, and emergency response branch in CDC’s office of bioterrorism preparedness and response. "I think what we have to do is step back and find out her daily activities for the last 12 days [during the incubation period for anthrax]."

However, area hospitals already had been on alert. St. Francis Medical Center in Trenton, NJ, is served by the Hamilton Township mail-processing center, where anthrax was found, and the hospital is serving as an evaluation center for postal workers.

"Each of our [mailroom] employees have been given special education sessions by our safety officers," says Carol McAloon, RN, MSN, director of critical care. "They have access to N95 respirators and masks if they desire to wear them. They are not a requirement." In fact, most mailroom workers have chosen not to wear the respirators, though most wear the gloves. All employees have received additional education about bioterrorism, she says. That education helps allay fears, as does the regular disaster preparedness training conducted by the hospital, says McAloon.

Assessing risk is a critical part of any preparedness, says Susan McLaughlin, MBA, CHSP, MT (ASCP)SC, a Barrington, IL-based consultant on health care safety and regulatory compliance. "[Hospitals] have to look at their area, their circumstances. In Washington, DC, you’re probably going to look at it differently than you are in the middle of Iowa. "In some areas of the country where there have been incidents of the exposure, [N95 respirators] might be something they’d want to consider." McLaughlin notes that the use of N95 respirators requires fit-testing of employees.

At hospitals in areas that haven’t been affected by anthrax, employee health professionals are taking a low-key approach. For example, at Sewickley (PA) Valley Hospital, the mailroom clerk has the option of wearing gloves. With cases isolated in New York; New Jersey; Washington, DC; and Florida, she deemed the risk to be low and chose not to wear gloves, says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, employee health nurse practitioner. "[Mailroom employees] know they can do that if they need to or want to."

Employee health professionals are prepared to change their advice as new information evolves from CDC. That sense of flux can be unsettling, acknowledges Gruden, who is president of the Association of Occupational Health Professionals in Healthcare. "It is worrisome that they’re still finding cases," she said in late October. "It’s unfolding. Because we’ve not had the experience with it before, the experts even at CDC are learning as we go along here."

(Editor’s note: Up-to-date information on the anthrax scare and bioterrorism is available on the HEH web site at www.hospitalemployeehealth.com. Information from the CDC also is available from www.bt.cdc.gov.)