Anthrax in Kansas City, MO: The Local Health Department’s Response

1. Anthrax in Kansas City, MO:The Local Health Department’s Response Tiffany H. Wilkinson, M.P.H. Assistant Manager Communicable Disease Prevention Kansas City, MO Health Department

2. Kansas City, Missouri Health Department To Promote, Preserve and Protect the Health of Citizens in a Healthy Kansas City

3. Overview • Brief Anthrax 101 • Local HD Response • Background • Investigation • Response • Lessons Learned • Future Planning

4. What is Anthrax? • Infectious disease caused by Bacillus anthracis • Spore-forming bacteria • Usually a disease of livestock • Normally acquired from the soil or an infected animal

5. How is anthrax spread? • Inhalation: breathing in spores • Cutaneous: getting spores in a cut or broken skin • Intestinal: eating contaminated food

6. How is anthrax spread? • Anthrax is NOT spread from person to person

7. Inhalation Anthrax Symptoms • Initially resembles flu-like symptoms: • Non-productive cough • Fever / chills • Shortness of breath • Muscle ache • Malaise • Can rapidly progress to severe breathing problems and shock • Often fatal

8. Influenza vs. Anthrax

9. Cutaneous Anthrax Symptoms • Begins like an insect/spider bite • Become a fluid-filled blister • Center turns black (eschar) • Usually painless • Most common form of anthrax, and easiest form to treat • Low fatality rate

10. Intestinal Anthrax Symptoms Food poisoning symptoms: • Nausea • Loss of appetite • Vomiting • Fever • Diarrhea An Upset Stomach

11. How long does it take to develop anthrax? • Inhalation: typically 1-5 days • Cutaneous: 1-12 days (7-10 days from initial symptoms to black lesion) • Intestinal: 1-7 days

12. How is anthrax treated? • Can be cured with antibiotics • Must be started as early as possible • Physician and/or Health Department will decide if treatment or prophylaxis is necessary

13. Background 10/24/01: • Kansas City Health Department (KCHD) receives call from the Manager of Stamp Fulfillment Center (SFC) • United States Postal Service (USPS) Philatelic Center • Not a full-service mail facility • Located in Hunt Midwest Subtropolis • Underground limestone caves • 5 million square feet of developed space • 50 tenants with over 1,300 occupants • Rail and Truck Service • Controlled Climate (approx. 70 degrees F year-round) • Separate Air-Ventilation Systems in each building • Stamp Distribution Network: sister station located across the street from SFC that distributes stamps nationwide • 204 employees

14. Background • Received mail directly from Brentwood mail facility in Washington D.C. (anthrax confirmed in facility) • SFC received 10-trays of mail from Brentwood on 10/19/01 • Bulk mailings • Truck delivers directly from Washington D.C. • 10 trays with approximately 7-10,000 pieces of mail • 30-40 employees had begun to “process” this mail • First-day covers • Opening outer envelope (machine/hand) • Cancellation of stamps • Returning to sender

15. Background • SFC manager notified of contamination in Brentwood facility by USPS officials on 10/23/01 • Immediately halted further processing of all mail received from Brentwood • Collected all opened and unopened mail from this shipment, shrink-wrapped it and moved it to an unoccupied area of the facility • Called the Communicable Disease Prevention (CDP) program at KCHD the following morning

16. Investigation 10/24/01 continued: • Notified CDP management • Contacted Missouri Department of Health & Senior Services (MDHSS) • Forwarded inquiry to DRMS team • No recommendations at that time • Contacted CDC directly through hotline number • Significant enough to immediately be “bumped up” to the postal liaison team • Postal team was working on specific recommendations and would call back • No recommendations by end of day • Informed SFC manager

17. Investigation 10/25/01: • New CDC recommendations for postal facilities receiving mail from Brentwood • Recommend antibiotic prophylaxis for postal facilities receiving mail directly from Brentwood postal facility • Facilities should remain open • Duration of treatment dependent on results of environmental testing • Specifics of environmental testing unavailable at the time • Contacted SFC manager • Advised to have ALL employees receive antibiotics from private physician • Keep potentially-contaminated mail sequestered

18. Investigation • Began receiving calls from physicians as well as other tenants within Subtropolis • Advised against nasal swab testing for employees • Some physicians tested anyway (50 employees) • CDC postal liaison called stating the need for “targeted environmental testing” • Contacted MDHSS to see if their Environmental Section could offer assistance • Without FBI involvement, MDHSS Environmental Services would be unable to get involved • Not yet a criminal investigation (no confirmed anthrax)

19. Investigation 10/26/01: • SFC manager contacted CDP with name of environmental firm contracted through USPS to conduct testing • Environmental testing to be initiated on 10/28/01 • CDP requested list of all SFC employees with contact information • Many employees refusing meds • Reiterated importance of everyone being on prophy

20. Investigation 10/29/01: • SFC manager reports that nasal swab testing on 50 employees—all negative • Again, stressed importance of prophylaxis regardless of clinical specimen results • Environmental specimens in route to private laboratory in Atlanta • Results expected by 10/31/01 or 11/01/01 • No further recommendations from CDC

21. Investigation 10/31/01 at 4:45 p.m. CST: • CDC Postal liaison notifies CDP that 2 out of 19 samples were POSITIVE for B. anthracis • Private laboratory forwards specimens to CDC for confirmation • CDC states that this laboratory has been correct 99.9% of the time • CDP management, Division management and KCHD Health Director notified • SFC manager notified • SFC closes facility until further notice

22. Response • City Management notified: • Mayor, City Manager, City Council • State Officials notified: • Director of Health, State Epidemiologist • KCHD Bioterrorism Plan Activated? • CDP staff called back in to work • Incident Command Post initiated • Collaborative effort to develop response plan • City, State, Federal, SFC, USPS • Press conference announced

23. Response • Press Conference • SFC employees notified to come in to KCHD the following morning: • Attempted to reach all 204 employees by phone (able to reach all but 39) • Told employees and visitors of the facility since 10/19/01 to come in for an assessment • Screening for symptoms • Prophylaxis information • Antibiotics • Answer all questions • KCHD requested pharmaceutical stockpile shipment from CDC through the State Epidemiologist • CDP staff manned phones throughout the night

24. 11/01/01: SFC Employees Two shifts: Clinical assessment: Short form Long form Medication dispensed Questions answered Overall traffic flow Identification of “clogged” areas Pulling in additional personnel in these areas Public Inquiries Specific phone lines and personnel designated to field calls from the public “Public panic” Education Media Joint Information Center activated PIO’s handled all media calls Directed media traffic Press conference schedules announced Response

25. Clinical Assessment

26. Response 11/02/01: • By Friday afternoon: all but two SFC employees were evaluated (1 out of town, 1 refused) • KCHD Bioterrorism plan deactivated-normal operations 11/03/01: • CDC confirms B.anthracis in the two samples collected from trash bags within SFC • MDHSS requests assistance from CDC 11/04/01: • CDC team arrives and includes 3 medical epidemiologists, 1 laboratorian, 3 industrial hygienists/environmental specialists and 1 public information officer • Hunt Midwest consults with firm to do environmental testing in various locations within Subtropolis complex

27. 11/05/01: MDHSS calls meeting with CDC team, KCHD, SFC, USPS representatives, Hunt Midwest Subtropolis officials and a representative from Kansas Department of Health & Environment Ordered additional environmental testing On-site Hunt Midwest Subtropolis meeting: Evaluation and assessment of complex and SFC layout Identification of other tenants and services within complex CDC environmental team determines potential sampling scheme Response

28. Response 11/06/01: • CDC conducts extensive environmental testing within SFC (55 additional samples collected) • SFC “all-hands” meeting • Occupational assessment • Provide another week of antibiotics • Update on investigation and answer questions • SFC employees begin arriving at KCHD for an additional weeks worth of medication

29. Response 11/07/01: • Hunt Midwest contractor collects additional samples (perimeter of SFC as well as various sites throughout complex) • CDC Adverse Event and Occupational Surveys • Adverse Event surveys going on nationwide • Contacting all employees and visitors • Interviewing for potential side effects of antibiotics • Interviewing SFC employees for specific job duties • Screening for any symptomatic individuals

30. Response 11/08/01: • All additional tests conducted by CDC team are NEGATIVE • Private environmental test results still pending • CDC offers new guidelines for post-exposure prophylaxis • No antibiotics needed for trace amounts found in a facility • Needed for inhalational risk only not cutaneous • KCHD notifies employees and visitors to stop taking medicine

31. Response 11/09/01: • Private test results through Hunt Midwest also come back NEGATIVE • USPS begins working with contractor for decontamination process and followup testing • Adverse Event Surveys continue 11/10/01: • CDC completes survey quota and heads back to Atlanta • Decontamination process of SFC begins

32. Response 11/15/01: • Decontamination process complete and followup testing is all NEGATIVE 11/16/01: • SFC employees return to work • Back to business as usual…and A LOT of catching up to do

33. Lessons Learned • All employees involved in response asked to submit both pros and cons associated with this event • Lists were compiled for an “After Action Review” meeting • These were categorized and distributed for the meeting • Facilitated group discussion • Future planning needs identified

34. Pros Call backs--all returned to work Cooperation of all KCHD staff Escorting SFC employees Through process Around media Provision of lunch Cooperation and patience of SFC employees Cons Overall communication Activation of BT plan Staff identification Overall flow 2 levels Slow elevators Limited access to stairs Interview forms Content Training SFC employee lists Too many Not electronic format Lessons Learned

35. Future Planning • Overall process: • BT plan activation, incorporating levels of activation into plan • Clear-cut chain of command and decision making authority • Internal planning and frequent informational meetings • Staff identification • Identification and coordination of phone lines

36. Future Planning • Overall flow: • Staff assignments • Current list of personnel and specific areas of training/education • Limited number of individuals who would assign staff to specific areas of need • Patient flow • Signs • Specified entrance and exits • Designated escorts • No loitering in patient/clinic areas • Staff access within building

37. Future Planning • Communication: • Devise mechanism to keep all levels informed as decisions are made and/or plans are changed • Informational updates • Press releases distributed internally • Radios or walkie-talkies? • Media Logistics: • Develop standard operating procedure (SOP) for handling media • Press conferences • Signage for Department • Non-glare back drop • Designated parking for large media vans/trucks

38. Additional Local Health Department Needs • Additional funding to build local public health infrastructure: • Additional staff • Staff to Investigation Ratio from 1:800 to 1:400 • Doubling field staff (12 to 24) • Hospital Liaisons--nurses assigned to each hospital to assist with reporting and surveillance issues • Computer programmer support • Proposal for legislative changes • Required reporting of environmental specimens

39. Anthrax Cases, US, 2001 Sept Oct Nov

40. Questions?