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Leery of taking any incident too lightly, hard-pressed infection control professionals are responding to anthrax hoaxes and suspicious powder reports that are bedeviling both public health efforts and delivery of care. With bioterrorism, perception is nearly as disturbing as reality.
"We have been putting out fires constantly," says George Allen, PhD, CIC, director of infection control at University Hospital of Brooklyn in New York City. A recent incident at the hospital involved a suspicious powder in a women’s restroom that turned out to be some kind of makeup or beauty product, he notes. "We were called about a powder in the bathroom," he says. "I had to go in there and look. They cordoned off the area, and security was there. It’s amazing. The whole place was cordoned off."
But those kinds of incidents are not limited to the epicenters of the Sept. 11, 2001, terrorism attacks. They appear to be occurring throughout the country. For example, a call came in at 10 p.m. to the home of Patti Grant, RN, MS, CIC, an ICP at RHD Memorial Medical Center and Trinity Medical Center, both in Dallas. At one of her hospitals — Grant prefers not to say which — a woman had just walked into the emergency department (ED) with an envelope she feared contained anthrax.
"I’m talking, listening, and taking notes, but my mind is having a 30-second meltdown, because the decision I have to make is: Do I treat this as a full-blown bioterrorism event or not?" Grant explains. "That decision has to be made. Once you make the decision that it is the real thing, then you have to notify all of the people in the protocol."
The woman had bagged the envelope before bringing it into the ED, and health care workers put a biohazard bag around that and locked it in a room of the hospital. Grant struggled to get local law enforcement to come to the scene.
"I had to get downright adamant that [the police] had to send somebody to the ED," she says. "I couldn’t get them to understand if we find out that this woman has anthrax, I cannot show a chain of custody for this letter. They didn’t think it was a big deal."
Indeed, public health guidelines recommend that such letters should be left where they are found (rather than transported to the nearest ED), and law enforcement — as Grant was arguing — are to be called to the scene. (See "CDC tips on dealing with suspect mail, anthrax hoaxes" in this issue.) The suspect letter was left in the locked hospital office overnight, and the next day, a hospital vice president delivered it to the health department. The department notified the hospital a few hours later that the envelope and its contents were harmless. A few days later, another hospital in the area reported a similar incident, and this time, law enforcement and security officials responded promptly, she adds.
The disruptive incident essentially served as a disaster drill, as Grant educated workers and reviewed the hospital response. An initial concern was easing the fears of workers by reminding them that existing hospital infection control precautions would be sufficient to protect employees from bioterrorism agents. (To see handout, click here.) The incident revealed that lines of communication need to be improved between hospitals, law enforcement, and public health, she noted. "It is the operational issues that are going to drive ICPs, local law enforcement, and health departments to drink," she says.
While a concerned citizen prompted Grant’s situation, other hospitals have had to deal with actual malice. Hazmat teams in full protective regalia were called to Huntington Hospital in Pasadena, CA, after a suspicious powder was found scattered around the ED floor, says Mary Mendelson, RN, CIC infection control coordinator at the facility. "We followed the procedure we set up on this: Alert our own security and then notify local officials, who decided to come out with a hazmat team. And of course, it was nothing. The powder that was spread around our ED was later deemed to be NutraSweet. That was malicious," she adds.
Hospital security investigated the incident, but no leads have turned up, she adds. Another case at the hospital that also prompted a full hazmat response was of a more innocent origin. An envelope used in a magic kit fell out of somebody’s pocket, she says. "I think that one was just a mistake," Mendelson says. "It was just pure coincidence. It had some powder in used in magic tricks or something."
Having gone through the routine twice, she says it is becoming difficult to rationalize the incidents as needed preparedness drills. "I think probably the first time it happens, you think of it as a learning experience," Mendelson says. "If it continues to happen, it becomes an interruption to providing the services that you are already stretched to provide. Certainly, from the local fire department/police angle, they are very tired of it. They are just exhausted, and they feel stretched beyond [limits]. It’s not all for nothing, but it feels that way."
Underscoring Grant’s point, Mendelson says the main problem appears to be clear communication between the various agencies and facilities involved when an envelope or suspicious powder incident is reported. People are confused about whom they should call and whether they should immediately seek medical treatment. "Some people are getting a runaround," she says. "One of the things we need to do is try to coordinate with our local agencies and make sure we are all saying the same things to people. It’s a work in progress."
More than 99% of the samples that have come in for testing in such incidents have been baking powder, talcum, salt, or some other benign substance, says Eric K. Noji, MD, MPH. Noji is chief of the epidemiology, surveillance, and emergency response branch in the Centers for Disease Control and Prevention (CDC) office of bioterrorism preparedness and response. "But we simply can’t ignore it," he says. "It is a tremendous allocation of personnel time. The same amount of time is spent analyzing a hoax as is spent analyzing a real sample of anthrax. As you can imagine, that is playing right into the terrorists’ hands."
Anthrax hoaxes have actually been a growing trend for several years, he says, adding that several hundred occurred last year in the United States. "Most of them were [about] revenge — people mad at the federal government," Noji says, though adding that one was sent to an auto dealer from an incensed "lemon" owner. "We had about 300 hoax samples within all of [the year] 2000. Already, just in one month, we’ve had to analyze 3,500. We are [already] overwhelmed at CDC analyzing the real samples."
During the last three weeks in October, the CDC received 8,860 telephone inquiries from all 50 states, Puerto Rico, Guam, and 22 foreign countries. Of these, 590 (6.7%) calls were thought to represent a potential threat as defined by a report of exposure to a substance possibly associated with bioterrorism or symptoms consistent with an illness associated with bioterrorism. The 590 calls regarding potential threats were from physicians or other health care workers (40%); local or state health departments (14%); private citizens (14%); and police, fire, or emergency response departments (7%). In addition to the CDC, public health laboratories in 46 states participating in the Laboratory Response Network have reported receiving thousands of specimens and isolates for anthrax testing.
Hospital anxiety, in particular, climbed another notch following the death of a health care worker in New York City due to inhalational anthrax. The woman worked in a medical supply area of the Manhattan Eye, Ear and Throat Hospital, where no anthrax spores have been recovered. Investigators are tracing her movements in the days prior to developing the disease.
"It is going to be a painstaking investigation, tracing back," Noji says. "One, we don’t know where she was exposed. So we have to find where she was exposed and then [determine] if it is any place near where we have confirmed environmental spores. If she never went to any of those places, then the question is where was she exposed? That raises the issue of another source. Some people have been saying there must be multiple letters, [including one] sent to the post office that serves her home. That’s possible, because we are so focused on the mail. But how do we even know she was even contaminated by another envelope? The theories are cross-contamination of the mail: that she got it from another contaminated envelope [or] that there was more than one letter. I think what we have to do is step back and find out her daily activities for the last 12 days."
While there is no evidence that the hospital where the woman worked was the target, reassuring health care workers — particularly those who handle hospital mail — became an immediate priority in the aftermath of the case, Allen says. The hospital does not have high-speed sorting equipment that could generate aerosols, he says. "I tell staff that frequent hand washing is one of the most important things they possibly can do," he says.
But even in Washington, DC, health care workers are being urged not to overreact to the New York hospital case. Though mail workers certainly are on the lookout for suspicious mail, blanket new policies for hospitals should not be enacted based on a single case, argues Allan J. Morrison Jr., MD, MSc, FACP, health care epidemiologist for the Inova Health System in Washington, DC. "I don’t think one case linked occupationally to health care should warrant — either locally, regionally, or nationally — an alteration in behavior," he says. "Eventually, there will be some linkage of that woman to a source of anthrax that is plausible. At that point, we can make determinations about what is reasonable, but to do it prior to that with only one case, to me, is imprudent."
Ruth Carrico, RN, MA, CIC, director of infection control at the University of Louisville (KY) Hospital, takes a somewhat different view, allowing mail workers to wear protective gear if it makes them feel safer. "If you are looking at it from a scientific perspective and you know epidemiologically we haven’t seen this in our area, is this something you should be concerned about?" she asks. "You have a higher risk [to your health] if you hop in your car and drive out for lunch. However, when emotion is involved, science doesn’t mean a lot."
Thus hospital workers concerned about the mail may wear a mask and vinyl gloves, Carrico says. "I can’t say no, you are not going to be exposed to this. Nobody can say that. At some point, you have to balance what is rational with a recognition of the emotion in this situation. We have to go on [processing mail], so a couple of pennies for a mask and a pair of gloves weighed against somebody feeling that the workplace is not concerned about [him or her] — I think it is money well spent."
A psychological factor that may be contributing to the general jitteriness is a looming sense that another wave of attacks is coming, she says. The government’s recurring but nonspecific warnings and the CDC’s rush toward smallpox preparedness: Both may be necessary, but they have done little to ease such fears. "Is what we are seeing the beginning?" Carrico asks. "I think everybody worries about that. So what are some things we can control? From our perspective, it is trying to do a lot of community education that this is not something we have seen in this area. Every white powder [incident] that occurs does not mean that we are dealing with anthrax."