First case of bioterrorism-related inhalational anthrax in the United States, Palm Beach County, Florida, 2001. (Bioterrorism-Related Anthrax).On October 4, 2001, we confirmed the first bioterrorism-related anthrax anthrax (ăn`thrăks), acute infectious disease of animals that can be secondarily transmitted to humans. It is caused by a bacterium (Bacillus anthracis case identified in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. in a resident of Palm Beach County, Florida Palm Beach County is a county located in the state of Florida. As of 2007, the county had a population of 1,351,236 according to the University of Florida, Bureau of Economic and Business Research. . Epidemiologic investigation indicated that exposure occurred at the workplace through intentionally contaminated contaminated,
v 1. made radioactive by the addition of small quantities of radioactive material.
2. made contaminated by adding infective or radiographic materials.
3. an infective surface or object. mail. One additional case of inhalational anthrax was identified from the index patient's workplace. Among 1,076 nasal cultures performed to assess exposure, Bacillus anthracis Bacillus anthracis Infectious disease A gram-positive organism which causes often fatal infections when its endospores–resistant to heat, drying, UV light, gamma radiation, and many disinfectants–enter the body and cause septicemia Military medicine was isolated from a co-worker later confirmed as being infected, as well as from an asymptomatic mail-handler in the same workplace. Environmental cultures for B. anthracis showed contamination at the workplace and six county postal facilities. Environmental and nasal swab cultures were useful epidemiologic tools that helped direct the investigation towards the infection source and transmission vehicle. We identified 1,114 persons at risk and offered antimicrobial prophylaxis prophylaxis (prō'fĭlăk`sĭs), measures designed to prevent the occurrence of disease or its dissemination. Some examples of prophylaxis are immunization against serious diseases such as smallpox or diphtheria; quarantine to confine .
In Florida, human anthrax has been rare; among eight human cases reported in Florida in the 20th century, the most recent was a cutaneous cutaneous /cu·ta·ne·ous/ (ku-ta´ne-us) pertaining to the skin.
Of, relating to, or affecting the skin.
Pertaining to the skin. case in 1974 (1). On October 2, 2001, a 63-year-old Florida man was hospitalized for a non-localizing severe illness that began 2 days earlier, characterized by fever, chills, sweats, fatigue, and malaise, which progressed to vomiting, confusion, and incoherent speech. No history of cough, dyspnea dyspnea /dysp·nea/ (disp-ne´ah) labored or difficult breathing.dyspne´ic
paroxysmal nocturnal dyspnea , abdominal pain Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem. , diarrhea, or skin lesions Skin Lesions Definition
A skin lesion is a superficial growth or patch of the skin that does not resemble the area surrounding it.
Skin lesions can be grouped into two categories: primary and secondary. was reported. On October 4, the Florida Department of Health Florida Department of Health is a category of Government of Florida. Orange County Health Department is one of the branches of Florida Department of Health and Government of Florida. (FDOH FDOH Florida Department of Health ) Bureau of Laboratories confirmed B. anthracis from a culture of cerebrospinal fluid cerebrospinal fluid (CSF)
Clear, colourless liquid that surrounds the brain and spinal cord and fills the spaces in them. It helps support the brain, acts as a lubricant, maintains pressure in the skull, and cushions shocks. . The patient's condition deteriorated, and he died 3 days after admission (2).
After anthrax was confirmed and in consideration of possible bioterrorism, we initiated an investigation to determine the extent and source of the event, develop control strategies, and protect potentially exposed persons. This report summarizes the findings of our epidemiologic investigation.
We performed a detailed investigation of the index patient's exposures during the 60 days before his illness. We visually inspected and obtained culture specimens for Bacillus anthracis at locations he visited during the 60-day period, including his home, recreational destinations, retail outlets patronized pa·tron·ize
tr.v. pa·tron·ized, pa·tron·iz·ing, pa·tron·iz·es
1. To act as a patron to; support or sponsor.
2. To go to as a customer, especially on a regular basis.
3. , and workplace. Initial samples from the workplace were from the patient's work area and the company mailroom and photo library, as well as air ventilation filters.
Case-Finding and Surveillance
A confirmed case of anthrax was defined as a clinically compatible cutaneous, inhalational, or gastrointestinal illness confirmed as anthrax by laboratory tests, including 1) isolation of B. anthracis from an affected tissue or site or 2) other laboratory evidence of B. anthracis infection based on at least two supportive laboratory tests (3). Supportive laboratory tests included polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is (PCR PCR polymerase chain reaction.
polymerase chain reaction
Polymerase chain reaction (PCR) ) (4) of DNA DNA: see nucleic acid.
or deoxyribonucleic acid
One of two types of nucleic acid (the other is RNA); a complex organic compound found in all living cells and many viruses. It is the chemical substance of genes. from patient fluid from a normally sterile site, immunohistochemical staining of patient tissue samples, and enzyme-linked immunosorbent assay enzyme-linked immunosorbent assay
Enzyme-linked immunosorbent assay (ELISA)
A diagnostic blood test used to screen patients for AIDS or other viruses. serologic tests to detect immunoglobulin G immunoglobulin G
n. Abbr. IgG
The most abundant class of antibodies found in blood serum and lymph and active against bacteria, fungi, viruses, and foreign particles. Immunoglobulin G antibodies trigger action of the complement system. (IgG) response to B. anthracis protective antigen (PA) (5).
We implemented case-finding through daily chart review in Palm Beach County intensive-care units (ICUs) and regionally in ICUs in North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures
Area, 52,586 sq mi (136,198 sq km). Pop. , where the index patient had traveled during the potential exposure period. ICU ICU intensive care unit.
intensive care unit
see intensive care unit.
ICU patients who had blood or cerebrospinal fluid cultures performed within 24 hours of hospital admission had more detailed chart reviews and interviews. If anthrax was not ruled out, further interviews were done with patients, family members, and medical providers. Laboratory testing for B. anthracis and other potentially causative pathogens was offered if indicated. Nearby counties implemented similar case-finding efforts in ICUs and emergency departments.
We initiated enhanced surveillance locally through alerts to medical examiners and statewide through requests to laboratory directors to forward to the FDOH laboratories any cultures suspicious for Bacillus bacillus (bəsĭl`əs), any rod-shaped bacterium or, more particularly, a rod-shaped bacterium of the genus Bacillus. Some bacterium in the genus cause disease, for example B. species isolated from sterile sites. A statewide veterinary alert was issued for cases of anthrax in animals. All case-finding surveillance was retrospective to September 11, 2001, and prospective beginning October 5.
Surveillance in Potentially Exposed Groups
Workplace-exposed persons were defined as those who, within 60 days of onset of illness in the index patient, spent >1 h in the building where he worked. On October 3 through the employer, on October 8 through press releases and media briefings, and on October 8-10, 13, 17, and 19 through information bulletins, we asked workplace-exposed persons and medical personnel caring for them to report influenzalike illness or skin lesions to the FDOH. Beginning October 8, hospitals were notified through infection-control professionals and public health alerts.
We obtained nasal swabs from workplace-exposed persons while dispensing prophylactic antibiotics on October 8-10 and from workers who handled trash at the workplace on October 13. Immediately after specimens were obtained, nasal swabs were applied to sheep-blood agar culture medium plates and transported to the Florida Public Health Laboratory. B. anthracis was confirmed in nonmotile, nonhemolytic isolates by gamma-phage lysis lysis /ly·sis/ (li´sis)
1. destruction or decomposition, as of a cell or other substance, under influence of a specific agent.
2. mobilization of an organ by division of restraining adhesions.
3. and PCR and later by detection of B. anthracis capsule and cell-wall antigens with direct fluorescent antibody Direct fluorescent antibody (DFA or dFA) is a laboratory test that uses antibodies tagged with fluorescent dye to detect the presence of microorganisms. This is the main test used to detect rabies in animals and requires the examination of brain tissue. tests. Testing for serum IgG antibody response to the PA component of the anthrax toxins was offered on October 10, 13, 17, and 19 to workplace-exposed persons.
We conducted interviews to investigate contaminated mail as an anthrax transmission vehicle at the workplace and to estimate incubation periods among anthrax patients. Persons who reported seeing or handling mail perceived as unusual or suspicious and persons with suspected anthrax exposure based on nasal swab cultures or preliminary serologic test results were interviewed to describe details surrounding unusual mail incidents as well as their routine exposure to the mail.
On October 12, we obtained nasal swabs from postal workers most likely to have handled contaminated mail at two county postal facilities that supplied mail to the workplace. We initiated anthrax surveillance on October 25 among postal employees in Palm Beach County through postal worker illness reports, a toll-free hotline for postal employees, and hospital infection-control professional reports of postal worker hospitalizations in Palm Beach County.
We collected bulk objects (e.g., filters from heating, ventilation, and air conditioning air conditioning, mechanical process for controlling the humidity, temperature, cleanliness, and circulation of air in buildings and rooms. Indoor air is conditioned and regulated to maintain the temperature-humidity ratio that is most comfortable and healthful. [HVAC (Heating Ventilation Air Conditioning) In the home or small office with a handful of computers, HVAC is more for human comfort than the machines. In large datacenters, a humidity-free room with a steady, cool temperature is essential for the trouble-free ] units, mail, soil samples) and swab, wipe, vacuum, and air specimens to test for B. anthracis environmental contamination by standard collection and shipping techniques (6). Control samples were routinely performed.
After contamination was confirmed at the workplace, we performed focused environmental sampling on October 8-10. Samples were obtained at work areas of the index patient and persons identified with potential B. anthracis exposures through nasal swab cultures, preliminary serologic test results, and interviews. Samples were also obtained from trash receptacles, items removed from the building, and the company mail van. Subsequent sampling throughout the 68,000 square-foot, three-story building was performed on October 25November 8, 2001, to characterize the extent of contamination in the workplace. Samples were obtained from all floors, the parking garage, and the roof.
Beginning on October 12, 2001, we obtained surface samples for cultures at Palm Beach County postal facilities that processed workplace mail. We obtained samples from mail facilities sequentially, in reverse order of a route the mail most likely followed to arrive at the workplace. Facilities from postal routes serving two workplace buildings were tested. One route included three postal facilities that process >99% of mail the workplace received, and another route included four other postal facilities that might process workplace mail if the mail had been sent to a previous office, vacated by the company 13 months earlier. We sampled areas in each facility where workplace mail was most likely to have been processed.
Selected environmental and clinical specimen isolates of B. anthracis were analyzed by determining base-pair sequences in designated portions of isolate DNA to characterize subtypes, and sequences were then compared. Base sequence analysis was performed by multiple-locus variable-number of tandem repeat This is a term from genetics, which describes a pattern that helps determine an individual's inherited traits.
Tandem repeats and variable number tandem repeats in DNA occur when a pattern of two or more nucleotides is repeated and the repetitions are directly adjacent to typing analysis (MLVA MLVA Micro Light Valve Array
MLVA Multi-locus VNTR Analysis
MLVA Multiple VNTR Locus Analysis ) techniques (7).
Prophylaxis and Control Measures
We offered prophylactic antibiotics for B. anthracis to workplace-exposed persons (8). Until the risk for Florida postal workers could be assessed, we initiated prophylaxis for selected postal workers most likely to have handled workplace mail at two local postal facilities. Subsequent adjunct vaccination was later made available for workplace-exposed persons (9).
An autopsy of the index patient supported the diagnosis of inhalational anthrax. Autopsy findings included markedly enlarged hemorrhagic Hemorrhagic
A condition resulting in massive, difficult-to-control bleeding.
Mentioned in: Hantavirus Infections
pertaining to or characterized by hemorrhage. mediastinal mediastinal /me·di·as·ti·nal/ (-as-ti´n'l) of or pertaining to the mediastinum.
of or pertaining to the mediastinum. lymph nodes Lymph nodes
Small, bean-shaped masses of tissue scattered along the lymphatic system that act as filters and immune monitors, removing fluids, bacteria, or cancer cells that travel through the lymph system. on gross examination and laboratory detection of B. anthracis by immunohistochemical tests in mediastinal lymph nodes, spleen, liver sinusoids, and phagocytic cells Phagocytic cells
A cell that ingests microorganisms and foreign particles.
Mentioned in: Chronic Granulomatous Disease .
The patient had no reported exposure typically associated with naturally occurring anthrax, including exposure to animals or animal products potentially harboring B. anthracis spores. He worked as a photo editor for a national media company that produces tabloid newspapers and other publications. He bicycled and fished for recreation, and his only travel in the 60 days before symptom onset on September 30 was a 5-day automobile trip to North Carolina. No typical naturally occurring anthrax sources were seen at any location inspected, and no B. anthracis contamination was detected among 44 samples from nonworkplace specimens. B. anthracis was identified in 2 of 12 specimens obtained on October 5: from the index patient's computer keyboard and his mailbox in the company mailroom.
Workplace interviews regarding mail exposure showed that the index patient rarely handled or opened workplace mail, but co-workers recalled that he had examined a piece of stationery containing a fine, white, talc-like powder on September 19. The patient was observed holding the stationery close to his face as he looked at it over his computer keyboard.
Case-Finding and Surveillance
No anthrax cases were detected in Palm Beach County ICU patients, although six patients underwent extensive follow-up from >500 medical charts reviewed through October 31, 2001. No anthrax cases were reported through surveillance by medical examiners. An autopsy was performed to rule out anthrax in one case reported through surveillance of medical examiners and Palm Beach County ICUs, and the patient was determined not to have anthrax. Through 2001, FDOH laboratories reported no B. anthracis isolations among 293 clinical isolates received to rule out anthrax. No reports of veterinary anthrax were received through the Florida Department Florida is a department (departamento) of Uruguay. Population and Demographics
As of the census of 2004, there were 68,181 people and 21,938 households in the department. The average household size was 3.1. For every 100 females, there were 100.4 males. of Agriculture and Consumer Services Consumer Services refers to the formulation, deformulation, technical consulting and testing of most consumer products, such as food, herbs, beverages, vitamins, pharmaceuticals, cosmetics, hair products, household cleaners, [paints, plastics, metals, waxes, coatings, minerals, . No anthrax cases were reported through nearby county case-finding efforts among persons not exposed in the workplace.
Surveillance among Potentially Exposed Groups
Among six workplace-exposed persons who were extensively evaluated after medical providers reported their illness, one was also identified among Palm Beach ICU patients, and inhalational anthrax was confirmed in another, a Miami-Dade County resident. This second case-patient was a 73-year-old mail distributor and co-worker of the index patient, who was reported by his medical provider on October 4. His illness began, on September 28, and he was admitted to a hospital in Miami-Dade County on October 1, 2001. A nasal swab culture obtained on October 5 showed B. anthracis, but cultures from blood, bronchial washings, and pleural fluid pleural fluid
The thin film of serous fluid between the visceral and parietal pleurae. , obtained after initiation of antibiotics, were negative. Two specimens of pleural fluid obtained on October 5 and 12 were tested by PCR and were positive for B. anthracis. Immunohistochemical staining of B. anthracis capsule and cell-wall antigens from pleural fluid cytology cytology (sītŏl`əjē), in biology, the study of the structure of all normal and abnormal components of cells and the changes, movements, and transformations of such components. preparations and from transbronchial and pleural biopsy Pleural Biopsy Definition
The pleura is the membrane that lines the lungs and chest cavity. A pleural biopsy is the removal of pleural tissue for examination. tissues obtained on October 5 and 12 were positive. Serial serum samples, obtained on October 7, 10, 11, and 17, indicated a serum IgG antibody response to the PA component of the anthrax toxin consistent with acute B. anthracis infection. The patient was treated with antibiotics and was discharged from the hospital on October 17 (10).
Of 1,076 nasal cultures obtained from workplace-exposed persons, two yielded B. anthracis. The first was the second case-patient, and the second was from an asymptomatic mail sorter in the same workplace. Nasal swab cultures obtained from two workers that handled workplace trash did not yield B. anthracis.
Interviews with employees regarding suspicious mail showed that the two workplace-exposed persons with nasal cultures positive for B. anthracis had extensive mail exposure. One, the second case-patient, was the workplace mail distributor; he did not generally open mail and did not recall handling or seeing any mail containing powder or described as unusual or as hate mail. He picked up 10,000-15,000 pieces of mail from the post office each weekday in the company mail van and distributed it at the workplace. The other co-worker, a 36-year-old woman, sorted mail and opened mail addressed to a periodical different from the one to which the index patient contributed. She recalled opening an envelope that released powder in her office on or about September 25. Afterwards, she discarded it in the trash without reading it. The letter most likely had arrived during the previous 2 weeks while she was on vacation. No other workplace mail likely to contain B. anthracis was suggested through further interviews.
Workplace information about exposure to suspicious mail indicated that the incubation period for both Florida case-patients was <12 days (Figure 1). The index patient had onset of illness 11 days after handling suspicious mail on September 19. The second case-patient had illness onset September 28, 9 days after the index-patient viewed suspicious mail on September 19 and 3 days after his co-worker opened a letter with powder in it on September 25.
[FIGURE 1 OMITTED]
Serial or paired serum tests for IgG antibody response to the PA component of the anthrax toxins were performed on serum of 436 workplace-exposed persons. No serum indicated a reaction consistent with acute B. anthracis infection except for that of the second case-patient. For most of the serologic tests, specimens were collected on October 10 and 17.
Among 32 postal workers who potentially handled workplace mail at two county postal facilities, 31 nasal cultures were obtained; none yielded B. anthracis. No anthrax cases were detected among 3,263 postal workers working at the 51 Palm Beach County postal facilities through the county postal worker surveillance system, which reported 226 illnesses and 7 hospitalizations during October 25-November 9, 2001.
Of 136 investigation-directed environmental samples obtained during October 8-10 from the workplace and company mail van, 20 were positive, including 10 of 20 from the mailroom, 1 of 2 from the company mail van, 5 of 6 from the office of the asymptomatic mail-sorter who had a positive nasal culture and had opened a letter containing powder, 2 of 21 from the index patient's work area (at an incoming-mail desk near his workspace and a repeat sample from his computer keyboard), 1 of 9 in the text library, and 1 from the single basement ventilation filter sample. No B. anthracis contamination was detected from 8 trash receptacles or 2 roof ventilation filters, 28 bulk items removed from the building containing security camera information, 18 samples from a construction area, or 21 other samples from other work areas and the entrance lobby. Five samples from the third-floor HVAC ducts (three from the index patient's office and one from another office), and three samples from the first floor HVAC ducts (from the mailroom, an office where an envelope with powder was opened, and the text library) were negative.
Eighty-four of 460 workplace samples obtained during October 25-November 8 yielded B. anthracis (Figure 2). Isolates of B. anthracis were obtained from 66 of 247, 10 of 95, and 8 of 112 samples from the first, second, and third floors, respectively; none of 6 specimens were positive from the parking garage or roof vents. The northeast quadrant of the third floor, which contained executive office suites, a conference room, and storage areas, was the only quadrant of any floor without detected contamination. The index-patient's office was located on the third floor of the building. The mailroom (the work area of the second case-patient) and the office near the mailroom where a powder-containing letter was opened are both on the first floor.
[FIGURE 2 OMITTED]
No mail containing B. anthracis spores was recovered. Because workplace refuse is incinerated and waste receptacles did not show contamination, no environmental specimens were obtained from waste sites.
B. anthracis contamination was detected at six of seven postal facilities tested, from routes serving the current workplace headquarters and a former office. Contamination was not detected at a facility that receives mail addressed to the post office box of the former workplace office, last used 13 months earlier.
Molecular subtyping analysis (MLVA) was performed on one B. anthracis isolate recovered from a postal facility that processed workplace mail, 18 isolates recovered from the workplace, cerebrospinal fluid and blood culture isolates from the index patient, and two nasal swab isolates from workplace-exposed persons. All B. anthracis isolates tested were indistinguishable by MLVA.
Prophylaxis and Control Measures
Beginning October 8, we recommended 60-day antibiotic postexposure prophylaxis Postexposure prophylaxis (PEP)
Any treatment given after exposure to a disease to try to prevent the disease from occurring. In the case of rabies, PEP involves a series of vaccines given to an individual who has been bitten by an unknown animal or one that is (2) to 1,114 workplace-exposed persons identified through employers and responses to public service announcements. We provided medication refills on October 17-19 and November 1 at a workplace branch office and as needed as needed prn. See prn order. through the Palm Beach County Health Department. Beginning October 24, we attempted telephone contact with persons who did not refill medications and advised them about our recommendations and how to obtain medications. Adjunct anthrax vaccination anthrax vaccination A series of 6 shots over 6 months and booster shots annually, given routinely to veterinarians, livestock workers, military personnel in the US, UK, Russia. See Anthrax, Biological warfare, Sverdlosk. , available beginning December 22, was accepted by three workplace-exposed persons.
When the postal system postal system
System that allows persons to send letters, parcels, or packages to addressees in the same country or abroad. Postal systems are usually government-run and paid for by a combination of user charges and government subsidies. risk assessment was initiated on October 12, antibiotic prophylaxis was offered to 32 postal workers who were most likely to have handled workplace mail at two local postal facilities. After we determined that at least 24 days had passed since contamination most likely took place in postal facilities, we did not recommend prophylactic antibiotics to Florida postal workers since more than two of the typical 1- to 7-day incubation periods for inhalational anthrax had passed, or two of the up to 12-day incubation periods estimated for the two Florida cases.
This report describes the investigation of the first bioterrorism-related anthrax case identified in the United States. We detected two inhalational anthrax cases (including the index case) among workers of a Florida media company. Anthrax transmission and widespread environmental contamination throughout the workplace and in six local postal facilities most likely resulted from two letters containing B. anthracis spores delivered to the workplace.
The index patient's infection most likely occurred from inhalation of B. anthracis spores following a primary aerosolization, i.e., spores released into the air after opening a spore-containing letter. This scenario is consistent with coworkers' recollections that the index patient held a letter containing powder over his computer keyboard, as well as environmental samples showing contamination at his keyboard, an incoming-mail desk near his workspace, and his mailroom mailbox. The second case-patient did not recall opening or seeing a letter containing powder, and the mechanism of spore aerosolization resulting in his infection is unclear. He was likely exposed while delivering 10,000-15,000 mail pieces daily to the workplace mailroom; both the mailroom and mail van were contaminated with B. anthracis spores. He may have inhaled spores after mail was compressed or shaken during delivery or after he (unknowingly) or a co-worker opened a spore-containing envelope. A secondary aerosolization, i.e., spores resuspended in the air after settling to a surface following an initial release, may also have resulted in his infection.
Results from environmental specimens and nasal swab cultures helped guide the investigation and were especially useful when combined as epidemiologic tools. The first environmental sample yielding B. anthracis, from the index patient's work area, when paired with the first positive nasal swab culture, which was obtained from the second case-patient, indicated that the exposure source was at the workplace. Evidence that mail was the transmission vehicle was provided through two nasal swab cultures yielding B. anthracis from workplace mail handlers (one who recalled opening a letter containing powder) and results of environmental specimen cultures, revealing contamination in the workplace mail van and mail room. The usefulness of nasal swab cultures may have been limited by the interval of [greater than or equal to] 13 days between the primary aerosolized Adj. 1. aerosolized - in the form of ultramicroscopic solid or liquid particles dispersed or suspended in air or gas
gaseous - existing as or having characteristics of a gas; "steam is water is the gaseous state" spore exposures (letters opened on or about September 19 and 25) and the date nasal cultures were obtained (most on October 8). A high yield from nasal cultures would not be expected after [greater than or equal to] 7 days had elapsed e·lapse
intr.v. e·lapsed, e·laps·ing, e·laps·es
To slip by; pass: Weeks elapsed before we could start renovating.
n. . One study showed that only one of eight nasal cultures from rhesus monkeys exposed to aerosolized B. anthracis spores yielded B. anthracis 7 days later (11). Environmental sampling was valuable independently in areas where no contamination was detected, by directing the investigation away from uncontaminated areas.
Environmental sampling revealed widespread contamination. However, the number or percentage of positive samples in a given area could not be used to quantify the contamination because quantitative spore counts were not performed when samples were cultured, a variety of sampling techniques were used (swabs, wipes, vacuum, and air sampling), and the distribution of samples obtained was not uniform.
This report documents the public health investigation into the first recognized case of anthrax due to intentional dissemination of B. anthracis spores in the United States. We demonstrated the usefulness of nasal swab cultures when combined with environmental specimen and epidemiologic data to identify the exposure site and vehicle used for anthrax transmission. Public health workers and clinicians should remain vigilant for anthrax because of the continued threat of bioterrorism.
We thank the Palm Beach County Health Department, the Florida Public Health Laboratory, the laboratories of the National Center for Infectious Diseases infectious diseases: see communicable diseases. , the Environmental Protection Agency Environmental Protection Agency (EPA), independent agency of the U.S. government, with headquarters in Washington, D.C. It was established in 1970 to reduce and control air and water pollution, noise pollution, and radiation and to ensure the safe handling and , the Federal Bureau of Investigation Federal Bureau of Investigation (FBI), division of the U.S. Dept. of Justice charged with investigating all violations of federal laws except those assigned to some other federal agency. , the U.S. Army Medical Research Institute of Infectious Diseases, the U.S. Postal Service The U.S. Postal Service (USPS) processes and delivers mail to individuals and businesses within the United States. The service seeks to improve its performance through the development of efficient mail-handling systems and operates its own planning and engineering programs. , and Epidemic Intelligence Officers for their assistance in this investigation and in preparing this article.
Dr. Traeger is a Public Health Service clinician and administrator in the Indian Health Service The Indian Health Service (IHS) is an Operating Division (OPDIV) within the U.S. Department of Health and Human Services responsible for providing federal health services to American Indians and Alaska Natives. . During this investigation, he was working at the Florida Department of Health, Bureau of Epidemiology, for the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. as an Epidemic Intelligence Service The Epidemic Intelligence Service is a program of the United States' Centers for Disease Control and Prevention. Established in 1951 due to biological warfare concerns arising from the Korean War, it has become a hands-on two-year postgraduate training program in epidemiology, with officer.
(1.) Department of Health and Rehabilitative Services. State of Florida. Annual Report, 1974 (262). Tallahassee (FL): Florida Department of Health; 1974.
(2.) Bush L, Abrams B, Beall A, Johnson C. Index case of fatal inhalational anthrax due to bioterrorism in the United States. N Engl J Med 2001;345:1607-10.
(3.) Centers for Disease Control and Prevention. Update: investigation of anthrax associated with intentional exposure and interim public health guidelines, October 2001. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morb Mortal Wkly Rep 2001;50:889-3.
(4.) Hoffmaster AR, Meyer RF, Bowen M, Marston CK, Weyant RS, Barnett GA, et al. Evaluation and validation of a real-time polymerase chain reaction In Molecular Biology, real-time polymerase chain reaction, also called quantitative real time polymerase chain reaction (QRT-PCR) or kinetic polymerase chain reaction assay for rapid identification of Bacillus anthracis. Emerg Infect Dis 2002;8;1178-82.
(5.) Quinn CP, Semenova VA, Elie CM, Romero-Steiner S, Greene C, Li H, et al. Specific, sensitive, and quantitative enzyme-linked immunosorbent assay for human immunoglobulin G antibodies to anthrax toxin protective antigen. Emerg Infect Dis 2002;8;1103-10.
(6.) Centers for Disease Control and Prevention. Comprehensive procedures for collecting surface environmental samples for culturing Bacillus anthracis. Available from: URL URL
in full Uniform Resource Locator
Address of a resource on the Internet. The resource can be any type of file stored on a server, such as a Web page, a text file, a graphics file, or an application program. : http://www.bt.cdc.gov/Agent/Anthrax/ environmentai-sampling-apr2002.asp. Accessed August 19, 2002.
(7.) Keim P, Price LB, Klevytska AM, Smith KL, Schupp JM, Okinaka R, et al. Multiple-locus variable-number tandem repeat analysis reveals genetic relationships within Bacillus anthracis. J Bacteriol 2000;182:2928-36.
(8.) Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax, 2001. MMWR Morb Mortal Wkly Rep 2001;50:1008-10.
(9.) Centers for Disease Control and Prevention. Additional options for preventive treatment preventive treatment
See prophylactic treatment. for persons exposed to inhalational anthrax. MMWR Morb Mortal Wkly Rep 2001;50:1142,1151.
(10.) Jernigan JA, Stephens DS, Ashford DA, Omenaca C, Topiel MS, Galbraith M, et al. Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States. Emerg Infect Dis 2001;7:933-44.
(11.) Hail A, Rossi C, Ludwig G, Ivins B, Tammariello R, Henchal E. Comparison of noninvasive sampling sites for early detection of Bacillus anthracis spores from Rhesus monkeys after aerosol exposure. Mil Med 1999;164: 833-7.
Address for correspondence: Marc S. Traeger, Whiteriver Indian Health Service Hospital, P.O. Box 860, Whiteriver, AZ 85941, USA; fax: 928-338-1122; e-mail: Marc.Traeger@mail.ihs.gov
Marc S. Traeger, * ([dagger]) Steven T. Wiersma, ([dagger]) Nancy E. Rosenstein, * Jean M. Malecki ([double dagger double dagger
A reference mark () used in printing and writing. Also called diesis.
Noun 1. ]), Colin W. Shepard, * Pratima L. Raghunathan, * Segaran P. Pillai, ([section]) Tanja Popovic, * Conrad P. Quinn, * Richard F. Meyer, * Sharif R. Zaki, * Savita Kumar, ([double dagger]) Sherrie M. Bruce, * James J. Sejvar, * Peter M. Dull, * Bruce C. Tierney, * Joshua D. Jones, * Bradley A. Perkins, * and the Florida Investigation Team (1)
* Centers for Disease Control and Prevention, Atlanta, Georgia, USA; ([dagger]) Florida Department of Health, Tallahassee, Florida For other uses, see Tallahassee (disambiguation).
Tallahassee is the capital of the State of Florida and the county seat of Leon County. Tallahassee became the capital of Florida in 1824. As of 2006, the population recorded by the U.S. , USA; ([double dagger]) Palm Beach County Department of Public Health, West Palm Beach, Florida West Palm Beach, also known as West Palm, is the most populous city in Palm Beach County, Florida, USA. The city is also the oldest incorporated municipality in South Florida. According to the University of Florida's 2006 estimates, the city had a population of 107,617. , USA; and ([section]) Florida Department of Health, Miami, Florida “Miami” redirects here. For the Native American tribe, see Miami tribe.
Miami is a major city in southeastern Florida, in the United States. It is the county seat of Miami-Dade County. Miami is a gamma world city with an estimated population of 404,048. , USA
(1) John Agwunobi, Soundia Akerele, Alina Alonso, Stephanie Athertey, Romualde Augustin, Jodi Baldy baldy, baldy-faced
said of cattle to mean a white face and usually indicating a Hereford influence in the animal's breeding. , Gwen Barnett, April Bell, John Bellamy, Maxine Bennett, Robert Benson, Richard Besser, Melanie Black, Carina Carina (kərē`nə) [Lat.,=the keel], southern constellation, representing the keel of the ancient constellation Argo Navis, or Ship of the Argonauts. Carina contains Canopus, the second brightest star in the sky. Blackmore, Michelle Bonds, Melinda Bronsdon, Erica Bruce, Larry Bush, Phillip Campagna, George Carlone, Marty Cetron, Ilin Chuang, Judith Cobb, Nicole Coffin, Raul Cortes, Rosayda Cortes, Larry Cseh, Barun De, Marc Diamante di·a·man·te or di·a·man·té
1. A small, glittering ornament, such as a rhinestone or a sequin, applied to fabric or a garment.
2. Fabric that has been covered with many of these ornaments. , Jody Dielmann, Cheryl Elie, Marc Fischer, Lisa Flanagan, Dwight Frazier, Alison Freeman, Aurora Garcia, Gabriel Garcia, Pablo Gonzalez, Carolyn Greene, Robert Hawley, Kevin Helmer, Leta Helsel, Alex Hoffmaster, Patricia Holder, Douglas Holt, Max Kiefer, John Jernigan, Barbara Johnson, Scott Johnson, Dolly Katz, Molly Kellum, Phil Lee, Paul Levett, Han Li, Walter Livingstone, Tillman McAdams, Robert McCleery, Jose Marcelino, Chung Marston, Sandra Martin, Ken Martinez, Eisa Merlo, Megan Merrill, Trudy Messmer, Rosa Moreno, William Morrill, Elizabeth Mothershed, Zuber Mulla, Annie Neasman, Michael O'Reilly, Elena Page, Anil Panackal, Frank Penela, Brian Plikaytis, Janet Pruckler, Martha Roberts, Sandra Romero-Steiner, Laura Rose, Taraz Samandari, Jackie Sampson, Roger Sanderson, Daniel Schmidt, Stephanie Schwartz, Vera Semenova, Donald Sharp, Peter Shih, Willie Spear, Karen Stamey, Sandy Steiner, Evelene Steward-Clark, Fred Stroud, David Sylvain, Tom Taylor Jr., Kathryn Teates, W. Lanier Thacker, Renee Thomas, Kathleen Thurman, John Walls, Donald Ward, Angela Weber, Rob Weyant, Robert Whisenhunt, Anne Whitney, Kathy Wilson, Andrea Winquist, Betty Wong, and Susie Wootton.