BY STEVEN M. DE LISI AND TIMOTHY R. CROLEY
Anthrax became a household word in October 2001. Within days of the first reported U.S. death from anthrax in Florida, emergency service organizations nationwide were overwhelmed by reports from citizens of sightings of suspicious substances believed to be the organism that causes this deadly disease. Throughout the country, personnel from fire, EMS, and law enforcement agencies, along with members of hazardous materials teams, responded to thousands of calls for assistance, suddenly placing them in the forefront of the war on terrorism. Although most calls were associated with mailed packages, powder on any surface, in any container, anywhere, and at anytime was now also suspect.
In addition to having to deal with the uncertainty of the hazards posed by these unknown substances, emergency personnel also were under the media spotlight probably more so than at any other time in the past. Their actions were chronicled in daily news accounts in every medium available; and, as always, their decisions were expected to be the right ones.
Prior to September 11, 2001, training for most first responders generally indicated that a biological terrorist attack would likely result in an increase in the number of sick people, all with similar symptoms, and an associated increase in the workload for EMS and hospital providers. As such, most first responders likely would play a lesser role during the early stages of a biological attack.
Of course, the realities encountered during the fall of 2001 were largely contrary to this original theory. Furthermore, the effects of this 21st century biological threat, although not the physical ones anticipated, nevertheless produced psychological trauma as well.
According to the Centers for Disease Control and Prevention (CDC), anthrax is caused by the organism Bacillus anthracis.1 The disease is reported to have three major clinical forms: cutaneous (skin lesions), inhalation, and gastrointestinal. The inhalation form posed the greatest concern at that time because it is often the most fatal form of the disease and also because it is caused by an airborne and potentially invisible hazard. These facts exacerbated the public’s fear of this new enemy.
THE CALLS BEGIN
One of the first known calls in metro Richmond in 2001 involved a woman who received a package ordered from a company owned by individuals of Arab descent. She had ordered products from them before without incident. She opened a package from the company on Friday, October 5; during the next two days, she developed signs and symptoms related to the common cold. There initially was no connection between contact with the package and her illness.
However, on Monday, October 8, media outlets were reporting a death in Florida from anthrax, along with statements that those suffering from this deadly disease likely would exhibit flu-like symptoms. The woman’s knowledge of the terrorist attacks on September 11, the source of the package, and the ever-constant media reports led her to erroneously conclude that her illness no doubt was anthrax. She immediately contacted local emergency services officials. She was not alone in her concerns.
Soon after, any powder-like substance was suspect of being anthrax, regardless of its location or any logical explanation relative to its origin. Powder found near a coffee pot was no longer spilled coffee creamer, just as a white powder found on a baby changing table in a department store was no longer talcum powder. One concerned citizen even reported the discovery of “amtrax” (an obvious reference to anthrax) on his front porch; another called after midnight terrified that his “runny nose” was a sure sign that he had contracted anthrax after handling a magazine that had contained a powdery material earlier in the day. Efforts to convince him that the powder likely was corn starch, often used in the production of certain magazines, were to no avail.
DEVELOPING A RESPONSE STRATEGY
Following the initial incident, on October 10, representatives from law enforcement, fire, EMS, and public health agencies operating in the metro Richmond area held a planning meeting. The purpose was to develop a response strategy for the anticipated overwhelming number of calls that would be similar to those received earlier in the week. The underlying theme of this strategy was that no one could assume immunity from a terrorist attack involving a biological agent and that, therefore, no call would be ignored.
Since state and federal assets were limited, the majority of the responses would originate at the local level. It became obvious that some type of plan would be needed if the available local resources were to be used most effectively on a priority basis. It was decided that the level of response would be based on the perceived threat presented by each call and that in many instances fire and law enforcement officials would work jointly to assess these threats. Soon after the initial planning meeting, the call volume related to suspicious packages and substances increased dramatically, to the extent that some localities found it necessary to dedicate personnel full time to manage the assessment activities.
Considerations used to assess the threat of packages generally included the type of container, the recipient, the point of origin or postmark, and the potential for a concealed explosive device. As an example, it was known by October 12 that an unsolicited envelope with a Trenton, New Jersey, postmark that was addressed to a high-profile government official likely would garner a lot of attention as opposed to a solicited package sent to a private citizen without this postmark. Of course, communicated threats regarding specific exposure to anthrax, regardless of any other factor, would present a serious concern.
The process of assessing threats was simplified through the use of a document referred to as the Known Mailing List, which was made available over the Internet by David Margritz, a postal inspector in Omaha, Nebraska. The list appeared during the weeks following October 8 and was revised almost daily.
According to Margritz, the Known Mailing List was “designed to be a source document to identify suspicious mailings that receive investigative attention by postal inspectors and other law enforcement agents.” Furthermore, its stated intent was to “reduce the frequency of actual responses to frivolous calls reporting suspicious mail that turned out to be legitimate.” One notable example referenced in an early list was a sample of granular dishwashing detergent mailed to thousands of homes with a Trenton, New Jersey, postmark soon after October 8. With this post office confirmed as a source of mail that contained the deadly Bacillus anthracis, any substance associated with the Trenton postmark was suspect. The Known Mailing List helped to allay fears and expedite threat assessments.
Threat assessments also became the underlying theme for all other actions that followed. They included managing the environment in which the substance or package was located and dealing with individuals exposed in the immediate area. Managing the environment included evacuation and control of building HVAC systems; management of those exposed involved decontamination and follow-up medical care.
Soon after the initial planning meeting, there were weekly conference calls that involved federal and state officials along with emergency services coordinators from localities in the region. These conference calls allowed first responders to share information, learn from those who had experienced unique incidents during the previous week, and develop their own local database of “known mailings.” The conference call format was preferable to face-to-face encounters, since most first responders were too busy to attend meetings.
BALANCING THE LEVEL OF RESPONSE
As would be anticipated, the higher the perceived level of threat, the greater the level of response. For incidents that occurred in buildings, the response ranged from evacuating one room to one floor to the entire facility. It sometimes was difficult to determine the most appropriate extent of evacuation. It was also difficult at the beginning to determine the best manner for dealing with individuals who had handled a suspect package or substance.
Training related to the emergency management of contaminated or potentially contaminated individuals at that time was based more on exposure to chemicals than on exposure to biological agents. First responders, consequently, were taught to decontaminate the victim by flushing with large amounts of water, usually from a hose on a fire truck; completely removing the victim’s clothing; and then flushing again. However, these aggressive tactics were often unnecessary for individuals who only handled a suspicious package with no evidence of contamination.
It is important to note that these decontamination practices used by first responders during the first few days of responding to calls for suspicious substances were merely the result of good intentions: They were only doing what they had been trained to do. Most first responders had never heard of decontamination for persons exposed to “biological agents.”
Soon after, though, interim guidelines were developed. They stipulated that under most circumstances individuals who had handled suspicious packages and who had possibly been exposed to an unknown substance were only to wash their hands or other affected areas and to change their clothing. Only in situations involving credible threats or extensive contamination of clothing with an unknown substance would more aggressive decontamination procedures be employed.
MEDICAL TREATMENT FOLLOWING EXPOSURE TO BACILLUS ANTHRACIS
During the initial planning meeting on October 10, it was decided that medical care for an individual who possibly may have been exposed to a biological agent would best be managed by the individual’s private physician, with support from representatives of the local health departments following a laboratory analysis of the suspicious substance or package. This was a dramatic paradigm shift for some EMS providers, since, as was the case with firefighters dealing with contaminated people, some believed that anyone exposed to a suspected biological agent needed immediate medical care. It took some time for first responders to learn that with most diseases, in particular anthrax, there is an incubation period and that unless the victim is suffering from cardiac arrest or some other serious condition, immediate medical care and a speedy trip to the hospital with lights and sirens would likely be unnecessary.
Overreaction was not the sole domain of first responders. It was not long before the public learned of a recommended course of treatment for exposure to Bacillus anthracis, which included the administration by physicians of antibiotics, such as penicillin, doxycycline, and ciprofloxacin. Although the extent of the medial care would preferably be based on threat assessments and the results of laboratory analysis, the overabundance of information from the news media led some citizens to believe they could prescribe their own treatment. As a result, some local physicians soon encountered situations where their patients demanded drugs like ciprofloxacin following an exposure to an unknown substance, regardless of the perceived threat level or other factors that likely would have negated the need for such aggressive intervention.
To ensure that people who required it received proper medical care during the incubation period, the presence of the deadly bacteria had to be confirmed in those incidents where a high level of suspicion was apparent. To accomplish this, representatives from Virginia’s Division of Consolidated Laboratory Services (DCLS) analyzed numerous suspicious packages and substances to confirm or deny concerns related to a perceived threat.
DCLS is a member of the Laboratory Response Network (LRN) and serves as a reference lab.2 According to the CDC, “Reference labs are also referred to as confirmatory reference and can perform tests to detect and confirm the presence of a threat agent. They ensure a timely local response in the event of a terrorist incident. Rather than having to rely on confirmation from labs at CDC, reference labs are capable of producing conclusive results. This allows local authorities to respond quickly to emergencies.”3
Following laboratory analysis, the results then were usually forwarded to officials from local health departments, who would then contact individuals exposed to the substance and tell them if additional follow-up medical care was necessary.
OBTAINING SAMPLES FOR LABORATORY ANALYSIS
As discussed earlier, the initial response to reports of suspicious substances or packages generally included evacuation of the affected area, an assessment of the perceived threat level presented by the incident, and appropriate decontamination of individuals exposed. Once people were safely out of a building, the questions often posed to first responders by these individuals were “Am I going to die?” and “Is it safe to go back inside?” Of course, for those situations on the low end of the threat spectrum, the answers generally would be “No” and “Yes,” respectively.
To be certain, the initial approach was to have DCLS analyze all suspicious parcels and substances. This quickly resulted in an unmanageable workload at the lab, and DCLS soon requested first responders to limit their submissions only to items with credible threats.
In response to the request from DCLS, some first responders in the region employed a twofold solution to manage low-threat scenarios: (1) A suspicious package had to be on the Known Mailing List and efforts to convince the public that the item was harmless were ineffective and (2) mail had to be unsolicited. First responders soon learned that they could resolve some incidents involving “unsolicited” packages by questioning the complainant relative to the possible origins of the “suspicious” parcel. On many occasions, citizens had forgotten that they had ordered a package, and they remembered only after some thought that the item they received was legitimate.
Another solution for low-threat “unsolicited” mail citizens were reluctant to keep in their homes and businesses was to place the item in a standard “red bag” normally reserved for infectious waste and to dispose of it as part of the medical waste stream already established in most fire stations and rescue squads. Next, any surface potentially contaminated by the parcel or substance was decontaminated.
Recommendations for decontamination were available from a variety of sources, including the Guidance for First Responders document prepared by the Virginia Department of Emergency Management (VDEM), which recommended: “The suspicious powders be sprayed with a 10 percent household bleach [solution], left alone for 15 minutes to kill any organism present, and then swept up.”4
Note: A “Guidance” document for responders was made available from the federal government in November 2004 (see Guidance on Initial Responses to a Suspicious Letter/Container with a Potential Biological Threat above).
Keep in mind, as noted above, that the “disposal and decontamination” approach was for low-threat scenarios only and that the application of bleach to a “contaminated” surface was more a means of dealing with psychological trauma and convincing people in these situations that it was safe to return to their home or business.
For incidents that posed a higher and more credible threat, the strategy involved obtaining a sample of the suspicious substance and safely transporting that material and the associated package to DCLS for analysis. Questions then posed by first responders were how to get the sample, package it, and protect first responders while doing so. In addition, it was understood that some situations likely could include potential criminal evidence and that, as such, sampling activities would need to meet applicable legal standards that included proper documentation, such as completing “chain of custody” forms.
The obvious solution to questions on maintaining the credibility of evidence would be to allow law enforcement personnel to obtain, package, and transport the samples, since they would be most familiar with the applicable legal requirements. However, it was also obvious that law enforcement personnel generally were not equipped or trained to protect themselves from possible exposure to a potentially deadly environment. So just who would collect these samples?
HAZ MAT TEAMS BECOME EVIDENCE COLLECTION TECHNICIANS
Firefighters, specifically those trained to deal with hazardous materials, were in the best position to protect themselves from potential airborne contaminants because of the availability of respiratory protective equipment. This type of equipment included self-contained breathing apparatus (SCBA) and filter respirators. Although training law enforcement personnel to use respiratory equipment owned by fire departments would have been a major hurdle in itself, another factor was Occupational Safety and Health Administration (OSHA) standard 1910.134, which mandates that those using respiratory equipment meet certain minimum requirements.
These requirements include undergoing an annual physical to determine if an individual is physically fit to use the equipment and a “fit test” to ensure that a face piece will work properly and provide the wearer with the necessary protection. In addition, those wearing a “tight-fitting” face piece, such as SCBA, could not have beards or other types of facial hair that would interfere with tightly sealing the face piece against the skin. In October 2001, there was no time for training or fit tests, so the responsibility for sampling often fell to firefighters and members of haz mat teams.
Respiratory protection was only part of the concern. Those entering a potentially contaminated area also needed some way to easily decontaminate their clothing and thereby avoid removing any biological agents from the scene. This was best accomplished through the use of chemical protective clothing (CPC) such as coveralls or fully encapsulating Level A suits.
We now had to decide the extent of CPC to be used. CDC issued a recommendation that stated the following:5
“Responders should use a NIOSH-approved, pressure-demand SCBA in conjunction with a Level A protective suit in responding to a suspected biological incident where any of the following information is unknown or the event is uncontrolled:
- -the type(s) of airborne agent(s);
- -the dissemination method;
- -if dissemination via an aerosol-generating device is still occurring or it has stopped, but there is no information on the duration of dissemination or what the exposure concentration might be.”
After reviewing the CDC guidelines, it became apparent that when entering an area to obtain a sample for analysis, first responders were essentially dealing with an unknown type of airborne agent and, as such, had to comply with these guidelines: Any activity would require Level A. However, the continuous use of Level A suits presented its own problems of expense and wearer fatigue.
Reusable Level A suits are an expensive investment for most haz mat teams, and although disposable or “limited use” Level A suits are less costly, their continued use over the course of several hundred calls had the potential to deplete the financial resources of most organizations. Furthermore, with most teams having only a limited number of Level A suits, there was serious concern of exhausting these supplies that likely would be required should the need arise to respond to a chemical emergency.
VDEM, in its Guidance for First Responders, also noted that scenarios identified by the CDC that would require the use of Level A suits were at the time, “extremely unlikely and had not been experienced during the rash of current incidents.”(4) Instead, VDEM suggested that “the use of a Level B ensemble is more than adequate for the response to any of the incidents … seen so far.”(4)
During most incidents at the time, Level C ensembles (air-purifying respirator and protective clothing that affords skin protection) were most often used by first responders. This use was consistent with the recommendations then issued by the CDC, which stated that this level of protection would be adequate where “the dissemination [of biological materials] was by way of a letter or package that can be easily bagged.”(4) VDEM concurred with this recommendation, stating that situations when CDC guidelines would call for Level C ensembles were “the most common scenario … seen to date.”(4)
SAMPLING EQUIPMENT AND PROCEDURES
For powder-like substances on surfaces, sampling to obtain a sufficient quantity of the material involved the use of sterile swabs moistened with a sterile saline solution. These swabs were then double sealed using sterile bags known as “Whirl Paks” and placed into sturdy metal one-gallon cans. However, prior to placing any material in a can, the exterior surface of the outer containment bag was sprayed with a 10:1 bleach solution. This bleach solution was made available in a unique spray device that included two separate containers, one for water and one for household bleach, and a proportioning mechanism that delivered the bleach solution in the appropriate concentration. DCLS provided haz mat teams in the region with all necessary sampling equipment, including the bleach sprayer. Additional information regarding this equipment is available from Dr. Tim Croley, who may be reached at (804) 648-4480 or by e-mail at tim.croley@dgs.virginia.gov/.
 (1) Shown left to right are a bleach spray device, a sterile Dacron swab, a syringe containing sterile saline, and a sterile “Whirl Pak” sample bag. (Photo by Steven De Lisi.) |
Laboratory analysis included an initial microscopic examination to determine the presence of spores with characteristics similar to Bacillus anthracis. Following this initial exam, efforts were made to “culture” the sample or otherwise allow the organism to grow. Samples that failed this test were obviously of no concern. However, samples successfully cultured under laboratory conditions were subjected to additional confirmatory tests, including hemolysis, motility, sporulation, lysis by gamma-phage, and direct fluorescence assay (DFA). In addition, DCLS performed a chemical analysis to identify unknown substances.
CONCLUSION
The events that occurred shortly after September 11, 2001, involving fear of contracting anthrax demonstrated the extent to which a potential terrorist act could tax available emergency services resources in an effort to protect the public. Yet, it also demonstrated the benefits available to local, state, and federal agencies that chose to join forces in a time of need. Using their resources in a cooperative and supportive manner served not only to minimize duplication of effort but also to provide for the safest and most effective working environment for their personnel.
From early October through mid-November 2001, first responders in metro Richmond invested considerable sums of money in sampling equipment, personal protective clothing, and overtime pay for personnel responding to hundreds of calls related to suspicious packages and substances. None of these incidents yielded positive results for the Bacillus anthracis organism, and no reported cases of anthrax occurred in the region.
In the aftermath of September 11, 2001, the world in which we live has changed forever in many ways. But there has been little change to response protocols for these types of incidents since 2001. Our response and lessons learned will better prepare us for future incidents involving biological substances
References
1. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/anthrax_t.htm
2. http://dcls.dgs.state.va.us/ER/EmergencyResponse.aspx
3. http://www.bt.cdc.gov/lrn/factsheet.asp
4. Guidance for First Responders, Virginia Department of Emergency Management, 2001.
5. http://www.bt.cdc.gov/documentsapp/Anthrax/Protective/10242001Protect.asp
STEVEN M. DE LISI is deputy chief for the Virginia Air National Guard Fire and Rescue in Henrico County and a 26-year veteran of the fire service. He is a certified hazardous materials specialist and served the Technological Hazards Division of the Virginia Department of Emergency Management from 1997-2002. De Lisi is chairman of the Virginia Fire Chiefs Association’s Hazardous Materials Committee and a former member of the NFPA committee on hazardous materials protective clothing.
DR. TIM CROLEY is the project leader for chemical terrorism laboratory response and preparedness at the Division of Consolidated Laboratory Services for the Commonwealth of Virginia, Virginia’s state laboratory. Research in Dr. Croley’s lab focuses on development and validation of novel, robust, and rugged methods for identifying traditional and new chemical warfare agents and emerging contaminants in a variety of matrices.
GUIDANCE ON INITIAL RESPONSES TO A SUSPICIOUS LETTER/CONTAINER WITH A POTENTIAL BIOLOGICAL THREAT
The document Guidance on Initial Responses to a Suspicious Letter/Container with a Potential Biological Threat was published in November 2004; it was a coordinated effort among the Federal Bureau of Investigation, the Department of Homeland Security, and the Health and Human Services Centers for Disease Control. Its stated intent is to provide “recommendations for local responders based on existing procedures (including recommendations from the International Association of Fire Chiefs). This document provides guidance on the initial response to a suspicious letter/container, while other follow-on response plans, such as portions of the National Response Plan (NRP), may be utilized if a threat is deemed credible.”
The document introduces local responders to five scenarios they are likely to encounter:
- Letter/container with unknown powder-like substance and threatening communication (with or without illness).
- Letter/container with a threat but no visible powder or substances present.
- Letter/container with unknown powder, no articulated threat, and no illness.
- Letter/container with no visible powder, no threat, but recipients are ill.
- Letter/container arrives with no powder, no threat, the recipient is not ill, but the recipient is concerned about the package.
The document also reinforces important lessons similar to those learned by first responders in metro Richmond in 2001, including that “response agencies should follow standard law enforcement procedures and hazard risk assessments in response to calls and should pre-identify the relevant local public health points of contact to be notified in the event of a potential bioterrorism event.”
This document is available at http://www.bt.cdc.gov/planning/pdf/suspicious-package-biothreat.pdf.
