Search

Background: Recognition of bioterrorism-related infections by hospital and emergency department clinicians may be the first line of defense in a bioterrorist attack., Methods: We identified unexplained infectious deaths consistent with the clinical presentation of anthrax, tularemia, smallpox, and botulism using Connecticut death certificates and hospital chart information. Minimum work-up criteria were established to assess the completeness of diagnostic testing., Results: Of 4558 unexplained infectious deaths, 133 were consistent with anthrax (2.9%) and 6 (0.13%) with tularemia. None were consistent with smallpox or botulism. No deaths had anthrax or tularemia listed in the differential diagnosis or had disease-specific serology performed. Minimum work-up criteria were met for only 53% of cases., Conclusions: Except for anthrax, few unexplained deaths in Connecticut could possibly be the result of the bioterrorism agents studied. In 47% of deaths from illnesses that could be anthrax, the diagnosis would likely have been missed. As of 2004, Connecticut physicians were not well prepared to intentionally or incidentally diagnose initial cases of anthrax or tularemia. More effective clinician education and surveillance strategies are needed to minimize the potential to miss initial cases in a bioterrorism attack.

Connecticut established telephone-based gram-positive rod (GPR) reporting primarily to detect inhalational anthrax cases more quickly. From March to December 2003, annualized incidence of blood isolates was 21.3/100,000 persons; reports included 293 Corynebacterium spp., 193 Bacillus spp., 73 Clostridium spp., 26 Lactobacillus spp., and 49 other genera. Around-the-clock GPR reporting has described GPR epidemiology and enhanced rapid communication with clinical laboratories.

Background: Family physicians are likely to care for patients that have been exposed to diseases associated with bioterrorism. Persons with seemingly nondescript initial disease symptoms could be harbingers of a larger outbreak, whether naturally occurring or purposefully created., Methods: We report a missed sentinel case of pneumonic tularemia associated with a naturally occurring outbreak. The patient's initial clinical symptoms and signs were nondescript, and the diagnosis was recognized by subsequent blood tests. The medical literature was searched using the key words "tularemia," "bioterrorism," "index of suspicion," and "sentinel case.", Results and Conclusions: Being alert to possible unexpected causes of a pneumonic summer illness in a patient with associated weight loss might have led to an earlier diagnosis of this sentinel case tularemia and its association with the subsequent outbreak. Individual patients are likely to visit a physician's office after a purposeful bioterrorism event. Greater efforts must be made to increase awareness in all primary care physicians who might see patients exposed to a bioterrorism illness.

On November 20, 2001, inhalational anthrax was confirmed in an elderly woman from rural Connecticut. To determine her exposure source, we conducted an extensive epidemiologic, environmental, and laboratory investigation. Molecular subtyping showed that her isolate was indistinguishable from isolates associated with intentionally contaminated letters. No samples from her home or community yielded Bacillus anthracis, and she received no first-class letters from facilities known to have processed intentionally contaminated letters. Environmental sampling in the regional Connecticut postal facility yielded B. anthracis spores from 4 (31%) of 13 sorting machines. One extensively contaminated machine primarily processes bulk mail. A second machine that does final sorting of bulk mail for her zip code yielded B. anthracis on the column of bins for her carrier route. The evidence suggests she was exposed through a cross-contaminated bulk mail letter. Such cross-contamination of letters and postal facilities has implications for managing the response to future B. anthracis-contaminated mailings.

On November 19, 2001, a case of inhalational anthrax was identified in a 94-year-old Connecticut woman, who later died. We conducted intensive surveillance for additional anthrax cases, which included collecting data from hospitals, emergency departments, private practitioners, death certificates, postal facilities, veterinarians, and the state medical examiner. No additional cases of anthrax were identified. The absence of additional anthrax cases argued against an intentional environmental release of Bacillus anthracis in Connecticut and suggested that, if the source of anthrax had been cross-contaminated mail, the risk for anthrax in this setting was very low. This surveillance system provides a model that can be adapted for use in similar emergency settings.

After inhalational anthrax was diagnosed in a Connecticut woman on November 20, 2001, postexposure prophylaxis was recommended for postal workers at the regional mail facility serving the patient's area. Although environmental testing at the facility yielded negative results, subsequent testing confirmed the presence of Bacillus anthracis. We distributed questionnaires to 100 randomly selected postal workers within 20 days of initial prophylaxis. Ninety-four workers obtained antibiotics, 68 of whom started postexposure prophylaxis, and of these, 21 discontinued. Postal workers who never started or stopped taking prophylaxis cited as reasons disbelief regarding anthrax exposure, problems with adverse events, and initial reports of negative cultures. Postal workers with adverse events reported predominant symptoms of gastrointestinal distress and headache. The influence of these concerns on adherence suggests that communication about risks of acquiring anthrax, education about adverse events, and careful management of adverse events are essential elements in increasing adherence.

In October 2001, the first inhalational anthrax case in the United States since 1976 was identified in a media company worker in Florida. A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis. Surveillance was enhanced through health-care facilities, laboratories, and other means to identify cases, which were defined as clinically compatible illness with laboratory-confirmed B. anthracis infection. From October 4 to November 20, 2001, 22 cases of anthrax (11 inhalational, 11 cutaneous) were identified; 5 of the inhalational cases were fatal. Twenty (91%) case-patients were either mail handlers or were exposed to worksites where contaminated mail was processed or received. B. anthracis isolates from four powder-containing envelopes, 17 specimens from patients, and 106 environmental samples were indistinguishable by molecular subtyping. Illness and death occurred not only at targeted worksites, but also along the path of mail and in other settings. Continued vigilance for cases is needed among health-care providers and members of the public health and law enforcement communities.

We describe the 11th case of bioterrorism-related inhalational anthrax reported in the United States. The presenting clinical features of this 94-year-old woman were subtle and nondistinctive. The diagnosis was recognized because blood cultures were obtained prior to administration of antibiotics, emphasizing the importance of this diagnostic test in evaluating ill patients who have been exposed to Bacillus anthracis. The patient's clinical course was characterized by progression of respiratory insufficiency, pleural effusions and pulmonary edema, and, ultimately, death. Although her B anthracis bacteremia was rapidly sterilized after initiation of antibiotic therapy, viable B anthracis was present in postmortem mediastinal lymph node specimens. The source of exposure to B anthracis in this patient is not known. Exposure to mail that was cross-contaminated as it passed through postal facilities contaminated with B anthracis spores is one hypothesis under investigation.