On October 9, 2001, New York City’s DOH was notified of a possible case of cutaneous anthrax in a female staff member of a nightly news team at a large media company (). On October 10, the department’s incident command system was put into effect, and team leaders were informed of the situation. From then until October 12, 2001, when the diagnosis was confirmed, DOH finalized an antibiotic distribution plan, including development of a medical charting system, standing orders for dispensing antibiotics, training curricula for staff, and reproduction of antibiotic fact sheets (in English and Spanish). Clinical materials were reviewed by the department’s general counsel, and scripts were developed for information hotlines. DOH staff were identified and reassigned to this effort.
Chronological summary of six anthrax events requiring PODsa
On October 12, 2001, the department began collecting nasal swabs and distributing prophylactic antibiotics to persons working at the media company who might have been exposed to a letter implicated in the index case. Included in this effort were those working on the same floor as the index patient. Initially, the exposure source was believed to be a letter postmarked September 25, 2001, and potentially exposing an estimated 200 persons. This letter was tested for Bacillus anthracis
multiple times, however, and all tests were negative (2
Within hours of the Mayor’s public announcement of this case, DOH and the Office of Emergency Management established an antibiotic distribution site (referred to as a point of distribution [POD]), at the main building that housed the media company. The space provided for prophylaxis was in the same building complex that housed the letter but did not share the ventilation systems that served the areas in the letter’s path. The layout of the space provided for the POD and its operations could not accommodate large groups of people seeking antibiotics. Moreover, the letter was a matter of a criminal and epidemiologic investigation, so law enforcement agencies needed to conduct their own interviews on site. Thus we coordinated with law enforcement personnel to minimize disruption of client flow and ensure that client medical confidentiality would not be compromised. The epidemiologic aspects of the investigation were initially incorporated into the medical record used.
Soon after distribution of antibiotics was begun, the source of anthrax was confirmed to be a letter postmarked September 18, 2001. Consequently, the time interval during which exposure may have occurred was reevaluated and the number of people possibly exposed substantially expanded.
Between Friday, October 12, and Tuesday, October 16, after approximately 42 hours of operation and an average of 55 staff persons per shift, 1,322 persons were briefed, completed epidemiologic and law enforcement interviews, underwent medical assessments, had nasal swabs taken to better define exposures, and were given a 14-day supply of antibiotics within the POD space. The average throughput time (the time from a client’s entry into the POD space to exit) was 30 minutes per client. Initially, the briefing of staff consisted of providing written materials. This system was augmented by a combination of information distributed over closed-circuit television throughout the still-operating company and by direct electronic communication from the company’s senior management. Within the first day of operations, it became apparent that both potentially exposed and unexposed persons needed emotional support and further information about the event, the risk for anthrax exposure, and the dangers of antibiotic misuse. Counselors (medical and mental health) were made available immediately outside the POD, and hotline staff were given scripts to assist them in answering concerned callers. The city’s DOH supplied each potentially exposed person with an initial 2-week course of antibiotics to provide time for public health officials to complete the investigation and develop specific criteria for persons needing to complete the balance of the 60-day prophylactic regimen.
Once the investigation was complete (October 20, 2001), DOH narrowed the criteria for antibiotic prophylaxis to those met by the 12 persons who directly handled the contaminated letter and recommended that all others discontinue antibiotics. This general information was communicated by the employers to all antibiotic recipients and by letters mailed from DOH to affected persons. We also directly contacted all 12 persons who needed to continue prophylaxis. Ultimately, 60-day inhalational anthrax prophylactic regimens were provided to 11 persons (6 working in the building and 5 involved in the recovery of the tainted letter) by means of the on-site employee health unit. One person refused prophylaxis. We later assisted the Centers for Disease Control and Prevention in evaluating adherence and adverse drug effects among those receiving 60-day regimens.
Four cutaneous anthrax cases were subsequently identified in New York City; these cases occurred at three other media outlets (one case each at two locations and two cases at the third) (3
). All these cases were believed to be associated with contaminated mail. No inhalational anthrax cases were associated with the media outlets. These three PODs served persons potentially in direct contact with the suspect letters. POD activities, however, were restricted to registration, provision of printed information, epidemiologic interviews, and obtaining of a very limited number of nasal swabs within the POD space. Subsequently, the decision to provide antibiotics was based on confirmed exposure, as determined by the epidemiologic investigation. Antibiotics were dispensed on an individual basis, as was monitoring for adherence and adverse events. Epidemiologic and law enforcement interviews and large informational sessions for all staff were held separately, in separate facilities, and at different times from those for the POD. Counseling was available immediately after the information sessions or thereafter through the DOH anthrax hotline.
The fifth POD was conducted in New York City by the U.S. Public Health Service (USPHS). This site’s purpose was to provide an initial 10-day course of antibiotics to prevent inhalational anthrax in ~7,000 postal employees who worked at facilities that processed the anthrax-containing letters sent to the above referenced media outlets (events 1–4). Although no anthrax cases had been reported among the city’s postal workers, inhalational anthrax cases had occurred in postal workers in New Jersey and in the Washington, D.C., area (4
). Anthrax spores were subsequently found in one of New York City’s postal facilities. Both labor and management at affected facilities requested prophylaxis for inhalational anthrax. As these were federal facilities and federal employees, prophylaxis efforts remained in the jurisdiction of the federal government. The POD was conducted by USPHS in the basement of a New York City mail-processing center (5
). U.S. Postal Service management was instrumental in securing space and identifying and scheduling staff. USPHS determined the initial operational layout, medical charting, and staff needed for this effort on the basis of its prior experiences in the Washington, D.C., area postal facilities. Additionally, written information was deemed insufficient for this setting. The increased throughput time reflects the inclusion of extensive live briefings accommodated within this POD space.
Liaisons from DOH’s clinical response team were assigned to this effort as consultants. DOH’s role was limited to increasing the efficiency of POD operations. We assisted USPHS effort by providing detailed clinician training materials, medication fact sheets, and on-site flow analyses with recommendations to improve client throughput on the basis of local POD experiences. Collaborative efforts also included the timely sharing of information with DOH for response to public inquiry, DOH assistance in establishing local medical and mental health referral patterns, and follow-up of these referrals. USPHS, in turn, accommodated visits to the operation by members of the New York City Office of Emergency Management and DOH staff for educational purposes.
Between Wednesday, October 24, and Saturday, October 27, in approximately 67 hours of operations with 65–70 staff persons per shift, this fifth POD provided 7,081 persons with a 10-day supply of antibiotics. The POD provided registration; completion of a medical screening form; detailed live briefings on risk for exposure, signs and symptoms of anthrax, and side effects of the recommended antibiotics; medical screenings; and antibiotic distribution. The average throughput time for these activities was 33 minutes per client. In addition to the medical personnel who were on site to evaluate symptoms and adjust antibiotic regimens, staff were available for mental health and other counseling issues. Epidemiologic and law enforcement interviews were conducted separately; no nasal swabs were collected because >30 days had elapsed since the suspect letters were processed. The federal agencies directly managing prophylactic efforts subsequently offered additional prophylactic antibiotics with or without the anthrax vaccine to those persons thought to have been most highly exposed to aerosolized B. anthracis.
On October 28, 2001, DOH was notified of a case of inhalational anthrax in a 64-year-old woman working in a hospital stockroom. The patient had no discernable association with the media companies or the postal service, although a section of the stockroom where she worked was adjacent to the hospital mailroom (6
). While environmental samples were being collected, DOH immediately set up a POD (event 6) for hospital staff, patients, and visitors who had spent >1 hour in the hospital since October 11 and thus might have a risk for exposure to aerosolized B. anthracis.
During the environmental investigation, the hospital was closed.
Between Monday, October 29, and Friday, November 2, over the course of 28 hours and with a staff of 53 persons per shift, 1,923 persons received prophylactic antibiotics. Epidemiologic and law enforcement interviews were targeted to include only hospital staff. Nasal swab specimens were collected from 28 persons who worked in and around the mailroom. The average POD throughput time was 6½ minutes per person. POD activities involved registration, triage, medical evaluation, dispensing antibiotics, counseling, and overall management. No informational sessions were conducted; however, written information (including DOH hotline telephone numbers) was distributed, and counseling staff were available. Nasal swabs were not routinely collected. This POD, which was situated in a hospital and focused on hospital personnel, was facilitated by close collaboration with the hospital administration, which helped coordinate prophylaxis efforts and mobilize hospital staff to assist in POD operations.
Antibiotic distribution was discontinued on November 2, when all environmental samples from the hospital tested negative for B. anthracis. By mail, DOH informed all persons provided with antibiotic prophylaxis to discontinue their regimens.