1. White Powder in the Mail Is it anthrax? How can you tell? What do you do?

2. What is Anthrax? Bacillus Anthracis –Spores –Bacteria

3. Knight Ridder/Tribune News/UCLA School of Public Health Dept. of Epidemiology

4. What Diseases are Caused by Anthrax? Cutaneous –Most common naturally occurring form –Low mortality Gastrointestinal –Results from eating contaminated, undercooked meat –Up to 50% mortality if untreated Inhalational –Most likely in bioterrorism –High mortality without prompt treatment

5. Inhalation Anthrax Onset of symptoms 2 days up to 60 days post-exposure Antibiotics most effective before onset of symptoms LD 50 about 8000 spores – Infective dose probably less than 10 spores in susceptible persons

6. History of Anthrax Biblical plagues –Fifth and Sixth Plagues in Exodus Believed to be Anthrax Animal disease –Endemic to horses, cows, goats, sheep –Economically important agricultural disease

7. Natural Incidence of Anthrax Most common in temperate agricultural regions –Rare in US –More common in India and southern Africa Human infection unusual –95% is cutaneous –Result of contact with infected animals

8. Naturally Occurring Human Anthrax Endemic in south/central Asia, central America, southern Africa Several thousand human cases each year –Always associated with livestock –Often associated with war Largest human outbreak Zimbabwe 1978-1980

9. Development of Anthrax as a Biological Weapon Historical use US and UK Development Soviet Development

10. Sverdlovsk Outbreak, 1979 Spores accidentally released from army microbiology lab 96 Infected, 66 Dead All victims lived or worked in a narrow band downwind from lab –Human casualties within 4 km –Animal deaths extended to 50 km downwind

11. Late 1990s: Rising incidence of Mailed Anthrax Hoaxes

12. ...the hundreds of anthrax hoaxes involving envelopes filled with harmless powders lack a plausible delivery system and hence are more of a nuisance than a serious danger. Jonathan Tucker Toxic Terror: Assessing Terrorist Use of Chemical and Biological Weapons, 2000

15. The Anthrax Letters Five Known Letters to Media and Political Targets –Four letters recovered, mailed on two dates from Trenton, NJ Letters Contained ~1g anthrax –Fine particle size –Treated to Enhance Dispersion

16. Anthrax Letters: Effects Anthrax in Second Mailing – <5 micron size –Escaped through pores in envelopes –Contamination throughout US postal service –Cross-contamination to many other letters Most illnesses and all but one death resulted from spores leaking through envelopes

17. Anthrax Letters: Casualties 5 dead from inhalational anthrax 17 ill –11 cutaneous –6 inhalational 10000 people taking antibiotics All but few survivors still suffering effects

18. Anthrax Letters: Effect on Business >500 reports of anthrax per day –Investigations –Facility Closures Side Effects from Cipro –57% reported serious side effects –26% missed work

19. Anthrax Letters: Cleanup Costs AMI Building in Boca Raton remains shuttered Clean-up of Hart Senate Office Building cost $41.7 million –Building was closed for three months 23 US Postal Service Facilities Contaminated –Clean-up costs estimated at $800 million

20. Hoaxes and Suspicious Packages Post 9/11 2001 before 9/11, 368 incidents, including one simultaneous mailing of 350 letters 2001 after 9/11, 7089 hoaxes and other reports of suspicious substances

21. Hoaxes and Suspicious Packages Post 9/11 2001 before 9/11, 368 incidents, including one simultaneous mailing of 350 letters 2001 after 9/11, 7089 hoaxes and other reports of suspicious substances

22. After the Anthrax Mailings, Everything is Taken Seriously Any suspicious powder received full response FBI director reported that agents responded to over 29,000 reports in the year following the attack Practical jokes and powdered sugar merited hazmat crews Attacks inspired other hoaxers

23. Suspicious Powder: Response First Responders including hazmat teams and FBI arrive Area is evacuated and possibly closed Field tests are done –If positive, those exposed are decontaminated Suspicious package is sent to CDC- certified lab for testing

24. Hoaxes Continue Today FBI's National Capital Response Squad responds to 5-10 reports per week of suspicious substances in Washington area U.S. Capitol Police respond to 3-10 reports per day on Capitol Hill Washington Post, 13 April 2004

25. Sometimes the Threat is Real Ricin in ‘Fallen Angel’ Letters –Intercepted at mail handling facility Greenville SC 10/03 –Intercepted at White House mail handling facility Washington DC 11/03 Ricin in Senator Frist’s Office 2/04 –No source letter found

26. USPS Guidelines for Suspicious Mail

27. What to do if you see Suspicious Powder If parcel is closed, don’t open or shake it Isolate area of package or powder Turn off fans or ventilation units and shut down the air handling system in the building Keep track of who has had contact with the powder Call 911

28. Would USPS Guidelines Have Helped to Recognize Anthrax Letters?

29. USPS Protective Measures Procedures –Off-site handling for potential targets –Irradiation of Government Mail Hazardous material detection –BDS in distribution centers –Detects anthrax only –Can potentially be modified to detect other hazards

30. What Your Company Can Do to Protect Itself Establish mail handling procedures Establish policies in case of discovery of powder –Include in emergency action plan Evaluate risk level Establish plan for keeping business operating in case of facility closure –Clean-up plan –Back-ups of important documents

31. Selected References Office of the Surgeon General, US Army Medical Aspects of Chemical and Biological Warfare. Washington 1997 Centers for Disease Control and Prevention, Emergency Preparedness Website http://www.bt.cdc.gov/agent/anthrax/index.asp Cole, Leonard A. The Anthrax Letters: A Medical Detective Story. Washington: Joseph Henry Press 2003 Meselson, Matthew et al. “The Sverdlovsk Anthrax Outbreak of 1979” Science, November 18,1994 Tucker, Jonathan Toxic Terror: Assessing Terrorist Use of Chemical and Biological Weapons Cambridge: Belfer Center 2000