Bioterrorism/Risk Communication/Disaster Preparedness Web Site Resources

October 19, 2001

Dear Doctor:

The recent terrorist attacks in New York City and Washington, D.C., and the human cases of inhalational and cutaneous anthrax underscore the need for all physicians to be alert for any unusual illnesses or disease clusters that may represent the intentional release of a biological agent, while at the same time seeking to reassure patients about the current low level of risk. The purpose of this letter is to provide instructions for recognizing unusual illnesses or disease clusters, to emphasize the appropriate use of diagnostic testing and preventive antibiotic therapy for anthrax, and to provide reference materials for you and your patients on biological agents of concern.

I. Recognizing Illnesses that Might be due to Bioterrorism

Physicians and other healthcare providers should be alert and able to recognize illness patterns and diagnostic clues that might represent the intentional release of a biological agent. The covert release of a biological agent may not have an immediate impact because of the delay between exposure and onset of illness. Consequently, the first indication of a biologic attack may be when ill patients present to physicians or hospitals for care. Attachments 1 and 2 outline important clinical and epidemiologic clues that might suggest a bioterrorist event.

II. Reporting Unusual Illnesses or Clusters

Any unusual illness or disease clusters, and individual suspect cases of cutaneous or inhalation anthrax, should be reported immediately to your local health department. Physicians in New York City should call the New York City Department of Health Mental Hyigene at 212-295-5658 or 347-538-0961 during business hours, or the Poison Control Center at 212-764-7667 after hours.

A telephone "hotline" (1-800-278-2965) has been established by the New York State Department of Health to assist local health departments with technical questions and for physicians and healthcare providers who are unable to reach their local health department. This number is not for questions from the general public, which should be referred to the local health department. In New York City, the telephone number for the public to call is 1-877-817-7621. State Department of Health staff can provide information to assist you in making diagnostic and treatment decisions.

III. Responding to Patients Concerned about Possible Exposure to Anthrax

Talking with Patients about Assessing Risk. Many patients are understandably very concerned about bioterrorism and specifically about anthrax. Patients should be reassured that anthrax infection is very rare and that the likelihood of finding anthrax is very low in samples being tested from suspicious or threatening envelopes, packages or other environmental sources. The great majority of suspect materials have tested negative for anthrax. In addition, physicians should emphasize that anthrax is not contagious from person-to-person. Attachment 3 is a patient fact sheet on anthrax that you can give to your patients.

Possible Exposure to Anthrax. We are advising patients who are concerned that they have been directly exposed to possible anthrax or another biological agent (e.g., direct skin or direct inhalation exposure to an unknown powder in a threatening letter) to put down the material, leave the room and warn others to avoid exposure; refrain from touching eyes, nose, or any other part of their body; and wash hands, forearms, and any other exposed areas thoroughly with soap and water. They should then call 911 to arrange for an assessment of risk and to determine if testing of the substance is indicated.

Testing of Patients for Anthrax. The Centers for Disease Control and Prevention (CDC) and the State Health Department DO NOT recommend the use of nasal cultures ("swabs") in evaluating patients who think they may have been exposed to anthrax. There is no reliable clinical screening test for the detection of anthrax infection in an asymptomatic person. Although Florida and New York City public health officials obtained nasal swab specimens from employees of the buildings where individuals with confirmed anthrax infection worked, according to the CDC this is being done for epidemiologic purposes in settings where there are confirmed cases.

Clinical laboratory testing may be appropriate for patients who have symptoms compatible with anthrax (e.g., typical cutaneous lesion or fever and respiratory distress, muscle aches, or mediastinal widening on chest radiograph suggesting inhalational anthrax). In these circumstances, your local health department should be notified immediately so that they can begin an epidemiologic investigation. Appropriate clinical laboratory testing should be done based on the clinical form of anthrax that is suspected (inhalational, gastrointestinal, or cutaneous):

  • Inhalational anthrax: blood cultures, CSF (if meningeal signs are present);
  • Sputum culture, chest X-ray
  • Gastrointestinal anthrax: blood cultures, stool culture
  • Cutaneous anthrax: vesicular fluid and blood cultures, biopsy.

Management of Patients with Possible Exposure to Anthrax. In situations of direct cutaneous or inhalation exposure to a suspicious powder or substance, testing of the substance for anthrax in a biosafety level 3 laboratory is recommended. Clinical testing of the patient is not indicated. In situations where there is no powder/substance to test, observation without culturing or antibiotic prophylaxis, is recommended. Give the patient copies of the enclosed fact sheets and make them aware of the symptoms to watch for.

The NYSDOH strongly discourages the inappropriate prescribing of prophylactic antibiotics in situations of unconfirmed anthrax exposure. The currently accepted standard of care is that prophylactic antibiotic therapy should be prescribed only for patients with a clear medical indication such as a known exposure to confirmed anthrax (e.g., laboratory confirmation of anthrax in an environmental sample) or in extraordinary circumstances such as full face exposure to fine powder with heavy contamination of eyes, nose and throat while environmental testing is pending. Preventive antibiotic therapy should not be prescribed without documentation of an exposure to anthrax. Antibiotics should not be prescribed for patients to stockpile for future use. The repeated prescription of antibiotics in the absence of valid medical indications is dangerous and inappropriate, and is considered by the Department of Health to be inappropriate prescribing.

Anthrax Vaccine. At this time, anthrax vaccine is available only for military personnel thought to be at higher risk for potential exposure to anthrax in the course of armed conflict. The vaccine is not available to the general public or the medical community.

Further information on the manifestations, diagnosis and treatment of anthrax can be found in Attachment 4 (Reprinted with the permission of the American Medical Association), the Consensus Statement on "Anthrax as a Biological Weapon," and in Attachment 5. Finally, Attachment 6 is a list of websites that contain detailed information on pathogens that might be used in a bioterrorist event.

We appreciate your assistance in speaking with concerned patients in these difficult times. In most cases, the appropriate response is to calm unnecessary fears and to rely on common sense. However, vigilance is needed to ensure that potential significant exposures or disease events are detected in a timely fashion.


Antonia C. Novello, M.D., M.P.H., Dr.P.H.
Commissioner of Health

cc: Local Health Departments
New York City Department of Health Mental Hyigene
NYSDOH Regional Offices
Hospital CEOs