Lessons learned from the investigation of a cluster of cutaneous anthrax cases in Connecticut.

In 2007, two cases of cutaneous anthrax associated with West African drum making were reported in Connecticut in a drum-maker and his child. Although both cases were due to exposure to naturally occurring Bacillus anthracis from imported animal hides, ensuing investigative and remediation efforts were affected by the intentional B anthracis attacks in 2001. To share our experience of responding to an outbreak of anthrax in the biologic terrorism preparedness era, we summarize Connecticut's investigation and describe lessons learned. Laboratory capacity to rapidly assist in diagnosing anthrax, collaborative associations between epidemiologists and law enforcement personnel, and training in use of the Incident Command System, all these a result of public health preparedness, enhanced the initial recognition and subsequent investigation of these anthrax cases. However, without established guidelines for environmental risk assessment and remediation of private residences contaminated by B anthracis, challenges were encountered that resulted in a conservative and expensive approach to remediation. Without a more rigorous approach to ensuring that B anthracis spore-free hides are used, the making of animal hide drums is likely to pose a continuing risk for anthrax to those working with contaminated hides and those exposed to subsequently contaminated environments.

Fatal inhalational anthrax in a 94-year-old Connecticut woman.

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.

Bioterrorism-related inhalational anthrax in an elderly woman, Connecticut, 2001.

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.