1. You local fire department responded to an incident at the courthouse where about ¼ teaspoon of white powder spilled from an envelope that contained payment for a parking ticket. What level of decontamination is required for the person handling the letter and those in the room?

A. No decontamination.

B. Soap and water wash of hands and areas where powder contaminated.

C. Soap and water wash of everyone in the room.

D. Quarantine the entire building and burn it to prevent spread.

Answer B. Any person in direct contact with the powder should do soap and water cleansing and visibly contaminated clothing should be removed and bagged. This has less to do with anthrax than preventing chemical reactions, as if it is a harmful substance, it’s more likely to be a chemical compound than a biologic. These instances are common, and what occurred in St. Paul yesterday is that a provisional field test identified the substance as a potential biohazard (these tests are notoriously unreliable – very poor specificity). MDH did initial testing that confirmed within hours that it was not anthrax, (final cultures and processing take about 5 days though). Given that weaponized anthrax isn’t exactly easy to obtain, unless a nationally prominent target is selected, these are assumed to be false alarms until proven otherwise, so decontamination isn’t performed and on the off chance it would be a hazard, names and contact information are taken so that MDH can follow up and provide appropriate prophylaxis as needed.


2. The Fire Department notifies you that they are responding to an alarm at the downtown post office. The detector has alerted on a small package being sent to the special agent in charge of the FBI and contains a threatening letter as well as white powder. Three postal employees have arrived at the ED and are requesting decontamination. What do you do?

A. No decontamination.

B. Soap and water decontamination, control clothing.

C. Bleach decontamination of skin.

D. Prescribe Percocet and follow up with Medicine Direct clinic.

Answer B. The postal service has an anthrax detector that screens the downtown mail. It can have false positives, but is much better than the field HAZMAT tests. If there is a positive hit, and the threat analysis is legitimate (different case than the situation in question 1) then it’s reasonable to do soap and water decon – but mainly to contain spores rather than prevent illness. Providers should wear N95 masks (or better yet, the HAZMAT PAPRs which provide a higher level of protection. LD50 for anthrax is about 40k inhaled spores, but this is highly variable by individual, and far less amounts can cause illness). Re-aerosolization is a legitimate concern with weaponized forms of anthrax but again, there are few sources for this and a mail attack is unlikely vs. a larger-scale attack. There are internal processes that should prevent employees from seeking care like this, but it could happen, and if they present for evaluation after on-site decontamination check with MDH to see if prophylaxis (cipro usually) should be offered based on initial testing pending further analysis.

3. You hear through the grapevine that BioWatch has had a positive hit for anthrax. What this means is:

A. You should fire up the BioWatch channel on youtube and see what’s shaking.

B. Likely an airborne contaminant.

C. You should take the next few days off.

D. You’re doomed.

Answer – More likely B, but possibly C, less likely D. BioWatch is a system of environmental samplers that are designed to provide early warning of a bio attack (which otherwise would usually go undetected) in major cities – each day, samples are collected and run from the sites by the health department. Thus far, everything picked up by the systems has been environmental contaminants (anthrax not among them, as it’s rare to see that in the wind – in grass, yes, as especially in the spring spores unearthed by flooding that were deposited on the ground 100 plus years ago can germinate, contaminate grasses, be eaten by animals and cause disease). If an actual bioattack was picked up it would provide us crucial days to determine what areas were affected and get prophylactic antibiotics to the majority of those persons prior to them getting sick. Still, a lot of people would get sick and die as it’s impossible to reach everyone. You may be interested to know that similar air monitoring is performed on a routine basis for many mass gatherings such as NFL games. In this case, there is no need for decontamination of presenting patients though if they are still wearing original clothing it should be contained – healthcare providers that are at risk may need prophylaxis and instructions will be provided about this. Anthrax is NOT contagious, so at least that’s good.

Compiled by Dr. John Hick, Medical Director for the Office of Emergency Preparedness with the Minnesota Department of Health.