Healthcare workers (HCWs) in hospitals, clinics, and other settingsmay have exposure to BA resulting from contact with spores that may contaminate a patient's skin, clothing, or personal effects, or through contact with contaminated equipment. HCWs may also be at risk of inhaling BA spores that are re-aerosolized (put back into the air) from contaminated patients or if they are in an area where a BA release has occurred.

In addition to the General Guidance, applicable to all workers, provided at the beginning of this page, OSHA recommends the following controls for HCWs serving as first receivers of patients potentially exposed to BA. HCWs and their employers involved in emergency response operations outside healthcare facilities should also consult the First Responders section of this web page.

Engineering Controls

Because anthrax is not generally transmissible from person to person, the engineering controls typically making up the first line of defense for other infectious agents usually are not required when treating patients with possible BA exposure. The exception is when there is visible evidence of powder on the patient that requires decontamination. In such cases, isolate the patient in an airborne infection isolation room (AIIR) until decontamination is completed. Morgues often have ventilation isolation to prevent mixing of airflow with other area systems and are a good option for use as decontamination rooms.³ If AIIRs or other special isolation rooms are not available, isolate potentially contaminated patients away from other patients and staff. Use barriers, such as sheets or disposable coveralls, to prevent spread of the BA spores until completion of decontamination procedures. This is discussed further in the "Administrative controls" section, below.

Use high-efficiency particulate arrestance (HEPA) vacuums to clean contaminated areas.

Administrative Controls & Safe Work Practices

For small-scale (i.e., isolated exposure) incidents involving anthrax, follow recognized good infection control practices. This includes changing gloves after direct patient care and before touching anything else; washing hands thoroughly with non-antibacterial or -antimicrobial soap at completion of direct patient contact and procedures; and decontamination, disinfection and proper disposal of PPE, bedding and other items potentially contaminated by a patient. See the General Guidance section for more information on standard precautions.

Follow contact precautions, as well, particularly if the patient has uncontained drainage from skin lesions.4 This includes placing such patients in single-patient rooms and providing workers with additional PPE and training (see the PPE and Training sections, below).

If the patient requires decontamination, restrict the number of personnel entering the room until completion of decontamination procedures. In addition to using AIIRs, first-receiver facilities may also consider implementing policies that include covering contaminated patients in an outer garment (e.g., disposable coverall) or sheet to contain spores, or misting such patients with a soap/water solution to reduce spore dissemination until the patient can be decontaminated fully (e.g., in a decontamination shower).

Clean and disinfect rooms and bedside equipment of patients with anthrax infections using the same procedures used for all patients as an element of recognized good infection control practices, unless the amount of environmental contamination indicates a need for special cleaning. See the General Guidance for cleaning and disinfection for recommendations on disinfection of environmental surfaces and noncritical patient care equipment potentially contaminated with BA. When handling cases of cutaneous anthrax, sterilize surgical tools immediately after use and incinerate dressings. The CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 provides practices for disinfection and sterilization of surfaces and equipment in healthcare settings.

Handle all waste as regulated medical waste and place it in red biohazard bags. Under the HMR, waste potentially contaminated with BA, including PPE and other materials associated with patient care activities, generally does not contain a Category A infectious substance unless it includes cultures of BA.

Personal Protective Equipment

All HCWs involved in direct patient care must wear clean, disposable gloves while taking specimens or dressing lesions, and disposable gowns to protect the skin and/or clothing. In cases requiring contact precautions, put on PPE when entering a patient care area and discard it prior to exiting.

For medical and support staff not directly involved in patient contact, wear gloves even though the risk of transmission is low.

OSHA's non-mandatory Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances offers recommendations for selecting respiratory protection to protect HCWs during the receipt of contaminated victims from mass casualty incidents occurring at locations other than the hospital.

See the General Guidance section for specific recommendations on PPE selection, use, and good practices for protection against BA.

Training

See the General Guidance section for information on worker training.

Further Information

The CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings provides detailed information about infection control and prevention for anthrax in healthcare settings.

See the Guidance for Protecting Responders' Health During the First Week following A Wide-area Aerosol Anthrax Attack for specific information on measures to minimize responders' exposure to B. anthracis spores after a terrorist/criminal act involving BA.

Diagnostic and research samples may contain viable BA bacteria and spores—including at high concentrations, in some cases. Exposure can result in severe infections. Laboratory workers who handle clinical specimens from patients with suspected/confirmed anthrax or samples of BA as part of research and development work may be exposed through direct and indirect contact with the bacteria or spores through broken skin or inhalation as a result of laboratory accidents/mishaps, laboratory activities that generate aerosols, and releases of infectious materials outside of containment equipment. While a laboratory-acquired infection with anthrax is rare, blood, drainage from skin lesions, cerebrospinal (brain and spinal cord) fluid, pleural (membranes that line the lungs) fluid, and sputum may all contain BA.5 Urine and feces rarely contain the bacteria.

Follow good infection control practices to prevent or minimize transmission of anthrax as specified in the general guidance above. Follow standard laboratory practices when working with anthrax or BA samples/specimens, including in clinical and microbiological laboratories performing routine diagnostic, analytical, or other research-related tests on serum, blood, skin, and respiratory specimens. Decontaminate working surfaces, including those within biosafety cabinets, after each use and dispose of supplies and equipment in proper receptacles. The Cleaning & Disinfection section of the general guidance, above, provides information about selection of appropriate disinfectants and sterilants.

Avoid touching the face, including any mucous membranes, such as the eyes, nose, or mouth, or any exposed skin with hands (gloved or ungloved). Never eat, drink, smoke, or apply cosmetics in the laboratory.

Use an autoclave to inactivate infectious material (i.e., kill all associated infectious agents) in all waste prior to disposal. Adhere to applicable federal, state, and local regulations when disposing of laboratory waste.

Note: Federal regulations require laboratories in healthcare facilities to retain the on-site capability of destroying discarded cultures and stocks if they isolate any microorganism or toxin identified as a Select Agent from a clinical specimen. Healthcare facilities transferring the isolated cultures to a facility registered to accept such agents, including BA, in accordance with federal regulations are exempt from the requirement. State medical waste regulations may prevent this transfer if the cultures are determined to be medical waste since most states regulate the inter-facility transfer of untreated medical wastes.6

Immediately report to management, any incidents or accidents involving potential or actual exposure to anthrax, as well as development of symptoms consistent with cutaneous or inhalation anthrax.

Implement appropriate protocols for handling, storing, and shipping specimens and ensure adherence by all laboratory workers. The BBP standard (29 CFR 1910.1030) includes packaging requirements for samples of, or that are contaminated with, human blood, body fluids, or other potentially infectious materials. The U.S. Department of Transportation's Hazardous Materials Regulations, CDC and USDA permitting requirements for biological select agents and toxins, the U.S. Postal Service (USPS), the International Air Transport Association (IATA) and state and local requirements may apply when packaging, shipping, and transporting specimens suspected or known to be contaminated with anthrax.

The following CDC guidelines may provide additional details on packaging and shipping procedures for anthrax samples:

• Laboratory Response Network for Biological Terrorism
• Etiologic Agent Import Permit Program (EAIPP)
• Interstate Shipment of Etiologic Agents
• Anthrax: Collecting, Preparing, and Shipping Serum Samples to CDC for Serology Testing

Laboratories should ensure that their facilities and precautions meet the appropriate Biosafety Level (BSL) for the type of work conducted in the lab. Increasing BSLs involves more worker training, higher levels of containment of samples and other sources of pathogens, specially designed air handling systems, additional worker PPE, and other stricter controls. For example, BSL-2 practices limit access to laboratories and other controlled work areas during work operations and during use of biosafety cabinets (BSCs) or other containment equipment for certain procedures. At BSL-3, in addition to controlling access to laboratories and work areas, all work involving infectious materials is conducted in BSCs or other containment equipment.

The CDC and the National Institutes of Health publication Biosafety in Microbiological and Medical Laboratories (BMBL) provides guidance on protecting workers in laboratory environments. The following sections from BMBL guidance may be particularly relevant to employers and workers if their workplaces contain BA:

• Section IV - Laboratory Biosafety Level Criteria
• Section VII - Occupational Health and Immunoprophylaxis
• Section VIII - A – Bacterial Agents
• Appendix A - Primary Containment for Biohazards: Selection, Installation and Use of Biological Safety Cabinets
• Appendix B - Decontamination and Disinfection

Also, see the recommendations on disinfection of environmental surfaces and noncritical patient-care equipment potentially contaminated with BA contained in the General Guidance section.

Train workers on proper laboratory safety and health procedures and adherence to guidelines; test competency of workers in appropriate implementation of these procedures and guidelines, including appropriate use of engineering controls and PPE; conduct refresher training on a routine basis; and verify consistent adherence to the safety and health procedures and guidelines.

In addition to the recommendations outlined in the General Guidance section, engineering controls, administrative controls, work practices, and PPE needed when working with samples known to contain or suspected of containing BA vary between clinical and research laboratories. The following sections on Clinical and Research Laboratories outline controls specific for each setting.

Clinical Laboratories

OSHA's guidance for protecting workers in clinical laboratories generally follows BSL-2 controls and practices, as described in the BMBL.

Engineering Controls

Use Class II BSCs or other containment equipment for all procedures with potential for infectious aerosol or splash creation. Class II BSCs use airflow into the front of the cabinet to keep potentially contaminated air and materials (i.e., BA spores) in the cabinet and high-efficiency particulate absorption (HEPA) filters to remove infectious agents from exhaust air.
For all centrifugation, use aerosol-tight rotors and open within the BSC after each run.

Administrative Controls & Safe Work Practices

BSL-2 is appropriate for handling moderate-risk agents that cause human disease of varying severity by ingestion or through percutaneous or mucous membrane exposure. Conduct clinical laboratory work on samples from patients with suspected or confirmed anthrax at BSL-2, as a minimum. Use BSL-2 practices for work on samples from patients with suspected or confirmed anthrax. This includes performing all procedures to minimize the creation of splashes and/or aerosols and decontaminating work surfaces upon work completion and after spills or splashes potentially contaminated with BA.

Personal Protective Equipment

PPE for clinical laboratory workers handling BA specimens include gloves (vinyl or nitrile) and laboratory coats. Use eye protection (e.g., goggles, including with face shields, if appropriate) when handling BA outside the BSC or other containment device.

Almost all if not all work that could generate aerosols should be done in an appropriate BSC; use appropriate respiratory protection if aerosol generation outside of a containment device is possible.

When using a BSC, remove the outer pair of gloves before exiting the BSC, and don a new pair each time reentering the BSC.

The general guidance above provides additional information on types of PPE protective against BA.

Training

As per BSL-2 precautions, train laboratory personnel in handling pathogenic agents with supervisors competent in handling infectious agents and associated procedures.

Train all laboratory personnel on any additional procedures developed by the employer for safely handling clinical specimens from patients with known or suspected anthrax and research specimens. This includes training on the communication procedures in effect between the clinical and laboratory staff to ensure timely notification and proper labeling of known or suspected BA-contaminated specimens.

Research Laboratories

OSHA's guidance for protecting workers in non-clinical/research laboratories, where laboratory samples may contain higher concentrations of BA or its spores, follows BSL-3 controls and practices, as described in the BMBL.

Engineering Controls

Use Vertebrate Animal Biosafety Level Criteria (ABSL-2) practices, containment equipment, and facilities for studies involving experimentally infected laboratory rodents.

Use Class III BSCs for work involving high concentrations of cultures, for screening environmental samples (especially powders) from anthrax-contaminated locations, and for activities with a high potential for aerosol production. Class III BSCs are gas-tight enclosures incorporated with gloves, non-opening windows, and mechanisms for decontaminating equipment and samples. Exhaust air from Class III BSCs passes through two HEPA filters, or a HEPA filter and an air incinerator, before releasing outdoors.

Administrative Controls & Safe Work Practices

Limit access to the animal facility. Authorize only workers required for program or support purposes to enter the facility and the areas where BA and/or animals are housed or handled.

Use BSL-3 facilities for work involving high concentrations of cultures, for screening environmental samples (especially powders) from anthrax-contaminated locations, and for activities with a high potential for aerosol production. BSL-3 work practices build on the BSL-2 work practices and include, among other things, the requirement to place materials potentially infected with BA in durable, leak- proof containers during collection, handling, processing, storage, or transport within a facility.

Some lab workers may meet the criteria for vaccination as outlined in the CDC Advisory Committee on Immunization Practices (ACIP) recommendations for Use of Anthrax Vaccine in the United States. See the Medical Information page for more details.

See the Training section, below, for information about worker training.

Personal Protective Equipment

Wear laboratory coats, gowns, or uniforms when working in laboratories handling BA-infected rodents to prevent contamination of personal clothing.

Wear nitrile or vinyl gloves to prevent skin contact with BA-contaminated materials, and when handling animals. Gloves for workers handling animals that may bite should also provide bite protection.

Use eye, face, and respiratory protection in rooms containing infected rodents, based on the risk of exposure.

PPE for research laboratory workers may include dedicated work clothing, such as surgical scrubs under PPE, dedicated washable footwear, double gloves, face protection, eye protection (e.g., disposable full-face shield), single-use lab coat, and shoe/boot cover.

Remove all PPE in a manner that prevents transfer of infectious materials to clean areas.

Use a NIOSH-approved N95 (or higher) respirator at BSL-3, including when conducting procedures that may generate aerosols.

When using a BSC, remove the outer pair of gloves before exiting the BSC, and don a new pair each time reentering the BSC.

If a Class III BSC is not available, or work cannot be done in a Class III BSC, a full-body, air-supplied positive-pressure suit should be worn.

Training

The OSHA Fact Sheet, Laboratory Safety Biosafety Cabinets (BSC) provides guidance on training and effective use of BSCs.

Further Information

The CDC's Biosafety in Microbiological and Biomedical Laboratories (BMBL), 5th Edition provides detailed guidance on BSLs in Section IV - Laboratory Biosafety Level Criteria.

For additional information, see Recommended Specimens for Microbiology and Pathology for Diagnosis: Inhalation, Cutaneous, and Gastrointestinal Anthrax.

The WHO resource, Laboratory Biosafety Manual - Third Edition, contains additional practical guidance on biosafety techniques for use in laboratories at all levels.

The recommendations made by the CDC-convened Biosafety Blue Ribbon Panel, entitled Guidelines for Safe Work Practices in Human and Animal Medical Diagnostic Laboratories provides science-based guidance to address the unique operation needs of diagnostic laboratories and includes recommendations that supplement BMBL-5.

OSHA's Laboratory Safety Guidance contains an entire chapter on biological hazards, including anthrax which employers and laboratory workers may find useful.

Workers involved in emergency response operations to intentional or accidental releases of BA are also at risk of exposure. Potentially affected first responders include police officers and other law enforcement personnel, firefighters, emergency medical services (EMS) workers, and others who are responsible for responding to bioterrorism/criminal acts or accidental releases of anthrax.

Employers whose workers will be involved in emergency response operations for releases of, or substantial threats of releases of, hazardous substances regardless of the location of the hazard must comply with OSHA's HAZWOPER standard (29 CFR 1910.120). This may include emergency response following an anthrax incident. Instruction CPL 02-02-073 describes OSHA enforcement procedures under the relevant provisions of the HAZWOPER standard.

The U.S. Environmental Protection Agency (EPA) has promulgated a standard applying OSHA's HAZWOPER standard to state and local government workers in states where there is no OSHA-approved State Plan. See 40 CFR Part 311.

In addition to the General Guidance, applicable to all workers, and provided at the beginning of this page, OSHA also recommends the following controls for first responders:

Engineering controls

Place impermeable physical barriers or use other methods to isolate contaminated areas and objects.

Implement dust control measures, such as water mist, if needed to reduce the risk of re-aerosolization of settled infectious materials.

For medical transport workers in ambulances or other vehicles: If there is visible evidence of powder on a patient, close the door/window between the driver/patient compartments before bringing on-board a patient with suspected anthrax or BA exposure. Minimize air flow as much as possible in the patient compartment. Vehicles that have separate driver and patient compartments and can provide separate ventilation to these areas are preferred for transport of these types of patients. If a vehicle without separate compartments and ventilation is used, the outside air vents in the driver compartment should be open, and the rear, exhaust ventilation fans turned on at the highest setting to provide a gradient of negative pressure in the patient care compartment.

Administrative Controls & Safe Work Practices

If possible, deploy first responders previously vaccinated against anthrax.

Follow standard precautions (as well as contact and aerosol precautions, as appropriate, based on work tasks and visible evidence of powder on the patient).

If possible, decontaminate patients before transporting them for medical care in order to reduce contamination of ambulances, other transport vehicles, and receiving facilities.

Avoid activities that increase air movement and potentially re-disperse settled spores into the air.

Sharing of information during transfer of patient care from the medical transport team to HCWs in a receiving facility is critical for effective infection prevention and control. When transporting a patient with visible evidence of powder on skin or clothing, transport workers need to convey this information to the receiving healthcare facility in advance, if possible, or immediately upon arrival to ensure that the receiving facility is ready to implement appropriate isolation and decontamination procedures.

Decontaminate vehicles as soon as possible after transporting a patient with suspected anthrax or BA exposure. See the General Guidance on cleaning and disinfection provided. When cleaning the interior of ambulances and other transport vehicles, do not use compressed air or water sprays, as these techniques may re-aerosolize anthrax spores.

Clean non-patient-care areas of the vehicle according to standard employer protocols.

Clean and disinfect patient-care compartments (including stretchers, railings, medical equipment, control panels, and flooring, walls and work surfaces in accordance with recommendations for disinfection specified in the General Guidance section.

Ensure that facilities are available for decontaminating workers responding to an anthrax release. Depending on the level of contamination, this may require establishment of a decontamination line. For isolated releases, facilities for showering and changing clothes after response and clean-up activities may be sufficient. If at all possible, remove shoes prior to leaving the worksite and launder clothes on site using detergent and hot water. Avoid laundering potentially contaminated clothing at home to prevent taking BA spores home.

See the Training section, below, for information about worker training.

Personal Protective Equipment

The type of personal protective equipment (PPE) needed for effective protection depends on different response situations, what is known or unknown about the situation, and the potential risk.

As stated above, the HAZWOPER standard is performance-oriented and requires the selection and use of PPE to be proportional to the anticipated risk of exposure and appropriate to the nature of the anticipated hazard. For example, security personnel are first responders if their task involves securing the area where there is a suspected release of BA spores. These workers may be first responders at either the "awareness" or the "operations" level depending on the tasks involved. Security personnel fall under the "first responder's awareness level" if they will not take any actions other than to cordon off the affected area and/or initiate the emergency response sequence. Security personnel required to close doors, physically isolate the area, or take any other defensive action fall under the "first responders at the operations level."

Full-facepiece APRs with N100 (or P100) filters or full-facepiece PAPRs with HEPA filters offer protection against inhalation exposure to BA spores during the conduct of high-risk activities, such as environmental sampling and remediation activities. When there is an ongoing release of BA spores from an aerosol-generating device or when the agent is unknown, workers need higher levels of protection, such as chemical, biological, radiological, and nuclear (CBRN)-rated self-contained breathing apparatus (SCBAs).

Depending on their specific tasks, first responders may need some level of protection from dermal exposure, such as disposable hooded coveralls, gloves, and foot coverings. In some settings, however, changing the outer layer of clothing may be sufficient.

EMS workers involved in direct patient care should use the same PPE recommended for healthcare workers throughout triage and transport of a patient with suspected exposure to BA.

Responders riding in the patient compartment of the vehicle should wear an N-95 respirator (or higher) if there is visible evidence of powder on the patient. If the driver compartment cannot be closed off from the patient-care compartment, drivers also need to wear N-95 (or higher) respirators. Drivers assisting with direct patient care, including moving patients on stretchers, should wear all other recommended PPE for healthcare workers. Employers should monitor the driver's use of respirators to ensure that the respirator does not restrict the worker's ability to operate a vehicle safely.

When patient care is completed or when items are soiled or damaged, remove and discard PPE in accord with procedures for handling infectious waste, described in the General Guidance section.

Personnel who clean the patient-care compartment of emergency vehicles should wear gloves, chemical-resistant or - impermeable suits, and eye protection.

Training

See the General Guidance section for general information on worker training.

OSHA's HAZWOPER Safety and Health Topics page explains requirements of the OSHA HAZWOPER standard, including worker training.

For additional information about emergency responders and training levels, please refer to Inspection Procedures for 29 CFR 1910.120 and 1926.65, Paragraph (q): Emergency Response to Hazardous Substance Releases.

Further Information

See the Guidance for Protecting Responders' Health During the First Week following A Wide-area Aerosol Anthrax Attack for specific information on measures to minimize responders' exposure to B. anthracis spores after a terrorist/criminal act involving BA.

NIOSH provides emergency response resources to help emergency responders prepare for critical events, including potential exposure to biological agents and infectious diseases, such as anthrax.

Also see Interim Recommendations for the Selection and Use of Protective Clothing and Respirators Against Biological Agents for help in determining whether existing health and safety precautions are adequate for protection against BA exposure during emergency situations.

Bioterrorism/criminal acts involving the shipment of BA spores via U.S. mail or private delivery or courier services, as well as worksite contamination where such articles are processed, delivered and opened, have increased the risk of occupational exposure for jobs involving package and mail handling. These jobs include jobs in post offices, mail and package distribution/handling centers, bulk mail centers, air mail facilities, public and private mailrooms (e.g., in office buildings), and other settings in which workers are responsible for the handling and processing of mail and packages.

Cutaneous (skin) exposure may result from handling contaminated packages or envelopes.

Inhalation exposure may occur from machinery that generates aerosolized particles as it handles contaminated packages or envelopes. Employers must protect workers who operate, maintain, or work near such machinery from inhalation exposure. This includes workers who hand-sort mail or work at other sites with the potential for airborne particle generation (e.g., where mailbags are unloaded or emptied).

It is critically important that all such worksites develop an emergency plan describing appropriate actions to take when a known or suspected exposure to BA occurs. The scope of the emergency plan and the procedures it includes may be based on an employer's risk assessment. For example, mail handling workers in facilities that are likely to be the targets of intentionally contaminated packages or letters may need more robust emergency plans. Select the measures included in the plan based on an initial evaluation of the worksite. Focus this evaluation on determining which processes, operations, jobs, or tasks would be most vulnerable to an exposure if a contaminated envelope or package enters the worksite.

Employers also should designate individuals who are trained to respond in the event that a worker receives a suspicious mailing. At a minimum, the designated responders should know how to contact facility managers, local emergency responders, and local law enforcement officials. Additionally, the designated responders should have authority to secure potentially contaminated areas or to direct other individuals to do so and limit the movement of potentially exposed/contaminated workers and visitors within the facility. Protecting trained responders may also involve the recommendations for control measures in the sub-sections below or in the other worker-specific sections of this page (e.g., guidance for first responders or clean-up workers).

NOTE: While much of the guidance presented in this section directly relates to mail and package handlers, employers may also find this information useful for administrative workers who open office mail and packages.

OSHA offers recommendations for assessing workplace risk and determining prudent work practices and PPE in the Anthrax in the Workplace Risk Reduction Matrix.

Engineering controls

Aerosolization of BA spores may occur during the operation and maintenance of high-speed, mail-sorting or other package processing machines, creating potential exposure to workers operating these machines. These operations also create the potential for spores to enter heating, ventilation, and air-conditioning (HVAC) systems, resulting in exposure to ancillary workers as well. Engineering controls are the best option for preventing worker exposure to potential aerosolized particles and reducing the risk for inhalational anthrax.

When using mail-sorting machines, clean the machines using an industrial vacuum cleaner equipped with a HEPA filter.

Consider installing local exhaust ventilation at pinch roller areas and HEPA-filtered exhaust hoods in areas where there is dust generation. Air curtains (using laminar air flow) also can provide isolation for areas processing large amounts of mail. HEPA filters placed in the building's HVAC systems are useful to eliminate re-circulation of aerosolized spores.

Implement procedures for rapid detection (i.e., biohazard detection systems) for real-time identification of aerosolized BA spores in an air sample. Located on or near incoming mail or package processing equipment, biohazard detection systems allow timely identification of contamination, preventing inhalation anthrax through early recognition of and response to an exposure situation (e.g., immediate on-site decontamination of workers and post-exposure treatment).

The U.S. Postal Service (USPS) FAQ: What is the USPS^® Biohazard Detection System? offers more information on rapid detection systems.

Administrative Controls & Safe Work Practices

Establish handling and screening procedures for mail in all mail handling and packaging worksites.

Instruct mail handlers to:

• Be on the lookout for suspicious envelopes or packages.
• NOT open suspicious mail.
• Open all non-suspicious mail with a letter opener or another method that minimizes skin contact with the mail and is least likely to disturb contents.
• Open mail with a minimum amount of movement.
• NOT blow into envelopes.
• Keep hands away from nose and mouth while opening mail.
• Turn off fans, portable heaters, and other equipment that may create air currents.
• Wash hands after handling mail.

When encountering a suspicious piece of mail, adhere to the following procedures:

• DO NOT open the package or letter.
• DO NOT shake, empty, or otherwise disturb its contents.
• Put the package down and do not handle it further.
• DO NOT touch or try to clean up the substance.
• Alert others nearby.
• DO NOT remove ANY items from area.
• Leave the area and gently close the door, and then:
  • Wash hands well with soap and water.
  • Contact your supervisor, designated responder or other appropriate authority.
  • Limit movements within the building to prevent spread of substance.

See the Homeland Security Response Checklist for steps to take when encountering a suspicious package.

Restrict entry into and limit the number of persons working at or near sites with potential for aerosolized particle generation (such as mail-sorting machinery or areas where emptying and unloading of mailbags occurs).

Follow proper procedures and work practices during maintenance of machinery to protect workers from other injuries.

Do not use compressed air to clean machinery. Avoid dry sweeping and dusting of all areas with potential for aerosolized particle generation. Use wet-cleaning methods and vacuum with HEPA-equipped vacuum cleaners.

After a release of anthrax, such as BA being used as a biological weapon, ensure that adequate facilities are available to workers for washing and changing clothes prior to leaving the worksite. Also, remove shoes prior to leaving the worksite and launder clothes on site using detergent and hot water.

See the Training section, below, for information about worker training.

Personal Protective Equipment

Base PPE selection (e.g., gloves, smocks, eye protection, respiratory protection) for workers in mail and package handling/processing worksites on the potential for cutaneous or inhalation exposure to BA spores (e.g., the amount of mail a worker handles, how he or she handles the mail, and where he or she works). Factors to consider when determining PPE selection include the nature of the workplace and amount of mail received; whether the facility receives mail directly from a USPS facility with a higher risk of receiving contaminated mail; and whether the facility uses equipment that might disperse dust or anthrax spores into the air. Employers may rely on information from local, state, and federal authorities (e.g., the U.S. Department of Homeland Security National Terrorism Advisory System), their own biohazard detection systems, and other information in order to characterize threat levels upon which to base risk assessment and PPE decisions.

Thorough risk assessment, biohazard detection systems, and other controls (e.g., those discussed in the engineering and administrative controls and work practices subsections, above) can reduce the risk of anthrax exposure and the need for certain types of PPE. However, depending on threat levels for a release, workers working with or near machinery that is capable of generating aerosolized particles (e.g., electronic mail sorters) or at other worksites potentially generating such particles, may require NIOSH-approved respirators that are at least as protective as an N95 respirator. In these cases, respirators must be used in the context of a comprehensive respiratory protection program that includes medical exams, training, and fit-testing. For day-to-day operations when there is no reason to suspect BA contamination of the workplace or packages and mail; remove PPE prior to leaving the work area and discard single-use PPE as regular trash. When an incident occurs involving a suspicious piece of mail, dispose of the worker's protective gear as a potentially contaminated material, and place the PPE in an appropriately labeled and/or color-coded container that is closable and leak-proof. Dispose of the container as infectious/regulated waste.

See the General Guidance section for more information on PPE selection, respiratory protection, and establishing a respiratory protection program that complies with the provisions of OSHA's Respiratory Protection standard (29 CFR 1910.134).

Training

Training is essential to ensure worker protection and safety from potentially contaminated mail. Train mail and package handlers in basic security procedures, suspicious package recognition, and reporting, proper use of PPE, safe work practices, and procedures relating to their specific job tasks. The USPS Mail Security Center page contains links to FAQs, posters, and best practices that can be useful in developing training programs for package and mail workers.

The characteristics of suspicious packages and letters include:

• Discoloration, oily stains, or an unusual odor
• Crystals, powder, or powder-like residue on the surface
• Suspicious or threatening language on the outside of package or letter
• Postmark that does not match return address or no return address
• Restrictive endorsements such as "Personal" or "Confidential"
• Distorted handwriting, block-printed or poorly typed addresses
• Excessive tape or string
• Rigid, uneven, irregular, or lopsided package
• Package with soft spots, bulges, or excessive weight
• Handwritten, block-printed or poorly typed addresses
• Excessive postage
• Title but no name or incorrect title
• Misspelled addressee's name, title, or location
• Misspelled common words
• Addressee unknown or no longer with organization
• Protruding wires or aluminum foil
• Ticking sound
• Unexpected mail from a foreign country

Further Information

Designated responders or other appropriate authority will determine the need for further action, which may include:

• Directing further evacuation.
• Reporting the incident to building security and notifying the appropriate authorities, such as the local police or federal authorities.
• Perform additional decontamination activities as directed by the proper authorities.
• Reporting the incident to facility managers so they can cut off electrical power and shut down ventilation systems serving the potentially contaminated areas.
• Compiling a list of the names of all potentially affected individuals, including those who were in area when the suspicious mail was encountered.
• Providing this list to the appropriate authorities.

The U.S. Postal Service poster Suspicious Letters or Packages graphically illustrates some of the characteristics of a suspicious letter or package.

The U.S. Postal Service guidance U.S. Postal Inspection Service Guide to Mail Service Security provides general advice and recommends protective measures to help mail and package workers assess, prevent, and respond to several types of mail-related threats including biological threats.

The Guidance on Initial Responses to a Suspicious Letter / Container With a Potential Biological Threat is a coordinated effort by various agencies to provide recommendations for local responders on the initial response to a suspicious letter/container, while other follow-on response plans, such as portions of the National Response Plan (NRP), may be used if a threat is deemed credible.

Workers whose jobs involve wild and domestic (e.g., cattle, sheep, goats, antelope, and deer) animals, animal hides, or animal fibers (e.g., workers who process hides, hair, bone and bone products and wool) are at increased risk for occupational exposure. These workers include veterinarians; animal breeders; hunters and trappers; slaughterhouse workers; fur industry workers; tanning and leather industry workers; and wildlife, agricultural, and laboratory workers who handle infected animals or specimens. Inhalation anthrax has also been associated with making drums from animal hides.7

While exposure risk for animal and agricultural workers is much higher in developing countries or countries without veterinary public health programs, workers in the U.S. in these jobs are at risk. BA spores can remain viable (i.e., able to cause diseases) in soil for many years. Infection in livestock occurs when an animal ingests (i.e., swallows) sufficient quantities of spores from the soil. For the most part, spores in soil do not pose a direct risk of infection for animal and agricultural workers. Disease in workers usually follows contact with contaminated carcasses or animal products. Animal and agricultural workers are at increased risk of exposure to BA when handling dead carcasses and bedding or other contaminated material, and when cleaning and disinfecting stables, pens, milking barns, and equipment used on livestock.

Engineering Controls

Ensure that the workspace is well-ventilated. OSHA recommends that workers processing products from animals have adequate ventilation systems, including local exhaust systems, to reduce dust levels.

Administrative Controls & Safe Work Practices

Arrange for veterinary supervision of animal production and slaughter to ensure animals are healthy and to minimize the risk of widespread anthrax infection among grazing animals.

Implement a program of routine pre-exposure vaccination for veterinarians, veterinarian workers, and workers who come into contact with imported animal hides, furs, bone meal, wool, animal hair, or bristles when standards and restrictions (e.g., disinfection of hides prior to shipment to tanneries) are insufficient to prevent exposure to anthrax spores.

Observe recognized good infection control practices to prevent exposure and spread of the disease as specified in the General Guidance section.

As appropriate, maintain a clean workspace. Use a high-efficiency particulate arrestance (HEPA) filter-equipped vacuum to clean workspaces, avoiding use of compressed air, dry sweeping, and shaking or beating of animal hides.

Do not remove objects from the workspace to prevent contamination of clean areas.

Employ procedures for rapid detection and reporting of animals suspected or confirmed to have anthrax, quarantine, treatment of asymptomatic animals (post-exposure prophylaxis) and burning/burial of deceased animals suspected or confirmed to have anthrax.

Dispose of potentially infected animal carcasses by burning or deep burial. Disinfect the premises and appliances with an EPA-registered disinfectant specific against BA. Never conduct a post mortem (after death) examination on an animal suspected of having anthrax.

The CDC Treatment of Products web page discusses different methods for processing hides that can reduce the BA exposure risk.

The CDC Advisory Committee on Immunization Practices advises against routinely vaccinating veterinarians in the U.S., due to the low incidence of animal cases in the U.S.

See the Training section, below, for information about worker training.

Personal Protective Equipment

Cover all exposed skin with clothing (pants, long sleeves). Keeping cuts and abrasions covered with bandages will also help prevent BA spores from entering those wounds.

Also see the CDC anthrax Web page Protection from Exposure for detailed information on worker protection from exposure to BA spores specific to working with animal hides.

Use appropriate personal protective equipment (PPE) as specified in the General Guidance section based upon the potential risk for exposure to BA spores.

Ensure that adequate facilities are available to workers for washing and changing clothes after work. Remove shoes prior to leaving the worksite and launder clothes on site using detergent and hot water.

Training

Inform workers who handle live animals and raw animal materials about modes of transmission for BA.

Train workers to report any suspicious symptoms immediately.

See the General Guidance section for more information on training workers.

Further Information

The CDC's People Who Handle Animal Products page contains information for animal workers on exposure to hides/drums, treatment of products, protection from exposure, importation of animal products and worker safety.

The World Health Organization (WHO) Guidelines for the Surveillance and Control of Anthrax in Humans and Animals provides useful information on the pathogenesis, pathology, treatment, control, and surveillance of anthrax.

This section provides control and prevention information for two categories of clean-up workers:

• Clean-up workers in small-scale decontamination operations such as may exist in healthcare facilities, laboratories, and small mailroom operations where workers are tasked with cleaning and disinfecting areas potentially contaminated with BA. Examples of situations involving small-scale clean-up include a specimen spill in a laboratory and cleaning a hospital room after decontaminating patients whose bodies or clothing were exposed to BA.
• Clean-up workers involved in large-scale decontamination operations from bioterrorist/criminal attacks or accidental releases of BA spores.

Clean-up Workers (small scale)

Engineering Controls

When feasible, use engineering controls, such as HEPA vacuums and local exhaust ventilation, to protect clean-up workers from exposure to BA during clean-up procedures.

Administrative Controls & Safe Work Practices

Immediately report to management any suspicious and/or unknown fine-powdered substances.

Isolate and clearly mark the immediate area where a spill or suspicious substance is located to keep other workers away from the area until first responders arrive.

Clean and disinfect environmental surfaces adhering to the General Guidance, Cleaning and Disinfection described.

Use recognized good infection control practices when cleaning small areas not grossly contaminated with BA and when encountering any suspicious, unknown, fine-powder substance.

Avoid touching, handling or removing, any suspicious, unknown, fine-powder substance until the substance has been determined by qualified experts to pose no threat to workers in the area. Stirring up a fine-powered substance containing anthrax spores increases the potential for airborne, inhalation exposure.

When cleaning a small area potentially contaminated with BA, do not dry sweep or dust the areas. Use wet-cleaning methods and vacuum with high-efficiency particulate arrestance (HEPA)-equipped vacuum cleaners.

Follow proper hand washing procedures after cleaning areas contaminated or potentially contaminated with BA.

See the Training section, below, for information about worker training.

Personal Protective Equipment

Select PPE based on the potential for exposure during clean-up. At a minimum, wear vinyl or nitrile gloves at all times when cleaning and disinfecting surfaces.

During cleaning operations, when the potential exists for exposure to BA spores through inhalation, use appropriate respiratory protection as specified in the General Guidance, Personal Protective Section above.

See the General Guidance section, Personal Protective Equipment for detailed information on PPE selection, use, handling, and disposal.

Training

Refer to the General Guidance section for detailed information on worker training.

Clean-up Workers (large scale)

OSHA's HAZWOPER standard (29 CFR 1910.120) applies to these operations. The HAZWOPER standard protects workers who respond to uncontrolled or emergency releases of hazardous substances and clean-up of sites contaminated with these substances. Under the standard, the definition of hazardous substances includes both chemicals and biological agents such as BA. Employers of clean-up workers responding to an uncontrolled or emergency release of BA must follow the HAZWOPER requirements for emergency planning, training, exposure monitoring, and exposure control through protective measures such as work practices and personal protective equipment (PPE).

Engineering Controls, Administrative Controls, and Work Practices

HAZWOPER requirements are performance-oriented and based on the risk anticipated in the clean-up task. Review HAZWOPER requirements and choose how to best apply the recommended controls for the specific BA clean-up operation. Employ appropriate engineering and administrative controls and work practices as necessary and feasible.

See the Training section, below, for information about worker training.

Personal Protective Equipment

Like the other requirements under HAZWOPER, the PPE requirements are performance-oriented. This means that the level of protection chosen, and the PPE used is proportional to the risk anticipated for the task. OSHA provides the following recommendations on PPE for clean-up workers:

Workers investigating suspected releases or cleaning up these types of releases may be able to respond in modified Level C protection. Level C PPE generally includes a full-face or half-mask, NIOSH-approved air-purifying respirator (APR); hooded chemical-resistant clothing (e.g., overalls; two-piece chemical-splash suit; disposable chemical-resistant overalls); and inner and outer chemical-resistant gloves. Depending on the hazard, modified Level C protection may include coveralls, outer chemical-resistant steel toe and shank boots with chemical-resistant boot covers, a hard hat, an escape mask, and/or a face shield. Employers also may need to provide enhanced respiratory protection, such as a full-face powered air-purifying respirator (PAPR) or self-contained breathing apparatus (SCBA). (Note: Adding a SCBA increases the PPE to Level B and additional training, fit-testing, and medical clearance requirements may apply.)

Use modified Level C protection during the investigation and clean-up of a known anthrax release where the agent dispersal occurred from a letter or package and is easily bagged. Under these conditions, no potential exists for splashing possibly contaminated materials.

Do not use modified Level C if the BA spores dispersal was from an aerosol-generating device (e.g., a garden duster), or no information exists about the BA spores' mechanism of release. Modified Level C should be consistent with the description in HAZWOPER Appendix B, but employees should wear a tight-fitting, full-face PAPR and skin protection with an integral hood and booties.

Releases of anthrax spores where there is no information about the potential source or dispersal method, or where the release is still occurring, require higher levels of protection as recommended in Modified A and B protection described below.

Use Level B protection during response to or clean-up of a release of BA spores dispersed with an aerosol-generating device that has stopped, or where there is a high potential for splashing possibly contaminated materials. Level B protection should be consistent with the description in HAZWOPER Appendix B. It requires the highest level of respiratory protection, but a lesser level of skin protection than Level A.

Use Level A PPE for response to or clean-up of a release involving an unknown dispersal method, a release involving an aerosol-generating device and the release is still occurring, or involving an aerosol-generating device where the release has stopped but no information exists about the duration of the release or the airborne concentrations of anthrax spores. Level A protection provides the greatest level of skin, respiratory, and eye protection. Level A protection should be consistent with the description in HAZWOPER Appendix B.

Use PPE that is equivalent to one level below what is required for the responder or clean-up personnel for those assisting in decontamination of emergency responders or clean-up personnel (e.g., if responder is in Level A, then decontamination personnel will be in Level B).

Training

Use only highly trained and qualified clean-up workers to clean sites contaminated with BA through accidental or intentional releases.

In accordance with OSHA's HAZWOPER standard (29 CFR 1910.120), all responders who enter a hazardous area, including an area where BA spores are present, must receive certain training. Federal OSHA does not cover state and local government workers. Emergency responders employed by state or local governments are covered either by OSHA-approved State Plans (which must have standards that are at least as effective as the Federal OSHA standards) or by the EPA's HAZWOPER standard (40 CFR Part 311). (The EPA standard adopts OSHA's HAZWOPER standard by reference.)

OSHA's HAZWOPER Safety and Health Topics page explains requirements of the OSHA HAZWOPER standard, including required worker training.

Further Information

OSHA's Workplace Risk Pyramid – Anthrax for additional information on BA response and clean-up operations.

OSHA's Model Health & Safety Plan (HASP) for Clean-up of Facilities Contaminated with Anthrax Spores provides model language acceptable to OSHA in meeting the requirements of the HAZWOPER standard (29 CFR 1910.120).