An attack on the United States using weaponized anthrax — although considered a low-probability event — would have a high impact on the affected communities. If left untreated, the death rate for those who inhale anthrax is more than 99 percent, according to the Military Vaccine Agency.
Anthrax, an acute infectious disease caused by spore-forming bacteria, can be used for biological warfare because the spores can be spread using missiles, artillery, aerial bombs and other methods, making it easily airborne. The good news is that oral medications can be used to treat people who have been exposed; however, the medication must be administered within 48 hours of infection. A bioterrorist attack would likely take place in a large, metropolitan area, and depending on wind speed and direction, the spores could travel hundreds of miles.
In response, state and local health departments are prepared to set up mass dispensing sites to distribute medication from the Centers for Disease Control and Prevention’s (CDC) Strategic National Stockpile to people who may have been infected. But the federal government sought additional methods to dispense the medical countermeasures, and in its planning found a partner in a program that visits nearly all U.S. residences Monday through Saturday — the U.S. Postal Service (USPS). The plan was put on the federal front burner in December 2009 when President Barack Obama signed an executive order stating: “The U.S. Postal Service has the capacity for rapid residential delivery of medical countermeasures for self-administration across all communities in the United States.” The order gave the USPS and U.S. Department of Health and Human Services (HHS) 180 days to create a national dispensing model for U.S. cities to respond to a large-scale anthrax attack.
The result was a program — the postal plan — that uses the nation’s letter carriers to deliver medical countermeasures. “The postal plan puts letter carriers on the street to deliver medications in the event of such an attack,” said Peter Nowacki, a USPS spokesman in Minneapolis. “Mail delivery would be curtailed, and they would just be going house to house delivering the medication along with information sheets telling people how to take the medication or whether they could take the medication.”
The postal plan was identified as a viable delivery method following an anthrax attack, because postal workers would be doing their everyday job, but with a different material.
“It’s something that enhances the existing capabilities to do the distribution and goes further to helping protect our American people in the event of this kind of crisis,” said John Koerner, chief of the Chemical, Biological, Radiological, Nuclear and Explosives Branch within the HHS’ Division of Preparedness Planning.
The “postal plan,” as people working on the initiative call it, is being tested in the Minneapolis/St. Paul area for locations within the ZIP codes beginning with 551 and 554. The plan is part of the CDC’s Cities Readiness Initiative (CRI), which enhances preparedness in the nation’s largest metropolitan areas and has developed a set of strategies for the rapid delivery of preventive medication to people living in major metropolitan areas following a biological attack. Although the executive order was issued in late 2009, the CRI began in 2004. Cities are selected based on criteria, including population and potential vulnerability to a bioterrorism threat.
The question that comes to many minds is why focus on anthrax when there’s a broad spectrum of potential biological weapons. “The CDC has identified a criteria list of certain agents that we could anticipate being used for such purposes,” Koerner said, “and some of the intelligence and other information we have suggest that if one is going to be used, anthrax is, for a number of reasons, probably the likeliest agent.”
Before the president called for the creation of a national dispensing model in 2009, proof-of-concept exercises had been conducted in Boston, Philadelphia and Seattle. During the exercises, letter carriers delivered mock antimicrobial agents to 20,000, 40,000 and 50,000 separate housing units in each jurisdiction, Koerner said.
“The process went well, and it took only about six to nine hours for them to cover their route and make sure all those folks — the 20, 40 and 50 thousand — received their mock antibiotics in a timely fashion,” he said. “The proof of concept showed that it can work.”
The planning regiment that was used in the drills was applied to the Minneapolis/St. Paul area’s postal plan. USPS representatives visited some post offices within the 551 and 554 ZIP codes and spoke with managers, letter carriers and delegates from the letter carriers’ union to outline the program and its expectations, as well as enlist volunteers to participate in the pilot, Nowacki said.
Before the volunteer postal workers began training, they completed a medical screening to ensure that they could ingest the antibiotics and were fitted for safety equipment. Volunteers were trained on what types of safety equipment to wear; where they’d report if called upon to distribute the medication; what their specific assignments would be; and the procedures for obtaining the medication, loading it into their vehicles and how to deliver it.
About 400 people — including letter carriers, USPS supervisors and public health representatives — in the Minneapolis/St. Paul area are participating in the pilot program, Nowacki said.
Jude Plessas, executive manager of counter- measures delivery and distribution at USPS Headquarters, stressed that this project requires collaboration and participation from all the
parties involved. “If one party decides that they’re not interested in pursuing this, we basically have to pick up our tents and go home,” he said. “But what we saw in Minneapolis/St. Paul was really an extraordinary collaboration between the Postal Service, Health and Human Services, the public health departments — principally the Minnesota Department of Health, which is the regional planning lead — and also law enforcement agencies, because we require security for our volunteer carriers as they’re performing this mission.”
The cities approached the USPS about participating in the postal plan when the concept was floating around, Plessas said, adding that the Minnesota Department of Health looked at its dispensing network and determined it needed methods to supplement its primary distribution model: mass dispensing sites.
In an anthrax attack in the area, most residents would receive antibiotics by visiting a mass dispensing site, which will be located throughout the metropolitan area, according to Buddy Ferguson, a risk communication specialist with the Minnesota Department of Health. “However, initially we also may activate the postal plan and have postal personnel deliver antibiotics to addresses in selected high-density, highly populated ZIP codes,” he said, “basically so we can take some of the pressure off the mass dispensing sites.”
Although some people will receive the pills through the mail service, affected individuals will need to visit a dispensing site at some point. Each household will initially receive 20 pills, Ferguson said, but individuals exposed to anthrax must take the medication for 60 days. Also, people who cannot take doxycycline — “the first-choice antibiotic” according to Ferguson — will have to visit a mass dispensing site to obtain alternative medication.
“If we can get everyone started within 48 hours, that’s the goal,” he said. “That’s what we would need to do to prevent the very serious outcome that we would see if there were a mass attack using airborne anthrax.”
As of press time, the Minneapolis/St. Paul area had yet to complete an on-the-ground test of putting letter carriers on the street delivering mock antibiotics, but the plan is in place and ready for execution. “Right now in Minneapolis/St. Paul, the plan — at least for the first sector in 20 ZIP codes — is operational,” Plessas said. “If we received the call from the Minnesota Department of Health and the governor made the request, we would follow through on bringing carriers in and we would perform the mission.”
Before the postal program is expanded to other cities, another pilot will take place in Louisville, Ky. Plessas said the city, like the Minneapolis/St. Paul area, completed a strategic security plan, and the USPS is working with Louisville officials on the initiative.
“We would like to take some lessons learned from what we went through in Minneapolis/St. Paul and tweak a few things when it comes to the solicitation process, screening process and overall planning process,” he said. “So Louisville will probably be our bridge between the pilot and full program implementation.”
However, as with all initiatives during this economic climate, the program’s future depends on funding. There’s very little funding available for the postal program, Plessas said, and it costs money to screen and train volunteers, equip delivery units with supplies, and exercise the plan. It should also be noted that none of the funding for this initiative comes from stamp sales — it’s funded through HHS appropriations in the annual budget. “If they continue to show up and we can continue to put together that selection process,” Plessas said, “we should be able to expand it to other cities.”
Many major municipalities already have contacted the HHS about the postal program, Koerner said, and he urged interested localities that want to participate to do the same. “The idea is that over the next couple of years we’ll expand this particular program to help supplement, augment and enhance whatever is existing in a locality,” Koerner said.
Jurisdictions that aren’t included in the Centers for Disease Control and Prevention’s Cities Readiness Initiative, which develops preparedness programs in large cities and metropolitan areas, can still actively equip their agencies for a bioterrorist event like an anthrax attack. John Koerner, chief of the U.S. Health and Human Service’s Chemical, Biological, Radiological, Nuclear and Explosives Branch, said the first piece in preparing for such an emergency is to ensure that jurisdictions’ planning is evidence-based by using existing experience and expertise to inform plans and processes.
He recommends the department’s Public Health Emergency website, www.phe.gov, as a reference for planning and preparedness. An anthrax playbook on the website offers a high-level description of what the federal response to an anthrax attack looks like and planning factors that must be identified.