Health Advisory
RICIN AT SOUTH CAROLINA U.S. POSTAL FACILITY

The United States Postal Service (USPS), Centers for Disease Control and Prevention (CDC), and law enforcement agencies have identified ricin in an unmarked, sealed envelope at a USPS facility in South Carolina. The envelope contained an unsigned, threatening note. Federal authorities do not believe this to be an act of terrorism and there is no apparent public health threat at this time.

Ricin is extremely toxic. Exposure may be fatal. Symptoms and treatment depend on route of exposure as described below.

Agent

• Toxin distilled from by-products of castor bean processing into castor oil.
• Potential terrorism uses: aerosol release, food contaminant for ingestion, or via injection into tissue.
• Blocks protein synthesis at the cellular level causing cell death.
• colorless, odorless, and tasteless.
• The organ systems affected and time to onset depend on the route of exposure. (See signs/symptoms)

Signs and Symptoms

• Inhalation may begin to cause effects in the respiratory tract in 3-8 hours or up to 24 hours.
  • Initial symptoms are cough and tightness in the chest.
  • Patients may have nausea and generalized muscular aching.
  • Progressive inflammation of the airways follows over the next few hours.
  • Pulmonary edema and cyanosis are late findings.
• Ingestion would cause GI bleeding within hours producing both blood in the vomit and bloody diarrhea.
  • Liver and kidney failure follow over the next few days.
  • Damage to the spleen may also be seen as a delayed complication.
• Injection may take 1-2 days to produce local inflammation and lymphadenopathy.
  • Rapid systemic progression with liver and kidney failure may follow.
• Skin or eye exposure may be an irritant but will not produce systemic signs of poisoning.
• In severe poisonings, illness progresses to multi-system organ failure 36-48 hours after symptom onset and may lead to death.

Transmissibility

• Not a transmissible illness from person to person. Patients who have toxin on their person may present a risk to health providers by transfer of toxin.

Protective Measures Required

• Respiratory precautions only. Ricin is not dermally active. Patients presenting after-acute exposure to liquid or aerosol may be decontaminated.

Samples Requested for Evaluation

• There is no rapid, reliable test for the presence of Ricin toxin nor is any test available to exclude Ricin exposure.

Prophylaxis

• None

Candidates for Outpatient Evaluation

• Those patients who do not have signs of illness but are concerned they may have been exposed can be interviewed, examined, and given reassurance (if no signs of illness) or referred for re-evaluation or treatment (if ill or at risk).

Treatment For Those With Possible Signs Of Illness

• No definitive cure available; supportive care directed at the system exposed to the toxin.
• Inhalation exposures require respiratory support possibly including positive pressure ventilation.
• Acute ingestions may benefit from cathartics or GI lavage.
• Activated charcoal is not effective.
• Antibiotics have no effect on the toxin.
• Inpatient care or monitoring required:
  • Monitor patients with potential exposures who have mild symptoms (no respiratory distress) that may or may not represent Ricin poisoning. These patients can be discharged in 24-36 hours if their symptoms do not progress.
• Hospital admission is reserved for the most seriously ill patients.
  • Patients with any signs of respiratory distress should be admitted to a hospital as their condition can deteriorate rapidly and require ventilatory support.
  • Patients with severe GI bleeding or hemodynamic instability should also be admitted to the hospital.

Concerns of General Public

Unaffected patients and others in the general community who may hear news reports of this incident and concerned about their potential exposure should be advised as follows:

• There is no known public health threat at this time.
• It is prudent at all time to be aware of suspicious mail. Some characteristics of suspicious packages and envelopes include the following:
  • Inappropriate or unusual labeling
    • Excessive postage
    • Handwritten or poorly typed addresses
  • Misspellings of common words
  • Strange return address or no return address
  • Incorrect titles or title without a name
  • Not addressed to a specific person
  • Marked with restrictions, such as "Personal," "Confidential," or "Do not x-ray"
  • Marked with any threatening language
  • Postmarked from a city or state that does not match the return address
  • Appearance
    • Powdery substance felt through or appearing on the package or envelope
    • Oily stains, discolorations, or odor
    • Lopsided or uneven envelope
    • Excessive packaging material such as masking tape, string, etc.
  • Other suspicious signs
    • Excessive weight
    • Ticking sound
    • Protruding wires or aluminum foil
  • If a package or envelope appears suspicious, DO NOT OPEN IT.
• Handling of Suspicious Packages or Envelopes
  • Do not shake or empty the contents of any suspicious package or envelope.
  • Do not carry the package or envelope, show it to others or allow others to examine it.
  • Put the package or envelope down on a stable surface; do not sniff, touch, taste, or look closely at it or at any contents which may have spilled.
  • Alert others in the area about the suspicious package or envelope. Leave the area, close any doors, and take actions to prevent others from entering the area. If possible, shut off the ventilation system.
  • WASH hands with soap and water to prevent spreading potentially infectious material to face or skin. Seek additional instructions for exposed or potentially exposed persons.
  • If at work, notify a supervisor, a security officer, or a law enforcement official. If at home, contact the local law enforcement agency.
  • If possible, create a list of persons who were in the room or area when this suspicious letter or package was recognized and a list of persons who also may have handled this package or letter. Give this list to both the local public health authorities and law enforcement officials

For More Information

• The Delaware Division of Public Health is monitoring this situation carefully and will advise the Delaware health care community of any concerns through the Delaware Health Alert Network.
• Attached to this advisory are information sheets suitable for posting for health care personnel and first responders, respectively.
• CDC Ricin Website: http://www.bt.cdc.gov/agent/ricin/index.asp
• DPH: 1-888-295-5156. This number is available during normal business hours and during non-business hours for emergencies.