Intended Recipients	Rationale	Recommendations
Worksite safety officer and welding employer	B. tropicus containing anthrax toxin genes was detected in a soil sample at patient A’s worksite, and it was a genetic match to the patient’s clinical isolate. Multiple other environmental samples tested real-time PCR-positive for the anthrax toxin genes. Therefore, the bacteria were still present at the worksite at the time of sampling and may pose a public health risk.	Use a labor-management health and safety working group to discuss these recommendations and develop an action plan. Those involved in the work can best set priorities and assess the feasibility of the recommendations for the specific situation at this workplace. Helpful guidance can be found in “Recommended Practices for Safety and Health Programs”: https://www.osha.gov/shpguidelines/index.html. Educate employees and contractors on hazards associated with welding and Bacillus cereus group bacteria expressing the anthrax toxin genes and train them on measures to help minimize potential exposures and recognizing signs and symptoms of inhalation anthrax-like illness. Conduct a hazard assessment for all welders and welding supervisors at this worksite, given the apparent link between this bacterium and welders/metalworkers. Additional guidance on welding safety may be found in the OSHA Fact Sheet “Controlling Hazardous Fume and Gases during Welding”: https://www.osha.gov/Publications/OSHA_FS-3647_Welding.pdf. Require all employees and contractors to always wash their hands before eating, drinking, or smoking, and each time they leave the workplace. Do not allow employees to consume or store food or drink in work areas. ◦ Ensure that employees have adequate break areas—separated from work areas by closed doors—for eating, drinking, and storing food. Avoid dry sweeping and avoid use of compressed air to clean dust, dirt, and other debris off work surfaces, tools, and equipment. ◦ Use a vacuum equipped with a HEPA filter or wet cleaning methods to clean surfaces. ◦ Provide, at a minimum, annual training to ensure compliance with approved cleaning practices. Provide a dedicated space for employees and contractors to change in and out of their work clothing to reduce the risk of taking contaminants home. Encourage employees and contractors with possible work-related health concerns to talk to their healthcare provider about their exposures at work. Offer smoking cessation programs at no cost to employees and contractors. Encourage those who smoke to participate in smoking cessation programs. Smoking cessation may decrease respiratory symptoms worsened by workplace exposures.
Family members sharing residence with patient A	Multiple environmental samples of work-related clothing and gear at patient A’s residence tested real-time PCR-positive for the anthrax toxin genes. Given that B. tropicus containing anthrax toxin genes was detected in a sample at the worksite and was a genetic match to the patient’s clinical isolate, it is possible these items were contaminated with the same bacteria that caused patient A’s illness and may pose a public health risk.	Family members may choose to keep or discard patient A’s work-related clothing and gear. If anyone is discarding any of these items, they should wear disposable gloves and place the items into a sealed plastic bag. The bag should be placed outside, preferably in a garbage bin, and thrown away with regular household garbage. After anyone handles the bag, they should remove their gloves by turning them inside out and dispose of them, and then wash their hands with soap and water [32]. If keeping any items, the following steps to safely clean them are recommended: Work clothing: Wearing disposable gloves, place any unwashed clothing into a sealed plastic bag until the clothes can be placed directly into a washing machine. The clothing can be washed as normal using laundry detergent. Work boots: Wearing disposable gloves, wash the boots with soap and water and remove any dirt or debris with a brush or sponge. Then spray the exterior of the boots with a 10% bleach solution * (one-part regular household bleach to nine-parts water) and let it sit for at least five minutes before wiping them clean. Work lunch cooler and other items: Wearing disposable gloves, spray the exterior with a 10% bleach solution * (one-part regular household bleach to nine-parts water) and let it sit for at least five minutes before wiping it clean. Hand hygiene: After anyone handles these items, they should remove their gloves by turning them inside out and dispose of them, and then wash their hands with soap and water [32]
* A 10% bleach solution was preferred over pH-adjusted bleach for safe use outside of a laboratory setting and was deemed adequate for disinfection of environmental surfaces. The resulting concentration of chlorine should be at least 5000 parts per million (ppm).