Posted on 09/22/2001 8:20:51 AM PDT by Nita Nupress
He was worried only about herpes vaccinations.
Nita, do we even have a Civil Defense department any more? If not, is Civil Defence going to be under this new department Tom Ridge is heading (with Gary CONDIT?? on the committee) for homeland defense?
Call me selfish, but although I do not want to see anything happen to those brave souls in our military, I'm a mite interested in seeing that at least something is done to protect the lives of civilians. The prevention of pocket knives and nail clippers being carried on airplanes somehow just doesn't cut it.
I'm almost sure programs are running. But since nobody has ever hit the US with an anthrax or smallpox attack, I'm still believing it isn't as easy as some people are making it sound out to be. The press (and some people here) make it sound like anyone can make it in their basement and kill a hundred thousand people with it. And the Tokoyo guys spent millions researching and making sarin, but only managed to kill 12 people with it. It seems like successfully deploying chemical or biological weapons to kill a lot of people still requires a significant amount of technical expertise.
The most difficult part, and that nobody apparently has a solution for yet, is getting the agent into an aerosol solution so it can be easily sprayed. Just creating large amounts of the agent is simple, and a load of botulinum toxin, for instance, could be used to poison pretty much anything, from rivers to individuals.
So it seems like the flaw in your plan below is equipping the crop dusters with sprayers that can handle anthrax (although I've heard other problems are converting the anthrax into a powder form, and judging wind conditions so it goes over a lot of people). As for the botulinum toxin problem, if it is that easy to poison rivers with it effectively, why hasn't any nut (not even Arab, but a pissed off biology student mad at life) done it yet?
Bill Gertz reported Russia built a bunker complex Bigger Than Washington, D.C. Inside The Beltway under Yamantau Mountain--illegal, so sue us, Americanskis.
Saddam has been the recipient of Russian largesse, and I posit he stashed it under his palaces, specifically right under the day care/children's hospital/formula factory/old folks' shelter.
Scott Ritter was hot on his trail--until Nose Where It Doesn't Belong JoJo Biden smacked Scott Ritter around on CSPAN--well, now, those decisions are made several pay grades above yours, sonny jim--
I suggest that the goodies which the moles may use will be top drawer--and don't you know, they could come in inside any of the millions of COSCO containers (that's China Ocean Shipping Company, as in ChiCom PLAN, not some warehouse for yuppie bargainhunters).
Time to cut our nuclear arsenal--drop ten per cent on Saddam's palaces. This stuff can't survive at thousands of degrees Kelvin--Kelvin, what's the frequency?
A nuke a day keeps Osama away, Dave.
The likely threat will not be any one form but rather a cocktail which would leave a signature for authorities to trace. In all likelihood the next bioterror event will come from Iraqi sources which developed the bugs by buying them mail order from the US. Scary thought.
The product name is Immunite it is a liquid that you mix with water 1 bottle of concentrate makes 24 gallons there is little or no taste..the main ingredient is Fulvic Acid outside of air and water Fulvic Acid is the building block of life....
IMHO if you agree it is of no use thinking that the government is going to protect you the best defense against biological weapons is by you having a strong immune system...you cannot hope to build your immune system by eating loads of fruit and vegetables...todays produce has little or no nutrients in them....long story
I am not saying that even if you have a strong Immune system that it protects you from biological I am saying that you will stand a better chance of surviving should a attack take place...PS...don't drink water unless it is treated....best for this British Berkfield I list my web page for no other reason than hope this offers an alternative plus a bunch of research.... failing that ... the next option.... build a bunker :-)
U.S. Department of Defense
News Briefing
Tuesday, September 4, 2001
Presenter: Victoria Clarke, ASD(PA)
[...]
Q: A different topic. Can you describe in any way the current efforts of the United States to conduct research into biological weapons and what the purpose of that research might be, and whether it falls within the confines of the Chemical -- Biological Weapons Convention?
Clarke: Again, we've said pretty consistently that we're very concerned about the threat of offensive biological weapons, of the proliferation of materials and technology that could enhance the proliferation of chemical and biological warfare. And we are doing work in places. All of the work is consistent with U.S. treaty obligations. All of the work is thoroughly briefed and gone through a heavy consultation process, both interagency and the appropriate legal reviews and the appropriate congressional briefings.
Q: What is the purpose of that research?
Clarke: The purpose is to protect the men and women in uniform and the American people from what we see is a real and growing threat.
Q: Does this research involve creating any germs in the laboratory?
Clarke: There has been, about 1997, I think it was, and what you're talking about, is some reporting about developing a strain, a new strain of anthrax. In 1997 there was a journal called "Vaccine" which reported on a new or modified anthrax strain that the Russians may have been developing. We have a vaccine that works against most of the known -- all of the known anthrax strains. What we want to do is make sure we are prepared for any surprises, we're prepared for anything else that might happen that might be a threat. So about in the early part of this year, the DIA started to look into the feasibility, and doing all the legal consultations, doing all the appropriate interagency consultations to look into how we could develop that modified anthrax strain so we could test our vaccines against it and make sure we prevent against any surprises, and make sure we could protect the men and women in uniform from potential threats.
Q: Are you growing it?
Clarke: Right now there is no work going on on the modified anthrax strain. The director --
Q: Is it going to go forward?
Clarke: The director has made it very clear that he wants further interagency consultation work done -- that's with the DoD and other agencies; that he wants the legal reviews to continue; and further congressional briefings.
Q: Director of DIA?
Clarke: Yes.
Q: Well what work has been done prior? You say no work is being done now. Was this strain actually developed prior to today?
Clarke: In the United States? No.
Q: By the U.S. government --
Clarke: No.
Q: -- it wasn't?
Clarke: Right.
Q: Was it worked with? Did you get a hold of agent? Were there other bio-agents that were created for these programs?
Clarke: No.
Q: No bio-agent of any kind was created for these programs?
Clarke: For this particular program that we're talking about, which is this modified anthrax strain that was reported on in 1997, I believe it was, in this magazine "Vaccine," we have had consultations with the Russians about this, we have had cooperative efforts with the Russians on biological warfare in the past. But on this particular strain, no work has been done.
Q: And the U.S. had asked for a sample of the Russian and that was not provided; is that correct?
Clarke: To date, it has not been provided. And I've asked, I don't yet have the answer; I know as early as '97 we started talking to them about providing a strain so our folks could take a look at it and test the vaccine and see what we can do to prepare against those sorts of threats.
Q: The U.S. then didn't attempt to simulate that vaccine or create its own version of -- not of the vaccine, but of the agent, rather?
Clarke: No, that's what I was trying to say. Earlier this year, the DIA started to look into what it would take to get the legal approvals, to get the interagency coordination, to do the congressional briefings, to look into developing that strain so they could test vaccines and they could see what we have to do to make sure we're protected against it.
Q: That appears to be the path that you're now headed down, is doing that interagency process, making sure it is legal, and then going ahead and developing or growing this strain?
Clarke: Correct.
Q: That is? Okay.
And secondly, on the issue of making bomblets, which are some of the pieces of technology that other countries have done to dispense biological weapons, has the United States made these small bomblets for experimenting or any other reason?
Clarke: That comes under the Clear Vision program, which is a CIA project, so you should direct your questions over there.
Yes. Second row.
Q: In the -- you say the Russians haven't provided samples of this strain of anthrax. Have they provided notes or research or anything? How would we know that we're going to get the same strain that they came up with?
Clarke: You know, that we'll have to get back to you with some information. I just know there's been ongoing work with them in a cooperative nature on other elements when it comes to biological warfare. There's been a fair amount of communication lab to lab, if you will. But I don't know about all those aspects of -- [Update: the Department of Defense Cooperative Threat Reduction Program is funding a collaborative research project on anthrax monitoring with the State Research Center for Applied Microbiology in Obolensk, Russia. In August 2001 the State Research Center applied to the Russian Export Control Commission for a license to transfer the anthrax strain to the U.S. Centers for Disease Control. The application is currently pending a decision of the Russian Export Control Commission, and the U.S. government will seek Russian approval of the export license.]
Q: To the best of your knowledge, has the United States developed other strains of biological warfare agents in an effort to study them, strains of basically banned biological agents?
Clarke: I'll have to take that question. [Update: no, we do not develop biological weapons within the DOD.]
Q: Do the Russians acknowledge that they have, in fact, produced this hybrid strain of anthrax?
Clarke: Not to my knowledge.
Yes.
Q: New subject?
Q: Can we please stick on this subject?
Clarke: I'm sorry. How about Pam, and then back to you?
Q: So far, what is the legal determination with regard to the Bio Weapons Convention? Does DIA think they're going to be able to push ahead with this with no problem?
Clarke: We're compliant.
Q: This -- right now you're compliant because you haven't done it yet. But if you do it, will --
Clarke: We're compliant, and the legal reviews that have been done to date indicate that the work would be compliant. The Biological Weapons Convention allows you to do work that is purely defensive in nature. It allows you to have small quantities of a known agent, limited quantities of an agent if you want to study it for the purpose of protecting people against that threat.
Q: And is -- does the United States consider what Russia did compliant with the Bio Weapons Convention?
Clarke: You know, we have, as I said at the start of this questioning, we have concerns about the spread of biological and chemical warfare-enabling technology whatever the source and whoever is engaged in those activities. We have raised these concerns about chemical and biological warfare with the Russians, and we will continue to do so.
Q: Victoria, in the New York Times article today, according to the Times, the Times and ABC News were given a tour of a germ warfare laboratory in Nevada. Can you explain what the purpose -- what that facility does and what the purpose of it is?
Clarke: The facility, the Battelle facility of one that looks at -- I'm sorry, it's not the Battelle facility, it's the DTRA facility. And they are looking at signatures -- and I'm clearly going to get beyond my level of knowledge here -- but looking at signatures which indicate biological activity. They're using commercially available equipment, using commercially available organisms.
Q: And did -- are there any germs or biological agents produced at that facility?
Clarke: You know, that -- I'm going to have to refer you to DTRA. But on this particular project that was referred to in the New York Times, again, they were using commercially available equipment and commercially available organisms to test again the signatures, which is your ability to -- the level of activity -- not the level, but the activities of organisms.
Q: Is that for detection purposes?
Clarke: I believe so.
Yes?
Q: What's the rationale for having kept this work a secret up to now?
Clarke: Which work are you referring to?
Q: The research that we've been talking about, these various projects --
Clarke: Well, the DIA, for instance, doing this work, is trying to protect us and protect the men and women in uniform against threats of chemical and biological warfare. There are certain countries that we know are trying to do very bad things out there. The less information we give them about it, the better. Intelligence activities tend to remain secret.
Q: This is going to sound a little cynical, but let me just ask, on behalf of the public, how can the American public be assured that as the United States government conducts this kind of research, which is aimed at protection, that in the process they don't -- they're not also at the same time developing some offensive capability or creating some new strain of dangerous bacterial agent?
Clarke: Well, for instance -- and I think we can provide you with a chronology of the activities that have to do with this modified anthrax strain -- the Jefferson project, as it's referred to. And you look at this -- there was a long litany of interagency coordination, legal reviews, congressional briefings, all of which are obviously to ensure the appropriate, you know, coordination. It's also to make sure that all the appropriate steps are taken to make sure we are compliant. This program's undergone serious, serious scrutiny by a number of people. We are compliant, and we will remain so. And the BWC does allow you to do these things, as Project Jefferson has done.
Q: Is it safe to say that -- as you said here, that the United States intends -- intends -- to go ahead and develop this strain of anthrax, unless something -- retain the interagency process, but you made pretty clear the United States feels that it would be legal, as of now, to do so, and you fully intend to do it?
Clarke: Yeah. And let me repeat, again, we take the threat of the spread of biological and chemical warfare very, very seriously. We have an obligation -- and it's an important obligation -- to make sure we protect, first and foremost, the men and women in uniform against those threats. There's absolutely an obligation and responsibility that we do so. So with all the appropriate legal reviews, with all the appropriate interagency coordination and congressional briefing, we plan to proceed.
Q: Just to be clear, we'd be talking about in this instance a minute quantity of bacterial agent, or how would you characterize how much of this anthrax variant should be produced?
Clarke: You know, the question I asked before I came down here, and gotten the answer back, was to actually define that a little more clearly. But the BWC does make clear "small, limited quantities" of a known agent. And I'll try to get a better definition of that for you.
Yes?
Q: Was the desire to maintain the confidentiality and details of these programs related in any way to the administration's decision not to participate in developing a verification and on-site inspection protocol for BWC?
Clarke: Absolutely not. I mean, remember, we are signatories to the Biological Weapons Convention. This administration has made clear one of its priorities is to work against the threat of biological warfare. That is one of our top priorities. Concerns with the protocol had to do, one, it couldn't really do what some said it might be able to do; two, the information that would be revealed about our biodefense capabilities, as well as confidential business information.
But I dare say almost every meeting of every high-level administration official over the last several months, as we've met with friends and allies on a variety of issues, this issue has been put on the table and said this is a concern; we want to do everything we can together around the world to reduce this threat.
Q: Nevertheless, the verification protocol would have allowed demand inspections by any party to the treaty. And had any party demanded inspection rights to these projects, the United States would have been obliged to provide those inspections.
Clarke: The protocol has lots of problems recognized by lots of people other than us. Foremost among them, it would make it very hard to do biodefense. It would make it very clear that some confidential commercial business information would be revealed. But again, I'd try to put the emphasis on what is really important, which is our commitment to the Biological Weapons Convention and the fact that we have made this issue and the priority of reducing the threat of chemical and biological warfare right front and center for this administration.
Q: Is it the intention of this administration to keep this kind of research as secret as the last administration did? Or is it the intention of this administration to be more forthcoming, to explain to the public what you are doing so there will be no misunderstandings about what the U.S. is doing behind closed doors?
Clarke: Let me clear up one thing and then come back.
No biological agents were produced, only simulants, as part of the research and the study in Nevada. So there were no biological agents used there, they were just simulants. I hope that clears that up.
And, I'm sorry, just do it one more time quickly.
Q: Is it the intention of this administration to continue the very extreme levels of secrecy surrounding all of these projects, which the administration says are benign and within the purview of the various conventions, or is it the intention of this administration, as has been indicated in a newspaper article today, to keep it even more secret than the previous administration?
Clarke: Well, I believe the intention will be to keep that information secret that we think by not doing so would have serious national security concerns. Giving those who have hostile intent information about what we can do to protect against the threats they might be carrying out against us is not a good thing.
Q: Does the revelation of these three projects threaten the United States?
Clarke: I feel pretty confident. You know, I've looked into this pretty hard for the last couple of days, and I feel pretty confident with the way this program is being run, the way it is being executed, the way it's being briefed throughout the interagency process and getting the appropriate legal consultations and doing the correct and appropriate congressional consultations, I feel confident that we're on a good path. And again, I go back to what I think is most important: the threat is real, it is growing, and it is the responsibility of the country, of the United States, the United States military and this administration to take steps to protect us against it.
Q: Let me try it again. Does the disclosure of these three projects threaten the United States? In other words, in the future, if the disclosure of this doesn't threaten the United States and letting the public know what you're doing doesn't threaten the United States, why not continue to follow that path in the months and years ahead? Or does this disclosure threaten the United States? Has it done harm?
Clarke: I don't think there is a level of detail that has been revealed that has done any harm to the program.
Q: So one might conclude then that it's okay to talk about this and other projects which are currently classified as secret or top secret. Or does the press have to rule it out?
Clarke: It's hard -- no, it's hard for me to make a blanket statement about all things going forward. But I will say this: if it's good and important that people know something about the level and the nature of the threat, absolutely. Is it good and important that people know what this administration is trying to do to protect them and their friends and colleagues and family members in uniform? Absolutely. But I just -- I can't help you on a blanket statement going forward.
Yes, sir.
Q: Another topic?
Q: One more.
Clarke: I'm sorry, one more.
Q: Just to pick up on the thread of Jack's question, do the scientists who are involved in this research, are they involved in any exchange programs with foreign counterparts, much like scientists at Los Alamos, where they might be susceptible to, you know, espionage or something like that? Do they come into contact with any of their counterparts overseas?
Clarke: There is cooperative work, yes.
Q: With which countries?
Clarke: You know, I'll have to take that question.
Q: But -- but their activities are monitored --
Clarke: (Inaudible due to cross talk) -- but they're -- yes, there are cooperative activities underway.
Q: And on the same subject, was the very existence of these programs classified as secret or top secret?
Clarke: What -- I'm sorry, what do you mean?
Q: Was the fact that there was work going on in this area classified as top secret? Was the name of these -- were the names of these projects classified? Were these things really kept so secret, or is it the details of what's going on in these projects that was categorized as secret or top secret?
Clarke: Well, I can speak to the Jefferson project, which has been going on since 1997. And the Jefferson project covers a variety of issues in terms of preventing surprise on biological and chemical warfare. They do the work such as we're talking about, or may do the work such as we're talking about on the modified anthrax strain. They study literature. They consult with others. The Jefferson project, for instance, is one that has been known. Now, the level of detail in some of these projects has not.
Q: So the existence of these -- of this project, at least, was not classified.
Clarke: The Jefferson project. That's correct.
Q: Right. But the details of the work that was going on under that project may have been classified.
Clarke: Yes.
Q: And you're not sure when it comes to the other projects.
Clarke: Right.
Q: Okay.
Clarke: If you want, we can get a more detailed list of the kinds of work that they do, because it's pretty extensive. And again, it's a broad range of work designed to prevent surprise and make sure we have the capabilities we need to protect us.
[...]
Source: Defenselink
Not for commercial use. Solely to be used for the educational purposes of research and open discussion.
Inhalational anthrax: Threat, clinical presentation, and treatment
Journal of the American Academy of Nurse Practitioners
Vol. 13, Issue 4, p. 164
Apr 2001Leslie Henry
PURPOSE
To provide nurse practitioners (NPs) with a basic understanding of clinical presentation, transmission, diagnosis, pharmacological treatment, and post-exposure prophylaxis of inhalational anthrax.
DATA SOURCES
Selected research and clinical articles and government guidelines.
CONCLUSIONS
Inhalational anthrax has an incubation period of 1 to 6 days and is very difficult to diagnose early. The chest radiograph consistently reveals a widened mediastinum and pleural effusion without infiltrates. Mortality for inhalational anthrax is high, despite aggressive treatment after onset of symptoms. Delays in diagnosis contribute to the high mortality rate.
IMPLICATIONS FOR PRACTICE
The potential use of aerosolized anthrax as a biological warfare weapon has renewed interest in inhalational anthrax. Primary care providers are cornerstones in the defense against biological weapons because they may be the first to recognize and report suspicious cases.
KEY WORDS
Anthrax; bacillus anthracis; biological warfare; woolsorter's disease.
SCOPE OF THE PROBLEMAn infectious disease of antiquity, anthrax has caused outbreaks and numerous fatalities in humans and animals as far back as 1500 BC (Cieslak, & Eitzen, 1999; Pile, Malone, Eitzen, & Friedlander, 1998). Anthrax is caused by Bacillus anthracis (B. anthracis), a large gram-positive spore-forming rod. In spore form, B. anthracis can survive for decades in the environment (Cieslak, & Eitzen, 1999; Penn, & Klotz, 1997).
The potential use of aerosolized anthrax as a biological weapon has renewed interest in this infectious disease. Aerosolized anthrax is lethal in an unprotected population and remains stable and virulent during storage, making it a manageable weapon (Zilinskas, 1999). The United States (U. S.) developed anthrax in the 1950s and 1960s as an offensive biological weapon before terminating its program in 1972 (Franz et al, 1997). Iraq admitted to conducting research on anthrax as a biological weapon during the Persian Gulf war (Franz et al., 1997). In response to this threat, U.S. troops have received the anthrax vaccine; however, the military's vaccination program remains controversial due to questions regarding the safety and efficacy of the vaccine (Shafazand, Doyle, Ruoss, Weinacker, & Raffin, 1999).
An epidemic of anthrax in Sverdlovsk, part of the former Soviet Union, occurred in 1979. Autopsies performed on 42 of the 66 patients who died documented inhalational anthrax. The possible source of the exposure was an accidental release of anthrax from a nearby military facility (Ibrahim, Brown, Wright, & Rotschafer, 1999; Pile et al, 1998; Penn, & Klotz, 1997).
Several bioterrorist threats in the U. S. alleging exposure to anthrax occurred in 1998. Decontamination and prophylaxis therapy was initiated until the threats were proven to be hoaxes (Centers for Disease Control and Prevention [CDC], 1999). As a result of these threats, the CDC developed recommendations for post-exposure prophylaxis and biological warfare response guidelines.
It is important for primary care nurse practitioners (NPs) and physicians to become familiar with anthrax ("Reporting of cluster," 2000). Primary care providers are cornerstones in the defense against biological weapons because they may be the first to recognize and report potential cases (Cieslak, & Eitzen, 1999). In the event of a covert or hidden release of anthrax, health care providers will be the front-line responders in the U. S. (Dixon, Meselson, Guillemin, & Hanna, 1999; "Reporting of cluster," 2000).
This article reviews the pathophysiology, clinical presentation, diagnosis, and treatment of inhalation anthrax and discusses vaccination and post-exposure prophylaxis. The purpose is to provide NPs with a basic understanding of inhalational anthrax, the deadliest form of the disease.
Anthrax most commonly occurs in nature in animals such as cattle, goats, and sheep (Pile et al, 1998). Humans become infected after close contact with infected animals or animal products. In humans, an infection with anthrax can take three forms: cutaneous, gastrointestinal, and inhalational.
Cutaneous anthrax is the most frequently occurring form of anthrax in humans, but it is rare in the U. S. A cut or abrasion of the skin is the usual site of entry for anthrax spores. A painless, pruritic papule will appear in 3 to 5 days. Cutaneous anthrax is recognized by the typical black eschar on the affected areas and is easily treated with antibiotics (Cieslak, & Eitzen, 1999; Dixon et al, 1999).
Gastrointestinal anthrax is usually caused by consuming contaminated meat. Although this form has not been reported in the U. S., it can be fatal (Dixon et al, 1999). Death occurs from blood loss, intestinal perforation, and shock.
Inhalational anthrax is also known as woolsorter disease (Pile et al, 1998). Wool handlers inhale the B. anthracis spores during early processing of animal hides and become deathly ill (Franz et al., 1997). Robert Koch discovered anthrax in 1876, demonstrating for the first time the origin of a specific bacterial disease (Pile et al, 1998). John Bell recognized B. anthracis as the cause of woolsorter disease and established disinfection procedures that became the standard for the British woolen industry. In 1880, William Greenfield developed an anthrax immunization for livestock; subsequently, Louis Pasteur developed a live vaccine for anthrax. In 1881, Pasteur tested the heat-cured vaccine on sheep.
As a result of animal immunization, anthrax has been virtually eliminated as an occupational hazard of textile workers and meat packers in the U. S. (Cieslak, & Eitzen, 1999). However, anthrax remains a problem in Asia, Africa, South America, and southern Europe where animal vaccination programs are sporadic (Pile et al, 1998). The last fatal case of inhalational anthrax in the U. S.occurred in 1976 (Penn & Klotz, 1997).
PATHOPHYSIOLOGY
Inhalational anthrax begins after spores, less than 5 microns in size, enter the body and reach the alveolar spaces (Dixon et al, 1999). The spores are transported by pulmonary macrophages, an antiphagocytic capsule is produced, and germination occurs within the macrophage (Cieslak, & Eitzen, 1999; Dixon et al, 1999; Friedlander, 1999). Macrophages transport the spores to the mediastinal and tracheobronchial lymph nodes where the bacilli cause a hemorrhagic lymphadenitis by growing in regional lymph nodes.
The bacillus produces at least three proteins, known as edema factors (EF), lethal factor (LF), and protective antigen (PA), that interfere with host defenses (Cieslak, & Eitzen, 1999; Friedlander, 1999; Ibrahim et al, 1999). The proteins form toxins called edema toxin and lethal toxin. Edema toxin is formed from EF and PA and produces excessive fluid accumulation. Lethal toxin is formed from a combination of LF and PA and releases cytokines such as interleukin -1 and tumor necrosis factor (Cieslak, & Eitzen, 1999; Dixon et al, 1999; Ibrahim, et al, 1999; Shafazand et al, 1999).
Edema toxin and lethal toxin interfere with host defenses, causing necrosis of lymphatic tissue and the release of high numbers of bacilli into the blood and lymph, which in turn leads to toxemia, septicemia, and in some cases meningitis (Cieslak, & Eitzen, 1999; Dixon et al, 1999). The hemorrhagic lymphadenitis of the mediastinal and tracheobronchial lymph nodes causes a hemorrhagic mediastinitis, which is pathognomonic for inhalational anthrax (Shafazand et al, 1999). Hemorrhagic mediastinitis results in pulmonary lymphatic blockage and pulmonary edema (Dixon et al, 1999). The overwhelming pulmonary edema and septicemia cause death in approximately 1 to 7 days after exposure.
CLINICAL PRESENTATION
Inhalational anthrax has a reported incubation period of one to six days and is very difficult to diagnose early (Cieslak, & Eitzen, 1999). After incubation, inhalational anthrax is biphasic in nature (Shafazand et al, 1999). The first phase, lasting an average of four days, is a non-- specific flu-like syndrome presenting with low-grade fever, non-- productive cough, myalgia, headache, malaise, and possibly mild chest pain (Cieslak, & Eitzen, 1999; Dixon et al, 1999; Franz et al., 1997; Shafazand et al, 1999). This initial phase, or prodrome, may be followed by a period of one to three days of symptomatic improvement.
The second phase presents with an abrupt onset of acute respiratory distress. Fever, severe dyspnea, cyanosis, and shock mark the rapid deterioration (Cieslak, & Eitzen, 1999; Penn & Klotz, 1997). The enlarged mediastinal lymph nodes may partially compress the trachea and cause stridor (Shafazand et al, 1999). Auscultation of lung sounds may be remarkable for crackles and signs of pleural effusion. Diaphoresis is often present, resulting in hypotension and chills ("U.S.Army," 1996). A decreased level of consciousness and possible coma may be symptoms of meningitis, which occurs when an overwhelming bacterial load is present (Shafazand et al, 1999; Penn & Klotz, 1997; "U.S.Army," 1996). After onset of respiratory distress, shock followed by death occurs within 24 to 36 hours (Franz et al., 1997; "U.S.Army," 1996).
DIAGNOSIS
The chest radiograph consistently reveals a widened mediastinum and pleural effusion without infiltrates, which is a hallmark of inhalational anthrax (a typical chest radiograph can be viewed on-line at http://phil.cdc.gov/public/1118.htm). This widened mediastinum is a result of mediastinitis and pleural effusion and may be present as early as the second day following exposure (Dixon, et al, 1999; Cieslak, & Eitzen, 1999; Franz et al., 1997; Ibrahim, et al, 1999; Penn & Klotz, 1997; Pile et al, 1998; Shafazand et al, 1999; "U.S.Army", 1996).
Blood cultures and a Gram stain should be obtained. Grampositive bacilli can be detected during the illness in blood smears; spores are not found in blood samples. Bacillus anthracis cultured from blood confirms the diagnosis (Cieslak, & Eitzen, 1999; "U.S.Army", 1996). A nasal swab, or environmental sample, containing gram-positive B. anthracis supports a diagnosis of anthrax due to intentional release as in war or terrorist activity (Cieslak, & Eitzen, 1999). Detecting circulating antibodies against the toxins with the enzyme-linked immunosorbent assay (ELISA) can help to confirm the diagnosis (Franz et al., 1997; Ibrahim, et al, 1999).
A confirmed or suspected case of anthrax must be reported to the CDC and local health and law enforcement authorities immediately (CDC, 1999). "Although inhalation anthrax in man is usually fatal, prompt recognition of disease may improve outcome and allow for immunization/prophylaxis for other individuals who may have been exposed" (Penn, & Klotz, 1997, p. 29). Immediate reporting may also deter further terrorist activity.
TREATMENT
Management Mortality for inhalational anthrax is high, despite aggressive treatment after onset of symptoms. Delays in diagnosis contribute to the high mortality rate. The Sverdlovsk outbreak reported 11 survivors of inhalation anthrax, suggesting that aggressive management and early diagnosis may optimize survival (Shafazand et al, 1999). Support in an intensive care unit is necessary due to severe respiratory distress in the second phase. Standard universal precautions are adequate since human-to-human transmission of anthrax has not been reported (Cieslak, & Eitzen, 1999; CDC, 2000).
Pharmacological therapy. Penicillin G has historically been the drug of choice for treating inhalational anthrax (Cieslak, & Eitzen, 1999; Franz et al., 1997; "U.S. Army", 1996). The recommended dose is 2 million units of penicillin G intravenously (IV) every 2 hours. Penicillin is still recommended in cases where the susceptibility of the organism is known. Adding streptomycin 30 mg/kg intramuscularly (IM) every day has demonstrated a synergistic effect in animal studies (Franz et al., 1997; Ibrahim, et al, 1999).
The possibility of an antibiotic-resistant strain of B.anthracis has prompted experts to recommend ciprofloxacin as the drug of choice until drug sensitivity reports confirm the sensitivity of the organism to penicillin (Cieslak, & Eitzen, 1999; Ibrahim, et al, 1999). Ciprofloxacin was recently approved to reduce the incidence and progression of inhalational anthrax following exposure to aerosolized B.anthracis (Food and Drug Administration [FDA], 2000). Ciprofloxacin also provides the convenience of twice-daily dosing. It is recommended to initiate treatment at the earliest signs of disease with ciprofloxacin 400 mg, IV every 12 hours (Cieslak, & Eitzen, 1999; Franz et al., 1997). An alternative regimen starts with a 200mg dose of doxycycline IV, followed by 100 mg IV every 12 hours (Franz, et al., 1997; Dixon et al, 1999; "U.S.Army", 1996). A 30-day or longer course of antibiotics may help to maintain long-term protection (Ibrahim, et al, 1999). The FDA (2000) recommends ciprofloxacin be administered for a total of 60 days. Cieslak and Eitzen note that these recommendations are based on animal studies and in vitro data: "...no human clinical experience with these regimens exists" (p. 4, 1999).
In children, penicillin G 100,000-150,000 U/kg/day in divided doses every 4-6 hours is preferred (Dixon et al, 1999). The FDA has approved the use of ciprofloxacin in pediatric patients for inhalational anthrax. The recommended pediatric dose of ciprofloxacin for post-exposure inhalational anthrax is 15mg/kg orally twice a day or 10mg/kg IV twice a day (FDA, 2000). Penicillin may also be the drug of choice during pregnancy, although the life-threatening nature of a biologically altered strain of B. anthracis may warrant the use of ciprofloxacin, despite adverse indication, until drug sensitivity is confirmed (Shafazand et al, 1999; "U.S. Army," 1996).
Corticosteroid therapy should be started in cases of meningitis, massive edema, and toxemia. Possible choices include dexamethasone, prednisone, and hydrocortisone (Dixon et al, 1999; Ibrahim, et al, 1999).
Post-exposure prophylaxis. Individuals exposed to anthrax who do not display symptoms will not require support with intensive care or IV antibiotic regimens (Ibrahim, et al, 1999). Post-exposure prophylaxis should be started at the earliest opportunity with ciprofloxacin 500 mg orally every 12 hours or doxycycline 100 mg orally every 12 hours (Cieslak, & Eitzen, 1999; Ibrahim, et al, 1999; FDA, 2000). In the event of an anthrax threat, drug therapy can be delayed 24-48 hours until evidence of release is verified (Cieslak, & Eitzen, 1999). Post-exposure chemoprophylaxis should continue for 4 to 6 weeks until anthrax vaccination provides antibodies or exposure can be excluded (Dixon et al, 1999; CDC, 1999). According to recent recommendations (FDA, 2000), ciprofloxacin prophylaxis should be administered for a total of 60 days.
Fluoroquinolones are not usually recommended for children or during pregnancy due to the risk of arthropathy (Shafazand et al, 1999). However, the CDC (1999) recommends weighing the adverse effects of ciprofloxacin against the potential life-threatening effects of inhalational anthrax. The FDA (2000) has approved the use of ciprofloxacin for prophylaxis in children who have been exposed as a result of an intentional release of inhalational anthrax. The prophylactic pediatric dose of ciprofloxacin is 15 mg/kg orally twice a day or 10 mg/kg twice a day IV (FDA, 2000). The CDC recommends ciprofloxacin in children and pregnant women until sensitivity to penicillin is known. Amoxicillin 40 mg/kg/day orally in divided doses every 8 hours is the recommended prophylactic dose in children once susceptibily to penicillin is determined (CDC, 1999).
Vaccination. Vaccination after a biological incident is recommended, in conjunction with post-exposure chemoprophylaxis (CDC, 1999). The anthrax vaccine can be obtained from the CDC and should be administered in a series of three doses. The first 0.5ml subcutaneous injection should be given as soon as possible after confirmed exposure and repeated at 2 weeks and 4 weeks (CDC, 1999; Ibrahim, et al, 1999). This vaccine has not been evaluated for efficacy and safety in the elderly or children. The anthrax vaccines developed for animals should not be administered to humans (CDC, 2000). Patients should be closely monitored for early symptoms of anthrax during prophylaxis and after antibiotic therapy is discontinued. In animal studies, relapse after antibiotics are discontinued occurred in unvaccinated subjects (Penn, & Klotz, 1997).
Decontamination. Decontamination of people potentially exposed to a biological release of anthrax may be appropriate (CDC, 1999; Cieslak, & Eitzen, 1999). Clothing and personal effects should be removed and sealed in plastic bags; a shower with soap and water is necessary to complete decontamination procedures (CDC, 1999; Cieslak, & Eitzen, 1999). Environmental surfaces can be cleaned with a hypochlorite solution of one part bleach to 10 parts water after an investigation of the release has been completed.
PREVENTION
Active immunization by vaccination is the key to prevention of inhalational anthrax in high-risk populations (Friedlander, 1997; Ibrahim, et al, 1999). The FDA approved an anthrax vaccine in 1970 for human use in the U. S. The vaccine has been referred to as MDPH-PA or Michigan Department of Public Health Protective Antigen (Pile et al, 1998; Ibrahim, et al, 1999).
The vaccine should be stored at 2 to 8 degrees Celsius. The schedule for vaccination is 0.5 ml subcutaneously at 0, 2, and 4 weeks, followed by boosters of the same dose given at 6, 12 and 18 months. An annual booster is recommended in the event of continued exposure (Friedlander, 1997). High-risk populations, such as workers who could be exposed to animal products from countries that lack adequate anthrax control or individuals working with anthrax in a laboratory setting, should be vaccinated. United States military at risk for exposure to biological weapons in the Persian Gulf region received the vaccine (Friedlander, 1997).
Reported side effects of the vaccine are local reactions and rare systemic reactions. Local reactions occur in about 30% of vaccine recipients and include edema, warmth, erythema, pruritis, and tenderness with a small painless nodule at the injection site (Ibrahim, et al, 1999; Pile et al, 1998). The most severe local reaction noted is edema from the injection site to the elbow or forearm (Friedlander, 1997). Local reactions have been noted after the first injection which increase with subsequent injections and subside by the 6th and 7th injections, suggesting an allergic reaction (Ibrahim, et al, 1999). Systemic reactions are reported in less than 0.2% of vaccine recipients. Symptoms include mild myalgia, malaise, and headache, which may last from 1 to 2 days (Friedlander, 1997).
New vaccines are being researched and developed that would provide a less frequent dosing schedule. A cost-effective vaccine available for public protection may be developed in the near future (Ibrahim, et al, 1999).
CONCLUSION
The potential use of anthrax as a biological weapon has renewed interest in the clinical presentation and treatment of this infectious disease. Recognizing the clinical presentation, diagnosing, reporting, and treating casualties of biological warfare are developing responsibilities for the NP It is important for NPs to stay informed of developing technology aimed at prevention and protection against anthrax, and the potential of terrorist activity in metropolitan areas, port cities, military installations, and rural communities. Knowledge of local emergency and disaster plans is important for prompt and efficient response to an intentional or unintentional release of B. anthracis. Methods for procurement of antibiotics and vaccines in case of mass casualties must be part of the disaster plan. Disease reporting protocols for suspected and diagnosed infectious disease should be readily available. Despite the best efforts of NPs and other health care providers, the consequences of an intentional release of anthrax could result in a public health disaster. The knowledgeable and immediate response of NPs in the event of an intentional release of aerosolized anthrax will control public panic and minimize morbidity and mortality.
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Centers for Disease Control and Prevention. (2000). Anthrax - General informaton. Division of Bacterial and Mycotic Diseases, April 5. Retrieved October 10, 2000 from World Wide Web: http://www.cdc.gov/incidod/dbmd/diseaseinfo/anthrax-g.htm
Cieslak, T. J., & Eitzen, E. M. (1999). Clinical and epidemiologic principles of anthrax. Emerging Infectious Diseases, 5(4). Retrieved March 24, 2000 from World Wide Web: http://www.cdc.gov/ncidod/EID/vol5no4/cieslak.htm
Dixon, T. C., Meselson, M., Guillemin, J., & Hanna, R C. (1999). Anthrax. The New England Journal of Medicine, 341(11), 815-826.
Food and Drug Administration (2000, August 31). Approval of Cipro for use after exposure to inhalational anthrax. FDA Talk Paper. Rockville, MD: Author. Retrieved September 5, 2000 from the World Wide Web: http://www.fda.gov/bbs/topics/ANSWERS/ANS01030.htmlFranz, D. R., Jahrling, R B., Friedlander, A. M., McClain D. J., Hoover, D. L., Bryne, W. R., Pavin, J. A., Christopher, G. W., & Eitzen, E. M. (1997). Clinical recognition and management of patients exposed to biological warfare agents. Journal of the American Medical Association, 278(5), 399-411.
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Friedlander, A. M. (1999). Clinical aspects, diagnosis and treatment of anthrax. Journal of Applied Microbiology, 87, 303.
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Penn, C. C., & Klotz, S. A. (1997). Anthrax pneumonia. Seminars in Respiratory Infections, 12(1), 28-30.
Pile, J. C., Malone, J. D., Eitzen, E. M., & Friedlander, A. M. (1998). Anthrax as a potential biological warfare agent. Archives of Internal Medicine, 158, 429434.Reporting of cluster of cases with possible public health significance including those that suggest a possible chemical bioterrorist incident (2000). Maine Epi-Gram, March 2000, 2-3.
Shafazand, S., Doyle, R., Ruoss, S., Weinacker, A., & Raffin, T. A. (1999). Inhalational anthrax: Epidemiology, diagnosis and management. Chest, 116 (5), 1369-1376.
U. S. Army Medical Research Institute of Infectious Diseases. (1996). Medical management of biological casualties handbook, August 1996 (Second edition). Frederick, MD: Author. Retrieved April 27, 1998 from the World Wide Web: http://www.nbc-med.org/FMs/medman/index.htm
Zilinskas, R. A. (1999). Iraq's biological warfare program: The past as future? In J. Lederberg (Ed.), Biological weapons (137-158). Cambridge, MA: MIT.
I'd still stay away from any night games for a while. Especially cool windless ones.
www.cdc.gov/ncidod/EID/vol5no4/henderson.htm
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