Anthrax

cidrap.umn.edu/infectious-disease-topics/anthrax

Stephanie Soucheray | News Reporter | CIDRAP News | Sep 21,

2018

Agent and Pathogenesis

Agent
Pathogenesis

Agent
Key microbiological characteristics of Bacillus anthracis follow (ASM 2013):

Vegetative cell: large, gram-positive bacillus (1.0 to 1.5 mcm x 3.0 to 5.0 mcm); "jointed
bamboo-rod" appearance
Endospore: oval, central-to-subterminal, does not usually swell cell wall (1.0 x 1.5
mcm); CO2 levels within the body inhibit sporulation
Forms long chains of vegetative cells in vitro; single cells or short chains of two to four
cells in direct clinical samples
Readily forms spores in the presence of oxygen
Aerobic or facultatively anaerobic
Nonmotile
Catalase-positive
Nonhemolytic growth on sheep blood agar (SBA)
Rapid growth on SBA; colonies are 2 to 5 mm in diameter after 16 to 18 hours of
incubation, are flat or slightly convex, are irregularly round, are gray to white, and
have a "ground glass" appearance
Colonies may exhibit a comma-shaped projection or a "Medusa head" appearance
caused by chains of bacilli growing out from the edge of colonies
When lifted using an inoculating loop, colonies show a tenacity that allows them to
stand upright with the consistency of beaten egg whites
Forms mucoid capsule when grown on agar with sodium bicarbonate and incubated
in CO2-enriched atmosphere; capsule can be visualized with India ink preparation
Susceptible to lysis by gamma phage (Davison 2005)

B anthracis strains from around the world have been subtyped using molecular techniques
such as variable number tandem repeat (VNTR) analysis. On the basis of such testing, all
known anthrax strains can be classified into three different clades (A, B, and C) (Pilo 2011).

Spores germinate and form vegetative cells in environments rich in nutrients (eg, glucose,
amino acids, nucleosides). Vegetative bacteria generally survive poorly outside of
1/105
mammalian hosts. Conversely, vegetative cells form spores when exposed to air and
nutrients in the environment are exhausted. Spores are protected by a morphologically
complex protein coat (Giorno 2007). The exosporium may restrict dispersal and thereby
increase the probability of a lethal dose for the grazing animal (Hugh-Jones 2009). Spores
have been shown to have heat-resistance characteristics similar to other Bacillus species,
and can survive in the environment for more than 40 years (Manchee 1990, Montville 2005).

Back to top

Pathogenesis

Virulence Factors
The primary virulence factorsproduced by B anthracis are plasmid coded and include:

A poly-D-glutamic acid (PGA) capsule (coded for on plasmid pXO2) that inhibits
phagocytosis of vegetative bacilli. In mice PGA increases the toxicity of lethal toxin (LT),
intensifying the toxemia in the fulminant stage of infection (Jang 2011).
Three exotoxins that combine to produce two binary toxins:
Protective antigen (PA) is a binding protein that permits entry of toxin into host
cells via endocyte formation. Once in the endocyte, PA toxin forms a pore, which
creates a small passageway in the endosomal membrane that allows the
enzymatic components of the toxin to enter the cytoplasm.
Edema factor (EF) is a calmodulin-dependent adenylate cyclase. EF combines
with PA to form edema toxin (coded by the cya gene of plasmid pXO1).
Edema toxin converts adenosine triphosphate to cyclic adenosine
monophosphate (cAMP); high intracellular levels of cAMP lead to impaired
maintenance of water homeostasis and characteristic edema (Kumar
2002).
Edema toxin also inhibits neutrophil function and stimulates production or
release of multiple inflammatory mediators, including neurokinins,
prostanoids, and histamine (Tessier 2007).
Lethal factor (LF) is a zinc metalloprotease. LF combines with PA to form lethal
toxin (coded by the lef gene on pXO1).
Lethal toxin is thought to stimulate overproduction of cytokines (eg, tumor
necrosis factor [TNF] alpha and interleukin [IL] 1-beta), which leads to lysis
of macrophages.
Lethal toxin has been shown to cause endothelial cell apoptosis and
endothelial barrier dysfunction, which may contribute to vascular
destruction (Kirby 2004, Warfel 2005). It has also been shown to reduce
myocardial function (Moayeri 2009, Sweeney 2010).

2/105
During early stages of infection (prodromal stage), LT and edema toxin (ET) may coordinate
to incapacitate neutrophils and macrophages, which allows for a systemic infection to occur
(Liu 2010, Cote 2011). During the fulminant stage of infection (see Staging of Inhalational
Anthrax for additional description) the combined vascular impacts of LT and ET lead to
shock (Guichard 2011, Hicks 2011).

Virulence of B anthracis appears to be related to clonality and to the numbers of copies of

the pXO1 and pXO2 plasmids within each bacterial cell (Coker 2003). The complete genomic
sequence of B anthracis (Ames strain) has been analyzed; several chromosomally encoded
potential virulence factors were identified, including hemolysin, phospholipases, and iron
acquisition proteins (Read 2003).

B anthracis toxin genes are located on plasmids, and translocation of the plasmids has been
identified in a naturally occurring B cereus isolate obtained from a patient with an illness
similar to inhalational anthrax (Hoffmaster 2004). More recently, anthrax-like illnesses were
identified in two metalworkers who had inhalation exposure to B cereus that contained B
anthracis toxin genes (Avashia 2007). In another situation, a Bacillus strain, with a higher
similarity to B thuringiensis and B cereus than to B anthracis, was isolated from a chimpanzee
in Cote d'Ivoire that died with clinical signs of anthrax (Klee 2010).

Cutaneous Anthrax
The pathogenesis of cutaneous anthrax involves the following process:

Endospores are introduced through the skin (usually via preexisting skin lesions or
abrasions).
Low-level germination at the site of introduction produces localized necrosis with
eschar formation and soft-tissue or mucosal edema (which can be massive in some
cases). Epithelial damage appears to be required for germination of spores.
Germination begins 1 to 3 hours after inoculation, but spore germination by itself is
not sufficient to produce infection in undamaged skin (Bischof 2007).
Endospores often are phagocytosed by macrophages and carried to regional lymph
nodes, causing painful lymphadenopathy and lymphangitis.

Hematogenous spread with resultant toxemia can occur, although such spread is not
common with appropriate antibiotic therapy.

Inhalational Anthrax
Pathogenesis of inhalational anthrax involves the following steps (Abramova 1993, Hanna
1998):

3/105
 Endospores are introduced into the body via inhalation. Endospores are 1 mcm x 1.5
mcm in size (ASM 2013) and are, therefore, able to reach the alveoli (ie, <5 mcm).
Endospores are phagocytosed by macrophages and carried to regional lymph nodes.
They also appear to be taken up by lung epithelial cells (Russell 2008).
The endospores then germinate inside macrophages and become vegetative cells,
which leave the macrophages and multiply in the lymphatic system.
Regional hemorrhagic lymphadenitis of mediastinal and peribronchial lymph nodes
causes hemorrhagic mediastinitis (Abramova 1993). A widened mediastinum may be
noted on chest radiograph or enlarged lymph nodes may be directly visualized on
chest computed tomography.
Pulmonary lymphatic drainage can be blocked, leading to pulmonary edema.
Pleural effusions are common and may be massive. B anthracis bacilli, bacillary
fragments, and antigens can be noted with immunohistochemistry (IHC) testing of
pleural effusions (Guarner 2003).
True pneumonia rarely occurs, although a focal, hemorrhagic, necrotizing pneumonic
lesion (similar to the Gohn complex of tuberculosis) may be seen (Abramova 1993).
Intraalveolar edema, focal areas of hyaline membrane formation, and interstitial
mononuclear inflammation may be noted (Guarner 2003).
Bacteria enter the bloodstream and lead to septic shock and toxemia; hematogenous
spread can lead to hemorrhagic meningitis.
Compression of the lungs and septic shock are the major causes of death.

Gastrointestinal Anthrax
The pathogenesis of gastrointestinal anthrax is not clear, since this condition is relatively
rare. Historically, illness has been thought to result from ingestion of B anthracis spores;
however, more recently experts have postulated that illness predominantly results from
ingestion of large numbers of vegetative cells (such as may be found in poorly cooked meat
from infected animals) (Inglesby 2002).

Two forms of gastrointestinal anthrax have been recognized: oropharyngeal and

abdominal.
In oropharyngeal anthrax, the portal of entry is the oral or pharyngeal mucosa. A
mucosal ulcer occurs initially, followed by regional lymphadenopathy and localized
edema.
In abdominal anthrax, the portal of entry often is the terminal ileum or cecum.
Intestinal lesions occur and are followed by regional lymphadenopathy. Edema of the
bowel wall and ascites (sometimes massive) may be present.
Hematogenous spread with resultant toxemia can occur.

4/105
Infectious Dose
The median infective dose (ID 50 ) for inhalational anthrax is estimated at 8,000 to
50,000 spores (Franz 1997), although the minimum infective dose may be considerably
lower. On the basis of experimental studies involving primates, the US Department of
Defense (DoD) has estimated that the median lethal dose (LD50 ) for inhalational
anthrax in humans from weapons-grade anthrax is 2,500 to 55,000 spores (DIA 1986).
Extrapolation of dose-response curves involving cynomolgus monkeys suggest that
the LD10 (dose at which 10% of the population is expected to die) in humans following
exposure to airborne anthrax spores may be as low as 50 to 98 spores, the LD5 (5%
fatalities) may be only 14 to 28 spores, and the LD1 (1% fatalities) may be only 1 to 3
spores (Peters 2002).
In rabbits, the LD 50 for the Ames strain of B anthracis is 5.18 x 104 colony forming
units (CFU) (95% confidence interval, 6.14 x 103 to 7.27 x 10 5 CFU). Rabbits exposed to
less than 2.06 x 103 CFU of B anthracis survived for the duration of the study (21 days)
(EPA 2011).
Mathematical modeling of airborne anthrax infection based on observations from the
US Postal Service experience during the 2001 anthrax outbreak (and an assumption
that 10,000 people may have been exposed) suggests that exposures ranged from 18
to 863 spores and may have been as low as 2 to 9 spores (Fennelly 2004).
The dose-response relationship for inhaled B anthracis is highly uncertain. However, a
review of animal and human studies, including those that documented spore
exposures insufficient to cause inhalational anthrax, suggests that an exposure
threshold may exist (Coleman 2008).
Animal data have suggested that anthrax spores might be able to survive in the lungs
for longer than 60 days; in one study, live spores were detected in the lymph nodes of
a monkey 100 days after exposure (Henderson 1956).
The infective dose for gastrointestinal anthrax is not known. In animal models (guinea
pigs, rabbits, and rhesus monkeys), investigators failed to induce infection following
oral challenge with 108 spores; these animals are all thought to be more susceptible to
anthrax than humans (Beatty 2003).
A rare case of gastrointestinal anthrax was identified in New Hampshire following an
exposure to infected animal hides. Environmental sampling data from this case
suggested that the infective dose can be very low (CDC 2009: Gastrointestinal anthrax
after an animal-hide drumming event).
The infective dose for cutaneous anthrax is not known.

Back to top

Epidemiology

Reservoirs
5/105
B anthracis is found in soil in many areas of the world. Ecologic factors (such as abundant
rainfall following a period of drought) may enhance spore density in soil, although the exact
influence of such factors remains poorly understood.

The organism generally exists in the endospore form in nature; germination of spores
outside an animal host may occur when the following conditions are met (WHO 1998):

Temperature between 8°C and 45°C

pH between 5 and 9
Relative humidity >95%
Presence of adequate nutrients

Endospores are resistant to drying, heat, ultraviolet light, gamma radiation, and some
disinfectants. Spores can persist in soil for decades, as illustrated by biological warfare
experiments during World War II on the Scottish island of Gruinard (Manchee 1990). During
1943 and 1944, an estimated 4 x 1014 anthrax spores were dispersed on the island through
explosive means. Spores were still detectable more than 40 years later. Disinfection of the
island was finally completed in 1987, using a combination of seawater and formaldehyde.

Frequent outbreaks of anthrax caused the death of 1.5 million deer in northern Russia from
1897 to 1925 (Revich 2011). Because anthrax spores can survive in permafrost for
approximately 100 years, researchers have expressed concern that thawing of the
permafrost in Siberia will expose extensive animal burial grounds that contain the remains
of animals that died from anthrax (Revich 2011). These researchers have suggested that
careful monitoring of permafrost conditions in areas where anthrax outbreaks occurred is
warranted, since it is unclear if further warming will lead to release of viable spores.

Back to top

Anthrax in Animals
Most mammals are susceptible to anthrax, but it is predominantly a disease of livestock.
Livestock or other herbivores (eg, cattle, sheep, goats, pigs, bison, water buffalo) acquire
infection from consuming contaminated soil or feed. Anthrax in animals is hyperendemic or
endemic in the following areas of the world (WHOCC):

Most areas of the Middle East

Most areas of equatorial Africa
Mexico and Central America
Chile, Argentina, Peru, and Bolivia
Certain Southeast Asian countries (eg, Myanmar, Vietnam, Cambodia, Thailand)
Papua New Guinea
China
6/105
 Some Mediterranean countries

In most of the rest of the world, anthrax in animals occurs only sporadically. In the United
States, outbreaks in animals have occurred since 1990 in the Midwest (Kansas, Minnesota,
Missouri, Nebraska, North Dakota, South Dakota), in the West (California, Nevada), and in
Texas and Oklahoma (MBAH 2006, WHOCC). Outbreaks also occurred in 2006 in
Saskatchewan and Manitoba, Canada, affecting more than 800 animals (APHIS 2006). Other
notable points about anthrax in animals include the following.

Anthrax has been reported as the cause of death among chimpanzees in Ivory Coast
(Leendertz 2004) and chimpanzees and a gorilla in Cameroon (Leendertz 2006).
Investigators postulated that the chimps became ill either from consuming an infected
animal or drinking contaminated water. Isolates from the wild apes in both outbreaks
showed that the strains were clearly different from those of any previously described.
The isolates established a new "forest anthrax cluster," termed "F," suggesting that B
anthracis is a far less homogeneous species than currently believed (Leendertz 2006).
Anthrax also has been reported in cheetahs following consumption of infected meat
(Good 2008).
Anthrax spores were detected in two of six species of raptors (road-side hawks and
chimango caracaras [a bird of prey that is in the falcon family]) in central Argentina,
suggesting that scavenger and nonscavenger bird species may influence anthrax
epidemiology in some countries (Saggese 2007).
During an outbreak investigation of anthrax in white-tailed deer in Texas in 2005,
investigators found that necrophilic flies that were feeding on animals that died from
anthrax and tested positive for B anthracis. This raises the possibility that such flies
may play a role in the dispersion of B anthracis during animal outbreaks (Blackburn
2010).

Back to top

Modes of Transmission
Illness in humans most commonly occurs following exposure to infected animals or
contaminated animal products; such exposures include:

Contact with infected tissues of dead animals (eg, butchering, preparing contaminated
meat), which generally leads to cutaneous anthrax
Consumption of contaminated undercooked meat, which can lead to gastrointestinal
anthrax
Contact with contaminated hair, wool, or hides (particularly during processing) or
contact with products made from them, which can lead to either inhalational or
cutaneous anthrax. Animal hair from endemic regions continues to represent an
occupational risk for modern woolworkers (Wattiau 2008).
7/105
 Consumption of contaminated illicit drugs (through injection and possibly through
smoking or snorting)

Cases following laboratory exposure have been recognized (Brachman 1980, CDC 2002:
Suspected cutaneous anthrax in a laboratory worker). Person-to-person transmission of B
anthracis has been reported rarely with cutaneous anthrax, but has not been recognized
with gastrointestinal or inhalational disease (Weber 2001, Weber 2002).

Back to top

Anthrax in Humans—United States

Approximately 130 human cases of anthrax occurred annually in the United States
during the early 1900s. The incidence has gradually declined over time, with typically
fewer than 10 cases reported each year since the early 1960s (CDC 1995).
About 95% of naturally occurring cases in the United States are cutaneous and 5% are
inhalational. Only one case of gastrointestinal infection has been recognized in this
country (Brachman 1980, Ramer 2010).
Only 18 cases of naturally occurring inhalational anthrax were reported in the United
States during the 20th century (Brachman 1980). All but three were associated with
industrial exposures; two of the remaining cases were laboratory-acquired, and the
source of exposure for the third case remains unknown.
Between 1990 and 2000, only two cases of naturally occurring anthrax were reported
in the United States (one in 1992 and one in 2000); both patients had cutaneous
disease. The latter case occurred in North Dakota and resulted from agricultural
exposure (CDC 2001: Human anthrax associated with an epizootic among livestock).
Since 2006, three cases of anthrax have resulted from direct occupational association
with djembe drums made from untreated West African animal hides. Two cases were
of cutaneous anthrax (CDC 2008), and one case was inhalational (CDC 2006, Walsh
2007). This was the first new case of naturally occurring inhalational anthrax in the
United States since 1976. In response to this case, the Centers for Disease Control and
Prevention (CDC) developed a document on safety issues related to anthrax and
animal hides (CDC: Q & A: anthrax and animal hide drums).
In December 2009, a New Hampshire woman developed gastrointestinal anthrax after
attending a drum circle gathering. Two animal hide drums and environmental samples
from the building later tested positive for the same strain of B anthracis that infected
the woman. She is believed to have swallowed airborne anthrax spores released from
the drums during the gathering (CDC 2010: Gastrointestinal anthrax after an animal-
hide drumming event).
A molecular analysis of B anthracis isolates from recent anthrax cases in the United
States found that the New York, Connecticut, and New Hampshire isolates all were of
the same lineage (although the New Hampshire isolates were of a slightly different
8/105
 genotype) (Marston 2011). However, limited information is available on the molecular
subtypes of B anthracis that circulate in West Africa, so the isolates could not be traced
back to that region of the world. These findings illustrate the value of acquiring and
subtyping isolates from around the world so that accurate predictions can be made
about isolate origins.

Back to top

Anthrax in Humans—Global Perspective

An estimated 2,000 to 20,000 human cases of anthrax occur globally each year
(Brachman 1984).
Human cases generally follow disease occurrence in ruminants and are most
prevalent in Africa, the Middle East, and parts of Southeast Asia.
Most cases are cutaneous.
Viable anthrax spores were detected in goat hair fibers, airborne dust, and
unprocessed wastewater in a Belgian factory that scours wool and goat hair. Although
no definitive clinical cases of anthrax were recorded among this unvaccinated
workforce, evidence of asymptomatic B anthracis infection was found in
approximately 10% of the employees (Wattiau 2009). These workers had positive
serologic tests for anti-PA immunoglobulin G (IgG). A second serologic survey was
conducted in the same facility a year later. All who were seropositive in the first study
remained seropositive. In addition, five persons seroconverted between the two
periods and none had symptoms compatible with anthrax (Kissling 2011). These
results suggest that repeated exposure to low doses of anthrax spores can cause an
anti-PA IgG response to B anthracis in the absence of clinical disease and support the
concept of a dose-response association between exposure and illness.
Two fatal cases of inhalational anthrax occurred in the United Kingdom, one in
Scotland in 2006 and one in England in 2008. Both patients were drum makers
(Anaraki 2008).
A systematic review of MEDLINE (1996-2005) and selected journal indexes (1900-1966)
for inhalational anthrax cases worldwide between 1900 and 2005 identified 82 cases
of inhalational anthrax (Holty 2006: Systematic review: a century of inhalational
anthrax cases from 1900 to 2005). Cases from the 1979 Sverdlovsk outbreak in the
former Soviet Union (see section Use as a Biological Weapon) were excluded from
analysis because symptoms, treatment, and disease progression were not described.
Seventy-one of the 82 identified cases were naturally occurring, and 11 were
part of the 2001 bioterrorism outbreak in the United States.
Among naturally occurring cases, most involved exposure to contaminated wool,
goat hair, or animal hides.
An outbreak of anthrax was first observed among injection-drug users in Scotland in
December 2009 (Ramsay 2010) and subsequently spread to several other countries.
9/105
 In Scotland 119 cases and 14 deaths were recognized, with an additional 5 cases
in the England and 2 in Germany.
The patients reported injecting, smoking, and/or snorting heroin. Although B
anthracis was not identified in any heroin samples, epidemiologic evidence
implicated heroin as the source of contamination (HPS 2011). The strain of B
anthracis was identical in all cases and represented a new introduction into the
United Kingdom; it was related to Trans-Eurasian (TEA) B anthracis strains
previously identified in goats in Turkey.
The symptoms at presentation varied greatly, were inconsistent, and were not
typical of cutaneous, inhalational, or gastrointestinal anthrax (Booth 2010). Most
patients presented with soft-tissue infections, localized swelling, or symptoms
similar to necrotizing fasciitis. Among confirmed cases, swelling was the most
common symptom, followed by pain, malaise, and fever. Some patients
presented with only generalized symptoms suggesting systemic infection (HPS
2011). In one case, a man presented with acute abdominal pain, leading to
peritonitis, then septic shock and death (Johns 2011).

Back to top

Outbreaks of Naturally Occurring Disease

Outbreaks have been reported in industrial settings where animal products are processed
and in agricultural settings following consumption of or exposure to ill animals. Notable
examples of outbreaks include the following:

A major outbreak involving nearly 10,000 cases and 182 deaths (most of them
cutaneous infection) occurred in Zimbabwe during the late 1970s and early 1980s
(Davies 1982). An epizootic in cattle occurred at that time in the same area.
An outbreak involving 9 cases (5 inhalational and 4 cutaneous) occurred in 1957 in the
United States in a New Hampshire goat-hair processing plant (Brachman 1960, Plotkin
1960). This was the last recognized outbreak of naturally occurring infection in this
country.
An outbreak of oropharyngeal anthrax involving 24 cases occurred in Thailand in 1982
following consumption of contaminated meat (Sirisanthana 1984). Oropharyngeal
disease is an unusual manifestation of infection, which makes this outbreak of
particular interest.

Back to top

Use as a Biological Weapon

Aerosol Release of Anthrax Spores

10/105
Aerosol release of weaponized spores is the most likely mechanism for use of anthrax as a
biological weapon (Inglesby 2002). Although there is no formal definition of weaponized
anthrax, weaponization for aerosol release generally involves:

Use of small particles

A high concentration of spores
Treatment to reduce clumping
Neutralization of the electrical charge
Use of antimicrobial-resistant strains or genetic modification of the organism to
increase virulence or escape vaccine protection

The impact of a large aerosol release of weaponized anthrax spores remains unknown;
however, scenarios have been hypothesized, including:

A 1970 World Health Organization (WHO) report estimated that an aerosol release of
50 kg of dried powder containing 6 x 1015 anthrax spores over a city of 5 million
people in an economically developed country (such as the United States) would
produce 250,000 incapacitating illnesses and up to 100,000 deaths (WHO 1970).
A 1993 Office of Technology Assessment (OTA) study estimated that up to 3 million
deaths could occur following the release of 100 kg of B anthracis (OTA 1993).

Experience with aerosol spraying of B thuringiensis in Canada to control the European gypsy
moth demonstrated the following pertinent findings (Levin 2003):

Approximately 5 to 6 hours after the spray application began, indoor concentrations of

airborne B thuringiensis actually exceeded outdoor concentrations, suggesting that the
organisms entered homes and buildings after the aerosol release.
Although most of the particles were relatively large, particles with a medium diameter
of 2 to 7 microns were detected both inside and outside of homes. The authors
estimated that, at 5 to 6 hours after spraying, adults in the spray zone inhaled
approximately 203 spores per hour.
Nasal swabs from asthmatic children in the spray zone were collected after spraying;
Bacillus species with genetic patterns consistent with B thuringiensis were identified in
76.6% of isolates obtained from nasal passages.

The findings from this study suggest that it is technologically feasible to disseminate
biological agents from aircraft; however, the applicability of this information to an
intentional aerosol release of B anthracis is unknown. These data also raise concerns about
indoor air safety should an intentional outdoor release of a biological agent occur.

Back to top

Contamination of Food or Water

11/105
Deliberate contamination of food or water with anthrax spores also is a possibility. During
World War II, the Japanese reportedly impregnated chocolate with anthrax to kill Chinese
children. The apartheid government of South Africa also experimented with anthrax in
chocolate (Sirisanthana 2002).

Even though contamination of a water supply is unlikely owing to the large volume of water
involved and the chlorination process, contamination of smaller water sources is
theoretically feasible since spore counts remain stable in water for at least several days
following inoculation (Beatty 2003). Since B anthracis spores are not destroyed by
pasteurization, contamination of milk is another theoretical possibility (Perdue 2003).

Back to top

Historical Perspective
Although anthrax has not been responsible for the massive number of deaths associated
with cholera, plague, or smallpox, it has played a prominent role in the history of infectious
diseases. Anthrax was the first disease for which a microbial origin was definitively
established. Robert Koch identified the bacterium that causes anthrax in 1877 (Martin 2010:
Bacillus anthracis [anthrax], Purcell 2007). Anthrax also was the first disease for which an
effective live bacterial vaccine was developed; Louis Pasteur developed this vaccine in 1881
and tested it in domesticated animals. Additionally, inhalational anthrax among wool and
animal hide processors introduced the concept of occupational infectious disease risk.

Intentional spread of anthrax dates back to World War I, when German operatives infected
horses and cattle with B anthracis while they were awaiting shipment overseas. During
World War II, both the Axis and the Allies had biowarfare programs that involved anthrax
(Martin 2010: Anthrax as an agent of bioterrorism). The US military has been concerned
about anthrax as a potential biological weapon for many years because of its infectiousness
via the aerosol route and the associated high mortality rate for untreated inhalational
anthrax (Purcell 2007). B anthracis is readily accessible and easy to grow; in the spore form it
is stable, easily stored, and portable. Spores may be dispersed or sprayed as a powder or
liquid. Thus, anthrax remains the agent of greatest concern for bioterrorism (Martin 2010:
Anthrax as an agent of bioterrorism).

In 1972, more than 140 countries signed the Biological and Toxin Weapons Convention,
which called for termination of all offensive biological weapons research and development
and destruction of existing biological weapons stocks. However, the former Soviet Union
continued to expand its biological weapons program (which included weaponization of
anthrax) throughout the 1980s and early 1990s.

After the demise of the Soviet Union, many of the scientists who worked in the biological
weapons program left the country. The status of those scientists remains unknown;
12/105
however, Iraq, Iran, Syria, Libya, and North Korea actively have recruited such experts
(Henderson 1999). These countries and others have been suspected of ongoing
development of offensive bioweapons programs. Reports from the past few years suggest
that at least three countries have offensive biological weapons programs and at least an
additional six have research programs with possible production of offensive weapons (MIIS).

Weaponization of anthrax spores has caused two outbreaks of disease (key points from
each are outlined in the sections below). In addition, in July 1993, the religious group Aum
Shinrikyo aerosolized a liquid suspension of B anthracis from the roof of an eight-story
building in the Kameido district of Tokyo, but the release did not cause any human cases.
Factors contributing to failure of this bioterrorist act included use of an attenuated B
anthracis strain, low spore concentration, ineffective dispersal, a clogged spray device, and
inactivation of spores by sunlight (Takahashi 2004).

Sverdlovsk, USSR—1979
This outbreak in Sverdlovsk in the Union of the Soviet Socialist Republics (now
Ekaterinburg, Russia) resulted from accidental release of anthrax spores from a
military microbiological facility, Compound 19, where weaponized anthrax was being
produced (Dembek 2007, Meselson 1994).
Seventy-seven human cases were reported and 66 of the patients died, for a case-
fatality rate of 86%; 75 cases were inhalational and two were cutaneous (one on the
back of the neck and one on the shoulder). A subsequent statistical analysis of
available data suggests that 250 cases with 100 fatalities actually may have occurred
(Brookmeyer 2001).
The mean incubation period was 9 to 10 days (range, 2 to 43 days), and the mean time
between illness onset and death was 3 days.
Mean patient age for male cases was 42 years and for female cases was 55 years, and
no cases occurred in children.
The geographic distribution of human and animal cases indicated that the outbreak
was confined to a narrow zone, downwind from a point of origin in Sverdlovsk
(approximately 4 km for humans and 40 km for animals). Historical meteorological
data, combined with this case distribution, identified Compound 19 as the point of
origin. These data also showed that the release most likely took place on April 2, 1979.
Approximately 2 weeks after the presumed date of exposure, a vaccination campaign
of 59,000 eligible residents was begun; an estimated 80% of the target population
received at least one dose of vaccine. Prophylactic antibiotics also were provided to
both suspected and confirmed cases.
Investigators postulated that the weight of spores released as aerosol "could have
been as little as a few milligrams or as much as nearly a gram."
Modeling studies suggest that the incubation period for anthrax is dose-dependent.
The authors postulate that the relatively long incubation period for cases associated
13/105
 with Sverdlovsk was related to the level of exposure (Wilkening 2006).

United States—2001
An outbreak of cutaneous/inhalational anthrax occurred in the United States in 2001.
The outbreak predominantly involved direct exposure to mail that was deliberately
contaminated with anthrax spores. Several contaminated letters were sent to
members of Congress and media outlets, and one was reported to contain 2 g of
powder, with 100 billion to 1 trillion anthrax spores per gram (Inglesby 2002).
The following features were noted in an epidemiologic report that summarized the
outbreak findings (Jernigan 2002):
Twenty-two cases (11 inhalational and 11 cutaneous) were identified. Five of the
patients with inhalational anthrax died, for a case-fatality rate of 45% among
that group.
Cases occurred in residents of seven states along the East Coast (Connecticut,
Florida, Maryland, New Jersey, New York, Pennsylvania, and Virginia), with illness
onsets between September 22 and November 16, 2001.
Four contaminated letters were recovered; all four were mailed in or around
Trenton, New Jersey. Two were postmarked September 18, 2001, and two were
postmarked October 9, 2001.
Twenty of the patients were either mail handlers or were exposed to work sites
where mail was handled or received; one of these cases was a 7-month-old
infant. The remaining two cases had no apparent association with contaminated
mail. These persons likely became exposed through cross-contamination of bulk
mail that passed through contaminated mail facilities (Griffith 2003, Holtz 2003).
Illness in the 7-month-old infant with cutaneous anthrax was complicated by
quick progression to severe microangiopathic hemolytic anemia despite early
antibiotic treatment. The source was thought to be the workplace of the infant's
mother, which the infant visited the day before symptom onset. One possible
exposure scenario, according to the authors, is that spores on the hands of
someone in the workplace who lifted or held the child may have contacted an
exposed or possibly abraded area of the child's skin (Freedman 2002).
B anthracis isolates were obtained from the 4 contaminated letters, 17 clinical
specimens from cases, and 106 environmental samples collected along the mail
path of the contaminated letters; all were identical by molecular subtyping.
Following recognition of anthrax cases in postal workers, air sampling was conducted
before and during activation of a contaminated mail-sorting machine at a Washington,
DC, postal facility. This testing (which was conducted several weeks after the
contaminated mail passed through the machine) demonstrated that a mail-sorting
machine can remain contaminated for many days after processing mail contaminated
with B anthracis (Dull 2002).
The outbreak demonstrated several important points about weaponized anthrax:
14/105
 Mail can be an effective vehicle for disseminating anthrax spores.
Cross-contamination of mail likely can occur within postal facilities.
Persons who handle or process unopened contaminated mail are at risk of
acquiring anthrax.
Substantial environmental contamination can occur in facilities handling
contaminated mail or in offices where contaminated mail is opened.
Following the outbreak, a case of cutaneous anthrax occurred in a laboratory worker
in Texas who was working at a private laboratory that was processing environmental
samples from the CDC investigations (CDC 2002: Suspected cutaneous anthrax in a
laboratory worker).
A 1-year health assessment of adult anthrax survivors demonstrated that survivors
continued to report moderate to severe health complaints affecting multiple organ
systems and had significantly greater overall psychological distress compared with US
referent populations (Reissman 2004). Fifty-three percent had not returned to work
since their infection.
The alleged perpetrator and the source of the anthrax in this outbreak have been
identified. Bruce Ivins, the scientist named by Federal Bureau of Investigation (FBI)
investigators as the sole orchestrator of the attack, committed suicide before he was
charged. Ivins worked at the US Army Medical Research Institute of Infectious
Diseases (USAMRIID) and had access to the spores used in the attack. Sequence
analyses of anthrax strains allowed investigators to trace the spores to two flasks, one
at USAMRIID that was under Ivin's charge and one flask from another laboratory.
Several factors continue to be discussed, including the basis on which the FBI ruled
out spores from the other flask and ruled out other individuals who had access to the
spores. Some scientists remain skeptical of the FBI statements, in light of the
circumstantial nature of the the evidence. The FBI closed the case on February 19,
2010, in spite of the remaining unanswered questions (Bhattacharjee 2008, Warrick
2010).
In response to this skepticism, the FBI requested that the National Research Council
(NRC) of the National Academy of Sciences (NAS 2011) launch an independent review
of the scientific approaches used and the conclusions reached during the FBI
investigation. On Feb 15, 2011, the NRC completed its review; in its report, the NRC
ruled that the genetic analyses conducted by the FBI were scientifically sound but the
results could not by themselves conclusively link the anthrax strain to the flask
(designated "RMR-1029") in Ivins' custody (NRC 2011). "Spores in the mailed letters
and in RMR-1029 … share a number of genetic similarities consistent with the FBI
finding that the spores in the letters were derived from RMR-1029," the NAS said in a
press release (NAS 2011). "However, the committee found that other possible
explanations for the similarities—such as independent, parallel evolution—were not
definitively explored during the investigation." The FBI replied in a statement, "The FBI
has long maintained that while science played a significant role, it was the totality of

15/105
 the investigative process that determined the outcome of the anthrax case" (FBI 2011).
In March 2011, scientists involved in the anthrax investigation reported how, through
whole-genome sequencing and comparative genomics, they were able to identify four
mutations in spore material from letter samples. The mutations were related to a
regulatory protein involved in sporulation and were found only in spores linked to the
B anthracis in Ivins' custody (Rasko 2011). Only 8 of the 947 isolates they studied had
all four mutations, and these all came directly or indirectly from the "parent" strain
from Ivins' lab (see Feb 15, 2011, CIDRAP News story).
The original Ames strain came from a laboratory in College Station, Texas (rather than
Ames, Iowa). Several distinct Ames strains have been identified.
As a result of this outbreak, the US Postal Service has deployed an autonomous
biodetection system (BDS) for anthrax in mail-processing systems across the United
States (CDC 2004: Responding to detection of aerosolized Bacillus anthracis by
autonomous detection systems in the workplace).
A summary of public health actions during this attack was compiled by the Trust for
America's Health on the 10-year anniversary of the attacks (TFAH 2011).

Back to top

Preparedness
In October 2011, the bipartisan WMD (weapons of mass destruction) Terrorism Research
Center published a bio-response report card on the level of preparedness in the United
States for responding to various levels of biological attacks (WMD Center 2011). According to
that report, the United States is moderately well prepared for small-scale biological
incidents but is seriously unprepared for a large-scale incident.

As part of the preparedness for a large-scale incident, the US Postal Service is

evaluating distributing medical countermeasures along its mail routes (HHS 2011: HHS
preparedness grants help cities plan for anthrax attacks).
Since its inception, project BioShield has been focused on ensuring that effective
medical countermeasures are available in the event of a bioterrorism incident. Some
experts question if the financial investments in BioShield have been worth it, with the
limited number of acquisitions that made it to the Strategic National Stockpile (SNS).
However, these acquisitions probably would not have happened without the influx of
BioShield funding (Cohen 2011).

Back to top

Clinical Syndromes and Differential Diagnosis

Clinical Features
16/105
The three primary forms of anthrax correspond to the route of exposure: cutaneous,
inhalational, and gastrointestinal (HPA 2007). A fourth form, anthrax meningitis, may occur
as a complication of cutaneous, inhalational, or gastrointestinal anthrax, or it may be the
presenting form. These four clinical forms are described in the tables below.

Anthrax also has been recognized in injecting drug users following the use of contaminated
heroin (mostly from injection, but snorting and smoking also may play a role). Such patients
may have localized findings at injection sites (including presentations similar to necrotizing
fasciitis), or they may present with relatively nonspecific findings, such as malaise and fever
(HPS 2011).

Clinical Features of Cutaneous Anthrax

Feature Characteristics

Incubation 1-7 days (more commonly 2-5 days; may be as long as 12 days)
period

Signs and —Initial lesion is small papule or vesicle, which may be pruritic.
symptomsa —By second day, papule ulcerates with central necrosis and drying.
—Painless, localized, nonpitting edema surrounds ulcerated area.
—Fine vesicles may encircle ulcer; these enlarge over next 1-2 days and may
discharge serosanguineous fluid.
—After 1-2 days, painless black eschar forms over ulcerated area.
—Eschar sloughs off after 12-14 days.
—Lesions resolve without complications or scarring in 80%-90% of patients.
—Extensive nonpitting edema, lymphangitis, and painful lymphadenopathy may
occur.
—Malignant edema is rare complication and is characterized by severe edema,
multiple bullae, and shock.b
—Fever and malaise are common. a
—Lesions tend to occur on exposed areas of body (eg, hands, arms, face, neck).
—One outbreak in Thailand demonstrated the following cutaneous findings for
13 patients with cutaneous anthraxc:
~Eschar (85%)
~Blister (92%)
~Ulcer (23%)
~Edema around lesion (77%)
~Lymphadenopathy (100%)

17/105
Case- —Currently <1% a,g (most patients recover with appropriate antimicrobial therapy)
fatality rate —In preantibiotic era, case-fatality rates of about 20% were reported. d
—A literature review of pediatric anthrax cases identified between 1900 and 2005
demonstrated an overall mortality rate for cutaneous disease of 14% (5 of 37
cases).e Not all cases in this report received antimicrobial therapy.

Laboratory —Gram stain of lesion may reveal gram-positive rods; neutrophils are
findings uncommon.
—WBC count often is normal or may be slightly elevated. a
—Histologic examination shows necrosis, edema, and lymphocytic infiltrate. f

Abbreviation: WBC, white blood cell.

aGold 1955.
bAmidi 1974.
cKunanusont 1990.
dSmyth 1941.
eBravata 2007.
fDixon 1999.
gDoganay 2009.

Clinical Features of Inhalational Anthrax

Feature Characteristics

Incubation 1-43 days (usually 1-6 days) a

period

18/105
Signs and —Illness may be biphasic, with an initial prodrome (which includes symptoms
symptoms such as fever, malaise, fatigue, anorexia) followed by sudden increase in fever,
severe respiratory distress, diaphoresis, and shock, if left untreated.
—Symptoms for 10 patients with inhalational anthrax identified during the 2001
US outbreakb-c:
~Fever, chills (100%) (7 were febrile on initial presentation)
~Sweats, often drenching (70%)
~Fatigue, malaise, lethargy (100%)
~Cough (minimally or nonproductive) (90%)
~Nausea or vomiting (90%)
~Dyspnea (80%)
~Chest discomfort or pleuritic pain (70%)
~Myalgias (60%)
~Headache (50%)
~Confusion (40%)
~Abdominal pain (30%)
~Sore throat (20%)
~Rhinorrhea (10%)
—In the 2001 US outbreak, no evidence of a mild form of inhalational anthrax was
detected through follow-up serologic testing of exposed persons.b
—A systematic review of 82 inhalational anthrax cases reported between 1900
and 2005 found that the most common symptoms or findings on admission
included the followingd:
~Abnormal lung findings (80%)
~Fever or chills (67%)
~Tachycardia (66%)
~Fatigue or malaise (64%)
~Cough (62%)
~Dyspnea (52%)
~All 26 patients who had chest radiography had abnormal findings, including
pleural effusion (69%) or widened mediastinum (54%).

Case- —Sverdlovsk outbreak: 86% a

fatality —US outbreak: 45% c (lower observed CFR in the US outbreak likely was due to
rate early diagnosis and aggressive therapy)
—In a systematic review of 82 cases of inhalational anthrax, the overall CFR was
85%; however, patients in the US 2001 outbreak who received early antibiotic
therapy (ie, during the prodromal phase [<4.7 days after illness onset]) had a CFR
of 40% and those who received antibiotics >4.7 days after illness onset had a CFR
of 75%.d
—A literature review of pediatric anthrax cases identified between 1900 and 2005
demonstrated an overall mortality rate for inhalational disease of 60% (3 of 5
cases).e Not all cases in this report received antimicrobial therapy.

19/105
Laboratory Findings for 10 patients with inhalational anthrax identified during 2001 US
findings outbreakc:
—Median WBC count at presentation was 9,800/mm 3 (range, 7,500/mm 3 to
13,300/mm 3)
—Differential WBC count >70% neutrophils (70%)
—Neutrophil band forms present (4 of 5; 80%)
—Peak WBC during illness was 26,400/mm 3 (range, 11,900/mm 3 to 49,600/mm 3)
—Elevated transaminases (SGOT or SGPT) >40 (90%)
—Hypoxemiaf (60%)
—Metabolic acidosis (20%)
—Abnormal chest radiograph (100%):
~Mediastinal widening (70%)
~Infiltrates, consolidation (70%)
~Pleural effusion (80%)
—Abnormal CT scan (8 of 8; 100%):
~Mediastinal lymphadenopathy, widening (7 of 8; 88%)
~Pleural effusion (8 of 8; 100%)
~Infiltrates, consolidation (6 of 8; 75%)

Clinical Features of Gastrointestinal Anthrax

Feature Characteristics

Incubation 1-7 days (usually 2-5 days)

period

20/105
Signs and —One outbreak of GI anthrax in Uganda demonstrated the following findings in
symptoms 143 patientsa:
~Fever (may be low-grade) (70%)
~Abdominal tenderness (85%)
~Diarrhea (80%; bloody in only 5%)
~Vomiting (may be coffee-ground or blood-tinged) (90%)
~Headache (100%)
~Pharyngeal edema (10%)
—Ascites may develop 2-4 days after onset (fluid may be clear or purulent) b and in
rare instances GI anthrax cases may present with progressive ascites without
other classic symptoms. c
—Ulcerations can occur anywhere along the GI tract and may cause hemorrhage,
obstruction, or perforation.d
—If the patient survives, symptoms last about 2 wk
—One outbreak of oropharyngeal anthrax in Thailand demonstrated the following
findings for 24 patientse:
~Neck swelling (100%)
~Fever (96%)
~Sore throat, dysphagia (63%)
~Mouth or pharyngeal ulcerative or necrotic lesions (100%) (pseudomembranes
also were noted in some patients)
~Respiratory distress (25%)
~Hoarseness (8%)
~Sensation of a "lump in throat" (8%)
~Diarrhea (4%)
~Bleeding from the mouth (4%)

Case- —Rate for GI anthrax is between 25% and 60%. f,j In outbreaks where patients
fatality received antibiotic therapy, rates have ranged from 0% to 29%.g
rate —A literature review of pediatric anthrax cases identified between 1900 and 2005
demonstrated an overall mortality rate for gastrointestinal disease of 65% (13 of
20 cases).h Not all cases in this report received antimicrobial therapy.
—In Thai outbreak of oropharyngeal disease, rate was 13%. e In another report of
6 cases of pharyngeal anthrax, rate was 50%.i

Laboratory —Gram stain of peritoneal fluid or oropharyngeal ulcers may demonstrate gram-
findings positive rods.
—Median WBC count for 13 patients with oropharyngeal anthrax in Thailand
outbreak was 15,635/mm3 (range, 5,100/mm 3 to 30,570/mm 3). Mean percentage
of neutrophils was 79.6% (range, 73% to 91%). e
—B anthracis has been cultured from oropharyngeal swabs and stool specimens
in patients with GI anthrax.g

21/105
Clinical Features of Anthrax Meningitis

Feature Characteristics

Incubation Varies according to primary source of infection.

period

Signs and —May occur as complication of cutaneous, inhalational, or gastrointestinal

symptomsa a- anthrax, and symptoms of primary site of infection usually will be present;
d
however, meningitis may be the presenting illness.
—Characteristic features of bacterial meningitis usually present (eg, fever,
nuchal rigidity, headache, change in mental status, seizures).
—Nausea and/or vomiting are common.
—Hemorrhagic meningoencephalitis is a characteristic presentation.

Case-fatality —Illness fatal in >90% of cases.

ratee —A review of human anthrax in Turkey from 1990 to 2007 identified 5 cases of
anthrax meningitis; 100% of cases died despite antibiotic and supportive
therapy.f
—A literature review of pediatric anthrax cases identified between 1900 and
2005 demonstrated an overall mortality rate for meningoencephalitis of 100%
(6 of 6 cases).g Not all cases in this report received antimicrobial therapy.
—Death usually occurs 1 to 6 days after illness onset, and 75% of patients die
within 24 hr of presentation.

Laboratory —Gram stain of CSF reveals many gram-positive rods.

findings —CSF is usually bloody.
—Report of 2 cases demonstrated elevated WBC counts in both patients at
presentation (24,000 with 84% neutrophils and 18,000 with 90% neutrophils).b
—CT or MRI of head may show focal intracerebral hemorrhage, subarachnoid
hemorrhage, diffuse cerebral edema, intraventricular hemorrhage, and/or
leptomeningeal enhancement.d

Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography; MRI, magnetic resonance
imaging; WBC, white blood cell.

aDixon 1999.
bRangel 1975.
cMeyer 2003.
dSejvar 2005.
eLanska 2002.
fDoganay 2009.
gBravata 2007.

22/105
Back to top

Differential Diagnosis
The differential diagnosis for anthrax depends upon the clinical syndrome (cutaneous,
inhalational, gastrointestinal, or meningeal). Other diagnoses to consider are outlined in the
tables below.

Differential Diagnosis for Cutaneous Anthrax

(Note: Two key features that distinguish cutaneous anthrax from other conditions in differential
diagnosis are painlessness of the lesion and the relatively large extent of associated edema.)

B megaterium, B pumilus, B cereus cutaneous infections may resemble cutaneous anthrax

(Duncan 2011).

Diagnosisa-c Distinguishing Features

Ecthyma gangrenosum —Usually in neutropenic patients with

Pseudomonas aeruginosa bacteremia
—Edema usually not present

Ulceroglandular tularemia (Francisella —Clinical course usually indolent; disease often

tularensis) self-limited
—Systemic toxicity uncommon

Bubonic plague (Yersinia pestis) —Systemic toxicity common

—Extremely tender regional lymphadenopathy
present
—Ulceration and eschar formation usually absent

Staphylococcal or streptococcal cellulitis —May be history of trauma or preexisting lesion

at site of infection
—Eschar formation does not occur
—Usually painful

Necrotizing soft tissue infections —Severe systemic toxicity often present

(particularly Group A Streptococcus and —Early in course, pain usually more severe than
Clostridium species) clinical findings would indicate

23/105
Bite of brown recluse spider (Loxosceles
reclusa)d
Rickettsialpox (Rickettsia akari)
Scrub typhus (Orientia tsutsugamushi;
formerly Rickettsia tsutsugamushi)
Orf (orf virus, a parapox virus)
Necrotic herpes simplex infection
aDixon 1999.
bSwartz 2001.
cBell 2002.
dNelson 2002.
Differential Diagnosis for Inhalational Anthrax
—Brown recluse spiders prefer warm
temperatures and are not native to northern half
of United States
—Spiders tend to hide in barns, woodpiles, and
similar places
—Bite usually causes painful blister that
progresses to necrosis (unlike anthrax, which is
painless)
—Edema generally absent
—Initial presentation involves painless papule
that forms black eschar
—Generalized maculopapular rash appears 2-3
days later
—Zoonotic infection from chigger bites; occurs in
endemic areas (Asia and Western Pacific)
—Often associated with generalized
maculopapular rash
—Occurs in farm workers
—Characterized by pustule that progresses to
weeping nodule
—Eschar formation does not occur
—Edema usually absent
—More likely to occur in immunocompromised
host
24/105
(Note: Features that distinguish inhalational anthrax from other conditions in differential diagnosis
include presence of widened mediastinum and pleural effusions on chest radiograph or CT scan with
minimal evidence of pneumonia.)
Diagnosisa,b
Pneumonic plague (Yersinia pestis)
Tularemia (Francisella tularensis)
Community-acquired bacterial
pneumonia
—Mycoplasmal pneumonia
(Mycoplasma pneumoniae)
—Pneumonia caused by Chlamydia
pneumoniae
—Legionnaires' disease (Legionella
pneumophila or other Legionella
species)
—Psittacosis (Chlamydia psittaci)
—Other bacterial agents (eg,
Staphylococcus aureus, Streptococcus
pneumoniae, Haemophilus influenzae,
Klebsiella pneumoniae, Moraxella
catarrhalis)
Viral pneumonia
—Influenza
—Hantavirus
—RSV
—CMV
—Q fever (Coxiella burnetii)
Distinguishing Features
—Hemoptysis relatively common with pneumonic
plague, but rare with inhalational anthrax
—Clinical course usually indolent, lasting weeks
—Less likely to be fulminant
—Rarely as fulminant as inhalational anthrax
—Legionellosis and many other bacterial agents ( S
aureus, S pneumoniae, H influenzae, K pneumoniae, M
catarrhalis) usually occur in persons with underlying
pulmonary or other disease or in elderly
—Bird exposure with psittacosis
—Gram stain of sputum may be useful
—Community outbreaks caused by other etiologic
agents not likely to be as explosive as pneumonic
plague outbreak
—Outbreaks of S pneumoniae usually institutional
—Community outbreaks of Legionnaires' disease
often involve exposure to cooling towers
—Influenza generally seasonal (October-March in
United States) or involves history of recent cruise ship
travel or travel to tropics
—Exposure to mice infected with hantavirus or their
urine or feces
—RSV usually occurs in children (although may be
cause of pneumonia in elderly); tends to be seasonal
(winter/spring)
—CMV usually occurs in immunocompromised
patients
—Exposure to infected parturient cats, cattle, sheep,
goats
—Severe pneumonia not prominent feature
25/105
Abbreviations: CMV, cytomegalovirus; CT, computed tomography; RSV, respiratory syncytial
virus.

aDixon 1999.
bBell 2002.

Differential Diagnosis for Gastrointestinal Anthrax

Diagnosis Distinguishing Features

Abdominal Subtype a

Typhoid fever (Salmonella typhi) —Ascites usually not present

—Other clinical features may be similar

Intestinal tularemia (Francisella tularensis)
—Illness often less severe than that seen
with gastrointestinal anthrax
—Ascites not present
—Less likely to resemble acute abdomen
—Fever may be less prominent

Bacillary dysentery (Shigella dysenteriae) —Ascites usually not present

—Other clinical features may be similar

Acute bacterial gastroenteritis caused by other
agents (eg, Campylobacter jejuni, Shiga toxin–
producing Escherichia coli, Yersinia enterocolitica )
—Illness often less severe than that seen
with gastrointestinal anthrax
—Ascites not present
—Less likely to resemble acute abdomen
—Fever may be less prominent
—Hemolytic uremic syndrome may occur
with infection caused by Shiga toxin–
producing E coli

26/105
Bacterial peritonitis —Gastrointestinal symptoms (nausea,
vomiting, gastrointestinal bleeding,
diarrhea) not prominent features
—Tends to occur in persons with
underlying medical conditions (eg,
alcoholism, other liver disease)

Acute abdomen (eg, appendicitis) b —Anthrax generally begins with vague

systemic symptoms rather than abdominal
pain
—Ascites is relatively common with
gastrointestinal anthrax and less common
with appendicitis and similar conditions

Oropharyngeal Subtype

Diphtheria (Corynebacterium diphtheriae) —Primarily occurs in nonimmune children

under 15 yr of age
—Pharyngeal membrane is prominent
feature; ulcerative or necrotic lesions
generally not present
—Removal of pharyngeal membrane often
causes bleeding of submucosa

Pharyngeal tularemia (Francisella tularensis) —Neck swelling usually absent

—Exudative pharyngitis common;
ulcerative lesions may occur

Streptococcal pharyngitis (Streptococcus pyogenes) —Exudative pharyngitis most prominent

feature; necrotic ulcers generally absent
—Neck edema usually absent, although
cervical lymphadenopathy may be
prominent

Infectious mononucleosis —Most common in young adults

—Splenomegaly commonly occurs
—Neck edema usually absent, although
cervical lymphadenopathy may be
prominent

27/105
Enteroviral vesicular pharyngitis (coxsackievirus) —Small vesicles noted on soft palate,
uvula, or anterior tonsillar pillars
—Generally occurs in children
—Neck edema usually absent

Acute herpetic pharyngitis (herpes simplex virus)
—Vesicles, shallow ulcers may be noted,
but lesions usually not necrotic
—Neck edema usually absent, although
cervical lymphadenopathy may be
prominent

Anaerobic pharyngitis (Vincent's angina) —Purulent exudate covers posterior

pharynx
—Tonsillar abscesses may occur
—Neck edema usually absent

Yersinia enterocolitica pharyngitis —Exudative pharyngitis most prominent

feature
—Neck edema usually absent
—Cervical adenopathy, abdominal pain
may occur

aDixon 1999.
bKanafani 2003.

Differential Diagnosis for Anthrax Meningitis

Diagnosis Distinguishing Features

Subarachnoid hemorrhage —Fever not usually prominent feature

—Can be distinguished by CT without contrast a

Bacterial meningitis from other —Meningitis not usually hemorrhagic as seen with anthrax
causes meningitis
—CSF Gram stain may be useful in diagnosis

Aseptic meningitis —Meningitis not hemorrhagic

—CSF does not show characteristic gram-positive bacilli
—CSF usually demonstrates lymphocytosis

28/105
 Encephalitis —CSF findings may be variable, depending on etiology
—CSF Gram stain may be useful in diagnosis

Abbreviations: CSF, cerebrospinal fluid; CT, computed tomography.

aDixon 1999.

Back to top

Staging of Inhalational Anthrax

Historically, inhalational anthrax has been divided into a prodromal phase and a fulminant
phase. The table below outlines a proposed staging scheme (Lucey 2005) that adds an
intermediate stage in which symptoms are clearly worsening but the illness may still be
treated successfully.

Proposed Staging of Inhalational Anthrax

Stage Comments

1: —Usually <1 wk after exposure and rarely >1 mo

Asymptomatic

2: Early— —Nonspecific malaise, myalgias, low-grade fever, mild headache, nausea,

Prodromal general "flu-like" prodromal illness

3: —Blood cultures positive in <24 hr

Intermediate —Mediastinal lymphadenopathy
—Progressive —Pleural effusions that are often hemorrhagic and large and require repeated
drainage
—Findings may include: high fever, dyspnea, confusion or syncope, increasing
nausea/vomiting
—Patients at this stage can still be cured with antibiotics and intensive support

29/105
 4: Late— —Respiratory failure requiring intubation, sepsis, meningitis, end-organ
Fulminant hypoperfusion (ie, "shock")
—Cure less likely at this stage
—Future therapies for this stage may require inhibitors of both anthrax toxin
and systemic inflammatory response, in addition to antibiotics and intensive
care

Adapted from Lucey 2005.

Back to top

Distinguishing Inhalational Anthrax from Influenza-Like Illness (ILI)

and Community-Acquired Pneumonia (CAP)
Early symptoms of inhalational anthrax, ILI, and CAP are similar and include fever, chills,
myalgias, fatigue, malaise, and cough. However, several features can be used to distinguish
these illnesses. One study of symptomatic patients with possible exposure to anthrax found
that the presence of nonheadache neurologic symptoms (eg, dizziness, confusion), dyspnea,
and upper gastrointestinal tract symptoms (eg, nausea, vomiting) were more suggestive of
anthrax, whereas rhinorrhea and sore throat were far more common in patients with viral
illnesses (Hupert 2003).

Another study reviewed the CDC guidelines for inhalational anthrax during the 2001
outbreak and found that the guidelines would have missed 10 of the 11 cases (Mayer 2003).
The authors found that the modifications to the CDC guidelines shown below in italics
would have led to recognition of 8 of the 11 cases.

Fever
Sweats
Fatigue
Cough
Chest discomfort, pleuritic pain
Nausea, vomiting
Headache
Dyspnea
Myalgias
Abdominal pain
Confusion
Fever (low grade: mean temperature, 38°C)
Tachycardia (mean heart rate, 121 beats per minute)
Clinical presentation consistent with inhalational anthrax when five or more of the above
30/105
 symptoms are present, in addition to tachycardia and fever

Howell and colleagues have suggested that use of this revised screening protocol may incur
lower medical costs than the screening protocol proposed by Hupert and coworkers
(outlined in the first paragragh of this section) and may be similar in its sensitivity to detect
anthrax cases (although the numbers of anthrax cases in the comparison study were small)
(Howell 2004, Hupert 2003, Mayer 2003).

Another study examined the clinical features of the 2001 inhalational anthrax cases and
compared them with those of ILI cases seen in an ambulatory clinic and of hospitalized
patients with CAP. On the basis of these comparisons, the authors developed scoring
systems for distinguishing ILI and CAP from inhalational anthrax (Kuehnert 2003).

The scoring system for comparing inhalational anthrax with ILI included the following
features. Patients with a score of 4 or more were more likely to have inhalational
anthrax (sensitivity, 100%; specificity, 96.1%) than those with lower scores.
Low serum albumin (2 points)
Tachycardia (2 points)
No nasal symptoms (2 points)
No myalgias or arthralgias (1 point)
Low serum sodium level (1 point)
No headache (1 point)
High hematocrit or hemoglobin level (1 point)
The scoring system for comparing inhalational anthrax with CAP included the
following features. Patients with a score of 2 or more were more likely to have
inhalational anthrax (sensitivity, 100%; specificity, 48%) than those with lower scores.
When the score was increased to 3 or more, the sensitivity dropped to 82% and the
specificity increased to 81%.
Elevated serum alanine aminotransferase (ALT) and aspartate aminotransferase
(AST) levels (1 point)
Low serum sodium level (1 point)
Normal white blood cell count (1 point)
Nausea and vomiting (1 point)
Tachycardia (1 point)

A third study, which compared 47 historical anthrax cases (including 11 with bioterrorism-
related anthrax) with 376 controls with CAP or ILI, found that the most accurate predictor of
anthrax was mediastinal widening or pleural effusion on chest radiograph (Kyriacou 2004).

A report from the CDC included the following table, which compared the clinical features of
10 patients with inhalational anthrax to patients with laboratory-confirmed influenza.

31/105
Symptoms and Signs of Inhalational Anthrax, Laboratory-Confirmed Influenza, and
Influenza-Like Illness (ILI) from Other Causes

Inhalational Laboratory-Confirmed ILI from Other

Anthraxa (%) Influenza (%) Causes (%)

Elevated 70 68-77 40-73

temperature

Fever or chills 100 83-90 75-89

Fatigue/malaise 100 75-94 62-94

Cough 90 84-93 72-80

Shortness of 80 6 6
breath

Chest 60 35 23
discomfort/pain

Headache 50 84-91 74-89

Myalgias 50 67-94 73-94

Sore throat 20 64-84 64-84

Rhinorrhea 10 79 68

Nausea or 80 12 12
vomiting

Abdominal pain 30 22 22

32/105
 an = 10.

Adapted from CDC 2001. Considerations for distinguishing influenza-like illness from inhalational
anthrax.

A literature review of 42 patients who had atypical anthrax presentations (ie, patients with
confirmed anthrax infection who did not have known cutaneous, gastrointestinal, or
inhalational ports of entry) revealed that these patients were significantly less likely to have
cough, chest pain, or abnormal lung findings, even though they most likely had inhalational
anthrax (Holty 2006: Anthrax: a systematic review of atypical presentations).

A 2004 study used a decision-analytic model to assess the best treatment strategy for
patients presenting with ILI in settings with varying probabilities for inhalational anthrax
(Fine 2004). The authors concluded that, for inhalational anthrax probabilities between 0.1%
and 2%, when the sensitivity of blood culture exceeds 95%, the best strategy is to treat with
a short course of empiric ciprofloxacin until blood culture results are available. During
influenza season, the best strategy involves rapid testing for influenza followed by empiric
treatment for anthrax pending blood culture results for those who test negative for
influenza.

Back to top

Pediatric Considerations
Reports in the literature support the following observations about anthrax in children.

Inhalational anthrax is uncommon in children. For example, none of the cases in the
Sverdlovsk inhalational anthrax outbreak occurred in children (Meselson 1994), and
reports of inhalational disease among children are rare.
Naturally occurring cutaneous anthrax also is uncommon in children, probably
because children have less opportunity for exposure to infected animals.
Other modes of transmission (such as person-to-person through skin-to-skin contact
or transmission via fomites) may be more common for young children who acquire
cutaneous anthrax (Freedman 2002).
The skin lesions described for children who have cutaneous anthrax are usually
similar to those seen in adults. Progression to severe systemic disease can occur
(Freedman 2002).
Anthrax meningitis has been reported in children and may be the presenting feature
(Rangel 1975, Tabatabaie 1993).
A review of 73 cases (5 inhalational, 22 gastrointestinal, 37 cutaneous, 6 primary
meningoencephalitis, and 3 atypical) in children from 1900 to 2005 noted that children
with inhalational anthrax lacked nonheadache neurologic symptoms, a key
33/105
 distinguishing finding (Bravata 2007).
Another review of 62 pediatric cases of anthrax (2 inhalational, 20 gastrointestinal, 37
cutaneous, and 3 atypical) between 1966 and 2005 suggests that infected children
may manifest different symptoms than do infected adults and that difficulties in
diagnosing the disease in children may lead to delays in care (AHRQ 2006). Children
with gastrointestinal anthrax have two distinct clinical presentations, similar to adults;
however, children with inhalational anthrax may have atypical presentations, including
meningoencephalitis. Clinicians and public health officials must recognize the broad
spectrum of potential presentations for timely diagnosis and detection.

Back to top

Anthrax During Pregnancy

A report summarized two cases of anthrax in pregnant women; the features of these cases
are outlined in the table below (Kadanali 2003).

Summary of Clinical Features for Two Pregnant Women with Anthrax

Patient Weeks of Gestation Clinical Presentation of Outcome of

Age at Illness Onset Anthrax Pregnancy

33 32 Cutaneous anthrax (treated with —Infant delivered

penicillin G and prednisone) preterm at 35 wk
—No evidence of
congenital infection

29 33 Cutaneous anthrax (treated with —Infant delivered

procaine penicillin) preterm at 34 wk
—No evidence of
congenital infection

Back to top

Images
Back to top

Clinical Laboratory Testing

Specimen Collection and Transport

34/105
When the diagnosis of anthrax is being considered, the hospital clinical laboratory should
be alerted, because some laboratories will not further identify Bacillus species unless
specifically requested. The American Society for Microbiology (ASM), in collaboration with
the CDC and the Association of Public Health Laboratories (APHL), has developed sentinel
laboratory guidelines to enable clinical laboratories to perform microbiological analyses to
rule out B anthracis (ASM 2013). When anthrax is suspected or B anthracis cannot be ruled
out, sentinel laboratories should contact their Laboratory Response Network (LRN)
reference laboratory for specimen collection consultation, and isolates should be referred
for confirmation testing. The following table outlines the collection of laboratory specimens
for diagnosis of anthrax.

Collection and Transport of Laboratory Specimens for the Diagnosis of Anthraxa-d

Type of Specimen Collectione and Transport Comments f,g,h

Illness

35/105
Cutaneous —All stages: Collect 2 swabs, one for Gram
anthraxg stain and culture, and 1 for PCR.
—Vesicular stage: Perform Gram stain,
culture, and PCR of fluids from unroofed
vesicle (soak two dry sterile swabs in
vesicular fluid). Note: Gram stain is most
sensitive during vesicular stage.
—Eschar stage: Perform Gram stain,
culture, and PCR of ulcer base or edge of
eschar without removing it.
—Ulcer (no vesicle or eschar present): swab
base of ulcer with pre-moistened sterile
saline
—A thick punch biopsy for IHC testing and a
second biopsy for Gram stain, culture, PCR,
and frozen-tissue IHC if patient has not
received antibiotics should be obtained on
all patients with suspected cutaneous
anthrax. Include skin adjacent to papule or
vesicle. If vesicles and eschars are both
present, separate biopsies should be
obtained.
—Serum: collect acute serum within first 7
days of symptom onset, and convalescent
serum 14-35 days after symptom onset.
—Collect blood prior to antibiotic therapy
for Gram stain, culture, and PCR (if evidence
of systemic involvement).
—Swabs: Moisten with sterile
saline or water; transport in
sterile tube at 2 o-8 oC.
Transport swabs for PCR only
at –70oC. Do not use
transport medium.
—Tissue, fresh, >5 mm 3: Store
and transport at 2o-8 oC (<2
hr) or frozen at –70oC (>2 hr).
—Tissue, preserved in 10%
buffered formalin, 1.0 cm 3:
Store and transport at room
temperature.
—Biopsy of lesions for
histopathology, preserved in
10% buffered formalin, 0.3
mm diameter: Store and
transport at room
temperature.
—Freeze serum after
separation at –20oC or colder,
ship on dry ice. Ship part of
sample (>1.0 mL) and retain
part in case of shipping
problems.h
—Obtain blood for culture per
local protocol. Collect blood
for PCR in EDTA (purple top)
tube. Transport at room
temperature (<2 hr transport
time) or 2-8oC (>2 hr transport
time).
36/105
Inhalational —Obtain blood prior to antibiotic therapy
anthraxg for smear, culture, and PCR.
—Collect sputum (if being produced) for
Gram stain and culture (note: inhalational
anthrax does not usually result in sputum
production).
—If a pleural effusion is present, collect a
specimen for Gram stain, culture, and PCR.
—Collect CSF if meningeal signs are present
or meningitis is suspected for Gram stain,
culture, and PCR.
—Serum: Collect acute serum within first 7
days of symptom onset, and convalescent
serum 14-35 days after symptom onset.
—Biopsy material: Bronchial or pleural
biopsy material can be evaluated by IHC
testing, if available.
—Sputum: transport at room
temperature in sterile, screw-
capped container (<1 hr
transport time) or at 2o-8 oC
(>1 hr transport time).
—Blood cultures: Obtain
appropriate blood volume,
number, and timing of sets
per laboratory protocol;
transport at room
temperature. (<2 hr transport)
or 2°-8oC (>2 hr transport).
—Blood for PCR: 10 mL in
EDTA (purple top) tube (for
pediatric patients, collect
volumes allowable). Transport
directly to laboratory at room
temperature (<2 hr transport)
or 2°-8oC (>2 hr transport).
—Pleural fluid: Collect >1.0 mL
in sterile container; store and
transport at 2°-8oC.
—CSF: Transport directly to
laboratory at room
temperature (<2 hr transport)
or 2°-8oC (>2 hr transport).
—Transport serum or citrated
plasma (separated and
removed from clot) at 2°-8oC
(transport <2 hr) or freeze at –
20oC or colder (transport >2
hr); ship on dry ice. Ship part
of sample (>1.0 mL) and retain
part in case of shipping
problems.h
—Preserve biopsies in 10%
buffered formalin, and
transport at room
temperature.
37/105
 Gastrointestinal —Collect blood for Gram stain, culture, and —Stool: Transport in sterile
anthraxg PCR. Blood cultures are most likely to yield container unpreserved (<1 hr
B anthracis if taken 2-8 days postexposure transport time) or at 2o-8 oC in
and prior to administration of antibiotics. Cary-Blair medium or
—Collect stool specimen for culture and equivalent (>1 hr transport
PCR (>5.0 g). time); specimen >5.0 g.
—Collect rectal swab for culture and PCR —Blood: Transport at room
from patients unable to produce stool temperature (<2 hr transport)
(insert swab 1 in. beyond anal sphincter). or 2°-8oC (>2 hr transport).
—If ascites is present, obtain a specimen for
Gram stain and culture (and possibly PCR
testing).
—Collect swab from oropharyngeal lesions
(if present) for Gram stain, culture, and PCR.
—Serum: Collect acute serum within first 7
days of symptom onset, and convalescent
serum 14-35 days after symptom onset.

Anthrax —Collect CSF specimen for Gram stain,
meningitis culture, and PCR.
—Collect blood prior to antibiotic therapy
for Gram stain, culture, and PCR.
—Blood cultures: Obtain
appropriate blood volume,
number, and timing of sets
per laboratory protocol;
transport at room
temperature (<2 hr transport)
or 2-8oC (>2 hr transport).

Abbreviations: CSF, cerebrospinal fluid; EDTA, ethylenediaminetetraacetic acid; IHC,

immunohistochemistry; PCR, polymerase chain reaction.

aASM 2013.
bASM 2012.
cBell 2002.
dCDC: Algorithm for laboratory diagnosis of anthrax.
eSerologic testing may be useful in certain situations for retrospective diagnosis, since

antibodies take several weeks to develop.

fConsult with testing laboratory for specific instructions.
gCDC: Recommended specimens for microbiology and pathology for diagnosis: inhalation,

cutaneous, and gastrointestinal anthrax.

hCDC. Anthrax: collecting, preparing, and shipping serum samples to CDC for serology testing.

Guidelines have been published for packing and shipping of infectious substances,
diagnostic specimens, and biological agents from suspected acts of bioterrorism (ASM
2012).

Back to top
38/105
Laboratory Biosafety
B anthracis may be present in blood, skin-lesion exudates, cerebrospinal fluid, pleural
fluid, sputum, and rarely, in urine and feces. The primary hazards to laboratory
personnel are: direct and indirect contact of broken skin with cultures and
contaminated laboratory surfaces, accidental parenteral inoculation, and, rarely,
exposure to infectious aerosols. To avoid production of aerosols, work with infectious
organisms should be done in a biosafety cabinet. In addition, all centrifugation should
be done using aerosol-tight rotors that are opened within the biosafety cabinet after
each run (CDC 2007).
Because B anthracis cells present in clinical samples are primarily vegetative and not
easily transmitted to clinical laboratory workers, BSL-2 practices, containment
equipment, and facilities are recommended for activities using clinical materials and
diagnostic quantities of infectious cultures. BSL-2 practices, containment equipment,
and facilities are recommended for studies using experimentally infected laboratory
rodents (CDC 2007).
BSL-3 practices, containment equipment, and facilities are recommended for work
involving production quantities or high concentrations of cultures, screening
environmental samples (especially powders) from anthrax-contaminated locations,
and activities with a high potential for aerosol production. Workers who frequently
centrifuge B anthracis suspensions should use autoclavable aerosol-tight rotors ( CDC
2007).

Hospital laboratories are not sufficiently staffed, trained, or equipped for

environmental sample testing. This testing should be performed at the nearest LRN
reference laboratory under BSL-3 conditions.

Anthrax spores may remain viable after standard DNA purification procedures
(Rantakokko-Jalava 2003). Experimental heat treatment of anthrax spores at 121 oC for
45 minutes appears to eliminate viability without significantly affecting polymerase
chain reaction (PCR) efficiency (Fasanella 2003). Spores also can be irradiated with
gamma rays to inactivate them without affecting PCR results (Dauphin 2008).
Inadvertent exposure to B anthracis spores occurred in 2004 in a California laboratory
when workers used a suspension from a contract laboratory that was supposed to
contain nonviable vegetative cells but actually contained viable B anthracis spores
(CDC 2005: Inadvertent laboratory exposure to Bacillus anthracis). Following this
report, the CDC stated that "Research laboratory workers should assume that all
inactivated B anthracis suspension materials are infectious until inactivation is
adequately confirmed."

Back to top

39/105
Biosecurity Information
B anthracis is classified under WHO risk group 3. Cultures of B anthracis must be
transported as "Category A infectious substances." The US Department of
Transportation regulations and International Air Transport Association (IATA) rules
require training of all individuals involved in the transport of dangerous goods,
including infectious substances (DOT and IATA 2012).
B anthracis is classified as a select agent and therefore is regulated under 42 CFR Part
73 (Possession, Use, and Transfer of Select Agents and Toxins), which was published in
final form in the Federal Register in March 2005 and amended in October 2012 (HHS
2012). As specified in the Public Health Security and Bioterrorism Preparedness and
Response Act of 2002, 42 CFR Part 73 provides requirements for laboratories that
handle select agents (including registration, security risk assessments, biosafety plans,
security plans, emergency response plans, training, transfers, record keeping,
inspections, and notifications). Effective April 3, 2013, B anthracis will be considered a
Tier 1 agent and subject to additional security requirements. (HHS 2012) Select agents
are biological agents designated by the US government to be major threats to public
health and safety. A current list of select agents is published on the CDC Web site
under information about the Select Agent Program (CDC/APHIS 2008). In addition, the
CDC has published additional guidelines for enhancing laboratory security for
laboratories working with select agents (CDC 2002: Laboratory security and
emergency response guidance for laboratories working with select agents).

Back to top

The Laboratory Response Network (LRN)

The LRN is a network of more than 150 national and international laboratories. The network
includes federal, state, and local public health, military, food testing, environmental,
veterinary, and international laboratories (CDC: Facts about the Laboratory Response
Network, CDC: Laboratory Response Network [The]).

The LRN structure for bioterrorism designates laboratories as sentinel, reference, or

national. Designation depends on the types of tests a laboratory can perform and how it
handles infectious agents to protect workers and the public.

Sentinel laboratories, formally called "level A laboratories,"represent an estimated

25,000 hospital-based laboratories that have direct contact with patients. In an
unannounced or covert terrorist attack, sentinel laboratories could be the first facilities
to encounter suspicious specimens. These laboratories generally have at least BSL-2
containment capabilities. A sentinel laboratory's responsibility is to rule out B anthracis
or refer a suspicious sample to the nearest LRN reference laboratory. Sentinel
laboratories use the ASM Sentinel Level Clinical Microbiology Laboratory Guidelines to
40/105
 rule out microorganisms that might be suspected as agents of bioterrorism (ASM:
Sentinel level clinical microbiology laboratory guidelines).
Reference laboratories, sometimes referred to as "confirmatory reference," can
perform tests to detect and confirm the presence of a threat agent. These laboratories
ensure a timely local response in the event of a terrorist incident. Rather than having
to rely on confirmation from laboratories at the CDC, reference laboratories are
capable of producing conclusive results; this allows local authorities to respond quickly
to emergencies. These are mostly state or local public health laboratories but also
include military, international, veterinary, agriculture, and food- and water-testing
laboratories. Reference laboratories operate with BSL-3 containment facilities that
have been given access to nonpublic testing protocols and reagents. One of the roles
of the LRN reference laboratories is to provide guidance, training, outreach, and
communications to the sentinel laboratories in their jurisdictions.
National laboratories have unique resources to handle highly infectious agents and the
ability to identify specific agent strains through molecular characterization methods.
These laboratories also are responsible for methods development, bioforensics, and
select-agent activity.

Back to top

Standard Tests for Detection of B anthracis

The ASM Sentinel Level Clinical Microbiology Laboratory Guidelines for Bacillus anthracis (ASM
2013) are the approved clinical laboratory procedures to isolate and rule out B anthracis.
Current standard tests for detection of B anthracis are outlined in this document.When B
anthracis cannot be ruled out, sentinel laboratories should contact their LRN reference
laboratory and isolates should be referred for confirmation testing.

Back to top

Additional Tests
PCR-based assays for rapid identification of B anthracis:
A real-time PCR assay for rapid identification of B anthracis was evaluated by the
CDC during the 2001 anthrax outbreak (Hoffmaster 2002: Evaluation and
validation of a real-time polymerase chain reaction assay for rapid identification
of Bacillus anthracis, Hoffmaster 2002: Supplement to above).
Real-time PCR assays capable of detecing multiple agents have been developed
for detection of B anthracis, Francisella tularensis, and Yersinia pestis in a single
assay without any cross-reactivity. The assay may prove useful as a rapid tool for
detection of category A bioterrorism agents (Skottman 2007). Commercial ready-
to-use reagent systems have been developed for use in PCR assays (Sohni 2008).

41/105
 PCR primers that distinguish B anthracis from related Bacillus species have been
developed. The primers may be useful for developing an efficient diagnostic tool
for rapid identification (Kim 2008). A restriction site insertion–PCR (RSI-PCR)
method can distinguish B cereus group strains closely related to B anthracis from
B anthracis strains (Gierczynski 2007).
IHC is a sensitive and specific method for detection of B anthracis in affected tissues
that uses antibody directed against cell-wall and capsule components. This test is
unaffected by prior administration of antibiotics or formalin fixation (Guarner 2003,
Shieh 2003). IHC is not widely available, but requests for testing can be made by
contacting an LRN reference laboratory prior to specimen collection.
Molecular subtyping(multilocus variable-number tandem repeat analysis [MLVA]), is
used by the CDC and others for strain identification and tracking (Hoffmaster 2002:
Molecular subtyping of Bacillus anthracis and the 2001 bioterrorism-associated
anthrax outbreak, United States, Keim 1999, Keim 2000). Applications of single
nucleotide polymorphism (SNP) and MLVA also have been used to discriminate closely
related B anthracis isolates during outbreaks in animals. The combined SNP-MLVA
analysis may hold promise for use in forensic investigations (Kenefic 2008).

Serologic testing for anti-PA antibodies can be used for retrospective diagnosis.

During the 2001 anthrax outbreak, the CDC developed, optimized, and qualified an
enzyme-linked immunosorbent assay (ELISA) for IgG antibodies to B anthracis PA
(Quinn 2002). The diagnostic sensitivity of the assay was 97.8% and the diagnostic
specificity was 97.6%; a competitive inhibition anti-PA IgG ELISA enhanced the
diagnostic specificity to 100%.
Serum should be collected at 0 to 7 days for acute-phase testing and at 14 to 28 days
for convalescent-phase testing.
Development of measurable antibodies in confirmed cases required 10 to 16 days
after onset of overt disease, but peak IgG levels may not be seen until 40 days after
symptom onset (Bell 2002).
Requests for serologic testing can be made by contacting an LRN reference laboratory
prior to specimen collection.
The Anthrax QuickELISA, a simplified lateral-flow immunochromatographic assay for
anthrax antibody, has received approval from the Food and Drug Administration
(FDA). The test, developed by Immunetics in collaboration with the CDC, has a
diagnostic sensitivity and specificity of 100%, and is commercially available. Positive
results on paired sera (-/+ or +/+) should be sent to the CDC for quantitative
confirmation (Biagini 2006, CDC 2004:CDC collaboration yields new test for anthrax,
Stephenson 2004).

Other tests for detection of B anthracis infection:

42/105
 Testing for toxins (particularly LF) in the serum has been used in an outbreak setting
to identify acute cutaneous infections that were culture negative due to prior antibiotic
use (Boyer 2011). Investigators demonstrated that toxins can be detected in the serum
relatively early in the clinical course before antibodies to PA are detectable. They
concluded that although skin lesions remain relatively localized, in many cases of
cutaneous anthrax toxins are secreted into the blood in sufficient quantity to be
measured during the acute phase of infection; therefore, toxin testing (if available)
may be a useful tool to confirm infection when B anthracis cannot be cultured or
visualized by staining methods.

A skin test for delayed-type hypersensitivity to anthrax antigen has been widely used
in the former Soviet Union since 1962 for retrospective diagnosis of human and
animal anthrax infection and for vaccine evaluation. An 81.5% positivity rate has been
reported during the first 3 days of disease; this increases to 97% to 99% within the
next 2 to 3 weeks. Anthraxin, as the product is called, is not available in the United
States and has not been evaluated in this country (Pfisterer 1991, Shlyakhov 1996,
WHO 1998).

Antimicrobial susceptibility testing should be performed on clinical isolates at LRN reference

laboratories or the CDC. Clinical Laboratory Standards Institute (CLSI) protocols for broth
microdilution have been used with staphylococcal breakpoints (Coker 2002).

Back to top

Antimicrobial Susceptibility Studies

Several studies have examined antimicrobial susceptibilities of B anthracis strains to various
antibiotics. Data from four such studies are shown in the table below. Naturally occurring
ciprofloxacin or doxycycline resistance has not been described, but isolates resistant to
each of these antibiotics have been acquired in vitro (Brook 2001, Price 2003). Because
resistance can be induced relatively rapidly in vitro, close monitoring of patients treated for
anthrax is important (Athamna 2004).

MICs of Various Antibiotics for Bacillus anthracis Isolates as Identified in Four Studies

STUDYa

Coker 2002 Cavallo 2002 Turnbull Luna 2007

2004

Antibiotic MIC S-I-R MIC S-I-R MIC S-I-R MIC S-I-R

rangeb (#) c rangeb (%)c ranged (%)c ranged (%)c

43/105
Amoxicillin 0.125- 88.5-0-
16 11.5

Amoxicillin– 0.016- 100-

clavulanic acid 0.5 0-0

Ampicillin 0.016- 100-

0.032 0-0

Azithromycin 1-12 26-

64-10

Aztreonam 1->128 0-0-100

Cefaclor 0.125- 25-0-

0.75 0

Cefotaxime 3-32 1-0-

99

Cefoxitin 1-64 74-15.3-

10.7

Ceftriaxone 4-64 1-100-0

Cefuroxime 6-48 1-19-

5

Cephalexin 0.38-2 25-0-

0

Cephalothin 0.125- 83.2-

32 12.2-
24.6

44/105
Chloramphenicol 1-4 100-0-0 0.75-4 100-
0-0

Ciprofloxacin 0.032- 25-0- 0.03- 100-0-0 0.032- 100- 0.023- 100-

0.38 0 0.5 0.094 0-0 0.064 0-0

Clindamycin 0.125-1 100-0-0 0.064- 100-

.0125 0-0

Doxycycline 0.094- 25-0- 0.125- 100-0-0

0.38 0 0.25

Erythromycin 0.5-4 95.4-4.6- 0.5-4 15- 0.25-1 15-3-

0 85-0 0

Gatifloxacin 0.125- 100-0-0 0.016- 100-

0.125 0.047 0-0

Gentamicin 0.125- 100-0-0 0.064- 100- 0.032- 100-

0.5 0.5 0-0 0.19 0-0

Imipenem 0.125-2 100-0-0

Levofloxacin 0.03-1 100-0-0 0.064- 100-

0.125 0-0

Moxiflaxacin 0.016- 100-

0.094 0-0

Nalidixic acid 0.125- 94.8-4.2-

32 1

Ofloxacin 0.06-2 99-1-0

Oxacillin 0.047- 100-

0.5 0-0

45/105
Penicillin <0.016- 22-0- 0.125- 88.5-0- <0.016- 97-0- 0.008- 100-
0.5 3 16 11.5 >32 3 0.032 0-0

Pefloxacin 0.03-1 100-0-0

Piperacillin 0.25-32 99-1-0

Quinupristin/ 0.25-2 100-

dalfopristin 0-0

Rifampin 0.125- 100-0-0 0.064- 100-

0.5 0.5 0-0

Streptomycin 0.5-2 100-0-0

Teicoplanin 0.125- 100-0-0

0.5

Tetracycline 0.016- 100- 0.016- 100-

0.094 0-0 0.047 0-0

Tobramycin 0.25- 25-0-

1.5 0

Trimethoprim/ >32 0-0-

sulfamethoxazole 100

Vancomycin 0.25-2 100-0-0 0.75-5 99-1- 0.5-2 100-

0 0-0

46/105
 Abbreviation: MIC, minimum inhibitory concentration; S-I-R, susceptible, intermediate, and
resistant.

a See References: Cavallo 2002, Coker 2002, Luna 2007, Turnbull 2004.
bMIC values in mcg/mL.
c Categorical interpretation: susceptible (S), intermediate (I), and resistant (R); expressed as

percent of isolates (%) or number of isolates (#), per author preference. (Note: Standard
interpretive criteria for B anthracis have not been established.)
dMIC determination by Etest.
eA subset of 20 isolates were tested and found to be susceptible to clinafloxacin, gatifloxacin,

gemifloxacin, levofloxacin, moxifloxacin, ofloxacin, sparfloxacin, and trovafloxacin.

fA subset of 20 isolates were also tested to clarithromycin (MIC range: 0.12-0.25 mcg/mL),

azithromycin (MIC range: 1-2 mcg/mL), and doxycycline (MICs < 0.015 mcg/mL).

Multiple new antifolate compounds (multiple 2, 4-diaminopyrimidine derivatives, a class of

compounds with dihydrophthalazine side chains) have demonstrated in vitro activity against
trimethoprim (TMP)–resistant B anthracis and have the potential to become the basis of
clinically important antibacterial therapies (Barrow 2007).

Antimicrobial susceptibility testing (AST) requires time for the growth of the organism. A
rapid AST for B anthracis recently has been described (Weigel 2010). With this test, a broth
microdilution method is combined with a real-time quantitative PCR method to yield
comparable results in less than 6 hours.

Back to top

Tests for Exposure

Nasal swab cultures were used in the 2001 US outbreak as an epidemiologic tool to assess
exposure to aerosolized B anthracis spores. In one study of 625 persons potentially exposed
to anthrax spores in the Hart Senate Building, nasal swabs were positive in 28 (4.5%) (Hsu
2002).

All positive swabs were identified from persons who were in the immediate exposure
area during the hour after the contaminated letter was opened. Seventy-one persons
were in the exposure area during this time; therefore, the percentage of positive
swabs among this group was 39% (28 of 71). Swabs from the 71 persons who were in
the immediate area were obtained the day of exposure.
Swabs collected from persons other than those in the immediate area were collected
4 days after exposure; all were negative.
All exposed persons were placed on antimicrobial therapy, and repeat nasal swaps
obtained 7 days later were negative. Results of serologic testing at 7, 21, and 42 days
after exposure were negative for all exposed persons.
47/105
Another study at a worksite where a contaminated letter was opened demonstrated that
two (<1%) of 1,076 nasal swabs taken from potentially exposed persons were positive;
however, these swabs were obtained about 13 days after exposure (Traeger 2002). Similarly,
all nasal swabs collected 9 to 10 days after exposure from 3,110 postal employees at a
Washington, DC, postal facility that handled contaminated mail were negative (Dewan 2002).
These findings, along with the findings from nasal swab testing of persons exposed in the
Hart Senate Building, suggest that early collection of nasal swabs results in a higher yield of
positive tests.

Because the sensitivity, specificity, and predictive value of nasal swab cultures are not
known, nasal swabs are not recommended for use in the clinical setting. According to the
CDC (CDC 2001: Interim guidelines for investigation of and response to Bacillus anthracis
exposures), collection of nasal swabs is not indicated to:

Diagnose anthrax
Determine risk of exposure and the need for antimicrobial prophylaxis
Determine when antimicrobial prophylaxis should be stopped
Supplement random environmental sampling

Although nasal swabs should not be used to determine the need for antimicrobial
prophylaxis, if a swab is performed for some reason and is positive, then the patient should
receive a course of postexposure antibiotics, since a positive nasal swab indicates exposure
to aerosolized B anthracis (Inglesby 2002). Methods for collection, labeling, transport, and
processing of swabs have been published (ASM 2012).

Serologic testing does not appear to be a useful tool for assessing asymptomatic exposure
to B anthracis unless it is being used as part of an epidemiologic study (Dewan 2002, Hsu
2002, Traeger 2002).

Back to top

Treatment and Postexposure Prophylaxis

Treatment
Postexposure Prophylaxis
New Therapeutic Approaches

Treatment
Anthrax countermeasures include antibiotics (for treatment and postexposure prophylaxis
[PEP]), antibodies, antitoxin agents, and vaccines. The tables below review available
treatment recommendations for clinical disease caused by B anthracis.

48/105
Protocol for Treatment of Cutaneous Anthraxa-c

Patient Category Initial Therapy (Oral)d Duratione

Adults Ciprofloxacin: 500 mg PO twice daily 60 days

or
Doxycycline: 100 mg PO twice daily

Children Ciprofloxacin: 10-15 mg/kg PO twice daily (maximum 60 days

daily dose, 1 g)
or
Doxycyclinef:
>8 yr and >45 kg: same as adult
>8 yr and <45 kg: 2.2 mg/kg PO twice daily
<8 yr: 2.2 mg/kg PO twice daily

Pregnant women g Same as for nonpregnant adults (high death rate from 60 days
the infection outweighs risk posed by antimicrobial
agent)

Immunocompromised Same as for nonimmunocompromised persons and 60 days

persons children

49/105
Abbreviation: PO, orally.

aThese treatment recommendations were made during the US 2001 anthrax outbreak. In other
settings, antimicrobial susceptibility testing should be used to guide therapy decisions.
bCutaneous anthrax cases with signs of systemic involvement, extensive edema, or lesions on

the head or neck require intravenous therapy, and a multidrug approach is recommended (see
table just below).
cTreatment of cutaneous anthrax does not prevent the evolution of the skin lesions; however, it

usually will prevent progression to systemic disease (Inglesby 2002).

dCiprofloxacin or doxycycline should be considered first-line therapy. Amoxicillin (500 mg orally

3 times daily for adults or 80 mg/kg/day divided every 8 hr for children) is an option for
completion of therapy after clinical improvement. Oral amoxicillin dose is based on need to
achieve appropriate minimum inhibitory concentration.
eIn cases of naturally occurring cutaneous anthrax, previous recommendations have indicated

that treatment for 7 to 10 days is adequate; however, in the setting where inhalational exposure
also is likely, treatment should be continued for 60 days.
fThe American Academy of Pediatrics recommends treatment of young children with

tetracyclines for serious infections (eg, Rocky Mountain spotted fever).

gAlthough tetracyclines and ciprofloxacin are not recommended for pregnant women, their use

may be indicated for life-threatening illness. Adverse effects on developing teeth and bones are
dose-related; therefore, doxycycline might be used for a short time (7-14 days) before 6 months
of gestation.

Adapted from CDC 2001: Investigation of bioterrorism-related anthrax and interim guidelines for
exposure management and antimicrobial therapy, October 2001.

Protocol for Treatment of Inhalational and Gastrointestinal Anthraxa

Patient Category Initial IV Therapyb,c Oral Regimens (continue

therapy for 60 days [IV and PO
combined])

Adults Ciprofloxacin: 400 mg twice daily Patients should be treated with IV

or
Doxycycline: 100 mg twice daily e
and
One or two additional
antimicrobials (agents with in
vitro activity include rifampin,
vancomycin, penicillin, ampicillin,
chloramphenicol, imipenem,
clindamycin, and clarithromycin)f
therapy initially.d
Treatment can be switched to oral
therapy when clinically
appropriate:
Ciprofloxacin: 500 mg PO twice
daily
or
Doxycycline: 100 mg PO twice daily

50/105
Children Ciprofloxacin: 10-15 mg/kg twice
daily (maximum daily dose, 1 g)g
or
Doxycyclinee,h :
>8 yr and >45 kg: same as adult
>8 yr and <45 kg: 2.2 mg/kg
twice daily
<8 yr: 2.2 mg/kg twice daily
and
One or two additional
antimicrobials (see agents listed
under therapy for adults)f
Pregnant women i Same as for nonpregnant adults
(high death rate from the
infection outweighs risk posed
by antimicrobial agent)
Immunocompromised Same as for
persons nonimmunocompromised
persons and children.
Patients should be treated with IV
therapy initially.d
Treatment can be switched to oral
therapy when clinically
appropriate:
Ciprofloxacin: 10-15 mg/kg PO
twice daily (maximum daily dose, 1
g)
or
Doxycyclineh:
>8 yr and >45 kg: same as adult
>8 yr and <45 kg: 2.2 mg/kg PO
twice daily
<8 yr: 2.2 mg/kg PO twice daily
Patients should be treated with IV
therapy initially. d Treatment can
be switched to oral therapy when
clinically appropriate. Oral therapy
regimens are the same as for
nonpregnant adults.
Same as for
nonimmunocompromised persons
and children.
51/105
 Abbreviations: IV, intravenously; PO, orally.

aMeningitis involvement must be assumed in all systemic infections. Antibiotic selection must
consider penetration across blood-brain barrier (Stern 2008). These treatment
recommendations were made during US 2001 anthrax outbreak. In other situations,
antimicrobial susceptibility testing should be used to guide therapy decisions.
bCiprofloxacin or doxycycline should be considered an essential part of first-line therapy for

inhalational anthrax.
cSteroids may be considered an adjunct therapy for patients with severe edema (Doust 1968)

and for meningitis based on experience with bacterial meningitis of other causes.
dInitial therapy may be altered based on clinical course of patient; one or two antimicrobial

agents (eg, ciprofloxacin or doxycycline) may be adequate as patient improves.

eIf meningitis is suspected, doxycycline may be less optimal because of poor central nervous

system penetration.
fBecause of concerns of constitutive and inducible beta-lactamases in B anthracis isolates,

penicillin and ampicillin should not be used alone. Consultation with an infectious disease
specialist is advised. Other agents with in vitro activity include tetracycline, linezolid, macrolides,
aminoglycosides, and cefazolin (Inglesby 2002). B anthracis strains are naturally resistant to
sulfamethoxazole, trimethoprim, cefuroxime, cefotaxime sodium, aztreonam, and ceftazidime
(Inglesby 2002).
gIf IV ciprofloxacin is not available, oral ciprofloxacin may be acceptable because it is rapidly and

well absorbed from gastrointestinal tract with no substantial loss by first-pass metabolism.
Maximum serum concentrations are attained 1-2 hr after oral dosing but may not be achieved if
vomiting or ileus is present.
hThe American Academy of Pediatrics recommends treatment of young children with

tetracyclines for serious infections (eg, Rocky Mountain spotted fever).

iAlthough tetracyclines are not recommended for pregnant women, their use may be indicated

for life-threatening illness. Adverse effects on developing teeth and bones are dose-related;
therefore, doxycycline might be used for a short time (7-14 days) before 6 months of gestation.

Adapted from CDC 2001: Investigation of bioterrorism-related anthrax and interim guidelines for
exposure management and antimicrobial therapy, October 2001, Stern 2008.

A systematic review of inhalational anthrax cases identified between 1900 and 2005
reported the following observations with regard to treatment (Holty 2006: Systematic
review: a century of inhalational anthrax cases from 1900 to 2005).

Initiation of therapy with antibiotics or anthrax antiserum during the prodromal phase
was associated with improved survival.
Patients who progressed to the fulminant phase, regardless of therapy, had a very
high case-fatality rate (97%).
Multidrug antibiotic therapy and pleural fluid drainage were associated with
decreased mortality; however, since these modalities were predominantly used during
the 2001 US anthrax outbreak, other confounding factors (eg, differences in patient
characteristics, anthrax exposure, supportive care, antibiotic efficacy) may have
52/105
 contributed to enhanced overall survival.

Because mortality for inhalational anthrax remains high despite use of antibiotics, potential
adjuvant therapies are being studied. Examples include gamma and alpha/beta interferon
and adefovir (Gold 2004, Shen 2004). As noted above, drainage of pleural fluid (through
repeated thoracentesis or chest tube drainage) may enhance survival in cases of
inhalational anthrax (Holty 2006: Systematic review: a century of inhalational anthrax cases
from 1900 to 2005).

Raxibacumab is a human monoclonal antibody directed against PA. The efficacy of

raxibacumab for the treatment of inhalational anthrax has been evaluated in rabbits and
monkeys. Following inhalational challenge, the survival rate was significantly higher among
rabbits that received a 40 mg/kg dose of raxibacumab (44%; 8 of 18) than among rabbits
that received placebo (0%; 0 of 18). Treated monkeys also had significantly increased
survival (64%, 9 of 14) compared with untreated monkeys (0%, 0 of 12) (Migone 2009).

Treatment of Anthrax Meningitis

Anthrax meningitis is treated in similar fashion to inhalational anthrax, although initial
treatment should include an intravenous (IV) fluoroquinolone and not doxycycline, because
doxycycline has poor central nervous system (CNS) penetration. In addition to an IV
fluoroquinolone, one or two other agents that have good CNS penetration and activity
against B anthracis should be added (eg, penicillin, ampicillin, meropenem, vancomycin,
rifampin) (Sejvar 2005). Case reports suggest that adding corticosteroids may be of benefit
in the management of cerebral edema/inflammation (Sejvar 2005).

The optimal duration of therapy is not known, but treatment should be continued for 10 to
14 days or as long as is clinically indicated.

Back to top

Postexposure Prophylaxis
The CDC currently recommends 60 days of oral antimicrobial therapy in combination with a
three-dose series of anthrax vaccine adsorbed (AVA) for PEP following potential inhalational
exposure to aerosolized B anthracis spores (Stern 2008).

Antimicrobial therapy should be continued for at least 60 days for the following persons:

Those exposed to an air space known to be contaminated with aerosolized B anthracis

Those exposed to an air space known to be the source of an inhalational anthrax case
Those along the transit path of an envelope or other vehicle containing B anthracis
that may have been aerosolized (eg, a postal sorting facility in which an envelope
containing B anthracis was processed)
53/105
 Unvaccinated laboratory workers exposed to confirmed B anthracis cultures in
situations where aerosolization is suspected

Antimicrobial prophylaxis is not indicated for the following:

Prevention of cutaneous anthrax

Autopsy personnel examining bodies infected with anthrax when appropriate isolation
precautions and procedures are followed
Hospital personnel caring for patients with anthrax
Persons who routinely open or handle mail (in the absence of a suspicious letter or
credible threat)

The decision to prescribe PEP to asymptomatic persons in the setting of an outbreak of

inhalational anthrax should be based on the likelihood of exposure and not on nasal swab
testing (see Tests for Exposure in the Clinical Laboratory Testing section).

In the event of a mass exposure, local and state public health agencies would rapidly make
antibiotics available to the exposed population (see the discussion of mass exposure in the
Management of Exposure Events section).

Since experience with gastrointestinal anthrax is limited, currently there are no

recommendations for using PEP in the setting of gastrointestinal exposure, such as in a
foodborne outbreak or intentional contamination of a food source. However, if public health
officials determine that the risk of B anthracis infection is high, it may be reasonable to
consider using PEP in the setting of gastrointestinal exposure (CDC 2000:Human ingestion of
Bacillus anthracis-contaminated meat).

The FDA has approved several antimicrobial agents for use as anthrax PEP (FDA: Products
approved for anthrax, Meyerhoff 2004).

Ciprofloxacin
Doxycycline
Penicillin G procaine
Levofloxacin

Analysis of published reports suggests that development of antibiotic resistance may be less
likely to occur with doxycycline than with fluoroquinolones. In addition, doxycycline is
several times less expensive than most fluoroquinolones and appears in clinical studies to
have similar efficacy in most scenarios (Brouillard 2006). An in vitro analysis of five
antibiotics found that doxycycline was more effective against spore-forming B anthracis and
least effective against vegetative-phase B anthracis. For vegetative-phase B anthracis,
meropenem was the most effective antibiotic (Louie 2011: Impact of spores on the
comparative efficacies of five antibiotics for the treatment of Bacillus anthracis in an in vitro
hollow fiber pharmacodynamic model). Other antimicrobial agents, including clindamycin,
54/105
chloramphenical, rifampin, vancomycin, and other fluoroquinolones, may be considered for
off-label use in patients unable to tolerate FDA-approved antimicrobial agents for PEP (Stern
2008). In an in vitro analysis, linezolid was found to work as well as ciprofloxacin and it also
prevented toxin production (Louie 2011: Differential effect of linezolid and ciprofloxacin on
toxin production by Bacillus anthracis in an in vitro pharmacodynamic system). Athamna
and colleagues found that the combination of rifampin and clindamycin demonstrated a
synergistic effect in vitro against two strains of B anthracis (Athamna 2005). A number of
other combinations were either indifferent or antagonistic.

The CDC recommendations for PEP to prevent inhalational anthrax (those issued during the
2001 bioterrorism anthrax attack as well as later modifications) are outlined in the table
below.

Initial CDC Recommendations for PEP for Prevention of Inhalational Anthrax

Following Exposure to Bacillus anthracis

Patient Category Initial Therapy Durationa

Adults (including Ciprofloxacin: 500 mg PO twice daily 60 days

immunocompromised or
patients) Doxycycline: 100 mg PO twice daily
or
Levofloxacin: 500 mg PO once daily
[Note: Levofloxacin is FDA-approved for PEP for
inhalational anthrax in adults >18 years; however, data
on the safety of using levofloxacin beyond 28 days are
limited. Therefore, levofloxacin is recommended as a
second-line PEP agent, to be reserved for instances in
which medical issues call for its use (FDA: Levaquin
[levofloxacin] information for inhalational anthrax, Stern
2008).]

Pregnant women and Ciprofloxacin: 500 mg PO twice daily (first-line oral agent 60 days
breastfeeding for PEP in pregnant women.)
mothers or
Doxycycline: 100 mg PO twice daily (In pregnant women,
doxycycline should be used only during the third
trimester.)
[Note: Amoxicillin, 500 mg orally three times daily, may
be used if isolate involved in exposure is determined to
be susceptible to penicillin.b-d]

55/105
Children (including Ciprofloxacin: 10-15 mg/kg PO twice daily (maximum 60 days
immunocompromised daily dose, 1 g)
patients) or
Doxycycline:
>8 yr and >45 kg: same as adult
>8 yr and <45 kg: 2.2 mg/kg PO twice daily
<8 yr: 2.2 mg/kg PO twice daily
[Note: Amoxicillin, 80 mg/kg/day divided every 8 hr not to
exceed 500 mg/dose, may be used if the isolate involved
in exposure is determined to be susceptible to
penicillinc]
or
Levofloxacin: 500 mg PO once daily for children >50 kg,
or 8 mg/kg twice daily (not to exceed 250 mg per dose)
for children <50 kg.
[Note: In May 2008, the FDA approved the use of
levofloxacin for PEP for inhalational anthrax in children.
As noted above for adults, data on the safety of using
levofloxacin beyond 28 days are limited. In addition,
levofloxacin may cause an increase in musculoskeletal
adverse events in children (FDA: Levaquin [levofloxacin]
information for inhalational anthrax).]

56/105
 Abbreviation: FDA, Food and Drug Administration; PEP, postexposure prophylaxis; PO, orally.

aRecommended in combination with a 3-dose series of anthrax vaccine adsorbed (AVA)

(BioThrax [BioPort Corp, Lansing, MI]) administered at time zero, 2 weeks, and 4 weeks. AVA is
not FDA-approved for PEP and therefore would be available under an Investigational New Drug
(IND) protocol (Stern 2008). After the 2001 attack, exposed persons were subsequently given
the option to take an additional 40 days of antibiotics with or without anthrax vaccine; see
comments below. Other antimicrobial agents, including clindamycin, chloramphenical, rifampin,
vancomycin, and other fluoroquinolones, may be considered for off-label use in patients unable
to tolerate FDA-approved antimicrobial agents for PEP (Stern 2008).
bSee comments below from American College of Obstetricians and Gynecologists regarding use

of amoxicillin.
cAmoxicillin is not approved by the FDA for PEP or treatment of anthrax; however, the CDC has

indicated that it could be used for pregnant women or children for PEP if the isolate is
determined to be susceptible. In such situations, amoxicillin could be provided under an IND or
under an Emergency Use Authorization in a declared emergency (CDC 2001: Interim
recommendations for antimicrobial prophylaxis for children and breastfeeding mothers and
treatment of children with anthrax, CDC 2001: Updated recommendations for antimicrobial
prophylaxis among asymptomatic pregnant women after exposure to Bacillus anthracis, Stern
2008). A study to evaluate the pharmacokinetics of amoxicillin during pregnancy and
postpartum found that drug concentrations adequate to prevent anthrax may be difficult to
achieve during pregnancy and in the postpartum period (Andrew 2007). Amoxicillin given to
pediatric patients <40 kg should yield adequate time above the minimum inhibitory
concentration for susceptible B anthracis (0.5 mcg/mL) over most of the dosing interval
(Alexander 2008)
dThe American Academy of Pediatrics considers ciprofloxacin and tetracyclines to usually be

compatible with breastfeeding because the amount of either drug absorbed by infants is small,
but little is known about the safety of long-term use. Therefore, amoxicillin may be considered
an alternative for breastfeeding mothers if the isolate causing exposure is known to be
susceptible to penicillin. Alternatively, mothers could consider expressing and discarding breast
milk during therapy with ciprofloxacin or doxycycline and resuming breastfeeding after therapy
is complete.

Adapted from CDC 2001: Investigation of bioterrorism-related anthrax and interim guidelines for
exposure management and antimicrobial therapy, October 2001, Stern 2008.

More than 10,000 people were placed on PEP during the 2001 anthrax outbreak; no cases of
anthrax occurred among this group (CDC 2001: CDC responds: an update on treatment
options for postal and other workers exposed to anthrax).

A follow-up study of those persons who were offered antimicrobial prophylaxis

demonstrated that 5,343 took at least one dose of antimicrobial therapy (Shepard
2002). Of this group, 3,032 (57%) reported adverse events during the first 60 days of
therapy. Gastrointestinal complaints (nausea, vomiting, diarrhea, stomach pain) were
reported by 44% of those with adverse events and neurologic symptoms (headache,

57/105
 dizziness, light-headedness, fainting, and seizures) were reported by 33%. Fewer than
half of respondents (2,712 [44%]) reported taking antimicrobial prophylaxis for at least
60 days. Of the 2,631 persons who stopped therapy before 60 days, 43% stopped
because of adverse events, 25% stopped because of a low perceived risk of anthrax,
and 7% stopped because of concern about long-term side effects of prolonged
antimicrobial therapy.
A statistical model was used to estimate the number of anthrax cases prevented
among about 5,000 persons placed on prophylaxis who were potentially exposed to
airborne anthrax spores at one of three locations (the media center in Florida, the two
postal facilities in New Jersey, and the postal facility in Washington, DC). The model
suggested that about nine cases were prevented through the use of postexposure
antibiotics (Brookmeyer 2002).
Another model-based study explored the impact of initial response time, anthrax
incubation period, and antibiotic effectiveness on hospital surge after a large-scale
release of anthrax spores over a major urban area. If an antibiotic prophylaxis
campaign was begun within 2 days after the exposure event and completed within 48
hours, approximately 87% of exposed persons would be protected from illness
(assuming a 95% attack rate and 90% antibiotic effectiveness). On average, each
additional day of delay in initiating the campaign (beyond 2 days) would result in 5.2%
to 6.5% additional hospitalizations in the exposed population, whereas every
additional day needed to complete the campaign would result in 2.4% to 2.9%
additional hospitalizations. The authors concluded that commencement of the
prophylaxis campaign (no more than 3 days) and antibiotic effectiveness (greater than
90%) are the parameters with the greatest preventive impact (Hupert 2009).

The American College of Obstetricians and Gynecologists (ACOG) has recommended the
following for anthrax prophylaxis in pregnant women (ACOG 2002):

Prophylactic treatment should be limited to women who have been exposed to

confirmed environmental contamination or a high-risk source as determined by public
health authorities.
Pregnant women who have been exposed to anthrax should be started on a 60-day
course of ciprofloxacin.
Therapy should be switched to amoxicillin if the strain is found to be penicillin-
sensitive.

According to ACOG, doxycycline use in pregnant women generally should be avoided

because it can cause problems in fetuses, including staining of teeth and impeded bone
growth; however, doxycycline should be used for exposed pregnant women who are allergic
to amoxicillin and ciprofloxacin, since the risk of anthrax outweighs any potential risks to
the fetus from doxycycline.

Results of a recent nationally representative survey found that 89% of participants would be
58/105
very likely (65%) or somewhat likely (24%) to follow public health recommendations to
obtain postexposure prophylaxis medication for themselves within 48 hours of an anthrax
attack, and 91% indicated that they would be very or somewhat likely to obtain medication
for their children (SteelFisher 2011). Ninety percent of participants also believed that
inhalational exposure to anthrax spores can lead to a serious illness or death.

Back to top

New Therapeutic Approaches

In addition to available treatment protocols, a variety of promising new therapeutic
approaches for treatment of anthrax are being researched; many involve use of monoclonal
antibodies (Chen 2011, Froude 2011, Artenstein 2012)). An alternative to monoclonal
antibodies is antisera from previously vaccinated persons undergoing serial plasmapheresis.
Hyperimmune plasma and immune globulin isolated in this way could potentially serve as
the basis for new therapeutic treatments (Pittman 2006).

In 2005, the Department of Health and Human Services (HHS) awarded a contract to
Human Genome Sciences, Inc (HGS) of Rockville, Maryland, to provide the US
government with 10 grams of ABthrax (raxibacumab), a human monoclonal antibody
for treating anthrax (see Dec 19, 2005, CIDRAP News story). In June 2006, HHS
announced that it would purchase 20,000 treatment courses of ABthrax (HHS 2006:
HHS to acquire new anthrax therapeutic treatment for stockpile). In April 2009, HGS
finished delivery of the first 20,000 doses of ABThrax (HGS 2012). HHS then placed a
second order for an additional 45,000 doses of ABthrax, which is expected to be
delivered by the end of 2012 (HGS 2009).
HHS also has contracted with Elusys Therapeutics to evaluate its anthrax antitoxin
(humanized monoclonal antibody against PA), known as Anthim, for potential usage in
the SNS (HHS 2011: Novel anthrax vaccine and antitoxin being developed with federal
support).
Similarly, HHS has contracted with Cangene (a company based in Winnipeg, Manitoba)
to supply anthrax immune globulin (AIG) for preliminary efficacy testing. The company
describes AIG as a hyperimmune product for treating or preventing inhalational
anthrax. In July 2006, HHS announced that it will purchase 10,000 treatment courses of
AIG from Cangene (HHS 2006: HHS to acquire anthrax immune globulin for stockpile).
Cangene completed shipment of AIG to the SNS in the fourth quarter of 2011
(Cangene 2011).

Back to top

Vaccination

59/105
Current Anthrax Vaccine
Vaccine Efficacy
Recommendations for Use
Dosage, Route of Administration, and Vaccination Schedule
Contraindications and Precautions
Adverse Reactions
Postlicensure Adverse Event Reporting
Development of New Vaccines

Current Anthrax Vaccine

AVA (BioThrax), manufactured by BioPort, a subsidiary of Emergent BioSolutions, Inc
in Lansing, Michigan, is the only licensed human anthrax vaccine in the United States
(Emergent BioSolutions: BioThrax package insert).
Most AVA vaccine has been used by the US military; it is not available to the general
public (except through public health officials during an anthrax emergency as part of
the SNS).
AVA is prepared from cell-free filtrates of microaerophilic cultures of an avirulent,
nonencapsulated strain of B anthracis. The final product contains no live or dead
bacteria.
The final product is formulated to contain 1.2 mg/mL aluminum, added as aluminum
hydroxide in 0.85% sodium chloride.
The final product is formulated to contain 25 mcg/mL benzethonium chloride and 100
mcg/mL formaldehyde, added as preservatives.

Back to top

Vaccine Efficacy
One group reviewed randomized controlled trials on the clinical effectiveness,
immunogenicity, and safety of anthrax vaccines. The authors concluded that vaccines based
on anthrax antigens are immunogenic in most vaccinees with few adverse events, although
limited data were available (Donegan 2009).

The efficacy of AVA is based on several animal studies, one controlled human trial,
and immunogenicity data from humans and other mammals (Brachman 1962,
Gladstone 1946, Mahlandt 1966, Turnbull 1986). One study demonstrated that
vaccination of adults induced an immune response in 83% of vaccinees 2 weeks after
the first dose and in 91% of vaccinees who received two or more doses (Turnbull
1986). Approximately 95% of vaccinees seroconverted after three doses. However, the
correlation between antibody titer and protection against infection has not been
60/105
 defined.
Analysis of serum from vaccinees and clinical anthrax patients shows that vaccination
with three AVA injections and anthrax infection both elicited anti-PA, IgG1, IgG2, and
IgG3 subclass responses (Semenova 2007). One study suggests that AVA-induced
antibodies to PA are sufficient to neutralize toxin activity and that AVA-induced LF and
EF antibodies do not contribute to anthrax toxin neutralization in humans (Taft 2008).
Duration of efficacy is unknown, although data from animal studies suggest that it
may be 1 to 2 years after two doses. Studies of military personnel vaccinated during
the 1990-1991 Gulf War indicate that antigen-specific T-cell recall responses present in
the circulation are comparable in magnitude to those of tetanus-diphtheria toxoids
(Allen 2006).
Anthrax vaccines intended for animals should not be used in humans.

Back to top

Recommendations for Use

Preexposure Vaccination
Preexposure immunization with AVA is licensed for individuals aged 18 to 65 who have a
high likelihood of coming into contact with B anthracis (CDC 2010: Use of anthrax vaccine in
the United States). The vaccine is not licensed for pregnant women. The vaccine also is not
licensed for children because no studies have been conducted in the pediatric population;
however, the vaccine probably is safe and efficacious in children, based on experience with
other inactive vaccines (Inglesby 2002).

Preexposure vaccination is indicated for the following groups (CDC 2010: Use of anthrax
vaccine in the United States):

Laboratory personnel engaged in work involving production of quantities or

concentrations of B anthracis cultures
Laboratory personnel handling environmental specimens (especially powders) and
performing confirmatory testing for B anthracis in LRN reference and national
laboratories
Workers who will be making repeated entries into known B anthracis-spore-
contaminated areas after a terrorist attack
Persons who come in contact in the workplace with imported animal hides, furs, bone
meal, wool, animal hair, or bristles in areas where current standards and restrictions
are insufficient to prevent exposure to anthrax spores
Veterinarians and other high-risk persons handling potentially infected animals in
areas of the world that have a high incidence of anthrax cases (Note: The incidence of
anthrax in the United States is low; therefore, routine vaccination of US veterinarians

61/105
 is not recommended)
Military personnel and other select populations who have a risk for exposure to
weaponized B anthracis. After a lapse due to legal action, the DoD has resumed
mandatory vaccinations for military personnel, essential DoD civilians, contractors
stationed in the Middle East and South Korea, and units involved in homeland
bioterrorism defense (DoD 2006, and see Oct 19, 2006, CIDRAP News story).
Vaccination is the best defense currently available for first responders in the event of
an anthrax attack with an antibiotic resistant strain (Zink 2011). The Department of
Homeland Security and the CDC are developing a program to provide anthrax
vaccines that are nearing expiration to first responders. Approximately two million
doses of vaccine in the SNS expire annually. A pilot program involving two federal
agencies or departments and two state or local jurisdictions is being developed to
assess the feasibility of this program (Polk 2012).

Laboratory workers using standard BSL-2 practices are not considered by the Advisory
Committee on Immunization Practices (ACIP) to be at increased risk for exposure to B
anthracis spores.

Postexposure Vaccination
ACIP guidelines state that anthrax vaccine can be used in combination with antibiotics
following inhalational exposure to anthrax (CDC 2010: Use of anthrax vaccine in the United
States):

Exposed persons should receive a three-dose regimen of vaccine subcutaneously (0, 2,

and 4 weeks following exposure) and at least a 60-day course of antimicrobial therapy.
Persons who do not receive vaccine also should take antimicrobial therapy for at least
60 days.
Anthrax vaccine is not currently licensed for postexposure use in any age-group, so it
must be given under an emergency use authorization for adults. The use of AVA in
children under 18 years of age has never been studied and therefore would need to
occur as part of an investigational new drug (IND) application with the FDA.

Use of AVA in children under an IND raises a number of complex clinical, ethical, and
regulatory issues, since the vaccine has not been studied in children. The National
Biodefense Science Board (NBSB) developed a position paper on this issue in 2011. They
recommended that, if the ethical considerations can be adequately addressed, HHS should
develop a plan for and conduct a pre-event study of AVA in children, to include a research
IND (NBSB 2011).

Because of problems of noncompliance and side effects associated with prolonged

antibiotic treatment, investigators have studied whether a short course of antibiotics
combined with vaccination could provide protection after exposure. Monkeys were exposed
62/105
to an aerosol dose (1,600 LD50 ) of B anthracis spores (Vietri 2006). One group of animals
received only ciprofloxacin (an initial loading dose of 250 mg of ciprofloxacin within 2 hours
after exposure followed by 125 mg twice daily for 14 days). Another group of animals
received ciprofloxacin (as described) and was vaccinated (0.5 ml of AVA on day 0 within 2
hours after exposure, and on days 14 and 28). In contrast to the untreated control group, all
animals in both the ciprofloxacin-only and the ciprofloxacin-plus-vaccine groups survived
during the 14 days of antibiotic prophylaxis. However, once the antibiotics were
discontinued, only four of nine animals (44%) in the ciprofloxacin-only group survived
compared with 10 of 10 animals (100%) in the ciprofloxacin-plus-vaccine group. These data
provide evidence that postexposure vaccination can shorten the duration of antibiotic
prophylaxis required to protect against inhalational anthrax.

Back to top

Dosage, Route of Administration, and Vaccination Schedule

Each vaccine dose is 0.5 mL. The current vaccination schedule consists of a primary series of
two intramuscular injections followed by three booster intramuscular injections as outlined
in the table below. In December 2008, the FDA approved a change in the primary series
from three doses subcutaneously (0, 2, and 4 weeks) to two doses intramuscularly (0 and 4
weeks). The ACIP supported this change in February 2009 (see Feb 25, 2009, CIDRAP News
story). The change is based on a randomized, phase 4 trial, which found that a three-dose
intramuscular schedule provided similar immunologic priming by month 7 compared with a
four-dose subcutaneous regimen. An intramuscular route also significantly reduced the
occurrence of injection-site adverse events (Marano 2008).

To maintain immunity among those with anticipated ongoing exposure, the manufacturer
recommends an annual booster injection using the same dosage and route after
completion of the primary and booster series.

Schedule for Anthrax Vaccinationa

Primary series (2 injections) Week 0

Week 4

Booster series (3 injections)b 6 mo after primary series

12 mo after primary series

18 mo after primary series

63/105
 aAll
doses are 0.5 mL and should be given intramuscularly.
bAdditional
boosters to be given annually (same route and dose) for those at ongoing risk of
exposure.

Back to top

Contraindications and Precautions

The main contraindication is a history of anaphylaxis after receiving a dose of AVA or
any of the vaccine components.
History of anthrax disease may increase the potential for severe local adverse
reactions.
If AVA is administered to immunocompromised persons, including those receiving
immunosuppressive therapy, the immune response may be diminished.
AVA is labeled as Pregnancy Category D (Emergent BioSolutions: BioThrax package
insert). According to the manufacturer's package insert, "Pregnant women should not
be vaccinated against anthrax unless the potential benefits of vaccination have been
determined to outweigh the potential risk to the fetus."
Few studies have been published regarding the use of anthrax vaccine in pregnant
women.
A study among US army women demonstrated that anthrax vaccine had no
effect on subsequent pregnancies, birth rates, or adverse birth outcomes,
although the power to detect adverse birth outcomes in the cohort was limited
(Wiesen 2002).
A retrospective cohort study evaluated birth defects in relation to maternal
anthrax vaccination for infants born to US military service women from 1998
through 2004. Among 115,169 infants born to military women during this period,
37,140 were born to women ever vaccinated, and 3,465 were born to women
vaccinated in the first trimester of pregnancy. Birth defects were slightly more
common among infants born to women vaccinated during the first trimester
compared with infants born to women vaccinated beyond the first trimester;
however, this finding was not statistically significant. An analysis of infants born
to women vaccinated in the first trimester and infants born to women who were
never vaccinated found that birth defects were slightly higher (odds ratio = 1.2;
95% confidence interval = 1.02 to 1.42) in the vaccinated group (Ryan 2008).

Back to top

Adverse Reactions
Injection site adverse reactions are the most common and occur in more than half of
64/105
 vaccine recipients. These include warmth, tenderness, itching, erythema, induration,
edema, and nodule formation. Most local adverse reactions are mild or moderate in
severity.
Systemic reactions (fever, chills, myalgia, nausea) following vaccination may occur in
10% to 25% of recipients.
One report identified five cases of new-onset rheumatoid arthritis (RA) temporally
related to anthrax vaccine. The most recent occurred in a 42-year-old man who
experienced knee and interphalangeal joint stiffness and pain 5 days after receiving
the first dose of anthrax vaccine. Serologic and radiologic examinations revealed mild
degenerative changes in his hands and knees bilaterally (Vasudev 2006). It is unclear
at this time whether or not these case reports represent a true association between
anthrax vaccination and RA, since this issue has not been systematically evaluated.

Back to top

Postlicensure Adverse Event Reporting

Between 1998 and 2008, the Vaccine Adverse Event Reporting System (VAERS)
received 6,015 reports of adverse events following anthrax vaccination (CDC 2010: Use
of anthrax vaccine in the United States). The most frequent adverse events that
occurred were arthralgia (n = 1,036, 17%), headache (981, 16%), pruritus (878, 15%),
pain (824, 14%), injection-site erythema (753, 13%), fever (655, 11%), erythema (626,
10%), injection-site pain (613, 10%), rash (606, 10%), and myalgia (583, 10%). A total of
600 (10%) serious adverse events were reported.
Review of anthrax vaccination data from a 1967 to 1972 study and medical literature
from 1955 to 2005 suggests that women have at least twice the risk of having a
vaccine reaction compared with men. The age-adjusted relative risk for injection site
reaction was 2.78 (95% confidence interval, 2.29 to 3.38) (McNeil 2007: Short-term
reactogenicity and gender effect of anthrax vaccine).
Between December 15, 1997, and April 12, 2000, 425,976 service members received
1,620,793 doses of AVA. As of April 7, 2000, 428 VAERS reports had been received
through the DoD (CDC 2000: Surveillance for adverse events associated with anthrax
vaccine). Of these reports, 311 (72.7%) involved systemic reactions, 78 (18.2%) were
mild or moderate local reactions, and 39 (9.1%) were large or complicated local
reactions. As of March 21, 2000, a panel of civilian scientific and medical experts had
not identified any pattern of adverse events among 674 reports that had been
reviewed. Comparative analysis of immunization records in the military VAERS reports
and the Defense Medical Surveillance System suggests that the information contained
in both sets of records is similar for anthrax and for nonanthrax vaccine
immunizations (McNeil 2007: A comparative assessment of immunization records in
the Defense Medical Surveillance System and the Vaccine Adverse Event Reporting
System).
65/105
 To evaluate the potential for AVA to contribute to disability in US service members, a
cohort of persons who had received AVA was identified. Between December 15, 1997,
and February 15, 2005, a total of 439,059 service members received at least one dose
of AVA (Sulsky 2011). There was no difference in risk of disability among these service
members when compared with service members who did not receive AVA.
Some reports have suggested an association between optic neuritis and anthrax
vaccination (or receipt of other vaccines). However, a matched case-control study
among US military personnel from Jan 1, 1998, through Dec 31, 2003, revealed no
significant associations between optic neuritis and anthrax vaccination (Payne 2006).
LRN workers who were vaccinated with AVA did not show any change in physical or
mental functional status when compared with LRN workers who were not vaccinated
(Stewart 2012). These workers were followed for 30 months for any health-related
quality-of-life issues postvaccination.
Some investigators have proposed that AVA (and possibly other vaccines) may be
associated with the development of type 1 diabetes. But a retrospective cohort study
among military personnel did not find any evidence of an increased risk for the
disease among those who received AVA vaccine or five other vaccines commonly
administered to military personnel (Duderstadt 2012).

The Institute of Medicine's Committee to Assess the Safety and Efficacy of Anthrax Vaccine
found no evidence that people receiving the anthrax vaccine are at increased risk of life-
threatening or permanently disabling adverse events. An FDA review of VAERS reports also
found no causal relationship between anthrax vaccination deaths and other serious adverse
events (other than some serious injection site and allergic reactions). Similarly, the HHS
Anthrax Vaccine Expert Committee concluded that there was not a high frequency or an
unusual pattern of serious or other medically important adverse events. A review of 4,753
anthrax vaccine–related VAERS reports from January 1, 1990 through January 16, 2007
confirmed these previous findings (Niu 2009).

Back to top

Development of New Vaccines

Research into new anthrax vaccines is ongoing. Most vaccines that have been studied utilize
recombinant technology or employ new adjuvants to increase the immune response.

Current human anthrax vaccines consist of supernatant material from cultures of a

toxigenic, nonencapsulated strain of B anthracis. Second-generation vaccines using
recombinant PA (rPA) are being developed as an alternative, as much of the
immunogenicity of the current vaccine arises from this protein component (Rhie 2005).
The Biomedical Advanced Research and Development Authority (BARDA), which is
within the Office of the Assistant Secretary for Preparedness and Response in HHS, is

66/105
 funding the development of an rPA nasal spray vaccine made by Vaxin (HHS 2011:
Novel anthrax vaccine and antitoxin being developed with federal support).
Emergent BioSolutions (maker of the current anthrax vaccine) is studying a new
candidate vaccine (AV7909), which comprises AVA in combination with the
immunostimulatory compound CPG 7909 as an adjuvant (Emergent BioSolutions
2008). This vaccine increased the immune response and reduced the time to peak
immune response in human subjects compared with AVA alone (Rynkiewicz 2011).
Combination vaccines such as one against anthrax and plague may represent the next
generation of vaccines against potential agents of bioterrorism (DuBois 2007).

Back to top

Management of Exposure Events

Potential Types of Exposures

Handling of Suspicious Packages
Mass Exposure Events
Surveillance During Exposure Events or for Early Detection of Outbreaks

Potential Types of Exposures

The most likely methods of exposure to weaponized anthrax spores include:

Localized exposure to a white powder (such as a contaminated letter or package sent

through the mail)
Contamination of a closed air supply (such as the ventilation system of a building)
Broad contamination of outdoor air (such as release of anthrax spores via a crop
duster or similar aircraft)
Contamination of a commercial food or beverage source (which would cause
gastrointestinal disease)

Only exposure to a white powder would be recognized at the time of the event. The other
methods of exposure most likely would not be recognized until cases of disease occurred
(unless indoor or outdoor air-monitoring systems are in place and capable of detecting B
anthracis spores with some degree of sensitivity).

Back to top

Handling of Suspicious Packages

According to the US Postal Service, suspicious letters or packages should not be opened (US
Postal Service). A letter or package should be considered suspicious if it:

Has any powdery substance on the outside

67/105
 Is unexpected or from someone unfamiliar to you
Has excessive postage, a handwritten or poorly typed address, an incorrect title or a
title with no name, or misspellings of common words
Has no return address or one that can't be verified as legitimate
Is of unusual weight, given its size, or is lopsided or oddly shaped
Has an unusual amount of tape
Is marked with restrictive endorsements, such as "Personal" or "Confidential"
Has a strange odor or stain

During the 2001 anthrax attacks, cases occurred among persons who opened mail and
among persons who merely handled contaminated mail; therefore, suspicious packages or
letters should be handled as little as possible. Forensic analysis has indicated that nearly 8 x
106 CFU were removed from the most highly cross-contaminated piece of mail found
(Beecher 2006). The CDC has published specific recommendations regarding handling
suspicious packages or letters (CDC 2001: Investigation of bioterrorism-related anthrax and
interim guidelines for exposure management and antimicrobial therapy, October 2001):

Do not shake or empty the contents of a 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 on a stable surface; do not sniff, touch, taste, or look
closely at it or any contents that may have spilled.
Alert others in the area about the suspicious package or envelope. Leave the area,
close 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 (ie, police).
If possible, create a list of persons who were in the room or area when the suspicious
letter or package was recognized and a list of persons who also may have handled the
package or letter. Give the list to both the local public health authorities and law
enforcement officials.

If a patient reports exposure to a suspicious package that contains an unknown white

powder, further evaluation should be undertaken by public health and law enforcement
officials.

Recommendations for testing the package contents for B anthracis should be made on
the basis of a risk assessment conducted by public health and law enforcement
officials.
If the patient is considered at risk and is asymptomatic, then antimicrobial prophylaxis

68/105
 should be initiated pending results of microbiological testing of the package contents.
If the patient has symptoms compatible with anthrax, then appropriate antimicrobial
treatment should be administered.

A prospective longitudinal study of 124 subjects who may have been exposed to B anthracis
during the anthrax attack in the US Capitol demonstrated that the significance of low-level
exposure should not be underestimated (Doolan 2007). The authors’ conclusion is based on
the following:

Spore exposure primed immune responses in a dose-dependent manner and may

have enhanced vaccine boost and recall responses.
Immune responses were detected among subjects inside the defined exposure zone
as well as subjects outside the zone, implying more extensive spore migration than
had been predicted.
Despite the fact that subjects received PEP with antibiotics, spore inhalation provoked
immune system stimulation consistent with subclinical infection (and possibly
antibiotic-aborted infection after germination of viable spores); greater levels of
exposure corresponded to more complete immune responses.

Back to top

Mass Exposure Events

In the event of a mass exposure, rapid delivery of prophylactic antibiotics to the
exposed population would be critical to prevent illness and death (Wein 2003). A
simulation analysis suggested that postattack antibiotic therapy and vaccination of
exposed individuals represents the most cost-effective strategy for a small-scale attack
(Schmitt 2007).
In emergency situations involving a bioterrorist release, state governments can
request antibiotic and medical supplies from the SNS through the CDC; the CDC is
ready to rapidly deploy the stockpile as needed and can deliver initial supplies within
several hours.
In locations with a high risk of an attack, several additional strategies can be used to
enhance rapid access to appropriate medical countermeasures (IOM 2011). These
include forward-deployed (positioning of medical countermeasures geographically
near where they may be used), cached (storage of medical countermeasures at
specific locations where they will be used such as worksites or hospitals), and
predispensed (storage of medical countermeasures by intended users such as home
storage) countermeasures. Each of these strategies has benefits and costs, which
should be evaluated for each location. The IOM has provided a framework to help
officials perform such an evaluation (IOM 2011). HHS is considering how to
incorporate this work into its preparedness efforts (HHS 2011: Statement by Dr. Nicole

69/105
 Lurie).
State and local health departments have bioterrorism preparedness plans in place to
provide points of distribution for mass antibiotic prophylaxis against anthrax and
other biological agents as needed. During the 2001 anthrax outbreak, the New York
City Department of Health and Mental Hygiene activated its incident command system
and put its antibiotic distribution plan into effect. Lessons learned from this
experience were published (Blank 2003).

One analysis suggests that the critical determinant of mortality after an anthrax
bioterrorism event is local dispensing capacity (Bravata 2006). Modeling suggests a
higher mortality among sites with low dispensing capacities, compared with those
with high dispensing capacities. Doubling local inventories at high dispensing sites
makes stockpiling fivefold more cost-effective than at low dispensing sites.
Mass prophylaxis campaigns carry the risk of overwhelming emergency health
services owing to visits for actual or perceived medication-related adverse events
(Hupert 2007). Modeling suggest that the length of a mass prophylaxis campaign (eg,
10 days vs 2 days) plays an importantrole in determining the subsequent intensity in
emergency servicesuse due to real or suspected adverse events.

Back to top

Surveillance During Exposure Events or for Early Detection of

Outbreaks
Early disease outbreak recognition may significantly modify the outcome of a biological
attack. A list has been developed of potential epidemiologic clues or "red flags" for an
unusual event. Although these clues may be associated with natural outbreaks and
bioterrorism events, their occurrence should heighten suspicion. Potential clues include the
following (Dembek 2007):

Highly unusual event with large numbers of casualties

Higher morbidity or mortality than is expected
Uncommon disease
Unusual disease manifestation
Lower attack rates in protected persons
Point-source outbreak
Multiple epidemics
Downwind plume pattern
Dead animals
Reverse or simultaneous spread of human and animal cases
Direct evidence

70/105
A review of the accidental release of aerosolized anthrax spores in Sverdlovsk showed that
the resulting outbreak had many characteristics of an unusual event. Of the clues listed
above, the first four were present in the outbreak, as were the sixth (point-source outbreak)
and eighth and ninth (downwind plume pattern and dead animals). Despite concealment of
information and confiscation of records by the Soviet military and government, public
health response measures were implemented within 10 days of the event. The public health
response is estimated to have prevented an additional 14% of fatalities.

Several reports have examined surveillance approaches for anthrax either in the setting of a
known exposure or as an early population-based detection tool.

During 2003, the Connecticut Public Health Department (CPHD) implemented gram-
positive rod surveillance for early anthrax detection (Begier 2005). The CPHD reported
that this laboratory-based surveillance system is a tool that could provide early
detection of even a single case of inhalational anthrax.
During the 2001 anthrax outbreak, the New York City Department of Health and
Mental Hygiene established the Cutaneous Anthrax Rapid Referral System for rapid
referral and early diagnosis of anthrax cases (Redd 2005). This system functioned to
efficiently assess patients but also provided a mechanism for rapid centralized
reporting, which could be a good surveillance model in the setting of a known mass
exposure to anthrax.
Syndromic surveillance may be a valuable tool for early detection of anthrax cases in
the setting of a mass exposure where relatively large numbers of cases would be
expected to occur (CDC 2005: Syndromic surveillance: reports from a national
conference, 2004, Nordin 2005).
One review found evidence from the Sverdlovsk outbreak that livestock (such as
cattle, sheep, and goats) can provide early warning of a bioterrorist event caused by B
anthracis. In addition to livestock, cats and dogs might serve as markers for ongoing
exposure risk following an anthrax bioterrorist attack (Rabinowitz 2006).

Back to top

Hospital Infection Control (Including Autopsies and Burial)

Isolation Precautions
Cleaning Surfaces and Instruments
Personal Protective Equipment for Workers
Other Issues
Autopsy Practices
Burial

Isolation Precautions
71/105
 Although people with inhalational anthrax may have had contamination of hair and
clothing at the time of their exposure, residual contamination at the time of medical
presentation does not appear to be of concern. Also, no secondary cases occurred
among household contacts of the inhalational cases in the 2001 US outbreak.
Standard Precautions are considered adequate for patients with inhalational and
gastrointestinal anthrax, since person-to-person transmission for these forms of
disease has not been reported.
Most sources also recommend Standard Precautions for cases of cutaneous anthrax
(APIC/CDC 1999, Inglesby 2002). However, person-to-person transmission rarely has
been reported for patients with cutaneous anthrax; therefore, several sources have
recommended that Contact Precautions be followed for patients who have draining
cutaneous lesions (Swartz 2001, Weber 2001). Contact Precautions include the
following:
Place the patient in a private room, or, if a private room is not available, place
the patient in a room with a patient who has an active infection with the same
pathogen (ie, cohort). When a private room is not available and cohorting is not
possible, a spatial separation of at least 3 ft should be maintained between the
infected patient and other patients and visitors.
Gloves should be worn when entering the room and removed before leaving the
room; hands should be washed with an antimicrobial agent or a waterless hand
washing agent immediately after removing gloves, and clean hands should not
touch potentially contaminated items or environmental surfaces.
Gowns should be worn when entering the room if it is anticipated that clothing
will have substantial contact with the patient, environmental surfaces, or items
in the room; the gown should be removed before leaving the patient's
environment.
Patient transport should be limited to essential purposes only; if the patient is
transported out of the room, precautions should be maintained.
Noncritical patient-care equipment should be dedicated whenever possible. If
equipment cannot be dedicated, then it should be adequately cleaned and
disinfected between patients.
Soiled dressings should be incinerated or autoclaved.
A study on the use of hand-hygiene agents to remove B atrophaeus (a surrogate of B
anthracis) from contaminated hands demonstrated that use of a waterless hand rub
containing ethyl alcohol was not effective in removing spores (Weber 2003).
Conversely, hand washing with soap and water, 2% chlorhexidine gluconate, or
chlorine-containing towels reduced the level of spore contamination.

Back to top

Cleaning Surfaces and Instruments

72/105
According to the CDC, the following procedures should be followed when cleaning surfaces
following spills or when cleaning instruments (CDC 2001: Basic laboratory protocols for the
presumptive identification of Bacillus anthracis):

Commercially available bleach or 0.5% hypochlorite solution (a 1:10 dilution of

household bleach) is considered adequate for cleaning.
Contaminated items (eg, pipettes, needles, loops, microscope slides) should be
immersed in decontamination solution until autoclaving.
Work surfaces should be wiped down before and after use with decontamination
solution.
Spills involving fresh cultures or samples known to have low concentration of spores
should be flooded with decontamination solution and soaked for 5 minutes before
cleanup.
Spills that involve samples with high concentration of spores, involve organic matter,
or occur in areas of lower than room temperature (eg, refrigerators, freezers) should
be exposed to decontamination solution for at least 1 hour before cleanup.
Personnel involved in the cleanup of any spill should wear gloves, safety glasses, and a
laboratory coat or gown during the cleanup process.
Respiratory protection should be considered for spills in which a substantial
aerosolization is suspected.

Back to top

Personal Protective Equipment for Workers

Information regarding personal protective equipment for first responders and others with
potential occupational exposure to anthrax spores can be found on the following Web
pages:

CDC: Protecting investigators performing environmental sampling for Bacillus

anthracis: personal protective equipment
CDC: Interim recommendations for the selection and use of protective clothing and
respirators against biological agents
OSHA: Anthrax prevention and controls

Back to top

Other Issues
One study examined biocide inactiviation of B anthracis spores in the presence of food
residues (Hilgren 2007). The presence of food residues had only a minimal effect on
peroxyacetic acid and H20 2 sporicidal efficacy, but the efficacy of sodium hypochlorite
was markedly inhibited by whole-milk and egg yolk residue. Decontamination
73/105
 procedures should be adjusted to address situations for food-soiled surfaces.

Back to top

Autopsy Practices
Instruments used in autopsies should be autoclaved or incinerated.
Guidelines from the CDC indicate that Standard Precautions should be used for
postmortem care. These include using a surgical scrub suit, surgical cap, impervious
gown or apron with full sleeve coverage, a form of eye protection (eg, goggles or face
shield), shoe covers, and double surgical gloves with an interposed layer of cut-proof
synthetic mesh (CDC 2004: Medical examiners, coroners, and biologic terrorism).
In addition, autopsy personnel should wear N-95 respirators during all autopsies,
regardless of suspected or known pathogens. Powered air-purifying respirators
equipped with N-95 or high-efficiency particulate air (HEPA) filters should be
considered.

Back to top

Burial
Contact with corpses should be limited to trained personnel, and routine precautions
should be implemented when transporting corpses.
According to the CDC, cremation is the preferred disposition method. If cremation is
not possible, bodies should be "properly secured in a sealed container (eg, a Ziegler
case or other hermetically sealed casket) to reduce the potential risk of pathogen
transmission" (CDC 2004: Medical examiners, coroners, and biologic terrorism).
According to WHO guidelines (WHO 1998), "In fatal cases, postmortem should be
discouraged; cremation is preferable to burial where local custom permits. It is
advisable for the body to be placed in an impervious body bag for transport from the
place of death and preferably the body should not be extracted from the bag. Where
only burial is permitted, the bagged body should be placed in a hermetically sealed
coffin and buried without re-opening."
An example of the type of system that can be used to seal remains prior to placing
them in a casket for burial is the BioSeal Systems, produced by Barrier Products, LLC.
This system utilizes a poly-aluminum foil–extruded laminate material that, when used
with a heat sealer, will provide level 1 containment for all gases, fluids, vapors, and
odors associated with the transport and storage of human and animal remains.

Back to top

Environmental Testing and Decontamination

74/105
Environmental Testing as a Detection Tool
Environmental Testing Following a Release
Decontamination of Persons Exposed to Anthrax
Decontamination of Environment
Waste Management
Gaps in Decontamination Policy and Practice

Environmental Testing as a Detection Tool

Autonomous detection systems (ADSs) have been developed to detect B anthracis spores in
the environment (indoor or outdoor) as the first signal of an aerosol release. Examples
include the following:

Biohazard Detection System (BDS): The BDS is a fully automated air-sampling system
consisting of an aerosol collector, PCR cartridge based on Cepheid GeneXpert
technology, and controller computer. It has been deployed in mail processing and
distribution centers across the United States. Positive BDS signals will be confirmed by
an LRN reference or national laboratory (CDC 2004: Responding to detection of
aerosolized Bacillus anthracis by autonomous detection systems in the workplace,
NALC).
According to the CDC guidelines, when a positive BDS signal occurs, the following
immediate response is appropriate:
Stop work activities.
Stop and secure any potential aerosol-generating equipment.
Turn off heating, ventilation, and air conditioning (HVAC) units serving the
production or processing area (leave local exhaust ventilation on machines
turned on).
Notify local and federal law enforcement and public health officials.
Immediately account for all workers to ensure their evacuation.
Gather personal identification and contact information.
Depending on the level of potential exposure, decontamination of employees
(with removal of clothing and washing exposed areas or showering at the site)
may be necessary.
The decision to begin postexposure antibiotic prophylaxis should be made on
the basis of risk of exposure, threat assessment, validity of preliminary
laboratory testing, and logistics of initiating an intervention.
Autonomous Pathogen Detection System (APDS): Consists of an aerosol collector, flow-
through PCR subsystem with sequential injection analysis, and a multianalyte flow-
cytometry subsystem for PCR product detection (Hindson 2004, LLNL 2002).
Anthrax Smoke Detector (ASD): An automated system designed by the National
Aeronautics and Space Administration (NASA) to detect changes in airborne bacterial
spore concentrations, including spores of B anthracis. The system measures dipicolinic
75/105
 acid (DPA), a chemical marker of bacterial spores. The ASD is intended as a relatively
low-cost screening tool and requires that positive signals be confirmed by B anthracis–
specific assays (Lester 2004). One test revealed that the device had a detection limit of
16 spores/L when 250 L of air was sampled (Yung 2007).
Handheld Advanced Nucleic Acid Analyzer (HANAA). A real-time PCR analyzer using a
miniaturized thermal cycling process (LLNL 2002).
Mobile laboratory systems (used primarily by the military): Automatic Biological Agent
Testing System (ABATS), PortalShield, Joint Biological Point Detection System (JBPDS),
and Biological Integrated Detection System (BIDS) (Fitch 2003).

Back to top

Environmental Testing Following a Release

Environmental testing for B anthracis should be conducted by public health or law
enforcement officials in the context of an environmental, epidemiologic, or criminal
investigation. Sampling should be guided by available data whenever possible (Teshale
2002) and should be performed in accordance with the most recently recommended
sampling methods and protocols.

Criteria for performing directed sampling of environmental surfaces as specified by the CDC
include the following (CDC 2001: Interim guidelines for investigation of and response to
Bacillus anthracis exposures):

To identify a site or source of B anthracis exposure that resulted in a case(s) of anthrax

To trace the route of an exposure vehicle (eg, powder-containing letter)
To obtain the B anthracis strain when isolates from patients are not available
To guide cleanup activities in a contaminated area or building
To assess biosafety procedures in laboratories processing B anthracis specimens

ASTM International (formerly the American Society for Testing and Material Standards), a
voluntary standards development organization, has published a standard on practices for
"bulk sample collection and swab sample collection of visible powders suspected of being
biological agents from nonporous surfaces." A collaborative study validated the methods in
the standard and showed that high levels of B anthracis and B thuringiensis spores can be
recovered from surfaces by both dry and wet swab sampling methods (Locascio 2007).

Environmental sampling of a US postal facility in Washington, DC, during the 2001 anthrax
outbreak demonstrated the following (Sanderson 2002):

Sampling using wipes or HEPA vacuum socks provided a better yield than sampling
with wet or dry swabs.
Dry swabs generally should not be used for sampling, since yields are so low.

76/105
 Wet swabs may be useful in certain situations (eg, crevices, inside machinery, other
areas difficult to reach by wipe or HEPA vacuum samples).
Wipes are preferable for sampling areas with light dust.
HEPA vacuum socks should be used to sample surfaces with heavy dust.

One study evaluated four swab materials (cotton, macrofoam, polyester, and rayon) and
methods of processing to determine optimal spore recovery. Results demonstrated that
premoistened cotton and macrofoam swabs were the most efficient (Rose 2004). In a study
of polyester-rayon wipes, sonication extraction improved recovery of spores from wipes
used for cleaning surfaces. The wipe recovery quantitative limits of detection were
estimated at 90 CFU per unit of stainless steel surface area and 105 CFU per unit of painted
wallboard (Brown 2007). In a study of recovery efficiencies of anthrax spores, contact plates
performed better than other methods for flat, nonporous, nonabsorbent surfaces, with
recovery rates of 28% to 54%. Contact plates also performed the best on flat, porous,
absorbent surfaces, although recoveries were low (less than 7%). For moistened devices
(wipes, swabs, and sample collection and recovery devices), wipes were generally the best
(Frawley 2008).

Official procedures for testing food and waterhave not been published, but protocols
reportedly have been developed by USAMRIID (Higgins 1999) and are under development
elsewhere.

A number of commercial test kits for environmental sampling are available. A study of three
such systems, BioThreat Alert (BTA), BioWarfare Agent Detection Devices (BADD), and
SMART II, found a minimum detection limit of 105 spores, far above the level of 10 2 spores
desired by first-responders (King 2003). The specificities of these systems have not been
independently evaluated.

Back to top

Decontamination of Persons Exposed to Anthrax

According to guidelines from the Association for Professionals in Infection Control and
Epidemiology (APIC) and the CDC (APIC/CDC 1999):

Patients should remove contaminated clothing and store in labeled, plastic bags.
Clothing should be handled as little as possible to avoid agitation.
Patients should shower thoroughly with soap and water.

Back to top

Decontamination of Environments

77/105
Concerns regarding environmental contamination involve both primary and secondary
aerosolization.

Primary aerosolization occurs when the spores are first made airborne. This is the
period when the risk of inhalation is the greatest. The risks of primary aerosolization
depend on how long spores remain airborne and how far they travel before falling to
the ground or other surfaces. Meteorological conditions and aerobiological properties
of the dispersed aerosol will influence the duration and scale of the risk (HPA 2007).
Secondary aerosolization involves resuspension of spores into the air after they have
initially settled on environmental surfaces. The risks posed by secondary
aerosolization have not been defined and are dependent on a number of variables (eg,
concentration of spores in the environment, type of powder used in the suspension,
level of activity in the contaminated area, type of environmental surface involved).

Determining the extent of remediation necessary for contaminated environments remains

controversial. Ideally, the remediation effort should be timely and cost-effective and protect
the public health (Martin 2010: Anthrax as an agent of bioterrorism). A process for
determining what level of contamination is acceptable has been proposed as follows (Price
2009):

Decide on the level of risk that is acceptable.

Convert the risk to an airborne spore concentration, via an assumed dose-response
curve.
Convert the airborne spore concentration to a surface concentration, using an
assumed resuspension rate.
Convert the surface concentration to a probability that any single sample is positive
for B anthracis, using a sampling effectiveness curve.
Find the number of samples needed (for the single-sample probability above) such
that if all the samples are negative, then the building or area is "safe" with a specified
certainty.

During the 2001 anthrax attacks, the Environmental Protection Agency (EPA) assessed the
potential for secondary aerosolization inside the Hart office building by conducting
environmental sampling under semiquiescent (minimal activity) conditions and under
simulated active office conditions (Weis 2002).

Findings demonstrated that viable B anthracis spores could be reaerosolized during

simulated active office conditions.
CFU levels detected through air sampling demonstrated as much as a 65-fold increase
under the active office conditions compared with the semiquiescent conditions.
These findings support the need for environmental decontamination and protection of
decontamination workers following release of high concentrations of anthrax spores
into indoor environments.
78/105
During the 2001 US anthrax outbreak, several buildings underwent environmental
decontamination to eliminate the risk of potential secondary aerosolization. In the setting of
a bioterrorism attack, the EPA is charged with directing cleanup activities and providing the
necessary technical expertise to guide such efforts. The EPA used several methods and
technologies to decontaminate buildings during the 2001 outbreak (ie, chlorine dioxide,
decontamination foam, ethylene oxide). Cleanup plans generally involve the following:

Assess the size and type of the potentially contaminated area.

Assess how the contamination was delivered.
Conduct sampling to determine the level of contamination.
Determine the microbiocide to be used and methods of delivery for decontamination.
Carry out decontamination procedures.
Conduct environmental sampling after decontamination to ensure that anthrax spores
have been removed or killed and that the area is safe to reoccupy.

A recent review of decontamination technologies and strategies following an anthrax

release identified the following as key considerations when determining the appropriate
decontamination strategy (Campbell 2012):

The identity and characteristics of the biological agent (including its environmental
persistence and ability to aerosolize), the mode of delivery (release), and the nature of
spread
Boundaries (ie, exclusion zones) that restrict and control access to contaminated areas
(ie, hot zones)
Results of environmental sampling, including extent and magnitude of contamination
Analysis of epidemiologic evidence
Health risks posed by the agent and its susceptibility to medical countermeasures;
balancing risk mitigation through reducing exposure versus large-scale prophylaxis
programs
Clearance goals and clearance criteria to meet the goals
Nature of the sites and items to be decontaminated
Prioritization of facilities, areas, and infrastructure from the results of characterization
and according to possible national security considerations
Projected timelines to complete decontamination, if performed
Public perception, such as acceptance of proposed decontamination technologies
Quantities of estimated waste and suitable staging and storage areas for waste

Until the 2001 anthrax attack, experience with decontamination of buildings after
contamination with weapons-grade anthrax spores was limited. Questions regarding the
best methods for decontamination in such situations still remain (Spotts Whitney 2003). In

79/105
addition, reasonable standards for cleanup effectiveness remain to be established (Canter
2005). Using Bayesian statistical methods can improve the decision making process for
anthrax clean up, as it helps to overcome gaps in empirical data (Linkov 2011).

The EPA has tested seven sporicidal products to evaluate their efficacy in inactivating B
anthracis spores, and all products successfully inactivated the pathogen in at least one test
(EPA 2010). In these tests gaseous chlorine dioxide and vapor-phase hydrogen peroxide
performed the best under the most stringent test conditions. Paraformaldehyde has been
used to decontaminate laboratories and postal equipment. There are four fumigants that
can potentially be used for neutralization of anthrax spores: gaseous chlorine dioxide,
vapor-phase hydrogen peroxide, paraformaldehyde, and methyl bromide (Campbell 2012).
An EPA exemption is required to use methyl bromide; thus, it has largely been phased out
of use.

Several hypochlorite-containing household products on the market were found to be

effective in decontaminating milk or similar food products contaminated by spores to allow
safe disposal (Black 2008). A combination of high temperature (90°C to 95°C) and hydrogen
peroxide also could be used to inactivate B anthracis spores (Xu 2008).

Back to top

Waste Management
The waste generated in response to anthrax incidents has been problematic, owing to the
challenges of identifying locations willing to take such waste, procedures for disposing of
waste, and procedures for minimizing risks associated with placing the waste in a landfill
(EPA 2012). Decisions regarding waste management need to be made within a
comprehensive recovery framework (Lesperance 2011: Developing a regional recovery
framework). While there are several research questions that need to be addressed, the
most pressing waste management issue is the classification of the waste, which will dictate
waste management plans (Lesperance 2011: Challenges in disposing of anthrax waste).

Gaps in Decontamination Policy and Practice

The environmental decontamination response following the 2001 postal anthrax attacks
required hundreds of millions of dollars in direct costs, and some facilities were closed for
more than 2 years (Franco 2010). It cost $320 million to clean up seven contaminated
buildings after the 2001 postal anthrax attack (Schmitt 2012). Although the attack represents
the worst case of bioterrorism in US history, it is considered to be small in scale. Recently,
an analysis was undertaken to identify current gaps in decontamination policy and practice
at the federal level that must be addressed to achieve a successful response following a
large-scale attack (Franco 2010). Identified gaps include:

80/105
 Unclear roles and responsibilities for federal agencies involved in a decontamination
response
Lack of a coordinated, sustained, and adequately funded research program for
biological decontamination
Limited technologies and methods for sampling, testing, and analysis of
contamination
Scientific uncertainty about biological agent properties, decontamination methods,
and risks to human health
Absence of decontamination standards
Shortage of trained personnel to carry out decontamination response

Back to top

Public Health Reporting and Case Definitions

Clinical Description
Confirmed Cases

Anthrax cases should be reported immediately to local or state health departments,

according to disease reporting rules.

The anthrax case definition for public health surveillance is as follows (CDC 1997, CDC 2001:
CDC update: CDC case definition of anthrax and summary of confirmed cases):

Clinical Description
An illness with acute onset characterized by several distinct clinical forms, including the
following:

Cutaneous:a skin lesion evolving during a period of 2 to 6 days from a papule, through
a vesicle, to a depressed black eschar
Inhalational: a brief prodrome resembling a viral respiratory illness, followed by
development of hypoxemia and dyspnea, with radiographic evidence of mediastinal
widening
Gastrointestinal:

Abdominal (or intestinal) subtype: severe abdominal distress followed by fever

and signs of septicemia
Oropharyngeal subtype: mucosal lesion in the oral cavity or oropharynx, cervical
adenopathy and edema, and fever

Back to top

Confirmed Cases
81/105
The CDC defines a confirmed case of anthrax as:

A clinically compatible case of cutaneous, inhalational, or gastrointestinal illness that is

laboratory-confirmed by isolation of B anthracis from an affected tissue or site, or
other laboratory evidence of B anthracis infection based on at least two supportive
laboratory tests.

Back to top

Bibliography

Abramova FA, Grinberg LM, Yampolskaya OV, et al. Pathology of inhalational anthrax in
42 cases from the Sverdlovsk outbreak of 1979. Proc Natl Acad Sci 1993 Mar 15;90(6):2291-4
[Full text]

ACOG (American College of Obstetricians and Gynecologists). Management of

asymptomatic pregnant or lactating women exposed to anthrax. Feb 2002 [Full text]

AHRQ (Agency for Healthcare Research and Quality). Pediatric anthrax: implications for
bioterrorism preparedness. Publication 06-E013. 2006 Aug [Full text]

Alexander JJ, Coangelo PM, Cooper CK, et al. Amoxicillin for postexposure inhalational
anthrax in pediatrics: rationale for dosing recommendations. Pediatr Infect Dis J 2008
Nov;27(11):955-7 [Abstract]

Allen JS, Skowera A, Rubin GJ, et al. Long-lasting T cell responses to biological warfare
vaccines in human vaccinees. Clin Infect Dis 2006 Jul 1;43(1):1-7 [Full text]

Amidi S, Dutz W, Kohout E, et al. Human anthrax in Iran: report of 300 cases and review of
literature. Tropenmed Parasitol 1974 Mar;25(1):96-104

Anaraki S, Addiman S, Nixon G, et al. Investigations and control measures following a case
of inhalation anthrax in East London in a drum maker and drummer, October 2008. Euro
Surveill 2008 Dec 18;13(51):pii=19076 [Full text]

Andrew MA, Easterling TR, Carr DB, et al. Amoxicillin pharmacokinetics in pregnant
women: modeling and simulations of dosage strategies. Clin Pharmacol Ther 2007
Apr;81(4):547-56 [Abstract]

APIC (Association for Professionals in Infection Control and Epidemiology)/CDC.

Bioterrorism readiness plan: a template for healthcare facilities. 1999 Apr 13 [Full text]

APHIS (Animal and Plant Health Inspection Service). Summary of selected disease events
July-September 2006. (Info sheet) 2006 Oct 30 [Full text]

82/105
Artenstein AW, Opal SM. Novel approaches to the treatment of systemic anthrax. Clin
Infect Dis 2012 Apr 15;54(8):1148-61[Abstract]

ASM (American Society for Microbiology). Sentinel laboratory guidelines for suspected
agents of bioterrorism and emerging infectious diseases: packing and shipping infectious
substances. 2012 Dec 20 [Full text]

ASM. Sentinel level clinical microbiology laboratory guidelines for suspected agents of
bioterrorism and emerging infectious diseases: Bacillus anthracis. 2013 Jul 23

ASM. Sentinel level clinical microbiology laboratory guidelines [Web page]

Athamna A, Athamna M, Abu-Rashed N, et al. Selection of Bacillus anthracis isolates

resistant to antibiotics. J Antimicrob Chemother 2004 Aug;54(2):424-8 [Full text]

Athamna A, Athamna M, Nura A, et al. Is in vitro antibiotic combination more effective

than single-drug therapy against anthrax? Antimicrob Agents Chemother 2005
Apr;49(4):1323-5 [Full text]

Avashia SB, Riggins WS, Lindley C, et al. Fatal pneumonia among metalworkers due to
inhalation exposure to Bacillus cereus containing Bacillus anthracis toxin genes. Clin Infect
Dis 2007 Feb 1;44(3):414-6 [Full text]

Baggett HC, Rhodes JC, Fridkin SK, et al. No evidence of a mild form of inhalational
Bacillus anthracis infection during a bioterrorism-related inhalational anthrax outbreak in
Washington, DC, in 2001. Clin Infect Dis 2005 Oct 1;41(7):991-7 [Full text]

Barrier Products, LLC. BioSeal Systems [Home page]

Barrow EW, Dreier J, Reinelt S, et al. In vitro efficacy of new antifolates against
trimethoprim-resistant Bacillus anthracis. Antimicrob Agents Chemother 2007
Dec;51(12):4447-52 [Full text]

Beatty ME, Ashford DA, Griffin PM, et al. Gastrointestinal anthrax: review of the
literature. Arch Intern Med 2003 Nov 10;163(20):2527-31 [Abstract]

Beecher DJ. Forensic application of microbiological culture analysis to identify mail

intentionally contaminated with Bacillus anthracis spores. Appl Environ Microbiol 2006
Aug;72(8):5304-10 [Abstract]

Begier EM, Barrett NL, Mshar PA, et al. Gram-positive rod surveillance for early anthrax
detection. Emerg Infect Dis 2005 Sep;11(9):1483-6 [Full text]

Bell DM, Kozarsky PE, Stephens DS. Clinical issues in the prophylaxis, diagnosis, and
treatment of anthrax. Emerg Infect Dis 2002 Feb;8(2):222-5 [Full text]
83/105
Bhattacharjee Y, Enserink M. Anthrax investigation: FBI discusses microbial forensics—
but key questions remain unanswered. Science 2008 Aug 22;321(5892):1026-7 [Full text]

Biagini RE, Sammons DL, Smith JP, et al. Rapid, sensitive, and specific lateral-flow
immunochromatographic device to measure anti-anthrax protective antigen
immunoglobulin g in serum and whole blood. Clin Vaccine Immunol 2006 May;13(5):541-6
[Full text]

Bischof TS, Hahn BL, Sohnle PG. Characteristics of spore germination in a mouse model of
cutaneous anthrax. J Infect Dis 2007 Mar 15;195(6):888-94 [Full text]

Black DG, Taylor TM, Kerr HJ, et al. Decontamination of fluid milk containing Bacillus
spores using commercial household products. J Food Prot 2008 Mar;71(3):473-8 [Abstract]

Blackburn JK, Curtis A, Hadfield TL, et al. Confirmation of Bacillus anthracis from flesh-
eating flies collected during a West Texas anthrax season. J Wildl Dis 2010;46(3):918-22
[Abstract]

Blank S, Moskin LC, Zucker JR. An ounce of prevention is a ton of work: mass antibiotic
prophylaxis for anthrax, New York City, 2001.Emerg Infect Dis 2003 Jun;9(6):615-22 [Full text]

Booth MG, Hood J, Brooks TJ, et al. Anthrax infection in drug users. Lancet 2010 Apr
17;375(9723):1345-6 [Full text]

Boyer AE, Quinn CP, Beesley CA, Et al. Lethal factor toxemia and anti-protective antigen
antibody activity in naturally acquired cutaneous anthrax. J Infect Dis 2011 Nov;204(9):1321-
7 [Full text]

Brachman PS. Anthrax. In: Warren KS, Mahmoud AF, eds. Tropical and geographic
medicine. New York: McGraw-Hill, 1984:826-30

Brachman PS. Inhalation anthrax. Ann NY Acad Sci 1980;353:83-93

Brachman PS, Gold H, Plotkin SA, et al. Field evaluation of a human anthrax vaccine. Am J
Public Health 1962;52(4):632-45 [Full text]

Brachman PS, Plotkin SA, Bumford FH, et al. An epidemic of inhalation anthrax: the first
in the twentieth century. II. Epidemiology. Am J Hyg 1960;72:6-23

Bravata DM, Holty JE, Wang E, et al. Inhalational, gastrointestinal, and cutaneous anthrax
in children: a systematic review of cases: 1900 to 2005. Arch Pediatr Adolesc Med 2007
Sep;161(9):896-905 [Full text]

84/105
Bravata DM, Zaric GS, Holty JE, et al. Reducing mortality from anthrax bioterrorism:
strategies for stockpiling and dispensing medical and pharmaceutical supplies. Biosecur
Bioterr 2006;4(3):244-62 [Abstract]

Brook I, Elliott TB, Pryor HI 2nd, et al. In vitro resistance of Bacillus anthracis Sterne to
doxycycline, macrolides and quinolones. Int J Antimicrob Agents 2001 Dec;18(6):559-6
[Abstract]

Brookmeyer R, Blades N. Prevention of inhalational anthrax in the US outbreak. Science

2002 Mar 8;295(5561):1861 [Abstract]

Brookmeyer R, Blades N, Hugh-Jones M, et al. The statistical analysis of truncated data:

application to the Sverdlovsk anthrax outbreak. Biostatistics 2001 Jun;2(2):233-47 [Abstract]

Brouillard JE, Terriff CM, Tofan A, et al. Antibiotic selection and resistance issues with
fluoroquinolones and doxycycline against bioterrorism agents. Pharmacotherapy 2006
Jan;26(1):3-14 [Abstract]

Brown GS, Betty RG, Brockmann JE, et al. Evaluation of a wipe surface sample method for
collection of Bacillus spores from nonporous surfaces. Appl Environ Microbiol 2007
Feb;73(3):706-10 [Full text]

Campbell CG, Kirvel RD, Love AH, et al. Decontamination after a release of B. anthracis
spores. Biosecur Bioterror 2012 Mar 28;10(1):108-22 [Abstract]

Cangene. First quarter report, fiscal 2012. 2011 Dec 12

Canter DA. Addressing residual risk issues at anthrax cleanups: how clean is safe? J Toxicol
Environ Health A 2005 Jun 11-25;68(11-12):1017-32 [Abstract]

Cavallo JD, Ramisse F, Girardet M, et al. Antibiotic susceptibilities of 96 isolates of Bacillus

anthracis isolated in France between 1994 and 2000. Antimicrob Agents Chemother 2002
Jul;46(7):2307-9 [Full text]

CDC. Algorithm for laboratory diagnosis of anthrax

CDC. Anthrax: collecting, preparing, and shipping serum samples to CDC for serology testing
[Full text]

CDC. Basic laboratory protocols for the presumptive identification of Bacillus anthracis.
2001 Apr 18

CDC. Biosafety in microbiological and biomedical laboratories (BMBL). Ed 5, 2007 [ Full text]

85/105
CDC. Case definitions for infectious conditions under public health surveillance. MMWR
1997 May 2;46(RR10):1-55 [Full text]

CDC. CDC update: CDC case definition of anthrax and summary of confirmed cases. 2001
Oct 21 [Press release]

CDC. CDC collaboration yields new test for anthrax. 2004 Jun 7 [Press release]

CDC. CDC responds: an update on treatment options for postal and other workers exposed
to anthrax. 2001 Dec 27 [Transcript]

CDC. Considerations for distinguishing influenza-like illness from inhalational anthrax.

MMWR 2001 Nov 9;50(44):984-6 [Full text]

CDC. Cutaneous anthrax associated with drum making using goat hides from West Africa—
Connecticut, 2007. MMWR 2008 Jun 13;57(23):628-31 [Full text]

CDC. Facts about the Laboratory Response Network [ Web page]

CDC. Gastrointestinal anthrax after an animal-hide drumming event—New Hampshire and

Massachusetts, 2009. MMWR 2010 Jul 23;59(28):872-7 [Full text]

CDC. Human anthrax associated with an epizootic among livestock—North Dakota, 2000.
MMWR 2001 Aug 17;50(32):677-80 [Full text]

CDC. Human ingestion of Bacillus anthracis-contaminated meat—Minnesota, August 2000.

MMWR 2000 Sep 15;49(36):813-6 [Full text]

CDC. Inadvertent laboratory exposure to Bacillus anthracis—California, 2004. MMWR 2005

Apr 1;54(12);301-4 [Full text]

CDC. Inhalation anthrax associated with dried animal hides—Pennsylvania and New York
City, 2006. MMWR 2006 Mar 17;55(10):280-2 [Full text]

CDC. Interim guidelines for investigation of and response to Bacillus anthracis exposures.
MMWR 2001 Nov 9;50(44):987-90 [Full text]

CDC. Interim recommendations for antimicrobial prophylaxis for children and breastfeeding
mothers and treatment of children with anthrax. MMWR 2001 Nov 16;50(45):1014-6 [Full
text]

CDC. Interim recommendations for the selection and use of protective clothing and
respirators against biological agents [Full text]

86/105
CDC. Investigation of anthrax associated with intentional exposure and interim public health
guidelines, October 2001. MMWR 2001 Oct 19;50(41):889-93 [Full text]

CDC. Investigation of bioterrorism-related anthrax and interim guidelines for exposure

management and antimicrobial therapy, October 2001. MMWR 2001 Oct 26;50(42):909-19
[Full text]

CDC. Laboratory Response Network (The) [ Slide show]

CDC. Laboratory security and emergency response guidance for laboratories working with
select agents. MMWR 2002 Dec 6;51(RR19):1-8 [Full text]

CDC. Medical examiners, coroners, and biologic terrorism: a guidebook for surveillance and
case management. MMWR 2004 Jun 11;53(RR8):1-27 [Full text]

CDC. Protecting investigators performing environmental sampling for Bacillus anthracis:

personal protective equipment [Full text]

CDC. Q & A: anthrax and animal hide drums

CDC. Recommended specimens for microbiology and pathology for diagnosis: inhalation,
cutaneous, and gastrointestinal anthrax [Web page]

CDC. Responding to detection of aerosolized Bacillus anthracis by autonomous detection

systems in the workplace. MMWR 2004 Jun 4;53(RR7):1-12 [Full text]

CDC. Summary of notifiable diseases, United States, 1994. MMWR 1995 Oct 6;43(53):1-80
[Full text]

CDC. Surveillance for adverse events associated with anthrax vaccination—US Department
of Defense, 1998-2000. MMWR 2000 Apr 28;49(16):341-5 [Full text]

CDC. Suspected cutaneous anthrax in a laboratory worker—Texas, 2002. MMWR 2002 Apr
5;51(13):279-81 [Full text]

CDC. Syndromic surveillance: reports from a national conference, 2004. MMWR 2005 Aug
26;54(suppl) [Full text]

CDC. Updated recommendations for antimicrobial prophylaxis among asymptomatic

pregnant women after exposure to Bacillus anthracis. MMWR 2001 Nov 2;50(43):960 [Full
text]

CDC. Use of anthrax vaccine in the United States: recommendations of the Advisory
Committee on Immunization Practices (ACIP), 2009. MMWR 2010 Jul 23;59(RR6):1-30 [Full
text]
87/105
CDC/APHIS. HHS and USDA select agents and toxins. 7 CFR part 331, 9 CFR part 121, and 42
CFR part 73. 2008 Nov 17 [Web page]

Chen Z, Moayeri M, Purcell R. Monoclonal antibody therapies against anthrax. Toxins

(Basel) 2011 Aug;3(8):1004-19 [Abstract]

Cohen J. Biodefense: 10 years after: reinventing project BioShield. Science 2011 Sep
2;333(6047):1216-8 [Abstract]

Coker PR, Smith KL, Fellows PF, et al. Bacillus anthracis virulence in guinea pigs
vaccinated with anthrax vaccine adsorbed is linked to plasmid quantities and clonality. J Clin
Microbiol 2003 Mar;41(3):1212-8 [Full text]

Coker PR, Smith KL, Hugh-Jones ME. Antimicrobial susceptibilities of diverse Bacillus
anthracis isolates. Antimicrob Agents Chemother 2002 Dec;46(12):3843-5 [Full text]

Coleman ME, Thran B, Morse SS, et al. Inhalation anthrax: dose response and risk
analysis. Biosecur Bioterror 2008 Jun;6(2):147-60 [Abstract]

Cote CK, Welkos SL, Bozue J. Key aspects of the molecular and cellular basis of inhalational
anthrax. Microbes Infect 2011 Dec;13(14-15):1146-55 [Abstract]

Dauphin LA, Newton BR, Rasmussen MV, et al. Gamma irradiation can be used to
inactivate Bacillus anthracis spores without compromising the sensitivity of diagnostic
assays. Appl Environ Microbiol 2008 Jul;74(14):4427-33 [Full text]

Davies JC. A major epidemic of anthrax in Zimbabwe. Cent Afr J Med 1982;28:291-8
Davison S, Couture-Tosi E, Candela T, et al. Identification of the Bacillus anthracis
(gamma) phage receptor. J Bacteriol 2005 Oct;187(19):6742-9 [Full text]

Dembek ZF, Pavlin JA, Kortepeter MG. Epidemiology of biowarfare and bioterrorism. In:
Dembek ZF, ed. Textbooks of military medicine: medical aspects of biological warfare.
Washington, DC: Borden Institute, 2007:39-68 [Full text]

Dewan PK, Fry AM, Laserson K, et al. Inhalational anthrax outbreak among postal
workers, Washington, DC, 2001. Emerg Infect Dis 2002 Oct;8(10):1066-72 [Full text]

DIA (Defense Intelligence Agency). Soviet biological warfare threat. Publication DST-
161OF-057-86. 1986 [Full text]

Dixon TC, Meselson M, Guillemin J, et al. Anthrax. N Engl J Med 1999 Sep 9:341(11):815-26
[Full text]

88/105
DoD (Department of Defense). DoD to resume anthrax vaccinations. 2006 Oct 16 [Press
release]
DOT (Department of Transportation). Hazardous Materials Regulations (HMR; 49 CFR
Parts 171-180) [Web page]

Doganay M, Almac A, Hanagasi R. Primary throat anthrax: a report of six cases. Scand J
Infect Dis 1986;18(5):415-9 [Abstract]

Doganay M, Metan G. Human anthrax in Turkey from 1990 to 2007. Vector Borne Zoonotic
Dis 2009 Apr;9(2):131-40 [Abstract]

Donegan S, Bellamy R, Gamble CL. Vaccines for preventing anthrax. Cochrane Database
Syst Rev 2009 Apr 15;(2):CD006403 [Abstract]

Doolan DL, Freilich DA, Brice GT, et al. The US Capitol bioterrorism anthrax exposures:
clinical epidemiological and immunological characteristics. J Infect Dis 2007 Jan
15;195(2):174-84 [Full text]

Doust JY, Sarkarzadeh A, Kavoossi K. Corticosteroid in treatment of malignant edema of

chest wall and neck (anthrax). Dis Chest 1968 Jun;53(6):773-4

DuBois AB, Freytag LC, Clements JD. Evaluation of combinatorial vaccines against anthrax
and plague in a murine model. Vaccine 2007 Jun 11;25(24):4747-54 [Full text]

Duderstadt SK, Rose CE Jr, Real TM, Et al. Vaccination and risk of type 1 diabetes mellitus
in active component U.S. Military, 2002-2008. Vaccine 2012 Jan 17;30(4):813-9 [Abstract]

Dull PM, Wilson KE, Kournikakis B, et al. Bacillus anthracis aerosolization associated with
a contaminated mail sorting machine. Emerg Infect Dis 2002 Oct;8(10):1044-7 [Full text]

Duncan KO, Smith TL. Primary cutaneous infection with Bacillus megaterium mimicking
cutaneous anthrax. J Am Acad Dermatol 2011 Aug;65(2):e60-1 [Abstract]

Emergent BioSolutions. BioThrax package insert [Full text]

Emergent BioSolutions. Emergent BioSolutions signs contract with BARDA/NIAID, valued at

up to $29.7 million, to fund development of AV7909 - a next generation anthrax vaccine.
2008 Sep 12 [Press release]

EPA (Environmental Protection Agency). Acute Low Dose Bacillus anthracis Ames
Inhalation Exposures in the Rabbit. 2011 Sep [Full text]

EPA. Anthrax spore decontamination using hydrogen peroxide vapor. 2007 Jul [Full text]

89/105
EPA. Determining the efficacy of liquids and fumigants in systematic decontamination
studies for Bacillus anthracis using multiple test methods. 2010 Dec [Full text]

EPA. Report on the 2011 Workshop on Chemical-Biological- Radiological Disposal in

Landfills. 2012 [Full text]

Fasanella A, Losito S, Adone R, et al. PCR assay to detect Bacillus anthracis spores in heat-
treated specimens. J Clin Microbiol 2003 Feb;41(2):896-9 [Full text]

FBI (Federal Bureau of Investigation). FBI and Justice Department response to NAS review
of scientific approaches used during the investigation of the 2001 anthrax letters. 2011 Feb
15 [Press release]

FDA (Food and Drug Administration). Doxycycline and penicillin G procaine administration
for inhalational anthrax (post-exposure). Fed Reg 2001 Nov 2;66(213):55679-82 [Full text]

FDA. Levaquin (levofloxacin) information for inhalational anthrax. [Web page]

Fennelly KP, Davidow AL, Miller SL, et al. Airborne infection with Bacillus anthracis—from
mills to mail. Emerg Infect Dis 2004 Jun:10(6):996-1002 [Full text]

Fine AM, Wong JB, Fraser HS, et al. Is it influenza or anthrax? A decision analytic approach
to the treatment of patients with influenza-like illnesses. Ann Emerg Med 2004
Mar;43(3):318-28 [Abstract]

Fitch JP, Raber E, Imbro DR. Technology challenges in responding to biological or chemical
attacks in the civilian sector. Science 2003 Nov 21;302(5649):1350-4 [Abstract]

Franco C, Bouri N. Environmental decontamination following a large-scale bioterrorism

attack: federal progress and remaining gaps. Biosecur Bioterror 2010 Jun;8(2):107-17
[Abstract]

Franz DR, Jahrling PB, Friedlander AM, et al. Clinical recognition and management of
patients exposed to biological warfare agents. JAMA 1997 Aug 6;278(5):399-411 [Full text]

Frawley DA, Samaan MN, Bull RL, et al. Recovery efficiencies of anthrax spores and ricin
from nonporous or nonabsorbent and porous or absorbent surfaces by a variety of
sampling methods. J Forensic Sci 2008 Sep;53(5):1102-7 [Abstract]

Freedman A, Afonja O, Chang MW, et al. Cutaneous anthrax associated with

microangiopathic hemolytic anemia and coagulopathy in a 7-month-old infant. JAMA 2002
Feb 20;287(7):869-74 [Full text]

Froude JW 2nd, Stiles B, Pelat T. Antibodies for biodefense. MAbs 2011 Nov 1;3(6):517-27
[Abstract]
90/105
Gierczynski R, Zasada AA, Raddadi N, et al. Specific Bacillus anthracis identification by a
plcR-targeted restriction site insertion-PCR (RSI-PCR) assay. FEMS Microbiol Lett 2007
Jul;272(1):55-9 [Abstract]

Giorno R, Bozue J, Cote C, et al. Morphogenesis of the Bacillus anthracis spore. J Bacteriol
2007 Feb;189(3):691-705 [Full text]

Gladstone GP. Immunity to anthrax: protective antigen present in cell-free culture filtrates.
Br J Exp Pathol 1946 Dec;27(6):394-418 [Abstract]

Gold H. Anthrax: a report of one hundred seventeen cases. Arch Intern Med 1955
Sep;96(3):387-96 [Abstract]

Gold JA, Hoshino Y, Hoshino S, et al. Exogenous gamma and alpha/beta interferon
rescues human macrophages from cell death induced by Bacillus anthracis. Infect Immun
2004 Mar;72(3):1291-7 [Full text]

Good KM, Houser AM, Arntzen L, et al. Naturally acquired anthrax antibodies in a cheetah
(Acinonyx jubatus) in Botswana. J Wildl Dis 2008 Jul;44(3):721-3 [Abstract]

Griffith KS, Mead P, Armstrong GL, et al. Bioterrorism-related inhalational anthrax in an

elderly woman, Connecticut, 2001. Emerg Infect Dis 2003 Jun;9(6):681-8 [Full text]

Guarner J, Jernigan JA, Shieh WJ, et al. Pathology and pathogenesis of bioterrorism-
related inhalational anthrax. Am J Pathol 2003 Aug;163(2):701-9 [Full text]

Guichard A, Nizet V, Bier E. New insights into the biological effects of anthrax toxins:
linking cellular to organismal responses. Microbes Infect 2011 Sep;12(2):97-118 [Abstract]

Hanna P. Anthrax pathogenesis and host response. Curr Top Microbiol Immunol
1998;225:13-35 [Abstract]

Hatami H, Ramazankhani A, Mansoori F. Two cases of gastrointestinal anthrax with an

unusual presentation from Kermanshah (western Iran). Arch Iran Med 2010;13(2):156-9
[Abstract]

Henderson DA. The looming threat of bioterrorism. Science 1999 Feb 26;283(5406):1279-82
[Abstract]

Henderson DW, Peacock S, Belton FC. Observations on the prophylaxis of experimental

pulmonary anthrax in the monkey. J Hyg 1956;54:28-36 [Full text]

HGS (Human Genome Sciences). Raxibacumab 2012

91/105
HGS. Human Genome Sciences announces new order for raxibacumab (abthrax) from US
government. 2009 Jul 22 [Press release]

HHS (Department of Health and Human Services). HHS to acquire anthrax immune
globulin for stockpile. 2006 Jul 28 [Press release]

HHS. HHS preparedness grants help cities plan for anthrax attacks. 2011 Aug 1 [ Press
release]

HHS. HHS to acquire new anthrax therapeutic treatment for stockpile. 2006 Jun 20 [Press
release]

HHS. Novel anthrax vaccine and antitoxin being developed with federal support. 2011 Sep
15 [Press release]

HHS. Possession, use, and transfer of select agents and toxins: final rule. 42 CFR parts 73.
Fed Reg 2012 Oct 3;77(194):61084-115 [Full text]

HHS. Statement by Dr. Nicole Lurie, Assistant Secretary for Preparedness and Response on
the Sept. 30, 2011 IOM report on prepositioning antibiotics for anthrax. 2011 Sep 30 [Press
release]

Hicks CW, Cui X, Sweeney DA. The potential contributions of lethal and edema toxins to
the pathogenesis of anthrax associated shock. Toxins (Basel) 2011 Sep;3(9):1185-202 [Full
text]

Higgins JA, Ibrahim MS, Knauert FK, et al. Sensitive and rapid identification of biological
threat agents. Ann NY Acad Sci 1999;894:130-48

Hilgren J, Swanson KMJ, Diez-Gonzalez F, et al. Inactivation of Bacillus anthracis spores by

liquid biocides in the presence of food residue. Appl Environ Microbiol 2007
Oct;73(20):6370-7 [Full text]

Hindson BJ, Brown SB, Marshall GD, et al. Development of an automated sample
preparation module for environmental monitoring of biowarfare agents. Anal Chem 2004 Jul
1;76(13):3492-7 [Abstract]

Hoffmaster AR, Fitzgerald CC, Ribot E, et al. Molecular subtyping of Bacillus anthracis and
the 2001 bioterrorism-associated anthrax outbreak, United States. Emerg Infect Dis 2002
Oct;8(10):1111-6 [Full text]

Hoffmaster AR, Meyer RF, Bowen MP, et al. Evaluation and validation of a real-time
polymerase chain reaction assay for rapid identification of Bacillus anthracis. (Letter)
Emerging Infect Dis 2002 Oct;8(10):1178-82 [Full text]

92/105
Hoffmaster AR, Meyer RF, Bowen MP, et al. Supplement to above. Emerging Infect Dis
2002 Oct;8(10):1178-82 [Full text]

Hoffmaster AR, Ravel J, Rasko DA, et al. Identification of anthrax toxin genes in a Bacillus
cereus associated with an illness resembling inhalation anthrax. Proc Natl Acad Sci 2004 Jun
1;101(22):8449-54 [Full text]

Holty JE, Bravata DM, Liu H, et al. Systematic review: a century of inhalational anthrax
cases from 1900 to 2005. Ann Intern Med 2006 Feb 21;144(4):270-80 [Abstract]

Holty JE, Kim RY, Bravata DM. Anthrax: a systematic review of atypical presentations. Ann
Emerg Med 2006 Aug;48(2):200-11 [Abstract]

Holtz TH, Ackelsberg J, Kool JL, et al. Isolated case of bioterrorism-related inhalational
anthrax, New York City, 2001. Emerg Infect Dis 2003 Jun;9(6):689-96 [Full text]

Howell JM, Mayer TA, Hanfling D, et al. Screening for inhalational anthrax due to
bioterrorism: evaluating proposed screening protocols. Clin Infect Dis 2004 Dec
15;39(12):1842-7 [Full text]

HPA (Health Protection Agency, United Kingdom). Guidelines for action in the event of a
deliberate release of anthrax. Version 5.9. 2007 Apr 16 [Full text]

HPS (Health Protection Scotland). An outbreak of anthrax among drug users in Scotland,
December 2009 to December 2010. December 2011 [Full text]

Hsu VP, Lukacs SL, Handzel T, et al. Opening a Bacillus anthracis-containing envelope,
Capitol Hill, Washington, DC: the public health response. Emerg Infect Dis 2002
Oct;8(10):1039-43 [Full text]

Hugh-Jones M, Blackburn J. The ecology of Bacillus anthracis. Mol Aspects Med 2009
Dec;30(6):356-67 [Abstract]

Hupert N, Bearman GML, Mushlin AI, et al. Accuracy of screening for inhalational anthrax
after a bioterrorist attack. Ann Intern Med 2003 Sep 2;139(5 pt 1):337-45 [Abstract]

Hupert N, Wattson D, Cuomo J, et al. Anticipating demand for emergency health services
due to medication-related adverse events after rapid mass prophylaxis campaigns. Acad
Emerg Med 2007 Mar;14(3):268-74 [Abstract]

Hupert N, Wattson D, Cuomo J, et al. Predicting hospital surge after a large-scale anthrax
attack: a model-based analysis of CDC's cities readiness initiative prophylaxis
recommendations. Med Decis Making 2009 Jul-Aug;29(4):424-37 [Abstract]

93/105
IATA (International Air Transport Association). Dangerous Goods Regulations; 53rd
Edition. 2012. May be purchased at: [Web Page]

Inglesby TV, O'Toole T, Henderson DA, et al, for the Working Group on Civilian
Biodefense. Anthrax as a biological weapon, 2002: updated recommendations for
management. JAMA 2002 May 1;287(17):2236-52 [Full text]

IOM (Institute of Medicine). Prepositioning antibiotics for anthrax. Washington, DC:

National Academies Press, 2011 [Full text]

Jang J, Cho M, Chun JH. The poly-gamma-D-glutamic acid capsule of Bacillus anthracis
enhances lethal toxin activity. Infect Immun 2011 Sep;79(9):3846-54 [Abstract]

Jernigan DB, Raghunathan PL, Bell BP, et al. Investigation of bioterrorism-related anthrax,
United States, 2001: epidemiologic findings. Emerg Infect Dis 2002 Oct;8(10):1019-28 [Full
text]

Jernigan JA, Stephens DS, Ashford DA, et al. Bioterrorism-related inhalational anthrax: the
first 10 cases reported in the United States. Emerg Infect Dis 2001 Nov-Dec;7(6):933-44 [Full
text]

Johns N, Cooper D, Terrace J. An unusual case of peritonitis in an intravenous drug user.

Gastroenterology 2011 Aug;141(2):435-6, 780-1 [Abstract]

Kadanali A, Tasyaran MA, Kadanali S. Anthrax during pregnancy: case reports and review.
Clin Infect Dis 2003 May 15;36(10):1343-6 [Full text]

Kanafani ZA, Ghossain A, Sharara AI, et al. Endemic gastrointestinal anthrax in 1960s
Lebanon: clinical manifestations and surgical findings. Emerg Infect Dis 2003 May;9(5):520-5
[Full text]

Keim P, Klevytska AM, Price LB, et al. Molecular diversity in Bacillus anthracis. J Appl
Microbiol 1999 Aug;87(2):215-7 [Abstract]

Keim P, Price LB, Klevytska AM, et al. Multiple-locus variable-number tandem repeat
analysis reveals genetic relationships within Bacillus anthracis. J Bacteriol 2000
May;182(10):2928-36 [Abstract]

Kenefic LJ, Beaudry J, Trim C, et al. High resolution genotyping of Bacillus anthracis
outbreak strains using four highly mutable single nucleotide repeat markers. Lett Appl
Microbiol 2008 May;46(5):600-3 [Full text]

Kim W, Kim JY, Cho SL, et al. Glycosyltransferase—a specific marker for the discrimination
of Bacillus anthracis from the Bacillus cereus group. J Med Microbiol 2008 Mar;57(3):279-86
[Full text]
94/105
King D, Luna V, Cannons A, et al. Performance assessment of three commercial assays for
direct detection of Bacillus anthracis spores. J Clin Microbiol 2003 Jul;41(7):3454-5 [Full text]

Kirby JE. Anthrax lethal toxin induces human endothelial cell apoptosis. Infect Immun 2004
Jan;72(1):430-9 [Full text]

Kissling E, Wattiau P, China B. B. anthracis in a wool-processing factory: seroprevalence

and occupational risk. Epidemiol Infect 2011 Aug 11:1-8 [Abstract]

Klee SR, Brzuszkiewicz EB, Nattermann H, et al. The genome of a Bacillus isolate causing
anthrax in chimpanzees combines chromosomal properties of B. cereus with B. anthracis
virulence plasmids. PLoS ONE 2010 Jul 9;5(7):e10986 [Full text]

Kuehnert MJ, Doyle TJ, Hill HA, et al. Clinical features that discriminate inhalational
anthrax from other acute respiratory illnesses. Clin Infect Dis 2003 Feb 1;36(3):328-36 [Full
text]

Kumar P, Ahuja N, Bhatnagar R. Anthrax edema toxin requires influx of calcium for
inducing cyclic AMP toxicity in target cells. Infect Immun 2002 Sep;70(9):4997-5007 [Full text]

Kunanusont C, Limpakarnjanarat K, Foy HM. Outbreak of anthrax in Thailand. Ann Trop

Med Parasitol 1990 Oct:84(5):507-12 [Abstract]

Kyriacou DN, Stein AC, Yamold PR, et al. Clinical predictors of bioterrorism-related
inhalational anthrax. Lancet 2004 Jul 31-Aug 6;364(9432):449-52 [Abstract]

Lanska DJ. Anthrax meningoencephalitis. Neurology 2002 Aug 13;59(3):327-34 [Abstract]

Leendertz FH, Ellerbrok H, Boesch C, et al. Anthrax kills wild chimpanzees in a tropical
rain forest. Nature 2004 Jul 22;430(6998):451-2 [Abstract]

Leendertz FH, Yumlu S, Pauli G, et al. A new Bacillus anthracis found in wild chimpanzees
and a gorilla from west and central Africa. PLoS Pathog 2006 Jan;2(1):e8 [Full text]

Lester ED, Bearman G, Ponce A. A second-generation anthrax "smoke detector." IEEE Eng
Med Biol Mag 2004 Jan-Feb;23(1):130-5 [Full text]

Lesperance AM, Stein S, Upton JF. Challenges in disposing of anthrax waste. Biosecur
Bioterror 2011 Sep;9(3):310-4 [Abstract]

Lesperance AM, Olson J, Stein S. Developing a regional recovery framework. Biosecur

Bioterror 2011 Sep;9(3):280-7 [Abstract]

95/105
Levin DB, Valadares de Amorim G. Potential for aerosol dissemination of biological
weapons: lessons from biological control of insects. Biosecur Bioterror 2003 Jan;1(1):37-42
[Full text]

Linkov I, Coles JB, Welle P. Anthrax cleanup decisions: statistical confidence or confident
response. Environ Sci Technol 2011 Nov 15;45(22):9471-2 [Abstract]

Liu S, Miller-Randolph S, Crown D, et al. Anthrax toxin targeting of myeloid cells through
the CMG2 receptor is essential for establishment of Bacillus anthracis infections in mice. Cell
Host Microbe 2010;8(5):455-62 [Abstract]

LLNL (Lawrence Livermore National Laboratory). Rapid field detection of biological

agents. S&TR 2002 Jan/Feb:24-6 [Full text]

Locascio LE, Harper B, Robinson M. Standard practice for bulk sample collection and swab
sample collection of visible powders suspected of being biological agents from nonporous
surfaces: collaborative study. J AOAC Int 2007 Jan-Feb;90(1):299-333 [Abstract]

Louie A, Vanscoy BD, Brown DL, et al. Impact of spores on the comparative efficacies of
five antibiotics for the treatment of Bacillus anthracis in an in vitro hollow fiber
pharmacodynamic model. Antimicrob Agents Chemother 2011 (published online Dec 12)
[Abstract]

Louie A, Vanscoy BD, Heine HS 3rd. Differential effect of linezolid and ciprofloxacin on
toxin production by Bacillus anthracis in an in vitro pharmacodynamic system. Antimicrob
Agents Chemother 2011 (published online Nov 7) [Abstract]

Lucey D. Anthrax.In:Mandell GL, Bennett JE, Dolin R. Principles and Practice of Infectious
Diseases. Ed 6. Philadelphia, PA: Elsevier Churchill Livingstone, 2005;2:3618-24

Luna VA, King DS, Gulledge J, et al. Susceptibility of Bacillus anthracis, Bacillus cereus,
Bacillus mycoides, Bacillus pseudomycoides, and Bacillus thuringiensis to 24 antimicrobials
using Sensititre automated microbroth dilution and Etest agar gradient diffusion methods. J
Antimicrob Chemother 2007 Sep;60(3):555-67 [Full text]
Mahlandt BG, Klein F, Lincoln RE et al. Immunologic studies of anthrax. IV. Evaluation of
the immunogenicity of three components of anthrax toxin. J Immunol 1966 Apr;96(4):727-33
[Abstract]

Manchee RJ, Broster MG, Stagg AJ, et al. Out of Gruinard Island. Salisbury Med Bull
1990;68(special suppl):17-8

Marano N, Plikaytis BD, Martin SW, et al. Effects of a reduced dose schedule and
intramuscular administration of anthrax vaccine adsorbed on immunogenicity and safety at
7 months: a randomized trial. JAMA 2008 Oct 1;300(13):1532-43 [Full text]
96/105
Marston CK, Allen C a, Beaudry J, et al. Molecular epidemiology of anthrax cases
associated with recreational use of animal hides and yarn in the United States. PLoS One
2011 Dec 9;6(12):e28274 [Full text]

Martin GJ, Friedlander AM. Anthrax as an agent of bioterrorism. In: Mandell GL, Bennett JE,
Dolin R. Principles and practice of infectious diseases. Ed 7. Philadelphia, PA: Elsevier
Churchill Livingstone, 2010;2:3983-92

Martin GJ, Friedlander AM. Bacillus anthracis (anthrax). In: Mandell GL, Bennett JE, Dolin R.
Principles and practice of infectious diseases. Ed 7. Philadelphia, PA: Elsevier Churchill
Livingstone, 2010;2:2715-25

Mayer TA, Morrison A, Bersoff-Matcha S, et al. Inhalational anthrax due to bioterrorism:

would current Centers for Disease Control and Prevention guidelines have identified the 11
patients with inhalational anthrax from October through November 2001? Clin Infect Dis
2003 May 15;36(10):1275-83 [Full text]

MBAH (Minnesota Board of Animal Health). Minnesota experiences second largest

anthrax outbreak in state history. 2006 Jul 24

McNeil MM, Chiang IS, Wheeling JT, et al. Short-term reactogenicity and gender effect of
anthrax vaccine: analysis of a 1967-1972 study and review of the 1955-2005 medical
literature. Pharmacoepidemiol Drug Saf 2007 Mar;16(3):259-74 [Abstract]

McNeil MM, Ma M, Aranas A, et al. A comparative assessment of immunization records in

the Defense Medical Surveillance System and the Vaccine Adverse Event Reporting System.
Vaccine 2007 Apr 30;25(17):3428-36 [Abstract]

Meselson M, Guillemin J, Hugh-Jones M, et al. The Sverdlovsk anthrax outbreak of 1979.

Science 1994 Nov 18;266(5188):1202-8 [Abstract]

Meyer MA. Neurologic complications of anthrax: a review of the literature. Arch Neurol
2003 Apr;60(4):483-8 [Full text]

Meyerhoff A, Albrecht R, Meyer JM, et al. US Food and Drug Administration approval of
ciprofloxacin hydrochloride for management of postexposure inhalational anthrax. Clin
Infect Dis 2004 Aug 1;39(3):303-8 [Full text]

Migone TS, Subramanian GM, Zhong J, et al. Raxibacumab for the treatment of
inhalational anthrax. N Engl J Med 2009 Jul 9;361(2):135-44 [Full text]

MIIS (Monterey Institute of International Studies). Chemical and biological weapons:

possession and programs past and present. [Web page]

97/105
Moayeri M, Crown D, Dorward DW, et al. The heart is an early target of anthrax lethal
toxin in mice: a protective role for neuronal nitric oxide synthase (nNOS). PLoS Pathog 2009
May 29;5(5):e1000456 [Full text]

Montville TJ, Dengrove R, De Siano T, et al. Thermal resistance of spores from virulent
strains of Bacillus anthracis and potential surrogates. J Food Prot 2005 Nov;68(11):2362-6
[Abstract]

NALC (National Association of Letter Carriers). BDS technology: fact sheet [Web page]

NAS (National Academy of Sciences). Science alone does not establish source of anthrax
used in 2001 mailings. 2011 Feb 15 [Press release]

NBSB (National Biodefense Science Board). Challenges in the use of anthrax vaccine
absorbed (AVA) in the pediatric population as a component of post-exposure prophylaxis
(PEP). Oct 2011 [Full text]

Ndyabahinduka DGK, Chu IH, Abdou AH, et al. An outbreak of human gastrointestinal
anthrax. Ann Ist Super Sanita 1984;20(2-3):205-8

Nelson LS, Hanner R, Hoffman RS. Cutaneous anthrax infection. (Letter) N Engl J Med 2002
Mar 21;346(12):945-6 [Extract]

Niu MT, Ball R, Woo EJ, et al. Adverse events after anthrax vaccination reported to the
Vaccine Adverse Event Reporting System (VAERS), 1990-2007. Vaccine 2009 Jan 7;27(2):290-7
[Abstract]

Nordin JD, Goodman MJ, Kulldorff M, et al. Simulated anthrax attacks and syndromic
surveillance. Emerg Infect Dis 2005 Sep;11(9):1394-8 [Full text]

NRC (National Research Council). Review of the scientific approaches used during the
FBI's investigation of the 2001 anthrax letters. Washington, DC: National Academies Press,
2011 [Full text]

OSHA (Occupational Safety and Health Administration). Anthrax prevention and

controls [Web page]

OTA (Office of Technology Assessment). Proliferation of weapons of mass destruction:

assessing the risks. Publication OTA-ISC-559. Washington, DC: US Government Printing
Office, 1993 Aug [Full text]

Payne DC, Rose CE, Kerrison J, et al. Anthrax vaccination and risk of optic neuritis in the
United States military, 1998-2003. Arch Neurol 2006 Jun;63(6):871-5 [Full text]

98/105
Perdue ML, Karns J, Higgins J, et al. Detection and fate of Bacillus anthracis (Sterne)
vegetative cells and spores added to bulk tank milk. J Food Prot 2003 Dec;66(12):2349-54
[Abstract]

Peters CJ, Hartley DM. Anthrax inhalation and lethal human infection. Lancet 2002 Feb
23;359(9307):710-1 [Full text]

Pfisterer RM. [An anthrax epidemic in Switzerland: clinical, diagnostic and epidemiological
aspects of a mostly forgotten disease.] (Article in German) Schweiz Med Wochenschr 1991
Jun 1;12(22):813-25 [Abstract]

Pilo P, Frey J. Bacillus anthracis: molecular taxonomy, population genetics, phylogeny and
patho-evolution. Infect Genet Evol 2011 Aug;11(6):1218-24 [Abstract]

Pittman PR, Norris SL, Barrera Oro JG, et al. Patterns of antibody response in humans to
the anthrax vaccine adsorbed (AVA) primary (six-dose) series. Vaccine 2006 Apr
24;24(17):3654-60 [Abstract]

Plotkin SA, Brachman PS, Utell M, et al. An epidemic of inhalation anthrax, the first in the
twentieth century. I. Clinical features. Am J Med 1960;29:992-1001 [Abstract]

Polk JD. Testimony before the House Committee on Emergency Preparedness, Response,
and Communications. April 17, 2012 [Full text]

Price LB, Vogler A, Pearson T, et al. In vitro selection and characterization of Bacillus
anthracis mutants with high-level resistance to ciprofloxacin. Antimicrob Agents Chemother
2003 Jul;47(7):2362-5 [Full text]

Price PN, Sohn MD, Lacommare KS, et al. Framework for evaluating anthrax risk in
buildings. Environ Sci Technol 2009 Mar 15;43(6):1783-7 [Abstract]

Purcell BK, Worsham PL, Friedlander AM. Anthrax. In: Dembek ZF, ed. Textbooks of
military medicine: medical aspects of biological warfare. Washington, DC: Borden Institute,
2007:69-90 [Full text]

Quinn CP, Semenova VA, Elie CM, et al. Specific, sensitive, and quantitative enzyme-linked
immunosorbent assay for human immunoglobulin G antibodies to anthrax toxin protective
antigen. Emerg Infect Dis 2002 Oct;8(10):1103-10 [Full text]

Rabinowitz P, Gordon Z, Chudnov D, et al. Animals as sentinels of bioterrorism agents.

Emerg Infect Dis 2006 Apr;12(4):647-52 [Full text]

Ramer H. Woman infected with anthrax is improving. Concord Monit 2010 Jan 7

99/105
Ramsay CN, Stirling A, Smith J, et al. An outbreak of infection with Bacillus anthracis in
injecting drug users in Scotland. Euro Surveill 2010 Jan 14;15(2):pii=19465 [Full text]

Rangel RA, Gonzalez DA. Bacillus anthracis meningitis. Neurology 1975;25:525-30

Rantakokko-Jalava K, Viljanen MK. Application of Bacillus anthracis PCR to simulated

clinical samples. Clin Microbiol Infect 2003 Oct;9(10):1051-6 [Abstract]

Rasko DA, Worsham PL, Abshire TG, et al. Bacillus anthracis comparative genome analysis
in support of the Amerithrax investigation. Proc Natl Acad Sci 2011 Mar 22;108(12):5027-32
[Full text]

Read TD, Peterson SN, Tourasse N, et al. The genome sequence of Bacillus anthracis
Ames and comparison to closely related bacteria. Nature 2003 May 1;423(6935):81-6
[Abstract]

Redd JT, Van Beneden C, Soter NA, et al. Performance of a rapid dermatology referral
system during the anthrax outbreak. J Am Acad Dermatol 2005 Jun;52(6):1077-81 [Abstract]

Reissman DB, Whitney EA, Taylor TH Jr, et al . One-year health assessment of adult
survivors of Bacillus anthracis infection. JAMA 2004 Apr 28;291(16):1994-8 [Full text]

Revich BA, Podolnaya MA. Thawing of permafrost may disturb historic cattle burial
grounds in East Siberia. Glob Health Action 2011;4 [Full text]

Rhie GE, Park YM, Han JS, et al. Efficacy of non-toxic deletion mutants of protective antigen
from Bacillus anthracis. FEMS Immunol Med Microbiol 2005 Aug 1;45(2):341-7 [Abstract]

Rose L, Jensen B, Peterson A, et al. Swab materials and Bacillus anthracis spore recovery
from nonporous surfaces. Emerg Infect Dis 2004;10(6):1023-9 [Full text]

Russell BH, Liu Q, Jenkins SA, et al. In vivo demonstration and quantification of
intracellular Bacillus anthracis in lung epithelial cells. Infect Immun 2008 Sep;76(9):3975-83
[Full text]

Ryan MAK, Smith TC, Sevick CJ, et al. Birth defects among infants born to women who
received anthrax vaccine in pregnancy. Am J Epidemiol 2008 Aug 15;168(4):434-42 [Full text]

Rynkiewicz D, Rathkopf M, Sim I, Et al. Marked enhancement of the immune response to

BioThrax (Anthrax Vaccine Adsorbed) by the TLR9 agonist CPG 7909 in healthy volunteers.
Vaccine 2011 Aug 26;29(37):6313-20 [Abstract]

Saggese MD, Noseda RP, Uhart MM, et al. First detection of Bacillus anthracis in feces of
free-ranging raptors from central Argentina. J Wildl Dis 2007 Jan;43(1):136-41 [Abstract]

100/105
Sanderson WT, Hein MJ, Taylor L, et al. Surface sampling methods for Bacillus anthracis
spore contamination. Emerg Infect Dis 2002 Oct;8(10):1145-51 [Full text]

Schmitt B, Dobrez D, Parada JP, et al. Responding to a small-scale bioterrorist anthrax

attack: cost-effectiveness analysis comparing preattack vaccination with postattack
antibiotic treatment and vaccination. Arch Intern Med 2007 Apr 9;167(7):655-62 [Full text]

Schmitt K, Zacchia N. Total decontamination cost of the anthrax letter attacks. Biosecur
Bioterror 2012 Mar 28;10(1):98-107 [Abstract]

Sejvar JJ, Tenover FC, Stephens DS. Management of anthrax meningitis. Lancet Infect Dis
2005 May;5(5):287-95 [Abstract]

Semenova VA, Schmidt DS, Taylor TH Jr, et al. Analysis of anti-protective antigen IgG
subclass distribution in recipients of anthrax vaccine adsorbed (AVA) and patients with
cutaneous and inhalation anthrax. Vaccine 2007 Feb 26;25(10):1780-8 [Abstract]

Shen Y, Zhukovskaya NL, Zimmer MI, et al. Selective inhibition of anthrax edema factor
by adefovir, a drug for chronic hepatitis B virus infection. Proc Natl Acad Sci 2004 Mar
2;101(9):3242-7 [Full text]

Shepard CW, Soriano-Gabarro M, Zell ER, et al. Antimicrobial postexposure prophylaxis

for anthrax: adverse events and adherence. Emerg Infect Dis 2002 Oct:8(10):1124-32 [Full
text]

Shieh WJ, Guarner J, Paddock C, et al. The critical role of pathology in the investigation of
bioterrorism-related cutaneous anthrax. Am J Pathol 2003 Nov;163(5):1901-10 [Abstract]

Shlyakhov E, Rubinstein E. Evaluation of the anthraxin skin test for diagnosis of acute and
past human anthrax. Eur J Clin Microbiol Infect Dis 1996 Mar;15(3):242-5 [Abstract]

Sirisanthana T, Brown AE. Anthrax of the gastrointestinal tract. Emerg Infect Dis 2002
Jul;8(7):649-51 [Full text]

Sirisanthana T, Navachareon N, Tharavichitkul P, et al. Outbreak of oral-oropharyngeal

anthrax: an unusual manifestation of human infection with Bacillus anthracis. Am J Trop
Med Hyg 1984 Jan;33(1):144-50 [Abstract]

Skottman T, Piiparinen H, Hyytiainen H, et al. Simultaneous real-time PCR detection of

Bacillus anthracis, Francisella tularensis and Yersinia pestis. Eur J Clin Microbiol Infect Dis
2007 Mar;26(3):207-11 [Abstract]

Smyth, HF. A 20 year history of anthrax in the USA. In: Symposium on anthrax. Harrisburg,
PA: Department of Health, Commonwealth of Pennsylvania, Apr 1, 1941

101/105
Sohni Y, Kanjilal S, Kapur V. Performance evaluation of five commercial real-time PCR
reagent systems using TaqMan assays for B anthracis detection. Clin Biochem 2008
May;41(7):640-4 [Abstract]

Spotts Whitney EA, Beatty ME, Taylor TH Jr, et al. Inactivation of Bacillus anthracisspores.
Emerg Infect Dis 2003 Jun;9(6):623-7 [Full text]

SteelFisher G, Blendon R, Ross LJ. Public response to an anthrax attack: reactions to mass
prophylaxis in a scenario involving inhalation anthrax from an unidentified source. Biosecur
Bioterror 2011 Sep;9(3):239-50 [Abstract]

Stephenson J. Rapid anthrax test approved. JAMA 2004 Jul 7;292(1):30 [Full text]

Stern EJ, Uhde KB, Shadomy SV, et al. Conference report on public health and clinical
guidelines for anthrax. Emerg Infect Dis 2008 Apr;14(4):pii:07-0969 [Full text]

Stewart B, Zhang Y, Rose,Jr. CE, et al. Health-related quality of life in the anthrax
vaccination program for workers in the laboratory response network. Vaccine 2012 Feb
27;30(10):1841-6 [Abstract]

Sulsky SI, Luippold RS, Garman P. Risk of disability for US army personnel vaccinated
against anthrax, 1998-2005. Vaccine 2011 Aug 11;29(35):6035-41 [Abstract]

Swartz MN. Recognition and management of anthrax–an update. N Engl J Med 2001 Nov
29;345(22):1621-6 [Full text]

Sweeney DA, Cui X, Solomon SB, et al. Anthrax lethal and edema toxins produce different
patterns of cardiovascular and renal dysfunction and synergistically decrease survival in
canines. J Infect Dis 2010 Dec 15;202(12):1885-96 [Full text]

Tabatabaie P, Syadati A. Bacillus anthracis as a cause of bacterial meningitis. Pediatr Infect

Dis J 1993;12(12):1035-7

Taft SC, Weiss AA. Neutralizing activity of vaccine-induced antibodies to two Bacillus
anthracis toxin components, lethal factor and edema factor. Clin Vaccine Immunol 2008
Jan;15(1):71-5 [Full text]

Takahashi H, Keim P, Kaufmann AF, et al. Bacillus anthracis incident, Kameido, Tokyo,
1993. Emerg Infect Dis 2004 Jan;10(1):117-20 [Full text]

Teshale EH, Painter J, Burr GA, et al. Environmental sampling for spores of Bacillus
anthracis. Emerg Infect Dis 2002 Oct;8(10):1083-7 [Full text]

102/105
Tessier J, Green C, Padgett D, et al. Contributions of histamine, prostanoids, and
neurokinins to edema elicited by edema toxin from Bacillus anthracis. Infect Immun 2007
Apr;75(4):1895-1903 [Full text]

Traeger MS, Wiersma ST, Rosenstein NE, et al. First case of bioterrorism-related
inhalational anthrax in the United States, Palm Beach County, Florida, 2001. Emerg Infect
Dis 2002 Oct;8(10):1029-34 [Full text]

TFAH (Trust for America's Health). Remembering 9/11 and anthrax: public health's vital
role in national defense. Sep 1, 2011 [Full text]

Turnbull PCB, Broster MG, Carman JA, et al. Development of antibodies to protective
antigen and lethal factor components of anthrax toxin in humans and guinea pigs and their
relevance to protective immunity. Infect Immun 1986 May;52(2):356-63 [Abstract]

Turnbull PCB, Sirianni NM, LeBron CI, et al. MICs of selected antibiotics for Bacillus
anthracis, Bacillus cereus, Bacillus thuringiensis, and Bacillus mycoides from a range of
clinical and environmental sources as determined by the Etest. J Clin Microbiol 2004
Aug;42(8):3626-34 [Full text]

US Postal Service. Information on handling mail

Vasudev M, Zacharisen MC. New-onset rheumatoid arthritis after anthrax vaccination. Ann
Allergy Asthma Immunol 2006 Jul;97(1):110-2 [Abstract]

Vietri NJ, Purcell BK, Lawler JV, et al. Short-course postexposure antibiotic prophylaxis
combined with vaccination protects against experimental inhalational anthrax. Proc Natl
Acad Sci 2006 May 16;103(20):7813-6 [Full text]

Walsh JJ, Pesik N, Quinn CP, et al. A case of naturally acquired inhalation anthrax: clinical
care and analyses of anti-protective antigen immunoglobulin G and lethal factor. Clin Infect
Dis 2007 Apr 1;44(7):968-71 [Full text]

Warfel JM, Steele AD, D’Agnillo F. Anthrax lethal toxin induces endothelial barrier
dysfunction. Am J Pathol 2005 Jun;166(6):1871-81 [Full text]

Warrick J. FBI investigation of 2001 anthrax attacks concluded; US releases details. The
Washington Post 2010 Feb 20 [Full text]

Wattiau P, Govaerts M, Frangoulidis D, et al. Immunologic response of unvaccinated

workers exposed to anthrax, Belgium. Emerg Infect Dis 2009 Oct;15(10):1637-40 [Full text]

Wattiau P, Klee SR, Fretin D, et al. Occurrence and genetic diversity of Bacillus anthracis
strains isolate in an active wool-cleaning factory. Appl Environ Microbiol 2008
Jul;74(13):4005-11 [Full text]
103/105
Weber DJ, Rutala WA. Recognition and management of anthrax. (Letter) N Engl J Med 2002
Mar 21;346(12):943-5 [Full text]

Weber DJ, Rutala WA. Risks and prevention of nosocomial transmission of rare zoonotic
diseases. Clin Infect Dis 2001 Feb 1;32(3):446-56 [Full text]

Weber DJ, Sickbert-Bennett E, Gergen MF, et al. Efficacy of selected hand hygiene agents
used to remove Bacillus atrophaeus (a surrogate of Bacillus anthracis) from contaminated
hands. JAMA 2003 Mar 12;289(10):1274-7 [Full text]

Weigel LM, Sue D, Michel PA, et al. A rapid antimicrobial susceptibility test for Bacillus
anthracis. Antimicrob Agents Chemother 2010;54(7):2793-2800 [Full text]

Wein LM, Craft DL, Kaplan EH. Emergency response to an anthrax attack. Proc Natl Acad
Sci 2003 Apr 1;100(7):4346-51 [Full text]

Weis CP, Intrepido AJ, Miller AK, et al. Secondary aerosolization of viable Bacillus
anthracis spores in a contaminated US Senate office. JAMA 2002 Dec 11;288(22):2853-8 [Full
text]

WHO (World Health Organization). Guidelines for the surveillance and control of anthrax
in humans and animals. 3rd ed. 1998 [Full text]

WHO. Health aspects of chemical and biological weapons. Geneva, Switzerland: World
Health Organization, 1970:98-109 [Full text]

WHOCC (WHO Collaborating Center). World anthrax data site

Wiesen AR, Littell CT. Relationship between prepregnancy anthrax vaccination and
pregnancy and birth outcomes among US army women. JAMA 2002 Mar 27;287(12):1556-60
[Full text]

Wilkening DA. Sverdlovsk revisited: modeling human inhalation anthrax. Proc Natl Acad Sci
2006 May 16;103(20):7589-94 [Full text]

WMD Center. Bio-response report card. Oct 12, 2011 [Full text]

Xu S, Labuza TP, Diez-Gonzalez F. Inactivation kinetics of avirulent Bacillus anthracis spores

in milk with a combination of heat and hydrogen peroxide. J Food Prot 2008 Feb;71(2):333-8
[Abstract]

Yung PT, Lester ED, Bearman G, et al. An automated front-end monitor for anthrax
surveillance systems based on the rapid detection of airborne endospores. Biotechnol
Bioeng 2007 Nov 1;98(4):864-71 [Abstract]

104/105
Zink TK. Anthrax attacks: lessons learned on the 10th anniversary of the anthrax attacks.
Disaster Med Public Health Prep 2011 Oct;5(3):173-4 [Abstract]

Back to top

105/105