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Date: Thu, 17 Jul 1997 07:11:32 -0700
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From: Paul Andrew Mitchell [address in tool bar]
Subject: SLS: US Army clinical data on anthrax and plague (fwd)
<snip>
>
>>From US ARMY HANDBOOK ON THE MEDICAL ASPECTS OF NBC DEFENSIVE OPERATIONS FM
>8-9
>PART II - BIOLOGICAL, ANNEX B CLINICAL DATA SHEETS FOR SELECTED BIOLOGICAL
>AGENTS
>1 FEBRUARY 1996
>http://www.nbc-med.org/amedp6/PART_II/annexb.htm
>
>B.02. Anthrax.
>
> a. Clinical Syndrome.
>
> (1) Characteristics. Anthrax is a zoonotic disease caused by Bacillus
>anthracis. Under natural conditions,
> humans become infected by contact with infected animals or contaminated
>animal products. Human anthrax is
> usually manifested by cutaneous lesions. A biological warfare attack
>with anthrax spores delivered by aerosol
> would cause inhalation anthrax, an extraordinarily rare form of the
>naturally occurring disease.
>
> (2) Clinical Features. The disease begins after an incubation period
>varying from 1-6 days, presumably
> dependent upon the dose of inhaled organisms. Onset is gradual and
>nonspecific, with fever, malaise, and fatigue,
> sometimes in association with a nonproductive cough and mild chest
>discomfort. In some cases, there may be a
> short period of improvement. The initial symptoms are followed in 2-3
>days by the abrupt development of severe
> respiratory distress with dyspnea, diaphoresis, stridor, and cyanosis.
>Physical findings may include evidence of
> pleural effusions, edema of the chest wall, and meningitis. Chest x-ray
>reveals a dramatically widened
> mediastinum, often with pleural effusions, but typically without
>infiltrates. Shock and death usually follow within
> 24-36 hours of respiratory distress onset.
>
> b. Diagnosis.
>
> (1) Routine Laboratory Findings. Laboratory evaluation will reveal a
>neutrophilic leucocytosis. Pleural and
> cerebrospinal fluids may be hemorrhagic.
>
> (2) Differential Diagnosis. An epidemic of inhalation anthrax in its
>early stage with nonspecific symptoms could
> be confused with a wide variety of viral, bacterial, and fungal
>infections. Progression over 2-3 days with the
> sudden development of severe respiratory distress followed by shock and
>death in 24-36 hours in essentially all
> untreated cases eliminates diagnoses other than inhalation anthrax. The
>presence of a widened mediastinum on
> chest x-ray, in particular, should alert one to the diagnosis. Other
>suggestive findings include chest-wall edema,
> hemorrhagic pleural effusions, and hemorrhagic meningitis. Other
>diagnoses to consider include aerosol exposure
> to SEB; but in this case onset would be more rapid after exposure (if
>known), and no prodrome would be evident
> prior to onset of severe respiratory symptoms. Mediastinal widening on
>chest x-ray will also be absent. Patients
> with plague or tularemia pneumonia will have pulmonary infiltrates and
>clinical signs of pneumonia (usually absent
> in anthrax).
>
> (3) Specific Laboratory Diagnosis. Bacillus anthracis will be readily
>detectable by blood culture with routine
> media. Smears and cultures of pleural fluid and abnormal cerebrospinal
>fluid may also be positive. Impression
> smears of mediastinal lymph nodes and spleen from fatal cases should be
>positive. Toxemia is sufficient to permit
> anthrax toxin detection in blood by immunoassays.
>
> c. Therapy. Almost all cases of inhalation anthrax in which treatment
>was begun after patients were symptomatic
> have been fatal, regardless of treatment. Historically, penicillin has
>been regarded as the treatment of choice, with
> 2 million units given intravenously every 2 hours. Tetracyclines and
>erythromycin have been recommended in
> penicillin-sensitive patients. The vast majority of anthrax strains are
>sensitive in vitro to penicillin. However,
> penicillin-resistant strains exist naturally, and one has been
>recovered from a fatal human case. Moreover, it is not
> difficult to induce resistance to penicillin, tetracyclines,
>erythromycin, and many other antibiotics through
> laboratory manipulation of organisms. All naturally occurring strains
>tested to date have been sensitive to
> erythromycin, chloramphenicol, gentamicin, and ciprofloxacin. In the
>absence of information concerning antibiotic
> sensitivity, treatment should be instituted at the earliest signs of
>disease with oral ciprofloxacin (1000 mg initially,
> followed by 750 mg po (orally) bid (twice daily)) or intravenous
>doxycycline (200 mg initially, followed by 100
> mg q (every) 12 hrs). Supportive therapy for shock, fluid volume
>deficit, and adequacy of airway may all be
> needed.
>
> d. Prophylaxis.
>
> (1) Vaccine. A licensed, alum-precipitated preparation of purified B.
>anthracis protective antigen (PA) has been
> shown to be effective in preventing or significantly reducing the
>incidence of inhalation anthrax. Limited human
> data suggest that after completion of the first three doses of the
>recommended six-dose primary series (0, 2, 4
> weeks, then 6, 12, 18 months), protection against both cutaneous and
>inhalation anthrax is afforded. Studies in
> rhesus monkeys indicate that good protection is afforded after two
>doses (10-16 days apart) for up to 2 years. It
> is likely that two doses in humans is protective as well, but there is
>too little information to draw firm conclusions.
> As with all vaccines, the degree of protection depends upon the
>magnitude of the challenge dose; vaccine-induced
> protection is undoubtedly overwhelmed by extremely high spore
>challenge. At least three doses of the vaccine (at
> 0, 2, and 4 weeks) are recommended for prophylaxis against inhalation
>anthrax. Contraindications for use are
> sensitivity to vaccine components (formalin, alum, benzethonium
>chloride) and/or history of clinical anthrax.
> Reactogenicity is mild to moderate: up to 6% of recipients will
>experience mild discomfort at the inoculation site
> for up to 72 hours (tenderness, erythema, edema, pruritus), while a
>smaller proportion (<1%) will experience
> more severe local reactions (potentially limiting use of the extremity
>for 1-2 days); modest systemic reactions
> (myalgia, malaise, low-grade fever) are uncommon, and severe systemic
>reactions (anaphylaxis, which precludes
> additional vaccination) are rare. The vaccine should be stored at
>refrigerator temperature (not frozen).
>
> (2) Antibiotics. Choice of antibiotics for prophylaxis is guided by
>the same principles as that for treatment; i.e., it
> is relatively easy to produce a penicillin-resistant organism in the
>laboratory, and possible, albeit somewhat more
> difficult, to induce tetracycline resistance. Therefore, if there is
>information indicating that a biological weapon
> attack is imminent, prophylaxis with ciprofloxacin (500 mg po bid), or
>doxycycline (100 mg po bid) is
> recommended. If unvaccinated, a single 0.5 ml dose of vaccine should
>also be given subcutaneously. Should the
> attack be confirmed as anthrax, antibiotics should be continued for at
>least 4 weeks in all exposed. In addition,
> two 0.5 ml doses of vaccine should be given 2 weeks apart in the
>unvaccinated; those previously vaccinated with
> fewer than three doses should receive a single 0.5 ml booster, while
>vaccination probably is not necessary for
> those who have received the initial three doses within the previous 6
>months (primary series). Upon
> discontinuation of antibiotics, patients should be closely observed; if
>clinical signs of anthrax occur, patients
> should be treated as indicated above. If vaccine is not available,
>antibiotics should be continued beyond 4 weeks
> until the patient can be closely observed upon discontinuation of
>therapy.
>
>B.09. Plague.
>
> a. Clinical Syndrome.
>
> (1) Characteristics. Plague is a zoonotic disease caused by Yersinia
>pestis. Under natural conditions, humans
> become infected as a result of contact with rodents, and their fleas.
>The transmission of the gram-negative
> coccobacillus is by the bite of the infected flea, Xenopsylla cheopis,
>the oriental rat flea, or Pulex irritans, the
> human flea. Under natural conditions, three syndromes are recognized:
>bubonic, primary septicemic, or
> pneumonic. In a biological warfare scenario, the plague bacillus could
>be delivered via contaminated vectors
> (fleas) causing the bubonic type or, more likely, via aerosol causing
>the pneumonic type.
>
> (2) Clinical Features. In bubonic plague, the incubation period ranges
>from 2 to 10 days. The onset is acute and
> often fulminant with malaise, high fever, and one or more tender lymph
>nodes. Inguinal lymphadenitis (bubo)
> predominates, but cervical and axillary lymph nodes can also be
>involved. The involved nodes are tender,
> fluctuant, and necrotic. Bubonic plague may progress spontaneously to
>the septicemic form with organisms spread
> to the central nervous system, lungs (producing pneumonic disease), and
>elsewhere. The mortality is 50 percent in
> untreated patients with the terminal event being circulatory collapse,
>hemorrhage, and peripheral thrombosis. In
> primary pneumonic plague, the incubation period is 2 to 3 days. The
>onset is acute and fulminant with malaise,
> high fever, chills, headache, myalgia, cough with production of a
>bloody sputum, and toxemia. The pneumonia
> progresses rapidly, resulting in dyspnea, stridor, and cyanosis. In
>untreated patients, the mortality is 100 percent
> with the terminal event being respiratory failure, circulatory
>collapse, and a bleeding diathesis.
>
> b. Diagnosis.
>
> (1) Presumptive. Presumptive diagnosis can be made by identification
>of the gram-negative coccobacillus with
> safety-pin bipolar staining organisms in Giemsa or Wayson's stained
>slides from a lymph node needle aspirate,
> sputum, or cerebrospinal fluid (CSF) samples. When available,
>immunofluorescent staining is very useful.
> Elevated levels of antibody to Y. pestis in a nonvaccinated patient may
>also be useful.
>
> (2) Definitive. Yersinia pestis can be readily cultured from blood,
>sputum, and bubo aspirates. Most naturally
> occurring strains of Y. pestis produce an "Fl" antigen in vivo which
>can be detected in serum samples by
> immunoassay. A fourfold rise of Y. pestis antibody levels in patient
>serum is also diagnostic.
>
> (3) Differential. In cases where bubonic type is suspected, tularemia
>adenitis, staphylococcal or streptococcal
> adenitis, meningococcemia, enteric gram-negative sepsis, and
>rickettsiosis need to be ruled out. In pneumonic
> plague, tularemia, anthrax, and staphylococcal enterotoxin B (SEB)
>agents need to be considered. Continued
> deterioration without stabilization effectively rules out SEB. The
>presence of a widened mediastinum on chest
> x-ray should alert one to the diagnosis of anthrax.
>
> c. Therapy. Plague may be spread from person to person by droplets.
>Strict isolation procedures for all cases are
> indicated. Streptomycin, tetracycline, and chloramphenicol are highly
>effective if begun early. Significant
> reduction in morbidity and mortality is possible if antibiotics are
>given within the first 24 hours after symptoms of
> pneumonic plague develop. Intravenous doxycycline (200 mg initially,
>followed by 100 mg every 12 hours),
> intramuscular streptomycin (1 g every 12 hours), or intravenous
>chloramphenicol (l g every 6 hours) for 10-14
> days are effective against naturally occurring strains. Supportive
>management of life-threatening complications
> from the infection, such as shock, hyperpyrexia, convulsions, and
>disseminated intravascular coagulation (DIC),
> need to be initiated as they develop.
>
> d. Prophylaxis. A formalin-killed Y. pestis vaccine is produced in the
>United States and has been extensively
> used. Efficacy against flea-borne plague is inferred from population
>studies, but the utility of this vaccine against
> aerosol challenge is unknown. Reactogenicity is moderately high and a
>measurable immune response is usually
> attained after a 3-dose primary series: at 0, 1, and 4-7 months. To
>maintain immunity, boosters every 1-2 years
> are required. Live-attenuated vaccines are available elsewhere but are
>highly reactogenic and without proven
> efficacy against aerosol challenge.
>
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Paul Andrew Mitchell : Counselor at Law, federal witness
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