Category A Agents

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• Category A Agents
• Anthrax

Centers for Disease Control and Prevention
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Objectives

• Understand and explain the major anthrax case
  studies
• Explore the toxic mechanisms associated with
  anthrax infection
• Study the epidemiology of anthrax infections

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Anthrax Case Studies

• Post 9/11 Attack
• Gruinard Island
• USSR

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Anthrax Incidents Post 9-11 Letters
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Anthrax Letters

• Letters laced with the Ames Strain of anthrax
  were sent to American Media, The New York Post,
  Senators Leahy and Daschele, and TV Newsman, Tom
  Brokaw
• Additional letters were believed to have been
  sent to ABC, CBS, and possibly other media
  organizations. The ABC/CBS letters were believed
  to have been addressed to Peter Jennings and Dan
  Rather
• Post marks from Trenton, NJ on 2 dates October 8
  and September 18

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Anthrax Letters

• The Daschle and Leahy envelopes had cellophane
  tape around the edges. 
• Was it there to prevent any anthrax from getting
  out of the envelope to contaminate the mail
  system? 
• Most "experts" think the tape was an attempt to
  keep the anthrax from getting out before the
  letter was opened - which it failed to do.

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Letters were Xerox-ed copies (2 total
letters)The paper is odd shaped
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Anthrax Letters
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The Pharmaceutical Fold

• The "pharmaceutical fold" is the way small
  quantities of medicinal powders were dispensed
  for centuries (and its also the way small
  quantities of cocaine and heroin are sold
  today). 
• The fold is done with two horizontal folds
  followed by two vertical folds, so that the
  powder inside the paper is neatly packaged. 
• Most scientists do not think the terrorist
  intended to contaminate the postal system

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Anthrax Letters

• The actual letters are obviously meant to be seen
  as coming from some Muslim terrorist. 
• There is nothing in the letters that would be
  known only to a Muslim. 
• Experts in such things say that these phrases are
  not common usage.  "Allah is great", for example,
  is not a common expression. 
• It is more common for a Muslim to say "Allahu
  akbar", which means "God is great".

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Anthrax Letters

• All the anthrax found in the letters is now known
  to be from the "Ames strain", which originated in
  Texas and was sent to the US Army for research in
  1980. 
• The Army later distributed it to various academic
  institutions for study. 
• Since that time the strain has been further
  widely distributed to researchers around the
  world. 
• A DNA analysis shows that the anthrax originated
  at an US Army facility in Fort Detrick, MD. 
• While other government laboratories obtained Ames
  anthrax from Ft. Detrick, the number of such labs
  is not very large.

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Anthrax Letters

• The FBI has stated "The anthrax utilized in (the
  Daschle letter) was much more refined, more
  potent, and more easily disbursed than letters
  (to the New York Post and NBC)'
• The Leahy and Daschle letters contained enough
  refined anthrax spores to kill over 100,000
  people.

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Anthrax Letters - Victims

• Age    Location         type       
  name
• 7 mos  ABC - New York   cutaneous   child
  23     NBC - New York   cutaneous   Casey
  Chamberlain 27     CBS - New York  
  cutaneous   Claire Fletcher 30     New York
  Post    cutaneous   Joanna Huden 32    
  NJ Post Office   cutaneous   Teresa Heller
  34     New York Post    cutaneous   male
  38     NBC - New York   cutaneous   Erin
  O'Connor 38     New YOrk Post   
  cutaneous   Mark Cunningham 39     NJ Post
  Office   cutaneous   Richard Morgano
  61    New York         inhalation 
  Kathy Nguyen 63    AMI - Florida   
  inhalation  Bob Stevens 73     AMI -
  FLorida    inhalation  Ernesto Blanco

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Anthrax Letters - Victims

• Age    Location         type        name
• 35     NJ Post Office   cutaneous   Patrick
  O'Donnell 43     NJ Post Office   inhalation 
  female 47    DC Post Office   inhalation 
  Joseph Curseen 51     NJ Post Office  
  cutaneous   Linda Burch 55    DC Post Office  
  inhalation  Thomas Morris 56     NJ Post
  Office   inhalation  Norma Wallace 56     DC
  Post Office   inhalation  Unk. 57     DC Post
  Office   inhalation  Leroy Richmond 59     DC
  Mail Center   inhalation  David Hose 94   
  Connecticutt     inhalation  Ottilie Lundgren

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Anthrax Letters Clean-up
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Anthrax Letters Clean-up

• The Hart Senate Building was fumigated for 13
  hours (9 hours pumping it in, 4 hours removing
  it) with chlorine dioxide gas (ClO2)
• The decon effort was lead by Richard Rupert of
  the EPA
• Initial efforts to decon had failed -
  afterwards, it was determined that the air was
  too dry
• The humidity was raised to 75 and the 2nd decon
  was successful

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Anthrax Letters - Summary

• Later information indicated that the anthrax in
  the letters to the two Senators was ten times as
  pure as the anthrax in the letters to the media.
• Because the anthrax spores in the mailing to the
  Senators were much plentiful and thereby more
  deadly, they did more harm. 

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Anthrax Letters - Summary

• In all the letters, individual spores could pass
  through the porous paper (All paper has tiny
  openings or pores that are too small for the eye
  to see). 
• Merely handling the unopened letter sent to The
  New York Post was enough to give three people
  cutaneous anthrax. 
• The Senators' letters allowed fine powdered
  anthrax to escape into the air and cause several
  deaths.

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Anthrax Letters - Summary

• Officials believe the attacks, which killed five
  people, made 13 others ill and caused more than
  30,000 people to take precautionary antibiotics,
  were the work of a scientist who had access to
  the a specific strain of the bacteria - the Ames
  strain.

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Anthrax Spore Trap
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Anthrax

• Gruinard Island

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Anthrax Island (Gruinard, G.B.)
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Gruinard Island, G.B.
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Anthrax Island

• During WWII (1942), British scientists
  experimented with anthrax as a potential
  biological warfare agent by using it to wipe out
  a flock of sheep on Gruinard, a small island off
  of Scotland.
• Not only did it do the job, it made the island
  uninhabitable for almost 50 years.

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Anthrax Island

• Sheep were taken to an open field, secured in
  wooden frames, and exposed to a bomb that
  scattered the spores. The sheep started dying
  three days later.
• Despite attempts to disinfect Gruinard Island,
  the spores left by the experiments kept the
  island in quarantine for 48 years.
• The final WW II report on the Gruinard Island
  tests suggested anthrax could be used to render
  cities uninhabitable "for generations".

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Anthrax Island

• In 1986 an English company was paid half a
  million pounds (over 800,000) to decontaminate
  the 520-acre island by soaking the ground in 280
  tons of formaldehyde diluted in 2000 tons of
  seawater.
• Topsoil was also removed in sealed containers.

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Anthrax Island

• To prove that the clean-up was successful a flock
  of sheep was allowed to graze the island at the
  behest of an independent watchdog set up by the
  Ministry of Defense.
• On 24 April, 1990, the then junior Defense
  Minister, Michael Neubert, made the half-mile
  journey from the mainland to declare Gruinard
  safe by removing its red warning sign.

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Symbolic Removal of Gruinard Island Sign
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Anthrax

• USSR
• Compound 19

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U.S.S.R. Compound 19

• People were stumbling into hospitals and clinics
  with high fevers, headaches, coughs, vomiting,
  chills and chest pains.
• Eventually at least 66 people died, and likely
  many more, never knowing the real reasons why.
• It was the beginning of one of the strangest and
  most horrifying episodes of the Cold War.
• In April, 1979, in the city of Sverdlovsk, an
  epidemic of deadly anthrax disease was spreading
  through homes and factories.
• Soviet authorities blamed the outbreak on
  contaminated meat.

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U.S.S.R. Compound 19

• In the weeks that followed, scientists carried
  out dozens of autopsies and found the anthrax
  bacteria in lungs and lymph nodes of those who
  had died, indicating it had been carried through
  the air, not by contaminated meat.
• The victims were all downwind from a top-secret,
  walled compound that was a Soviet biological
  warfare research center. -COMPOUND 19

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U.S.S.R. Compound 19

• G.I. and Inhalational Anthrax
• President Boris Yeltsin, who at the time of the
  epidemic was the Communist Party head of
  Sverdlovsk, said in May 1992 that "the KGB
  admitted that our military developments were the
  cause." But Yeltsin has never elaborated.

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U.S.S.R. Compound 19
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Compound 19 Today
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U.S.S.R. Bioweapons Program

• Known as Biopreparat
• Included 6 research laboratories
• Included 5 production facilities
• Employed 55,000 scientists

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Sverdlovsk Anthrax Spread
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Anthrax

• Toxicology, Epidemiology and Treatment

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Anthrax

• Zoonotic disease caused by Bacillus anthracis
  enters the human population (normally) through
  contact with infected animals
• Described in biblical times
• First animal vaccine developed by Louis Pasteur
  in 1881
• Used for bioterrorism in 2001

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Bacillus anthracis

• Gram-positive aerobic bacteria
• Spores may remain viable in soil for years
• Spores inactivated by paraformaldehyde vapor,
  hypochlorite, phenol, or autoclave
• Toxins responsible for tissue damage and edema

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Anthrax Toxins
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Anthrax Pathogenesis

• Spores enters through broken skin or mucous
  membranes
• Germinate in macrophages, replicate in lymph
  nodes and intracellular space
• Bacteria produce antiphagocytic capsule
• Production of toxins cause tissue destruction and
  edema

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Anthrax Pathogenesis

• Inhaled spores may reside in alveoli without
  germination for weeks
• Antibiotics effective against vegetative form but
  not spores
• Disease may develop after antibiotics
  discontinued
• Delayed onset not described for cutaneous or
  gastrointestinal forms

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Anthrax Clinical Features

• Three clinical forms
• cutaneous (most common in natural exposure
  situations)
• gastrointestinal (rare)
• inhalation

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Cutaneous Anthrax

• Incubation period 1-12 days
• Papule, then vesicle, then necrotic ulcer
  (eschar) with black center
• Usually painless
• Case-fatality
• without antibiotics 5-20
• with antibiotics - lt1

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Gastrointestinal Anthrax

• Incubation period 1-7 days
• Pharyngeal involvement includes oropharyngeal
  ulcerations with cervical adenopathy and fever
• Intestinal involvement includes abdominal pain,
  fever, bloody vomiting or diarrhea
• Case-fatality estimated at 25-60

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Inhalation Anthrax

• Incubation period 1-7 days (range up to 43
  days)
• Prodrome of cough, myalgia, fatigue, and fever
• Rapid deterioration with fever, dyspnea, cyanosis
  and shock, often with radiographic evidence of
  mediastinal widening
• Case fatality
• without antibiotic treatment 86- 97
• with antibiotic treatment - 75 (45 in 2001)

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Anthrax Laboratory Diagnosis

• Gram stain of clinical samples (skin lesion,
  blood, pleural fluid, CSF)    
• Culture
• Adjunct Assays
• PCR
• Serology (PA based ELISA)
• Immunohistochemistry

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Anthrax Medical Management

• Antibiotics
• ciprofloxacin or doxycycline and gt1 additional
  drug active against B. anthracis
• IV, then PO
• 30 to 60 days duration
• Aggressive supportive care

rifampin, vancomycin, penicillin, ampicillin,
chloramphenicol, imipenem, clincamycin,
clarithromycin
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Anthrax Epidemiology

• Reservoir Infected animals, soil
• Transmission Direct contact (cutaneous)
• Ingestion (gastrointestinal)
• Inhalation
• Temporal pattern None
• Communicability Not communicable (inhalation)
• or rare (cutaneous)

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Anthrax EpidemiologyPersons at Risk

• Agricultural exposure to animals (rare)
• Laboratorians exposed to B. anthracis spores
  (rare)
• Processors of wool, hair, hides, bones or other
  animal products (extremely rare)
• Biological terrorism

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• Anthrax - United States, 1951-2001

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Anthrax Bioterrorism Attacks United States, 2001

• 22 cases (11 inhalation, 11 cutaneous) in 4
  states and DC
• B. anthracis sent through U.S. mail
• Most exposures occurred in mail sorting
  facilities and sites where mail was opened

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Bioterrorism-Related Anthrax United States, 2001
NYC Letters
DC Letter
October
September
MMWR 200150941-8, 1077-9.
inhalation case
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Safe Mail Handling

• Do not open suspicious mail
• inappropriate or unusual labeling
• strange or no return address
• postmark different from return address
• excessive packaging material
• Keep mail away from face
• No not blow or sniff mail or mail contents
• Wash hands after handling
• Avoid vigorous handling (tearing, shredding)
• Discard envelopes

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Anthrax Vaccines

• 1881 Pasteur develops first live attenuated
• veterinary vaccine for livestock
• 1939 Improved live veterinary vaccine
• 1954 First cell-free human vaccine
• 1970 Improved cell-free vaccine licensed

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Anthrax Vaccine

• Cell-free culture filtrate of toxigenic strain of
  B. anthracis
• Filtrate contains protective antigen (PA) and
  other cellular products
• Adsorbed to aluminum hydroxide as an adjuvant
• Contains small amounts of benzethonium chloride
  (preservative) and formaldehyde (stabilizer)

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Anthrax Vaccine Efficacy

• 95 seroconversion following 3 doses
• One controlled human trial using earlier vaccine
• 92.5 efficacy (cutaneous and inhalation disease
  combined)
• Animal models suggest protection against
  inhalation anthrax
• Duration of immunity unknown

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• Anthrax Vaccine Efficacy in Macaques

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Anthrax Vaccine Schedule

• Initial doses at 0, 2, and 4 weeks
• Additional doses at 6, 12, and 18 months
• Annual booster doses thereafter
• Alternative schedules being investigated

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Anthrax VaccinePreexposure Vaccination

• Persons working with production quantities or
  concentrations of B. anthracis cultures
• Persons engaged in activities with a high
  potential for production of aerosols containing
  B. anthracis
• Persons with increased risk of exposure to
  intentional release of B. anthracis (e.g.,
  certain military personnel)

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Anthrax VaccinePostexposure Vaccination

• No efficacy data for postexposure vaccination of
  humans
• Postexposure vaccination alone not effective in
  animals
• Combination of vaccine and antibiotics appears
  effective in animal model

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Anthrax Postexposure Prophylaxis Vaccine Combined
with Antibiotics

• Henderson, et al (1956) earlier PA-based
  vaccine
• Methods 5 days of penicillin compared to
  penicillin plus postexposure vaccination
• Results 9 of the 10 receiving just penicillin
  died, while all of the macaques receiving both
  penicillin and vaccine survived
• Friedlander et al (1993) aluminum hydroxide PA
  filtrate vaccine (current FDA-licensed vaccine)
• Methods 30 days of various antibiotics compared
  to 30 days of doxycycline plus postexposure
  vaccination
• Results 9 of the 10 animals in the
  doxycycline-alone arm survived, while all
  receiving doxycycline and vaccine survived

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Anthrax Vaccine Adverse Events

• Local reactions
• minor 20-50
• severe 1
• Systemic symptoms 5-35
• Severe reactions rare

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Anthrax VaccinePrecautions and Contraindications

• Severe allergic reaction following a previous
  dose or to a vaccine component
• Previous anthrax disease
• Moderate or severe acute illness

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Anthrax Postexposure Antibiotic Prophylaxis

• Ciprofloxicin, doxycycline, and procaine
  penicillin G approved for postexposure
  prophylaxis after aerosol exposure to B.
  anthracis
• Due to latency of spores in lung, antibiotics
  should continue for 30-60 days or more
• Discontinue antibiotics after third dose of
  vaccine

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Recommended Postexposure Prophylaxis to Prevent
Inhalational Anthrax
Initial Therapy Duration Adults Ciprofloxacin
60 days (including pregnant 500 mg PO BID
women and OR immunocompromised) Doxycycline
100 mg PO BID Children Ciprofloxacin 60 days
10-15 mg/kg PO Q 12 hrs OR Doxycycline gt8
yrs and gt45 kg 100 mg PO BID gt8 yrs and lt45 kg
2.2 mg/kg PO BID lt8 yrs 2.2 mg/kg PO BID
Ciprofloxacin dose should not exceed 1 gram per
day in children.
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Anthrax in Biological Terrorism

• B. anthracis considered likely biological
  terrorism threat
• aerosolized stable spore form
• human LD50 8,000 to 40,000 spores (one deep
  breath at site of release) Clearly Debated
• acute illness with high fatality rate

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• Anthrax Cutaneous

Vesicle developmentDay 2
Day 6
Day 4
Day 10
Eschar formation
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Anthrax Cutaneous
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Anthrax Cutaneous
NEJM 1999 341 815 826
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• Anthrax Cutaneous

Healing after treatment
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Anthrax Cutaneous
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Anthrax Cutaneous
Notice the edema and typical lesions
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Anthrax Inhalational
?Mediastinal widening JAMA 199928117351745
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Mediastinal Widening and Pleural Effusion on
Chest X-Ray in Inhalational Anthrax
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Bioterrorism Information

• CDC Bioterrorism website
• www.bt.cdc.gov
• Smallpox and anthrax vaccine ACIP statements
• www.cdc.gov/nip/publications

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National Immunization Program

• Hotline [phone]
• Email nipinfo_at_cdc.gov
• Website www.cdc.gov/nip