Anthrax infection is a disease that can be acquired following the intentional release of anthrax spores as a biological weapon.

What are the signs and symptoms of anthrax?
Symptoms of disease vary depending on how the disease was contracted, but symptoms usually occur within 7 days.

Cutaneous anthrax is the most common naturally occurring type of infection (>95%) and usually occurs after skin contact with contaminated meat, wool, hides, or leather from infected animals. The incubation period ranges from 1-12 days. The skin infection begins as a small papule, progresses to a vesicle in 1-2 days followed by a necrotic ulcer. The lesion is usually painless, but patients also may have fever, malaise, headache, and regional lymphadenopathy. Most (about 95%) anthrax infections occur when the bacterium enters a cut or abrasion on the skin. Skin infection begins as a raised bump that resembles a spider bite, but (within 1-2 days) it develops into a vesicle and then a painless ulcer, usually 1-3 cm in diameter, with a characteristic black necrotic (dying) area in the center. Lymph glands in the adjacent area may swell. About 20% of untreated cases of cutaneous anthrax will result in death. Deaths are rare if patients are given appropriate antimicrobial therapy.

Inhalational anthrax is the most lethal form of anthrax. Anthrax spores must be aerosolized in order to cause inhalational anthrax. The number of spores that cause human infection is unknown. The incubation period of inhalational anthrax among humans is unclear, but it is reported to range from 1 to 7 days, possibly ranging up to 60 days. It resembles a viral respiratory illness and initial symptoms include sore throat, mild fever, muscle aches and malaise. These symptoms may progress to respiratory failure and shock with meningitis frequently developing.

Gastrointestinal anthrax usually follows the consumption of raw or undercooked contaminated meat and has an incubation period of 1-7 days. It is associated with severe abdominal distress followed by fever and signs of septicemia. The disease can take an oropharyngeal or abdominal form. Involvement of the pharynx is usually characterized by lesions at the base of the tongue, sore throat, dysphagia, fever, and regional lymphadenopathy. Lower bowel inflammation usually causes nausea, loss of appetite, vomiting and fever, followed by abdominal pain, vomiting blood, and bloody diarrhea.

What specific symptoms should I watch for?
People should watch for the following symptoms:

• Fever (temperature greater than 100 degrees F). The fever may be accompanied by chills or night sweats.

• Flu-like symptoms

• Cough, usually a non-productive cough, chest discomfort, shortness of breath, fatigue, muscle aches

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Cough, usually a non-productive cough, chest discomfort, shortness of breath, fatigue, muscle aches

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Cough, usually a non-productive cough, chest discomfort, shortness of breath, fatigue, muscle aches

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Flu-like symptoms

• Cough, usually a non-productive cough, chest discomfort, shortness of breath, fatigue, muscle aches

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Cough, usually a non-productive cough, chest discomfort, shortness of breath, fatigue, muscle aches

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Cough, usually a non-productive cough, chest discomfort, shortness of breath, fatigue, muscle aches

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Flu-like symptoms

• Cough, usually a non-productive cough, chest discomfort, shortness of breath, fatigue, muscle aches

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Cough, usually a non-productive cough, chest discomfort, shortness of breath, fatigue, muscle aches

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Cough, usually a non-productive cough, chest discomfort, shortness of breath, fatigue, muscle aches

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• Sore throat, followed by difficulty swallowing, enlarged lymph nodes, headache, nausea, loss of appetite, abdominal distress, vomiting, or diarrhea

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

• A sore, especially on your face, arms or hands, that starts as a raised bump and develops into a painless ulcer with a black area in the center.

Influenza (flu) and inhalation anthrax can have similar symptoms. Does CDC recommend that I get a flu shot to help diagnose anthrax?
You should get a flu shot only to prevent the flu. CDC does not recommend you get the flu shot so doctors can tell whether you have the flu or anthrax. Many illnesses (including anthrax) begin with flu-like symptoms, which include fever, body aches, tiredness, and headaches. In fact, most illnesses with flu-like symptoms are not either the flu or anthrax.

The flu vaccine is the best protection you can get to prevent the flu and its severe complications, especially among those who are at the highest risk (e.g., people older than 65 years old or younger people with chronic disease such as diabetes or heart disease). The flu shot can prevent 70%-90% of flu infections, but it will not prevent illnesses with flu-like symptoms caused by anything other than influenza.

Is there a way to distinguish between early inhalational anthrax and flu?
Early inhalational anthrax symptoms can be similar to those of much more common infections. However, a runny nose is a rare feature of anthrax. This means that a person who has a runny nose along with other common influenza-like symptoms is by far more likely to have the common cold than to have anthrax.

In addition, most people with inhalational anthrax have high white blood cell counts and no increase in the number of lymphocytes. On the other hand, people with infections such as flu usually have low white blood cell counts and an increase in the number of lymphocytes.

Chest X-rays are also critical diagnostic tools. Chest X-rays showed that all patients with inhalational anthrax have some abnormality, although for some patients, the abnormality was subtle. CT scans can confirm these abnormalities.

Is there a quick test that doctors can do to tell whether I have anthrax or an illness like the flu?
Some influenza detection tests give results fairly quickly. However, these tests are not perfect and are not appropriate for every patient. Rapid influenza tests can provide results within 24 hours; viral culture provides results in 3-10 days. However, as many as 30% of samples that test positive for influenza by viral culture may give a negative rapid test result. And, some rapid test results may indicate influenza when a person is not infected with influenza.

Is anthrax contagious?
No. Anthrax is not contagious; the illness cannot be transmitted from person to person.

What are the case fatality rates for the various forms of anthrax?
Early treatment of cutaneous anthrax is usually curative, and early treatment of all forms is important for recovery. Patients with cutaneous anthrax have reported case fatality rates of 20% without antibiotic treatment and less than 1% with it. Although case-fatality estimates for inhalational anthrax are based on incomplete information, the rate is extremely high, approximately 75%, even with all possible supportive care including appropriate antibiotics. Estimates of the impact of the delay in postexposure prophylaxis or treatment on survival are not known. For gastrointestinal anthrax, the case-fatality rate is estimated to be 25%-60% and the effect of early antibiotic treatment on that case-fatality rate is not defined.

Can the presence of Bacillus anthracis spores be detected by a characteristic appearance, odor, or taste?
Bacillus anthracis spores do not have a characteristic appearance (e.g., color), smell, or taste. Spores themselves are too small to be seen by the naked eye, but have been mixed with powder to transport them. The U.S. Postal Service advises that individuals be suspicious of letters or packages with any powdery substance on them, regardless of color. (See http://www.usps.gov/news/2001/press/pr01_1010tips.htm.)

What would be the approximate size of enough Bacillus anthracis spores to cause infection?
They could not be seen by the naked eye but could be seen under a microscope.

How can I know my cold or flu this season is not anthrax?
Many human illnesses begin with what are commonly referred to as flu-like symptoms, such as fever and muscle aches. However, in most cases anthrax can be distinguished from the flu because the flu has additional symptoms. In previous reports of anthrax cases, early symptoms usually did not include a runny nose, which is typical of the flu and common cold.

If I have the flu, can I still get anthrax?
Yes, a person could theoretically get both the flu and anthrax, either at the same time or at different times.

How is anthrax diagnosed?
Anthrax is diagnosed by isolating B. anthracis from the blood, skin lesions, or respiratory secretions or by measuring specific antibodies in the blood of persons with suspected cases.

In patients with symptoms compatible with anthrax, providers should confirm the diagnosis by obtaining the appropriate laboratory specimens based on the clinical form of anthrax that is suspected (i.e., cutaneous, inhalational, or gastrointestinal).

Cutaneous vesicular fluid and blood
Inhalational blood, cerebrospinal fluid (if meningeal signs are present) or chest X-ray
Gastrointestinal blood

Preventative Therapy

What is the therapy for preventing inhalational anthrax?
Interim recommendations for postexposure prophylaxis for prevention of inhalational anthrax after intentional exposure to B. anthracis may be found in the MMWR at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5041a1.htm.

What is cipro (ciprofloxacin)?
Ciprofloxacin, or cipro as it is commonly known, is a broad-spectrum, synthetic antimicrobial agent active against several microorganisms. The use of ciprofloxacin is warranted only under the strict supervision of a physician.

Does ciprofloxacin have an expiration date?
Yes. Antibiotics, just like all medicines, have expiration dates. If you received your ciprofloxacin through a pharmacist, the expiration date should be listed on the bottle. If you cant find it or have questions about the expiration date, contact your pharmacist directly.

What are the side effects of cipro?
Adverse health effects include vomiting, diarrhea, headaches, dizziness, sun sensitivity, and rash. Hypertension, blurred vision, and other central nervous system effects occur in <1% of patients and may be accentuated by caffeine or medications containing theophylline.

What are the guidelines for changing from ciprofloxacin to another antibiotic?
Considerations for choosing an antimicrobial agent include effectiveness, resistance, side effects, and cost. As a measure to preserve the effectiveness of ciprofloxacin against anthrax and other infections, use of doxycycline for preventive therapy may be preferable. As always, the selection of the antimicrobial agent for an individual patient should be based on side-effect profiles, history of reactions, and the clinical setting. For more information about possible adverse reactions from taking antimicrobial prophylaxis see Update: Investigation of Bioterrorism-Related Anthrax and Adverse Events from Antimicrobial Prophylaxis.

Should people buy and store antibiotics?
There is no need to buy or store antibiotics, and indeed, it can be detrimental to both the individual and to the community. First, only people who are exposed to anthrax should take antibiotics, and health authorities must make that determination. Second, individuals may not stockpile or store the correct antibiotics. Third, under emergency plans, the Federal government can ship appropriate antibiotics from its stockpile to wherever they are needed.

Will antibiotics protect me from a bioterrorist event? Should I stockpile them?
CDC does not recommend using antibiotics unless a specific disease has been identified. There are several different agents that could be used for bioterrorism, such as bacteria, viruses, and toxins. Not a single antibiotic (or vaccine) works for all of these agents. Antibiotics only kill bacteria, not viruses or other agents that could also be used in a bioterrorist event. Antibiotics are not harmless drugs. They can cause serious side effects and drug interactions. National and state public health officials have large supplies of needed drugs and vaccines if a bioterrorism event should occur. These supplies can be sent anywhere in the United States within 12 hours.

Who should receive antibiotics for 60 days?
People at risk for inhalational anthrax should receive 60 days of antibiotics. These people include the following:

1. People who have been exposed to an air space known to have been contaminated with aerosolized B. anthracis.

2. People who share the air space within a facility where others have acquired inhalational anthrax.

3. People who have been along the transit pathway of an envelope (or other vehicle) containing B. anthracis that may have been aerosolized.

4. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

5. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

6. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

7. People who have been along the transit pathway of an envelope (or other vehicle) containing B. anthracis that may have been aerosolized.

8. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

9. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

10. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

11. People who have been along the transit pathway of an envelope (or other vehicle) containing B. anthracis that may have been aerosolized.

12. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

13. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

14. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

15. People who share the air space within a facility where others have acquired inhalational anthrax.

16. People who have been along the transit pathway of an envelope (or other vehicle) containing B. anthracis that may have been aerosolized.

17. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

18. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

19. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

20. People who have been along the transit pathway of an envelope (or other vehicle) containing B. anthracis that may have been aerosolized.

21. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

22. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

23. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

24. People who have been along the transit pathway of an envelope (or other vehicle) containing B. anthracis that may have been aerosolized.

25. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

26. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

27. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

28. People who share the air space within a facility where others have acquired inhalational anthrax.

29. People who have been along the transit pathway of an envelope (or other vehicle) containing B. anthracis that may have been aerosolized.

30. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

31. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

32. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

33. People who have been along the transit pathway of an envelope (or other vehicle) containing B. anthracis that may have been aerosolized.

34. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

35. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

36. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

37. People who have been along the transit pathway of an envelope (or other vehicle) containing B. anthracis that may have been aerosolized.

38. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

39. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

40. Unvaccinated laboratory workers who have handled powder that has tested positive for B. anthracis and who may not have used appropriate biosafety precautions.

People who are unsure if they are at risk should discuss any concerns with their healthcare provider or local/state public health department.

When is a 60-day prescription of prophylactic antibiotics not needed?
People who are determined not to be at risk for inhalational anthrax do not need to take the 60-day course of prophylactic antibiotics. Prophylactic antibiotics are not indicated for the prevention of cutaneous anthrax, for hospital personnel caring for patients with anthrax, or for persons who routinely open or handle mail if there has not been a credible threat.

What if I develop side effects from the antibiotic?

If you develop side effects from the antibiotic, call your healthcare provider immediately. Depending on the type of side effects, you may be able to continue taking the medicine, or may be switched to an alternative antibiotic. If necessary, your physician may contact your State Department of Health for consultation on possible alternate antibiotics.

Has CDC tested the anthrax isolates for sensitivity to different antibiotics?
Yes. Antibiotic sensitivity testing performed at CDC has determined that the strain of anthrax was sensitive to a wide range of antibiotics, including penicillin and ciprofloxacin, giving public health officials important treatment information.

What are the risks of using tetracyclines and fluoroquinolones in children; are alternatives available?
Risks of using tetracyclines and fluoroquinolones in children must be weighed carefully against the risk for developing a life-threatening disease due to B. anthracis. Both agents can have adverse health reactions in children. If adverse reactions are suspected, therapy may be changed to amoxicillin or penicillin.

Are there special instructions for taking ciprofloxacin or doxycycline?
As with all antibiotics, take the medication according to the schedule you were instructed, and even if you begin to feel better, continue taking it for the full number of days. If you need an extension of the antibiotic at the end of your prescribed number of days, local emergency healthcare workers or your healthcare provider will inform and tell you how to get more medicine. They may also tell you to discontinue the antibiotic, or will change the type of antibiotic, depending on results of laboratory tests.

After I have started taking ciprofloxacin to protect me from developing anthrax, what side effects could I get from taking this antibiotic?
Side effects which sometimes occur include nausea, mild diarrhea, stomach pain, headache and dizziness. Talk with your doctor if you have any of these problems while you are taking the antibiotic. Certain foods and medications should not be taken with ciprofloxacin; this should be discussed at the time the antibiotic is prescribed, so that side effects will not occur from the combinations. Ciprofloxacin also can cause sun sensitivity which increases the chances of sunburn. More serious side effects include central nervous system side effects such as confusion, tremors, hallucinations, depression, and increased risk of seizures. High blood pressure and blurred vision are also possible. Allergic reactions could cause difficulty breathing; closing of the throat; swelling of the lips, tongue, or face; hives or severe diarrhea. Pain, inflammation, or rupture of a tendon are possible and also severe tissue inflammation of the colon could occur. Call your doctor or seek medical advice right away if you are having any of these side effects.

This list is NOT a complete list of side effects reported with ciprofloxacin. Your healthcare provider can discuss with you a more complete list of side effects.

After I have started taking doxycycline to protect me from developing anthrax, what side effects could I get from taking this antibiotic?
Less serious side effects include diarrhea, upset stomach, nausea, sore mouth or throat, sensitivity to sunlight, vaginal yeast infection or itching of the mouth lasting more than 2 days. You should talk with your doctor if you have any of these problems while taking doxycycline. Certain foods and medications should not be taken with doxycycline, and this should be discussed with your healthcare provider at the time the antibiotic is prescribed, so that side effects will not occur from the combinations. Doxycycline also causes sun sensitivity which increases the chances of sunburn. Serious side effects of doxycycline that are possible but uncommon include: life-threatening allergic reaction (symptoms are trouble breathing; closing of the throat; swelling of the lips, tongue, or face; hives), blood problems (symptoms are unusual bleeding or bruising), liver damage (symptoms are yellowing of the skin or eyes, dark urine, nausea ,vomiting, loss of appetite, abdominal pain), irritation of the esophagus. Call your doctor or seek medical attention right away if you are having any of these side effects. This list is NOT a complete list of side effects reported with doxycycline. Your healthcare provider can discuss with you a more complete list of side effects.

Why is CDC recommending doxycycline instead of ciprofloxacin for the treatment and prevention of anthrax?
Both doxycycline and ciprofloxacin are effective in treating Bacillus anthracis that we are dealing with in these investigations. Although CDC first recommended the use of either drug for postexposure prophylaxis for the prevention of inhalational anthrax, we are now recommending doxycycline in order to prevent other bacteria from developing resistance to ciprofloxacin. Ciprofloxacin is part of the fluoroquinolone family of drugs, a relatively new class of antibiotics used to treat infections caused by organisms for which doctors do not have information about antimicrobial susceptibility. This kind of treatment is known as empiric therapy. Ciprofloxacin and other fluoroquinolones are used for empiric treatment for a variety of serious and common infections in the United States, including pneumonia, gastrointestinal infections, and urinary tract infections. The number of people who have been exposed to B. anthracis and need antibiotics has increased dramatically since CDC first issued guidelines for treatment. If all those people take ciprofloxacin, other bacteria they carry in their bodies may develop resistance to fluoroquinolones, potentially limiting the usefulness of these drugs as empiric therapy. Doxycycline is less frequently used for empiric treatment than ciprofloxacin; therefore, we have fewer concerns regarding this drug and the emergence of new resistant bacteria.

Why are people who have been exposed to B. anthracis being given antibiotics for different amounts of time?
The initial number of people placed on prophylaxis may reflect conservative estimates with wide safety margins based on limited preliminary information. As the investigation progresses, and a clearer picture of exposure develops, the number of people advised to continue prophylaxis may be reduced. As of the last week of October 2001, when preliminary tests show that people have been exposed to Bacillus anthracis, those exposed may be provided with a starter packet of antibiotics; the number of days for which antibiotics are prescribed can vary according to the specific situation and person. Additional tests are then conducted of the area where exposure occurred and to determine the extent of exposure. Based on the results of these additional tests, those exposed may be instructed to return to a centralized location for additional care or to seek additional care from their primary care providers; additional antibiotics may be prescribed based on the particular situation and person. Lastly, it is recommended that people found to be at risk of inhalation anthrax be prescribed 60 days of antibiotics. These general procedures may change at any time as new information is gathered.

Are there different strains of B. anthracis? Do they all respond to antibiotics?
Yes, there are different strains of Bacillus anthracis. Some strains of B. anthracis may be naturally resistant to certain antibiotics and not others. In addition, there may be biologically mutant strains that are engineered to be resistant to various antibiotics. A laboratory analysis can help to define which strain of B. anthracis is present and which antibiotic would be the most effective in treating the resulting anthrax.

What is the FDA telling physicians and other health professionals about prescriptions for ciprofloxacin?
Although FDA does not regulate the practice of medicine, the agency is strongly recommending that physicians not prescribe ciprofloxacin for individual patients to have on hand for possible use against inhaled anthrax. Indiscriminate and widespread use of ciprofloxacin could hasten the development of drug-resistant organisms and lessen the effects of these agents against many infections.

Can other fluoroquinolones be used instead of ciprofloxacin for postexposure prophylaxis (PEP)/treatment?
Other fluoroquinolones, such as ofloxacin and levofloxacin, are not specifically recommended as alternatives to ciprofloxacin because of a lack of sufficient data on their efficacy. However, if first-line drugs were not available, these other fluoroquinolones may be effective.

Why do I need 60 days of antibiotics?
Anthrax spores grow like plant seeds. If you plant seeds and give them sun and water, they will grow into plants. If you give anthrax spores the right environment, such as the human body, they can grow into the harmful form of the bacteria that can cause anthrax disease. It takes anthrax spores an average of 7 days to grow into the harmful form of the bacteria, but it can take longer. For this reason, you must continue taking preventive antibiotics for the full 60 days.

What happens if I take ciprofloxacin, doxycycline, or amoxicillin for a few days, stop, and then restart the antibiotics?
You should complete the 60-day course of antibiotics that you were given. It is best to take antibiotics as prescribed and not to skip any doses.

The ciprofloxacin I am taking gives me headaches. Is there anything I can do to help this?
If you dont have a history of headaches, then your headache may be related to the medicine. Changing the time of day that you take the ciprofloxacin or eating after you take the medicine may help. Pain relievers such as acetaminophen may help your headache. If your headache does not go away, you should consult your doctor.

The ciprofloxacin, doxycycline, or amoxicillin I am taking makes me feel sick to my stomach. Is there anything I can do to help this?
Taking your antibiotic with food may help reduce this sick feeling. Ciprofloxacin and doxycycline should not be taken within 2 hours of taking antacids. Ciprofloxacin and doxycycline should not be taken with dairy or calcium-fortified products (such as ice cream or calcium-fortified orange juice).

The ciprofloxacin, doxycycline, or amoxicillin I am taking gives me diarrhea. Is there anything I can do to help this?
Antibiotics may disrupt bacteria in the gastrointestinal tract, causing diarrhea. Food may help relieve the diarrhea. If the diarrhea does not go away, your doctor may recommend another antibiotic. If you develop severe, long-lasting diarrhea, you may have a serious condition and should consult your doctor.

If taking one of the recommended antibiotics makes me feel terrible, can I switch to another of these antibiotics?
If you have tried taking the medicine with food or changing the time of your dose but still feel terrible, you should ask your doctor about switching antibiotics.

I am having terrible yeast infections while taking ciprofloxacin, doxycycline, or amoxicillin. Is there anything I can take for this?
Occasionally, women develop yeast infections while taking amoxicillin. You may treat the infection with over-the-counter medicines such as clotrimazole. If the symptoms do not go away, you should consult your doctor.

I feel much better if I take only one pill of ciprofloxacin, doxycycline, or amoxicillin each day. Is that okay?
No. The drug must be taken twice a day to kill the bacteria. If your body contains anthrax bacteria and you do not take the full dose, the bacteria may start to grow again and become harder to kill.

My prescription says to take one pill every 12 hours. If 15 hours have passed since my last dose, is it still okay to take the pill?
Yes. It is okay to take the next pill even if 15 hours have elapsed. However, you should not make a habit of this. The medicine works best when taken every 12 hours.

What side effects are serious enough that I should go to a doctor?
Any side effect that forces you not to take your medicine is serious enough that you should consult or see your doctor. Serious side effects of ciprofloxacin include seizures, mental confusion, rash that does not go away, or excessive diarrhea. If you have any of these effects, call your doctor.

Serious side effects of doxycycline include jaundice (yellow eyes or skin), rash that does not go away, or excessive diarrhea. If you have any of these effects, call your doctor.

Any reaction that causes a rapid swelling of the lips and face, shortness of breath, or hives is a medical emergency. You should call 911. These types of reactions are extremely rare.

Can I drink alcohol if I am taking ciprofloxacin, doxycycline, or amoxicillin?
Social drinking of alcohol (fewer than 2 drinks a day) should not cause any side effects unless you already have a liver problem. However, drinking too much alcohol can cause the medicine to leave your body faster, which will decrease the effectiveness of the medicine. If you drink more than two drinks a day, you should tell your doctor so that different medicines can be prescribed.

The ciprofloxacin, doxycycline, or amoxicillin I am taking makes me feel itchy all over. Is there anything I can do to help this?
Rashes that appear suddenly or do not go away after a few days may be signs of an allergic reaction. You should see your doctor immediately.

The ciprofloxacin, doxycycline, or amoxicillin gave me an allergic reaction and I stopped taking it. What should I do?
If the allergic reaction was severe or rapid, you should notify your doctor before taking another antibiotic. Your doctor will prescribe a different antibiotic that will kill the bacteria without causing an allergic reaction. Remember: you should complete the entire 60 days of treatment even if you change antibiotics.

Why cant I take a shot, wear a patch, or take one large dose of the medicine instead of taking it for 60 days?
Spores can stay in your body for some time before they start growing and causing you to become ill. When the spores are not growing, antibiotics are not effective. Only after the spores start to grow can the antibiotics work. Therefore, you need a constant level of antibiotic in your body for 60 days to make sure that when the spores start to grow, the antibiotic is there to kill them.

Ciprofloxacin and doxycycline look different and come in different doses. Is one better than the other?
Ciprofloxacin 500 mg and doxycycline 100 mg both have the same killing power in your bloodstream and are equally effective against anthrax bacteria. Doxycycline is available in both tablet and capsule form. Both will give you the same amount of medicine in your bloodstream to kill the bacteria.

Should all patients who have flu-like symptoms be treated with antibiotics?
No. CDC does not recommend treating all patients who have flu-like illness with antibiotics. Antibiotics do not kill viruses, which cause the flu. If the patient is not at risk for developing anthrax, antibiotics are not recommended because the person may experience serious side effects. Also, taking antibiotics can increase the chance that the medicine will not be as effective against other bacterial infections.

Does a patient have immunity after recovering from anthrax infection?
We do not have enough data at this time to make this determination. However, it is theoretically possible to gain post-infection immunity.

How do doctors treat inhalational anthrax to reduce the risk of death in patients?
When inhalational anthrax is suspected, physicians prescribe antibiotics to treat the disease. To be effective, antibiotic therapy should be initiated as soon as possible after exposure. Other treatment includes supportive care in hospital. B. anthracis usually responds effectively to several antibiotics including penicillin, doxycycline, and fluoroquinolones (such as ciprofloxacin).

I was told that I had been exposed to Bacillus anthracis and prescribed antibiotics. I took the medicine for a couple weeks. Wouldnt that weaken any anthrax thats in my body?
You should take the full 60 days of antibiotics even if you feel better. Inhaled anthrax spores become lodged in the body and may activate after initial exposure. Antibiotics have little or no effect when the spores are inactive. To be effective in preventing inhalational anthrax, the antibiotics must be in your system when the spores activate. It is necessary to take the medicine for at least 60 days to ensure the best protection against inhalational anthrax.

Why was ciprofloxacin ever publicized as the best drug for anthrax? How can we know which antibiotic is best?
At the beginning of the recent anthrax outbreak, investigators did not know which drugs would kill the strains of Bacillus anthracis responsible for the outbreak. They used ciprofloxacin because very few bacteria are resistant to it. Recent laboratory tests using all of the B. anthracis strains from the recent outbreak have indicated that all the strains are susceptible to ciprofloxacin, doxycycline, and other antibiotics.

Besides anthrax, what else is ciprofloxacin prescribed for? Has there been resistance to ciprofloxacin when used in other instances (historically)?
Ciprofloxacin is a broad-spectrum, highly effective antibiotic that has been part of the international travelers kit at CDC for at least a year. It can be used against most bacterial infections. However, ciprofloxacin is frequently overused for many diseases that can be treated with less powerful, narrower-spectrum drugs. Right now, most bacteria are susceptible to ciprofloxacin, which is why we want to be cautious about its use. Overuse of ciprofloxacin could lead to the development of resistance.

Is there a generic form of ciprofloxacin?
No, there is currently no generic form of ciprofloxacin in the United States.

CBRN - chemical, biological, radiological and nuclear attack

A growing concern among Homeland Security professionals, is that terrorists will someday unleash CBRN materials, in an attack against an unsuspecting public.

CBRN is a term that covers four distinct groups of hazards

Chemical. Poisoning or injury caused by chemical substances, including ex-military chemical warfare agents or legitimate but harmful household or industrial chemicals.

Biological. Illnesses caused by the deliberate release of dangerous bacteria, viruses or fungi, or biological toxins (e.g. ricin, a natural toxin occurring in plants).

Radiological (radioactive). Illness caused by exposure to harmful radioactive materials contaminating the environment.

Nuclear. Death and injury caused from caused from the effects of an explosion that includes blinding light, intense heat (thermal radiation), initial nuclear radiation, blast, fires started by the heat pulse, and secondary fires caused by the destruction.

CBRN weapons have been little used so far, largely due to the difficulty of obtaining the materials and the complexity of using them effectively. Where terrorists have tried to carry out CBRN attacks, they have generally used relatively simple materials. However, Al Qaida and related groups have expressed a serious interest in using CBRN.

The impact of any terrorist CBRN attack would depend heavily on the success of the chosen method of dissemination and the weather conditions at the time of the attack.

The likelihood of a CBRN attack remains low at this time, but should be considered in your preparedness planning. As with other terrorist attacks, you may not receive prior warning of a CBRN incident. Moreover, the exact nature of an incident may not be immediately obvious. First indicators may be the sudden appearance of powders, liquids or strange smells within the building, with or without an immediate effect on people.

Plague is an infectious disease that affects animals and humans. It is caused

Y. pestis is easily destroyed by sunlight and drying. Even so, when released into air, the bacterium will survive for up to one hour, although this could vary depending on conditions. Pneumonic plague is one of several forms of plague.

Depending on circumstances, these forms may occur separately or in combination: Pneumonic plague occurs when Y. pestis infects the lungs. This type of plague can spread from person to person through the air. Transmission can take place if someone breathes in aerosolized bacteria, which could happen in a bioterrorist attack.

Pneumonic plague is also spread by breathing in Y. pestis suspended in respiratory droplets from a person (or animal) with pneumonic plague. Becoming infected in this way usually requires direct and close contact with the ill person or animal.

Pneumonic plague may also occur if a person with bubonic or septicemic plague is untreated and the bacteria spread to the lungs. Bubonic plague is the most common form of plague. This occurs when an infected flea bites a person or when materials contaminated with Y. pestis enter through a break in a persons skin. Patients develop swollen, tender lymph glands (called buboes) and fever, headache, chills, and weakness. Bubonic plague does not spread from person to person.

Septicemic plague occurs when plague bacteria multiply in the blood. It can be a complication of pneumonic or bubonic plague or it can occur by itself. When it occurs alone, it is caused in the same ways as bubonic plague; however, buboes do not develop. Patients have fever, chills, prostration, abdominal pain, shock, and bleeding into skin and other organs.

Septicemic plague does not spread from person to person. Symptoms and Treatment With pneumonic plague, the first signs of illness are fever, headache, weakness, and rapidly developing pneumonia with shortness of breath, chest pain, cough, and sometimes bloody or watery sputum. The pneumonia progresses for 2 to 4 days and may cause respiratory failure and shock.

Without early treatment, patients may die. Early treatment of pneumonic plague is essential. To reduce the chance of death, antibiotics must be given within 24 hours of first symptoms. Streptomycin, gentamicin, the tetracyclines, and chloramphenicol are all effective against pneumonic plague. Antibiotic treatment for 7 days will protect people who have had direct, close contact with infected patients.

Wearing a close-fitting surgical mask also protects against infection.Plague is an infectious disease that affects animals and humans. It is caused by the bacterium Yersinia pestis. This bacterium is found in rodents and their fleas and occurs in many areas of the world, including the United States. Y. pestis is easily destroyed by sunlight and drying.

Even so, when released into air, the bacterium will survive for up to one hour, although this could vary depending on conditions. Pneumonic plague is one of several forms of plague. Depending on circumstances, these forms may occur separately or in combination:

Pneumonic plague occurs when Y. pestis infects the lungs. This type of plague can spread from person to person through the air. Transmission can take place if someone breathes in aerosolized bacteria, which could happen in a bioterrorist attack.

Pneumonic plague is also spread by breathing in Y. pestis suspended in respiratory droplets from a person (or animal) with pneumonic plague. Becoming infected in this way usually requires direct and close contact with the ill person or animal. Pneumonic plague may also occur if a person with bubonic or septicemic plague is untreated and the bacteria spread to the lungs.

Bubonic plague is the most common form of plague. This occurs when an infected flea bites a person or when materials contaminated with Y. pestis enter through a break in a persons skin. Patients develop swollen, tender lymph glands (called buboes) and fever, headache, chills, and weakness. Bubonic plague does not spread from person to person. Septicemic plague occurs when plague bacteria multiply in the blood. It can be a complication of pneumonic or bubonic plague or it can occur by itself. When it occurs alone, it is caused in the same ways as bubonic plague; however, buboes do not develop. Patients have fever, chills, prostration, abdominal pain, shock, and bleeding into skin and other organs.

Septicemic plague does not spread from person to person. Symptoms and Treatment With pneumonic plague, the first signs of illness are fever, headache, weakness, and rapidly developing pneumonia with shortness of breath, chest pain, cough, and sometimes bloody or watery sputum. The pneumonia progresses for 2 to 4 days and may cause respiratory failure and shock. Without early treatment, patients may die.

Early treatment of pneumonic plague is essential. To reduce the chance of death, antibiotics must be given within 24 hours of first symptoms. Streptomycin, gentamicin, the tetracyclines, and chloramphenicol are all effective against pneumonic plague. Antibiotic treatment for 7 days will protect people who have had direct, close contact with infected patients. Wearing a close-fitting surgical mask also protects against infection.

A plague vaccine is not currently available for use in the United States.

These reactions include a vigorous (toxic or allergic) reaction at the site of the vaccination and spread of the vaccinia virus (the live virus in the smallpox vaccine) to other parts of the body and to other people. These reactions typically do not require medical attention. Rarely, people have had very bad reactions to the vaccine. In the past, between 14 and 52 people per 1 million vaccinated experienced potentially life-threatening reactions, including eczema vaccinatum, progressive vaccinia (or vaccinia necrosum), or postvaccinal encephalitis. Based on past experience, it is estimated that between 1 and 2 people out of every 1 million people vaccinated will die as a result of life-threatening reactions to the vaccine. Careful screening of potential vaccine recipients is essential to ensure that those at increased risk do not receive the vaccine.

People most likely to have side effects are people who have, or even once had, skin conditions, (especially eczema or atopic dermatitis) and people with weakened immune systems, such as those who have received a transplant, are HIV positive, or are receiving treatment for cancer. Anyone who falls within these categories, or lives with someone who falls into one of these categories, should NOT get the smallpox vaccine unless they are exposed to the disease.

Pregnant women should not get the vaccine because of the risk it poses to the fetus. Women who are breastfeeding should not get the vaccine. Children younger than 12 months of age should not get the vaccine. Also, the Advisory Committee on Immunization Practices (ACIP) advises against non-emergency use of smallpox vaccine in children younger than 18 years of age. (updated Dec 9, 2002)

Who should NOT get the vaccine?
People who should not get the vaccine include anyone who is allergic to the vaccine or any of its components; pregnant women; women who are breastfeeding; anyone under 12 months of age; people who have, or have had, skin conditions (especially eczema and atopic dermatitis); and people with weakened immune systems, such as those who have received a transplant, are HIV positive, are receiving treatment for cancer, or are taking medications (like steroids) that suppress the immune system. (The Advisory Committee on Immunization Practices [ACIP] advises against non-emergency use of smallpox vaccine in anyone under 18 years of age.) These people should not receive the vaccine unless they have been exposed to smallpox. (updated Dec 9, 2002)

Should you get the smallpox vaccine if you have a weakened immune system (e.g., you are immunocompromised)?
No, you should not be vaccinated, unless there is a smallpox outbreak and you have been directly exposed to the smallpox virus. Vaccination can cause deaths in people with weakened immune systems. Thus, there is no need to take the risks associated with smallpox vaccination unless you have been directly exposed to smallpoxand even then, you should first consult a physician or health care provider. (added Nov 13, 2002)

Pregnant women are discouraged from getting the vaccine. Is there a danger to them (or to an unborn child) if broader vaccination occurs, increasing the potential for contact with vaccinated people?
Pregnant women should NOT be vaccinated in the absence of a smallpox outbreak because of risk of fetal infection. Inadvertent transmission of vaccinia virus to a pregnant woman could also put the fetus at risk. Vaccinated persons must be very cautious to prevent transmission of the vaccine virus to pregnant women or other contacts. (added Nov 13, 2002)

Is there any way to treat bad reactions to the vaccine?
Two treatments may help people who have certain serious reactions to the smallpox vaccine. These are Vaccinia Immune Globulin (VIG) and cidofovir. By the end of December 2002 there will be more than 2,700 treatment doses of VIG (enough for predicted reactions with more than 27 million people) and 3,500 doses of cidofovir (enough for predicted reactions with 15 million people). Additional doses of VIG are being produced, and measures are underway to increase supplies of cidofovir as well. VIG and cidofovir are both administered under investigational new drug (IND) protocol. (updated Nov 26, 2002)

Is a child under the age of 1 year in the household a contraindication to vaccination?

No, the presence of a child under the age of 1 year in the household is not a contraindication to vaccination. The Advisory Committee on Immunization Practices (ACIP) met on January 14, 2003 to consider, among several issues, the question of whether a child under the age of 1 year in the household should be added to the conditions or situations that are considered a contraindication to smallpox vaccination. A vote was taken and it was confirmed that the presence of an infant in the household is not a contraindication to vaccination.

Approved language from this meeting on this subject was: "The ACIP does not recommend vaccination of children and adolescents less than 18 years in the current pre-vaccination program, and smallpox vaccine is contraindicated for infants less than 1 year of age. The presence of an adolescent or child (including an infant) in the household, however, is not a contraindication to vaccination of other members of the household. Data suggests that the risk of serious complications from transmission from an adult to a child is extremely small. However, the ACIP recognizes that some programs may defer vaccination of household contacts of infants less than 1 year of age because of data suggesting a higher risk of adverse events among primary vaccinees in this age group, compared with that among older children." Vaccinated parents of young children need to be careful not to inadvertently spread the virus to their children.

They should follow site care instructions that are essential to minimizing the risk of contact transmission of vaccinia. These precautions include covering the vaccination site, wearing a sleeved shirt, and careful hand washing anytime after touching the vaccination site or anything that might be contaminated with virus from the vaccination site. If these precautions are followed, the risk for children is very low. Individuals who do not believe that they can adhere to such instructions should err on the side of caution and not be vaccinated at this time. (added Jan 29, 2003)

Are there any eye conditions that would preclude vaccination?

The concern surrounding eyes is that frequent touching of the eyes by someone who has gotten the smallpox vaccine may increase the chances that that person will experience spread of the vaccinia virus to the eyes (inadvertent inoculation of the eye) by touching the vaccine site or something contaminated with live virus and then touching their eyes before they wash their hands.

This side effect is a serious one because it can lead to damaged vision, or even blindness. People who wear contact lenses, or touch their eyes frequently throughout the day can get the smallpox vaccine, but they must be especially careful to follow instructions for care of the smallpox vaccination site. Frequent and thorough hand washing will minimize the chance of contact spread of the vaccinia virus.

As an additional precaution to minimize the risk of this type of transmission in selected groups of people, on January 14, 2003, the Advisory Committee on Immunization Practices (ACIP) decided that anyone with eye diseases or other conditions (e.g. recent LASIK surgery) that require the use of corticosteroid drops in the eye should wait until they no longer require such treatment before getting vaccinated.

Tularemia is an infectious disease caused by a hardy bacterium, Francisella tularensis, found in animals (especially rodents, rabbits, and hares).

People can get tularemia many different ways, such as through the bite of an infected insect or other arthropod (usually a tick or deerfly), handling infected animal carcasses, eating or drinking contaminated food or water, or breathing in F. tularensis.

Symptoms of tularemia could include sudden fever, chills, headaches, muscle aches, joint pain, dry cough, progressive weakness, and pneumonia. Persons with pneumonia can develop chest pain and bloody spit and can have trouble breathing or can sometimes stop breathing. Other symptoms of tularemia depend on how a person was exposed to the tularemia bacteria. These symptoms can include ulcers on the skin or mouth, swollen and painful lymph glands, swollen and painful eyes, and a sore throat. Symptoms usually appear 3 to 5 days after exposure to the bacteria, but can take as long as 14 days.

Tularemia is not known to be spread from person to person, so people who have tularemia do not need to be isolated. People who have been exposed to F. tularensis should be treated as soon as possible. The disease can be fatal if it is not treated with the appropriate antibiotics.

A vaccine for tularemia is under review by the Food and Drug Administration and is not currently available in the United States.

How Soon Do Infected People Get Sick?

Symptoms usually appear 3 to 5 days after exposure to the bacteria, but can take as long as 14 days.
What Should I Do if I Think I Have Tularemia?

Consult your doctor at the first sign of illness. Be sure to let the doctor know if you are pregnant or have a weakened immune system.

How Is Tularemia Treated?

Your doctor will most likely prescribe antibiotics, which must be taken according to the directions supplied with your prescription to ensure the best possible result. Let your doctor know if you have any allergy to antibiotics.

A vaccine for tularemia is under review by the Food and Drug Administration and is not currently available in the United States.

What Can I Do To Prevent Becoming Infected with Tularemia?

Tularemia occurs naturally in many parts of the United States. Use insect repellent containing DEET on your skin, or treat clothing with repellent containing permethrin, to prevent insect bites. Wash your hands often, using soap and warm water, especially after handling animal carcasses. Be sure to cook your food thoroughly and that your water is from a safe source.

Note any change in the behavior of your pets (especially rodents, rabbits, and hares) or livestock, and consult a veterinarian if they develop unusual symptoms.

Can Tularemia Be Used As a Weapon?

Francisella tularensis is very infectious. A small number (10-50 or so organisms) can cause disease. If F. tularensis were used as a weapon, the bacteria would likely be made airborne for exposure by inhalation. People who inhale an infectious aerosol would generally experience severe respiratory illness, including life-threatening pneumonia and systemic infection, if they are not treated. The bacteria that cause tularemia occur widely in nature and could be isolated and grown in quantity in a laboratory, although manufacturing an effective aerosol weapn would require considerable sophistication.

More Questions & Answers

Q. What is tularemia?
A. Tularemia, also known as rabbit fever, is a disease caused by the bacterium Francisella tularensis. Tularemia is typically found in animals, especially rodents, rabbits, and hares. Tularemia is usually a rural disease and has been reported in all U.S. states except Hawaii.

Q. How do people become infected with tularemia?
A. Typically, people become infected through the bite of infected insects (most commonly, ticks and deerflies), by handling infected sick or dead animals, by eating or drinking contaminated food or water, or by inhaling airborne bacteria.

Q. Does tularemia occur naturally in the United States?
A. Yes. Tularemia is a widespread disease in animals. About 200 human cases of tularemia are reported each year in the United States. Most cases occur in the south-central and western states. Nearly all cases occur in rural areas, and are caused by the bites of ticks and biting flies or from handling infected rodents, rabbits, or hares. Cases also resulted from inhaling airborne bacteria and from laboratory accidents.

Q. What are the signs and symptoms of tularemia?
A. The signs and symptoms people develop depend on how they are exposed to tularemia. Possible symptoms include skin ulcers, swollen and painful lymph glands, inflamed eyes, sore throat, mouth sores, diarrhea or pneumonia. If the bacteria are inhaled, symptoms can include abrupt onset of fever, chills, headache, muscle aches, joint pain, dry cough, and progressive weakness. People with pneumonia can develop chest pain, difficulty breathing, bloody sputum, and respiratory failure. Tularemia can be fatal if the person is not treated with appropriate antibiotics.

Q. Why are we concerned about tularemia being used as a bioweapon?
A. Francisella tularensis is highly infectious. A small number of bacteria (10-50 organisms) can cause disease. If Francisella tularensis were used as a bioweapon, the bacteria would likely be made airborne so they could be inhaled. People who inhale the bacteria can experience severe respiratory illness, including life-threatening pneumonia and systemic infection, if they are not treated.

Q. Can someone become infected with the tularemia bacteria from another person?
A. People have not been known to transmit the infection to others, so infected persons do not need to be isolated.

Q. How quickly would someone become sick if he or she were exposed to tularemia bacteria?
A. The incubation period (the time from being exposed to becoming ill) for tularemia is typically 3 to 5 days, but can range from 1 to 14 days.

Q. What should someone do if he or she suspects exposure to tularemia bacteria?
A. If you suspect you were exposed to tularemia bacteria, see a doctor quickly. Treatment with antibiotics for a period of 10-14 days or more after exposure may be recommended. If you are given antibiotics, it is important to take them according to the instructions you receive. All of the medication you are given must be taken.

Local and state health departments should be notified immediately so an investigation and infection control activities can begin.

Q. How is tularemia diagnosed?
A. When a person has symptoms that appear related to tularemia, the healthcare worker collects specimens, such as blood or sputum, for testing in a diagnostic or reference laboratory. Laboratory test results for tularemia may be presumptive or confirmatory. Presumptive (preliminary) identification may take less than 2 hours, but confirmatory testing will take more time, often 24 to 48 hours or longer depending on the methods that need to be used.

Depending on the circumstances, a person may be given treatment based on symptoms before the laboratory results are returned.

Q. Can tularemia be effectively treated with antibiotics?
A. Yes. Early antibiotic treatment is recommended whenever it is likely a person was exposed to tularemia or has been diagnosed as being infected with tularemia. Several types of antibiotics have been effective in treating tularemia infections. The tetracycline class (such as doxycycline) or fluoroquinolone class (such as ciprofloxacin) of antibiotics are taken orally. Streptomycin or gentamicin are also effective against tularemia, and are given by injection into a muscle or vein. Health officials will test the bacteria in the early stages of the response to determine which antibiotics will be most effective.

Q. How long can Francisella tularensis exist in the environment?
A. Francisella tularensis can remain alive for weeks in water and soil.

Q. Is there a vaccine available for tularemia?
A. A vaccine for tularemia was used in the past to protect laboratory workers, but it is not currently available.

What Is It?

VHFs refer to a group of illnesses that are caused by several distinct families of viruses. In general, the term "viral hemorrhagic fever" is used to describe a severe multi-system syndrome, where multiple organ systems in the body are affected.

VHFs include four families of viruses: filiviruses such as the Ebola and Marburg viruses, arenaviruses such as Lassa, bunyavirus such as Rift Valley Fever and flaviviruses such as yellow fever and dengue. They can all cause serious, life-threatening illnesses. Some, including Ebola, Marburg and Lassa, are contagious. Although the Ebola virus gained notoriety in various films such as Outbreak and books, VHFs arent expected to be prime bioweapon candidates since people die so quickly from them and often dont get a chance to infect others.

During World War II, the Japanese army fed botulinum toxin to prisoners of war in Manchuria, with lethal results.

How Is It Spread?

VHFs naturally occur in humans only after contact with an infected insect, rodent or larger mammal. Transmission can happen via touching fecal matter, receiving an insect bite or handling contaminated meat. Its possible VHFs can be manufactured for aerosol dissemination but the bacterium generally dont fare well in this form.

What Are the Symptoms of Exposure?

Characteristically, the overall vascular system is damaged, and the bodys ability to regulate itself is impaired. These symptoms are often accompanied by hemorrhage (bleeding); however, the bleeding is itself rarely life-threatening. While some types of hemorrhagic fever viruses can cause relatively mild illnesses, many of these viruses cause severe, life-threatening disease.

All types in severe cases can cause hemorrhagic syndromes that cause severe internal and external bleeding in places such as internal organs, under the skin and from the eyes, nose, mouth and ears. Symptoms generally include high fever, dizziness, muscle aches and exhaustion. The first symptoms may be felt from two days to three weeks after exposure. Advanced symptoms include shock, nervous system malfunction, seizures and coma. Fatality rates range from 90 percent for Ebola to 1 percent for Lassa.

How Is It Treated?

Treatment is available for some VHFs, but not all. In the event of an outbreak, routine infection control procedures, isolation and decontamination are usually enough to stop transmission. Treatments vary depending on which virus a victim has. No treatments or vaccines exist for Ebola or Marburg, but therapy can prevent shock and help organs function. Antiviral drug ribavirin can treat some VHFs fairly well if given early on. A yellow fever vaccine is available. Other treatments are under development.

Who Has It/Where Can It Be Found?

The most worrisome VHFs, such as Marburg and Ebola, are hard to acquire from the wild because their natural host is unknown and outbreaks are rare. VHFs are studied in some labs, mainly high-security ones. Research on Ebola and several others was done by the Soviet Unionbefore its biowarfare program was dismantled.

Experts warn that because microbe collections in Russia, Kazakhstan, Georgia and Uzbekistan are not adequately secured, terrorist groups or states might be able to steal or otherwise obtain weaponized strains of plague, tularemia and VHFs.