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Consensus Statement |

Anthrax as a Biological Weapon, 2002 Updated Recommendations for Management

Thomas V. Inglesby, MD; Tara O'Toole, MD, MPH; Donald A. Henderson, MD, MPH; John G. Bartlett, MD; Michael S. Ascher, MD; Edward Eitzen, MD, MPH; Arthur M. Friedlander, MD; Julie Gerberding, MD, MPH; Jerome Hauer, MPH; James Hughes, MD; Joseph McDade, PhD; Michael T. Osterholm, PhD, MPH; Gerald Parker, PhD, DVM; Trish M. Perl, MD, MSc; Philip K. Russell, MD; Kevin Tonat, DrPH, MPH; for the Working Group on Civilian Biodefense
JAMA. 2002;287(17):2236-2252. doi:10.1001/jama.287.17.2236.
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Objective To review and update consensus-based recommendations for medical and public health professionals following a Bacillus anthracis attack against a civilian population.

Participants The working group included 23 experts from academic medical centers, research organizations, and governmental, military, public health, and emergency management institutions and agencies.

Evidence MEDLINE databases were searched from January 1966 to January 2002, using the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, biological terrorism, biological warfare, and biowarfare. Reference review identified work published before 1966. Participants identified unpublished sources.

Consensus Process The first draft synthesized the gathered information. Written comments were incorporated into subsequent drafts. The final statement incorporated all relevant evidence from the search along with consensus recommendations.

Conclusions Specific recommendations include diagnosis of anthrax infection, indications for vaccination, therapy, postexposure prophylaxis, decontamination of the environment, and suggested research. This revised consensus statement presents new information based on the analysis of the anthrax attacks of 2001, including developments in the investigation of the anthrax attacks of 2001; important symptoms, signs, and laboratory studies; new diagnostic clues that may help future recognition of this disease; current anthrax vaccine information; updated antibiotic therapeutic considerations; and judgments about environmental surveillance and decontamination.

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Figure 1. Gram Stain of Blood in Culture Media
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Gram-positive bacilli in long chains (original magnification ×20). Enlargement shows typical "jointed bamboo-rod" appearance of Bacillus anthracis (original magnification ×100). Reprinted from Borio et al.36
Figure 2. Pathogenesis of Bacillus anthracis
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The major known virulence factors of B anthracis include the exotoxins edema toxin (PA and EF) and lethal toxin (PA and LF) and the antiphagocytic capsule. Although many exact molecular mechanisms involved in the pathogenicity of the anthrax toxins are uncertain, they appear to inhibit immune function, interrupt intracellular signaling pathways, and lyse cell targets causing massive release of proinflammatory mediators. ATP indicates adenosine triphosphate; cAMP, cyclic adenosine monophosphate; MAPKK, mitogen-activated protein kinase kinase; and MAPK, mitogen-activated protein kinase.
Figure 3. Lesion of Cutaneous Anthrax Associated With Microangiopathic Hemolytic Anemia and Coagulopathy in a 7-Month-Old Infant
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By hospital day 12, a 2-cm black eschar was present in the center of the cutaneous lesion. Reprinted from Freedman et al.63
Figure 4. Chest Radiograph and Computed Tomography (CT) Image
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A, Portable chest radiograph of 56-year-old man with inhalational anthrax depicts a widened mediastinum (white arrowheads), bilateral hilar fullness, a right pleural effusion, and bilateral perihilar air-space disease. B, Noncontrast spiral CT scan depicts an enlarged and hyperdense right hilar lymph node (white arrowhead), bilateral pleural effusions (black arrowheads), and edema of the mediastinal fat. Reprinted from Mayer et al.66



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