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Consensus Statement |

Anthrax as a Biological Weapon:  Medical and Public Health Management

Thomas V. Inglesby, MD; Donald A. Henderson, MD, MPH; John G. Bartlett, MD; Michael S. Ascher, MD; Edward Eitzen, MD, MPH; Arthur M. Friedlander, MD; Jerome Hauer, MPH; Joseph McDade, PhD; Michael T. Osterholm, PhD, MPH; Tara O'Toole, MD, MPH; Gerald Parker, PhD, DVM; Trish M. Perl, MD, MSc; Philip K. Russell, MD; Kevin Tonat, PhD; for the Working Group on Civilian Biodefense
JAMA. 1999;281(18):1735-1745. doi:10.1001/jama.281.18.1735.
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Objective To develop consensus-based recommendations for measures to be taken by medical and public health professionals following the use of anthrax as a biological weapon against a civilian population.

Participants The working group included 21 representatives from staff of major academic medical centers and research, government, military, public health, and emergency management institutions and agencies.

Evidence MEDLINE databases were searched from January 1966 to April 1998, using the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, biological terrorism, biological warfare, and biowarfare. Review of references identified by this search led to identification of relevant references published prior to 1966. In addition, participants identified other unpublished references and sources.

Consensus Process The first draft of the consensus statement was a synthesis of information obtained in the formal evidence-gathering process. Members of the working group provided formal written comments which were incorporated into the second draft of the statement. The working group reviewed the second draft on June 12, 1998. No significant disagreements existed and comments were incorporated into a third draft. The fourth and final statement incorporates all relevant evidence obtained by the literature search in conjunction with final consensus recommendations supported by all working group members.

Conclusions Specific consensus recommendations are made regarding the diagnosis of anthrax, indications for vaccination, therapy for those exposed, postexposure prophylaxis, decontamination of the environment, and additional research needs.

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Figures

Figure 1. Gram Stain of Bacillus anthracis
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Gram-positive anthrax bacilli in a peripheral blood smear from a rhesus monkey that died of inhalational anthrax. Reprinted with permission from Zajtchuk and Bellamy.23
Figure 2. Chest Radiograph of a Patient With Inhalational Anthrax
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Chest radiograph of a 51-year-old laborer with occupational exposure to airborne anthrax spores taken on day 2 of illness. Lobulated mediastinal widening (arrowheads) is present, consistent with lymphadenopathy, with a small parenchymal infiltrate at the left lung base. Reprinted with permission from Zajtchuk and Bellamy.23
Figure 3. Cutaneous Anthrax
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Left, Forearm lesion on day 7 of illness shows vesiculation and ulceration of the initial macular or papular anthrax skin lesion. Right, Eschar of the neck on day 15 of illness is typical of the last stage of the lesion before it resolves over 1 to 2 weeks. Reprinted with permission from Binford CH, Connor DH, eds. Pathology of Tropical and Extraordinary Diseases. Vol 1. Washington, DC: Armed Forces Institute of Pathology; 1976:119. AFIP negative 71-1290-2.
Figure 4. Day of Onset of Inhalational Anthrax Following Sverdlovsk Accident
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Figure is based on data from Guillermin.68

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