[EMED-L] CDC Update on Anthrax Investigation & Tx Recs (fwd)

measl at mfn.org measl at mfn.org
Thu Oct 18 13:56:24 PDT 2001



It is interesting to note that nasal swab appears to be a CDC standard
tool, yet they are recommending *against* this basic diagnostic technique
for John and Jane Doe physician...

 -- 
Yours, 
J.A. Terranson
sysadmin at mfn.org

---------- Forwarded message ----------
Date: Thu, 18 Oct 2001 16:31:49 EDT
From: Rachel Steinhart <RACHELS123 at AOL.COM>
Reply-To: EMED-L -- a list for emergency medicine practitioners.
    <EMED-L at ITSSRV1.UCSF.EDU>
To: EMED-L at ITSSRV1.UCSF.EDU
Subject: [EMED-L] CDC Update on Anthrax Investigation & Tx Recs

October 19, 2001 ASCII text edition of the Morbidity and Mortality
Weekly Report is enclosed. View this week's MMWR as a web page at:
   http://www.cdc.gov/mmwr   and
   http://www.cdc.gov/mmwr/PDF/wk/mm5041.pdf

Update: Investigation of Anthrax Associated with Intentional Exposure and
Interim Public Health Guidelines, October 2001
     On October 4, 2001, CDC and state and local public health authorities
reported a case of inhalational anthrax in Florida (1). Additional cases of
anthrax subsequently have been reported from Florida and New York City. This
report updates the findings of these case investigations, which indicate
that infections were caused by the intentional release of Bacillus
anthracis. This report also includes interim guidelines for postexposure
prophylaxis for prevention of inhalational anthraxand other information to
assist epidemiologists, clinicians, and laboratorians responding to
intentional anthrax exposures.
     For these investigations, a confirmed case of anthrax was defined as 1)
a clinically compatible case of cutaneous, inhalational, or gastrointestinal
illness* that is laboratory confirmed by isolation of B. anthracis from an
affected tissue or site or 2) other laboratory evidence of B. anthracis
infection based on at least two supportive laboratory tests. A suspected
case was defined as 1) a clinically compatible case of illness without
isolation of B. anthracis and no alternative diagnosis, but with laboratory
evidence of B. anthracis by one supportive laboratory test or 2) a
clinically compatible case of anthrax epidemiologically linked to a
confirmed environmental exposure, but without corroborative laboratory
evidence of B. anthracis infection.
     Laboratory criteria for diagnosis of anthrax consist of 1) isolation
and confirmation of B. anthracis from a clinical specimen collected from an
affected tissue or site or 2) other supportive laboratory tests, including
(a) evidence of B. anthracis DNA by polymerase chain reaction (PCR) from
specimens collected from an affected tissue or site, (b) demonstration of B.
anthracis in a clinical specimen by immunohistochemical staining, or (c)
other laboratory tests (e.g., serology) that may become validated by
laboratory confirmation.
Florida
     On October 2, the Palm Beach County Health Department (PBCHD) and the
Florida Department of Health (FDOH) were notified of a possible anthrax case
in Palm Beach County. The suspected case was identified when a gram stain of
cerebrospinal fluid (CSF) revealed a gram-positive bacilli. An epidemiologic
investigation was initiated by FDOH, PBCHD, and the FDOH state laboratory.
The state laboratory and CDC confirmed B. anthracis from a culture of CSF on
October 4. Later the same day, FDOH and CDC epidemiologists and laboratory
workers arrived in Palm Beach County to assist PBCHD with the investigation.
As of October 16, two confirmed cases of inhalational anthrax have been
identified.
     The index patient was a 63-year-old male resident of Palm Beach County
who sought medical care at a local hospital on October 2 with fever and
altered mental status. Despite antibiotic therapy, his clinical condition
deteriorated rapidly, and he died on October 5. An autopsy performed on
October 6 confirmed the cause of death as inhalational anthrax. An
investigation revealed no obvious exposures to B. anthracis.
     On October 1, the second patient, a 73-year-old co-worker of the index
patient, was admitted to a local hospital for pneumonia. On October 5, a
nasal swab was obtained from the patient that yielded a positive culture for
B. anthracis. Subsequent testing revealed positive PCR tests for B.
anthracis in hemorrhagic pleural fluid and reactive serologic tests. The
patient remains hospitalized on antibiotic therapy. Enhanced case finding
and retrospective and prospective surveillance systems were initiated in
Palm Beach, and surrounding counties. Environmental assessments and sampling
were performed at the index patient's home, work site, and travel
destinations for the 60 days preceding symptom onset. Environmental sampling
revealed B. anthracis contamination of the work site, specifically
implicating mail or package delivery. Environmental samples of other
locations the patient visited, including extensive sampling of his home,
were negative.
     Questionnaires were administered to employees at the index patient's
work site. Postexposure prophylaxis was administered, and nasal swabs were
obtained from those with exposure to the work site for >1 hour since August
1. Of 1,075 nasal swabs performed, one was positive for B. anthracis.
Environmental and co-worker testing indicated contamination of specific
locations at the work site. The investigation and environmental sampling are
ongoing.
New York
     On October 9, the New York City Department of Health notified CDC of a
person with a skin lesion consistent with cutaneous anthrax. CDC sent a team
to New York City to provide epidemiologic and laboratory support to local
health officials. As of October 16, two persons with confirmed cases of
cutaneous anthrax have been identified. One person with confirmed anthrax
was a 38-year-old woman who had handled a suspicious letter postmarked
September 18 at her workplace. The letter contained a powder that
subsequently was confirmed to contain B. anthracis. On September 25, the
patient had a raised lesion on the chest, which over the next 3 days
developed surrounding erythema and edema. By September 29, the patient
developed malaise and headache. On October 1, a clinician examined the
patient and described an approximately 5 cm long oval-shaped lesion with a
raised border, small satellite vesicles, and profound edema. The lesion was
nonpainful and was associated with left cervical lymphadenopathy. Serous
fluid from the lesion was obtained and was negative by gram stain and
culture. The patient was prescribed oral ciprofloxacin. Over the next
several days, the lesion developed a black eschar, and a biopsy was obtained
and sent to CDC for testing. The tissue was positive by immunohistochemical
staining for the cell wall antigen of B. anthracis.
     The other person with confirmed cutaneous anthrax was a 7-month-old
infant who visited his mother's workplace on September 28. The next day, the
infant had an apparently nontender, massively edematous, weeping skin lesion
on his left arm; he was treated with intravenous antibiotics. Over the next
several days, the lesion became ulcerative and developed a black eschar;
clinicians presumptively attributed the lesion to a spider bite. The
infant's clinical course was complicated by hemolytic anemia and
thrombocytopenia, requiring intensive care. The diagnosis of cutaneous
anthrax was first considered on October 12 after the announcement of the
other confirmed anthrax case in New York City. A serum specimen collected on
October 2 was positive for B. anthracis by PCR testing at CDC; a skin biopsy
obtained on October 13 was positive by immunohistochemical staining at CDC
for the cell wall antigen of B. anthracis. No suspicious letter with powder
was identified at the mother's workplace. Both patients were treated with
ciprofloxacin and are clinically improving.
     B. anthracis grew from swabs (two nasal and one facial skin swab) from
three other persons, suggesting exposure to anthrax. One of the exposures
was in a law enforcement officer who brought the letter containing B.
anthracis from the index patient's workplace to the receiving laboratory.
The other two exposures were in technicians who had processed the letter in
the laboratory. Environmental sampling in both workplaces is ongoing and
investigations of other exposed persons continue.
Reported by: L Bush, MD, Atlantis; J Malecki, MD, Palm Beach County Health
Dept, Palm Beach; S Wiersma, MD, State Epidemiologist, Florida Dept of
Health. K Cahill, MD, R Fried, MD; M Grossman, MD, Columbia Presbyterian
Medical Center; W Borkowsky, MD, New York Univ Medical Center, New York, New
York; New York City Dept of Health. National Center for Infectious Diseases;
and EIS officers, CDC.
Editorial Note: The findings in this report indicate that four confirmed
cases of anthrax have resulted from intentional delivery of B. anthracis
spores through mailed letters or packages. These are the first confirmed
cases of anthrax associated with intentional exposure in the United States
and represent a new public health threat.
     Anthrax is an acute infectious disease caused by the sporeforming
bacterium B. anthracis. It occurs most frequently as an epizootic or
enzootic disease of herbivores (e.g., cattle, goats, or sheep) that acquire
spores from direct contact with contaminated soil. Humans usually become
infected through direct contact with B. anthracis spores from infected
animals or their products (e.g., goat hair), resulting in cutaneous anthrax
(2) (Box 1). Inhalational and gastrointestinal are other forms of the
disease in the natural setting (4,5). Humantohuman transmission has not been
documented.
     Clinical laboratorians should be alert to the presence of Bacillus
species in patient specimens. In particular, laboratorians should suspect B.
anthracis when the specimen is from a previously healthy patient with a
rapidly progressive respiratory illness or a cutaneous ulcer. If B.
anthracis is suspected, laboratories should immediately notify the
health-care provider and local and state public health staff. For rapid
identification of B. anthracis, state and local health departments should
access the Laboratory Response Network for Bioterrorism (LRN). LRN links
state and local public health laboratories with advanced capacity
laboratories---including clinical, military, veterinary, agricultural,
water, and food-testing laboratories. Laboratorians should contact their
state public health laboratory to identify their local LRN representative.
     Postexposure prophylaxis is indicated to prevent inhalational anthrax
after a confirmed or suspected aerosol exposure. When no information is
available about the antimicrobial susceptibility of the implicated strain of
B. anthracis, initial therapy with ciprofloxacin or doxycycline is
recommended for adults and children (Table 1). Use of tetracyclines and
fluoroquinolones in children has adverse effects. The risks for these
adverse effects must be weighed carefully against the risk for developing
life-threatening disease. As soon as penicillin susceptibility of the
organism has been confirmed, prophylactic therapy for children should be
changed to oral amoxicillin 80 mg/kg of body mass per day divided every 8
hours (not to exceed 500 mg three times daily). B. anthracis is not
susceptible to cephalosporins or to trimethoprim/sulfamethoxazole, and these
agents should not be used for prophylaxis.
     CDC is assisting other states and local areas in assessing anthrax
exposures. Additional information about anthrax and the public health
response is available at <http://www.bt.cdc.gov>. This information was
current as of 4 p.m., eastern daylight time, October 17, 2001.
References
1. CDC. Ongoing investigation of anthrax---Florida, October 2001. MMWR
2001;50:877.
2. CDC. Human anthrax associated with an epizootic among livestock---North
Dakota, 2000. MMWR 2001;50:677--80.
3. Ashford DA, Rotz LD, Perkins BA. Use of anthrax vaccine in the United
States: recommendations of the Advisory Committee on Immunization Practice
(ACIP). MMWR 2000;49(no. RR-15).
4. Brachman PS. Inhalational anthrax. Ann NY Acad Sci 1980;353:83--93.
5. Brachman PS, Kaufmann A. Anthrax. In: Evans AS, Brachman PS, eds.
Bacterial infections of humans. New York, New York: Plenum Medical Book
Company, 1998.
*Cutaneous illness is characterized by a skin lesion evolving from a papule,
through a vesicular stage, to a depressed black eschar; edema, erythema, or
necrosis without ulceration may be present. Inhalational illness is
characterized by a brief prodrome resembling a "nonspecific febrile" illness
that rapidly progresses to a fulminant illness with signs of sepsis and/or
respiratory failure, often with radiographic evidence of mediastinal
widening; signs of bacterial meningitis may be present. Gastrointestinal
illness is characterized by severe abdominal pain usually accompanied by
bloody vomiting or diarrhea followed by fever and signs of septicemia.

BOX 1. Clinical forms of anthrax
     Clinical Forms of Anthrax
     The following clinical descriptions of anthrax are based on experience
in adults. The clinical presentation of anthrax in infants is not well
defined.
     Inhalational. Inhalational anthrax begins with a brief prodrome
resembling a viral respiratory illness followed by development of hypoxia
and dyspnea, with radiographic evidence of mediastinal widening.
Inhalational anthrax is the most lethal form of anthrax and results from
inspiration of 8,000--50,000 spores of Bacillus anthracis (3). The
incubation period of inhalational anthrax among humans typically ranges from
1--7 days but may be possibly up to 60 days. Host factors, dose of exposure,
and chemoprophylaxis may affect the duration of the incubation period.
Initial symptoms include mild fever, muscle aches, and malaise and may
progress to respiratory failure and shock; meningitis frequently develops.
Case-fatality estimates for inhalational anthrax are extremely high, even
with all possible supportive care including appropriate antibiotics.
     Cutaneous. Cutaneous anthrax is characterized by a skin lesion evolving
from a papule, through a vesicular stage, to a depressed black eschar. The
incubation period ranges from 1--12 days. The lesion is usually painless,
but patients also may have fever, malaise, headache, and regional
lymphadenopathy. The case fatality rate for cutaneous anthrax is 20%
without, and <1% with, antibiotic treatment.
     Gastrointestinal. Gastrointestinal anthrax is characterized by severe
abdominal pain followed by fever and signs of septicemia. This form of
anthrax usually follows after eating raw or undercooked contaminated meat
and can have an incubation period of 1--7 days. An oropharyngeal and an
abdominal form of the disease have been described. Involvement of the
pharynx is usually characterized by lesions at the base of the tongue,
dysphagia, fever, and regional lymphadenopathy. Lower bowel inflammation
typically causes nausea, loss of appetite, and fever followed by abdominal
pain, hematemesis, and bloody diarrhea. The case-fatality rate is estimated
to be 25%--60%. The effect of early antibiotic treatment on the
case-fatality rate is not established.







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