CONSENSUS STATEMENT Anthrax as a Biological Weapon, 2002 Updated Recommendations for Management Thomas V. Inglesby, MD Objective To review and update consensus-based recommendations for medical Tara O’Toole, MD, MPH and public health professionals following a Bacillus anthracis attack against a civilian population. Donald A. Henderson, MD, MPH Participants The working group included 23 experts from academic medical cen- John G. Bartlett, MD ters, research organizations, and governmental, military, public health, and emer- Michael S. Ascher, MD gency management institutions and agencies. Edward Eitzen, MD, MPH Evidence MEDLINE databases were searched from January 1966 to January 2002, using the Medical Subject Headings anthrax, Bacillus anthracis, biological weapon, Arthur M. Friedlander, MD biological terrorism, biological warfare, and biowarfare. Reference review identified Julie Gerberding, MD, MPH work published before 1966. Participants identified unpublished sources. Jerome Hauer, MPH Consensus Process The first draft synthesized the gathered information. Written comments were incorporated into subsequent drafts. The final statement incorpo- James Hughes, MD rated all relevant evidence from the search along with consensus recommendations. Joseph McDade, PhD Conclusions Specific recommendations include diagnosis of anthrax infection, in- Michael T. Osterholm, PhD, MPH dications for vaccination, therapy, postexposure prophylaxis, decontamination of the environment, and suggested research. This revised consensus statement presents new Gerald Parker, PhD, DVM information based on the analysis of the anthrax attacks of 2001, including develop- Trish M. Perl, MD, MSc ments 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 Philip K. Russell, MD disease; current anthrax vaccine information; updated antibiotic therapeutic consid- Kevin Tonat, DrPH, MPH erations; and judgments about environmental surveillance and decontamination. for the Working Group on Civilian JAMA. 2002;287:2236-2252 www.jama.com Biodefense F THE BIOLOGICAL AGENTS to several locations via the US Postal Ser- tory and to 18 occupational exposure that may be used as weap- vice. Twenty-two confirmed or suspect cases in the United States during the ons, the Working Group cases of anthrax infection resulted. 20th century. Information about the po- on Civilian Biodefense Eleven of these were inhalational cases, tential impact of a large, covert attack Oidentified a limited number of organ- of whom 5 died; 11 were cutaneous cases using B anthracis or the possible effi- isms that, in worst case scenarios, could (7 confirmed, 4 suspected).2 In this ar- cause disease and deaths in sufficient ticle, these attacks are termed the an- Author Affiliations: The Center for Civilian Biode- numbers to gravely impact a city or re- thrax attacks of 2001. The conse- fense Strategies (Drs Inglesby, O’Toole, Henderson, Bartlett, and Perl) and the Schools of Medicine (Drs gion. Bacillus anthracis, the bacterium quences of these attacks substantiated Inglesby, Bartlett, and Perl) and Public Health (Drs that causes anthrax, is one of the most many findings and recommendations in O’Toole and Henderson), Johns Hopkins University, Department of Health and Human Services (Drs Ascher, serious of these. the Working Group on Civilian Biode- and Russell and Mr Hauer), Baltimore, and US Army Several countries are believed to have fense’s previous consensus statement Medical Research Institute of Infectious Diseases, (Drs 3 Eitzen, Friedlander, and Parker), Frederick, Md; Cen- offensive biological weapons pro- published in 1999 ; however, the new ters for Disease Control and Prevention, Atlanta, Ga grams, and some independent terrorist information from these attacks war- (Drs Hughes, McDade, and Gerberding); Center for groups have suggested their intent to use rant updating the previous statement. Infectious Disease Research and Policy, University of Minnesota School of Public Health, Minneapolis (Dr biological weapons. Because the possi- Before the anthrax attacks in 2001, Osterholm); and the Office of Emergency Prepared- bility of a terrorist attack using bioweap- modern experience with inhalational ness, Department of Health and Human Services, Rock- ville, Md (Dr Tonat). ons is especially difficult to predict, de- anthrax was limited to an epidemic in Corresponding Author and Reprints: Thomas V. tect, or prevent, it is among the most Sverdlovsk, Russia, in 1979 following Inglesby, MD, Johns Hopkins Center for Civilian Bio- 1 defense Strategies, Johns Hopkins University, Can- feared terrorism scenarios. In Septem- an unintentional release of B anthracis dler Bldg, Suite 830, 111 Market Pl, Baltimore, MD ber 2001, B anthracis spores were sent spores from a Soviet bioweapons fac- 21202 (e-mail: [email protected]). 2236 JAMA, May 1, 2002—Vol 287, No. 17 (Reprinted) ©2002 American Medical Association. All rights reserved. Downloaded from jama.ama-assn.org by guest on April 25, 2012 MANAGEMENT OF ANTHRAX AS A BIOLOGICAL WEAPON cacy of postattack vaccination or thera- orders. However, some nations contin- tent to which they have been successful peutic measures remains limited. Poli- ued offensive bioweapons develop- is not reported.13 cies and strategies continue to rely ment programs despite ratification of In the anthrax attacks of 2001, B an- partially on interpretation and extrapo- the BWC. In 1995, Iraq acknowledged thracis spores were sent in at least 5 let- lation from an incomplete and evolv- producing and weaponizing B anthra- ters to Florida, New York City, and ing knowledge base. cis to the United Nations Special Com- Washington, DC. Twenty-two con- mission.7 The former Soviet Union is firmed or suspected cases resulted. All CONSENSUS METHODS also known to have had a large B of the identified letters were mailed The working group comprised 23 rep- anthracis production program as part from Trenton, NJ. The B anthracis resentatives from academic medical cen- of its offensive bioweapons program.8 spores in all the letters were identified ters; research organizations; and gov- A recent analysis reports that there is as the Ames strain. The specific source ernment, military, public health, and clear evidence of or widespread asser- (provenance) of B anthracis cultures emergency management institutions and tions from nongovernmental sources used to create the spore-containing agencies. For the original consensus alleging the existence of offensive bio- powder remains unknown at time of statement,3 we searched MEDLINE da- logical weapons programs in at least this publication. tabases from January 1966 to April 1998 13 countries.6 It is now recognized that the origi- using Medical Subject Headings of an- The anthrax attacks of 2001 have nal Ames strain of B anthracis did not thrax, Bacillus anthracis, biological heightened concern about the feasibil- come from a laboratory in Ames, Iowa, weapon, biological terrorism, biological ity of large-scale aerosol bioweapons at- rather from a laboratory in College Sta- warfare, and biowarfare. Reference re- tacks by terrorist groups. It has been tion, Tex. Several distinct Ames strains view identified work published before feared that independent, well-funded have been recognized by investigating 1966. Working group members identi- groups could obtain a manufactured scientists, which are being compared fied unpublished sources. weapons product or acquire the exper- with the Ames strain used in the at- The first consensus statement, pub- tise and resources to produce the mate- tack. At least 1 of these comparison lished in 1999,3 followed a synthesis of rials for an attack. However, some ana- Ames strains was recovered from a goat the information and revision of 3 drafts. lysts have questioned whether “weapons that died in Texas in 1997.14 We reviewed anthrax literature again grade” material such as that used in the Sen Daschle’s letter reportedly had 2 in January 2002, with special atten- 2001 attacks (ie, powders of B anthracis gofB anthracis containing powder; the tion to articles following the anthrax at- with characteristics such as high spore quantity in the other envelopes has not tacks of 2001. Members commented on concentration, uniform particle size, low been disclosed. The powder has been a revised document; proposed revi- electrostatic charge, treated to reduce reported to contain between 100 bil- sions were incorporated with the work- clumping) could be produced by those lion to 1 trillion spores per gram15 al- ing group’s support for the final con- not supported by the resources of a na- though no official analysis of the con- sensus document. tion-state. The US Department of De- centration of spores or the chemical The assessment and recommenda- fense recently reported that 3 defense em- composition of the powder has been tions provided herein represent our best ployees with some technical skills but published. professional judgment based on cur- without expert knowledge of bioweap- The anthrax attacks of 2001 used 1 rent data and expertise. The conclu- ons manufactured a simulant of B an- of many possible methods of attack. The sions and recommendations need to be thracis in less than a month for $1 mil- use of aerosol-delivery technologies in- regularly reassessed as new informa- lion.9 It is reported that Aum Shinrikyo, side buildings or over large outdoor ar- tion develops. the cult responsible for the 1995 re- eas is another