Current Medicine Research and Practice 9 (2019) 110e111

Contents lists available at ScienceDirect

Current Medicine Research and Practice

journal homepage: www.elsevier.com/locate/cmrp

Review Article

Bioterrorism: Clinical and public health aspects of anthrax

Tulsi Chugh*
D-702, Som Vihar Appartments, RK Puram, New Delhi, 110022, India

a r t i c l e i n f o a b s t r a c t

Article history: Bioterrorism is intentional use of bioweapons (bacteria, viruses, or fungi or their toxins) to harm people,
Received 30 April 2019 animals, agriculture, or environment of a country. Its impact can cause high mortality and morbidity and
Accepted 13 May 2019 serious disruption of economy and social and political life. Countries must be fully equipped to respond
Available online 16 May 2019
through adequate surveillance systems and management, containment, and preventive policies.
© 2019 Sir Ganga Ram Hospital. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights
Keywords:
reserved.
Bioterrorism
Anthrax
Bioweapons

Bioterrorism has an ancient history. Terrorism due to infectious economy. The Centers for Disease Control and Prevention (CDC) has
agents needs a different paradigm than nuclear or chemical bio- classified such agents into three categories (A, B, and C: A being the
terrorism.1 Polluting drinking water of enemies with rye ergot (a most and C being the least potent).4e6
fungus) by Assyrians in 600 BC was a common strategy. In Middle Category A: anthrax, botulinum, plague, smallpox, tularemia,
Ages, Tartar forces hurled plague-infected dead bodies in enemy viral hemorrhagic fevers.
cities and caused epidemic. Russians repeated it in Swedish forces Category B: brucellosis, Clostridium perfringens (epsilon toxin),
in 1710. British forces used blankets contaminated with smallpox cholera, Shigella, and Salmonella with water/food threats.
viruses in native Indians and French forces in America in the 18th Category C: Nipah virus, coronavirus, and hantavirus.
century AD. During World War I, the German Army developed
anthrax, glanders, and cholera as bioweapons. During World War II, 2. Anthrax
Japanese forces and USA developed botulinum and anthrax. The
British tested anthrax bombs in 1942. In 1979, there was an acci- Anthrax is a life-threatening disease caused by a gram-positive
dental release of spores of anthrax in the Union of Soviet Socialist capsulated spore-forming Bacillus. It produces a potent exotoxin.7
Republics with at least 68 deaths. In the Persian Gulf War, Iraq Spores can survive in the soil for years and decades. These get
stockpiled bioweapons of anthrax, botulinum, and aflatoxin. In activated in the host in 1e6 days, but some may take up to 60 days
1984, Bhagwan Rajneesh contaminated salad bars in Oregon, USA, or even more. Anthrax is common in herbivorous animals such as
with Salmonella spp. to cause food poisoning. In 2001, anthrax cattle, sheep, goats, and horses. The infective dose is only 1e10
spores were sent by postal mail to selective persons in the USA with spores. Humans acquire infection through respiratory, gastroin-
22 cases of cutaneous, inhalation, and meningeal anthrax and 5 testinal, or cutaneous route (this being the commonest, 95% in the
deaths.2,3 form of a malignant pustule). Inhalation anthrax is the most severe
one because it frequently causes septicemia and meningitis with
1. Biologic agents used as bioweapons high mortality and the highest risk of man-made spread. Con-
sumption of improperly cooked meat causes gastrointestinal
The characteristic features of agents used as bioweapons are low anthrax. Injection abscesses in drug abusers (contaminated heroin)
dose, easy transmissibility in the community, stability in environ- have been reported in Europe (especially Scotland). Humans are
ment, high mortality, difficult to diagnose and treat, lack of effective accidental dead-end hosts in this livestock-human interface. Any
vaccines, and potential to cause fear and disruption of life and unexplained sudden deaths in livestock and humans who process
or consume animal products must be properly investigated to rule
out anthrax. There is a need for immediate laboratory confirmation,
* Corresponding author. medical care, and containments because all types can lead to
E-mail address: [email protected]. septicemia and death.8e10

https://doi.org/10.1016/j.cmrp.2019.05.004
2352-0817/© 2019 Sir Ganga Ram Hospital. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
 T. Chugh / Current Medicine Research and Practice 9 (2019) 110e111 111

3. Management 5. A rapid and early detection test of anthrax infection has now
been designed to detect anthrax lethal factor (endopeptidase) in
CDC guidelines for treatment and prophylaxis have been blood using fluorescein-labeled peptide (MAPKKide Plus). It can
outlined. detect less than 5 pg of lethal factor per ml.18,19

4. Treatment For prevention of anthrax in individuals who have been exposed

(postexposure prophylaxis for aerosolized spores) but asymptom-
Uncomplicated cutaneous anthrax can be treated with mono- atic, doxycycline or ciprofloxacin is used and is equally effective.
therapy: ciprofloxacin 500 mg twice daily (BD), doxycycline 100 mg These should be used for 60 days in full dose irrespective of
BD, levofloxacin 750 mg once a day (OD), moxifloxacin 400 mg OD, vaccination status.
or clindamycin 600 mg thrice a day. If the strain is penicillin sen- Despite early treatment, patients of inhalation, gastrointestinal,
sitive, amoxicillin 1 g thrice a day or penicillin V 500 mg 6 hourly is and meningeal anthrax have a poor prognosis.
advised. The duration of treatment is 60 days during terrorism or Inhalation anthrax should be treated with combination therapy
for 7e10 days otherwise. The antitoxin is added for suspected with Anthrasil for 60 days.
systemic disease. Human anthrax immunoglobulin (Anthrasil) or
monoclonal antibody may be used.11,12 Conflict of interest
Meningeal disease: Three antibiotics (clindamycin must be
used) combination should be used for 60 days, at least one of which None.
is bactericidal and one protein synthesis inhibitor.13
Preexposure prophylaxis (in laboratory workers, veterinarians,
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