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      Investigation of Bioterrorism-Related Anthrax, United States, 2001: Epidemiologic Findings

      research-article
      Author(s): * , , * , * , † , ‡ , * , * , * , * , * , * , * , * , § , * , * , * , * , * , * , * , * , * , * , * , * , , * , * , * , * , # , ** , * , * , * , * , * , * , * , * , * , the National Anthrax Epidemiologic Investigation Team 1
      Publication date (Print):
      Journal: Emerging Infectious Diseases
      Publisher: Centers for Disease Control and Prevention

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          Abstract

          In October 2001, the first inhalational anthrax case in the United States since 1976 was identified in a media company worker in Florida. A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis. Surveillance was enhanced through health-care facilities, laboratories, and other means to identify cases, which were defined as clinically compatible illness with laboratory-confirmed B. anthracis infection. From October 4 to November 20, 2001, 22 cases of anthrax (11 inhalational, 11 cutaneous) were identified; 5 of the inhalational cases were fatal. Twenty (91%) case-patients were either mail handlers or were exposed to worksites where contaminated mail was processed or received. B. anthracis isolates from four powder-containing envelopes, 17 specimens from patients, and 106 environmental samples were indistinguishable by molecular subtyping. Illness and death occurred not only at targeted worksites, but also along the path of mail and in other settings. Continued vigilance for cases is needed among health-care providers and members of the public health and law enforcement communities.

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          Bioterrorism-related inhalational anthrax: the first 10 cases reported in the United States.

          J. A. Jernigan, D S Stephens, D. A. Ashford … (2001)
          From October 4 to November 2, 2001, the first 10 confirmed cases of inhalational anthrax caused by intentional release of Bacillus anthracis were identified in the United States. Epidemiologic investigation indicated that the outbreak, in the District of Columbia, Florida, New Jersey, and New York, resulted from intentional delivery of B. anthracis spores through mailed letters or packages. We describe the clinical presentation and course of these cases of bioterrorism-related inhalational anthrax. The median age of patients was 56 years (range 43 to 73 years), 70% were male, and except for one, all were known or believed to have processed, handled, or received letters containing B. anthracis spores. The median incubation period from the time of exposure to onset of symptoms, when known (n=6), was 4 days (range 4 to 6 days). Symptoms at initial presentation included fever or chills (n=10), sweats (n=7), fatigue or malaise (n=10), minimal or nonproductive cough (n=9), dyspnea (n=8), and nausea or vomiting (n=9). The median white blood cell count was 9.8 X 10(3)/mm(3) (range 7.5 to 13.3), often with increased neutrophils and band forms. Nine patients had elevated serum transaminase levels, and six were hypoxic. All 10 patients had abnormal chest X-rays; abnormalities included infiltrates (n=7), pleural effusion (n=8), and mediastinal widening (seven patients). Computed tomography of the chest was performed on eight patients, and mediastinal lymphadenopathy was present in seven. With multidrug antibiotic regimens and supportive care, survival of patients (60%) was markedly higher (<15%) than previously reported.
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            Anthrax as a biological weapon, 2002: updated recommendations for management.

            Thomas V. Inglesby, Tara O'Toole, Donald Henderson … (2002)
            To review and update consensus-based recommendations for medical and public health professionals following a Bacillus anthracis attack against a civilian population. The working group included 23 experts from academic medical centers, research organizations, and governmental, military, public health, and emergency management institutions and agencies. 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. 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. 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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              Multiple-locus variable-number tandem repeat analysis reveals genetic relationships within Bacillus anthracis.

              James M. Schupp, Paul S. Keim, A M Klevytska … (2000)
              Bacillus anthracis is one of the most genetically homogeneous pathogens described, making strain discrimination particularly difficult. In this paper, we present a novel molecular typing system based on rapidly evolving variable-number tandem repeat (VNTR) loci. Multiple-locus VNTR analysis (MLVA) uses the combined power of multiple alleles at several marker loci. In our system, fluorescently labeled PCR primers are used to produce PCR amplification products from eight VNTR regions in the B. anthracis genome. These are detected and their sizes are determined using an ABI377 automated DNA sequencer. Five of these eight loci were discovered by sequence characterization of molecular markers (vrrC(1), vrrC(2), vrrB(1), vrrB(2), and CG3), two were discovered by searching complete plasmid nucleotide sequences (pXO1-aat and pXO2-at), and one was known previously (vrrA). MLVA characterization of 426 B. anthracis isolates identified 89 distinct genotypes. VNTR markers frequently identified multiple alleles (from two to nine), with Nei's diversity values between 0.3 and 0.8. Unweighted pair-group method arithmetic average cluster analysis identified six genetically distinct groups that appear to be derived from clones. Some of these clones show worldwide distribution, while others are restricted to particular geographic regions. Human commerce doubtlessly has contributed to the dispersal of particular clones in ancient and modern times.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Emerg Infect Dis
                Journal ID (iso-abbrev): Emerging Infect. Dis
                Journal ID (publisher-id): EID
                Title: Emerging Infectious Diseases
                Publisher: Centers for Disease Control and Prevention
                ISSN (Print): 1080-6040
                ISSN (Electronic): 1080-6059
                Publication date (Print): October 2002
                Volume: 8
                Issue: 10
                Pages: 1019-1028
                Affiliations
                [* ]Centers for Disease Control and Prevention, Atlanta, Georgia, USA
                [† ]Maryland Department of Health and Hygiene, Baltimore, Maryland USA
                [‡ ]New Jersey Department of Health and Senior Services, Trenton New Jersey, USA
                [§ ]Connecticut Department of Public Health, Hartford Connecticut, USA
                []District of Columbia Department of Health, Washington D.C., USA
                [# ]New York City Department of Health, New York New York, USA
                [** ]Florida Department of Health, Tallahassee, Florida USA
                Author notes
                Address for correspondence: Daniel B. Jernigan, Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop A35, Atlanta, GA 30333, USA: fax: 404-639-2647; e-mail: DJernigan@ 123456cdc.gov
                Article
                Publisher ID: 02-0353
                DOI: 10.3201/eid0810.020353
                PMC ID: 2730292
                PubMed ID: 12396909
                SO-VID: 6a404e1c-061e-4bb2-86d6-dbad79c34e9b
                History
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                Subject: Research

                ScienceOpen disciplines: Infectious disease & Microbiology
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                ScienceOpen disciplines: Infectious disease & Microbiology

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