The only definitive diagnosis for anthrax is positive blood culture for the pulmonary and gastrointestinal type and positive wound culture of the cutaneous lesion. The treatment of choice after suspected exposure is one of four oral antibiotics given daily for eight weeks:
- ciprofloxacin (Cipro), 500 mg twice daily for adults and 20 to 30 mg per kilogram of body weight per day for children divided into two doses
- levofloxacin, 500 mg once daily for adults only
- ofloxacin, 400 mg twice daily for adults only
- doxycycline (for use if there is an allergy to any of the first three), 100 mg twice daily for adults and 5 mg per kilogram of body weight per day for children divided into two doses
Doctors will order the intravenous form of one these antibiotics if the patient becomes seriously ill.
If someone discovered an empty aerosol bomb in a commuter train station, most of the people who walked through at the time would seek immediate diagnosis and treatment. If this happened in Grand Central Station during one of the rush hours, the surrounding hospitals would have a flood of about one million patients demanding treatment. If as many as three hundred area hospitals were accessible, that would be about thirty-three hundred patients converging on each emergency room within one day. The authorities would have to open up all the convention centers and stadiums, equip them with public showers and a complete change of clothes for each patient, and hand out oral antibiotics like Halloween candy.
Therefore, every hospital needs to have an emergency preparedness plan that specifies how many anthrax exposure victims it can handle at one time. Hospitals should publicize this information so people would know from estimating the size of the attack whether they can expect to get treatment or become part of an angry mob standing in a panic outside the hospital.
Although a terrorist can infect large numbers of people by spraying spores into the air, the good news about anthrax is that there is no true airborne transmission. The spores settle on surfaces like the skin or objects that people normally touch. The infection only occurs from skin contact with a contaminated surface. Therefore, total isolation is not required. The precautions of wearing masks, gowns, and gloves with biohazard disposal are sufficient. The plan for decontaminating new arrivals to minimize the impact of the attack should be as follows:
- Remove patients' clothing slowly and carefully to avoid spreading spores to other surfaces.
- Place clothing in labeled plastic bags.
- Instruct patients to shower thoroughly in provided shower facilities.
- Decontaminate all environmental surfaces with chlorine bleach (one part bleach to nine parts water).
- Instruct personnel to wear full isolation gear (masks, gowns, and gloves) when disposing of contaminated material.
According to the Centers for Disease Control and Prevention, patients should get treatment immediately upon learning that there was a possible anthrax exposure. The ideal course of treatment is to first take blood and/or stool specimens (if there is suspicion of intestinal infection) for culture and prescribe in accordance with the sensitivity report. However, this would become impossible if there was a large-scale exposure.
Accordingly, public health officials must find out how many hospital microbiology laboratories there are in a given city and how many specimens they can process per day. For example, if New York City has 300 such facilities, and each place, given a limited number of technicians and incubators, can handle 200 tests during one crisis, then the local health-care system can confirm only up to 60,000 cases after a single attack that could infect hundreds of thousands.
Another question that officials must answer is whether there are enough antibiotics available to treat the exposed population. If our sample of 60,000 lined up for Cipro, each person would need 112 capsules. The total number required would be 6,720,000. Therefore, a single attack in one railway depot or stadium exposing half a million commuters or spectators would probably wipe out the regional supply of antibiotics before health-care providers could eradicate the infection.
Regarding preventive measures prior to attack, the BioPort Corporation has produced an immunization vaccine for anthrax. Currently, this is routinely available only to military personnel. The official position of the U.S. government is that the risk of anthrax exposure is not great enough to warrant manufacturing sufficient vaccine to inoculate the general population. The fact is that only one company makes the vaccine under contract to the U.S. Department of Defense, and there is not enough to go around. There are limited amounts available for known exposure victims including farmers and veterinarians.
It is important to note that taking antibiotics prior to an attack is unwise because a few hours after the last dose, the protection is gone. People should only take the antibiotics when they have a positive culture or they are reasonably certain that anthrax exposure has occurred.