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A large local employer for whom you do preplacement examinations calls to say that an employee in the mailroom saw an envelope with a suspicious white powder coming from its seams. Following the CDC guidelines, the company protocol for suspicious mail is followed: the envelope is left undisturbed and the room is vacated and locked. Although identification of the substance is pending, the company president has many questions, including whether his employees must be given a vaccine or antibiotics and wants your advice. What should you say?

Since antiquity, anthrax has affected livestock and humans. The name anthrax derives from the Greek word for “coal” because of the black skin lesions it can cause. One of the first records of anthrax is in the Old Testament’s Book of Exodus as the fifth and possibly sixth of the ten plagues (Fig. 14–1). Virgil wrote verses on the disease in 25 bc describing the toll it took on livestock and the health risks to humans from exposure to infected meats and skins. The modern history of anthrax begins in the late nineteenth century when Louis Pasteur identified the bacterium responsible for anthrax, an observation that lent early credibility to the germ theory of disease. Anthrax was used as a weapon in World War I as a means to cause economic havoc through the loss of livestock.

Figure 14–1

The Fifth Plague of Egypt, 1800, oil on canvas by S.M.W. Turner is located in the Indianapolis Museum of Art.

Anthrax (Bacillus anthracis) is a gram-positive, nonmotile spore-forming bacterium that infects both humans and animals, particularly livestock. Anthrax is found in a worldwide distribution. The spores, most commonly found in soil, are hardy and may survive for decades. In humans, the disease presents in three forms: inhalational, cutaneous, and gastrointestinal. Mortality is greatest for the inhalational form. If diagnosed early, anthrax is a highly treatable disease. Even weaponized anthrax, such as that used in the attacks through the U.S. Postal Service, is treatable with conventional antibiotics.

The incidence of anthrax has dropped significantly over the years in technologically advanced countries, in large part because of vaccination of high-risk groups—those regularly exposed to hides, wools, and other raw livestock products. Prior to the anthrax attacks in 2001, American experience with anthrax was limited. The only modern experience with the inhalational form was in 1979 with the accidental release of anthrax spores from the Soviet bioweapons facility in Sverdlosk, Russia, in which 72 died. The last case of inhalational anthrax in the United States occurred in 1972.

Worldwide the disease is more common, with best estimates ranging between 20,000 and 100,000 cases of anthrax annually, and almost all occurring in developing nations. Most current public health policies regarding anthrax, such as vaccination strategies and medical management human experience are based on limited ...

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