Surveillance Criteria for Suspected Human Cases of Anthrax
(Bacillus anthracis)Infection in New Jersey

CLINICAL DESCRIPTION
In human illness caused by B. anthracis, the New Jersey medical community is requested to evaluate the patient for the following signs and symptoms. An illness with acute onset has several distinct clinical forms:

1. Cutaneous: a skin lesion that evolves over 2 to 6 days from a papule, to a vesicle, to a depressed black eschar;
   
2. Inhalation: a brief prodrome (1 - 3 days) resembling a viral respiratory illness (including fever, malaise, mild cough or chest pain), followed by respiratory distress (hypoxia and dyspnea) and shock with radiographic evidence of mediastinal widening;
   
3. Intestinal: severe abdominal distress followed by fever and signs of septicemia;
   
4. Oropharyngeal: mucosal lesion in the oral cavity or oropharynx, cervical adenopathy and edema, and fever.

TRANSMISSION
Cutaneous infection is transmitted by contact with secretions or tissues of animals ill with the disease; inhalation anthrax is acquired through inhalation of spores, (according to USAMRIID, the infective dose equals approximately 8,000 - 10,000 spores), and intestinal and oropharyngeal anthrax is contracted through ingestion of contaminated, undercooked meat. Transmission from person to person is very rare; it is not seen with the inhalation form. The incubation period is from 1 to 7 days, but an incubation period up to 60 days is possible.

All clinicians should have a heightened awareness for inhalation anthrax. However, it is critical to remember that the probability of cold viruses causing typical URI symptoms in an individual, or influenza viruses causing an Influenza-Like-Illness (ILI) at anytime of the year is significantly higher than a case of inhalation anthrax presenting unrelated to any other known, confirmed case or any highly suspect incident. Please call 609-588-7500 if further clarification is required.

LABORATORY TESTING
The DHSS Public Health and Environmental Laboratories (PHEL) will ONLY perform testing on specimens from patients authorized by the Division of Epidemiology, Environmental and Occupational Health at 609-588-7500. Those specimens approved for testing MUST be submitted according to Chain of Custody and PHEL protocols (provided at the time of submission).

Laboratory testing criteria for inhalational anthrax are: A patient ill with compatible signs and symptoms: fever, respiratory distress, and a chest x-ray demonstrating a widened mediastinum; or

1. A patient ill with compatible symptoms (fever, respiratory distress, and a positive chest x-ray) and epidemiologically assessed (by DHSS) for potential exposure; or
   
2. There has been a patient with a potential exposure identical to a KNOWN CONFIRMED case.

1. A POSSIBLE case is one that is initially reported based on a clinical diagnosis (see above) while awaiting laboratory confirmation. After discussing the case with an epidemiologist at 609-588-7500, appropriate specimens (sputum, blood, stool and/or tissue) will be submitted to and processed by the New Jersey DHSS Public Health and Environmental Laboratories (PHEL).
   
2. A PROBABLE case is defined as a clinically ill patient, with a compatible syndrome, who is epidemiologically linked to a CONFIRMED case, as determined by the DHSS.
3. A CONFIRMED case of anthrax will present with a syndrome noted above (clinical diagnosis) and one or more of the following:

   • Isolation of B. anthracis from a clinical specimen, or
     
   • Anthrax electrophoretic immunotransblot (EITB) reaction to the protective antigen, or
     
   • Lethal factor bands obtained after onset of symptoms, or
     
   • Demonstration of B. anthracis in a clinical specimen by immunofluorescence.

PREVENTION

1. The CDC and DHSS DO NOT recommend prophylactic antibiotic therapy as a means of prevention unless there has been documented exposure to anthrax as has occurred in the America Media Inc. building in October 2001.
   
2. The suspicion of an anthrax exposure, without lab confirmation of environmental samples is insufficient indication for preventive antibiotic therapy.
   
3. For individuals working in the same building as the Florida inhalational anthrax case (10/2001), the CDC recommended the following for prophylaxis:
   1. For adult males (ages 18-65 y/o) and non-pregnant adult females (ages 18-65 y/o) Ciprofloxacin 500 mg orally bid for 60 days, OR Doxycycline 100 mg orally bid for 60 days, OR Amoxicillin 500 mg orally three times a day for 60 days. Drug-drug interactions and individual patient allergies should be considered when selecting an antibiotic prophylaxis.
      
   2. For pregnant adult females Amoxicillin 500 mg orally three times a day for 60 days. If allergic to amoxicillin or penicillin, consultation with a physician is required as Ciprofloxacin or Doxycycline may be indicated.
      
   3. For adults over 65 y/o Doxycycline 100 mg orally bid for 60 days, OR Ciprofloxacin 500 mg orally bid for 60 days, OR Amoxicillin 500 mg orally three times a day for 60 days. Drug-drug interactions and individual patient allergies should be considered when selecting an antibiotic prophylaxis. In older adults the potential CNS side effects of Ciprofloxacin should also be considered when selecting an antibiotic for prophylaxis.
      
   4. For children > 9 y/o Amoxicillin 500 mg orally three times a day for 60 days, OR Ciprofloxacin 500 mg orally bid for 60 days, OR Doxycycline 100 mg orally bid for 60 days. Drug-drug interactions and individual patient allergies should be considered when selecting an antibiotic prophylaxis. Amoxicillin is preferred for children. If allergic to amoxicillin or penicillin, consultation with a physician is required as Ciprofloxacin or Doxycycline may be indicated.
      
   5. For children < 9 y/o Amoxicillin 80 mg/kg/day orally, divided into three doses a day for 60 days. Drug-drug interactions and individual patient allergies should be considered when selecting an antibiotic prophylaxis.
4. Anthrax is a naturally occurring yet very rare disease that is not transmitted person-to-person. The vaccine against anthrax is not commercially available to the public except for United States military personnel who might encounter anthrax in the course of armed conflict. As reported in the news media, there has been some controversy over its mandatory administration among some members of the U.S. military.

TREATMENT OF CLINICALLY ILL PATIENTS
The Consensus Statement on "Anthrax as a Biological Weapon," JAMA, May 12, 1999, vol. 281, no.18, pp. 1735 - 1740, developed by 21 representatives from academic medical centers and research, government, military, public health, and emergency management institutions and agencies recommends:

Medical therapy for patients with clinically evident inhalational anthrax in the contained casualty setting:

1. Initial therapy for adults is Ciprofloxacin, 400 mg intravenously every 12 hours for 60 days;
   
2. Initial therapy for children is Ciprofloxacin, 20 - 30 mg/kg per day intravenously divided into 2 daily doses, not to exceed 1 g/d, for 60 days;
   
3. Optimal therapy for adults if strain is proven susceptible is Penicillin G, 4 million U intravenously every 4 hours or Doxycycline, 100 mg intravenously every 12 hours for 60 days; and
   
4. Optimal therapy for children age < 12 yrs, Penicillin G, 50,000 U/kg intravenously every 6 hours for 60 days or age > 12 yrs., Penicillin G, 4 million U intravenously every 4 hours for 60 days. (See Statement for other recommendations)