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people. This vaccine is prepared from a cell-free culture filtrate. Immunization consists of six SC
injections at 0, 2, and 4 weeks and at 6, 12, and 18 months, followed by annual boosters. The
vaccine is currently recommended for people at risk of repeated exposures to B. anthracis spores,
including select laboratory workers and military personnel. The vaccine is effective for
preventing cutaneous anthrax in adults. Protection against inhalational anthrax has not been
evaluated in people, but the vaccine has been effective in studies in nonhuman primates. Adverse
events are mainly local injection site reactions; systemic symptoms, including fever, chills,
muscle aches, and hypersensitivity are rare. No data on vaccine effectiveness or safety in
children are available, and the vaccine is not licensed for use in children or pregnant women.
Anthrax vaccine is not licensed for postexposure use in preventing anthrax.
Based on the limited available data, the best means of preventing inhalational anthrax after
exposure to B. anthracis spores is prolonged antimicrobial therapy in conjunction with a threedose
regimen (at 0, 2, and 4 weeks) of anthrax immunization. However, because BioThrax is not
licensed for postexposure prophylaxis or for use as a three-dose regimen or for use in children, it
can be used only under an investigational new drug application as part of an emergency public
health intervention. When no information is available about the antimicrobial susceptibility of
the implicated strain of B. anthracis, initial postexposure prophylaxis for adults or children with
ciprofloxacin or doxycycline is recommended. Although fluoroquinolones and tetracyclines are
not recommended as first-choice drugs in children because of adverse effects, these concerns
may be outweighed by the need for early treatment of pregnant women and children exposed to
B. anthracis after a terrorist attack. As soon as susceptibility of the organism to penicillin has
been confirmed, prophylactic therapy for children should be changed to oral amoxicillin, 80
mg/kg/day, divided TID (not to exceed 500 mg, TID). Bacillus anthracis is not susceptible to
cephalosporins and trimethoprim-sulfamethoxazole; therefore, these agents should not be used
for prophylaxis (see Table 4.5).
For more information, see http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5045a5.htm.
Reporting. If a case of anthrax is suspected, immediately contact the local and State health
departments and hospital infection control practitioner. If they are unavailable, contact the CDC
at 770-488-7100.
Botulinum Toxin
For a quick fact sheet, see http://www.bioterrorism.slu.edu/botulism/quick/botulism01.pdf.
For additional information, see http://jama.ama-assn.org/cgi/content/full/285/8/1059?.
Disease. Botulism is a rare disease caused by ingestion of the anaerobic, spore-forming bacillus
Clostridium botulinum. Botulism neurotoxins are the most potent toxins known. There are three
forms of naturally occurring botulism:
• Foodborne.
• Wound.
• Infant (intestinal).
In addition, inhalational disease could occur if aerosolized botulinum toxin were used, such as in
a bioterrorist incident. A thorough history may help determine the mode of infection. If no
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