Anthrax in the United States Postal Service

Anthrax: An Attack on the United States

Anthrax is an acute disease that is caused by a bacteria known as bacillus anthracis. Anthrax most commonly occurs in lower-level vertebrates both wild and domestic, such as cows, goats, sheep, and camels. However, anthrax infection can also occur in humans when they are exposed to animals that are infected, or to tissue from these animals ("Anthrax," 2003). The anthrax infection in humans can take three forms: cutaneous, inhalation, or gastrointestinal. This paper examines the signs and symptoms of anthrax, as well as looks at the circumstances of the most current outbreak of anthrax in the United States.

Anthrax is not very common in the United States, at least not anymore. Anthrax is primarily a disease of agricultural countries where contact with and exposure to animals is a common, daily occurrence. When anthrax infects a human being, it is normally through contact with an infected animal or parts of an infected animal. This sort of contact does not happen in the United States very frequently anymore, as we have become an industrialized nation. In countries that still have an agricultural economy and way of life, however, anthrax infection in humans is much more common.

The cutaneous form of anthrax occurs as an infection of the skin. This type of anthrax is caused by touching animals or animal products with an anthrax infection. The cutaneous form of anthrax is the least serious form of anthrax. The inhaled version of anthrax occurs when a person inhales anthrax spores that are present in infected animal products or in soil that has been exposed to infected animals. The inhaled version of anthrax is the most serious form of the disease. The gastrointestinal version of anthrax occurs by eating undercooked meat from animals with anthrax. This is the rarest form of anthrax that people can contract.

Anthrax has a wide variety of symptoms, depending upon which type of the disease has been contracted. The main symptoms of the three types of anthrax are as follows:

Cutaneous: This is the most common type of anthrax infection seen in humans. About ninety-five percent of human-based anthrax infections are cutaneous infections. These infections occur when the anthrax bacteria enter a cut or abrasion on the skin of a person handling infected animal products or animals. This type of anthrax infection begins as an itchy red bump on the skin. This bump resembles an insect bite. In one to two days, however, this bump becomes a vesicle and then a painless ulcer on the skin. This ulcer is usually one to three centimeters in diameter and normally has a black area of dying tissue in the center of it. Lymph glands surrounding the area of the ulcer will often swell, as well. Without proper treatment, about twenty percent of cutaneous anthrax cases will result in death for the victim. However, with antibiotic treatment, almost all cutaneous anthrax cases can be cured.

Inhalation: A person may test positive for anthrax spores in their nasal passages, but this only indicates they have been exposed to anthrax, not that they will get the disease. By treating an exposed person with antibiotics, infection can actually be avoided entirely. In order for the infection to progress to a full-blown anthrax infection, the anthrax spores in the person's nasal passages must be allowed to germinate ("Medical Encyclopedia," 2003). This process of germination may take anywhere from a few days to up to sixty days to occur. The anthrax spores will move to the lymph nodes where they will release several toxic substances into the victim's system once they germinate. These substances lead to hemorrhaging, swelling, and tissue death.

Inhalation anthrax infection has two main stages. The first stage includes symptoms that resemble a simple cold. However, in a few days, theses symptoms will change to the second stage symptoms, which include severe breathing problems and shock. This form of anthrax is highly fatal, even with antibiotic treatment. Due to the build-up of toxins, this form of anthrax is about ninety percent fatal. However, inhalation anthrax is the most rare form of anthrax.

Gastrointestinal: In this form of anthrax, the lining of the intestines becomes inflamed. The first signs of this type of anthrax are nausea, vomiting, and loss of appetite. These symptoms will gradually increase to severe abdominal pain, vomiting of blood, and diarrhea. Without proper treatment, gastrointestinal anthrax can result in death in twenty to sixty percent of cases ("Anthrax," 2003).

The main treatment for all types of anthrax is antibiotic therapy. This is because anthrax is caused by a bacteria. The earlier the treatment begins, the better the outlook for the patient. Penicillin, doxycycline, and ciprofloxacin are all effective against anthrax. Ciprofloxacin is normally the antibiotic of choice for anthrax, at least at first until it is determined if the anthrax strain present is resistant to any of the other antibiotics available. Since the germination process for anthrax can take up to sixty days, antibiotic treatment usually takes this long, too. Patients are usually given oral antibiotics for as long as they show no symptoms (meaning they were merely exposed to anthrax). If symptoms develop, intravenous antibiotics will be given for fourteen days, then oral antibiotics will be given for the remainder of the sixty day period. Though there is a vaccine against anthrax that is given in a six dose series, it is normally only given to U.S. military personnel, and is not recommended for use by the general public as it is a harsh vaccine with many unpleasant possibilities for side effects. However, there is no human to human spread of anthrax, so simply being around someone who has the disease will not cause infection to another person unless that person was exposed to the same source of anthrax.

In the wake of the recent anthrax bioterrorism attack in the United States, the question of physician preparedness to handle an anthrax outbreak is an important question. Since anthrax was (and still is) relatively uncommon in the United States, there has not been any real need for physicians to know about how to effectively treat the disease, and the availability of the anthrax vaccine is still reserved for only personnel of the U.S. military. This, of course, has raised concerns among the general public. If there were to be another or larger outbreak of bioterrorism using anthrax as the agent, how prepared would physicians in the United States be to treat the outbreak?

Currently, there is only one manufacturer of the anthrax vaccine in the United States. This manufacturer is the Bioport Corporation, based in Michigan. This company has been cited several times by the Food and Drug Administration for manufacturing violations. This is a concern, since the company is currently the only place in the United States from which the vaccine can be obtained. However, in light of the recent terrorist attacks, some say that the manufacturing standards should be relaxed anyway, in order to allow the vaccine to be produced more quickly.

The anthrax vaccine was developed using rhesus monkeys. The vaccine was completed for use in humans in the 1950s. Besides being used by the military, the anthrax vaccine has also been used to vaccinate those most likely to be exposed to the disease, such as lab workers, veterinarians, and people working in the livestock industry ("Anthrax Vaccine Availability Concerns USA," 2001). Severe reactions to the vaccine occur in less than one percent of cases. The anthrax vaccine works by aiding the immune system in preventing the anthrax bacteria from producing deadly toxins. The vaccine is made from dead bacteria from a strain of anthrax that is known to not cause the disease. Despite the low instance of severe side effects, there are some people who should not take the anthrax vaccine. These people are:

1) People with a history of severe reaction to the anthrax vaccine.

2) People with an acute anthrax infection or respiratory disease.

3) People with a depressed immune system.

4) People younger than 18 or older than 65.

5) Pregnant women.

The anthrax vaccine could prove important for the general population in the future, especially if there is a biological terrorism outbreak in the United States. This is because the vaccine is useful in those who have already been exposed or infected, especially in conjunction with antibiotics. The current vaccine must be administered in six doses over an eighteen month period. However, a new version of the vaccine is in development that would only require two or three doses, which would make the vaccine much easier to administer on a wide scale. While some people believe that the anthrax vaccine may need to begin being administered to the general population soon, there are many others who believe that this would be a hasty decision. Critics of the mass vaccination plan believe that the anthrax vaccine is still not proven safe enough for use in the general public. These critics say that while the anthrax vaccine should be held in reserve and available should the need arise, vaccinating now without a clear threat present to warrant it would be a mistake ("Anthrax Vaccine?," 2001).

The most recent outbreak of anthrax in the United States was during the fall of 2001. This was no typical anthrax outbreak, as it was not caused in the typical way from exposure to infected animals. This outbreak of anthrax was the result of an intentional attack. Anthrax spores were mailed to various locations through the U.S. postal system. This means that someone had to intentionally grow and cultivate the anthrax spores in their own lab. The fact that the anthrax spores implicated in the outbreak were of a highly refined variety created further proof that the attack was intentional. This person actually placed anthrax spores in envelopes and sent them through the mail.

Whoever his or her intended victims were, a number of postal workers contracted the disease from handling contaminated mail. Because the infections occurred in more than one state, the Federal Bureau of Investigations were called in to investigate the case. Because the case involved intentional infection with an infectious agent, epidemiologists were brought in to the investigation, as well. These epidemiologists were from the U.S. Center for Disease Control. The epidemiologists in this case played a unique role, one that was quite different from that of the FBI. While the FBI worked to determine who perpetrated this crime, with the intention of prosecuting this person, the epidemiologists tried to figure out what went wrong in the environments that experienced outbreaks, in order to determine what allowed the disease to take hold. The epidemiologists wanted to first contain the outbreak and then educate people on what to do in order to prevent another outbreak from occurring in the future. These containment and education efforts involve the general public by necessity, whereas the investigation by the FBI was largely conducted in secret ("American Anthrax Outbreak of 2001," n.d.).

The Centers for Disease Control were especially open and helpful in informing the general public about the ongoing status of the anthrax investigation and about efforts to contain it. While these reports certainly may have contributed to some fear and concern in the general population, they also went a long way toward alleviating some fears associated with the outbreak, as the reports allowed people to see just where and how the disease was being spread, and let people know what they could do to decrease their own chances of getting infected. For example, the first person to become infected with anthrax in the most recent outbreak was a sixty-three-year-old man who lived and worked in Florida ("Notice to Readers," 2001).. This man worked in a news media outlet which had been mailed an envelope containing anthrax spores. This man contracted the inhaled form of anthrax, and subsequently died. The Centers for Disease Control offered antibiotic treatment to anyone who had been inside of this man's office building for more than one hour since August first of that year. The Centers for Disease Control also informed the public of what the symptoms of inhaled anthrax were, so that people could be vigilant and aware of what to look for.

Another report was released by the Centers for Disease Control shortly after the first report, giving the public an update into the situation and the ongoing investigations surrounding it. In this second report, the public was informed for the first time that the anthrax case was not isolated and was probably intentional. By this time, anthrax cases had sprung up from Florida to New York. This was so unusual, and the victims so unlikely, that an intentional anthrax attack was the only plausible explanation for the situation. This new report also informed the public on how anthrax is tested for in the laboratory. Additionally, the public was informed that the home, travel destinations, and workplace of the initial victim were thoroughly investigated and tested for anthrax, with the results being that the home and travel destinations tested negative for anthrax, while the workplace, particularly the mail room area, tested positive ("Update," 2001) as the first solid proof that the anthrax was sent through the mail.

The third report from the Centers for Disease Control revealed for the first time that postal workers in New Jersey had been infected with anthrax. These postal worker cases included three cases of cutaneous anthrax and one case of inhaled anthrax. The postal workers at this facility were found to have handled contaminated mail that eventually found its way to New York and Florida, to the places there where other anthrax cases were reported. This discovery of anthrax among postal workers prompted the closing of the New Jersey mail facility where the initial infections occurred, and touched off a nationwide inspection of postal facilities for anthrax spores.

Later, the report revealed, four cases of inhalation anthrax were reported at a Washington D.C. postal facility. The U.S. Capitol was also contaminated with anthrax from a tightly sealed letter that was opened in a senator's office. Over two dozen people who had been in or near that particular senator's office that day tested positive for exposure to anthrax. Later, two of the four inhalation anthrax cases from the Washington D.C. postal facility resulted in fatalities for the victims ("Update: Investigation," 2001). As a result, the postal facility at which the victims worked was closed for further testing and decontamination efforts.

In the fourth report released by the Centers for Disease Control regarding the anthrax case, it was revealed that most of the inhalation anthrax cases were present among postal workers. This report also included some statistical information concerning the inhalation anthrax cases. Some of these statistics were:

1) Median age of inhalation anthrax victims: 56.

2) Incubation period from exposure to onset of symptoms: 7 days

3) Initial illness characterized by: Fever, chills, severe fatigue, nonproductive cough.

4) White blood cell count: Normal or slightly elevated.

5) Chest x-ray: Abnormal (though two patients initially had normal x-rays).

6) Number of inhalation anthrax patients: 10

7) Number of survivals: 6

Statistics were also included for the cutaneous anthrax patients. These statistics show:

1) Initial incubation period from exposure to onset of symptoms: 5 days

2) Location of lesions: forearm, neck, chest, and fingers.

3) Number of cases: 11

4) Number of survivals: 11

5) Occupations of patients: 4 mail handlers, 6 employees or visitors to media outlets, 1 bookkeeper ("Update: Investigation of Bio," 2001).

The next report from the Centers for Disease Control reported that one more person had developed cutaneous anthrax. This person worked at a media company. This report also revealed for the first time the adverse side effects that could occur when antibiotic therapy was given for anthrax exposure. Surveys were given to those who were taking antibiotics after being exposed to anthrax. The answers reported on these surveys revealed that side effects were common under this treatment, with approximately sixty-two percent of anti-biotic patients reporting some side effect or other from the antibiotic therapy ("Update: Prophylaxis," 2001).

The most commonly reported side effects of the anti-biotic therapy were itching, difficulty breathing, swelling of face, swelling of neck, swelling of throat, and seeking medical attention for unspecified side effects. Six people reported going off of the antibiotics due to adverse side effects. The frequency of side effects due to the antibiotics shows that there is a danger in the current treatment for anthrax, and makes it questionable as to whether antibiotic therapy should be the first way to go in treating anthrax exposure. This raises the question as to whether a wait-and-see approach might be preferable, if not to mention safer.

By this time, the Centers for Disease Control had developed a system for people to call in and report suspected cases of anthrax. This proved to be a popular system, as it received a lot of calls. Most of the calls received regarding potential threats were from health care workers (over forty percent). Fourteen percent of calls were from local of state health departments. Fourteen percent of calls were from private citizens, and seven percent of calls were from police, fire, and emergency response teams. In response to the calls, the Centers for Disease Control supplied information, assisted in diagnosis, and dispatched epidemiologists to suspected contamination sites ("Update: Adverse Events," 2001).

The sixth report from the Centers for Disease Control revealed more information about who should be treated for anthrax exposure. However, the seventh report revealed the details of the newest anthrax case, which arose out of suspicious circumstances in Connecticut. In this case, a ninety-four-year-old woman presented with inhalation anthrax. However, no one could determine at first just how she got the disease, since she did not work and rarely left her home. None of the tests done on her home or at the places she had visited revealed anthrax spores ("Update: Inhalation:, 2001). The patient later died from the inhalation anthrax, and the cause of her infection remained a mystery for some time, but was eventually traced to possible cross-contamination of her mail by anthrax-laced mail at a nearby mail processing facility.

The outbreak of anthrax among postal workers provoked a harsh backlash by the postal workers against the U.S. government. Postal workers felt that the government failed to protect them from the anthrax threat by not warning them of their risk for exposure. Postal workers said that they felt the government had shown an extremely callous attitude toward them, while at the same time taking extraordinary measures to protect politicians and media personalities. Further adding insult to injury, it was reported that police dogs at the U.S. Capitol were tested for anthrax exposure before postal workers were tested. In addition, workers complained that after anthrax was found at the Capitol, it was closed forthwith, while it took five or six days to get to the post office. Most postal workers did not understand why it took so long for government investigators to get to them, especially when the contaminated mail that shut down the Capitol went through postal facilities first.

Workers expressed further outrage that both the government and postal supervisors showed little concern about their health and welfare, keeping them in the dark about the anthrax situation and their risk of being in danger from it. Postal workers said that they received most of their information regarding the anthrax case from television and other news media outlets, with most of the information they received being inaccurate. What is certain is that the first day that it was realized the Capitol had been contaminated, it was also realized that the contaminating letter came from the nearby Brentwood mail processing facility. However, government officials insisted that the workers at Brentwood were not in any danger, since anthrax spores were not thought to be able to escape from sealed letters.

Postal officials acted on the advice of the Centers for Disease Control and kept the postal facilities open. They also did not test their employees for anthrax exposure. Congresspersons and their staffs received medical attention and time off, while at the same time the workers at the Brentwood mail facility not only were kept at their jobs, but were also kept in the dark about the real danger of the whole situation. Even when two employees began to complain about feeling ill, postal workers at the Brentwood facility were assured that their danger of exposure was practically nonexistent and that medical testing was not necessary. In fact, action to protect postal workers was not taken until well after the contamination at the Capitol, when several more postal employees became ill. At this time, anthrax testing began on postal employees, but was stopped after two employees died of inhalation anthrax. After these deaths, the Centers for Disease Control ordered the post office to administer antibiotic treatment to all postal employees without testing them for exposure first (White, 2001).

Authorities in charge later reported that they underestimated the threat to postal workers. It was announced that anthrax testing would begin at any facility through which contaminated mail may have passed and that antibiotics would be offered to any postal workers who worked at those facilities. It was also acknowledged that mail sorting equipment probably agitated the powder containing anthrax spores inside the envelopes and the blowers used to clear the machines most likely spread the spores. Still, this acknowledgement was hollow to some postal workers who became even more bitter when they lined up for anthrax testing and were told testing was not necessary. Instead, they were given a ten day supply of Cipro, the drug of choice for anthrax exposure. These postal employees wondered why they were only given a ten day supply when those who were exposed at the Capitol were given a sixty day supply of Cipro (White, 2001).

Other postal workers expressed concern that they were being given Cipro without being tested for anthrax first, since Cipro can cause many unpleasant side effects and may be dangerous to take without an actual bacteria present for it to fight. Many postal workers said they felt as though they were being used as experiment subjects by the government. Other employees felt that their conditions were not being monitored as much as other non-postal worker victims (Fernandez, 2002). In addition, the unions to which postal workers belong were offering workers no help, and were instead siding with the government in downplaying the dangers they faced from possible exposure. In fact, the American Postal Worker's Union went far as to state that postal workers should not wear or use such protective devices as face masks and rubber gloves, saying that this was not the image they wanted to project to the public that they served. This statement was issued out of a fear of the union of projecting an image of fear to the American public. Postal union officials were worried about what the perception of the American public would be toward the post office if it was perceived that postal workers feared the product that they delivered (White, 2001).