cutaneous anthrax prevention

Antibiotics work in two main ways, by killing the anthrax or by stopping the anthrax from growing. Samples or isolates from human cases are forwarded for identification to local public health reference laboratories. People who should not get the anthrax vaccine for routine occupational use include: For anyone with a moderate or severe illness, their doctor might ask them to wait until they recover to get the vaccine. Submit. For more about anthrax vaccine, visit CDC’s Anthrax Vaccination webpage, Centers for Disease Control and Prevention. Bob” Dittmar, a friend, colleague, and Texas Parks and Wildlife Department (TPWD) State Wildlife Veterinarian who, along with 2 TPWD colleagues, was killed August 8, 2020, in a helicopter crash while conducting aerial surveys for desert bighorn sheep in TPWD’s Black Gap Wildlife Management Area. Specialized characterization of organisms, bioforensics, select agent activity, and handling of highly infectious biologic agents is performed at national laboratories, the third tier of LRN. However, spores that could remain on a person’s skin, hair, or clothing after an exposure before they bathe or shower and change clothes might possibly transfer to someone else’s skin and cause cutaneous anthrax (20–22). Although a substantial portion (10%–40%) of patients with cutaneous anthrax would die if left untreated (4), most can recover with treatment (31). Because only 1 animal per affected premise usually is reported in a given year, the number of cases is a substantial underrepresention of the total number of affected animals and properties. Cutaneous anthrax begins as a painless, reddish brown papule. Patients seeking care with an eschar or eschar-like lesion should be asked about recent exposure to dead or dying herbivores or biting flies in an anthrax enzootic area; recent animal bites or scratches; and recent contact with lagomorphs, rodents, fleas, ticks, and spiders. Ranchers and veterinarians should receive authoritative information on animal vaccine use to break the cycle of transmission (including emphasis on avoiding administration of antibiotics 10 days before or after vaccine administration). Treatment is most effective when started as soon as possible.Although some cases of anthrax respond to antibiotics, advanced inhalation anthrax may not. A major epidemic of anthrax in Zimbabwe. Anthrax Vaccine Adsorbed (AVA) protects against anthrax. To stay protected, they should get annual boosters. At hospital A, he reported that his exposure had been »3 weeks earlier. To prevent infection after being exposed to anthrax spores, the Centers for Disease Control and Prevention recommends: 1. MSD and the MSD Manuals. Anthrax vaccine associated deaths in miniature horses. Overall in 2019, the laboratory reported 25 culture-positive animals, including cattle, horses, white-tailed deer, antelope, and a goat, from Crockett, Kinney, Sutton, Uvalde, and Val Verde counties. Meningitis is also a possible, and typically fatal, complication (32). B. anthracisspores can remain viable in soil for many years. Contact your local or state health department. data). Obtaining a good exposure history is key to determining the likelihood of various etiologies among the differential diagnoses and determining the best specimens to collect. Anyone who has a severe allergy to any component of the anthrax vaccine. Supportive care in an intensive care unit is a critical part of treatment for all but uncomplicated cutaneous infections. He was wearing shorts and a shirt while moving the carcasses, and his affected leg was scraped by the velvet-covered antlers. This form most commonly affects the exposed areas of the upper extremities and, to a lesser extent, the head and neck. O’Sullivan, K. Parker), Centers for Disease Control and Prevention, Atlanta, Georgia, USA (J.S. State and territorial health departments should notify the Centers for Disease Control and Prevention (CDC) within 4–24 hours (24) of the initial report for patients whose illness meets the probable or confirmed case definition (35). Sims), Shannon Medical Center, San Angelo, Texas, USA (P. Bradshaw), Texas Department of State Health Services, El Paso, Texas, USA (K.A. Another obstacle to controlling the outbreak was the inability to address the contribution of wildlife to the initiation and perpetuation of disease spread (e.g., lack of a licensed vaccine and impracticality of using physical or chemical restraint to administer vaccine “off label” to wildlife species). Surgery might occasionally be indicated for lesions complicated by compartment syndrome. This need is particularly pronounced where there is an abundance of susceptible wildlife species that are not vaccinated or where there is poor vaccination coverage of domestic hoofstock. You will be subject to the destination website's privacy policy when you follow the link. On 25 July 2012, 17 persons were exposed to a sick cow, which had been imported from northeast China a few days … The case was detected by an alert infectious diseases physician, Dr. Larry Bush, who raised the diagnostic possibility of inhalational anthrax when examination of CSF specimens revealed typical gram-positive rods [1]. Chloramphenicol in treatment of cutaneous anthrax. Texas experienced an increase of animal cases in 2019 and consequently higher than usual human risk. Laboratory A, … The least desirable disposal method is leaving the carcass in place, because scavenging can further disseminate the spores and increase future exposure risks for susceptible animals. Cutaneous anthrax lacking systemic manifestations such as fever, tachycardia, tachypnea, hypotension, leukocytosis, or leukopenia can usually be treated with 7 days of an oral antibiotic. Cutaneous anthrax is rarely fatal if treated, [18] but without treatment about 20% of cutaneous skin infection cases progress to toxemia and death. Search. Anthrax spores typically take 1 to 6 days to be activated, but some spores can remain inside the body and take up to 60 days or more before they are activated. During an emergency, the only people who should not get the anthrax vaccine after possible exposure are those who have had a serious allergic reaction to a previous dose of anthrax vaccine. Anthrax vaccine is approved for use in three groups of adults 18 to 65 years of age who may be at risk of coming in contact with anthrax because of their job. Control and Prevention of Anthrax, Texas, USA, 2019. A vaccine is available for anthrax. – Do not excise the eschar; daily dry dressings. If skin or mucus membrane contact occurs during carcass disposal, persons should seek medical attention and receive antibiotic PEP for 7 days (Table 1) and have their symptoms monitored for 14 days. A survey of ranchers in the outbreak area is planned by TAHC to assess knowledge, attitudes, and practices regarding anthrax, including information on livestock vaccination. Cutaneous anthrax is usually the most common form of anthrax and can occur after contact with infected livestock [4]. Cutaneous anthrax begins as an itchy bump or a group of small blisters. Lymphadenopathy can occur, and constitutional symptoms including fever and headache are also possible. Chest x-ray and CT scan are useful diagnostic tools in cases of inhalation anthrax. In some cases, treatment with monoclonal antibodies — raxibacumab and obiltoxaximab The necrophagous fly anthrax transmission pathway: empirical and genetic evidence from wildlife epizootics. “To date, we have more than 15 vaccines in stock but there is no human anthrax vaccine, either independently or in combination with others, among the 15” (Fatsi health center director, Gulomkada district). For preexposure prophylaxis of persons at high risk for B. anthracis exposure, AVA is administered intramuscularly as a priming series at 0, 1, and 6 months, with booster doses at 12 and 18 months and annually thereafter (19). Anthrax was identified through PCR and confirmed through culture at the state reference laboratory from swab specimens of a leg lesion. Health departments in endemic areas that have existing vaccination programs can acquire AVA from the manufacturer. No popliteal or inguinal adenopathy was present. Saving Lives, Protecting People, Emergency Use Instructions (EUI) for Doxycycline and Ciprofloxacin for Post-exposure Prophylaxis (PEP) of Anthrax, Analysis of Cases from 1945 to 2014 Identified Through a Systematic Literature Review (2015), Special Considerations for Pregnant and Postpartum Women, Anthrax Vaccine Adsorbed (AVA) Post-Exposure Prioritization, U.S. Food and Drug Administration website, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), What to Do if You Think You’ve Been Exposed, Doxycycline Fact Sheet for Healthcare Providers, Ciprofloxacin Fact Sheet for Healthcare Providers, Confirming Anthrax Through the Laboratory Response Network, Florida Retiree Gets—and Survives—Anthrax, Anthrax Case Investigation Epi-Info Database, U.S. Department of Health & Human Services, Certain laboratory workers who work with anthrax, Some people who handle animals or animal products, such as some veterinarians, Some members of the United States military. The primary control measure for animal anthrax is annual preventive vaccination; however, once an outbreak occurs, other control measures In these topics. It is a disease of herbivores that incidentally infects humans through contact with animals that are ill or have died from anthrax or through contact with Bacillus anthracis–contaminated byproducts. In addition, reports of vaccine-associated adverse events among goats and horses (2,10) made some owners reluctant to vaccinate these species. Injection anthrax causes infection deep under the skin or in muscle. Samples that are culture-positive for B. anthracis at veterinary reference laboratories are reported to DSHS and TAHC. Each of these antibiotics offers the same protection against anthrax. This form of anthrax is rarely fatal, providing it is treated. On March 6, 2002, CDC's National Institute for Occupational Safety and Health (NIOSH) received a request for a health hazard evaluation from the director of Laboratory A to assist in the evaluation of a worker who had been diagnosed with cutaneous anthrax. If this were to happen, people who were exposed would get 3 shots of anthrax vaccine over 4 weeks plus a 60-day course of antibiotics. Systemically ill patients (whether from cutaneous, ingestion, inhalation, or injection exposures) are candidates for 1 of the Food and Drug Administration–approved anthrax antitoxins. People with mild illness can usually be vaccinated. Anthrax spores typically take 1 to 6 days to be activated, but some spores can remain inside the body and take up to 60 days or more before they are activated. He reported no fever, chills, chest pain, shortness of breath, pain at rest, numbness, or tingling. In patients with an occupational exposure (contact with animals or their products), cutaneous anthrax is suspected if 3 to 5 days later, a painless, itchy papule forms. The organisms are inoculated through a break … Anyone with severe allergies, including allergy to latex, should tell their doctor. Also, see footnotes in Table 1. The last known naturally occurring human case of cutaneous anthrax associated with livestock exposure in the United States was reported from South Dakota in 2002. We describe the animal outbreak that occurred in southwest Texas beginning in June 2019 and an associated human case. Contact precautions should be used for the first day; after that, standard precautions are sufficient. Centers for Disease Control and Prevention. For a full list of topics: A-Z Index. Skin sores may also have a black appearance when they form dry scabs called "eschars." The term anthrakis means coal in Greek, and the disease is named after the black appearance of its cutaneous form. Any exposed area of skin may be affected; most commonly, the arms, hands, head or neck are affected. Texas Veterinary Medical Diagnostic Laboratory confirmed the first anthrax case of 2019 in an exotic antelope carcass from Uvalde County on June 19. 2.Anthrax – pathology. These same geographic characteristics create challenges in implementing the recommended disease control interventions, including appropriate carcass disposal and broad use of animal anthrax vaccine in species for which the vaccine is licensed, as well as off-label use in other species. He also reported being bitten by a fly. The historic practice of adding lime should be avoided (17). He was discharged on hospital day 13. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. [] The fifth plague described in the Old Testament book of Genesis may be among the earliest descriptions of anthrax. The zoonotic disease anthrax, caused by the bacterium Bacillus anthracis, has been known to humankind for thousands of years and is endemic to most continents (1–3). For a full list of topics: A-Z Index. Laboratory decontamination of HHS-listed and HHS/USDA overlap select agents and toxins. During animal outbreaks of anthrax, persons who handle and dispose of infected animals are at highest risk for exposure. Human and animal health authorities should remind at-risk populations of the following prevention measures when animal cases are first identified. Epidemiological and laboratory investigation were initiated to trace the source of infection and identify the risk factors of the outbreak. Cutaneous Anthrax . Patients with cutaneous anthrax should only continue oral antibiotics for PEP after antibiotic treatment is complete if the patient was also exposed to aerosolized spores; this would rarely be indicated for naturally acquired cutaneous infections because aerosol exposures are unlikely (Table 1). Even in the absence of a recognized anthrax outbreak, veterinarians and ranchers in endemic areas should always keep anthrax in mind as they interact with members of susceptible species that are ill. To do otherwise can result in inadvertent exposure to anthrax. In November 2015, FDA also approved the vaccine for use after exposure to anthrax for people 18 through 65 years of age. Standard precautions also include safe waste management and cleaning and disinfection of … Four days earlier, a small red spot had emerged and gradually enlarged and became painful. He did not use tobacco products. Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. CDC twenty four seven. His physician relayed the information first to the patient and then to hospital staff. Centers For Disease Control and Prevention, National Anthrax Epidemiologic Investigation Team. The second case was cutaneous anthrax, which was also detected by an alert infectious diseases physician in an NBC emplo… Emerg Infect Dis. Original Publication Date: November 12, 2020, Table of Contents – Volume 26, Number 12—December 2020. Saving Lives, Protecting People, Texas Department of State Health Services, Austin, Texas, USA (T. Sidwa, E. Swaney, B.J. Standard precautions include hand hygiene and use of appropriate PPE to avoid direct contact with BA. Cutaneous anthrax is the most common form of anthrax infection, and it is also considered to be the least dangerous. Saving Lives, Protecting People. These people would receive the 60-day course of antibiotics only. Upon arrival to the hospital, the patient reported pain, difficulty walking, and nausea. Clinicians should promptly notify their local or state health department when they suspect anthrax, although the mandated timing varies by jurisdiction. Given that half the cases in the 2001 anthrax incident in the United States (37) were cutaneous anthrax and most sporadic cases in the United States and worldwide are cutaneous, this article provides an overview of prevention and control measures for animals and a single resource for the prevention, diagnosis, infection control, and treatment of naturally acquired cutaneous anthrax. The patient began his ciprofloxacin the next evening (July 24). Concurrently, the state laboratory notified his primary-care physician that a preliminary laboratory report for the specimen was PCR-positive for B. anthracis; this result was confirmed by culture the following week (August 1) (Figures 3, 4). Tom Sidwa, Johanna S. Salzer, Rita Traxler, Erin Swaney, Marcus L. Sims, Pam Bradshaw, Briana J. O’Sullivan, Kathy Parker, Kenneth A. Waldrup, William A. Bower, and Kate Hendricks, Page created: November 12, 2020 10:48 AM EST, Page updated: November 19, 2020 12:27 PM EST, Page reviewed: November 19, 2020 12:27 PM EST, Centers for Disease Control and Prevention. Cutaneous anthrax. The last naturally occurring human case of cutaneous anthrax associated with livestock exposure in Texas was reported in 2001 (8,9). On the basis of anecdotal reports and 1 small study, tabanid flies (e.g., deer and horse flies) might play a role in transmission; whether fly control is achievable or would be effective remains an open question (2,12,13). The physician he visited in rural Texas included anthrax in the differential diagnosis, obtained and submitted diagnostic samples before treating the patient, and provided the patient with a prescription for oral ciprofloxacin. While anthrax is found in most soil, infection tends to come from handling infected animals or their skins. The outbreak we describe was confirmed in June 2019, but its actual start date is unknown; reliable recognition of epizootics might be impeded when they occur in vast, rough, and sparsely populated areas such as those in the anthrax-endemic areas of Texas. World Organization for Animal Health (OIE). Transmission routes include cutaneous, ingestion, inhalation, and injection; cutaneous accounts for most (95%) cases worldwide (2,4). Kevin Joseph Roche, M.D., Mary Wu Chang, M.D., and Herbert Lazarus, M.D. The index case of inhalational anthrax was associated with meningitis and occurred on 2 October 2001 in a patient who worked for America Media in Boca Raton, Florida. However, because properties in this area of Texas can be thousands of acres and not particularly navigable, reaching dead animals to cover and protect them from scavengers (that might further distribute B. anthracis–contaminated remains) is often not feasible. Anthrax is endemic to parts of the United States. The danger of lime use in agricultural anthrax disinfection procedures: the potential role of calcium in the preservation of anthrax spores. You will be subject to the destination website's privacy policy when you follow the link. Control and Prevention of Anthrax, Texas, USA, 2019. However, surgery usually is not necessary for cutaneous anthrax (36). In the United States, human risk is primarily associated with handling carcasses of hoofstock that have died of anthrax; the primary risk for herbivores is ingestion of B. anthracis spores that can persist in suitable alkaline soils in a corridor from Texas through Colorado, the Dakotas, and Montana (5–7). On examination at his physician’s office, the patient’s vital signs were as follows: blood pressure 177/87 mm Hg; heart rate 76 beats/min; and temperature 98.3°F. Livestock owners can sometimes cover dead animals with tarps if burial or burning is not an option. There was an unexpected error. Submit. A bioterrorism attack using anthrax spores is a possibility. However, with approval from public health authorities, specimens from lesions that are highly suspicious based on clinical or epidemiologic grounds can be sent directly from clinicians to an LRN laboratory (34). Anthrax is a per-acute, acute or sub-acute disease, primarily affecting herbivores as a soil-borne infection, but also capable of affecting other mammals, including man, and occasionally birds. It affects the skin and tissue around the site of infection. A Gram stain of a swab specimen from the lesion can often quickly identify possible cases and narrow the differential diagnosis (23). Microscopic visualization of the encapsulated bacilli, usually in … Because it was too late to send the specimens anywhere for testing on that day, the swabs were mailed directly to the Texas Department of State Health Services Laboratory on Wednesday after a phone consultation with the state health department. The body should be sealed in an airtight body bag and incinerated to prevent transmission of anthrax spores. Persons who live and work in anthrax-endemic areas and who anticipate interacting with animals that are dying or have died of anthrax might wish to consider preexposure prophylaxis with anthrax vaccine adsorbed (AVA). Even in the absence of a recognized anthrax outbreak, veterinarians and ranchers in endemic areas should keep anthrax in mind as they interact with ill members of susceptible species. Please use the form below to submit correspondence to the authors or contact them at the following address: Kate Hendricks, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop H24-12, Atlanta, GA 30329-4027, USA. On July 26, after having taken 4 doses of his antibiotics, he was feeling worse and sought additional care at the emergency department of hospital A, more than an hour’s drive from his residence. Specimens for tests such as Gram stain, culture, and PCR to rule anthrax in or out (Table 2) must be collected before the use of antibiotic therapy because they will rapidly become negative after the implementation of therapy (23). Atypical Femur Fracture Risk versus Fragility Fracture Prevention with Bisphosphonates ... Cutaneous Anthrax List of authors. As soon as anthrax is recognized in an animal population, public health and animal health agencies must collaborate to heighten awareness among medical and animal health communities, as well as among ranchers and other inhabitants of at-risk areas. In certain situations, such as a bioterrorist attack involving anthrax, anthrax vaccine might be recommended to prevent the disease in people after they have been exposed to the anthrax germs. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Confirmed human cutaneous anthrax in PHR 8. During 2000–2018, a total of 63 animal anthrax cases were confirmed by culture of B. anthracis in a reference laboratory (annual mean 3.3, range 0–20 cases/year) (T. Sidwa, unpub. data). It can be acquired by humans through contact with infected animals or their byproducts, such as carcasses or skins. All nine cases reported in Hungary in 2014 showed symptoms of cutaneous anthrax and had epidemiological links to animals positive for anthrax. Which single antibiotic or combination of antibiotics will be most effective for you depends on how you were infected with anthrax, your age, your overall health and other factors. The shots are injected into a muscle (intramuscular). Is anthrax a biological weapon? Microbiology and pathology testing are used to confirm the diagnosis. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. Although an eschar is the cardinal sign of cutaneous anthrax, in its early stages, anthrax can manifest as a group of small vesicles that might be pruritic. At examination, his vital signs were blood pressure 132/71 mm Hg; heart rate 91 beats/min; and respirations 24 breaths/min. 3.Anthrax – prevention and control. 5.Zoonoses. Proper and safe carcass disposal is critical for controlling anthrax outbreaks in enzootic areas because inappropriate carcass disposal seeds the soil with spores and increases the risk for future epizootics. The most common way to contract anthrax is by getting the bacteria or spores into the body through a cut or open sore in the skin. The vaccine is “…a cell-free filtrate containing protective antigen as the principal immunogen” (Joellenbeck). Activated spores release toxins—or poisons—that attack the body, causing the person to become sick. This will protect them from any anthrax spores in their body when the spores are activated. Cutaneous anthrax is most common on the head, neck, forearms, and hands. Antibiotic therapy should continue for >2 weeks or until the patient is stable. Waldrup). Cutaneous Anthrax Precautions. iSBn 978 92 4 154753 6 (nLM classification: WC 305) Contents Acknowledgements v development of these guidelines vi Preface vii Summary 1 1. For example, >6,000 anthrax cases in humans were reported in Zimbabwe in 1979 and 1980; the cases were associated with the slaughter of B. anthracis–infected cattle . The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Figure 1. The cutaneous anthrax patient associated with this outbreak was apparently exposed through a scratch on the leg from the antler of an untested deer carcass. Because the vaccine is live-attenuated, concurrent antibiotic administration can substantially diminish efficacy. When infection occurs in this manner, the skin develops a raised, sometimes itchy bump that looks and feels like an insect or spider bite. Control and Prevention of Anthrax, Texas, USA, 2019. Human anthrax in Iran. However, … Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Therapy of cutaneous anthrax with signs of system ic involvement, extensive edema, or lesion on the head or neck is the same as for inhalation anth rax (Table 1). Cutaneous anthrax develops 1-7 days (usually 2-5 days) after skin exposure and penetration of B anthracis spores [] In the most common cutaneous form of anthrax, spores inoculate a host through skin lacerations, abrasions, or biting flies. Other acceptable alternatives include ciprofloxacin and doxycycline. Sidwa, T., Salzer, J. S., Traxler, R., Swaney, E., Sims, M. L., Bradshaw, P....Hendricks, K. (2020). Primary prevention in humans is achieved through control of animal anthrax. His leukocyte count was 12,000 (103 cells/µL); hemoglobin, 15.5 g/dL; hematocrit, 46.9% g/dL; platelets, 83,000 (103 cells/mL); blood urea nitrogen, 35 mg/dL; and creatinine, 2.6 mg/dL. We describe the animal outbreak that occurred in southwest Texas beginning in June 2019 and an associated human case. Anthrax was described in the early literature of the Greeks, Romans, Egyptians, and Hindus. If exposure is recognized, antibiotic PEP should be considered by medical providers. That’s why people who have been exposed to anthrax must take antibiotics for 60 days. Antibiotic options for treatment and prevention of anthrax are listed in Tables 1 and 3. Despite the delay, the patient, like most patients with cutaneous anthrax, survived with antibiotic treatment (4,32). Cutaneous anthrax is the most common type, accounting for approximately 95% of cases. It is a disease of herbivores that incidentally infects humans through contact with animals that are ill or have died from anthrax or through contact with Bacillus anthracis-contaminated byproducts. Specimens for which B. anthracis is not ruled out by a sentinel laboratory should promptly be sent to a Laboratory Response Network (LRN) laboratory for confirmation (33). Implementing control measures (i.e., vaccination and proper carcass disposal) was challenging; thin topsoil over bedrock, vast and inaccessible terrain, and burn bans triggered by hot, dry weather conditions made it difficult for livestock owners and landowners to identify and bury or burn dead animals. Precautions are taken to avoid contact with the skin and any fluids exuded through natural body openings of a deceased body that is suspected of harboring anthrax. When a carcass cannot be burned, global recommendations are to bury it deeply (9). Suspected cutaneous anthrax in a laboratory worker--Texas, 2002. Veterinarians treating animals with illnesses compatible with anthrax must also report to DSHS and TAHC. In 2001, a U.S. military researcher mailed envelopes containing anthrax spores to members of Congress and the media. data). The frequency and effect of antibiotic use subsequent or simultaneous to vaccination was unknown. The vaccine also was “…found to be 93% effective in preventing both cutaneous and inhalation anthrax” (CDC). Timely delivery of information to ranchers on proper carcass disposal and appropriate use of personal protective equipment, as was done through various alerts, might reduce the number of exposures. Standard Precautions UNLESS wound drainage uncontrolled by bandage; If uncontrolled drainage, use Contact Precautions: Wear gown, gloves upon entryto patient room (regardless if contact with patient and/or patient environment is … – Antibiotherapy for 7 to 10 days: • If drug susceptibility is not known: ciprofloxacin PO is first-line treatment for all patients including pregnant women and children: Children: 15 mg/kg 2 times daily (max. Ciprofloxacin and doxycycline are two of the antibiotics that could be used to prevent anthrax. A 60-day treatment with antibiotics — ciprofloxacin, doxycycline and levofloxacin are approved for adults and children 2. Lesions should be covered until the patient has had 24 hours of effective antibiotics. An aggregate of four anthrax cases during the dry summer of 2011 in Epirus, Greece. A blood sample is collected and sealed in a container and analyzed in an approved laboratory to ascertain if anthrax is the cause of death. Clinical Framework and Medical Countermeasure Use During an Anthrax Mass-Casualty Incident: Antimicrobial Treatment for Systemic Anthrax: Antitoxin Treatment of Inhalation Anthrax: National Notifiable Diseases Surveillance System: Prevention and Treatment of Anthrax in Adults (2014): If you are in the U.S. military, visit the.

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