Faculty Bibliography

David Oshinsky reviews the book "The Brother: The Untold Story of the Atomic Spy David Greenglass and How He Sent His Sister, Ethel Rosenberg, to the Electric Chair" by Sam Roberts

Inhalation anthrax should be treated with two or more antibiotics, not one, as previously recommended, the Centers for Disease Control and Prevention in Atlanta said in its weekly report. The agency made that change in part because patients who have survived inhalation anthrax were treated with combinations of antibiotics. Previously, penicillin was recommended as a first-line drug. But the agency says laboratory studies of anthrax bacteria from victims of the attacks show that the germs have some resistance to penicillin, which could make it less effective than other antibiotics. Using drugs in combination can sometimes overcome resistance, so penicillin can still be used along with other antibiotics. Some experts have recommended use of an anthrax vaccine in combination with antibiotics to treat the inhalation form of the disease. But the disease agency does not support such a treatment, because evidence is lacking about the vaccine's benefit in treating inhalation anthrax, Dr. [Julie L. Gerberding] said. The agency has asked the Food and Drug Administration for permission to study the vaccine-antibiotic combination

Inhalation anthrax should be treated with two or more antibiotics, not just one, as previously recommended, the Centers for Disease Control and Prevention said in its weekly report. It made that change in part because patients who have survived inhalation anthrax have been treated with combinations of antibiotics. Previously, penicillin was recommended as a first-line drug for anthrax. But now, the agency says laboratory studies of anthrax bacteria from victims of the attacks show that the germs have some resistance to penicillin, which could make it less effective than other antibiotics. Using drugs in combination can sometimes overcome resistance, and so penicillin can still be used along with other antibiotics. One step was exposing the anthrax bacteria to a number of antibiotics to determine how susceptible the bacilli were to the drugs. The initial tests showed that the anthrax bacilli were mostly sensitive to penicillin, [Julie L. Gerberding] said. But there was some resistance. And the scientists knew from experience in patients that bacteria exposed to penicillin could switch on an enzyme that destroyed the drug

Some experts have recommended the use of anthrax vaccine in combination with antibiotics to treat the inhalation form of the disease. But the agency does not support such a treatment, because evidence is lacking about the vaccine's benefit in treating inhalation anthrax, [Julie L. Gerberding] said

Officials are recommending a 10-day course of the powerful antibiotic Cipro for thousands of postal workers around Washington while epidemiologists figure out who among them were most likely to have been infected. Those at risk would receive a 60-day course of Cipro or other equally effective antibiotics.Dr. Anne Schuchat, an epidemiologist at the Centers for Disease Control and Prevention in Atlanta, said in an interview that the four Washington postal workers who came down with inhaled anthrax -- two of whom died on Monday -- experienced initial symptoms of fever, headache, chills, sweating and malaise for a couple of days -- in short, the symptoms of flu. The recommendations apply only to areas where inhaled anthrax has been diagnosed or is strongly suspected. Elsewhere, flulike symptoms ''would not make us think of anthrax,'' said Dr. Schuchat, who is an expert in the epidemiology of respiratory illness. Because chest X-rays of postal workers in the early stage of inhalation anthrax have shown the swollen lymph nodes, Dr. Schuchat said, her agency is urging doctors to consider taking X-rays and carefully examining them for the abnormality. ''The mediastinal X-ray findings were immediate clues that something unusual was going on,'' she said, and led to more extensive testing that detected anthrax in the patients

Dr. Anne Schuchat, an epidemiologist at the Centers for Disease Control and Prevention, said in an interview that the four Washington postal workers who came down with inhaled anthrax -- two of whom died on Monday -- experienced initial symptoms of fever, headache, chills, sweating and malaise for a couple of days -- in short, the symptoms of flu. Anthrax bacilli that reach the small air sacs of the lung are carried by scavenger cells to the mediastinum, a space between the back of the lungs and the spine, where they cause lymph nodes to swell. Those swollen nodes are a characteristic finding in inhalation anthrax. Because chest X-rays of postal workers in the early stage of inhalation anthrax have shown the swollen lymph nodes, Schuchat said, her agency is urging doctors to consider taking X-rays and carefully examining them for the abnormality

What the drug company is not telling either patient or doctor is that [Cipro] was originally tested as an alternative treatment for anthrax only for penicillin-allergic patients. Antibiotics have never been properly tested for prophylaxis, so Cipro's usefulness for prevention is speculative, though there is clearly some rationale for prophylaxing patients with close exposure. But doxycycline, a generic, is just as effective and costs one-tenth of what Cipro costs. A month's supply of Cipro costs more than $300 US; the equivalent amount of doxy is $32

Yesterday's decision by public health officials to treat thousands of postal workers with Cipro just days after warning against over-prescribing the antibiotic was essentially an acknowledgment that they are struggling to contain an outbreak of anthrax for which there is no precedent. There is hardly any human data on the effects of inhaled anthrax spores. The only known epidemic in the history of the United States occurred at a mill in New Hampshire in 1957, when four of five workers infected died from the disease. The dose was uncertain because the workers might have inhaled differing amounts over several days. Dr. [Donald A. Henderson] said he hoped public health officials could persuade people to trust penicillin and doxycycline, antibiotics that animal experiments have shown to be as effective as Cipro in treating inhalation anthrax

Anthrax was not suspected when Mr. [Ernesto Blanco], who suffered from chronic lung disease, was admitted to Cedars for pneumonia on Oct. 1. The underlying lung disease might have made him more susceptible to inhalation anthrax. Because he worked at American Media, a swab of his nose was taken, and it showed anthrax spores. He did not show classic symptoms of inhalation anthrax, which suggests that doctors may need to modify their description of the condition, and his case was re-classified as ''atypical inhalation anthrax.'' The change was based on laboratory tests that showed evidence of Bacillus anthracis in bloody fluid in the sac covering his lungs. Anthrax spores can cause different types of infection, depending on where they enter the body. If they invade via a break in the skin, the result is cutaneous anthrax, which often resolves without treatment and is easily cured by antibiotics. But if the spores are breathed into the lungs, inhalation anthrax can occur. Doctors believe that the inhalation form is often fatal because by the time the symptoms of infection appear, a bacterial toxin is already doing its deadly work, and it may be too late for antibiotics to help. Second, an epidemiologic study in 1957 found that four of five workers died after contracting inhalation anthrax at a goat-hair processing plant in Manchester, N.H., over 10 weeks. The workers were all too familiar with anthrax; in the previous 16 years, 136 had developed cutaneous anthrax, the most curable form. Although air sampling showed that workers often breathed Bacillus anthracis spores at the plant, none developed inhalation anthrax until 1957

An envelope that might (or might not) be filled with ominous powder, the possibility that someone might slip across a border with a jar of viruses, the impossibility of guarding every subway entrance and roof ventilator against a terrorist with a spray can: ''In these times,'' said Dr. Frank Bia, an expert on infectious diseases and microbiology at Yale, ''the unthinkable has become thinkable.'' The response to confirmed anthrax cases in Florida, New Jersey, New York and Washington, is being viewed as a painful drill that has exposed gaping deficiencies in the country's ability to cope with bioterrorism. Experts on infectious diseases cited a number of areas that needed to be improved, including these: ''Our imaginations have not been broad enough,'' said Dr. Frank Bia, an expert in infectious diseases and microbiology at Yale. ''When someone comes to the emergency room with something unusual, doctors must trust their instincts and sixth sense to make the pieces fit together.''