Before an Attack
Learn about the nature of terrorism

Terrorists look for visible targets where they can avoid 
detection before or after an attack, such as international 
airports, large cities, major international events, resorts 
and high-profile landmarks.

Adapt, as appropriate, the same techniques used to prepare 
for earthquakes, fires and other emergencies.

Be prepared and observe your environment. Terrorists most 
often strike with little or no warning.

Use caution when you travel. Observe and report unusual 
activity. Keep your packages with you at all times. Do not 
accept packages from strangers.

Locate stairways and emergency exits and develop plans for 
evacuating buildings and crowded public areas.

If you live or work in multi-level buildings:

Identify the location of fire exits and review emergency 
evacuation procedures.

Locate and maintain fire extinguishers in working order 
and learn how to use them.

Obtain training in first aid and CPR.

Assemble and maintain an emergency supply kit in back packs 
to keep in your home and car.

Emergency Supply Kit
Maintaining an emergency supply kit is a good idea for any 
emergency. Individuals and organizations should be prepared 
to be without assistance for a minimum of 72 hours.

WATER
Food (canned, no-cook, packaged snacks)
Manual can opener
Battery-powered radio, flashlights, batteries
Whistle
First aid kit and manual
Essential medicines and eyeglasses
Fire extinguisher (A-B-C) type
Hard hats
Duct tape
Cash and credit cards
Change of clothing, rain gear, and sturdy shoes
Blankets or sleeping bags
Infant and feminine hygiene supplies
Fire extinguisher (A-B-C) type
Names, addresses, and telephone numbers of doctors 
and pharmacists
Food and water for pets
Large plastic bags for trash, waste, water protection
Toilet paper and paper towels
Charcoal grill or camp stove for outdoor cooking
Fluorescent tape to rope off dangerous areas

During an Attack
If there’s an explosion:

Remain calm. Take cover under a desk or sturdy table if 
ceiling tiles, bookshelves, their contents, etc. begin to fall.
Exit the building as quickly as possible.

If there’s a fire:

Stay low to the floor at all times and exit the 
building as quickly as possible. Heavy smoke and 
poisonous gases collect near the ceiling first.
Use a wet cloth to cover your nose and mouth.
Use the back of your hand to feel closed doors. 
If the door is not hot, brace yourself against the 
door and open it slowly. Do not open the door if it 
is hot. Seek another escape route.
Use appropriate fire exits, not elevators.

After an Attack
If you are trapped in debris:

If possible, use a flashlight or whistle to signal 
rescuers regarding your location.
Stay in your area so that you don’t kick up dust.
Cover your mouth with a handkerchief or clothing.
Tap on a pipe or wall so that rescuers can hear where 
you are.
Shout only as a last resort shouting can cause a person 
to inhale dangerous amounts of dust.

Protective Actions
Protective actions are actions we take to safeguard our 
family members and ourselves from harm. The most common 
emergency protective actions are evacuation and 
shelter-in-place.

Evacuation means to leave the area of actual or 
potential hazard.

Shelter-in-place means to stay indoors. This includes 
additional precautions such as turning off air-
conditioning, ventilation systems and closing all 
windows and doors.

What Should You Do?

Remain calm.
Be aware of your surroundings.
HAVE A FAMILY PREPARENESS PLAN.
Stay informed.

If an evacuation is ordered, follow the instructions of 
local officials regarding evacuation routes and the 
location of shelters.
If shelter-in-place is recommended, local officials will 
provide instructions on necessary actions. Do not leave 
your sheltered location or return to the evacuated area 
until it is deemed safe to do so by local officials.

Coping With Terrorism
First, keep in mind that the goal of terrorism is to fill 
people with intense fear, to intimidate people to deliver 
a political message, and to paralyze government and commerce. 
Americans have power over how we respond to these events, 
and our nation is choosing to respond with dignity, 
community, heroism, and patriotism. The terrorist events 
of September 11, 2001 have evoked strong and deep reactions 
in both adults and children. It is important for people to 
realize that their reactions are normal in these very 
abnormal and tragic circumstances, and to know that there 
are things people can do to cope and to help each other 
through these difficult times. Common reactions include shock, 
disbelief, disorientation, fear, worry about safety, concern 
about loved ones, and grief. After the initial shock wears off, 
people may have mood swings, crying, jumpiness, irritability, 
fatigue, feeling overwhelmed, trouble concentrating, difficulty 
sleeping, nightmares, and feeling numb or not particularly upset. 
These are normal reactions. Sometimes people seem to shut down 
for a while after a disaster. Children are affected by what they 
see and hear on television, and by how their parents react. 
Common reactions in children include asking questions about what 
happened and why, fear for safety, not wanting to be separated 
from family, regression to behaviors from a younger age, fear of 
sleeping alone, headaches and stomachaches, and a decline in 
school performance.

Coping Strategies
The following are some suggestions for dealing with the 
psychological and emotional impact of these terrorist events:

Try to understand at least the principal details about what 
happened and evaluate the chances that it could happen again.
Gather facts before reacting.
Try to maintain a normal routine. Unless public safety 
officials have issued warnings or closed buildings, continue 
in your normal daily activities. Remember that the goal of 
terrorism is to make you fearful. Rather than being intimidated, 
follow the advice of professional public safety officials.
Follow your usual routine of physical activity and exercise. 
Eat well and try to get rest, even if your sleep is not as restful 
as usual.
Avoid self-medication such as alcohol, caffeine, or other drugs.
Draw on known sources of comfort that have sustained you 
and helped you in difficult times in the past.
Share your concerns and worries by talking with a friend, 
family member, or clergy. Reach out to each other while taking 
care of yourself.
If you wish to participate in community recovery activities, 
volunteer or donate to a known disaster response agency with a 
clear mission. Spontaneous, unorganized volunteers at a disaster 
site only add to the confusion.

Children's Reactions
You can assist your children with some of the following suggestions:

Spend more time with them and be comfortable with their 
temporarily slipping back into behaviors from an earlier age. 
Talk with them about what has happened and do your 
best to answer their questions. No one can totally answer 
the question of "why" this has happened or why people do "bad" 
things. Help them to be aware of the positive response of 
people to the disaster-of the people all over the world 
who are responding to the crisis in a helpful way. 
Your children may be fearful about the safety of buildings 
or airplanes. Remind them that what happened is a very rare 
event, and not something that happens every day. Security 
at buildings and airports is higher than ever. Do everything 
possible to reasonably reassure your children about safety. 
Reassure your children that you care about them, that 
you understand their feelings and concerns, and that you are 
there for them. Physical affection is comforting, especially 
to young children. 
Try to limit the amount of television coverage both you 
and your children watch, especially children under the age 
of four. We know clearly from past disasters that media images 
can traumatize people, especially children. Encourage them to 
talk with you about their thoughts and feelings about what 
they have seen. Consider having them draw pictures, or for 
older children, write in their journal about some of their 
feelings. 
Try to keep a regular schedule of activities such as 
eating, playing, studying, and going to bed to help restore 
a sense of security and normalcy. Emotions and problems with 
concentrating may interfere with studying for awhile. 
Talk to your children’s teachers, day-care providers, and 
babysitters about your child’s response to the event and about 
what they doing to assist children. 
While children may be angry about what happened, caution 
them not to speak or act with prejudice against people of ethnic 
or religious groups that they think may have been involved. 
Justice for the people who made the attack must be done with 
dignity and within the structure of the law. 
Teenagers may want to volunteer or donate to community 
recovery activities and should be encouraged to do so. 
If you find that your reactions to the terrorist events of 
September 11 are disrupting your daily functions, such as job 
performance or relationships, it may be helpful to attend a 
community support group or debriefing group, or to talk with a 
mental health professional. For children, prolonged or extreme 
withdrawal, emotional outbursts, serious problems at school, 
or other signs of intense anxiety or emotion are signs that it 
may be helpful to talk to a mental health professional. Contact 
your local mental health agency for assistance.

TERRORISM FAQ
1. What is anthrax?
Anthrax is a disease caused by bacteria called Bacillus 
anthracis. The form of the disease that health authorities 
are concerned that a bioterrorist attack might produce is 
inhalational anthrax. Inhalational anthrax occurs when a 
person breathes in anthrax spores. As early as a day or two 
after exposure or as late as seven weeks afterward, the 
spores begin to grow rapidly and the victim develops fever, 
has difficulty breathing and feels miserable. Death typically 
occurs within a few days after these symptoms if the person 
doesn't receive medical treatment. It is believed that 
antibiotics can stop the disease if they are taken at the 
time the anthrax spores begin to grow or very soon thereafter. 
In the event of a bioterrorist attack, health authorities 
would conduct a rapid investigation, determine the place and 
time of the release, and identify individuals who need 
antibiotics. The federal government has stockpiled antibiotics 
for large-scale distribution in the event of a bioterrorist attack.

2. Is anthrax contagious?
Anthrax is not contagious between people. Healthy people 
who come into contact with persons sick with anthrax 
cannot acquire the disease. Anthrax can be transmitted 
through contact with infected animal products.

3. How dangerous is skin (cutaneous) anthrax?
Not very, if treated promptly. Anthrax can enter the 
skin through a cut or abrasion, but it rarely enters 
the bloodstream through this route. After infection, 
the area swells up, may get blisters, and turns into 
a dark brown or black scab, which falls off in one to 
two weeks. This form of anthrax has been common in
animal handlers in less developed areas of the world. 
Although skin anthrax can sometimes clear up without 
treatment, antibiotics are highly effective and 
easily available. Remember, soap and water are the 
first line of defense against germs on the skin.

4. Should I buy antibiotics just in case?
No. There are a number of different germs a 
bioterrorist might use to carry out an attack. Many 
antibiotics are effective for a variety of diseases, 
but there is no antibiotic that is effective against 
all diseases. Thus, no single pill can protect against 
all types of biological weapon attacks. Keeping a 
supply of antibiotics on hand poses other problems 
because the antibiotics have a limited "shelf life" 
before they lose their strength. There is currently 
no justification for taking antibiotics without a 
confirmed exposure to a specific organism, which that 
antibiotic would be effective against. Also, it should 
be known that antibiotics can cause side effects. They 
should only be taken with medical supervision.

5. Should I buy a gas mask?
No. A mask would only protect you if you were wearing 
it at the exact moment a bioterrorist attack occurred. 
Unfortunately, a release of a biological agent is most 
likely to be done "covertly," that is, without anyone 
knowing it. That means you would not know ahead of time 
to put on your mask. To wear a mask continuously or 
"just in case" a bioterrorist attack occurs, is 
impractical, if not impossible. To work effectively, 
masks must be specially fitted to the wearer, and wearers 
must be trained in their use. This is usually done for 
the military and for workers in industries and laboratories 
who face routine exposure to chemicals and germs on the job. 
Gas masks purchased at an Army surplus store or off the 
internet carry no guarantees that they will work. In fact, 
one national chain of surplus stores provides the following 
statement: "(X) has been selling gas masks as a novelty item 
since 1948. We have never been able to warrant their 
effectiveness and we cannot do so at this time...We do not 
know what each type of gas mask we sell might or might not 
be effective against...We do not know the age of each gas 
mask" In brief, no guarantees whatsoever are provided. 
More serious is the fact that the masks can be dangerous. 
There are reports of accidental suffocation when people 
have worn masks incorrectly, as happened to some 
Israeli civilians during the Persian Gulf War.

6. Is it safe for me to drink water from the tap?
Yes. It would be extremely difficult for a bioterrorist 
to contaminate our drinking water supplies to cause 
widespread illness. There are two reasons. First of all, 
huge amounts of water are pumped daily from our reservoirs, 
most of which is used for industrial and other purposes;
very little is actually consumed. Thus, anything 
deliberately put into the water supply would be greatly 
diluted. Secondly, water treatment facilities routinely 
filter the water supply and add chlorine in order to kill harmful 
germs.

7. What is smallpox?
Smallpox is a disease caused by the Variola virus. 
Historically, 1 out of 3 people who contracted the disease 
died. The disease can spread from person to person. 
Transmission usually occurs only after the patient develops 
a fever and rash. Although there is no treatment for the 
disease, a vaccine against smallpox provides excellent
protection and serves to stop the spread of the disease. 
While many vaccines must be given weeks or months before a 
person is exposed to infection, smallpox vaccine is different. 
It protects a person even when given 2 to 3 days after 
exposure to the disease and may prevent a fatal outcome even 
when given as late as 4 to 5 days after exposure. Smallpox
was stamped out globally by 1980 and vaccination stopped 
everywhere in the world. However, the Centers for Disease 
Control and Prevention (CDC) maintain an emergency supply 
of smallpox vaccine. Currently there are 12-15 million 
doses in storage, and a program to produce more vaccine 
began a year ago. 

8. If smallpox is a potential threat to the U.S., why 
shouldn't we all get vaccinated? The vaccine may cause 
serious side effects. In 1972, the U.S. decided to stop 
routinely vaccinating its citizens because many people 
were experiencing side effects, while they had almost no 
risk of getting smallpox. By 1972, the disease was present 
only in a few countries of Asia and Africa. Today, health 
authorities would only recommend vaccination if there was 
clear evidence that the disease had resurfaced and those 
in the U.S. were at risk of acquiring infection.Many people 
over age 30 have a vaccination scar. Vaccination consists of 
introducing the virus into the top layers of the skin. Over 
the following few days, a blister forms at the site of 
vaccination (usually the upper arm). The arm is sore, and 
there is fever. Very rarely, some people get a vaccine-
related infection of the brain (about 1 case per 300,000 
vaccinations); one fourth of these cases are fatal. Other 
potential negative effects of the vaccine are a severe skin 
reaction, spread of the vaccine virus (known as Vaccinia) 
to other parts of the body, and spread of the Vaccinia virus 
to other people.

9. If I was vaccinated against smallpox before 1980, am I 
still protected? Probably not. Vaccination has been shown 
to wear off in most people after 10 years but may last longer 
if the person has been successfully vaccinated on multiple 
occasions. If health authorities determine that you have been 
exposed to smallpox or are at risk of infection, they would 
recommend that you be re-vaccinated immediately.

10. What is the National Pharmaceutical Stockpile (NPS)?
The NPS is a large reserve of antibiotics, chemical antidotes 
and other medical supplies set aside for emergencies. The 
CDC reports that it has the capacity to move these stockpiled 
materials to affected areas in the U.S. within 12 hours of 
notification. There are a number of different stockpiles, 
strategically located around the country. In addition to the 
medical supplies already set aside, the federal government has 
made agreements with drug manufacturers to make large amounts 
of additional emergency medicine. For more information on 
the NPS.

11. What if my fear about bioterrorism is having a serious 
impact on my family and work life? Given the attacks upon 
civilians that took place on September 11, it is reasonable 
for citizens to feel anxious about their personal safety. 
Should your fear get to the point that it stops you from 
doing the things you would normally do in a day, it might 
be helpful to talk with someone. Your health care provider 
can make a referral if you do not already have someone in 
mind. In the wake of the attack on New York City, we have 
learned how helpful it has been to many New Yorkers to 
speak with a counselor or to go to a mental health center.
The information below describes how to identify a 
suspicious mail piece and the procedures to follow:

12. What constitutes a suspicious 
letter or parcel?
Some typical characteristics which ought to trigger suspicion 
include letters or parcels that:

Have any powdery substance on the outside.
Are unexpected or from someone unfamiliar to you.
Have excessive postage, handwritten or poorly typed address, 
incorrect titles or titles with no name, or misspellings of 
common words.
Are addressed to someone no longer with your organization or 
are otherwise outdated.
Have no return address, or have one that can't be verified as 
legitimate.
Are of unusual weight, given their size, or are lopsided or 
oddly shaped.
Have an unusual amount of tape. 
Are marked with restrictive endorsements, such as "Personal" 
or "Confidential."
Have strange odors or stains.

13. What Should I do if I Receive an Anthrax Threat by Mail?

Do not handle the mail piece or package suspected of 
contamination.
Make sure that damaged or suspicious packages are isolated 
and the immediate area cordoned off.
Ensure that all persons who have touched the mail piece 
wash their hands with soap and water.
Notify your local law enforcement authorities.
List all persons who have touched the letter and/or 
envelope.
Include contact information and have this information 
available for the authorities.
Place all items worn when in contact with the suspected 
mail piece in plastic bags and have them available for law 
enforcement agents.
As soon as practical, shower with soap and water.
Notify the Center for Disease Control Emergency Response 
at 770-488-7100 for answers to any questions.


BIOTERRORISM RESPONSE
by Meryl Nass, MD  

Issues that need to be addressed regarding the 
bioterrorism response include  the following:

1.Are the anthrax-containing envelopes an initial tease, or 
warning? They are a good way to disseminate small quantities, 
while avoiding identification of the sender.  But what may 
be ahead?  Spores in ventilation systems?  Spores at sports 
events or where there are dense population concentrations?  
Thousands or millions of letters containing anthrax?  How 
will we know in time, and how will we decontaminate 
ventilation systems, electronics, sports arenas, soil, etc.?

2.At the present time, public health authorities have 
continued to use (primarily cutaneous) human anthrax cases 
as the harbingers of anthrax dissemination.  Cutaneous 
infections require many fewer spores to induce illness, 
compared to inhalation anthrax.  The infected individuals 
are serving as the "canaries in the mineshaft" who warn 
that anthrax is present.  If the extent of spore dissemination 
increases (higher concentrations in ambient air from envelopes, 
or through other means) then the inhalation cases will serve 
as the canaries, and there will be many fatalities.

3. will continue to harp on the need for accurate and rapid 
sampling of the environment as the most important (by far) 
technology needed to deal with the offensive use of anthrax.  
There are likely to be many more envelopes that have already 
dispersed anthrax spores, but have not been identified yet, 
because there have (so far) been no cases of illness related 
to those envelopes, and spores were not seen by the person(s) 
handling the mail.  This means that anthrax spores may be 
contaminating a number of environments in which they have not 
been detected.  We may not see cases until small animals, 
children, or people with immune system impairment become 
exposed in those environments.

4.Only by identifying an environment contaminated with anthrax 
before illness appears are we likely to effectively treat 
inhalation cases.

5.Only by identifying these environments can we remove people 
from the environment and protect them from further exposure.

6.It is possible that we will not be able to do a complete 
clean up of contaminated environments, for the time being.  
There has not been a great deal of research into how to clean 
up homes and offices, for example.  Gruinard Island, off the 
coast of Scotland, was decontaminated 45 years after it was 
used as a test area for anthrax during World War II.  During 
those 45 years, humans and animals were barred from the island.  
Ten acres were decontaminated: this required defoliating the 
area, using 200 tons of 37% formaldehyde, diluted in seawater, 
that was sprayed over the area, and then additional 
formaldehyde was re-sprayed after deep soil sampling revealed 
persistent organisms.

7.What else works to kill anthrax spores, which can remain 
viable for decades or hundreds or years?  Bleach, which must 
be in contact with spores for at least 2 minutes.  
Paraformaldehyde gas, glutaraldehyde, hydrogen peroxide and 
peracetic acid also work, and need to be in contact with spores 
for at least as long.  But these materials can be corrosive and 
are not appropriate for homes and offices, though they can be 
used to decontaminate most laboratories. Spores can be boiled; 
the standard recommendation has been to keep the water at a 
rolling boil at least 10 minutes to kill spores of any pathogen.  
Steam also kills spores in from 1 to 10 minutes. In goat hair 
mills, the goat hair was treated at 170 degrees Fahrenheit for 15 
minutes, but many spores retained their viability after this 
treatment.  Moist heat works much better than dry heat. Fumigation 
can be performed with ethylene or propylene oxides, or 
paraformaldehyde gas.

8.I hope you can tell from this that I do not know a completely 
safe and effective way to perform decontamination.  This needs 
to be an area of intensive investigation now.  Dr. Alibek has 
suggested that methods used for decontamination in Sverdlovsk 
in 1979 (washing trees and houses, and paving dirt roads), may 
have re-aerosolized anthrax spores, and that this may have 
increased the number of cases of inhalation anthrax.

9.Dr. Ken Alibek suggested steam ironing letters before opening, 
which sounds like a good idea. Put a cloth between the iron and 
the letter. We need to know more about the temperature setting 
and how long the iron needs to be in contact with the letter.

10.The bottom line is that spores are odorless, tasteless, and 
invisible, individually.  In a worst case scenario, up to one 
trillion spores (1,000,000,000,000) might be present in one gram 
of material. One gram can be contained easily within a one-ounce 
(28 gram) letter. It theoretically could contain a million lethal 
doses, if the majority of the spores were viable, of the right 
size, and dispersed easily without clumping.

11.What is a lethal dose of spores?  The reason why you may read 
a variety of different estimates for this number is because a) 
there are no human-derived data, and b) there are a variety of 
factors that impact the answer.  There are many animal experiments, 
and those results are surprising at times.  It also depends on the 
virulence of the anthrax strain used, the amount of air you inhale 
(during exercise, you breathe in several times as much air as you 
do at rest), the % of viable spores, the distribution of size of 
spores, whether the spores easily separate from each other, and 
your own inherent immune system function.  Thus the number might 
range from 10,000 spores to many millions.  Animal tests of a 
sample from a letter should give us a rough idea of how virulent 
the potion is, and what a lethal dose might be.

12.Here are some animal data for lethal doses (LD50) of anthrax 
spores by subcutaneous injection and inhalation (from JM Barnes).  
This shows why there are so many cutaneous cases, compared to 
inhalation cases.

Species              # spores injected               # spores inhaled

Rabbit                     600,000                       100-1000                        

Guinea  Pig                370,000                       100-1000            

Mouse                      1,400,000                     10-100         

13.Another experiment in pigs:  each of 50 pigs was fed 
from 10 million to 10 billion Ames strain spores (C Redmond 
et al.)  Only 2 of the pigs died (4% of the total) and two 
others had anthrax isolated from blood, but survived.  By 
21 days after feeding the spores, the majority of pigs had 
developed antibodies to anthrax, indicating that they became 
infected and recovered.  Humans, like pigs, are probably 
relatively resistant to anthrax, compared to many other species.

14.How do we know antiserum is likely to be protective?  Mice, 
which are notoriously hard to protect against anthrax with 
vaccines, were given antiserum and then exposed to anthrax.  
The survival of mice given two different antisera was 80% at 
two weeks post exposure for both groups, while those given 
control sera had a 0% or 10% survival rate (RJ Beedham et al).

15.It remains very important to keep one's exposure to anthrax 
spores to a minimum, particularly if you work in a high risk 
industry, such as the postal service, UPS, Fedex, media or 
politics.  Although I earlier advised against gas masks, 
I have come to believe there is a role for appropriate, 
well-fitted masks that have demonstrated efficacy in preventing 
inhalation of particles of the 0.5 to 5.0 micron size.  My hope 
is that once environmental sensors are used widely, we will be 
able to discard masks.  For now, if you feel there has been an 
exposure, or if you are trying to avoid exposure at a high risk 
occupation, HEPA dust masks (such as 3M Corp has sold for 
tuberculosis prophylaxis) may be useful. The more HEPA sheets 
in the mask, the better it will filter. These masks have not 
been tested for anthrax or other bioterrorism exposures, so 3M 
cannot market them for this purpose.  However, such masks ought 
to keep out 95-99% of particles in the desired size range, and 
could be used for "high risk" activities such as opening mail. 
Gloves would also decrease one's exposure to spores, but must 
be discarded after use, or washed after use in order to reuse 
them.

16.Again, let me emphasize that a variety of soaps and 
detergents have been tested and were found to increase 
spore virulence by up to a factor of 16.  That means the 
spores could be made 16 times as virulent, because soaps 
may make them easier to disperse as individual particles. 
For now, wash only in water first to remove spores; you can 
then use soap when the spores are down the drain.

17.There are many methodologies for identifying spores in 
the environment.  I have collected a large number of articles 
on this subject, and will discuss what looks promising, and 
the differences between the methods, in a subsequent update.  
I continue to believe that PCR testing, because of its 
sensitivity and rapidity, should be the initial test done, 
with the understanding that some false positives will result, 
but no anthrax exposures will be missed, as long as sampling 
is adequate.  I have spoken at length to Tom O'Brien of 
Tetracore, in Gaithersburg, MD.  His company has some very 
promising PCR and immunoassays for anthrax that can be 
completed in under 12 hours, and can detect as few as 100 
cfu (viable spores) per milliliter of material.

18.Diagnosing exposure in people is not that easy.  
Although obtaining nasal swabs is a simple procedure 
to perform, one study shows that the spores rapidly 
disappear from the nose after exposure, suggesting 
that swabs are only likely to be positive within 24 hours 
of contact.  Thus sensitivity may be very low, and swabs 
will give you many false negative results.

19.Treatment is another question.  I have suggested that 
many other antibiotics are as good or better than 
ciprofloxacin.  Doxycycline, for instance, will also work 
for plague, tularemia and brucella, and effectiveness for 
all these other potential biowarfare pathogens has not been 
established for cipro.

20.The duration of antibiotic treatment needed remains 
uncertain. It is not clear if those currently being treated 
are being helped by antibiotics, or would not have become ill 
anyway.  Antibody titers will tell if you successfully fought 
off anthrax.  Although CDC Deputy Director David Fleming said 
that a four-fold rise in antibody titer is needed to confirm 
recent anthrax infection, this is not necessarily the case.  
Because anthrax is so rare, one positive antibody titer (by 
ELISA) should be adequate to make the diagnosis, as long as 
the ELISA test is accurate.

21.A pathologist called me today regarding an autopsy of a 
possible anthrax case.  Autopsies can be a problem; in animals, 
when the animal is opened, spores form and are released.  This 
could contaminate the autopsy suite.  There may be temperatures 
in which this does not occur, but I don't know that for sure.  
I recommended instead, that blood, CSF and mediastinal fluid 
be sampled for the presence of the relatively unique-appearing 
gram positive fat rods of anthrax.  This might save you from 
having to do a whole autopsy.

22.How to protect pets?  The animal vaccine works quite well 
though it may require yearly boosters (there is little data on 
how frequently they must be given).

23.I guess my take home message is that, unlike other
pathogens, which live in the environment for minutes to, at 
most, days, these spores last nearly forever.  Contamination 
does not resolve with time, although if spores are kicked up 
inside buildings, they may disperse to less infectious levels.  
Outdoors, the spores tend to stick to the soil components and 
do not easily re-aerosolize.  However, that may not be the case 
for indoor spore accumulations.  First responders, affected 
workers, and others who may be in the vicinity of an anthrax 
event should behave as if there are invisible, potentially
lethal spores everywhere: on surfaces, floors, your computer 
and desk, your person, walls and ceilings.  This requires an 
entirely new mindset for dealing with infectious emergencies.