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                         isolated
  If the agent has been           and identified, susceptibility to
current    antimicrobials should be determined   in order to  guide
therapy.    If the agent is unknown, empiric, multi-drug therapy may
be  pursued.     Ciprofloxacin,  a quinolone,  has  broad spectrum
activity that    includes anthrax.  The Armed Forces Epidemiology
Board   has  recommended that  every soldier  be  issued sufficient
ciprofloxacin to treat for five days at 500 mgm twice daily.   This
time frame should be sufficient to determine whether or not there
has been a BW attack and to either continue or discontinue therapy.
Sufficient supplies to treat every soldier for 30 days have been
procured and are available through routine medical supply channels.
Other broad spectrum agents that are well tolerated include: the
tetracyclines (doxycycline also has activity against anthrax) which
have broad spectrum activity against rickettsias to      include Q-
fever;   erythromycin,  which  can  cover tegionella  and  atypical
pneumonia    agents;  and   the  antifungal  azoles   (ketoconazole,
fluconazole) which can cover histoplasmosis and other respiratory
fungal agents.

  Prior to    identification of the agent,  a useful approach to a
large number of casualties with similar symptoms is the clinical
mini-trial.   First assign several (10 to 20) patients to two groups
with    different   combinations   of  empiric   therapy  (e.g.    -
ciprofloxacin,    erythromycin, ketoconazole  versus  tetracycline,
erythromycin,    fluconazole) or any combination available   (e.g. -
chloramphenicol).     Observation  of the  two groups  should  show
whether either combination is effective.      Once a response to a
combination of drugs is identified, another mini-trial to identify
which single drug or combination is most effective can guide future
therapy. ~apid identification of the agent and its sensitivities
will guide therapy and countermeasures.

4.  (U) METHODS OF DISSEMINATION

  While the routes by which infectious diseases are normally spread
(air,   water, food,  insect vector)  could be used for BW attack,
aerosols seem the most likely method.     Contamination of food or
water supplies is feasible as a terrorist activity but relatively
impractical    considering   standard  water  treatment   and  food
preparation procedures.     Targeting of these attacks would be very
difficult and affect a random population with random results.   Use
of vectors    (e.g. - fleas, mosquitos) is technically feasible but
the problems of production much less the difficulties in targeting
are obvious.      Aerosols have the advantage of  routine delivery
systems (artillery, rockets, aerosolizers) with specific targeting
and    infective   route  that   could  produce   rapid  casualties
(respiratory).    Aerosols must include particles 3 - 5 microns in
size in order to reach the pulmonary alveoli.  Infective doses vary
with the agent so prediction of those at risk will vary with the
agent, the delivery system, the weather, terrain, etc.

5.   ~SPECIFIC THREAT AGENTS

       a.   ANTHRAX:  Anthrax is primarily a disease of herbivores.


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