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Vaccines, Therapeutics, and Prophylaxis for Selected Biological Warfare Agents. (RX).

The threat of bioterrorism has stimulated renewed interest in the "Blue Book," a pocket-sized manual published by the United States Army Medical Research Institute of Infectious Diseases, Fort Detrick, Md. The fourth edition of the manual, entitled "Medical Management of Biological Casualties Handbook" (February 2001), includes a summary of medical agents from which this table is adapted.

The authors note that although most of the regimens are based on standard treatment guidelines some regimens may differ because the clinical presentation of certain diseased caused by biological weapons can vary from the endemic form. The regimens may be derived from in vitro data, animal models, and limited human data.

The authors also note that the investigational new drug (IND) products that are mentioned are often used in laboratory settings to protect health care workers, but these products are not available commercially and can be given only under a protocol with informed consent. They are mentioned for scientific completeness and are not necessarily to be construed as recommendations for therapy.
DISEASE VACCINE

Anthrax BioPort vaccine (licensed): 0.5 mL
 given subcutaneously at 0, 2, and
 4 wk and 6, 12, and 18 mo, then
 annual boosters





Botulism Department of Defense pentavalent
 toxoid vaccine for serotypes A-E
 (IND): 0.5 mL by deep subcutaneous
 injection at 0, 2, and 12 wk, then
 annual boosters


Brucellosis No human vaccine available




Cholera Wyeth-Ayerst vaccine: two doses of
 0.5 mL each, given IM or
 subcutaneously at 0 and 7-30 days,
 then boosters every 6 months






Q fever Investigation new drug (IND) 610:
 inactivated whole-cell vaccine
 given as single 0.5-mL
 subcutaneous injection




Smallpox Wyeth calf lymph vaccinia vaccine
 (licensed): single does by
 scarification


Tularemia IND, live attenuated vaccine:
 single 0.1-mL does given by
 scarification







Viral Venezuelan equine encephalitis TC-
encephalitides 83 live attenuated vaccine (IND):
 single 0.5-mL subcutaneous dose;
 Venezuelan equine encephalitis
 C-84 vaccine (formalin-inactivated
 TC-83, IND): up to three 0.5-mL
 doses given subcutaneously;
 Eastern equine encephalitis
 inactivated vaccine (IND):
 0.5 mL given subcutaneously at 0
 and 28 days; Western equine
 encephalitis inactivated vaccine
 (IND): 0.5 mL given subcutaneosuly
 at 0, 7, and 28 days

Viral Argentine hemorrhagic fever
hemorrhagic Candid No. 1 vaccine (cross-
fevers protection for Bolivian
 hemorrhagic fever) (IND); Rift
 Valley fever inactivated vaccine
 (IND)





DISEASE CHEMOPROPHYLAXIS

Anthrax Oral ciprofloxacin 500 mg b.i.d.
 for 4 wk; if unvaccinated, begin
 initial doses vaccine OR
 Oral doxycycline 100 mg b.i.d for
 4 wk plus vaccination In the
 absence of vaccine, continue
 chemoprophylaxis for at least 60
 days.

Botulism NA






Brucellosis Oral doxcycline 200 mg/day plus
 oral rifampin 600 mg/day for 6 wk



Cholera NA









Q fever Oral tetracycline 500 mg q.i.d.
 for 5 days (start 8-12 days after
 exposure) OR Oral doxycycline 100
 mg b.i.d. for 5 days (start 8-12
 days after exposure)



Smallpox IM vaccinia immune globulin 0.6
 mL/kg within 3 days of exposure;
 best within 24 hr


Tularemia Oral doxycycline 100 mg b.i.d. for
 14 days OR Oral tetracycline 500
 mg q.i.d. for 14 days OR Oral
 ciprofloxacin 500 mg every 12
 hr for 14 days





Viral NA
encephalitides













Viral NA
hemorrhagic
fevers








DISEASE CHEMOTHERAPY

Anthrax IV ciprofloxacin 400 mg every
 12 hr OR IV doxycycline 200 mg
 initially, then 100 mg every
 12 hr OR IV penicillin 4
 million units every 4 hr




Botulism Department of Defense heptavalent
 equine despeciated antitoxin for
 serotypes A-G (IND): one vial
 (10 mL) IV; CDC trivalent equine
 antitoxin for serotypes A, B, E
 (licensed)

Brucellosis Oral doxycycline 200 mg/day plus
 oral rifampin 600 mg/day for 6 wk
 OR Oral ofloxacin 400 mg/day plus
 oral rifampin 600 mg/day for 6 wk

Cholera Oral rehydration therapy plus:
 Tetracycline 500 mg every 6 hr
 for 3 days OR Doxcycline 300 mg
 once or 100 mg every 12 hr for
 3 day OR Ciprofloxacin 500 mg
 every 12 hr for 3 days OR
 Norfloxacin 400 mg every 12 hr for
 3 days


Q fever Oral tetracycline 500 mg every 6
 hr for 5-7 days, continued for at
 least 2 days after patient is
 afebrile OR Oral doxycycline 100
 mg every 12 hr for 5-7 days,
 continued for at least 2 days
 after patient is afebrile

Smallpox No current treatment other than
 supportive care; cidofovir
 effective in vitro; animal
 studies ongoing

Tularemia IM streptomycin 7.5-10 mg/kg
 b.i.d. for 10-14 days OR
 IV gentamicin 3-5 mg/kg per day
 for 10-14 days OR IV ciprofloxacin
 400 mg every 12 hr until improved,
 then 500 mg orally every 12 hr
 for a total of 10-14 days OR
 Oral ciprofloxacin 750 mg every
 12 hr for 10-14 days

Viral Supportive therapy: analgesics and
encephalitides anticonvulsants as needed













Viral IV ribavirin (Crimean-Congo
hemorrhagic hemorrhagic fever/Lassa fever)
fevers (IND): 30 mg/kg initial dose,
 then 16 mg/kg every 6 hr for 4
 days, then 8 mg/kg every 8 hr for
 6 days; passive antibody for
 Argentine hemorrhagic fever,
 Bolivian hemorrhagic fever, Lassa
 fever, and Crimean-Congo
 hemorrhagic fever

DISEASE COMMENTS

Anthrax Potential drug alternatives:
 gentamicin, erythromycin, and
 chloramphenicol. Use penicillin
 for sensitive organisms only.





Botulism Perform skin test for
 hypersensitivity before
 administering equine antitoxin.




Brucellosis Trimethoprim-sulfamethoxazole
 may be substituted for rifampin;
 however, relapse may reach 30%.


Cholera Vaccine not recommended for
 routine protection in endemic
 areas (50% efficacy, short-term
 protection). Drug alternatives:
 erythromycin, trimethoprim-
 sulfamethoxazole, and
 furazolidone. Use quinolones for
 tetracycline/doxcycline-resistant
 strains.

Q fever Currently testing vaccine to
 determine the necessity of skin
 testing prior to use.





Smallpox Preexposure and postexposure
 vaccination recommended if >3
 years since last vaccine.


Tularemia









Viral TC-83 is reactogenic in 20%;
encephalitides no seroconversion seen in 20%;
 only effective against subtypes
 1A, 1B, and 1C. C-84 vaccine used
 in nonrespnders to TC-83 vaccine.
 Eastern equine encephalitis and
 Western equine encephalitis
 inactivated vaccines are poorly
 immunogenic. Multiple
 immunizations are required.





Viral Aggressive supportive care and
hemorrhagic management of hypotension are
fevers very important.
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Copyright 2001 Gale, Cengage Learning. All rights reserved.

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Publication:Internal Medicine News
Geographic Code:1USA
Date:Nov 1, 2001
Words:994
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