In light of recent events, here is a guide to help you handle suspicious mail and learn general information about anthrax.

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.
• are addressed to someone no longer with your organization or are otherwise outdated.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 on them.
• are marked with restrictive endorsements, such as "Personal" or "Confidential."
• have strange odors or stains.
• show a city or state in the postmark that doesn't match the return address.

Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. Anthrax most commonly occurs in wild and domestic lower vertebrates (cattle, sheep, goats, camels, antelopes, and other herbivores), but it can also occur in humans when they are exposed to infected animals or tissue from infected animals. The spores are very stable and may remain viable for many years in soil and water. They will resist sunlight for varying periods.

Anthrax can be found globally. It is more common in developing countries or countries without veterinary public health programs. Certain regions of the world (South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, and the Middle East) report more anthrax in animals than others.

Anthrax is most common in agricultural regions where it occurs in animals. These include South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, and the Middle East. When anthrax affects humans, it is usually due to an occupational exposure to infected animals or their products. Workers who are exposed to dead animals and animal products from other countries where anthrax is more common may become infected with B. anthracis (industrial anthrax). Anthrax in wild livestock has occurred in the United States.

Anthrax infection can occur in three forms: cutaneous (skin), inhalation, and intestinal. B. anthracis spores can live in the soil for many years, and humans can become infected with anthrax by handling products from infected animals or by inhaling anthrax spores from contaminated animal products. Anthrax can also be spread by eating undercooked meat from infected animals. It is rare to find infected animals in the United States.

Symptoms of disease vary depending on how the disease was contracted, but symptoms usually occur within 7 days.

Cutaneous: Most (about 95%) anthrax infections occur when the bacterium enters a cut or abrasion on the skin, such as when handling contaminated wool, hides, leather or hair products (especially goat hair) of infected animals. Skin infection begins as a raised itchy bump that resembles an insect bite but within 1-2 days develops into a vesicle and then a painless ulcer, usually 1-3 cm in diameter, with a characteristic black necrotic (dying) area in the center. Lymph glands in the adjacent area may swell. About 20% of untreated cases of cutaneous anthrax will result in death. Deaths are rare with appropriate antimicrobial therapy.

Inhalation: Initial symptoms may resemble a common cold. After several days, the symptoms may progress to severe breathing problems and shock. Inhalation anthrax is usually fatal.

Intestinal: The intestinal disease form of anthrax may follow the consumption of contaminated meat and is characterized by an acute inflammation of the intestinal tract. Initial signs of nausea, loss of appetite, vomiting, fever are followed by abdominal pain, vomiting of blood, and severe diarrhea. Intestinal anthrax results in death in 25% to 60% of cases.

Direct person-to-person spread of anthrax is extremely unlikely to occur. Communicability is not a concern in managing or visiting with patients with inhalational anthrax.

After an incubation period of 1-7 days, the onset of inhalation anthrax is gradual. Possible symptoms include fever, malaise, fatigue, cough, and mild chest discomfort followed by severe respiratory distress.

This mild illness can progress rapidly to respiratory distress and shock in 2-4 days followed by a range of more severe symptoms, including breathing difficulty and exhaustion. Death usually occurs within 24 hours of respiratory distress.

Anthrax is diagnosed by isolating B. anthracis from the blood, skin lesions, or respiratory secretions or by measuring specific antibodies in the blood of persons with suspected cases.

Treatment with antibiotics beginning one day after exposure has been shown to provide significant protection against death in tests with monkeys, especially when combined with active immunization. Penicillin, doxycycline, ciproflaxin, are all effective against most strains of the disease. Penicillin is the drug of choice for naturally ocurring anthrax. If untreated, inhaled anthrax is fatal.

A vaccine is available and consists of a series of 6 doses over 18 months with yearly boosters. This vaccine, while known to protect against anthrax acquired through the skin, is also believed to be effective against inhaled spores.

Effective decontamination can be accomplished by boiling contaminated articles in water for 30 minutes or longer and using common disinfectants. Chlorine is effective in destroying spores and vegetative cells. Remember, anthrax spores are stable, able to resist sunlight for several hours and able to remain alive in soil and water for years.

In countries where anthrax is common and vaccination levels of animal herds are low, humans should avoid contact with livestock and animal products and avoid eating meat that has not been properly slaughtered and cooked. Also, an anthrax vaccine has been licensed for use in humans. The vaccine is reported to be 93% effective in protecting against anthrax.

The anthrax vaccine is manufactured and distributed by BioPort, Corporation, Lansing, Michigan. The vaccine is a cell-free filtrate vaccine, which means it contains no dead or live bacteria in the preparation. The final product contains no more than 2.4 mg of aluminum hydroxide as adjuvant. Anthrax vaccines intended for animals should not be used in humans.

The Advisory Committee on Immunization Practices has recommend anthrax vaccination for the following groups:

The anthrax Vaccine Immunization Program in the U.S. Army Surgeon General's Office can be reached at 1-877-GETVACC (1-877-438-8222). Pregnant women should be vaccinated only if absolutely necessary.

The immunization consists of three subcutaneous injections given 2 weeks apart followed by three additional subcutaneous injections given at 6, 12, and 18 months. Annual booster injections of the vaccine are recommended thereafter.

Mild local reactions occur in 30% of recipients and consist of slight tenderness and redness at the injection site. Severe local reactions are infrequent and consist of extensive swelling of the forearm in addition to the local reaction. Systemic reactions occur in fewer than 0.2% of recipients.

The Department of Defense recommends that servicemen and women contact their chain of command on questions about the vaccine and its distribution. The anthrax Vaccine Immunization Program in the U.S. Army Surgeon General's Office can be reached at 1-877-GETVACC (1-877-438-8222).