AAP calls attention to unique needs of children in anthrax attack
- Copyright © 2012 by the American Academy of Pediatrics
In 2001, Bacillus anthracis spores were distributed intentionally through the U.S. postal system, causing 22 cases of anthrax, including five deaths. Among these cases was a 7-month-old child, who was suspected of being exposed during a visit to an office where an anthrax-tainted package was delivered. The child was hospitalized and fully recovered.
This incident reflects that children’s needs must be considered in the event of an act of bioterrorism.
What is anthrax?
Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. Anthrax most commonly occurs in certain mammals but can occur rarely in humans when they are exposed to infected animals or animal products. The main routes of anthrax infection are cutaneous, gastrointestinal and inhalation, any of which can progress to overwhelming disseminated infection.
Anthrax spores can be used as a bioterrorist weapon, with large inocula leading to rapidly progressive infections with a high mortality rate. Due to its relative ease of dissemination and transmission, high rates of morbidity and mortality, and the need for public health preparedness, anthrax is categorized as a high risk Category A agent by the Centers for Disease Control and Prevention (CDC).
Children are particularly vulnerable to biological agents because they have a more rapid respiratory rate, increased skin permeability, higher ratio of skin surface area to mass and less fluid reserve compared with adults. Because fever, malaise, headache, vomiting and diarrhea can be presenting symptoms of anthrax as well as many other infectious diseases, it can be challenging for clinicians to discriminate between an act of terrorism and naturally occurring, ordinary infections.
Accurate and rapid diagnosis can be more difficult in children due to atypical presentations. Children also may have a much higher risk for disease progression and higher mortality rates for inhalation and gastrointestinal disease.
AAP Anthrax Work Group activities
The Academy recently has been engaged in initiatives to highlight the unique needs of children in the event of an anthrax exposure due to bioterrorism.
The Academy approved formation of an Anthrax Work Group in July 2011 at the request of the Disaster Preparedness Advisory Council (DPAC) to help advise AAP leaders about treatment concerns in children and in response to requests from federal partners for subject matter expertise. Pediatricians also have provided expert guidance recently on numerous government panels and have testified before Congress. To view testimony, visit www.aap.org/disasters/policymakers.cfm#testimony.
Considering countermeasures for children
The U.S. Strategic National Stockpile (SNS) is the national repository of medical countermeasures (MCMs), e.g. medications, vaccines and other critical medical equipment and supplies, that are delivered to state authorities in a public health emergency.
To protect the nation’s security, the specific contents of the SNS are not shared with the public, although past outbreaks have shed light on what is missing, particularly where children are concerned. Both the National Commission on Children and Disasters and the National Biodefense Safety Board have reported that the SNS not only is under-stocked with formulations of MCMs appropriate for children, but information also is lacking on pediatric dosing for MCMs.
Concern has been increasing at the federal level regarding adequate MCMs for children in the event of a chemical-biological terrorism attack. The Academy was given the opportunity to respond to questions posed by the U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response regarding the use of anthrax antimicrobial postexposure prophylaxis in children. Given the extraordinary morbidity of inhalation anthrax, the overarching AAP recommendations are as follows:
The SNS or other pre-deployed cache should always include an adequate supply of medication (e.g., doxycycline/ciprofloxacin) in liquid/suspension form. Guidelines for extemporaneous oral liquid formulation of crushed solid tablets or opened capsules could be developed and tested as alternatives to current pediatric formulations.
Ciprofloxacin and doxycycline tablets should be manufactured in smaller tablet sizes to facilitate accurate milligram/kilogram dosing in small children.
Pediatricians should receive adequate public health training about the approved protocols for administering countermeasures to children.
An approved written protocol for MCM distribution should undergo prospective simulated testing to ensure that it achieves efficient and accurate administration to children during a disaster.
Development of semi-solid or other liquid formulations of medication for the SNS should be explored (e.g., a gel or paste, powder, chewable or orally disintegrating tablets, or orally dissolving film strip).
DPAC and Anthrax Work Group experts will continue working with federal agencies to ensure the needs of children are considered with regard to medical countermeasures.
For information on anthrax disease (both natural and bioterror), diagnosis, management and reporting, visit the CDC website on anthrax, www.bt.cdc.gov/agent/anthrax.
For more information on the AAP Disaster Preparedness Advisory Council, updates on national and global disasters, and ways to become involved in disaster planning for children, visit www.aap.org/disasters.
Dr. Krug is chair of the AAP Disaster Preparedness Advisory Council. Dr. Bradley is a member of the AAP Anthrax Work Group.