Report from AAP, CDC offers guidance on managing children after anthrax attack
- Copyright © 2014 by the American Academy of Pediatrics
Bacillus anthracis spores can be used as a biological weapon, causing rapidly progressive infections with a high mortality rate. If such a bioterror incident occurs, pediatricians will be called on to quickly diagnose and treat children with suspected anthrax disease.
The Academy, in collaboration with the Centers for Disease Control and Prevention (CDC), has released a new clinical report that provides recommendations for the prophylaxis and treatment of neonates, infants, children, adolescents and young adults in the event of a deliberate B. anthracis release. The report, Pediatric Anthrax Clinical Management (Pediatrics 2014;133:e1411-e1436OpenUrl), also offers guidance in areas where the unique characteristics of children dictate clinical recommendations that differ from those for adults.
Anthrax is a zoonotic disease that can progress rapidly to systemic disease. Clinical descriptions of various manifestations of the infection (cutaneous anthrax, inhalation anthrax, gastrointestinal anthrax and hemorrhagic meningoencephalitis) are presented in the clinical report. Guidance on which diagnostic specimens to obtain for the different clinical presentations of anthrax is available at www.cdc.gov/anthrax/labs/recommended_specimen.html.
Treatment will vary by clinical manifestation. Easy-to-follow tables in the report outline antimicrobial agent selection and dosing for each of these clinical entities. A table is included for dosing in neonates.
The clinical report also discusses use of investigational Anthrax Immune Globulin as well as a Food and Drug Administration (FDA)-approved monoclonal antibody antitoxin, raxibacumab, as treatment options. They can be used selectively in children with systemic disease (pediatric dosing recommendations are provided). Use of corticosteroids also may be warranted for certain children.
Role of public health, pediatricians
If a bioterror incident involving anthrax occurs, public health authorities will communicate details to health care providers and the public on the CDC website, www.cdc.gov/anthrax. The Academy also will provide information.
Within 48 hours of the first known exposure, authorities will provide a 10-day course of antimicrobial prophylaxis with doxycycline and/or ciprofloxacin to the population likely to have been exposed, including children of all ages. This could be a difficult but feasible task if large numbers of people are exposed.
Shortly following this antimicrobial distribution, public health officials will identify individuals, including children, who had a significant anthrax spore exposure and would require an additional 50 days of antimicrobial post-exposure prophylaxis, as well as a three-dose series of anthrax vaccine (anthrax vaccine adsorbed [AVA], BioThrax) series. Routine immunizations for children should be delayed until four weeks after the last AVA dose.
The FDA has not yet approved AVA for use in children. Therefore, informed consent is required to receive the vaccine. Federal agencies are collaborating on ways to streamline the consent process in a public health emergency.
Public health officials will provide the antimicrobials and vaccine from the Strategic National Stockpile. Dispensing sites will be staffed by public health professionals and community volunteers.
Pediatricians will be a vital resource during a bioterror incident, as they are the trusted source of information for many parents. They will be called on to communicate with parents, schools and child care centers about infections, which left untreated are almost always fatal. The medical home can support adherence to prophylactic antimicrobial regimens, decrease panic among parents and caregivers, and possibly save lives in the midst of a public health emergency.
An executive summary of the clinical report, including links to appendices with treatment information, is available at http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2014-0564.
More information on anthrax is available in the AAP News article, “AAP calls attention to unique needs of children in anthrax attack,” at http://aapnews.aappublications.org/content/33/1/28.full.
The AAP Pediatric Preparedness Resource Kit, www.aap.org/disasters/resourcekit, provides information on how pediatricians and public health officials can prepare at the state and community levels to address children’s needs during disasters such as a bioterrorism incident.
For more information on the Strategic National Stockpile, visit www.cdc.gov/phpr/stockpile/stockpile.htm.
Dr. Bradley, Dr. Peacock and Dr. Krug are lead authors on the clinical report.