Should public safety workers be offered anthrax vaccine?

Consensus statement questioned by some

Scholars at the Institute for Biosecurity at the Saint Louis University School of Public Health are circulating a consensus statement calling for anthrax vaccine to be offered to civilian emergency responders and critical infrastructure workers.

"I strongly feel if one believes that the use of a biological agent is possible, and there is even some probability that it will occur, it is irresponsible for leadership not to offer vaccine protection for the first responder community," says William S. Stanhope, MA, PA associate director for special projects at the biosecurity institute. "The current policies have federal law enforcement agencies protect their workers but they do not afford the same degree of protection to the non-federal response community. It is discriminatory."

Regarding the charge of discrimination, the Food and Drug Administration states on its web site that "because of biological warfare threats, the military has had an active vaccination program against anthrax." It is unclear which federal officials are immunized, but the FDA officially recommends anthrax vaccine "for individuals who may come in contact with animal products that may be contaminated with Bacillus anthracis spores and for individuals engaged in diagnostic or investigational activities, which may bring them in contact with Bacillus anthracis spores. It is also recommended for persons at high risk, such as veterinarians and others handling potentially infected animals."

The St. Louis University consensus statement reads:

"Recognizing the reality of documented attempts of radical terrorist groups to develop and deploy anthrax as a weapon of terror, the undersigned are unanimous in their belief that the 'civilian' Emergency Responder and Critical Infrastructure workforce should be offered the same level of prospective protection afforded to their federal counterparts. We urge the Department of Health and Human Services, the CDC Advisory Committee on Immunization Practices, and the Department of Homeland Security to immediately clear all barriers to the funding, acquisition, and delivery of Anthrax Vaccine Adsorbed [AVA] to the Emergency Responder/Critical Infrastructure workforce on a voluntary basis.

Moreover, we believe that AVA availability should be prioritized to the Emergency Responder/Critical Infrastructure workforce in the UASI [Urban Area Security Initiative] cities and any other communities known or self-assessed to be at high risk for future terrorist attacks. Further recognizing the difficulties encountered during previous smallpox vaccination efforts, we strongly recommend that a reasoned, rational, and realistic education program be developed reflective of the threat and relative risk of another bioterrorist attack using B. anthracis. That education program should include a careful delineation of the efficacy and safety of AVA, the FDA-approved indications, and a discussion of the relative risks and benefits of voluntary immunization with AVA vs. relying on a post-exposure strategy that depends on antibiotics."

In addition to Stanhope, the statement is signed by the St. Louis institute's director R. Gregory Evans, PhD, MPH as well as several public safety officials representing police and fire departments.

No need, no demand?

However, the need for the vaccine and any widespread support for its use were openly questioned by an infection control consultant who works with the public safety community. "I lecture all across the country and I have not heard this issue — the need for this — voiced by anybody," says Katherine West, BSN, MSEd, CIC, an infection control consultant with Infection Control/Emerging Concepts in Manassas, VA.

People exposed to anthrax can be effectively treated with antibiotics within five days of the exposure in most cases, she reminds. "They're leaving out the whole issue of an incubation period," she says. "The reality is that someone in a mall [will be exposed] and they're going to be diagnosed later at a hospital or a private doctor's office. Then [the attack] will be put together, but there is not going to be a massive EMS response."

Indeed, an indoor exposure could play out in such a fashion, but there likely will be many public safety people already on duty at a prime target such as a presidential debate, Stanhope says. "There will be an ample number of people from the law enforcement and public safety sector likely to be on site where the indoor release occurs," he says. "If you take a presidential debate like we had in St. Louis, for example, I can assure you that proportionally there were a lot more people from the public safety community of greater St. Louis physically present inside the auditorium than there were people from the presidential candidate protection details, the [Secret Service] and the FBI."

Those federal officials are immunized for anthrax, but exposed public safety workers would be left to scramble for treatment in the aftermath, he emphasizes. "My concern is that we are not affording protection to the non-federal, non-military people that we are putting in harm's way in these various indoor venues," Stanhope says.

Indoor release of anthrax is one of the most likely scenarios for a bioterrorism incident because it is relatively easy to manufacture in small quantities, he says. "It is our belief that any young person coming out of a graduate program in the biological sciences at any of the major universities today has the capacity to produce some quantity of anthrax — to isolate it from the soil," he says. "I can think of a dozen places I could go right now to get anthrax. We think that not only can they isolate it, but they can propagate it in a clandestine 'kitchen' laboratory and make an agent. "

Such anthrax will not be of cold-war bioweapons caliber, nor would it likely be produced in sufficient quantity to attempt an outdoor attack, he adds. "That's not efficient unless you have pounds of dry agent," he says. "But if you use a relatively small quantity of agent in a carefully contrived indoor release you can end up with an inhaled dose hundreds of times an [infectious] dose."

The vaccine should be made available to public safety workers on a strictly voluntary basis and not offered with any coercion or pressure, he adds. Still, West argues that since the vaccine is approved for such a narrow group of people, public safety officials that take it will essentially have to "sign their legal rights away" regarding adverse effects. On the other hand, flu vaccine is a recommended approach to emergency planning for public safety workers to better identify and rule out biological agents. The anthrax vaccine also is contraindicated for the immune-compromised, pregnant women, and those who are breast feeding, she adds.