Some members of the orders Bacillales and Clostridiales form dormant spores when subjected to environmental stress. These resistant spores return to normal vegetative growth upon encountering nutrients. A family of membrane-bound proteins called germination (Ger) receptors is tasked with detecting metabolites that serve as germination signals. During the characterization of tripartite Ger receptor proteins from the genera Bacillus and Clostridium, we found numerous nomenclature inconsistencies. In this work, we issued guidelines to remediate this problem. We generated a sample of sequenced Bacillus, Clostridium and related endospore-forming genera. Ger receptor proteins were recovered from these genomes by PSI-BLAST. The resulting Ger receptor protein sequences were then clustered by neighbor-joining based on sequence alignment. Inconsistencies in Ger receptor labeling were noted and new names proposed. Finally, a systematic approach for naming of new Ger receptors was designed.

A panel of 10 physicians used the nominal group technique to assess the ability of the Centers for Disease Control and Prevention (CDC) interim guidelines for clinical evaluation of persons with possible inhalational anthrax (IA) to retrospectively identify the 11 patients with IA seen during the October 2001 bioterrorism outbreak. The guidelines would not have identified 10 of 11 of these patients, primarily because the guidelines were designed to address only those patients with a known history of exposure or clearly identified environmental or occupational risk. The panel suggested revisions to the guidelines, primarily consisting of broadening the criteria for evaluation to include either known exposure or environmental occupational risk, or to include clinical symptoms consistent with IA. These extensions of the guidelines retrospectively identified 8 of 11 of the patients with IA from October 2001.

Despite the apparently low disease rate from exposure, protection for remediation workers at B. anthracis-contaminated sites is warranted because inhalational anthrax is rapidly progressive and highly fatal, PPE does not guarantee 100% protection, and the risk for developing disease cannot be characterized adequately. The guidelines described here go beyond HAZWOPER requirements and include recommendations for treating inhalation exposure to B. anthracis spores as a medical emergency, medical follow-up as long as the risk for anthrax persists or a worker is receiving antibiotic prophylaxis, accommodation of a mobile workforce, and assurance that workers understand the need for immediate medical attention should symptoms of anthrax occur. Completion of the 6-dose series of anthrax vaccine followed by annual booster doses will decrease the reliance on antibiotics for the prevention of anthrax. Measures to protect workers must include both medical measures (i.e., vaccination, antibiotic prophylaxis, or a combination of both) and measures to prevent exposure (e.g., PPE and environmental controls).

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Environmental Sampling. Environmental testing to detect B. anthracis on surfaces or in the air can be used to investigate known or suspected exposure events. The highest priority of an investigation is to evaluate the risk for exposure to aerosolized B. anthracis spores. Persons collecting and testing samples should 1) obtain adequate samples, 2) avoid cross-contamination during processing, and 3) ensure proficient laboratory testing and interpretation of test results. A positive laboratory test for B. anthracis from a sample of an environmental surface may be caused by cross-contamination from an exposure vehicle (e.g., contact with an envelope containing B. anthracis), background occurrence of B. anthracis spores in the environment, or previously aerosolized B. anthracis that has settled onto environmental surfaces. Laboratory test results of environmental surface samples should not be the only criterion for starting, continuing, or stopping antimicrobial prophylaxis for inhalational disease.

Since October 3, 2001, CDC and state and local public health authorities have been investigating cases of bioterrorism-related anthrax. This report updates findings as of October 31, and includes interim guidelines for the clinical evaluation of persons with possible anthrax. A total of 21 cases (16 confirmed and five suspected) of bioterrorism-related anthrax have been reported among persons who worked in the District of Columbia, Florida, New Jersey, and New York City (Figure 1). Until the source of these intentional exposures is eliminated, clinicians and laboratorians should be alert for clinical evidence of Bacillus anthracis infection. Epidemiologic investigation of these cases and surveillance to detect new cases of bioterrorism-associated anthrax continues.

Since October 3, 2001, CDC and state and local public health authorities have been investigating cases of bioterrorism-related anthrax. This report updates previous findings, provides new information on case investigations in two additional areas, presents the susceptibility patterns of Bacillus anthracis isolates, and provides interim recommendations for managing potential threats and exposures and for treating anthrax.