Vaccines, therapeutics, and prophylaxis for selected biological warfare agents

OB/GYN News, Nov 15, 2001

DISEASE         VACCINE

Anthrax         BioPort vaccine (licensed): 0.5 mL
                given subcutaneously at 0, 2, and 4
                wk and 6, 12, and 18 mo, then
                annual boosters




Botulism        Department of Defense pentavalent
                toxoid vaccine for serotypes A-E
                (IND): 0.5 mL by deep
                subcutaneous injection at 0, 2, and
                12 wk, then annual boosters

Brucellosis     No human vaccine available




Cholera         Wyeth-Ayerst vaccine: two doses of
                0.5 mL each, given IM or
                subcutaneously at 0 and 7-30 days,
                then boosters every 6 months






Plague          Greer inactivated vaccine (licensed)
                is no longer available









Q fever         Investigational new drug (IND) 610:
                inactivated whole-cell vaccine given
                as single 0.5-mL subcutaneous
                injection



Smallpox        Wyeth calf lymph vaccinia vaccine
                (licensed): single dose by
                scarification

Tularemia       ND, live attenuated vaccine: single
                0.1-mL dose given by scarification








Viral           Venezuelan equine encephalitis TC-
encephalitides  83 live attenuated vaccine (IND):
                single 0.5-mL subcutaneous dose;
                Venezuelan equine encephalitis C-
                84 vaccine (formalin-inactivated TC-
                83, ND): up to three 0.5-mL doses
                given subcutaneously; Eastern equine
                encephalitis inactivated vaccine (IND):
                0.5 mL given subcutaneously at 0 and
                28 days; Western equine encephalitis
                inactivated vaccine (IND): 0.5 mL given
                subcutaneously at 0, 7, and 28 days

Viral           Argentine hemorrhagic fever Candid
hemorrhagic     No. 1 vaccine (cross-protection for
fevers          Bolivian hemorrhagic fever) (IND);
                Rift Valley fever inactivated vaccine
                (IND)




DISEASE         CHEMOPROPHYLAXIS

Anthrax         Oral ciprofloxacin 500 mg b.i.d. for
                4 wk; if unvaccinated, begin initial
                doses of vaccine OR
                Oral doxycycline 100 mg b.i.d. for
                4 wk plus vaccination
                In the absence of vaccine, continue
                chemoprophylaxis for at least 60 days.

Botulism        NA





Brucellosis     Oral doxycycline 200 mg/day plus
                oral rifampin 600 mg/day for 6 wk



Cholera         NA









Plague          Oral doxycycline 100 mg b.i.d. for
                7 days or duration of exposure OR
                Oral ciprofloxacin 500 mg b.i.d. for
                7 days OR
                Oral tetracycline 500 mg q.i.d. for
                7 days





Q fever         Oral tetracycline 500 mg q.i.d. for
                5 days (start 8-12 days after
                exposure) OR
                Oral doxycycline 100 mg b.i.d. for
                5 days (start 8-12 days after
                exposure)

Smallpox        IM vaccinia immune globulin 0.6
                mL/kg within 3 days of exposure;
                best within 24 hr

Tularemia       Oral doxycycline 100 mg b.i.d. for
                14 days OR
                Oral tetracycline 500 mg q.i.d. for
                14 days OR
                Oral ciprofloxacin 500 mg every 12
                hr for 14 days




Viral           NA
encephalitides











Viral           NA
hemorrhagic
fevers






DISEASE         CHEMOTHERAPY

Anthrax         IV ciprofloxacin 400 mg every 12 hr
                OR
                IV doxycycline 200 mg initially, then
                100 mg every 12 hr OR
                IV penicillin 4 million units every 4 hr



Botulism        Department of Defense heptavalent
                equine despeciated antitoxin for
                serotypes A-G (IND): one vial (10 mL)
                IV; CDC trivalent equine antitoxin for
                serotypes A, B, E (licensed)

Brucellosis     Oral doxycycline 200 mg/day plus
                oral rifampin 600 mg/day for 6 wk OR
                Oral ofloxacin 400 mg/day plus oral
                rifampin 600 mg/day for 6 wk

Cholera         Oral rehydration therapy plus:
                Tetracycline 500 mg every 6 hr for 3
                days OR
                Doxycycline 300 mg once or 100 mg
                every 12 hr for 3 days OR
                Ciprofloxacin 500 mg every 12 hr for
                3 days OR
                Norfloxacin 400 mg every 12 hr for 3
                days

Plague          IM streptomycin 30 mg/kg per day in
                two divided doses for 10-14 days OR
                IM or IV gentamicin 5 mg/kg once
                daily for 10-14 days OR
                IV ciprofloxacin 400 mg every 12 hr until
                clinically improved, then 750 mg orally
                b.i.d. for a total of 10-14 days OR
                IV doxycycline 200 mg, then 100 mg
                b.i.d. until clinically improved, then 100
                mg orally b.i.d. for a total of 10-14 days

Q fever         Oral tetracycline 500 mg every 6 hr
                for 5-7 days, continued for at least 2
                days after patient is afebrile OR
                Oral doxycycline 100 mg every 12 hr
                for 5-7 days, continued for at least 2
                days after patient is afebrile

Smallpox        No current treatment other than
                supportive care; cidofovir effective in
                vitro; animal studies ongoing

Tularemia       IM streptomycin 7.5-10 mg/kg b.i.d.
                for 10-14 days OR
                IV gentamicin 3-5 mg/kg per day for
                10-14 days OR
                IV ciprofloxacin 400 mg every 12 hr
                until improved, then 500 mg orally
                every 12 hr for a total of 10-14 days
                OR Oral ciprofloxacin 750 mg every
                12 hr for 10-14 days

Viral           Supportive therapy: analgesics and
encephalitides  anticonvulsants as needed











Viral           IV ribavirin (Crimean-Congo
hemorrhagic     hemorrhagic fever/Lassa fever) (IND):
fevers          30 mg/kg initial dose, then 16 mg/kg
                every 6 hr for 4 days, then 8 mg/kg
                every 8 hr for 6 days; passive antibody
                for Argentine hemorrhagic fever,
                Bolivian hemorrhagic fever, Lassa fever,
                and Crimean-Congo hemorrhagic fever

DISEASE         COMMENTS

Anthrax         Potential drug alternatives:
                gentamicin, erythromycin, and
                chloramphenicol.
                Use penicillin for sensitive
                organisms only.



Botulism        Perform skin test for
                hypersensitivity before
                administering equine antitoxin.



Brucellosis     Trimethoprim-sulfamethoxazole
                may be substituted for rifampin;
                however, relapse may reach 30%.


Cholera         Vaccine not recommended for
                routine protection in endemic
                areas (50% efficacy, short-term
                protection).
                Drug alternatives: erythromycin,
                trimethoprim-sulfamethoxazole,
                and furazolidone.
                Use quinolones for tetracycline/
                doxycycline-resistant strains.

Plague          No large therapeutic human trials
                have been conducted owing to the
                rarity of naturally occurring disease.
                IV chloramphenicol for plague
                meningitis is required: 25 mg/kg
                initially, then 15 mg/kg q.i.d. for
                14 days.
                Drug alternative: trimethoprim-
                sulfamethoxazole.


Q fever         Currently testing vaccine to
                determine the necessity of skin
                testing prior to use.




Smallpox        Preexposure and postexposure
                vaccination recommended if >3
                years since last vaccine.

Tularemia









Viral           TC-83 is reactogenic in 20%; no
encephalitides  seroconversion seen in 20%; only
                effective against subtypes 1A, 1B,
                and 1C.
                C-84 vaccine used in
                nonresponders to TC-83 vaccine.
                Eastern equine encephalitis and
                Western equine encephalitis
                inactivated vaccines are poorly
                immunogenic. Multiple
                immunizations are required.


Viral           Aggressive supportive care and
hemorrhagic     management of hypotension are
fevers          very important.