BW Agents: Vaccine, Therapeutics, and Prevention

Appendix D: BW Agents: Vaccine, Therapeutics, and Prophylaxis (Prevention)

Anthrax
Botulism
Brucellosis
Cholera
Glanders
Plague
Q Fever
Ricin
Smallpox
Staphylococcus Enterotoxin B
Tularemia
T-2 Mycotoxins
Viral Encephalitides
Viral Hemorrhagic Fevers

DISEASE VACCINE CHEMOTHERAPY (Rx) CHEMOPRO-
PHYLAXIS (Px) COMMENTS

Anthrax Bioport vaccine (licensed) 0.5 mL SC @ 0, 2, 4 wk, 6, 12, 18 mo then annual boosters Ciprofloxacin 400 mg IV q 8-12 h
OR
Doxycycline 200 mg IV, then 100 mg IV q 8-12 h
Ciprofloxacin 500 mg PO bid x 4 wk If unvaccinated, begin initial doses of vaccine Potential alternates for Rx: gentamicin, erythromycin, and chloramphenicol

- - Penicillin 4 million units IV q 4 h
Doxycycline 100 mg PO bid x 4 wk plus vaccination PCN for sensitive organisms only

Cholera Wyeth-Ayerst Vaccine 2 doses 0.5 mL IM or SC @ 0, 7-30 days, then boosters Q 6 months Oral rehydration therapy during period of high fluid loss N/A Vaccine not recommended for routine protection in endemic areas (50% efficacy, short term)

- - Tetracycline 500 mg q 6 h x 3 d
- Alternates for Rx: erythromycin, trimethoprim and sulfamethoxazole, and furazolidone

- - Doxycycline 300 mg once, or 100 mg q 12 h x 3 d - Quinolones for tetra/doxy resistant strains

- - Ciprofloxacin 500 mg q 12 h x 3 d - -

- - Norfloxacin 400 mg q 12 h x 3 d - -

Q Fever IND 610 - inactivated whole cell vaccine given as single 0.5 ml s.c. injection Tetracycline 500 mg PO q 6 h x 5-7 d continued at least 2 d after afebrite Tetracycline start 8-12 d post-exposure x 5 d Currently testing vaccine to determine the necessity of skin testing prior to use.

- - Doxycycline 100 mg PO q 12 h x 5-7 d continued at least 2 d after afebrite Doxycycline start 8-12 d post-exposure x 5 d -

Glanders No vaccine available Antibiotic regimens vary depending on localization and severity of disease - refer to text Post-exposure prophylaxis may be tried with TMP-SMX No large therapeutic human trials have been conducted owing to the rarity of naturally occurring disease.

Plague Greer inactivated vaccine (FDA licensed) is no longer available Streptomycin 30 mg/kg/d IM in 2 divided doses x 10 - 14 d
OR
Gentamicin 5 mg/kg IM or IV once daily x 10 - 14 d
OR
Ciprofloxacin 400 mg IV q 12 h until clinically improved then 750 mg PO bid for total of 10 - 14 d

Doxycycline 100 mg PO bid x 7 d or duration of exposure

Ciprofloxacin 500 mg PO bid x 7 d
Chloramphenicol for plague meningitis is required 25 mg/kg IV, then 15 mg/kg qid x 14 d

-

.
. Doxycycline 200 mg IV then 100 mg IV bid, until clinically improved then 100 mg PO bid for total of 10-14 d Tetracycline 500 mg PO qid x 7 d Alternate Rx: trimethoprim-
sulfamethoxazole

Brucellosis No human vaccine available Doxycycline 200 mg mg/d PO plus rifampin 600 mg/d PO x 6 wk Doxycycline 200 mg mg/d PO plus rifampin 600 mg/d PO x 6 wk Trimethoprim-
sulfamethoxazole may be substituted for rifampin; however, relapse may reach 30%

. . Ofloxacin 400/rifampin 600 mg/d PO x 6 wks . .

Tularemia IND - Live attenuated vaccine: single 0.1ml dose by scarification Streptomycin 7.5 - 10 mg/kg IM bid x 10 - 14 d Doxycyline 100 mg PO bid x 14 d .

. . Gentamicin 3 - 5 mg/kg/d IV x 10 - 14 d Tetracycline 500 mg PO qid x 14 d
Ciprofloxacin 500 mg PO q 12 h for 14 d

-

.

. . Ciprofloxacin 400 mg IV q 12h until improved, then 500 mg PO q 12 h for total of 10 - 14 d . .

. . Ciprofloxacin 750 mg PO q 12 h for 10 - 14 d . .

Viral
Encephalitides VEE DOD TC-83 live attenuated vaccine (IND): 0.5 mL SC x 1 dose Supportive therapy: analgesics and anticonvulsants prn N/A TC-83 reactogenic in 20%
No seroconversion in 20%
Only effective against subtypes 1A, 1B, and 1C

. VEE DOD TC-84 (formalin inactivated TC-83) (IND): 0.5 mL SC for up to 3 doses . . .

. EEE inactivated (IND): 0.5 mL SC at 0 & 28 d . . .

. WEE inactivated (IND): 0.5 mL SC at 0, 7, & 28 d . . .

Viral Hemorrhagic Fevers AHF Candid #1 vaccine (x-protection for BHF) (IND) Ribavirin (CCHF/Lassa) (IND)
30 mg/kg IV initial dose; then 16 mg/kg IV q 6 h x 4 d; then 8 mg/kg IV q 8 h x 6 d N/A Aggressive supportive care and management of hypotension very important

. RVF inactivated vaccine (IND) Passive antibody for AHF, BHF, Lassa fever, and CCHF . .

Smallpox Wyeth calf lymph vaccinia vaccine (licensed): 1 dose by scarification No current Rx other than supportive; Cidofovir (effective in vitro); animal studies ongoing Vaccinia immune globulin 0.6 mL/kg IM (within 3 d of exposure, best within 24 h) Pre and post exposure vaccination recommended if > 3 years since last vaccine

Botulism DOD pentavalent toxoid for serotypes A - E (IND): 0.5 ml deep SC @ 0, 2 & 12 wk, then yearly boosters DOD heptavalent equine despeciated antitoxin for serotypes A-G (IND): 1 vial (10 mL) IV N/A Skin test for hypersensitivity before equine antitoxin administration

. . CDC trivalent equine antitoxin for serotypes A, B, E (licensed) N/A .

Staphylococcus Enterotoxin B No vaccine available Ventilatory support for inhalation exposure N/A .

Ricin No vaccine available Inhalation: supportive therapy G-I : gastric lavage, superactivated charcoal, cathartics N/A .

T-2 Mycotoxins No vaccine available . Decontamination of clothing and skin .

Source: Blue Books: Free download at http://usamriid.detrick.army.mil under the Education Section reference material. For non-DoD personnel to order USAMRIID's Medical Management of Biological Casualties Handbook - Fourth Edition - February 2001, contact Diane Sexton at DAPS-Aberdeen 410-278-4635, or fax at 410-278-5080, or email dsexton@daps.dla.mil

DISEASE	VACCINE	CHEMOTHERAPY (Rx)	CHEMOPRO- PHYLAXIS (Px)	COMMENTS
Anthrax	Bioport vaccine (licensed) 0.5 mL SC @ 0, 2, 4 wk, 6, 12, 18 mo then annual boosters	Ciprofloxacin 400 mg IV q 8-12 h OR Doxycycline 200 mg IV, then 100 mg IV q 8-12 h	Ciprofloxacin 500 mg PO bid x 4 wk If unvaccinated, begin initial doses of vaccine	Potential alternates for Rx: gentamicin, erythromycin, and chloramphenicol
-	-	Penicillin 4 million units IV q 4 h	Doxycycline 100 mg PO bid x 4 wk plus vaccination	PCN for sensitive organisms only
Cholera	Wyeth-Ayerst Vaccine 2 doses 0.5 mL IM or SC @ 0, 7-30 days, then boosters Q 6 months	Oral rehydration therapy during period of high fluid loss	N/A	Vaccine not recommended for routine protection in endemic areas (50% efficacy, short term)
-	-	Tetracycline 500 mg q 6 h x 3 d	-	Alternates for Rx: erythromycin, trimethoprim and sulfamethoxazole, and furazolidone
-	-	Doxycycline 300 mg once, or 100 mg q 12 h x 3 d	-	Quinolones for tetra/doxy resistant strains
-	-	Ciprofloxacin 500 mg q 12 h x 3 d	-	-
-	-	Norfloxacin 400 mg q 12 h x 3 d	-	-
Q Fever	IND 610 - inactivated whole cell vaccine given as single 0.5 ml s.c. injection	Tetracycline 500 mg PO q 6 h x 5-7 d continued at least 2 d after afebrite	Tetracycline start 8-12 d post-exposure x 5 d	Currently testing vaccine to determine the necessity of skin testing prior to use.
-	-	Doxycycline 100 mg PO q 12 h x 5-7 d continued at least 2 d after afebrite	Doxycycline start 8-12 d post-exposure x 5 d	-
Glanders	No vaccine available	Antibiotic regimens vary depending on localization and severity of disease - refer to text	Post-exposure prophylaxis may be tried with TMP-SMX	No large therapeutic human trials have been conducted owing to the rarity of naturally occurring disease.
Plague	Greer inactivated vaccine (FDA licensed) is no longer available	Streptomycin 30 mg/kg/d IM in 2 divided doses x 10 - 14 d OR Gentamicin 5 mg/kg IM or IV once daily x 10 - 14 d OR Ciprofloxacin 400 mg IV q 12 h until clinically improved then 750 mg PO bid for total of 10 - 14 d	Doxycycline 100 mg PO bid x 7 d or duration of exposure Ciprofloxacin 500 mg PO bid x 7 d	Chloramphenicol for plague meningitis is required 25 mg/kg IV, then 15 mg/kg qid x 14 d
- .	.	Doxycycline 200 mg IV then 100 mg IV bid, until clinically improved then 100 mg PO bid for total of 10-14 d	Tetracycline 500 mg PO qid x 7 d	Alternate Rx: trimethoprim- sulfamethoxazole
Brucellosis	No human vaccine available	Doxycycline 200 mg mg/d PO plus rifampin 600 mg/d PO x 6 wk	Doxycycline 200 mg mg/d PO plus rifampin 600 mg/d PO x 6 wk	Trimethoprim- sulfamethoxazole may be substituted for rifampin; however, relapse may reach 30%
.	.	Ofloxacin 400/rifampin 600 mg/d PO x 6 wks	.	.
Tularemia	IND - Live attenuated vaccine: single 0.1ml dose by scarification	Streptomycin 7.5 - 10 mg/kg IM bid x 10 - 14 d	Doxycyline 100 mg PO bid x 14 d	.
.	.	Gentamicin 3 - 5 mg/kg/d IV x 10 - 14 d	Tetracycline 500 mg PO qid x 14 d Ciprofloxacin 500 mg PO q 12 h for 14 d	- .
.	.	Ciprofloxacin 400 mg IV q 12h until improved, then 500 mg PO q 12 h for total of 10 - 14 d	.	.
.	.	Ciprofloxacin 750 mg PO q 12 h for 10 - 14 d	.	.
Viral Encephalitides	VEE DOD TC-83 live attenuated vaccine (IND): 0.5 mL SC x 1 dose	Supportive therapy: analgesics and anticonvulsants prn	N/A	TC-83 reactogenic in 20% No seroconversion in 20% Only effective against subtypes 1A, 1B, and 1C
.	VEE DOD TC-84 (formalin inactivated TC-83) (IND): 0.5 mL SC for up to 3 doses	.	.	.
.	EEE inactivated (IND): 0.5 mL SC at 0 & 28 d	.	.	.
.	WEE inactivated (IND): 0.5 mL SC at 0, 7, & 28 d	.	.	.
Viral Hemorrhagic Fevers	AHF Candid #1 vaccine (x-protection for BHF) (IND)	Ribavirin (CCHF/Lassa) (IND) 30 mg/kg IV initial dose; then 16 mg/kg IV q 6 h x 4 d; then 8 mg/kg IV q 8 h x 6 d	N/A	Aggressive supportive care and management of hypotension very important
.	RVF inactivated vaccine (IND)	Passive antibody for AHF, BHF, Lassa fever, and CCHF	.	.
Smallpox	Wyeth calf lymph vaccinia vaccine (licensed): 1 dose by scarification	No current Rx other than supportive; Cidofovir (effective in vitro); animal studies ongoing	Vaccinia immune globulin 0.6 mL/kg IM (within 3 d of exposure, best within 24 h)	Pre and post exposure vaccination recommended if > 3 years since last vaccine
Botulism	DOD pentavalent toxoid for serotypes A - E (IND): 0.5 ml deep SC @ 0, 2 & 12 wk, then yearly boosters	DOD heptavalent equine despeciated antitoxin for serotypes A-G (IND): 1 vial (10 mL) IV	N/A	Skin test for hypersensitivity before equine antitoxin administration
.	.	CDC trivalent equine antitoxin for serotypes A, B, E (licensed)	N/A	.
Staphylococcus Enterotoxin B	No vaccine available	Ventilatory support for inhalation exposure	N/A	.
Ricin	No vaccine available	Inhalation: supportive therapy G-I : gastric lavage, superactivated charcoal, cathartics	N/A	.
T-2 Mycotoxins	No vaccine available	.	Decontamination of clothing and skin	.