The NYC Subway: Plague & Anthrax, but not Urine, Free

I often tell people that bacteria are everywhere, because they are. They lurk in almost every niche of the planet, including all the niches in and on our bodies. Some are found in more abundance in certain environments such as fresh water, salt water, on reptiles, in the soil, etc. 

So, when a study reported all the myriad microbes found in the NYC subway, I wasn't surprised as it as a perfect Petri dish for many different microbes because many people traverse it, it is littered with discarded food and often has puddles of liquid (which could be rain water on a good day, urine or some other substance on a bad day). Plus, rodents abound. 

The controversial part of the study, which detailed many different microbes being present, was the researchers detection of the bacteria that cause plague and anthrax in the subway. Such a finding immediately grabbed headlines. I also didn't find this to be too surprising because it is well known that both Bacillus anthracis and Yersinia pestis are widely distributed in the enviroment--though Y.pestis tends to stay west of the "plague line".  

The study was back in the headlines earlier this week when the research time clarified their findings, which now exclude the detection of the plague and anthrax bacilli in the subway. 

I would caution people--and rats--to not breath too deep a sigh of relief in the subway as, though not at risk for plague or anthrax, the smell of urine might do you in. 

Anthrax Guest Starring on House of Cards

On one of the episodes in the 2nd season of House of Cards there is a white powder incident at the US Capital, causing a lockdown. In the episode, the lockdown lasts for hours while the powder is tested and ultimately revealed to be a mixture containing flour (wheat) and talcum powder. It was stated that pesticide on the wheat caused a false positive on initial tests, requiring the longer lock down of the area while confirmatory tests were performed.. There were several references to anthrax, which was actually released from an envelope in the Capital in 2001, in the dialogue. 

White powder incidents abounded after the events of 2001 and still continue to this day--witness the Super Bowl's corn starch incident. What is often overlooked is the amount of law enforcement, public health, and clinical resources that are absorbed--and diverted from other functions--in the response to these incidents. Much like a bomb threat, a white powder incident can't be ignored as both anthrax and ricin have been sent in the mail. 



Treating Anthrax in 2014

It's been almost 13 years since the anthrax attacks of 2001 and, not suprisingly, medical care has advanced during that time. Accordingly, the CDC has released new guidelines for the treatment of anthrax. 

Several important highlights include:

  • Attention to the coagulation defects that occur with anthrax with the goal of keeping fibrinogen levels above 100 and avoiding pharmacological thromboprophylaxis
  • Emphasis on the drainage of pleural effusions--a procedure linked to improved outcome
  • Carryover of the recommendation for 60 days of post-exposure prophylaxis
  • Delineation of anthrax with possible meningitis from anthrax without possible meningitis
    • In cases where meningitis is a possibility the recommendation to use 3 drugs with high CNS penetration, 1 of which should be a protein synthesis inhibitor (ciprofloxacin, meropenem, and linezolid)
    • In cases where meningitis has been ruled out the recommendation to use 2 drugs, 1 of which should be a protein synthesis inhibitor (ciprofloxacin + linezolid)
  • Use of an anti-toxin therapy such as raxibacumab (or anthrax immune globulin--not FDA approved)

Overall, the guidelines are highly evidence-based and consistent with standard infectious disease and critical care practice. Hopefully, when followed the 45% mortality rate experienced in 2001 would be significantly diminished (in the cases that have occurred in the US since 2001, no patient has died).