By Valerie R. Johnson, MPH, CHES, and Dana Meaney-Delman, MD, MPH
National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention
Bacillus anthracis, the type of bacteria that causes anthrax, is one of the most likely agents to be used in a biological attack. If such an incident were to happen in the United States, state public health officials at all government levels would need to respond quickly. To help protect the health of pregnant and postpartum women, public health officials need to be aware of the unique challenges that would arise for this population during an anthrax incident:
- Antibiotics and vaccine must be given to everyone who has been exposed in order to prevent anthrax disease. All pregnant women (regardless of trimester) as well as postpartum and lactating women should receive a 60-day course of oral antibiotics as soon as possible and three doses of anthrax vaccine at zero, two, and four weeks postexposure. Antibiotic dosing is the same for pregnant, postpartum and lactating women as for nonpregnant adults. Ciprofloxacin is the preferred antimicrobial, and Amoxicillin may be used for susceptible strains.
- Pregnant and postpartum women experience normal physiologic changes that may make it more challenging to diagnose anthrax. Vitals signs (e.g., respiratory and heart rate) and laboratory values (e.g., white blood cell count) may differ during pregnancy. In addition, abnormal laboratory values and clinical findings observed in anthrax can mimic those of common obstetrical conditions, such as preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, fatty liver of pregnancy, and thrombotic thrombocytopenia purpura. Pregnancy complications such as preterm labor, fetal distress, or fetal loss may be observed and may be the first signs of anthrax infection or may indicate worsening health status. Therefore, the inclusion of epidemiologic and laboratory information, when available, and assessment of clinical signs are imperative when evaluating these patients.
- Inhalation anthrax can be deadly if it is not treated promptly with the correct antibiotics. Pregnant, postpartum and lactating women diagnosed with anthrax should receive a combination of intravenous antibiotics to treat anthrax. Because of concerns for transplacental transmission of anthrax in pregnant women, at least one of these intravenous antibiotics should cross the placenta. Antitoxin use would not differ from that for nonpregnant adults, and antitoxin dosing for infected pregnant, postpartum, and lactating women is the same as for nonpregnant adults.
- Critical and supportive care is important to meet the medical needs of mothers and their unborn babies. Pregnant women with anthrax should be hospitalized and might require obstetric monitoring. Given the severity of the infection, hospitals caring for these women must be equipped for possible emergency deliveries.
To help state health departments and other partners prepare for these challenges, CDC experts in anthrax and emergency preparedness developed resources that you can use in your pre-event planning and during an actual event. For example:
- Medscape CDC Expert Commentaries that provide a concise overview of treatment and post-exposure prophylaxis for adults (www.medscape.com/viewarticle/825411) as well as specific guidance for pregnant and postpartum women (www.medscape.com/viewarticle/825380).
- A communications toolkit that provides health departments with strategies for delivering effective messages during an anthrax emergency.
During an event
- Just-in-time training for clinicians, with special guidance for preventing, diagnosing and treating anthrax in pregnant and postpartum women.
- A text messaging program that states could use to provide critical messages to pregnant and postpartum women during an anthrax emergency: reminders to take their antibiotics or get their next shot of vaccine, ways they can text back to indicate if they are experiencing any side effects, and advice to help them recognize the symptoms of anthrax. These messages are free and will be available to health departments.
- An emergency CDC website that would be used only if an anthrax emergency occurred. The site includes critical information for people in and near the affected areas, including guidance for pregnant and postpartum women.
- Print materials and pictograms that health departments could use during an anthrax emergency to convey critical life-saving information to pregnant and postpartum women. These materials are available in English and Spanish and were tested with audiences, including English speakers with limited literacy. They will be available free of charge to health departments on a secure site managed by the CDC Strategic National Stockpile.
Public health officials have learned a lot from recent public health emergencies that can help us prepare for future events. These past events make a strong case for why we need to plan ways to protect pregnant and postpartum women during an anthrax incident. For a complete list of CDC prevention and treatment recommendations following exposure to anthrax, please visit the following websites: