21 Anticipating anthrax and other bioterrorism threats

Vibhuti Arya, PharmD, MPH

Kristin Bohnenberger, PharmD, DABAT

Tamara Foreman, PharmD

MaRanda Herring, PharmD, BCACP

Sheila Seed, PharmD, MPH, CTH®, RPh

Trang Trinh, PharmD, MPH, BCPS, BCIDP, AAHIVP

Trina von Waldner, PharmD

Topic Area

Emergency preparedness/infectious disease

Learning Objectives

At the end of this case, students will be able to:

  • Identify the clinical criteria for an inhalation anthrax diagnosis
  • Recommend an appropriate medication for post-exposure prophylaxis of anthrax
  • Describe the role of a pharmacist during a bioterrorist attack


Since the terrorist attacks of September 11, 2001, the US has been on high alert.1-3 The anthrax exposures that followed shortly thereafter amplified the public cognizance that biological weapons remain a potential threat associated with terrorism.1,3 Bioterrorism, the use of biological agents as a method of terrorism, may include agents such as anthrax, plague, smallpox, viral hemorrhagic fevers, or non-replicating agents such as toxins produced by living organisms.1 A likely scenario for a biologic attack is via the dispersal of a pathogen in a densely populated area.1 For this reason, it is imperative that health systems develop a disaster management team that they can quickly deploy in the event of a mass casualty event.

The role of the pharmacist in disaster management was first described in the 1960s.2 Pharmacists were acknowledged as medication experts, capable of assisting in the emergent treatment of patients, educating the public, and developing and coordinating emergency preparedness measures.2 In 1966, APhA advocated for the development of a national stockpile of medications and for disaster management plans to include plans for the preparation and mobilization of pharmacy activities throughout all phases of public health emergencies.2 It was not until after the 2001 attacks that APhA released formal guidelines to address pharmacist involvement in bioterrorism preparedness planning.

These guidelines called for pharmacies to develop their own disaster management plans and to identify team members who should deploy in the event of a public health emergency. Furthermore, they emphasized the need for pharmacists to stay up to date on these procedures.2 The following year, ASHP’s statement describing health system pharmacists’ role in counterterrorism measures emphasized that pharmacists are capable of not only medication dispensation but making therapy recommendations as well.4 The guidelines stated that as medication experts, pharmacists can help optimize therapy as well as limit the overuse of antibiotics in a setting when the demand often exceeds the available supply.4 During the 2001 anthrax exposures, the prescribing rate for ciprofloxacin and doxycycline far exceeded recommendations of the CDC.5 In a bioterrorism event, delayed treatment, selection of incorrect antibiotics, and the overuse of antibiotics can increase resistance.3 This further highlights the importance of incorporating pharmacists as members of disaster response teams.

The role of the pharmacist in disaster preparedness has further evolved since these early recommendations.2,5 Pharmacists have also been incorporated into teams intended to protect their fellow healthcare workers at the front lines of mass casualty events. For example, at Maimonides Medical Center, pharmacists are members of both the hospital’s incident command center and the pharmacy emergency response team (PERT). The PERT was developed with the goal of protecting the health of hospital staff and preventing the contamination of the healthcare facility.2 Similarly, pharmacists at Montefiore Medical Center participated in a point-of-distribution exercise in conjunction with the New York City Department of Health and Mental Hygiene to simulate the mass prophylaxis of healthcare workers in the event of a public health emergency.5 This exercise demonstrated that allowing pharmacists to immunize in a simulated public health emergency afforded approximately 12,000 healthcare workers the opportunity to receive prophylaxis within a 48 hour period.5 Pharmacists have the potential to reduce the financial impact of bioterrorist attacks on both the healthcare facility and the surrounding community.5



You are a pharmacist in an urban emergency department (ED).

CC: “I feel like I can’t breathe.”

HPI: PD is a 32-year-old white male (82 kg) who presents to the ED (along with his wife) in severe respiratory distress. For the past 24 to 48 hours, PD’s wife states he had a fever of 102.50F, non-productive cough, shortness of breath, chest pain, and fatigue. His wife denies other respiratory symptoms. He has no other neurological symptoms. He first started to experience respiratory symptoms about two days after attending a professional hockey game.

PMI: Seasonal allergies (spring)

SH: PD works full time at a mail distribution center, is married with one child (five years old), and lives in an urban city with medical insurance and full access to healthcare services. He reports drinking one to two alcoholic drinks per week (beer/wine with dinner) and two cups of coffee per day, but denies any tobacco and illicit drug use.

Allergies: NKDA


  • Loratadine 10 mg by mouth daily PRN seasonal allergies


  • Wife believes he received all routine childhood vaccines, Tdap booster 2 years ago, and is up to date on his annual flu vaccine (receives flu vaccine every year)


  • General: Well-nourished male in apparent respiratory distress
  • Chest: Rhonchi present
  • CV: No murmurs, gallops or rubs
  • Abdomen: NT/ND
  • Skin: WNL


  • BP 112/60 mmHg
  • RR 22 / min
  • HR 110 bpm
  • Temperature 102.5 0F

Labs and Imaging:

  • Chest x-ray: pleural effusion
  • Chest CT: mediastinal widening, pleural effusions with pericardial effusion
  • Lumbar puncture: negative
  • Gram stain (sputum): gram-positive rods, square-ended, in pairs
  • Sputum specimen sent to a Laboratory Response Network (LRN)

Additional context: Over the next several days, there are increasing numbers of patients complaining of similar symptoms seen at other hospitals throughout the area. The ED has reported ten other admissions with similar symptoms. PD sputum sample came back as culture confirmed detection of B. anthracis by LRN-validated polymerase chain reaction. The state department of public health has identified several other cases in two other hospitals in the state. The Incident Command Center is activated and the state requests Strategic National Stockpile (SNS) activation for mass prophylaxis.

Case Questions

1. During public health outbreaks, epidemiologists must have a working case definition to identify probable and confirmed cases. What clinical signs and laboratory criteria confirm a diagnosis of inhalation anthrax?

2. Which antibiotics are approved for post-exposure prophylaxis for those exposed to B. anthracis?

3. What type of inventory can the SNS supply? How long will take from the initial notification to when points of distribution (PODs) will receive SNS assets?

4. What methods are used to educate the public? Who can dispense these medications?

5. Who can dispense post-exposure prophylaxis antibiotics?

6. What are the considerations for pediatric dispensing?

Author Commentary

Pharmacists remain the most accessible healthcare member in the community. As medication experts, pharmacists are well-positioned to respond to bioterrorism threats. This role has evolved through the decades from public education and medication dispensing to formal training of pharmacists as volunteers, such as members of the Medical Reserve Corps. Following the September 11, 2001, terrorist attacks, thousands of ciprofloxacin and other antimicrobials were prescribed to postal workers, public health officials, and congressional staff members for potential anthrax exposure.Furthermore, the public was needlessly ordering ciprofloxacin from the internet and stockpiling it for future use without fully understanding the rare but serious adverse effects from unnecessary antibiotic exposure. This prompted the FDA to issue warnings to online vendors to prevent illicit drug sales.7

This scenario applies to bioterrorism threats beyond anthrax. Pharmacists can assist public health organizations and responders by administering vaccines, dispensing emergency medications on a mass scale and in a timely manner, providing emergency refills of chronic medications, counseling patients on appropriate antibiotic use and adverse effects, establishing community pharmacies as a point of dispensing (POD), and ensuring adequate medication supplies are available for the response.

Patient Approaches and Opportunities

The International Federation of Red Cross and Red Crescent Societies define disaster as “a sudden, calamitous event that seriously disrupts the functioning of a community or society, causing human, material, and economic or environmental loses that exceed the community’s or society’s ability to cope using its own resources.”8 Community resilience is the ability of a community to effectively utilize its own resources to respond to and recover from such a disaster.9 Pharmacists are essential in community resilience, and the degree to which pharmacists are prepared for a bioterror or pandemic event may have a significant impact on a community’s ability to respond and recover.

Patients may develop strong, trusting relationships with their pharmacists over a lifetime and may be more willing to share concerns and seek information from, or believe information provided by their pharmacists than from news outlets and public health agencies. In this way, pharmacists may mitigate community panic that can lead to drug hoarding, inappropriate medication use and abuse, and dissemination of inappropriate or inaccurate information. Pharmacists are also essential public health partners in infectious disease surveillance. Because social, economic, and cultural factors influence patients’ health-seeking behaviors, in communities where patients are less likely to seek care from a primary care provider, pharmacists may be the first health care practitioners to recognize the emergence of pandemic disease.

Overarching strategies for managing a bioterrorist attack can be applied to the management of pandemic influenza or other emerging, highly contagious, high mortality infectious disease. During a declared disaster or public health emergency such as a bioterror attack or pandemic event, a temporary, legal change may be made to a state’s pharmacy practice act. A state, county, or community-wide standing-order or collaborative practice agreement may be prepared expanding the pharmacist’s scope of practice. This can include diagnosis, assessment, and prescribing of medications specific to the bioterror or pandemic event. Such methods may allow pharmacists to immunize pediatric patients when the health-care system is strained.

Community pharmacies can develop formal, working-relationships with public health agencies before disaster strikes and may develop a memorandum of understanding (MOU), a formal, written agreement that defines the roles of all parties in advance. The Association of State and Territorial Health Officials (ASTHO) has partnered with the National Association of Chain Drug Stores (NACDS), the National Alliance of State Pharmacy Associations (NASPA), the CDC, and APhA to develop a toolkit. This toolkit will help public health agencies and community pharmacies develop a MOU that could “leverage all potential partners’ strengths and promote synergies that can be useful for additional services, beyond immunizations.”10 An MOU will allow pharmacies to coordinate and collaborate with public health agencies by becoming the POD for their neighborhood. In turn, community pharmacies benefit by receiving early allocation of federal vaccines and antibiotic supplies as needed.

Community pharmacies need to have a plan in place should disaster strike. To support public health, during a bioterror or pandemic event, community pharmacies should consider extending working hours and employing temporary pharmacies in quarantine or refugee areas.

Important Resources

Related chapters of interest:



  1. Anderson P, Bokor G. Bioterrorism: pathogens as weapons. J Pharm Pract. 2012;25(5):521-9.
  2. Cohen V. Organization of a health-system pharmacy team to respond to episodes of terrorism. Am J Health Syst Pharm. 2003;60(12):1257-63.
  3. Setlak P. Bioterrorism preparedness and response: emerging role for health-system pharmacists. Am J Health Syst Pharm. 2004;61(11):1167-75.
  4. American Society of Health-System Pharmacists. ASHP statement on the role of health-system pharmacists in counterterrorism. Am J Health Syst Pharm. 2002;59(3):282-3.
  5. Veltri K, Yaghdjian V, Morgan-Joseph T, et al. Hospital emergency preparedness: push-POD operation and pharmacists as immunizaers. J Am Pharm Assoc. 2012;52:81-85.
  6. M’ikanatha NM, Julian KG, Kunselman AR et al. Patients’ request for and emergency physicians’ prescription of antimicrobial prophylaxis for anthrax during the 2001 bioterrorism-related outbreak. BMC Public Health. 2005;5(2).
  7. FDA issues cyber-letters to web sites selling unapproved foreign ciprofloxacin. (2001, November 1). Retrieved from https://www.fda.gov/Drugs/EmergencyPreparedness/BioterrorismandDrugPreparedness/ucm133772.htm.
  8. What is a disaster? (n.d.) Retrieved from https://www.ifrc.org/en/what-we-do/disaster-management/about-disasters/what-is-a-disaster/.
  9. Patel SS, Rogers MB, Amlôt R, Rubin GJ. What Do We Mean by ‘Community Resilience’? A Systematic Literature Review of How It Is Defined in the Literature. PLoS Curr. 2017;9: ecurrents.dis.db775aff25efc5ac4f0660ad9c9f7db2.
  10. Memorandum of understanding toolkit for public health agencies and pharmacies: Guidance and templates for state and territorial health agencies to establish a memorandum of understanding with pharmacies to support a coordinated response to influenza pandemics and other vaccine-related emergencies. (Aug 2018). Retrieved from http://www.astho.org/Programs/Infectious-Disease/Pandemic-Influenza/MOU-Toolkit-for-Public-Health-and-Pharmacies/

Glossary and Abbreviations


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Public Health in Pharmacy Practice: A Casebook Copyright © by Jordan R Covvey, Vibhuti Arya, Natalie DiPietro Mager, Neyda Gilman, MaRanda Herring, Stephanie Lukas, Leslie Ochs, and Lindsay Waddington is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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