Journal of Exposure Science and Environmental Epidemiology (2010) 573

Exposure
Science
Digest
Exposure science is now being used for the early diagnosis of
anthrax and to assess the ecacy of medical countermeasures.
Detection and quantication of deadly anthrax toxins are used
to identify exposure to Bacillus anthracis spores and the develop-
ment of clinical anthrax at very early stages of disease. In rabbits
and nonhuman primates, anthrax lethal factor can be detected in
serum or plasma 12 hours after inhalation exposure to B. anthracis
spores, which provides much earlier diagnosis than is possible
with traditional biochemical techniques. Data from human clinical
and animal studies have indicated that anthrax lethal factor levels
in serum and plasma are predictive of the severity of disease and
eectiveness of treatment. Thus, monitoring anthrax toxin levels
is a crucial tool that enables earlier medical treatments and guide
both the course of treatments and the development of new medi-
cal countermeasures. In the case of an anthrax attack by terrorists,
such rapid identication would be invaluable in saving lives by
enabling treatment of immediate contacts and preventing the
spread of this highly infectious agent.
We now have the technology to detect and quantify anthrax
toxin levels. This technology has tremendous promise for
diagnosis at very early stages of disease and monitoring
the efcacy of treatments, including those for disease aris-
ing from anthrax-related terrorist events.
Anthrax: modern exposure
science combats a deadly,
ancient disease
JOHN R. BARR
a
, ANNE E. BOYER
a
AND CONRAD P. QUINN
a
a
US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Address all correspondence to jbarr@cdc.gov
doi:10.1038/jes.2010.49
BACKGROUND
Exposure to the spores of Bacillus anthracis causes the disease
anthrax. Spores gain entry into the host through dermal abrasions,
gastrointestinal lesions, injection (usually in intravenous drug use),
and inhalation, which cause cutaneous, gastrointestinal, injection,
and inhalation anthrax, respectively.
Anthrax is a naturally occurring disease in many parts of the
world, and it remains a bioterrorism threat. Inhalation anthrax has
a mortality rate higher than 90% if untreated and is often deadly
even with antibiotic therapy. During the anthrax-letter attacks
of 2001, mortality was 45%, even with antibiotics and aggres-
sive supportive care (Jernigan et al., 2002). Additionally, there is a
point of no return during anthrax infection after which all tradi-
tional treatments may fail.
The lethal consequences of this disease are caused by the an-
thrax toxins. Lethal toxin inactivates cell components central to
the victims defense against infection. Edema toxin causes mas-
sive uid retention and swelling (edema), as well as depressing
some parts of immune defenses. Both of these toxins also cause
bleeding late in the course of infection.
IMPACT AND IMPLICATIONS FOR EXPOSURE SCIENCE
Diagnosis of anthrax in the early stages of disease is critical for eective treatment and thus to saving lives. Mass spec-
trometric detection and quantication of anthrax toxins are highly selective and rapid diagnostic tools for early disease.
The ability to quantify the toxins provides an additional benet in understanding the course of disease and the ecacy
of treatments and therapies. For the anthrax toxins to be detected early in the disease, they must be quantied at exqui-
sitely low levels. Exposure science techniques have been developed to achieve this (Boyer et al., 2007).
Detection and quantication of the anthrax toxin lethal factor represent a major advancement in the diagnosis of an-
thrax. The anthrax exposure science technology has the following important features:
Detects infection earlier. Monitoring lethal factor detects B. anthracis infection as early as 12 hours after exposure to
anthrax spores and as much as 24 hours earlier than other technologies (Boyer et al., 2009). Anthrax can be detected even
before symptoms such as fever are present.
Shorter time to the first result. Quantitative lethal factor measurements and analyses are completed within 4 hours. By
comparison, traditional biochemical approaches to diagnosis anthrax may take several days to produce denitive results.
Analyzes many more samples per day. The new method to measure lethal factor has been automated and can analyze hun-
dreds to thousands of samples per day. This throughput represents a signicant advancement over previous techniques.
Colored scanning electron micrograph of anthrax bacteria (Bacillus anthracis), the cause
of anthrax in humans and livestock. (From Anthrax: From Lethal Factor to Life Extender,
Annual Report 20012002, Synchrotron Radiation Department: Warrington, UK, 2002.)
574 Journal of Exposure Science and Environmental Epidemiology (2010) 574 Journal of Exposure Science and Environmental Epidemiology (2010)
Tis Exposure Science Digest is sponsored by the International
Society of Exposure Science (www.isesweb.org) in celebration of
its 20th anniversary.
Not subject to antibiotic interference. Quantitative lethal factor monitoring can be used to identify and track infection even
if antibiotic treatment has started, unlike with historical methods, which cannot consistently detect infection in people
undergoing treatment.
Quanties toxin to track course of infection and responses to treatment. Quantication of lethal factor is an excellent measure of
treatment eectiveness by tracking changes in toxin levels. This capability could be helpful in the clinical management of patients
who are not progressing well. For example, such information could help doctors determine whether additional or alternative
therapeutics are necessary.
Monitoring anthrax lethal factor levels in animal and clinical studies has already yielded insights into the course of infection
and responses to treatment. The animal study data show that the progression of infection can occur in three stages, during which
traditional diagnostic tests can be at rst positive but then transiently revert to negative, only to become positive again later in
infection. In contrast to these traditional tests, quantication of anthrax lethal factor is detected throughout all stages of infection
(Boyer et al., 2009). In addition, the animal studies have shown that lethal factor levels may be predictive of the stage or severity of
illness, and they have been used to establish a potential toxin-related point of no return, when mortality is very likely. This would
indicate that additional therapeutics are required to remove high toxin levels from the blood. Quantication of lethal factor levels
on a daily basis during a clinical case would allow physicians to monitor changes and adjust treatment accordingly.
The application of exposure science to detect and quantify anthrax lethal factor levels has recently been used to respond to clini-
cal cases of inhalation (Walsh et al., 2007), cutaneous, injection, and gastrointestinal anthrax. A great deal has been learned about
the course of B. anthracis infection in humans and the ecacy of treatments. The information gained can be used to evaluate
therapeutics and help guide medical intervention. The use of exposure science to detect and quantify toxins produced by human
pathogens can have a major impact on the diagnosis and treatment of an even wider range of infectious diseases.
REFERENCES
Boyer A.E., Quinn C.P., Woolfitt A.R., Pirkle J.L., McWilliams L.G., Stamey K.L. et al. Detection and quantification of anthrax lethal factor in serum by mass spectrometry. Anal Chem
2007: 79: 84638470.
Boyer A.E., Quinn C.P., Hoffmaster A.R., Kozel T.R., Saile E., Marston C.K. et al. Kinetics of lethal factor and poly-D-glutamic acid antigenemia during inhalation anthrax in rhesus
macaques. Infect Immun 2009: 77: 34323241.
Jernigan D.B., Raghunathan P.L., Bell B.P., Brechner R., Bresnitz E.A., Butler J.C. et al. 2002. Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings.
Emerg Infect Dis 2002: 8: 1019-1028
Walsh, J.J., Pesik N., Quinn C.P., Urdaneta V., Dykewicz C.A., Boyer A.E. et al. A case of naturally acquired inhalation anthrax: clinical care and analyses of anti-protective antigen
immunoglobulin G and lethal factor. Clin Infect Dis 2007: 44: 968971.
Disclaimer: The information included in the text of this article is the opinion
of the authors and does not necessarily reect the ocial position of the
Centers for Disease Control and Prevention.