Antimicrobics and Infectious Disease
Newsletter (Elsevier Science) 2000
ANTHRAX VACCINE:
CONTROVERSY OVER SAFETY AND EFFICACY
Garth L. Nicolson
The Institute for Molecular Medicine, Huntington Beach, CA 92649
Meryl Nass
Parkview Hospital, Brunswick, ME 04011
Nancy L. Nicolson
The Institute for Molecular Medicine, Huntington Beach, CA 92649
In 1999 2.4 million U.S. Armed Forces personnel, including more
than one million reserve and National Guard members, were ordered
to receive anthrax vaccine over a period of several years. This
was justified to counter an increasing threat from hostile countries
and possibly terrorist groups that now or in the future will likely
possess the capability of fielding weaponized anthrax spores as
a Biological Weapon (BW). This decision has resulted in courts-martial
and disciplinary hearings among U.S. Armed Forces personnel who
have refused the anthrax vaccine on safety grounds. Are these
individuals overreacting to misperceived risks from the anthrax
vaccine that the military considers safe, or are there real safety
concerns that should be considered?
Bacillus anthracis as a BW Agent
Bacillus anthracis is a relatively common spore-forming soil bacterium
found rarely in the U.S. but more commonly in some areas of the
world as an endogenous infectious agent. Bacillus anthracis infection
can cause death within six days of exposure to a lethal dose,
usually by inhalation of spores. To be effective as a BW agent
a microorganism must be highly infectious, very pathogenic and
stable in the air and environment for the period of time needed
for dissemination and infection of large numbers of people. Spore-forming
bacteria like Bacillus anthracis are ideal for this purpose. Spores
are relatively inactive metabolically and are much more resistant
to sunlight, heat, dryness and chemicals than the replicating
microorganism. ‘Weaponized’ versions of anthrax spores
are more pathogenic and survive better than spores from native
strains of Bacillus anthracis. It is estimated that as few as
50,000 weaponized anthrax spores can kill a human after inhalation
and fewer can kill small primates.
Although weaponized anthrax spores are probably the most easily
manufactured BW weapon, they are only one of dozens of lethal
and incapacitating (causing nonlethal sicknesses) BW agents that
have been produced in large quantities suitable for BW deployment
and tactical use. Bacillus anthracis is also one of the few BW
agents for which a vaccine exists that is capable of preventing
some (but not all) lethal infections. Although dozens of additional
microbial candidates for BW have been produced in various quantities
by several countries, such as bacteria (Clostridium botulinum,
Brucella melitensis, Yersinia pestis, Clostridium perfringens,
Bacillus cereus, Francisella tularensis, Coxiella burnetii, among
others), toxins (ricin, aflatoxin, Clostridium botulinum toxin,
Staphylococcal enterotoxin B toxin, tricothecene mycotoxins, etc.),
viruses (Ebola, West Nile fever, Marburg, small pox, etc.) and
miscellaneous BW (rickettsias, mycoplasmas, fungi, etc.), weaponized
Bacillus anthracis is considered one of the greatest threats because
of the ease of its production, storage and dissemination (spores)
as a lethal BW agent.
There are basically three methods to counter anthrax BW: active
immunization, passive immunization and prophylactic antibiotics.
Antibiotics have to be administered shortly before or after exposure,
otherwise they won’t be effective, and they cannot prevent
a lethal infection once the Bacillus anthracis has produced signs
of illness. Passive immunoprophylaxis requires quantities of immune
sera or monoclonal antibodies not currently available, and their
administration in a monitored, hospital setting. Active immunity
using vaccines on the other hand can be administered years before
exposure as long as immunity is maintained. Thus vaccines can
be effective as long as there is enough immunity to neutralize
the Bacillus anthracis before it starts rapidly replicating en
masse from its inactive spore form and producing lethal toxins.
From a practical standpoint, only antibiotics and vaccines can
protect the large numbers of people who could be exposed in a
BW attack, and antibiotics are more effective when the BW agent(s)
and its(their) antibiotic sensitivity are identified so the appropriate
antibiotic(s) can be used.
Are anthrax vaccines then a reliable method of protecting against
Bacillus anthracis BW? Not necessarily. Although vaccines can
protect against accidental exposure of relatively small doses
of anthrax spores that infect skin wounds, such as encountered
occasionally in meat processing, it remains unproven whether anthrax
vaccines will actually protect against a lethal aerosol dose of
inhaled anthrax spores of the weaponized variety that are used
as BW agents. This is especially true if mixtures of BW agents
are used instead of single BW agents.
The Anthrax Vaccine: Safety Concerns
The anthrax vaccine in use remains unproven in its ability to
stop a lethal dose of weaponized Bacillus anthracis spores, and
there are questions about its safety. According to the U.S. Army
Medical Research Institute for Infectious Disease (USAMRIID) at
Fort Detrick, MD, the anthrax vaccine used by the military was
determined to be safe, and adverse reactions were found to occur
only at the rate of one per 50,000 doses (less than 0.002%). This
has now been revised to a rate of 0.02-0.2% or higher. Moreover,
in recent testimony by one of us [M.N.] to the National Academy
of Sciences the safety of the anthrax vaccine and the rates of
adverse reactions were questioned. Using Dover AFB as an example,
the rate of chronic health problems after receiving the anthrax
vaccine may be as high as 7%. The difference is that the official
rates are for acute reactions only. The Department of Defense
(DoD) claims that the rate for vaccine chronic reactions is zero.
A major part of the problem in assessing vaccine safety is in
how vaccine adverse effects are reported. Many people who suffer
from adverse anthrax vaccine effects are reluctant to step forward
to seek medical care, because they have seen their colleagues'
concerns dismissed as due to depression or stress. They also fear
that they could lose their ability to perform their duties, as
a number of the pilots and airmen at Dover AFB are now on DNIF
(duties not including flying) status because of undiagnosed illnesses
that began after they received their anthrax vaccinations. Lt.
Colonel Randy Randolf, director of the U.S. Army’s vaccination
program, counters that all vaccines, the anthrax vaccine included,
can produce adverse effects, such as soreness, redness, itching,
swelling, and lumps at the injection site. He has stated that
about 30% of men and 60% of women report these local reactions,
but they usually last only a short time. Lt. Col. Randolf further
describes that beyond the injection site, from 5% up to 35% of
people have noticed muscle aches, joint aches, headaches, rash,
chills, fever, nausea, loss of appetite, malaise, or related symptoms.
It is commonly thought that these symptoms go away after a few
days, and apparently there has been no completed studies of long-term
side effects of anthrax vaccine using active surveilance. Although
the DoD began such a study at Tripler Army Medical Center, Honolulu
in September, 1998, they have yet to release any preliminary data
on long-term problems that developed after anthrax vaccination.
The difference between what military and civilian physicians conclude
about adverse reactions and the anthrax vaccine seems to be based
on whether you accept that vaccines can cause chronic illnesses
beyond the initial reporting period of vaccine adverse effects.
The high incidence of unusual chronic health problems at Dover
AFB include systemic signs and symptoms, such as vomiting, diarrhea,
polyarthralgias, fever, splenic tenderness, cognitive problems,
polymyalgias, weakness and numbness, and these problems can occur
well after the usual reporting period for vaccine adverse effects.
Patients with preexisting autoimmune illnesses such as rheumatoid
arthritis, lupus, multiple sclerosis, among others, are probably
more likely to suffer a serious adverse reaction, as are those
with neurologic disease, such as those who had polio in childhood.
Stevens Johnson Syndrome, a severe allergic reaction in which
there is loss of epidermis (skin) and the lining of the GI tract,
was found in some patients as well as more classic allergic signs
and symptoms. Even more serious, many anthrax vaccine recipients
report seizures with complete loss of consciousness. Respiratory
distress and a variety of pulmonary illnesses have also been reported.
Because these types of reactions have rarely been identified with
other vaccines and because few of those reporting illness have
been subjected to an exhaustive medical evaluation, including
sophisticated immunological testing, the mechanisms by which anthrax
vaccine may be causing illnesses have not been elucidated. Furthermore,
the entire stockpile of anthrax vaccine is owned by the DoD, and
none has yet been made available for thorough, independent testing.
The Anthrax Vaccine: Source
One of the most difficult problems in dealing with anthrax vaccine
safety is obtaining specific information on the anthrax vaccine
and how it was determined to be safe. Most military vaccines in
the U.S. are from ‘sole-source’ manufacturers. In the
case of FDA-approved vaccines, a number of strict production and
safety requirements must be fulfilled, and evidence for effectiveness
in humans must be presented to the FDA before approval for production
and sale is granted. However, in the case of the anthrax vaccine
there seem to be missing elements in this safety net.
The sole producer of the anthrax vaccine was originally Michigan
Biologic Products, Inc., a state-owned corporation that obtained
U.S. Government approval for the anthrax vaccine at a time when
FDA approval was not required. The anthrax vaccine was approved
by the Bureau of Biologics at NIH in 1970, two years before efficacy
data and approval were required by the FDA. In the case of the
anthrax vaccine, long-term safety data were not supplied with
the license application, and none has yet been supplied to the
FDA. As it turns out, the Bacillus anthracis vaccine now being
produced may be different or the procedure for vaccine preparation
modified from the original vaccine approved by NIH. The usual
requirement is that any new product or modification in preparation
must be examined and approved by the FDA, but the FDA has apparently
not examined or approved every modification made to the current
vaccine for anthrax.
The original license and the facility producing the anthrax vaccine
was owned by Michigan Biologic Products, Inc. of the Michigan
State Department of Health. The new owner of both is a company
called Bioport, Inc., owned by a group of investors lead by Admiral
William Crowe, Jr., former head of the Joint Chiefs of Staff,
DoD, and Faud El-Hibri, a German citizen of Lebanese descent who
has since obtained American citizenship. The facility was sold
to Admiral Crowe’s investor group after the DoD decided to
vaccinate all of its servicemen and servicewomen against anthrax.
Recently Bioport ran into financial problems and negotiated a
series of changes in its DoD contract that increases by three-fold
the per dose price of the anthrax vaccine supplied to the military.
This and other problems have resulted in a congressional investigation
into the financial relationship between DoD and the new owners
of Bioport, which may constitute a conflict of interest.
The Anthrax Vaccine: Safety
Problems with the anthrax vaccine have raised questions about
previous vaccine programs. The former commander of the USAMRIID,
Dr. Phillip Russell, admitted in an infectious disease journal
(Infectious Disease Clinics of North America, 1990) that unlicensed
anthrax vaccines were used on Armed Forces personnel before the
Gulf War. There is, of course, no record of safety available for
unlicensed vaccines. In fact, there were no published studies
of safety or efficacy for the current anthrax vaccine until very
recently, well after the decision was made to vaccinate. A recent
brief publication from the USAMRIID in JAMA provides some safety
information about the anthrax vaccine, but it refers to previously
unpublished data that are not available for evaluation.
The normal procedure for post-marketing vaccine evaluation requires
that the FDA must review adverse vaccine reactions collected through
the Vaccine Adverse Event Reporting System (VAERS). Adverse events
are usually recorded independently by a FDA-approved contractor.
The contractor then sends their data to the FDA, and the FDA assembles
a committee that then evaluates adverse events for the likelihood
that the vaccine might have caused them, and it can recommend
further study. However, in the case of the anthrax vaccine, military
physicians were instructed that only certain adverse effects could
be vaccine reactions, such as classic immediate allergic reactions,
and others, such as joint pain, cognitive disturbances, etc. could
not be due to the vaccine. Physicians treating these patients
had no access to published data on anthrax vaccine side effects,
and there is no entry for anthrax vaccine in the Physicians Desk
Reference (PDR). The package insert for the vaccine is based on
data collected from an earlier anthrax vaccine, and it does not
list the range of possible reactions that could occur. Thus until
recently none of the long-term chronic effects of the vaccine
were even reported by medical providers. In the case of the anthrax
vaccine, only reactions that resulted in hospitalization or immediate
loss of 24 hours of duty time were reported to a military clearing-house
for vaccine reactions. This has changed recently, and it appears
now that other adverse vaccine effects will be entered in the
medical records of patients, but whether they are always reported
remains questionable. We feel strongly that traditional and accepted
means of FDA vaccine evaluation must be implemented for military
vaccines, just as they are required for commercial vaccines. Only
then can the safety of the anthrax vaccine be evaluated. The anthrax
vaccine should be treated just like any other commercial vaccine
and not
given special waivers or treatment in the evaluation process.
Only then will the public be satisfied that the current anthrax
vaccine is safe.
The Anthrax Vaccine: Quality
For years Michigan Biologic Products Inc. had been warned by the
FDA of intent to revoke their license to produce vaccines because
of violations in the production and testing of their vaccines.
As recently as 1997, MBPI received formal written notification
from the FDA that they had not complied with FDA-mandated requirements.
However, since MBPI was the only manufacturer of anthrax vaccine,
they were given a waiver and allowed to remain open, pending FDA
compliance. During this time vaccine lots were distributed to
the military. In 1998 some of these vaccine lots were retested,
and only 6 out of 31 lots passed initial supplemental testing.
Most of the retested vaccine lots had expired or had been redated
for an additional 3-year period once or even twice. This is obviously
unacceptable.
The question has been raised whether expired or failed vaccine
lots were used for vaccinating military personnel during the Gulf
War. Since supplemental testing on anthrax vaccines used in the
Gulf War was not undertaken, and some of these lots apparently
also had previously expired and had been redated, some personnel
could have received out-of-date vaccines, or worse, contaminated
vaccines. Information is not available on whether U.S. Forces
received contaminated vaccines (no such testing has been made
public), but the British Gulf War veterans report that several
vaccine lots from the Gulf War were reported to be contaminated
with “unknown microorganisms.” Thus some of the health
problems associated with the anthrax vaccine could be related
to possible vaccine contamination.
Vaccines and the Gulf War
Before military personnel were deployed to the Persian Gulf Theater
of Operations, they had to pass physical examinations and be fit
for active duty. After passing their physical exams, they received
several types of vaccinations, mostly with commercially available
vaccines. In the Persian Gulf area this was usually done by administering
as many as two dozen vaccine doses over a period of a few days,
even if the vaccines were normally required to be given over a
course of several months to over a year. In contrast to previous
wars, service personnel were not allowed to keep a record of these
vaccinations, and according to the DoD the shot records of hundreds
of thousands of deployed personnel have since disappeared. Some
health personnel administering the vaccines were also warned that
they would be courts-martialed if they kept any record of vaccines
given to military personnel. According to nurses that took part
in the vaccination program, many soldiers became sick after the
vaccines were given, but few were allowed to report the adverse
effects of the vaccines, unless they were hospitalized. Most had
to return to active duty, even if they suffered adverse effects
directly attributable to the vaccines. The records of these adverse
effects are for the most part also missing.
The problem with administering multiple vaccines all at once is
that this can result in immune-depression and leave individuals
susceptible to opportunistic infections, such as the types that
the vaccines were supposed to protect against. To be effective,
the vaccines used in the Gulf War should have been given in several
steps, the initial vaccination followed by several boosters given
over months to over a year to maximize immunity. If given all
at once, these vaccines are more likely to cause adverse reactions
and produce diminished immunity be useless in protecting an individual,
and they may even make the vaccinated person more susceptible
to opportunistic infections due to immune-suppression.
Gulf War Illnesses and Vaccines
Between 100,000-200,000 veterans of the Persian Gulf War in 1991
now have Gulf War Illnesses (GWI), which are characterized by
complex, multi-organ chronic signs and symptoms. These include
chronic fatigue, headaches cognitive problems, nausea, gastrointestinal
problems, vomiting, diarrhea, polyarthralgias, fever, splenic
tenderness, polymyalgias, among other signs and symptoms. Often
these patients show the appearance of rheumatic and other autoimmune
signs and symptoms. The signs and symptoms of GWI overlap with
Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME),
and often they meet the criteria for the diagnosis of CFS/ME or
Fibromyalgia syndrome (FMS) where the distinguishing feature is
the presence of chronic widespread muscle pain and tenderness.
Often included in this complex clinical picture are increased
sensitivities to various environmental agents and enhanced allergic
responses. There are other clinical problems in these patients,
including impaired cardiac function, increases in spontaneous
abortions and other chronic signs. The signs and symptoms reported
by many anthrax vaccine recipients also overlap with GWI.
In some cases GWI has spread to immediate family members. Although
incomplete, a 1994 report by investigators of a U.S. Senate committee
found after contacting approximately 1,200 GWI families that ~77%
of spouses and ~65% of children born after the war developed the
chronic signs and symptoms of GWI. Although officially denied
by the U.S. DoD and British Ministry of Defence, this indicates
that at least a subset of GWI patients have a illness that is
being passed to spouses and children. Since some of the GWI patients
have an illness that is transmissible to family members and perhaps
others as well, these GWI cases cannot be explained solely on
the basis of chemical or radiological exposures, or the even more
unlikely cause of battlefield stress leading to Post Traumatic
Stress Disorder.
Although stress can induce some illness, the General Accounting
Office (GAO), the investigational arm of the U.S. Congress, after
studying government and civilian data on GWI, concluded that the
link between stress and GWI was not established. Of course, stress
can exacerbate chronic illness but most military personnel indicated
to us that the Gulf War was not a particularly stressful war,
and they strongly doubted that stress was the origin of their
illnesses. However, in the absence of physical or laboratory tests
that could identify possible origins of GWI, many physicians accepted
that stress was the cause of GWI or that it was caused by combinations
of chemical exposure and stress. A recent psychiatric study indicates
that patients with GWI do not fit the classical picture of stress
related illness.
If stress is added to multiple vaccines given at once, plus chemical
and other toxic exposures encountered during the Gulf War, then
immune suppression and opportunistic infections could be a likely
outcome in at least a subset of the military personnel that subsequently
came down with GWI. This would also explain in some cases the
apparent transmission of illness to immediate family members and
the occurrence of GWI in some vaccinated forces that were not
deployed.
Vaccine Contamination and Gulf War
Illnesses
Testing of commercial vaccine lots demonstrates that contamination
can and does occur. A common vaccine contaminant is Mycoplasma
species of the class Molecutes, small cell wall-deficient bacteria
lacking many of the genes involved in macromolecular and lipid
synthesis. Although not widely appreciated for their ability to
cause disease, mycoplasmas have been implicated in a variety of
chronic illnesses, including CFS/ME, FMS, Rheumatoid Arthritis
and GWI. When we examined thousands of GWI patients for evidence
of blood mycoplasmal infections, we found evidence of mycoplasmas
in about one-half of GWI cases, and in particular, one species
of mycoplasma, Mycoplasma fermentans, was found at high incidence.
M. fermentans has been examined over the last decade or so by
the Armed Forces Institute of Pathology for its role in causing
a progressive, non-HIV AIDS-like fatal disease that has many of
the hallmarks of GWI.
Mycoplasmas like M. fermentans could be involved in the transmission
of GWI to immediate family members. When symptomatic family members
of veterans with GWI were tested for the presence of mycoplasmal
infections in their blood, they were found to have the same species
of mycoplasma as found in the sick veteran family member. In addition,
most of these patients responded to the appropriate antibiotics
and eventually recovered, albeit slowly, from their illness, similar
to what we have seen in CFS/ME, FMS and Rheumatoid Arthritis patients
with mycoplasmal infections. When recovered patients were retested
for mycoplasmal blood infections, they were no longer positive
for Mycoplasma species in their blood samples. This suggests that
mycoplasmal infections could be causing at least some if not most
of the signs and symptoms of GWI found in these patients, and
these infections can be passed to family members who then develop
similar illnesses.
What remains to be determined is whether the vaccines used in
the Gulf War were the source of the mycoplasmas found in veterans’
blood. A study reporting the presence of antibodies to an unlicensed
vaccine adjuvant in over 90% of the GWI patients evaluated has
just been published. This strongly suggests that experimental
vaccines were used in the Gulf War. Experimental vaccines are
unapproved vaccines without available safety and efficacy data.
Although listed as our number one possible source of the infections
found in GWI patients, vaccines are not the only possible source
of microorganisms from the Gulf War. In our sworn testimony to
the U.S. Congress [G.L.N., N.L.N.] we stated that there were several
potential sources of chronic biological agents in the Gulf War.
The Iraqis were known to have extensive stockpiles of BW agents
and the potential to deliver these weapons offensively, at short
range in modified Italian-made biological sprayers that deliver
BW agents onto the sand to create exclusionary zones or 'biological
minefields' and at long range in modified SCUD-B (SS-1) missiles
with 'airburst' warheads or sprayers carried by aircraft. Many
of the storage and factory facilities where BW agents were stored
were destroyed immediately up to, during and after the Desert
Storm ground offensive, releasing plumes containing these agents
high in the atmosphere where they could be carried downwind ('blow-back'
exposures) to our lines. These and other possible mechanisms of
potential exposure must be carefully examined as well as the possible
role of mycoplasmas and other chronic infections in GWI patients.
War, Terrorism and BW Attacks
If BW agents are ever deployed in war or terrorist attacks, many
times the lethal (human) dose could be encountered in an aerosolized
BW and chemical mixture that is designed to inhibit and overwhelm
the body’s defensive abilities. These mixtures, called ‘Russian
Doll Cocktails,’ contain microorganisms plus immune inhibitors
and other chemicals to impede the immune system’s ability
to contain the infection by blocking pulmonary defenses. The pulmonary
immune system, particularly the pulmonary macrophage, is the first
level of defense against inhaled foreign microorganisms and its
suppression could result in systemic infection. BW use on the
battlefield of the future will likely involve multiple BW agents,
not just one or even a few agents. Countries like Iraq operate
under ‘Soviet War Doctrine,’ a battle strategy that
stresses combinations of conventional and unconventional weapons.
Thus combinations of multiple BW, CW (Chemical Warfare) or even
NW (Nuclear Warfare) agents may be used together to heighten BW
virulence and confuse the diagnosis and treatment of casualties.
The rationale is to overwhelm a medical corps’ ability to
effectively manage large numbers of casualties with unknown or
incomplete diagnoses. Iraqi Field Manuals found during the Gulf
War described this strategy in detail. Unfortunately, BW can be
developed and produced at a fraction of the cost of other weapons
of mass destruction, making it likely that future terrorists will
choose BW agents over other weapons for terrorist attacks.
The U.S. military’s strategy of defense against BW agents
is prior immunization using multiple vaccines. Unfortunately,
this can only be successful if the exact BW agents likely to be
encountered are known in great detail and for some time in advance
of exposure. For example, the vaccine against Bacillus anthracis
requires a rather lengthy immunization protocol, administering
multiple vaccine and booster doses over more than a year. If multiple
vaccines were to be administered, then they would have to be administered
at different times to prevent immune suppression or excessive
stimulation. Obviously, this strategy requires advance knowledge
of the threat and careful long-term preparation against the threat.
To prepare for any new threat that arises will require some time,
possibly years or over a decade. Recent reports have appeared
indicating that the Russians have developed anthrax strains for
which it is claimed protective vaccines do not exist. What is
the evidence that our ‘multivalent’ Bacillus anthracis
vaccine will protect against all known anthrax strains?
Protection against BW Attacks
Other strategies besides the vaccine approach to BW defense are
available. During the Gulf War the French forces elected not to
use vaccines as a primary defense against Iraqi BW and not to
use anti-nerve agents as a defense against Iraqi Chemical Warfare
agents. Instead, they used prophylactic antibiotics to counter
Iraqi BW agents, and they depended on protective suits to counter
Iraqi chemicals. Interestingly, the French Armed Forces were the
only nation in the Coalition Forces that did not report any cases
of GWI, nor were there any illnesses reported in the immediate
families of French Gulf War veterans.
What assurances do we have that future vaccines will be free of
microbial contamination that could cause disease? Obviously, the
purity and safety of vaccines depend on their ability to remain
free of contamination by microorganisms. FDA-mandated vaccine
preparation methods are generally considered adequate to prevent
this possibility, but unless each ‘batch’ or lot of
vaccine is routinely tested for possible contamination, including
animal testing, this remains a possibility that must be carefully
examined, not uncritically dismissed by untrained bureaucrats
as a remote hypothetical possibility.
If prophylactic antibiotic or antiviral agents are used for BW
defense, can these be defeated? Yes, BW agents can be modified
or ‘constructed’ that have integrated into their genomes
antibiotic- or antiviral-resistance genes. Similar to the ‘engineering’
of more lethal BW agents to circumvent known vaccines, such microorganisms
can be ‘engineered’ to resist specific antibiotic or
antiviral agents. Interestingly, certain U.S. units were issued
antibiotics like ciprofloxacin and doxycycline just before the
ground offensive in the Gulf War. These antibiotics would be expected
to be effective in preventing infections of at least two of the
agents identified in veterans with Gulf War Illness (Mycoplasma
fermentans and Brucella spp.). Examination of the numbers, deployments
and types of casualties and their diagnoses in the units administered
antibiotics before and during the Gulf War could tell us if the
French approach to BW defense was more or less effective than
our approach of administering multiple vaccines to prevent BW
casualties.
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