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Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of:

 availability

 ease of production and dissemination

 potential for high morbidity and mortality rates and major health impact

 emerging infectious diseases such as Nipah virus and hantavirus.

Source: Based on Centers for Disease Control and Prevention. Bioterrorism Agents/Diseases [37].

A vaccine for anthrax is licensed in the United States and is administered in a five‐dose schedule with annual boosters thereafter [40]. A second vaccine is currently in clinical trials. Vaccination is not currently recommended for emergency first responders or medical personnel. However, it may be indicated for certain military personnel, laboratory workers who work with high concentrations of B. anthracis, and people such as farmers, veterinarians, and livestock handlers who might handle infected animals or contaminated animal products.

In cases of deliberate use of anthrax as a biological weapon, first responders should wear full‐face respirators with high efficiency particulate air filters or self‐contained breathing apparatus, gloves, and splash protection. If clothing is contaminated, it should be removed and placed in plastic bags. Soap and copious amounts of water should be used to decontaminate skin, and bleach should be applied for 10‐15 minutes in a one‐to‐ten dilution if there is gross contamination. If exposure to aerosolized anthrax occurs, post‐exposure prophylaxis (PEP) with ciprofloxacin or doxycycline should begin and continue for 60 days. Patients suspected of being infected with anthrax and requiring hospitalization should be immediately started on IV antibiotics [41–43]. Vaccination for PEP should be administered because of the persistence of anthrax spores in the lungs. Three licensed anthrax antitoxins are available from the U.S. Strategic National Stockpile. All work by binding to protective antigen, which blocks movement of toxins into cells and therefore the effects of toxins within the cells. Antitoxin use is indicated in all adults and children for the treatment of inhalation anthrax due to B. anthracis, in combination with other appropriate post‐exposure treatments.

Quarantine is not indicated for individuals exposed to anthrax as they are not contagious. A clinical framework and medical countermeasure is available that outlines an approach to an anthrax mass casualty incident [44].