Screening for Inhalational Anthrax Due to Bioterrorism: Evaluating Proposed Screening Protocols

4 patients (0.4%; 95% CI, 0.1%–0.9%) and generated charges of $1900. If 29 patients (2.6%; 95% CI, 1.7%–3.7%) with 5 symptoms (but without fever and tachycardia) were screened, charges were $13,325. The Hupert criteria [2] would have screened 273 patients (24%; 95% CI, 22%–27%) and generated charges of $126,025. In this outbreak of bioterrorism-related IA, applying the Mayer criteria would have identified both patients with IA and would have generated fewer charges than applying the Hupert criteria. Eleven known cases of bioterrorism-related inhalational anthrax (IA) were treated in the United States during October and November 2001. After its analysis of 10 of these cases, the Centers for Disease Control and Prevention (CDC) issued diagnostic criteria for evaluating persons with possible IA [3]. The CDC criteria suggested that both a documented history of environmental or occupational exposure and clinical signs and symptoms of the disease were required for screening and treatment. Mayer et al. [1] retrospectively analyzed the 11 known cases of bioterrorism-related IA and applied the CDC criteria in an effort to determine whether these criteria would identify patients with IA. This analysis revealed that the CDC criteria would have selected 1 of the 11 anthrax cases for further diagnostic study or treatment. The CDC diagnostic criteria were revised to include a history of either environmental or occupational exposure and the presence of 5 symptoms of the disease, plus fever and tachycardia (figure 1). These revised criteria would have selected 8 of the 11 anthrax cases for screening and treatment. Hupert et al. [2] proposed a screening protocol entitled