Dr. Thomas Inglesby of Johns Hopkins University and colleagues in the Working Group on Civilian Biodefense wrote that anthrax, one of numerous biological agents that could be used as weapons, could cripple a city or region. They cite a 1993 report that estimated the aerosolized release of 100 kilograms of anthrax spore upwind of Washington, D.C., could kill 130,000 to 3 million people -- matching or exceeding the lethal effects of a hydrogen bomb.

According to the report, anthrax is odorless, invisible and could travel miles through the air. They say the first evidence of an anthrax attack could be "the sudden appearance of a large number of patients in a city or region with an acute-onset, flu-like illness and case fatality rates of 80 percent or more, with nearly half of all deaths occurring within 24 to 48 hours."

Naturally occurring anthrax is a bacteria that infects animals. Livestock are usually vaccinated against the disease. The more usual ways humans become infected include handling material from infected animals and inhaling anthrax spores from infected animal materials. Human cases of anthrax are extremely rare in the United States.

If recognized in the initial stages of infection, anthrax is easily controlled with antibiotics. However, the initial symptoms, which include fever, difficulty breathing, shortness of breath, coughing, headache, vomiting, chills, weakness, abdominal pain and chest pain, are difficult to distinguish from a number of illnesses.

In the event of a bioterrorist attack with anthrax, the Working Group on Civilian Biodefense recommended:

• The first suspicion of anthrax infection must lead to immediate notification of the local or state health department, local hospital epidemiologist and local or state health laboratory.
• Vaccination of some essential service personnel should be considered if vaccine becomes available. If vaccines were readily available, post-exposure vaccination after an attack in combination with antibiotics would be recommended for those exposed.
• Early antibiotic therapy is essential after exposure to anthrax. A delay even by hours could substantially lessen chances for survival. Given the difficulty in achieving rapid diagnosis, all persons with fever or evidence of systemic disease in an area where anthrax cases are occurring should be treated for anthrax.
• Standard barrier isolation precautions are recommended for hospitalized patients with anthrax infection. Proper burial or cremation of humans and animals who have died because of anthrax infection is important. Serious consideration should be given to cremation.
• Anyone who comes into direct contact with any substance that could be anthrax should thoroughly wash any exposed skin or clothing with soap and water and should receive antibiotics until the substance is proved not to be anthrax.

"Most experts concur that the manufacture of a lethal anthrax aerosol is beyond the capacity of individuals or groups without access to advanced biotechnology," the authors wrote. "However, autonomous groups with substantial funding and contacts may be able to acquire the required materials for a successful attack," the report concluded.

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