Sidel article on anthrax vaccination

[Guest guest]

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[The Anthrax Dilemma, by Victor W. Sidel, MD, Meryl Nass, MD, Tod

Ensign, JD, LLM]

" The potential risks to inoculated military personnel are still largely

unknown... There is no reported experience with its use on a scale

comparable to the inoculation of 2.4 million people. "

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Abstract

In December 1997 the Pentagon announced that all 2.4

million active duty military personnel and reservists

would be inoculated with a vaccine against anthrax, a

potential biological weapon. This program is

questionable because of unknown efficacy of the vaccine,

unknown risks to those who will be inoculated; coercion

in the inoculation effort; and other ethical and policy

reasons. New strains of anthrax may have been developed

specifically to defeat the current vaccine. Previous

immunization programs conducted by the Pentagon have

been open to criticism. Researchers unaffiliated with

the Pentagon should conduct further studies on the

vaccine, and civilian public health agencies, including

the Centers for Disease Control and Prevention and the

National Institutes of Health should participate in

design, testing, implementation, and oversight. A more

effective way to deal with the threat of biological

weapons is for the US to dismantle its nuclear

capability, thereby removing an important incentive for

other countries to develop alternative weapons of mass

destruction. [M & GS 1998;5:97-104]

1

In October 1996 the Washington Post carried a front-page story about a

plan

being formulated by US military leaders to inoculate all members of the

US

armed forces with anthrax vaccine. The plan was developed, it was

reported,

because of the perceived risk of attack on US troops by weapons

containing

anthrax spores. In December 1997, despite public controversy about the

inoculation program, the Pentagon announced that all 2.4 million active

duty

military personnel and reservists would be inoculated [1]. One of the

first

to be publicly inoculated was the Secretary of Defense, Cohen.

Anthrax is a highly virulent disease of animals, especially ruminants,

caused by Bacillus anthracis. When transmitted to humans, usually by

contact

with infected animals or their products, the disease can take one of

three

forms. Cutaneous anthrax, which has in the past been quite common among

certain occupational groups such as farmers, wool-handlers and tanners,

causes severe skin ulcerations and may be accompanied by myalgia, fever

and

vomiting. It is treatable by penicillin and other commonly-available

antibiotics and is virtually never fatal if treated. Gastrointestinal

anthrax is caused by ingestion of contaminated meat. It is now quite

rare,

but sporadic outbreaks have occurred in areas where the disease is

endemic.

Human infection occurs when a break in the pharyngeal or intestinal

mucosa

permits invasion of the intestinal wall; hemorrhagic necrosis and

septicemia

with a high mortality rate may follow.

Inhalation anthrax, due to inhalation of anthrax spores, causes

infection of

the mediastinal lymph nodes with spread to the adjacent mediastinal

structures. Pulmonary edema and pleural effusion with severe respiratory

distress may develop, followed by cyanosis, shock, and coma. Even with

intensive treatment, the outcome is usually fatal. Aerosol inhalation

appears to be the pathway for human exposure preferred by those planning

to

use anthrax as a biologic weapon.

Anthrax has long been considered a potential biologic weapon because

anthrax

spores remain infectious under a wide range of adverse conditions. The

Japanese biologic warfare effort in Manchuria in the 1930s, the infamous

Unit 731, developed weapons containing anthrax spores [2]. The United

States

and Britain stockpiled anthrax spores for use as biologic weapons during

World War II and tested them on Gruinard Island off the coast of

Scotland.

The island remained off-limits to humans for 45 years after the test and

remained so until formaldehyde treatment was used to decontaminate the

soil.

An anthrax epizootic in Zimbabwe in the late 1970s may have been caused

by

deliberate spread [3]. Anthrax spores are believed to have been

stockpiled

by Iraq and perhaps by other nations as well, although it is not clear

whether these organisms were weaponized.

The vaccine that the Pentagon is using is produced by one supplier, the

Michigan Biologic Products Institute (MBPI) operated by Michigan’s

Department of Health under contract to the Department of Defense. The

vaccine was first developed during the 1950s, was reformulated in the

1960s,

and was approved by the US Food and Drug Administration (FDA) for

general

use in 1970. It has been given to about 3,000 veterinarians, people who

work

with livestock or animal products, special ops troops, those involved

with

vaccine manufacture, and anthrax researchers. The vaccine regimen

recommended for military personnel includes a series of six

inoculations.

The first three are given two weeks apart, followed by inoculations at

six

months, 12 months, and 18 months. A yearly booster inoculation is also

recommended.

This program appears to many observers to be questionable because of the

unknown efficacy of the vaccine for the purpose for which it is being

used,

the unknown risks of the vaccine to the personnel who will be

inoculated,

the coercion being used in the inoculation effort, and a number of other

ethical and policy reasons.

Efficacy

There is no good reason to believe that the MBPI vaccine will be

effective

in protecting troops against airborne infection with anthrax, the

pathway

that would most likely be used by biologic weapons. The only published

human

efficacy trial of an earlier anthrax vaccine was a study in the late

1950s

and early 1960s in a mill that processed raw imported goat hair

contaminated

with Bacillus anthracis and in which clinical anthrax infections

occurred

[4]. Some protective value against cutaneous anthrax was noted, but

there

was an insufficient number of cases of inhalation anthrax to reach any

conclusions about the efficacy of the vaccine in the prevention of

inhalation anthrax.

A controlled trial that involved purposeful exposure of humans to

inhalation

anthrax would obviously be unethical, but experiments have been done

exposing monkeys and guinea pigs to inhalation anthrax [5,6]. These

trials

of the vaccine have yielded contradictory results. However, the only two

Fort Detrick studies that studied vaccine efficacy against multiple

anthrax

strains isolated from around the world yielded similar results [7,8]. In

the

first study, 9 of 27 strains tested killed at least 50% of the

vaccinated

guinea pigs. In the second, 26 of 33 strains tested killed at least half

the

guinea pigs. When the Senate Veterans Affairs Committee examined the

issue

of efficacy and safety of the vaccine in 1995, it recommended that “the

vaccine should be considered investigational when used as a protection

against biologic warfare.”

Further complicating the question of efficacy is the consideration that

new

strains of anthrax may have been developed specifically to defeat the

current vaccine. It has been clear for some time that recombinant DNA

technology may be used to alter agents that cause illness so that they

are

no longer as susceptible to vaccines or to antibiotics. Researchers in

Russia disclosed in the British journal Vaccine in 1997 that they had

genetically engineered a strain of anthrax that uses genes from Bacillus

Cereus. The new strain is apparently able to overcome the protection

offered

by the Russian anthrax vaccine and it is therefore likely to be able to

overcome the protection offered by the MBPI vaccine [9].

Recent analysis of tissue specimens from the bodies of victims of an

explosion of a bioweapons factory in Sverdlovsk in the former Soviet

Union

in 1979 indicated that DNA sequences from four different strains of

anthrax

were present. These strains may have been selected to overcome the

protection offered by vaccines against anthrax [10,11,12]. Ken Alibek, a

Russian defector, has alleged that the USSR had prepared

genetically-altered

strains of anthrax in order to circumvent the use of vaccines against

them

[13].

Safety

The potential risks to inoculated military personnel are still largely

unknown. Sufficient small-scale testing of a similar vaccine convinced

the

FDA to license the current vaccine for use in protecting small numbers

of

at-risk workers [14]. But there are no published studies of the results

of

surveillance of vaccine recipients, and no data regarding long term side

effects have been submitted to the FDA [15]. There is no reported

experience

with its use on a scale comparable to the inoculation of 2.4 million

people.

Experience with other vaccines that have been used widely after

relatively

small field trials indicates that unanticipated problems can develop in

the

course of massive use of approved drugs or vaccines. Furthermore,

inspections by FDA of the MBPI have revealed unacceptable manufacturing

practices. The FDA had sent the MBPI a warning letter in 1995 and

threatened

to revoke its license in 1997 [16]. An FDA report of an inspection in

February 1998 made dozens of serious charges regarding compliance

problems,

including contamination of the vaccine, reuse of outdated vaccines, and

relabeling of lots that originally failed in order to place them in use

[17]. The MBPI is now closed for renovation, but the vaccine being used

by

the Pentagon was produced while the unacceptable conditions were in

place.

In May 1998 the Subcommittee on Human Resources of the Government Reform

and

Oversight Committee of the US House of Representatives began an

investigation of the safety and efficacy of the MBPI vaccine and asked

the

US General Accounting Office (GAO) to conduct an independent probe. The

GAO

report is expected by the end of 1998. The Subcommittee is concerned

that a

1987 Memorandum of Understanding (MOU) between the Department of Defense

and

the Food and Drug Administration may be restricting FDA’s oversight of

the

anthrax vaccine program. The Subcommittee Chairman asked the GAO to look

into the extent to which the MOU might limit FDA review of the vaccine

program; the extent to which claims regarding safety and efficacy of the

vaccine are supported by data; and the extent to which problems

identified

by FDA at the MBPI could effect the safety and efficacy of the vaccine

[18].

The Pentagon’s record of conducting immunization programs in the past

does

not inspire confidence. For example, the Presidential Advisory Committee

on

Gulf War Veterans’ Illnesses was sharply critical of the military’s poor

record-keeping on immunizations during the Gulf War. More recently, it

characterized the Pentagon’s efforts to improve its medical record

keeping

in Bosnia, where it used tick-borne encephalitis vaccine, as an “abysmal

failure” [19,20]. Furthermore, the full House Committee on Government

Reform

and Oversight unanimously approved a report on November 7, 1997 that

concluded, “DOD failure to adhere to record-keeping requirements [during

the

Gulf War] should result in the presumption of service connection for any

subsequent illness to service personnel to whom the drug...was

administered.”

Closely related is the question whether the Pentagon conducted adequate

record keeping and follow-up on the approximately 150,000 US troops who

are

reported to have received anthrax immunization during the Persian Gulf

War.

On September 8, 1991, just months after the Gulf War ended, the Army’s

Medical Research and Development Command prepared their “Update on

Medical

Biological Defense Vaccine Program.” It proposed a follow-up study of a

“unique pool of subjects” -- those troops who received anthrax

immunization.

If the military indeed conducted research on this population, such data

have

not been released publicly so that impartial analysts can review them.

If

the US military had placed the highest priority on the safety and

efficacy

of this vaccine, it would have started with placebo-controlled,

carefully-monitored trials limited to troops who are willing to give

free

and informed consent to be guinea pigs in such an experiment. If the

military has ever conducted such a trial, the results have not been

reported

in the open, peer-reviewed literature.

Coercion

Another issue in military use of the MBPI vaccine lies in the fact that

troops were ordered to take the vaccine without first giving their free

and

informed consent. Several members of the US armed forces are known to

have

refused inoculation with the anthrax vaccine. As of April 20, 1998, 14

sailors aboard two ships in the Persian Gulf were being punished for

refusing to permit the inoculation and two Air Force airmen have also

refused the vaccine and were also disciplined. After one of the sailors,

Nhut M. Nguyen, aboard the aircraft carrier USS. Independence, refused

the

vaccine, he was reduced in rank and was fined. He wrote to Navy Times

that

he was told that failure to have the inoculation could cost him his

ability

to receive US citizenship and could cause him to be thrown out of the

Navy

without any benefits. Nguyen wrote in one of his messages that many

sailors

are afraid of getting the vaccine but are even more frightened of the

consequences of refusing [21].

The anthrax vaccine was also given to the roughly 300 members of the

Canadian armed forces on the way to the Persian Gulf area [22]. The

newspaper Stars & Stripes reported in March that a Canadian sergeant was

facing disciplinary action for refusing an order to be vaccinated for

anthrax [23]. The armed forces of the United Kingdom have also been

offered

anthrax immunization, but on a voluntary basis. Recent reports indicate

that

73% of those offered the vaccine have refused to accept it [24].

A recent case indicates the length to which the US military has gone to

insist that its troops accept the vaccine. US Army PFC Baker

left

his post at Fort , Georgia because, as he stated in a letter to

the

Surgeon General of the US Army, “I indicated my concerns about being

given

the anthrax vaccine and was told by my First Sergeant that if I refused

to

submit to an anthrax vaccine hypodermic shot, I would be strapped down

to a

gurney and would be forcibly injected against my will.” In his letter

Baker

requested that a Court of Inquiry be convened to investigate the anthrax

vaccination program.

While it is clear that individual civil rights may be constrained for

those

in military services and that international law has generally supported

these constraints within certain bounds, it is not clear that a military

service forcibly injecting its troops with a vaccine, whose safety and

efficacy are in considerable dispute, would be considered lawful

activity.

Ethics and Policy

In addition to the specific issues related to the use of the MBPI

vaccine

against anthrax, other risks in vaccine policies also loom large, such

as

the impact that use of vaccines for inoculation of troops will have on

the

control of biologic weapons. In 1996 some military officials were

concerned,

according to the Washington Post, “that word the United States is about

to

embark on a program to defend against anthrax might be misread as a sign

Washington has a secret offensive capability or intends to develop one.”

Seymour Hersh, has recently reported [25] that one of the reasons the US

military was concerned about the threat of use of anthrax in the Persian

Gulf was evidence that Iraqi troops may have been immunized against

anthrax.

According to Hersh, one of the pieces of evidence that convinced the US

military that Iraq might be planning to use anthrax as a weapon in the

Persian Gulf War was the discovery that Iraqi soldiers captured in a US

covert operation had immunity against anthrax. Hersh writes that

“an elite American Special Forces team, operating deep inside Iraq

before the war, had kidnapped some Iraqi soldiers and determined,

from blood samples, that they had recently built up an immunity to

anthrax.... It was not clear whether the Iraqis had been

inoculated with anthrax vaccine or had developed immunity to the

disease, which occurs naturally in the animal population in some

areas of Iraq. It didn’t matter. Military planning had to assume

the worst--that the Iraqis would not be affected by a biologic

attack.”

In a world in which many nations are prepared to believe the worst about

the

military policies of other nations, information about immunization of

the

armed forces of a potential enemy may lead to destabilizing suspicions

and

unnecessary, costly, and risky countermeasures to possible bioattack.

Action

by the United States to immunize its troops is almost certain to

persuade

other nations to immunize theirs, thereby perpetuating a dangerous

aspect of

the biologic weapons race. There is also the long-recognized principle

among

planners of biologic weapons strategies that the surest way to cause a

potential user to switch from biologic weapon A to biologic weapon B is

to

learn that the enemy’s troops are immunized against A.

Moreover, immunizing troops with a vaccine that may be effective while

leaving civilians unprotected comes dangerously close to a violation of

the

Geneva Conventions, in that such a policy specifically puts civilians at

risk. Indeed, immunizing troops may convince another nation or group

desperate enough to use biologic weapons that it should attack

unprotected

civilians instead, perhaps in a clandestine manner so the attack cannot

be

traced and retaliation initiated. One of the most important ethical

problems

arises if the vaccine is considered to be effective, but is actually not

effective or has only limited effectiveness. Military commanders,

believing

the vaccine to be effective, may expose troops under their command to

situations that might have been avoided if the misleading impression of

protection had not been generated. Furthermore, the troops themselves,

feeling themselves to be protected, may take risks they would not

otherwise

take.

In recent months, another set of ethical issues has arisen because a

number

of publications have raised fears of bioterrorism. Many of these have

been

inaccurate and extremely alarmist. For example, a commentary in the

Lancet

suggested that inhalation anthrax was transmissible from an individual

with

the disease to others [26]. There is, however, no evidence that

inhalation

anthrax can be spread by person-to-person contact [27]. The fears caused

by

these reports have led to rehearsals for response to attacks on a series

of

US cities and proposals for stockpiling of vaccines and antibiotics.

Hearings on the issue before a committee of the US Senate on June 2,

1998

included witnesses, however, who stated that US preparation for biologic

defense is misguided because so much of the funding goes to the Pentagon

instead of hospitals and doctors [28]. Among the issues raised were the

question whether the funds spent on the drills and the stockpiling could

be

more effectively spent to prevent the consequences of bioterrorism by

providing adequate public health measures, preventive medicine, and

treatment for endemic illness to the population.

Another issue that must be faced is that of conflict of interest.

Profit-making from the immunization programs may influence military

decisions. An analysis of the decision-making process that led to the

awarding of contracts for stockpiling of vaccines to protect against

bioterrorism led the New York Times to question conflict of interest

among

those participating in the decisions who stand to gain financially from

a

decision to stockpile the vaccines [29]. On July 7, 1998, the State of

Michigan approved the sale of the MBPI to an investment firm headed by a

former Chairman of the Joint Chiefs of Staff, Admiral J. Crowe, Jr., who

was

an important supporter of President Clinton in the 1992 Presidential

campaign. The state of Michigan had earlier announced that it had

accepted a

25 million dollar bid from the firm, Bioport, a subsidiary of the

land-based corporation Intervac. The subsidiary is said to have been

created specifically for investment in MBPI. Admiral Crowe, who served

as

Chairman of the Joint Chiefs under Reagan, and as Ambassador to the

United

Kingdom under Clinton, is a principal investor in Bioport. Crowe told

United

Press International that, “with the ongoing threat of biological

attacks,

sales of the anthrax vaccine could expand beyond the United States.” “We

think the market is going to be pretty good,” he stated. It is also of

interest that the details of the contract that the Pentagon signed with

MBPI

to supply anthrax vaccine for all US military personnel remains secret,

although the New York Times reports that Admiral Crowe’s firm “now has

an

inside track on at least 60 million dollars in Pentagon contracts.”

Furthermore, as weapons of mass destruction that are frequently

described as

“the poor nation’s nuclear weapons,” biological (and chemical) weapons

cannot be considered in isolation from nuclear weapons. While both the

Biological Weapons Convention and the Chemical Weapons Convention were

negotiated and adopted without structural linkage to each other or to

the

treaties governing nuclear weapons, the ability to strengthen and

enforce

these agreements over the long term or, conversely, to prevent them from

unravelling, depends upon embracing disarmament policies across the full

range of weapons of mass destruction. Moreover, the incentives to

develop,

possess and, perhaps, use biological weapons and chemical weapons will

remain strong as long as nations without nuclear arsenals perceive these

weapons as equalizers of sorts. In short, the elimination of biological,

chemical and nuclear weapons are, ultimately, essentially the same goal.

Conclusion

When facing this issue of vaccinating two-and-a-half million people in

the

short run, for reasons of safety, efficacy, and public concerns over the

massive scope and potential risk of this program, the interests of

military

personnel as well as the public would be better served if researchers

unaffiliated with the Pentagon were permitted to conduct further studies

on

the vaccine. The Pentagon should invite major civilian US public health

agencies, including the Centers for Disease Control and Prevention and

the

National Institutes of Health and major non-governmental organizations

such

as the American Public Health Association, to participate actively in

the

design, testing, implementation, and oversight of this plan. It would be

tragic if these agencies were only brought in later, as was done with

nuclear bomb-test fallout and Agent Orange to write a post-mortem

analysis.

In the longer term, in responding to the profound policy concerns raised

by

the continuing threat of biologic and chemical weapons, the US and the

other

nuclear powers must recognize their obligations to move toward the

elimination of nuclear weapons. If the United States wishes to protect

its

troops against biologic weapons, the best method would be to join in

negotiating a Nuclear Weapons Convention and, in accordance with it, to

dismantle the US nuclear capability. Only then will it be possible for

all

nations to enjoy effective protection against weapons of mass

destruction.

Overall, there is little evidence that vaccines are an effective or

ethical

solution to the threat of biologic weapons.

References

1. Myers SL. US armed forces to be vaccinated against anthrax. New York

Times, December 16, 1997:A1,A22. [Return to text]

2. P, Wallace D. Unit 731: The Japanese Army’s Secret of

Secrets.

New York: The Free Press. 1989. [Return to text]

3. Nass M. Anthrax epizootic in Zimbabwe, 1978-1980: Due to deliberate

spread? PSR Quarterly 1992;2:198-209. [Return to text]

4. Brachman PS, Gold H, Plotkin SA, et al. Field evaluation of a human

anthrax vaccine. Am J Public Health 1962;56:632-645. [Return to text]

5. Ivins B, Fellows P, Pitt L, et al. Experimental anthrax vaccines:

Efficacy of adjuvants combined with protective antigen against an

aerosol

bacillus anthracis spore challenge in guinea pigs. Vaccine

1995;13:1779-1784. [Return to text]

6. Turnbull PCB. Anthrax vaccines: past, present, and future. Vaccine

1991;9:533-539. [Return to text]

7. Fellows P, Linscott M, Ivins B. Anthrax vaccine efficacy against

B.anthracis strains of diverse geographical origin. Paper presented at

3rd

International Anthrax Workshop, Plymouth, England, September 9, 1998.

[Return to text]

8. Little SF, Knudsen GB. Comparative efficacy of Bacillus anthracis

live

spore vaccine and protective antigen vaccine against anthrax in the

guinea

pig. Infection and Immunity 1986;52: 509-12. [Return to text]

9. Pomerantsev AF, Staritsin NA, Mockov YV, in LI. Expression of

cerolysine ab genes in bacillus anthracis vaccine strain ensures

protection

against experimental hemolytic anthrax infection. Vaccine

1997;15:1846-1850.

[Return to text]

10. PJ. Proceedings of the National Academy of Sciences.

Washington,

DC: NAS. February 3, 1998. [Return to text]

11. Wade N. Anthrax findings fuel worry on vaccine. New York Times,

February

3, 1998:A6. [Return to text]

12. Wade N. Tests with anthrax raise fears that American vaccine can be

defeated. New York Times. March 26, 1998:A24. [Return to text]

13. Preston R. The bioweaponers. The New Yorker. March 9, 1998:52-65.

[Return to text]

14. Brachman PS, Friedlander AM. Anthrax. In: Plotkin SA, Mortimer EA

(eds).

Vaccines, 2nd ed. Philadelphia: W.B. Saunders. 1994. [Return to text]

15. Zoon KC. (Director, Center for Biologics Evaluation and Research, US

Food and Drug Administration). Letter to G. Eddington (Director,

Veterans for Integrity in Government). April 28, 1998. [Return to text]

16. Zoon KC (Director, Center for Biologics Evaluation and Research, US

Food

and Drug Administration). Letter to Myers (Head, Michigan

Biologic

Products Institute). March 11, 1997. (Obtained by authors from FDA

through

Freedom of Information Act request.) [Return to text]

17. Inspectional Observations. Inspection of Michigan Biologic Products

Institute. Washington, DC: US Food and Drug Administration. February 20,

1998. [Return to text]

18. Congress probes safety/efficacy of anthrax vaccine, seeks GAO help.

FDA

Week Vol. 4, No. 30, July 24, 1998. [Return to text]

19. Presidential Advisory Committee on Gulf War Veterans' Illnesses.

Special

Report. October 31, 1997. Washington, DC: US Government Printing Office,

1997. [Return to text]

20. Sloat B, Epstein K. Army misled troops who got vaccine in Bosnia.

Plain

Dealer (Cleveland, Ohio), January 25, 1998:1A,18A. [Return to text]

21. Ginburg Y. Sailors refuse vaccine. Navy Times, April 20, 1998:3.

[Return

to text]

22. Godkin P. Canadians off to gulf get controversial vaccine. Toronto

Star,

February 21, 1998:A16. [Return to text]

23. Canada moves soldier who refused anthrax vaccine, Winnipeg paper

says.

Stars & Stripes, March 30, 1998. [Return to text]

24. Gilligan A. British troops " mutiny " over Gulf anthrax jab. The

Sunday

Telegraph. June 7, 1998. [Return to text]

25. Hersh S. Against All Enemies: Gulf War Syndrome: The War Between

Americas Ailing Veterans and Their Government. New York: Ballantine

Books.

1998. [Return to text]

26. Wise R. Bioterrorism: Thinking the unthinkable. Lancet,

1998;351:1378.

[Return to text]

27. Nass M. Biological Warfare. Lancet. 1998;352:491-492. [Return to

text]

28. J. US unprepared for bioterrorism, experts say. New York

Times,

June 3, 1998. [Return to text]

29. Broad WJ, J. Germ defense plan in peril as its flaws are

revealed. New York Times. August 7, 1998:A1,A16. [Return to text]

About the Authors

* VWS is Distinguished University Professor of Social Medicine at

Montefiore Medical Center and the Albert Einstein College of

Medicine.

He is Co-President of the International Physicians for the

Prevention

of Nuclear War.

* MN is an emergency physician at Parkview Hospital, Brunswick,

Maine.

She has investigated and written widely on issues of anthrax,

vaccines,

and biological warfare.

* TE is a lawyer and Director of Citizen Soldier, a non-profit

GI/veteran’s rights advocacy organization based in New York City.

Address correspondence to Victor W. Sidel, M.D., Montefiore Medical

Center,

111 East 210th Street, Bronx, New York 10467 USA; e-mail:

vsidel@....

© copyright 1998 Medicine and Global Survival

--

Meryl Nass, M.D.

Parkview Hospital, Brunswick, Maine 04011

email mnass@...

phone (207) 865-0875

fax (207) 865-6975