Anthrax Malignant Pustule, Malignant Edema, Woolsorters Disease, Ragpickers Disease, Maladi Charbon,...

AnthraxAnthrax

Malignant Pustule, Malignant Edema, Woolsorters’ Disease, Ragpickers’ Disease, Maladi Charbon, Splenic Fever

Center for Food Security and Public Health Iowa State University - 2004

OverviewOverview

• Organism• History• Epidemiology• Transmission• Disease in Humans• Disease in Animals• Prevention and Control

The OrganismThe Organism


The OrganismThe Organism

• Bacillus anthracis • Large, gram positive

non-motile rod• Vegetative form and

spores• Nearly worldwide

distribution• Over 1,200 strains


The SporeThe Spore

• Sporulation requires−Poor nutrient conditions −Presence of oxygen

• Spores −Very resistant to extremes −Survive for decades−Taken up by host and germinate

• Lethal dose 2,500 to 55,000 spores

HistoryHistory


Sverdlovsk, Russia, 1979Sverdlovsk, Russia, 1979

• 94 people sick – 64 died • Soviets blamed contaminated meat • Denied link to biological weapons• 1992

−Soviet President Yeltsin admits outbreak related to military facility

−Western scientists find victim clusters downwind from facility

• Caused by faulty exhaust filter


South Africa, 1978-1980South Africa, 1978-1980

• Anthrax used by Rhodesian and South African apartheid forces−Thousands of cattle died−10,738 human cases−182 known deaths−Black Tribal lands only−White populations untouched


Aum ShinrikyoAum Shinrikyo

• Japanese religious cult− “Supreme truth”

• 1993− Unsuccessful attempts

at biological terrorism− Released anthrax from office building

Vaccine strain used – not toxic− No human injuries

• Successful attempt in 1995− Sarin gas release in Tokyo subway− 1,000 injured – 12 deaths


2001 Anthrax Letters2001 Anthrax Letters



Anthrax Cases, 2001Anthrax Cases, 2001

• 22 cases−11 cutaneous−11 inhalation

• 5 deaths (all inhalation)− Index case in Florida−2 postal workers in Maryland−Hospital supply worker in NYC−Elderly farm woman in Connecticut



• 7 month old boy• Visited ABC Newsroom• Cutaneous lesion• Initial diagnosis:

− spider bite

• Punch biopsies confirmed anthrax



• CDC survey of health officials following 9-11-01−7,000 reports regarding anthrax

4,800 phone follow-ups 1,050 led to lab testing

−1996-2000 Less than 180 anthrax inquiries



• Antimicrobial prophylaxis−Ciprofloxacin

5,342 prescribed 60 day regime

−44% compliance−57% suffered side effects

TransmissionTransmission


Human TransmissionHuman Transmission

• Industry−Tanneries−Textile mills−Wool sorters−Bone processors−Slaughterhouses


Human TransmissionHuman Transmission

• Cutaneous−Contact with infected

tissues, wool, hide, soil−Biting flies

• Inhalational−Tanning hides,

processing wool or bone• Gastrointestinal

−Undercooked meat


Animal TransmissionAnimal Transmission

• Most commonly infected by ingestion from contaminated soil or contaminated feed or bone meal

EpidemiologyEpidemiology


20,000-100,000 cases estimated globally/yearhttp://www.vetmed.lsu.edu/whocc/mp_world.htm


Anthrax in U.S.Anthrax in U.S.

• Cutaneous anthrax−Early 1900’s: 200 cases annually−Late 1900’s: 6 cases annually

• Inhalation anthrax−20th century: 18 cases/16 fatal


Anthrax in the U.S.Anthrax in the U.S.

• Outbreaks in soil endemic areas• Alkaline soil• Wet spring that leads to grass kill

followed by hot, dry period in summer or fall−“Anthrax weather”

• Grass or vegetation damaged by flood-drought sequence

Disease in HumansDisease in Humans


Human DiseaseHuman Disease

• Three forms−Cutaneous− Inhalation−Gastrointestinal


Cutaneous AnthraxCutaneous Anthrax

• 95% of all cases globally• Incubation: 3-5 days (up to 12 days) • Spores enter skin through open

wound or abrasion• Papule progresses to black eschar• Severe edema• Fever and malaise


Day 2

Day 6

Day 4


Day 4

Day 6


Cutaneous AnthraxCutaneous Anthrax

• Case fatality rate 5-20%• Untreated – septicemia and death• Edema can lead to death from

asphyxiation

Day 10


Cutaneous Anthrax Cutaneous Anthrax

• 2000−32 farms quarantined−157 animals died

• 67 yr. old man in North Dakota−Helped in disposal of 5 cows that died of

anthrax−Developed cutaneous anthrax−Recovered with treatment


Gastrointestinal AnthraxGastrointestinal Anthrax

• Severe gastroenteritis− Incubation: 2-5 days after consumption

of undercooked, contaminated meat

• Case fatality rate: 25-75%• GI anthrax never documented in U.S.

−Suspected cases in 2000


Minnesota, 2000Minnesota, 2000

• Downer cow approved for slaughter by local vet

• 5 family members ate meat−2 developed GI signs

Diarrhea, abdominal pain, fever

• 4 more cattle die• B. anthracis isolated from farm but

not from humans


Inhalation AnthraxInhalation Anthrax

• Incubation: 1-7 days• Initial phase

−Nonspecific - Mild fever, malaise

• Second phase−Severe respiratory distress−Dyspnea, stridor, cyanosis, mediastinal

widening, death in 24-36 hours

• Case fatality: 75-90% (untreated)



Diagnosis in HumansDiagnosis in Humans

• Isolation of B. anthracis−Blood, skin−Respiratory secretions

• Serology• ELISA• Nasal swabs

−Screening tool


Diagnosis in HumansDiagnosis in Humans

• Anthrax quick ELISA test−New test approved by FDA on June 7th,

2004. −Detects antibodies produced during

infection with Bacillus anthracis −Quicker and easier to interpret than

previous antibody testing methods Results in less than ONE hour


Treatment Treatment

• Penicillin−Has been the drug of choice−Some strains resistant to penicillin and

doxycycline

• Ciprofloxacin−Chosen as treatment of choice in 2001−No strains known to be resistant

• Doxycycline may be preferable



VaccinationVaccination

• Cell-free filtrate• Licensed in 1970• At risk

−Wool mill workers−Veterinarians−Lab workers −Livestock handlers−Military personnel


Vaccine Side EffectsVaccine Side Effects

• Injection site reactions−Mild: 30% men, 60% women−Moderate:1-5%−Large local:1%

• 5-35% experience systemic effects−Muscle or joint aches, headache, rash,

chills, fever, nausea, loss of appetite, malaise

• No long-term side effects noted


Vaccine ScheduleVaccine Schedule

• 3 injections at two-week intervals• 3 injections 6 months apart• Annual booster


Protection Against Inhalational AnthraxProtection Against

Inhalational Anthrax

No human post

exposure trials have

been documented

• 21 monkeys vaccinated at 0 and 2 weeks.

o Challenged by anthrax spores at 8 week and 38 week later: All survived o Challenged at 100 weeks: 88% survived

• The two doses of vaccine (0 and 2 weeks) provided protection for most animals for almost two years


VaccinationVaccination

Animals and Anthrax Animals and Anthrax


Clinical Signs in AnimalsClinical Signs in Animals

• Signs differ by species−Ruminants at greatest risk

• Three forms of illness−Peracute

Ruminants (cattle, sheep, goats, antelope)

−Acute Ruminants and equine

−Subacute-chronic Swine, dogs, cats

Copyright WHO


RuminantsRuminants

• Peracute infection−Rapid onset−Sudden death−Bloody discharge

from body orifices− Incomplete rigor mortis−Rapidly bloat


RuminantsRuminants

• Acute infection: 1-3 days −Fever, anorexia−Decreased rumination−Muscle tremors−Dyspnea−Abortions−Disorientation−Bleeding from orifices−Hemorrhages on internal organs


RuminantsRuminants

• Chronic infection−Pharyngeal and lingual edema−Ventral edema −Death from asphyxiation

• Treatment successful if started early


Differential DiagnosisDifferential Diagnosis

• Blackleg• Botulism• Poisoning

−Plants, heavy metal, snake bite

• Lightening strike• Peracute babesiosis


EquineEquine

• Ingestion−Enteritis, severe colic,

high fever, weakness, death within 48-96 hours

• Insect bite/vector−Hot, painful swelling−Spreads to throat, sternum,

abdomen, external genitalia−Death

Copyright WHO


SwineSwine

• Sudden death without symptoms• Localized swelling of throat• Death by asphyxiation• Ingestion of spores

−Anorexia, vomiting, enteritis


Dogs & CatsDogs & Cats

• Relatively resistant− Ingestion of contaminated raw meat

• Clinical signs−Fever, anorexia, weakness−Necrosis and edema of upper GI tract−Lymphadenopathy and edema of head

and neck−Death

Due to asphyxiation, toxemia, septicemia


Diagnosis and TreatmentDiagnosis and Treatment

• Necropsy not advised!• Do not open carcass!• Samples of peripheral blood needed

−Cover collection site with disinfectant soaked bandage to prevent leakage

• Treatment −Penicillin, tetracyclines

• Reportable disease


Dogs/PigsInhalational Anthrax

Dogs/PigsInhalational Anthrax

• Experimental studies - 1968−14 dogs and 14 pigs infected−8/14 pigs had transient fevers−3/14 dogs significant temp elevations

• B. anthracis− Isolated from lungs and pulmonary

lymph nodes of dogs−Never isolated from blood


Case-ReportMississippi, 1991


• Golden retriever, 6 yrs old−2 days ptyalism and swelling of RF leg−Temp 106°F, elevated WBC−Died same day

• Necropsy −Splenomegaly, friable liver, blood in

stomach−2x2 cm raised hemorrhagic leg wound −Some pulmonary congestion




• Source of exposure in question−Residential area−1 mile from livestock−No livestock deaths in area−Dove hunt on freshly plowed field

6 days prior to onset

• Signs consistent with ingestion but cutaneous exposure not ruled out


Animal Anthrax VaccineAnimal Anthrax Vaccine

• Recommended for livestock in endemic areas

• Sterne strain− Live encapsulated spore vaccine

• Immunity in 7-10 days• Other countries use in pets and exotics

− No safety or efficacy data− Adjuvant may cause reactions

• Working dogs may be at risk


Animal Disease SummaryAnimal Disease Summary

• Anthrax should always be high on differential list when−High mortality rate in group of

herbivores−Sudden death with unclotted blood

from orifices−Localized edema

Especially neck of pigs or dogs

Prevention and ControlPrevention and Control



• Report to authorities • Quarantine the area• Do not open carcass• Minimize contact• Wear protective clothing

−Latex gloves, face mask

• Vaccination of susceptible animals



• Burn or bury carcasses,bedding, other materials

• Decontaminate soil • Remove organic

material and disinfect structures


DisinfectionDisinfection

• Effective disinfection can be difficult• Prevention of sporulation best• High pressure cleaners discouraged• Soil

−5% lye or quicklime−Hydrogen peroxide, peracetic acid or

gluteraldehyde• Bleach 1:10 dilution

−May be corrosive


DisinfectionDisinfection

• Preliminary disinfection− 10% formaldehyde− 4% glutaraldehyde (pH 8.0-8.5)

• Cleaning− Hot water, scrubbing, protective clothing

• Final disinfection: one of the following− 10% formaldehyde − 4% glutaraldehyde (pH 8.0-8.5)− 3% hydrogen peroxide,− 1% peracetic acid


Biological Terrorism: Estimated Effects

Biological Terrorism: Estimated Effects

• 50 kg of spores −Urban area of 5 million−250,000 cases of anthrax

100,000 deaths

• 100 kg of spores −Upwind of Wash D.C.−130,000 to 3 million deaths


AcknowledgmentsAcknowledgments

Development of this presentation was funded by a grant from the Centers for Disease Control and Prevention to the Center for Food Security and Public Health at Iowa State University.


AcknowledgmentsAcknowledgments

Author:

Co-authors:

Radford Davis, DVM, MPH

Jamie Snow, DVM, MPHKatie Steneroden, DVM, MPH

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