Anthrax

communicable disease course, master of community medicine university of Khartoum

1. ANTHRAX By; Randa Abdalla

2. Contents: Introduction History Epidemiology Causative organism Transmission Clinical manifestation Management Prevention and control

3. Introduction Malignant pustule, Malignant oedema , Woolsorter disease , Ragpicker disease. From the Greek word anthrakos for coal Caused by spores Primarily a disease of domesticated & wild animals Herbivores such as sheep, cows, horses, goats. Anthrax zones Soil rich in organic matter (pH < 6.0)

4. History of Anthrax (Early history) Although anthrax dates back more than 3,000 years, it was not recognized as a disease until the 18th century. 1500 B.C - A “ plague of boils ” in Egypt affected the Pharaoh ’ s cattle. ‘ Boils ’ are symptomatic of anthrax. 1600s - The “ Black Bane ” thought to be anthrax, in Europe kills over 60,000 cattle. 1700s - There are some accounts of human cases.

5. History (1800s) Early 1800s - The first human cases of cutaneous anthrax in the US and UK were reported in men who contracted the disease after having been in contact with infected livestock. The disease was called Wool Sorter ’ s disease or Rag Picker ’ s disease because it affected workers in those trades. 1868 - Anthrax was observed under a microscope. 1876 - German bacteriologist Robert Koch confirmed bacterial origin of anthrax.

6. History (Early 1900s) 1915 - German agents injected horses, mules, and cattle with anthrax . This was the first recorded use of anthrax as a biological weapon. 1937 - Japan started a biological warfare program in Manchuria, including tests involving anthrax. 1942 - UK demonstrated experiments using anthrax at Gruinard Island off the coast of Scotland. 1943 - United States began developing anthrax weapons. 1945 - In Iran an anthrax outbreak killed more than 1 million sheep.

7. History (Late 1900s) 1950s and 60s - U.S. biological warfare program continues after WWII at Fort Detrick , Maryland 1969 - President Nixon ended United States' offensive biological weapons program, but defensive work still continues. 1970 - Anthrax vaccine for humans was approved by U.S. FDA. 1978-80 - The world's largest outbreak of human anthrax via insect vectors or contaminated meat struck Zimbabwe, Africa where more than 10,000 cases were recorded and over 180 people died. 1979 - In Soviet Union , aerosolized anthrax spores were released accidentally at a military facility, affecting 94 and killing 64 people.

8. History (Recent years) 1991 - About 150,000 U.S. troops were vaccinated for anthrax in preparation for Gulf War . 1990-93 - The cult group, Aum Shinrikyo , released anthrax spores in Tokyo, fortunately no one was injured. On February 27, 2004, the leader of this group was given a sentence of death at a district court in Tokyo. 1995 - Iraq produced 8,500 liters of concentrated anthrax as part of the biological weapon program under Saddam Hussein ’ s administration. 2001 - Letters containing anthrax spores were mailed to many places in the US such as NBC, New York Times, and Media in Miami. In Florida, a man died after inhaling anthrax at the office.

9. Outbreaks in Thailand This picture is 9 days after the onset of symptoms of oral-pharyngeal anthrax. 1982 - In rural Northern Thailand, an outbreak of 52 cases of cutaneous anthrax and 24 cases of oral-pharyngeal anthrax occurred. Oral-pharyngeal anthrax: an unusual manifestation of human infection with B. anthracis . 1987 - 14 cases of both oral- pharyngeal and abdominal anthrax occurred. Caused by the consumption of contaminated water and buffalo meat.

10. Natural Outbreaks in North Dakota The highest occurrence of Anthrax outbreaks in the US 1989-1999 - 26 cases of infected livestock were reported. 2000 - 33 cases were reported during July-September. Total of 180 animals (beef cattle, horses, and bison) died and one person was infected with cutaneous anthrax.

11. Epidemiology Distribution worldwide Not common in West. Common in Africa ( Zimbabwe), S.E. Asia, China, South America, Turkey, Pakistan, India Human to human or animal to animal transmission is rare ( not contagious) Grazing animals become infected through ingestion of spores in the soil ( Carcasses become the source)

12. Causative organism - Etiologic agent : Bacillus anthracis Cohn 1875. - Large (8 x 1.2 mm) Gram positive, nonmotile , weakly hæmolytic ; central spores , straight ends , encapsulated in vivo, produces long chains . - Pathogenic to herbivores , man , lab animals .

13. - Habitat : Parasitic ; persists in “ cursed ” fields . - Sporulation only in aerobic conditions . - Capsule antigen : poly D- glutamic acid g- peptide - Immunogenic protein toxin , edematizing , lethal .

14. Bacillus anthracis : culture

15. (blue) (red)

16. STAGES OF INFECTION Encounter : organism and body surfaces Adhesion : generalized and receptor- specific Initial multiplication  in situ colonization Invasión  breaching of anatomic barriers Lymphatic stage  invasion of bloodstream Generalized infection , metastases .

17. Transmission

18. Transmission: Contact with tissues of animals (cattle, sheep, goats, horses, pigs and others) dying of the disease. Biting flies that have partially fed on such animals. Contact with contaminated hair, wool, hides or products made from them (e.g. drums, brushes, rugs). Contact with soil associated with infected animals or with contaminated bone meal used in gardening.

19. Transmission cont. Inhalation anthrax results from inhalation of spores in risky industrial processes—such as tanning hides and processing wool or bone—with aerosols of B. anthracis spores in an enclosed, poorly-ventilated area. Intestinal and oropharyngeal anthrax may arise from ingestion of contaminated undercooked meat ; there is no evidence that milk from infected animals transmits anthrax.

20. Transmission cont. The disease spreads among grazing animals through contaminated soil and feed ; and among omnivorous and carnivorous animals through contaminated meat, bone meal or other feeds derived from infected carcases . Accidental infections may occur among laboratory workers.

21. Transmission cont. Anthrax is not transmitted person to person . Articles and soil contaminated with spores in endemic areas may remain infective for many years.

22. Clinical manifestations

23. Clinical manifestations: Anthrax is an illness with acute onset. characterised by several distinct clinical forms including: a skin lesion a respiratory illness abdominal distress Ninety percent of cases are cutaneous anthrax

24. Cutaneous Anthrax Mainly in professionals( Veterinarian, butcher, Zoo keeper Spores infect skin- a characteristic gelatinous edema develops at the site (Papule- Vesicle-Malignant Pustule- Necrotic ulcer) 80-90% heal spontaneously ( 2-6wks) 0-20% progressive disease – develop septicemia 95-99% of all human anthrax occur as cutaneous anthrax

25. Site of Malignant pustule Head: usually no complication Face : severe , superinfection ; gangrene near eye Neck , breast or chest wall : massive edema, over thorax and sometimes involving scrotum Shoulders , arms : may be multiple , small lesions Forearms , fingers : atypical on palms General symptoms , fever , chills , depend on site . Weakness , hypotension are danger signs .

26. Notice the edema and typical lesions

27. Intestinal Anthrax Due to in ingestion of infected carcasses Mucosal lesion to the lymphatic system Rare in developed countries Extremely high mortality rate

28. Intestinal Anthrax Nausea, anorexia, vomiting, fever Progresses to severe abdominal pain and bloody emesis and diarrhea Ascites may develop on day 2 - 4 Death 2 to 5 days after onset of symptoms Very difficult to diagnose

29. Cecal Lesion from eating undercooked Carabao... (AFIP)

30. PULMONARY ANTHRAX Require very high infective dose ( > 10,000 spores) Acquired through inhalation of spores ( Bioterrorism - aerosol) Present with symptoms of severe respiratory infection( High fever & Chest pain) Haemorrhagic mediastinitis Progress to septicemia very rapidly 10 7 to 10 9 bacilli/ ml of blood at the time of death Mortality rate is very high > 95%

31. Anthrax Meningitis Usually a complication of anthrax septicemia. Subarachnoid haemorrhage is a common feature Very often fatal

32. Anthrax meningitis: Subarachnoid Haemorrhage (AFIP)

33. Anthrax - Disease in animals Fulminating , acute , subacute or chronic . Apoplectic death : “ fall ” - animals found dead . Acute : excitable, then depressed , cardiac and respiratory distress , trembling , staggering , convulsions . Edematous lesions , blood exudes, incoagulable. Death in 1-2 days , or 4-5. Chronic infection in more resistant animals : pigs .

34. Diagnosis: Clinical ; symptoms and signs . Incubation period—From 1 to 7 days , although incubation periods up to 60 days are possible

35. Laboratory confirmation requires at least one of the following : isolation of Bacillus anthracis from a clinical specimen demonstration of B. anthracis in a clinical specimen by immunofluorescence significant antibody titres developing in an appropriate clinical case.

36. Management

37. Management: Investigation Obtain a history of travel and contact with imported animal Restriction Standard infection control precautions apply for all direct clinical care. Although a cutaneous lesion will be sterile after 24 hours’ treatment , dressings soiled with discharges from lesions should be burned and reusable surgical equipment sterilised .

38. Treatment The case should be under the care of an infectious diseases physician. Penicillin is the drug of choice for cutaneous anthrax and is given for 5–7 days. Tetracyclines , erythromycin and chloramphenicol are also effective. The U.S. military recommends parenteral ciprofloxacin or doxycycline for inhalation anthrax though the duration of treatment is not well defined.

39. Counselling Advise the case and their caregivers of the nature of the infection and its mode of transmission. Management of contacts

40. Vaccination Cell-free filtrate At risk groups Veterinarians Lab workers Livestock handlers Military personnel Immunization series Five IM injections over 18-week period Annual booster 6/2/2015

41. Methods of control— A. Preventive measures : Immunize high-risk persons , Educate employees , Control dust, wash, disinfect or sterilize, immunize and annually reimmunize all domestic animals at risk….etc. B. Control of patient, contacts and the immediate environment Report to local health authority, Isolation, Concurrent disinfection, Investigation of contacts, Specific treatment….etc.

42. C. Epidemic measures D . Disaster implications E . International measures ; Sterilize imported bone meal before use as animal feed. Disinfect wool, hair and other products when indicated and feasible.

43. Prevention Control in animals . Annual vaccination protects . Disposal of animal carcasses : disinfect with oil , burn , bury deep , covered with quicklime . Spores will NOT form inside the carcass , and putrefaction kills the Bacillus . Flies feeding on incoagulable blood may be a problem .

44. An anthrax death. Notice flies feeding on blood and secretions

45. Burning a carcass in a hole... Not deep enough

46. Question The most common naturally occurring form of anthrax is: Cutaneous Gastrointestinal Inhalational Ocular Mediastinal

47. Question After low-level germination at the site of entry to the body, anthrax may be taken up by: Basophils Eosinophils Lymphocytes Macrophages Neutrophils

48. Thank you…