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

Overview
? Organism
? History
? Epidemiology
? Transmission
? Disease in Animals
? Disease in Humans
? Prevention and Control
Center for Food Security and Public Health, Iowa State University, 2011

The Organism
? Bacillus anthracis
? Large, gram-positive,
non-motile rod
? Two forms
– Vegetative, spore
? Over 1,200 strains
? Nearly worldwide
distribution

The Spore
? Sporulation requires:
– Poor nutrient conditions
– Presence of oxygen
? Spores
– Very resistant
– Survive for decades
– Taken up by host and germinate
? Lethal dose 2,500 to 55,000 spores

Sverdlovsk, Russia, 1979
? 94 people sick – 64 died
? Soviets blamed contaminated meat
? Denied link to biological weapons
? 1992
– President Yeltsin admits outbreak
related to military facility
– Western scientists find victim clusters
downwind from facility
? Caused by faulty exhaust filter

South 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

Tokyo, 1993
? Aum Shinrikyo
– Japanese religious cult
– “Supreme truth”
? Attempt at biological terrorism
– Released anthrax from office building
– Vaccine strain used
– No human injuries

U.S., 2001

U.S., 2001
? 22 cases
– 11 cutaneous
– 11 inhalational; 5 deaths
? Cutaneous case
– 7 month-old boy
– Visited ABC newsroom
– Open sore on arm
– Anthrax positive

U.S., 2001
? CDC survey of health officials
– 7,000 reports regarding anthrax
? 1,050 led to lab testing
– 1996-2000
? Less than 180 anthrax inquiries
? Antimicrobial prophylaxis
– Ciprofloxacin
? 5,343 prescriptions

Human Transmission
? Cutaneous
– Contact with infected
tissues, wool, hide, soil
– Biting flies
? Inhalational
– Tanning hides,
processing wool or bone
? Gastrointestinal
– Undercooked meat

Human Transmission
? Tanneries
? Textile mills
? Wool sorters
? Bone processors
? Slaughterhouses
? Laboratory workers

Animal Transmission
? Bacteria present in hemorrhagic
exudate from mouth, nose, anus
? Oxygen exposure
– Spores form
– Soil contamination
? Sporulation does not occur in a
closed carcass
? Spores viable for decades

Animal Transmission
? Ingestion
– Most common
– Herbivores
? Contaminated soil
? Heavy rainfall, drought
– Carnivores
? Contaminated meat
? Inhalation
? Mechanical (insects)

Anthrax Distribution
20,000 to 100,000 cases estimated globally/year
http://www.vetmed.lsu.edu/whocc/mp_world.htm

Anthrax in the U.S.
? Cutaneous anthrax
– Early 1900s: 200 cases annually
– Late 1900s: 6 cases annually
? Inhalational anthrax
– 20th century: 18 cases, 16 fatalities

Anthrax in the U.S.
? Alkaline soil
? “Anthrax weather”
– Wet spring
– Followed by hot, dry period
? Grass or vegetation damaged by
flood-drought sequence
? Cattle primarily affected

Cutaneous Anthrax
? 95% of all cases globally
? Incubation: 2 to 3 days
? Spores enter skin through open
wound or abrasion
? Papule ? vesicle ? ulcer ? eschar
? Case fatality rate 5 to 20%
? Untreated – septicemia and death

Day 2
Day 4
Day 6
Day 6
Day 10

Case Study:
Cutaneous Anthrax
? North Dakota, 2000
? 67 year old man
? Helped in disposal of 5 cows
that died of anthrax
? Developed cutaneous anthrax
? Recovered with treatment

Gastrointestinal Anthrax
? Severe gastroenteritis common
– Consumption of undercooked or
contaminated meat
? Case fatality rate: 25 to 75%
? GI anthrax not documented in U.S.
– Suspected in Minnesota outbreak

Case Study:
Gastrointestinal Anthrax
? Minnesota, 2000
? Downer cow approved for slaughter
by local veterinarian
? 5 family members ate meat
– 2 developed GI signs
? 4 more cattle died
? B. anthracis isolated from farm but
not from humans

Inhalational Anthrax
? Initial phase
– Nonspecific (mild fever, malaise)
? Second phase
– Severe respiratory distress
– Dyspnea, stridor, cyanosis, mediastinal
widening, death in 24 to 36 hours
? Case fatality: 75 to 90% (untreated)

Diagnosis in Humans
? Identification of B. anthracis
– Blood, skin, secretions
? Culture
? PCR
? Serology
– ELISA
? Nasal swabs
– Screening tool

Treatment
? Penicillin
– Most natural strains susceptible
? Additional antibiotic options
– Ciprofloxacin
? Treatment of choice in 2001
? No strains known to be resistant
– Doxycycline
? Course of treatment: 60 days

Prevention and Control
? Humans protected by preventing
disease in animals
?Veterinary supervision
?Trade restrictions
? Improved industry standards
? Safety practices in laboratories
? Post-exposure antibiotic prophylaxis

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

Vaccine Side Effects
? Injection site reactions
– Mild: 30% men, 60% women
– Moderate:1 to 5%
– Severe:1%
? Systemic effects rare
– Muscle or joint aches, headache, rash,
chills, fever, nausea, loss of appetite
? No long-term side effects noted

Clinical Signs
? Many species affected
– Ruminants at greatest risk
? Three forms
– Peracute
? Ruminants (cattle, sheep, goats, antelope)
– Acute
? Ruminants and equine
– Subacute-chronic
? Swine, dogs, cats

Ruminants
? Peracute
– Sudden death
? Acute
– Tremors, dyspnea
– Bloody discharge
from body orifices
? Chronic (rare)
– Pharyngeal and lingual edema
– Death from asphyxiation

Differential Diagnosis
(Ruminants)
? Blackleg
? Botulism
? Poisoning
– Plants, heavy metal, snake bite
? Lightning strike
? Peracute babesiosis

Equine
? Acute
– Fever, anorexia, colic,
bloody diarrhea
– Swelling in neck
? Dyspnea
? Death from asphyxiation
– Death in 1 to 3 days
? Insect bite
– Hot, painful swelling at site
Photo from WHO

Pigs
? Acute disease uncommon
? Subacute to chronic
– Localized swelling of throat
? Dyspnea
? Asphyxiation
– Anorexia
– Vomiting, diarrhea

Carnivores
? Relatively resistant
– Ingestion of contaminated raw meat
? Subacute to chronic
– 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 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

Case Study:
Canine Anthrax
? Golden retriever,
6 yrs old
– 2 day history of ptyalism
and swelling of
right front leg
– Temperature 106°F,
elevated WBC
– Died same day
? Necropsy
– Splenomegaly, friable liver, blood in stomach
– 2x2 cm raised hemorrhagic leg wound
– Some pulmonary congestion

Case Study:
Canine Anthrax
? 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

Vaccination
? Livestock in endemic areas
? Sterne strain
– Live encapsulated spore vaccine
? No U.S. vaccine for pets
– Used in other countries
– Adjuvant may cause reactions
? Working dogs may be at risk

Animals and Anthrax
? Anthrax should always be high on
differential list when:
– High mortality rates observed
in herbivores
– Sudden deaths with unclotted blood
from orifices occur
– Localized edema observed
? Especially neck of pigs or dogs

? Report to authorities
? Quarantine the area
? Do not open carcass
? Minimize contact
? Wear protective clothing
– Latex gloves, face mask

? Local regulations determine
carcass disposal options
– Incineration
– Deep burial
? Decontaminate soil
? Remove organic
material and
disinfect structures

? Isolate sick animals
? Discourage scavengers
? Use insect control or repellants
? Prophylactic antibiotics
? Vaccination
– In endemic areas
– Endangered animals

Disinfection
? Spores resistant to heat, sunlight,
drying and many disinfectants
? Disinfectants
– Formaldehyde (5%)
– Glutaraldehyde (2%)
– Sodium hydroxide (NaOH) (10%)
– Bleach
? Gas or heat sterilization
? Gamma radiation

Disinfection
? 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
? 50 kg of spores
– Urban area of 5 million
– Estimated impact
? 250,000 cases of anthrax
? 100,000 deaths
? 100 kg of spores
– Upwind of Wash D.C.
– Estimated impact
? 130,000 to 3 million deaths

Additional Resources
? World Organization for Animal Health
(OIE)
– www.oie.int
? U.S. Department of Agriculture (USDA)
– www.aphis.usda.gov
? Center for Food Security and Public Health
– www.cfsph.iastate.edu
? USAHA Foreign Animal Diseases
(“The Gray Book”)
– www.aphis.usda.gov/emergency_response/do
wnloads/nahems/fad.pdf

Acknowledgments
Development of this presentation was made possible
through grants provided to
the Center for Food Security and Public Health at Iowa
State University, College of Veterinary Medicine from
the Centers for Disease Control and Prevention,
the U.S. Department of Agriculture,
the Iowa Homeland Security and
Emergency Management Division, and the
Multi-State Partnership for Security in Agriculture.
Authors: Radford Davis, DVM, MPH, DACVPM; Jamie Snow, DVM; Katie Steneroden, DVM;
Anna Rovid Spickler, DVM, PhD;
Reviewers: Dipa Brahmbhatt, VMD; Katie Spaulding, BS; Glenda Dvorak, DVM, MPH,
DACVPM; Kerry Leedom Larson, DVM, MPH, PhD

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