Anthrax Malignant Pustule, Malignant Edema, Woolsorters’ Disease, Ragpickers’ Disease, Maladi Charbon, Splenic Fever
Mar 27, 2015
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
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The OrganismThe Organism
• Bacillus anthracis • Large, gram positive
non-motile rod• Vegetative form and
spores• Nearly worldwide
distribution• Over 1,200 strains
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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
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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
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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
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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
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2001 Anthrax Letters2001 Anthrax Letters
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Center for Food Security and Public Health Iowa State University - 2004
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
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Anthrax Cases, 2001Anthrax Cases, 2001
• 7 month old boy• Visited ABC Newsroom• Cutaneous lesion• Initial diagnosis:
− spider bite
• Punch biopsies confirmed anthrax
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Anthrax Cases, 2001Anthrax Cases, 2001
• 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
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Anthrax Cases, 2001Anthrax Cases, 2001
• Antimicrobial prophylaxis−Ciprofloxacin
5,342 prescribed 60 day regime
−44% compliance−57% suffered side effects
TransmissionTransmission
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Human TransmissionHuman Transmission
• Industry−Tanneries−Textile mills−Wool sorters−Bone processors−Slaughterhouses
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Human TransmissionHuman Transmission
• Cutaneous−Contact with infected
tissues, wool, hide, soil−Biting flies
• Inhalational−Tanning hides,
processing wool or bone• Gastrointestinal
−Undercooked meat
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Animal TransmissionAnimal Transmission
• Most commonly infected by ingestion from contaminated soil or contaminated feed or bone meal
EpidemiologyEpidemiology
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20,000-100,000 cases estimated globally/yearhttp://www.vetmed.lsu.edu/whocc/mp_world.htm
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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
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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
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Human DiseaseHuman Disease
• Three forms−Cutaneous− Inhalation−Gastrointestinal
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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
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Day 2
Day 6
Day 4
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Day 4
Day 6
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Cutaneous AnthraxCutaneous Anthrax
• Case fatality rate 5-20%• Untreated – septicemia and death• Edema can lead to death from
asphyxiation
Day 10
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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
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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
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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
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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)
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Diagnosis in HumansDiagnosis in Humans
• Isolation of B. anthracis−Blood, skin−Respiratory secretions
• Serology• ELISA• Nasal swabs
−Screening tool
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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
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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
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Center for Food Security and Public Health Iowa State University - 2004
VaccinationVaccination
• Cell-free filtrate• Licensed in 1970• At risk
−Wool mill workers−Veterinarians−Lab workers −Livestock handlers−Military personnel
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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
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Vaccine ScheduleVaccine Schedule
• 3 injections at two-week intervals• 3 injections 6 months apart• Annual booster
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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
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VaccinationVaccination
Animals and Anthrax Animals and Anthrax
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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
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RuminantsRuminants
• Peracute infection−Rapid onset−Sudden death−Bloody discharge
from body orifices− Incomplete rigor mortis−Rapidly bloat
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RuminantsRuminants
• Acute infection: 1-3 days −Fever, anorexia−Decreased rumination−Muscle tremors−Dyspnea−Abortions−Disorientation−Bleeding from orifices−Hemorrhages on internal organs
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RuminantsRuminants
• Chronic infection−Pharyngeal and lingual edema−Ventral edema −Death from asphyxiation
• Treatment successful if started early
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Differential DiagnosisDifferential Diagnosis
• Blackleg• Botulism• Poisoning
−Plants, heavy metal, snake bite
• Lightening strike• Peracute babesiosis
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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
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SwineSwine
• Sudden death without symptoms• Localized swelling of throat• Death by asphyxiation• Ingestion of spores
−Anorexia, vomiting, enteritis
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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
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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
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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
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Case-ReportMississippi, 1991
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
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Case-ReportMississippi, 1991
Case-ReportMississippi, 1991
• 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
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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
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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
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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
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Prevention and ControlPrevention and Control
• Burn or bury carcasses,bedding, other materials
• Decontaminate soil • Remove organic
material and disinfect structures
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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
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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
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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
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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.
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AcknowledgmentsAcknowledgments
Author:
Co-authors:
Radford Davis, DVM, MPH
Jamie Snow, DVM, MPHKatie Steneroden, DVM, MPH