1. Anthrax Malignant pustule, malignant edema, Woolsorters’ Disease, Ragpickers’Disease, Maladi Charbon, Splenic Fever Infectious and Tropical Pediatric Division Department of Child Health Medical Faculty University of Sumatera Utara

2. Overview Organism History Epidemiology Transmission Disease in Human

3. The Organism

4. Bacillus anthracis Large, gram positive non-motile rod Vegetative form and spores Nearly worldwide distribution Over 1,200 strains

5. The 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

6. History

7. Sverdlovsk, 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

8. 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 − White populations untouched

9. Aum 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

10. 2001 Anthrax Letters

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

13. Anthrax Cases, 2001 7 month old boy Visited ABC Newsroom Cutaneous lesion Initial diagnosis: − spider bite Punch biopsies confirmed anthrax

14. Anthrax 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

15. Anthrax Cases, 2001 Antimicrobial prophylaxis − Ciprofloxacin  5,342 prescribed  60 day regime − 44% compliance − 57% suffered side effects

16. Transmission

17. Human Transmission Industry − Tanneries − Textile mills − Wool sorters − Bone processors − Slaughterhouses

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

19. Animal Transmission Most commonly infected by ingestion from contaminated soil or contaminated feed or bone meal

20. Epidemiology

21. 20,000-100,000 cases estimated globally/year http://www.vetmed.lsu.edu/whocc/mp_world.htm

22. Anthrax in U.S. Cutaneous anthrax − Early 1900’s: 200 cases annually − Late 1900’s: 6 cases annually Inhalation anthrax − 20 th century: 18 cases/16 fatal

23. 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

24. Disease in Human

25. Human Disease Three forms − Cutaneous − Inhalation − Gastrointestinal

26. Cutaneous 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

27. Day 2 Day 6 Day 4

28. Day 6

29. Cutaneous Anthrax Case fatality rate 5-20% Untreated – septicemia and death Edema can lead to death from asphyxiation Day 10

30. 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

31. Gastrointestinal 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

32. Minnesota, 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

33. Inhalation 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)

35. Diagnosis in Humans Isolation of B. anthracis − Blood, skin − Respiratory secretions Serology ELISA Nasal swabs − Screening tool

36. Diagnosis in Humans Anthrax quick ELISA test − New test approved by FDA on June 7 th, 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

37. 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

39. Vaccination Cell-free filtrate Licensed in 1970 At risk − Wool mill workers − Veterinarians − Lab workers − Livestock handlers − Military personnel

40. Vaccine 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

41. Vaccine Schedule 3 injections at two-week intervals 3 injections 6 months apart Annual booster