By Joanne Beilby
INTRODUCTION
On the 4th of March, 2007, a community social event in Australia was inadvertently supplied with Anthrax infected beef carcasses by a local farmer, for use at a spit roast. Coupled with insufficient cooking and the heat resistant properties of the Anthrax spores, consumption of the beef resulted in Gastrointestinal Anthrax infection in several people. They presented to Newcastle Regional Hospital the 8th of March, 2007 for treatment and the diagnosis was made by the Local Medical Officer and reported to the National Notifiable Diseases Surveillance System. Concurrently, the local veterinarian was called to sick beef cattle in the area and the same diagnosis and notification was made.
The purpose of this paper is to review non-bioterrorism based global incidences of Anthrax infection since the 1960s and compare Australian primary health care response to an outbreak of this highly infectious disease, with practices in developing countries. Particular reference will be made to the economic impacts of the disease with regard to the meat industry. The illustrative purposes of which are to demonstrate the high level of surveillance and comprehensive primary, secondary, tertiary and quaternary health care required to achieve a desired level of preventative health care, and the difficulties this poses for a developing country.
What is Anthrax?
Bacillus anthracis is a bacterial soil dwelling organism. It is sporulating, making it highly resistant to environmental stresses such as heat, cold, pH, disinfection, irradiation and other adverse conditions. The survival of the spores is made possible by several thick and impermeable protein layers surrounding the bacterium. As a result, B. anthracis can lie dormant awaiting favourable conditions for tens of years.
Bacillus anthracis causes an aggressive infectious disease called Bacillus Anthracosis and known as Anthrax. Anthrax is characterized by rapid and high mortality. It generally occurs in herd animals such as cows, sheep, goats, camels and antelopes. It can also infect humans via contact or from consumption of infected animals or animal products, and bioterrorism agents.
TRANSMISSION & VECTORS
Epidemiology: How is Anthrax transmitted?
The epidemiology of Anthrax in humans is both agricultural and industrial.[i] Initially, animals can ingest Anthrax spores when grazing contaminated ground. Anthrax is then shed by a dead or dying animal infected with the disease, providing a source of infection for other animals and humans. Anthrax spores are heat resistant making it possible to contract the disease via ingestion of insufficiently cooked contaminated meat or via contact with an open skin wound, eyes or mucosal surface. Anthrax spores can be inhaled into the respiratory tract of people handling infected animal hides, hair, wool or meat, however transmission in this manner in an agricultural setting is rare.[ii]
Anthrax & Food
All continents are disease-endemic for Anthrax in tropical and sub-temperate areas. Globally, there have been numerous cases of Anthrax infection via the meat supply during the last fifty years. In the 1960s in the Bekaa Valley, Lebanon, several cases were reported due to consumption of raw goat meat infected with Anthrax.[iii] In Zimbabwe in the 1980s, over 9000 patients were infected with gastrointestinal Anthrax.[iv] In the 1980s, Thailand reported 74 cases due to consumption of infected water buffalo, bull and cow meat,[v] and in the year 2000, in Minnesota, USA, locally supplied Anthrax contaminated beef was consumed resulting in infection.[vi] In 2006, the Dobritch region of Bulgaria reported one case of Anthrax due to unvaccinated sheep.[vii]
Incidences of gastro-intestinal Anthrax have occurred in Iran, India, Thailand, Gambia and Uganda. In 1979, in Ekaterinburg, Russia (then Sverdlovsk), a large epidemic of Anthrax resulted in 60 cases and forty-two deaths.[viii] In Peru, from 2001-2006, 30-50 cases of Anthrax occurred annually. In 2007, nine cases of human cutaneous Anthrax occurred in the northern Province of Lambayeque, including one death.[ix]
In most industrialized countries during an outbreak, livestock are vaccinated against Anthrax. This is rarely the case in the developing world. Practices of slaughtering and eating infected animals in some developing countries are considered preferential to wasting scarce resources, hence the increased prevalence of outbreaks in these countries.
An example of an incidence of intentional consumption of infected meat came from India in 1989. Infection in an animal is highly visible due to massive bacteremia and it is highly unlikely that the Indian villagers consumed the meat unaware of its infectious status. The outbreak resulted in thirty cases of human anthrax in Ramabhadrapuram village of Chittoor district in Andhra Pradesh. All of the infected were very poor Harijans. Of the 30 people infected, 25% died. They were all women with gastro-intestinal Anthrax.[x]
In Chiang Mai in 1966, an incidence of Anthrax infection resulted from unintentional consumption of undercooked, infected meat by people who were unaware of the disease state of the animal, and the danger of exposure to infectious material. In Indonesia, in 2007, 10 confirmed reports of Anthrax amid reports of up to 761 cases emerged as a result of villagers slaughtering and consuming infected buffalo. Anthrax outbreaks were also confirmed in Guinea-Bissau, India, Indonesia, Krygyzstan, Mongolia, Peru, Togo, the United States, Zambia and Zimbabwe.
The lack of PHC is easily inferred by the incidence and nature of Anthrax outbreaks in these countries. Basic education and empowerment could easily have avoided many of these incidents. Unlike Australia, the response of many developing countries to an Anthrax outbreak is severely limited by resource constraints. There is a critical lack of financing and political commitment to develop and implement comprehensive PHC policy, particularly in the areas of complementary education. Supportive programmes in veterinary skills and safe food handling and preparation need to be developed and health promotion advanced. Further to this, empowering and educating locals to act as surveillance for the disease, monitoring and evaluating the safe handling of infected carcasses, would develop the participatory entitlements of people to ensure PHC in their community. Simple and relatively inexpensive programmes such as these would reduce the requirement for costly emergency responses to Anthrax outbreaks and reduce loss of life.
Anthrax Disease Manifestations in Humans
Anthrax infection in humans can range from sub-clinical to fatal and it is thought that the disease manifestation is closely related to a dose of viable spores and the immune state of the host.[xi] Anthrax is an under-diagnosed disease of rural areas that is manifested in humans in four ways:
1. Pulmonary (or inhalation) Anthrax;
2. Gastrointestinal Anthrax;
3. Cutaneous Anthrax; and
4. Anthrax meningitis.
Cutaneous anthrax is generally well recognized however Gastrointestinal Anthrax and Pulmonary Anthrax are less so. Due to its wide presentation, the extent of Anthrax infection in human populations is considered to be under appreciated and under reported, and the inclusion of Anthrax in disease differentials must be emphasized. All four syndromes have differing presentations and require immediate notification to local public health authorities.
Pulmonary Anthrax
Pulmonary Anthrax results from the inhalation of Anthrax spores into the lungs and respiratory tract. The incubation period is from 1 to 7 days however periods of up to 60 days have been documented. Initial symptoms lasting from a few hours to several days include fever, cough, headache, chills, emesis, dyspnea, chest pain, abdominal pain and weakness.[xii]
The next stage of the illness may be preceded by apparent improvement but quickly lapses into the more diagnostic symptoms of pyrexia, diaphoresis, cyanosis, hypotension, lymphadenopathy, shock and finally death. The onset of second stage symptoms may precede death by only a few hours.
Time from onset of initial symptoms to death averages three days. Early diagnosis (see Fig. 2) and treatment may increase the likelihood of survival however current statistics indicate 95% mortality.[xiii]
Gastrointestinal Anthrax
Gastrointestinal Anthrax results from the ingestion of Anthrax spores, usually via the consumption of contaminated meat. Gastrointestinal Anthrax is further sub-categorized into Oropharyngeal Anthrax and Adominal Anthrax. The presentation of Gastrointestinal Anthrax in Australia is rare and most PHC physicians will not be familiar with the primary presentation. The former indicates the intake of spores into the upper gastrointestinal tract and is characterized by oral or oesophageal ulcer, regional lymphadenopathy and eventually sepsis. Abdominal Gastrointestinal Anthrax is characterized by nausea, vomiting, bloody diarrhea, acute abdomen and sepsis. Abdominal Anthrax is due to the ingestion of Anthrax spores into the lower gastrointestinal tract.[xiv]
Both Oropharyngeal Anthrax and Abdominal Anthrax result in approx 50% mortality with a risk of secondary Pulmonary Anthrax and Anthrax meningitis.[xv]
Cutaneous Anthrax
Cutaneous Anthrax is the most common manifestation of the disease and results from Anthrax spore penetration of an open skin wound, (often located on the limbs or face). The initial symptom is a small, usually pruritic papule that transforms into an ulcer of less than two cm in diameter within two days. The ulcer progressively develops into a small vesicle and finally to a black painless eschar, surrounded by localized oedematous tissue.
Over the following one to two weeks, the eschar will desiccate and wither. Regional lymphadenopathy or lymphadenitis may also occur and secondary sepsis may develop. Cutaneous Anthrax has a mortality rate of approx 20% in the absence of therapy; however this drops to 1% given timely antibiotic treatment.[xvi]
Anthrax Meningitis
Anthrax Meningitis may result as a secondary complication of any of the aforementioned forms of Anthrax. Symptoms include headache and meningismus. Anthrax meningitis carries a near 100% mortality.[xvii]
Management of Affected Patients
Considerations & Requirements
The progression of Anthrax is rapid with high mortality. Therefore treatment should not be withheld pending laboratory results. Empirical therapy should be started immediately as any delay in treatment may increase the risk of mortality significantly. Intensive medical support including hospitalization, airway management, haemodynamic support, and organ system support may be necessary. Palliative care may be required.[xviii]
First-Line Treatments
Environmental Anthrax is usually sensitive to penicillin however bioterrorism strains will likely be resistant. Therefore, recommended first-line therapy is ciprofloxacin with doxycycline a suitable alternative. Treatment regime should continue for sixty days and sensitivity testing used to identify potentially resistant strains.[xix] For a tabulated summary of clinical findings, treatment and prognosis for Anthrax infection see Table 2.
ANTHRAX DISEASE MANIFESTATION IN ANIMALS
Symptoms, Signs and Tests in Herd Animals
Anthrax runs its course quickly in animals and detection of infection prior to death can consequently be difficult. It is therefore advisable to rule out Anthrax as the cause of death before the carcass is handled by others. This is crucial if the animal has died suddenly without having been observed as ill and if the meat is usually destined for consumption.
Clinical signs and symptoms of Anthrax in Herd Animals[xx]:
Ø Fever
Ø Diarrhoea
Ø Muscle tremors
Ø Respiratory distress
Ø Abortion
Ø Decline in milk production
Ø Convulsions
Ø Bloody discharge
Ø Swelling in the neck and shoulder areas
Herd animals infected with Anthrax usually die within 48 to 72 hours. Signs of the infection will be visible to farmers, handlers and butchers. After death, many visible signs of infection persist, especially mass hemorrhaging from the orifices as a symptom of clotting failure due to toxin released by Bacillus anthracis.[xxi] There may be rapid bloating and an absence of rigor mortis.[xxii] Veterinarians confirm Anthrax infection via blood smear stained with New Methylene Blue and analysed at a diagnostic laboratory or in the field by a District Veterinary Officer.
TESTING & DIAGNOSIS
Anthrax Testing in Humans
Several tests can be used to confirm Anthrax and to quantify the amount and stage of bacterial infection present.[xxiii]
Ø Tissue Histology
Ø Blood Cultures
Ø Cerebrospinal Fluid Micro and Culture
Ø Polymerase Chain Reaction (PCR)
Ø Nasal Swab
Ø Antibody Quantification
Ø Infectious Serology
Such tests are performed under strict conditions by microbiologists, molecular pathologists and hematologists at a diagnostic laboratory.[xxiv]
PUBLIC HEALTH: PREVENTION & VACCINES
Prevention for Humans: Vaccines
Currently, there is no vaccine against Anthrax that is approved for use in Australia. An FDA approved vaccine may be imported under special circumstances for those exposed to Anthrax spores: laboratory workers, abattoir workers, animal handlers, or professional cleaners of contaminated sites.[xxv]
The FDA approved vaccine contains an antigen from a non-pathogenic strain, (the Sterne strain).[xxvi] A series of six injections are required over an 18 month period to confer immunity. Some short term side effects of the vaccine can include localized reactions, muscle soreness and headaches. Reported long term side effects are yet to be confirmed.
Farmer & Handler OH&S
As prevention is the most effective method of controlling Anthrax infection, avoidance of contaminated livestock, animal produce and under-cooked meat is top priority. Furthermore, compliance with public health measures needs to observe the following: compliance with managing authorities, compliance with drug/vaccine regimes, maintenance of quarantine, responsible handling of infected animals, complete avoidance of contaminated meat and meat products.
IMPLICATIONS FOR THE meat INDUSTRY
The ramifications of an Anthrax outbreak for the commercial meat industry are very serious. Compromise of reputation as a safe and reliable meat exporter will see negative demand shocks affect the market in both the domestic and export sectors. A ban on meat exports will impair trade relations for years to come and loss of commercial viability for farmers, suppliers and associated businesses with see many suffering hardship and a loss of revenue. At a macro-economic level, price slumps across the market will be reflected in GDP, unemployment statistics and the CPI will increases as affordability is reduced by the absence of domestic suppliers in the market.
A single contaminated export of animal product can cripple the whole market and lead to huge economic losses. Correct management is vital. As a notifiable disease, Anthrax can be effectively and efficiently tracked by epidemiological authorities via identification tagging, tests on stomach contents, soil tests and DNA techniques.
An Anthrax outbreak would have a devastating effect on the domestic and export red meat and livestock industries. This was evidenced in 1997 when a multi-state outbreak in Victoria New South Wales
EU | West Europe | East Europe | USA | East USA | West Canada | East Canada | West Japan | Taiwan | Korea South | Other Asia | Middle East | Other Dest | Total | |
Beef & Veal | 8456 | 7 | 12537 | 196715 | 98552 | 6171 | 3437 | 405796 | 149663 | 28601 | 23922 | 3312 | 16762 | 953932 |
Buffalo | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 22 | 22 |
Mutton | 6714 | 568 | 12290 | 12357 | 6457 | 1786 | 27 | 6819 | 800 | 9521 | 15128 | 43071 | 47343 | 162881 |
Lamb | 11758 | 2450 | 868 | 24959 | 14876 | 1788 | 2461 | 11879 | 1639 | 1055 | 19104 | 17685 | 36185 | 146706 |
Goat | 0 | 0 | 0 | 8550 | 2782 | 669 | 382 | 157 | 149 | 5160 | 89 | 0 | 1581 | 19519 |
Pork | 0 | 0 | 10 | 0 | 0 | 0 | 0 | 1761 | 1331 | 40 | 26034 | 1 | 1568 | 30745 |
Fancy Meat | 40 | 0 | 20627 | 1506 | 2154 | 14 | 1 | 26128 | 20001 | 2207 | 40929 | 7217 | 18061 | 138886 |
Total | 26969 | 3025 | 46333 | 244086 | 124821 | 10429 | 6308 | 452540 | 173583 | 46585 | 125205 | 71287 | 121524 | 1452693 |
Prevention of Food Supply Contamination
Prevention of gastrointestinal Anthrax primarily relies on the avoidance of raw or partially cooked meat from any source. The carcasses of diseased animals carry the vegetative form of the bacterium and consumption may result in human infection.
Prevention and control of the disease in livestock is critical to reduce the incidence of Anthrax outbreaks. Sanitary farming and manufacturing practices coupled with a comprehensive vaccination programme maximize risk reduction strategies.[xxvii] Should infection of livestock occur, incineration of infected carcasses in burial pits is mandatory. This facilitates heat sterilization of the underlying soil. Site cleanup should involve the use of chemical agents such as peroxide and chlorine dioxide.
INFORMation: RESPONSIBILITY & VIGILANCE
Community Information
The dissemination and control of information should be handled in a careful and orderly manner. Once an outbreak is confirmed by a District Veterinary Officer and notified to the Chief Veterinary Officer according to the AUSVET Emergency Plan, stakeholders and affected health bodies such as hospitals, local medical officers and diagnostic laboratories should be informed and regularly updated. Information to the general public should follow.
Managing Outbreak Severity
Environmental tests should be conducted in the affected and surrounding areas and appropriate measures taken for decontamination. Infected animals should be isolated and treated, and carcasses decomposed according to protocol. All contaminated areas are to be cleaned. Animal products should be tested for spores and export suspended if required.
Industry Involvement
The Australian CVO and industry should cooperatively establish a strategic plan for management of the outbreak. All trading partners should be informed of the outbreak by a nominated industry spokesperson. No further business can be done until health authorities have confirmed the complete closure of the outbreak.
Public Notification
Public enquiries should be directed to a special helpline coordinated with appropriate bodies: hospitals, emergency services, and detection squad. Informing people via news telecasts is quick and efficient. Support updates on radio and in newspapers should target the local community and provide hotline details. A campaign focused on preventive measures and information is crucial. Information outlets should be placed at a few locations for direct public enquiries.
Key Action Plan Objectives for Management of Anthrax Outbreak |
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Statistics in brief
As evidenced by the table below, Australian states and territories have a low prevalence of Bacillus anthracis. They are well prepared to curtail and control outbreaks and thus the incidence of disease is low. Over the previous ten years there has been only one outbreak. Community training and preparedness should be regularly reviewed to ensure optimal response and management and to avoid complacency.
Table 3: Number of notifications of Anthrax, received from State and Territory health authorities in the period of 1991 to 2006 |
ACT | NSW | NT | Qld | SA | Tas | Vic | WA | Aust | |
2001 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
2002 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
2003 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
2004 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
2005 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
2006 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 0 | 1 |
Source: Communicable Diseases Authority, May 2007.
Discussion
Preventing Anthrax in animals prevents Anthrax in humans. Recognizing this is the first step to minimizing and preventing the incidence of disease in the human population. In Australian communities at risk, such as the Hunter Valley community considered in this report, a well-prepared multi-agency response plan provides immeasurable advantage as does a well educated general public.
Most developing countries will have less developed meat or meat product export sectors than Australia, as this industry is high cost in infrastructure, land and trade requirements. Therefore the economic impact of contamination of the meat supply may be barely felt on a macroeconomic level. However association of Anthrax with animal or hide products in any developing country will have significant potential to impede economic growth in cash markets, tourist markets and reliability of the domestic consumption markets. This has the potential to make considerable impact in the lives of those who need employment opportunities the most, the vulnerable unskilled or low skilled worker.
During an Anthrax outbreak, there is not time to waste. Precise management and execution of response is critical for containment and good health outcomes. The cornerstones of comprehensive primary health care are required immediately in these situations. Experienced epidemiologists, medical and veterinary clinical staff at the PHC and tertiary level, clinical specialists such as pathologists, nursing staff, public relations officers and exposure management teams all need to work together and provide urgent health care and community education to ensure maximum compliance with protocols and to enable containment to proceed with minimum diversion. Safety, prevention and vigilance must be a strong and clear message. Responsible surveillance, prevention and control of Anthrax outbreaks relies on rapid and coordinated multi-agency response at the emergent level. Adequate resourcing is required to expedite efficient and effective management of a potentially life threatening situation.
CONCLUSION
We are fortunate in Australia to have the resources and medical and political expediency to apply ‘the gold standard’ in communicable disease management. Even with these strengths our economic stability as a supplier of meat products domestically and to the world can and has been threatened. Surveillance is an expensive but necessary evil in the protection of economies and consumers and developing countries desperately need to protect their economic opportunities for the poor. Given the heavy demand on resources that public health and comprehensive primary health care management of Anthrax requires, outbreaks in developing countries are understandably less preventable, more frequent and more severe. However, it is precisely this deleterious paucity of multi-agency, comprehensive PHC, that is well-financed, self-sustaining, broad based, educative and supportive that fails to safeguard communities and results in costly accidents and loss of life.
CAUSATIVE ORGANISM | SYMPTOMS | TREATMENT | ||||
Syndrome | Incubation | Early | Late | First-line | Prognosis | |
Anthrax (Bacillus anthracis; gram positive, sporulating) | Pulmonary (Inhalational) | 1-7 days | Fever, chills, nausea, vomiting, headache, cough, dyspnoea, chest pain, abdominal pain. | High fever, diaphoresis, cyanosis, hypotension, lymphadenopathy, shock, death (within 3 days of late symptom onset). | Ciprofloxacin, 400 mg IV q 12 h or Doxycycline, 200 mg IV, then 100 mg IV q 12 h. Without use of vaccine, treat for 60 days; with use of vaccine, treat for 30 days. As patient improves begin oral therapy. | 95% Mortality |
Gastrointestinal (Upper) | 1-7 days | Oral or oesophageal ulcer. | Regional lymphadenopathy, sepsis. | As above | 50% Mortality | |
Gastrointestinal (Lower) | 1-7 days | Nausea & vomiting, diarrhea (bloody). | Acute abdomen, sepsis. | As above | 50% Mortality | |
Cutaneous | 2 days | Pruritic papule→ ulcer→vesicle→ painless eschar. | Regional lymphadenopathy, occasional sepsis (1-2 weeks post onset) | As above | 20% Mortality without treatment, 1% Mortality with treatment. |
Table 1. Clinical Findings, Treatment and Prognosis for Anthrax Infection.[xxviii]
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NNii. Vaccine Information http://www.immunizationinfo.org/vaccineInfo/vaccine_detail.cfv?id=25”
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http://www.hpa.org.uk/infections/topics_az/deliberate_release/Anthrax/OrganismDetails.asp?Source=Professional&Agent=Anthrax&Document=OrganismDetails
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Post Graduate Subject Reading Lists:
International Health and Primary Health Care (2010)
Centre for International Health - Curtin University
Centre for International Health - Curtin University
Economics of Health Financing (2011)
Centre for International Health - Curtin University
Centre for International Health - Curtin University
Photographs:
Fig 1 http://i.cnn.net/cnn/2002/US/03/26/Anthrax.investigation/story.microscope.jpg
Fig 2 www.search.com/reference/Anthrax
[iii] CDC, Emerging infectious diseases
[iv] Ibid
[v] MEDSCAPE website, article 437391
[vi] Ibid
[vii] WHO/Europe, 2006
[ix] International Survellliance Reports, 2008, Dept of Health and Ageing. www.health.gov.au
[xi] Anthrax of the Gastro-intestinal tract
[xii] Kasper, 2005
[xiii] Stone & Humphries, 2004
[xv] Schlossberg, 1999.
[xvi] Stone & Humphries, 2004
[xvii] Ibid
[xviii] Kasper, 2005
[xix] Stone & Humphries, 2004
[xx] National Agricultural Bio-security Center, Anthrax fact sheet
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