1. Anthrax Awareness
 By
 Dr.Ashok laddha
 MBBS, PGDC ,PGDD, PGDEM, AFIH Dip.
Workplace Health and safety, MBA-HA(In –
Progress)

2. Overview
 Anthrax in humans is rare unless the spores are spread on
purpose. It became a concern in the United States in 2001,
when 22 cases occurred as a result of bioterrorism. Most of
those cases affected postal workers and media employees
who were exposed to spores when handling mail.
 Most cases of anthrax occur in livestock, such as cattle,
horses, sheep, and goats. Anthrax spores in the soil can
infect animals who eat plants growing in the soil. People
can be exposed to spores in infected animal products or
meat.
 people can get anthrax from handling animal skins or
products made out of animal skins from parts of the world
where anthrax is more common

3. Anthrax
 Anthrax is an infectious and potentially fatal disease caused
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by the bacterium Bacillus anthracis. It spreads when the
anthrax spores are inhaled, ingested, or come into contact
with the skin lesion on a host.
a German physician and scientist, Dr. Robert Koch, who
proved that the anthrax bacterium was the cause of a
disease that affected farm animals in his community
anthrax organisms exist in a dormant form called spores
These spores are very hard and difficult to destroy
The spores have been known to survive in the soil for as
long as 48 years.
it affects both humans and animals.

4. Anthrax Facts
 Anthrax is an infection by bacteria transmitted from
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animals.
Anthrax causes skin, lung, and bowel disease and
can be deadly.
Anthrax is diagnosed by cultures from infected
tissues.
Anthrax is treated by antibiotics.
Anthrax can be prevented.
Sadly, the greatest threat of anthrax today is
through a bioterrorist attack.
Federal, state, and local agencies are working hard
to deal with this bioterrorist threat.

5. Bacteriology
 Bacillus anthracis is a large, gram-positive,
aerobic, spore-forming bacillus that measures
1.0 to 1.5 μm by 3.0 to 10.0 μm.1
 Unlike other saprobic bacillus species (B.
subtilis and B. cereus), it is nonmotile, is
nonhemolytic on sheep's-blood agar, grows
readily at a temperature of 37°C, and forms
large colonies with irregularly tapered
outgrowths (a “Medusa's head” appearance)

6. Pathogenesis
 The principal virulence factors of B. anthracis are
encoded on two plasmids — one involved in the
synthesis of a polyglutamyl capsule that inhibits
phagocytosis of vegetative forms and the other
bearing the genes for the synthesis of the
exotoxins.
 B (binding) protein that is necessary for entry
into the host cell and an A (enzymatically active)
protein. The B component is known as the
protective antigen and is common to both
toxins.

7. Pathogenesis
 The A component of the edema toxin is the edema
factor, a calmodulin-dependent adenylate cyclase
that is responsible for the prominent edema at sites
of infection,
 The A component of the second toxin, lethal toxin, is
a zinc metalloprotease that inactivates mitogenactivated protein kinase kinase, leading to the
inhibition of intracellular signaling. Lethal toxin
stimulates the release by macrophages of tumor
necrosis factor α and interleukin-1β — a mechanism
that appears to contribute to the sudden death from
toxic effects that occurs in animals with high degrees
of bacteremia

8. Who is at Risk
 People with Certain Jobs
 Travelers
 People Who Make or Play Animal Hide Drums

9. People with Certain Jobs
 People with certain jobs may be at an increased
risk of coming in contact with anthrax spores.
These include:
 Veterinarians
 Laboratory professionals
 Livestock producers
 People who handle animal products
 Mail handlers, military personnel, and response
workers who may be exposed during a bioterror
event involving anthrax spores

10. Travelers
 Visitors to countries where anthrax is common can get sick
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with anthrax if they have contact with infected animal
carcasses or eat meat from animals that were sick when
slaughtered. They can also get sick if they handle animal
parts, such as hides, or products made from those animal
parts, such as animal hide drums. Anthrax is most common
in agricultural regions of
Central and South America
Sub-Saharan Africa
Central and southwestern Asia
Southern and eastern Europe
The Caribbean

11. People Who Make or Play Animal Hide
Drums
 While the risk of exposure from handling an
animal hide drum is low, drums made in
countries where anthrax is common, or drums
made from hides imported from those countries,
have been known to make people sick.
 No tests are available to determine if animal
products are free from contamination with
anthrax spores. Be sure that any hide used to
make a drum has been removed and processed
according to existing government regulations.

12. Incubation period
 The incubation period (the period between
contact with anthrax and the start of
symptoms) may be relatively short
 I to 7 days, although incubation periods up to
60 days are possible. (In the Sverdlovsk
outbreak, incubation periods extended up to
43 days.)
 incubation period for anthrax is quite variable
and it may be weeks before an infected
individual feels sick.

13. Types of Anthrax
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 Cutaneous anthrax
 Inhalation anthrax
 Gastrointestinal anthrax
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14. Epidemiology--Mortality
 Inhalational 86-100% (despite treatment)
 Era of crude intensive supportive care
 Cutaneous <5% (treated) – 20% (untreated)
 GI approaches 100%

16. Cutaneous Anthrax
 This form accounts for over 95% of anthrax case
 1-The cutaneous (skin) form of anthrax starts as a red-brown
raised spot that enlarges with considerable redness around it,
blistering, and hardening.
 2-The center of the spot then shows an ulcer crater with bloodtinged drainage and the formation of a black crust called an
eschar.
 3-Local lymphadenpathy
 4-. Symptoms include muscle aches and pain, headache, fever,
nausea, and vomiting. The illness usually resolves in about six
weeks, but deaths may occur if patients do not receive
appropriate antibiotics.
 This form accounts for over 95% of anthrax case

17. Mode of transmission
 By contact with tissues of animals such as
cattle, horses, pigs and others dying of the
disease, or in processing after death
 By contact with contaminated hair, wool,
hides or products made from them (Hideporter’s disease)
 By contact with soil associated with infected
animals and contaminated bone meal used in
some gardening products possibly by biting
flies that have fed on infected animals

18. Stages of Cutaneous Anthrax
 papular stage
 vesicular stage with a blister that often
becomes haemorrhagic
 eschar stage that appears two to six days
after the haemorrhagic vesicle dries to
become a depressed black scab (malignant
pustule) which may have surrounding redness
and extensive oedema (swelling).

19. Ulcer and Vesicle ring
Cutaneous Anthrax

20. Black Eschars
Cutaneous Anthrax
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21. Pulmonary Anthrax
 The first symptoms are subtle, gradual and flu-like (influenza). In
a few days, however, the illness worsens and there may be severe
respiratory distress. Shock, coma, and death follow. Inhalation
anthrax does not cause a true pneumonia. In fact, the spores get
picked in the lungs up by scavenger cells called macrophages.
Most of the spores are killed. Unfortunately, some survive and
are transported to glands in the chest called lymph nodes. In the
lymph nodes, the spores that survive multiply, produce deadly
toxins, and spread throughout the body. Severe hemorrhage and
tissue death (necrosis) occurs in these lymph nodes in the chest.
From there, the disease spreads to the adjacent lungs and the
rest of the body.
 Inhalation anthrax is a very serious disease, and unfortunately,
most affected individuals will die even if they get appropriate
antibiotics. Why is this so? The antibiotics are effective in killing
the bacteria, but they do not destroy the deadly toxins that have
already been released by the anthrax bacteria.

22. Pulmonary anthrax (‘wool sorter's disease’)-Mode
of Transmission
 By inhalation of aerosolized spores in
industries that inadvertently may deal with
contaminated tissues or products such as
tanning hides, processing wool or bone
products, or by accident in laboratory workers
 By intentional release of spores using a
variety of aerosol devices including mailitems.
 Rare (<5%)
 Most likely encountered in bioterrorism event

23. Woolsorter’s Disease
Inhalation(Pulmonary ) Anthrax
Woolsorter’s Disease
(AFIP)

24. Gastrointestinal Anthrax
 Now rare less than 5%
 Mode of transmission-Ingestion
 Anthrax of the bowels (gastrointestinal anthrax)
is the result of eating undercooked,
Contaminated meat.
 The symptoms of this form of anthrax include
nausea, loss of appetite, bloody diarrhea and
fever followed by abdominal pain.
 The bacteria invade through the bowel wall.
Then the infection spreads throughout the body
through the bloodstream (septicemia) with
deadly toxicity.

25. Complications of Gastrointestinal
Anthrax
 Acute gastro-enterities ,Abdominal pain,
Prostration
 Intestinal Obstruction-Hage mesentric lymph
nodes
 Intestinal lesion edematous—with black
eschar
 Often Fatal

26. Anthrax Meningitis
 Complication of anthrax septicemia
 Subarachnoid Hemorrhage is common
feature
 Usually Fatal

27. Diagnosis
 Early diagnosis is difficult
 Non specific symptoms
 Initially mild
 No readily available rapid specific tests

28. Diagnosis
 The history, including the occupation of the
person, is important.
 The bacteria may be found in cultures or
smears in cutaneous (skin) anthrax and in
throat swabs and sputum in pulmonary
anthrax.
 Chest X-rays may also show characteristic
changes in and between the lungs. Once the
anthrax is disseminated, bacteria can be seen
in the blood using a microscope.

29. Laboratory Identification-1
 bamboo stick’ appearance-The ends of the
bacilli are truncated or of-ten concave and
somewhat swollen so that a chain of bacilli
presents a ‘bamboo stick’ appearance.
 M’Fadyean’s reaction-When blood films
con-taining anthrax bacilli are stained with
polychromemethylene blue for a few
seconds and examined under the microscope,
an amorphous purplish material is no-ticed
around the bacilli.

30. Laboratory Identification-2
 Frosted glass appearance- On agar plates,
irregularly round colonies are formed .raised,
dull, opaque, greyish white, with a frosted
glass appearance.
 ‘Medusa head appearance-Under the low
power microscope, the edge of the colony is
composed of long, interlacing chains of
bacilli, resem-bling locks of matted hair.

31. Laboratory Identification-3
 Characteristic ‘inverted fir tree’ appearance
 ‘String of pearls reaction-seen when B.
anthracisis grown on the surface of a solid
medium containing 0.05-0.5 units of
penicillin ml, in 3-6 hours the cells become
large, spherical, and occur in chains on the
surface of the agar, resembling a string of
pearls.

32. Treatment-1
 Immediately treat presumptive cases
 Prior to confirmation
 Rapid antibiotics may improve survival
 Differentiate between cases and exposed
 Cases
 Potentially exposed with any signs/symptoms
 Exposed
 Potentially exposed but asymptomatic
 Provide Post-Exposure Prophylaxis

33. Treatment-2
 Hospitalization
 IV antibiotics
 Empiric until sensitivities are known
 Intensive supportive care
 Electrolyte and acid-base imbalances
 Mechanical ventilation
 Hemodynamic support

34. Treatment-3
 In most cases, early treatment can cure anthrax.
The cutaneous (skin) form of anthrax can be
treated with common antibiotics such as
penicillin, tetracycline, erythromycin, and
ciprofloxacin (Cipro).
 The pulmonary form of anthrax is a medical
emergency. Early and continuous intravenous
therapy with antibiotics may be lifesaving. In a
bioterrorism attack, individuals exposed to
anthrax will be given antibiotics before they
become sick

35. Treatment-4
 Antibiotic selection
 Naturally occurring strains
 Rare penicillin resistance, but inducible β-lactamase
 Penicillins, aminoglycosides, tetracyclines, erythromycin,
chloramphenicol have been effective
 Ciprofloxacin very effective in vitro, animal studies
 Other fluoroquinolones probably effective
 Engineered strains
 Known penicillin, tetracycline resistance
 Highly resistant strains = mortality of untreated

36. Treatment
 Cases of gastrointestinal and cutaneous
anthrax can be treated with ciprofloxacin or
doxycycline for 60 days.
 Penicillin such as amoxicillin or amoxicillinclavulanate may be used to complete the
course if the strain is susceptible.

37. Treatment
 Individuals with inhalational anthrax should
receive a multidrug regimen of either
ciprofloxacin or doxycycline along with at
least one more agent, including a quinolone,
rifampin,
tetracycline,
vancomycin,
imipenem, meropenem, chloramphenicol,
clindamycin, or an aminoglycoside.
 After susceptibility testing and clinical
improvement, the regimen may be altered.

38. Effect of Treatment delay
 Delays of only a few days may make the disease
untreatable and treatment should be started even
without symptoms if possible contamination or
exposure is suspected. Animals with anthrax often
just die without any apparent symptoms. Initial
symptoms may resemble a common cold—sore
throat, mild fever, muscle aches and malaise. After a
few days, the symptoms may progress to severe
breathing problems and shock and ultimately death.
Death can occur from about two days to a month
after exposure with deaths apparently peaking at
about 8 days after exposure. Antibiotic-resistant
strains of anthrax are known

39. Antidote- Raxibacumab
 Raxibacumab is a recombinant human IgG1gamma monoclonal antibody directed at the
protective antigen of Bacillus anthracis.
 It is indicated for treatment of inhalational
anthrax in adults and children and used in
combination with appropriate antibacterial
drugs.
 It is also indicated for prophylaxis of inhalational
anthrax when alternative therapies are not
available or are not appropriate.

40. Prevention
 Public-health measures to prevent contact with infected
animals are invaluable.
 There is a vaccine available for people at high
 To prevent a bioterrorist attack and to be prepared to deal
with the consequences if one occurs. For anthrax and other
infectious diseases, vaccines with greater efficacy and
fewer side effects are under development.
 Currently, most vaccines are given by injection into fat or
muscle below the skin. Early studies in experimental
animals are showing promise for an oral vaccine for
anthrax. Obviously, a pill is easier to take than a shot, and
the pill may even be a safer and more effective route of
administration.

41. Vaccine
 Vaccines against anthrax for use in livestock and humans have
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had a prominent place in the history of medicine, from Pasteur’s
pioneering 19th century work with cattle (the second effective
vaccine ever) to the controversial 20th century use of a modern
product (BioThrax).
Human anthrax vaccines were developed by the Soviet Union in
the late 1930s and in the US and UK in the 1950s. The current
FDA-approved US vaccine was formulated in the 1960s.
Currently administered human anthrax vaccines include acellular
(USA) and live spore (Russia) varieties.
All currently used anthrax vaccines show considerable local and
general reactogenicity (erythema, induration, soreness, fever)
and serious adverse reactions occur in about 1% of recipients.[
New second-generation vaccines currently being researched
include recombinant live vaccines and recombinant sub-unit
vaccines

42. Prophylaxis-1
 If a person is suspected as having died from anthrax, every
precaution should be taken to avoid skin contact with the
potentially contaminated body and fluids exuded through natural
body openings.
 The body should be put in strict quarantine and then burnt. A
blood sample taken in a sealed container and analyzed in an
approved laboratory should be used to ascertain if anthrax is the
cause of death.
 Microscopic visualization of the encapsulated bacilli, usually in
very large numbers, in a blood smear stained with polychrome
methylene blue (McFadyean stain) is fully diagnostic, though
culture of the organism is still the gold standard for diagnosis.
Full isolation of the body is important to prevent possible
contamination of others. Protective, impermeable clothing and
equipment such as rubber gloves, rubber apron, and rubber boots
with no perforations should be used when handling the body

43. Prophylaxis-2
 Disposable personal protective equipment is
preferable, but if not available, decontamination
can be achieved by autoclaving. Disposable
personal protective equipment and filters should
be autoclaved, and/or burned and buried..
Anyone working with anthrax in a suspected or
confirmed victim should wear respiratory
equipment capable of filtering this size of
particle or smaller.) approved high efficiencyrespirator, such as a half-face disposable
respirator with a high-efficiency particulate air
(HEPA) filter, is recommended

44. Prophylaxis-3
 contaminated bedding or clothing should be
isolated in double plastic bags and treated as
possible bio-hazard waste. The victim should be
sealed in an airtight body bag. Dead victims that
are opened and not burned provide an ideal
source of anthrax spores. Cremating victims is
the preferred way of handling body disposal. No
embalming or autopsy should be attempted
without a fully equipped biohazard laboratory
and trained and knowledgeable personnel.

45. Is anthrax contagious?
 No. Spreading anthrax from person to person
is extremely unlikely to occur. It also requires
a relatively large dose to infect a person - one
would have to inhale 8,000 to 50,000 spores.

46. Anthrax –as a weapon
 Anthrax can also be used as a weapon. This
happened in the United States in 2001.
Anthrax was deliberately spread through the
postal system by sending letters with powder
containing anthrax. This caused 22 cases of
anthrax infection.

47. Question No-1
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What type of vaccine is the anthrax vaccine?
A) Attenuated bacteria
B) Inactivated toxin (toxoid)
C) Killed whole bacterial cells
D) Recombinant
E) Acellular

48. Question-2
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How do the endospores that cause cutaneous
anthrax enter the body?
A) Through breathing
B) By consuming contaminated foods
C) Through small cuts or abrasions in the skin
D) Through sexual activity
E) Through insect vectors

49. Question-3
 Most naturally occurring cases of anthrax
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occur in which group of people?
Daycare workers
News reporters
The elderly
Textile workers
Infants

50. Question-4
 What is the primary habitat for many Bacillus
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species? Select Two
A) Humans and other large primates
B) Dust
C) Water
D) Herbivores
E) Soil

51. Question-5
 Which type of anthrax is most common ?
 A)Pulmonary Anthrax
 B) Gastrointestinal anthrax
 C) Cutaneous anthrax

52. Question-6
 Spreading anthrax from person to person is
extremely common
 A)True
 B) False

53. QUESTION-7
 Anthrax symptoms may include all of the
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following EXCEPT
A-Fever
B-Abdominal pain
C-Dyspnoea
D-Rhinorrhoea

54. Question-8
 In Anthrax bioterrorism the post exposure
prophylaxis is available?
 True
 False

55. Question-9
 Which is true of endotoxins?
 They are disease-specific.
 They are produced by gram-positive
bacteria.
 They increase blood pressure.
 They are released upon cell lysis.
 They are proteins.

56. Question-10
 All of the following are true of A-B exotoxins
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except:
The A portion of the toxin is the active
component.
They are only produced by gram-negative
bacteria.
They consist of two polypeptide
components.
The B portion of the toxin binds to surface
receptors on host cells.

57. Question-11
 Which of the following is a true of cutaneous
anthrax?
 1) causes a black eschar which overlies pus
2) lesions are usually painful and tender
3) lesions are associated with marked edema
4) Mortality is approximately 20% despite
antibiotic therapy
5) Is very likely to occur in subjects exposed to
anthrax spores

58. Question-12
 Anthrax is caused by
 A)Fungi
 b) Bacteria
 c) Protozoa
 d) Virus

59. Question-13
 Subarachnoid Hemorrhage is common
feature in Anthrax meningitis
 A)True
 B)False

60. Question-14
 Symptoms of Cutaneous Anthrax includes all
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except
A small, raised bump that might itch.
The bump becomes a painless, fluid-filled
blister and later forms a black center of dying
tissue.
Swollen lymph nodes, headache, and fever
also may occur.
Difficulty in breathing

61. Question-15
 who are at higher risk for Anthrax exposure?
 Veterinarians
 Laboratory professionals
 Livestock producers
 People who handle animal products
 Mail handlers, military personnel, and response
workers who may be exposed during a bioterror
event involving anthrax spores
 All of the above

62. Question-16
 Which component is known as the protective
antigen?
 A)A component
 B)B component

63. Question-17
 ____ What changes of myelin basic protein
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can be studied under these conditions?
A. Its phosphorylation
B. Its dephosphorylation
C. Its degradation
D. Its ubiquitination

64. Question-18
 True or False -Anthrax is an Occupational
diseases
 A)True
 B) False

65. Question-19
 Anthrax is reportable diseases?
 A)True
 B)False

66. QUESTION-20
 Treatment for pulmonary Anthrax-Select one
 A)Multi drug Regime
 B)Ciprofloxacin
 C)Penicillin
 D) Multi drug Regime with at least one more
agent