Human Anthrax

Surveillance and Case Management

1st November 2023

Dr. Nyuma Mbewe

Case Management Specialist
National Cholera Elimination Program Coordinator
Emergency Preparedness and Response Cluster
 Outline
• Early After Action Review for Response (7.1.7)
• Human Anthrax
– Zambia Situation Update
– Southern Province Response Activities
• Human Anthrax Case Presentation
• Recommendations
ANTHRAX SITUATION UPDATE
 MICROBIOLOGY
• B. anthracis is a nonmotile spore-forming, gram-positive
rod.
• Virulent B. anthracis requires a poly-D-glutamic acid
capsule and three proteins (edema factor [EF], lethal
factor [LF], and protective antigen [PA]) that associate
into two protein exotoxins.
 EPIDEMIOLOGY
• Anthrax is endemic in Zambia’s Luangwa
valley and Zambezi floodplain and affects
both domestic and wild animals.
• Multiple Anthrax outbreaks have been
recorded in Zambia since 1990, usually
starting in animal populations and
subsequently into human population due
handling of carcases and ingestion of
contaminated beef and game meat.
• Case fatality rates (CFR) ranging from 4-
20%
• Although reported anthrax cases
have consistently decreased over the
past 10 years, outbreaks continue to
be reported in Sesheke, Kazungula,
Sioma, Nyimba and Chama districts.
• The organism remains an important
potential agent of bioterrorism and
biological warfare especially in the
HIC
EPIDEMIOLOGY
 IDSR – Human Anthrax
• Per the Public Health Act (Chapter 295, Section 9), Anthrax is a notifiable
disease; ie
• any suspected case requires a rapid Integrated Disease
Surveillance and Response (IDSR) field investigation.
• The DHD/DVO will task the local PHERRT to investigate
and gather information about the event within 24 hours
of receiving an alert.
• An outbreak will be declared at level one when there is
one case in human or animal.
Summary Statistics for Anthrax in Zambia
in 9 districts
 Epidemiologic Case Definition
• Suspected case: Any person with acute onset characterized by several
clinical forms which are:
• 1. Cutaneous form: Any person with skin lesion evolving over 1 to 6
days from a papular through a vesicular stage, to a depressed black
eschar invariably accompanied by oedema that may be mild to
extensive.
• 2. Gastro-intestinal: Any person with abdominal distress characterized
by nausea, vomiting, anorexia and followed by fever
 Epidemiologic Case Definition cont.
• Suspected case: Any person with acute onset characterized by several
clinical forms which are:
• 3. Pulmonary (inhalation): any person with brief prodromal resembling
acute viral respiratory illness, followed by rapid onset of hypoxia,
dyspnoea and high temperature, with X-ray evidence of mediastinal
widening.
• 4. Meningeal: Any person with acute onset of high fever possibly with
convulsions, loss of consciousness, meningeal signs and symptoms;
commonly noted in all systemic infections, but may present without
any other clinical symptoms of anthrax AND has an epidemiological link
to confirmed or suspected animal cases or contaminated animal
products.
 Epidemiologic Case Definition
• Confirmed case: A confirmed case of anthrax in a human can
be defined as a clinically compatible case of cutaneous,
inhalational or gastrointestinal illness that is laboratory-
confirmed by:
• Isolation of B. anthracis from an affected tissue or site; or
• Other laboratory evidence of B. anthracis infection based on at
least two supportive laboratory tests.
 Anthrax - Zambia

• Cases in Human •Districts with Cases in Animals

• Cummulative cases – 249 of which two •Sinazongwe
cases were confirmed •Kazungla
• Southern Province •Nalolo
– Sinaozngwe
•
•Lumezi
Cases - 212
• Deaths - 2 •Mongu
– Kazungula - 13
•Sioma
• Western Province
– Sesheke – 8 •Limulunga
•
•
Cases - 8 •Have reported anthrax in animals
Mongu – 5
• Sioma - 1 (cattle, hippo among others).
• Eastern Province
– Lumezi
• Cases - 8
• Deaths - 1
• Observed increased daily cases in the past weeks.
 ANTHRAX UPDATE IN SOUTRHERN PROVINCE
 Two more districts have reported suspected cases of Anthrax,
Choma 1 and Livingstone 2.
 4 total new case today, 1 from Sinazongwe, Choma 1, Kazungula 0,
and Livingstone 2
 6 total in admission, 3 Maamba hospital, 1 choma hospital, 2
Livingstone UTH
 Case management and monitoring of active cases currently on going
 Cumulative 229 case of Anthrax, 215 Sinazongwe and 14 Kazungula
 Community based home treatment – 159, Sinazongwe 147,
Kazungula 12
 Risk factors and Epidemiological Linkages
• Exposure to the environment suspected to be contaminated
• High interface between domestic and wild animals
• Inadequate grazing pasture in the areas
• Long free-range movement of cattle in most affected regions
• The opening of dead animals for consumption and sale.
• Sale of the meat from the dead animals facilitates spread of the suspected
disease from the epi – centre to other areas
• Possibility of spread to nearby areas:
– The majority of the meat from the deceased animals are placed in small markets and
sold to neighboring regions at a cheap price. As a result, there is a high likelihood of the
spread to other areas.
 CLINICAL MANIFESTATIONS
• There are four major anthrax syndromes:
– cutaneous anthrax
– inhalation anthrax
– gastrointestinal tract anthrax
– and rarely primary anthrax meningitis
 Cutaneous
• Cutaneous anthrax is the most
common form of the disease.
• Develops after spores of B.
anthracis are introduced
subcutaneously, through cuts or
abrasions
• Incubation period is usually 5 to 7
days with a range of 1 to 12 days
• > 90 % of lesions occur in
exposed areas such as the face,
neck, arms, and hands.
 LIVINGSTONE CASES

Livingstone University Teaching Hospital reported two cases of

suspected anthrax on 27.10.2023 which were referrals for severe
cellulitis from Dambwa North Urban Health Center and Army
School of Ordinance. The two cases have been LUTH care from
21.10.2023 to 27.10.2023
Sex/Age: Male/41 Years
Address: Dambwa site and service
Onset of sign &symptoms:18.10.2023
Sex/Age: Male/25 years
Address: Dambwa site and service
Onset of sign &symptoms:19.10.2023
Date of admission: 24.10.2023
Sample collection awaiting to be transported to UNZA veterinary
Laboratory
 Cutaneous
• Small, painless, pruritic papule
and quickly enlarges and develops
a central vesicle or bulla, followed
by erosion, leaving a painless
necrotic ulcer with a black,
depressed eschar
• An eschar with extensive
surrounding edema is highly
suggestive of anthrax.
– Less often causing palpebral
swelling and necrosis of the eyelids
Cellulitis due to Anthrax
 Cutaneous
• Systemic symptoms, including
fever, chills, malaise, and
headache.
• Complications; airway
obstruction from head and
neck involvement, sepsis
syndrome, and meningitis
• Mortality high if untreated.
 Inhalation (Pulmonary)
• Inhalation of B. anthracis spore-
containing particles.
– aerosolized while working with
contaminated animal products
such as wool, hair, or hides.
– inhalation of weaponized and
intentionally released spore
preparations. (bioterrorism)
• Median incubation period for
inhalation anthrax is estimated
to be 7 – 9 days
• Prodromal phase; non specific
– myalgia, fever, and malaise ~4-5
days
• Fulminant phase, rapid
progression - severe dyspnea
and hypoxemia, and shock
• 1/3 develop meningitis.
• Hematogenous spread causing
hemorrhagic meningitis and
submucosal gastrointestinal
lesions
 Inhalation (Pulmonary)
• Mortality within days ~ >95%
• Haemorrhagic mediastinitis,
• Rapid progression to
septicaemia
• Abx therapy of little help in
fulminant phase.
 Gastrointestinal
• Consumption of undercooked • Two clinical forms,
meat from animals infected oropharyngeal or Intestinal
with anthrax (cattle, buffalo, • Intestinal >> oropharyngeal
hippos common in our setting)
• Usually occurs in family
clusters or point-source
outbreaks.
 Gastrointestinal
Intestinal Oropharyngeal
• asthenia, headache, low-grade fevers, • Edema and painful swelling may
facial flushing, and conjunctival develop in the oropharynx and neck,
injection • Cervical lymphadenopathy, pharyngitis
• abdominal pain, nausea, hematemesis & fever
& occasionally diarrhea. • Mortality very high 2 -5 days of onset
• Ascites common with 2 -4 days
 Meningitis
• Primary meningitis is a rare
form of anthrax.
• Secondary meningitis through
bacteremic spread occurs in
about a third of patients with
other forms of systemic
anthrax and has been
associated with cutaneous,
inhalation, and
gastrointestinal cases
• Fever, headache, and
meningeal signs
• Delirium and coma
• Anthrax meningitis is
frequently associated with
intracranial (subarachnoid)
hemorrhage
 Disease in Animals
• Usually fulminant, can be • Mortality in 1-2 days usually
acute, subacute or chronic less than 5 days
• Sudden “apoplectic” death of • Resistant animals like pigs can
animals have chronic infection
• Acute; resp distress,
convulsions
• Edematous lesions, blood
exudes
 DIAGNOSIS
• Laboratory:
• Growth of B. anthracis on culture of a clinical
specimen.
•
• Clinical: Isolation of a B. cereus group organism from a
patient with a compatible clinical syndrome
• Signs, symptoms with and epidemiology ~ consider anthrax until
proven otherwise.
epidemiology – Depending on the syndrome, blood, skin lesion

• Clinical syndrome with the

specimens, pleural fluid, cerebrospinal fluid (CSF),
rectal swab, ascitic fluid or tissue can be cultured.
right epidemiology should • Supportive of diagnosis;
– Positive polymerase chain reaction (PCR) on one
be considered anthrax of these specimens
– Positive serologic testing, or detection of lethal
toxin in a patient with a compatible clinical
syndrome;
 Differential diagnosis of black eschar
• Anthrax • Cow pox
• Pasteurella multocida • Mpox
(Pasteurellosis) • spider bite,
• spotted fever rickettsiosis, • post-trauma
• tularaemia, • Other….???
• disseminated fungal infection.
MANAGEMENT
• B. anthracis susceptible to a
variety of antimicrobials
including penicillin,
chloramphenicol, tetracycline,
erythromycin, streptomycin,
carbapenems, linezolid, clinda
mycin, and fluoroquinolones
• It is not susceptible to
cephalosporins or Septrin
• – Pen V 500mgs QID
Cutaneous anthrax without
systemic involvement (ie,
without edema, fever, cough,
headache, etc)
• Antimicrobial monotherapy 7-
10days (Doxy or Cipro)
• Alternatives for penicillin
susceptible strains
– Amoxicilin 1g TDS or
MANAGEMENT

Systemic Anthrax Without Meningitis

• Antimicrobial combination therapy IV
(Doxycycline and Ciprofloxacin) 7- 10 days PLUS
• Antitoxin (raxibacumab, obiltoxaximab
or anthrax immunoglobulin),
• Other
– drainage of pleural effusions,
– consideration of adjunctive glucocorticoids
PREVENTION & CONTROL

• PrEP
– Five IM injections over 18 months
– Annual boosters
• PEP with Chemoprophylaxis
– Vaccine and,
– Doxycycline and Ciprofloxacin; 60
days
– Only for inhalational
exposure/bioterrorism!!
 PREVENTION & CONTROL
• Preventive measures,
Vaccination (PrEP & PEP)
– Immunize high risk groups; Vets,
military,
• Infection Control of patient,
contacts and environment
– Isolation, disinfection,
investigate contacts, specific
treatment
• Decontamination
– remove contaminated clothing ,
Decontaminating environmental
surfaces
• Control of animal infection
– Animal vaccination
– Sterilize bone meal when used
as animal feed
– Disinfect animal products when
feasible
 Key Priority Actions
Surveillance/Lab
Leadership Coordination
Case Management • Intensifying Event-based surveillanc
• One health approach to control the
and early case detection
outbreak • Active community and facility
• IMS activation at District and Provincial • Active community and facility case
case search (surveillance) search
Level
• Mobilization of vaccines by Ministry of
• Training both virtual and • Culturing of samples for laboratory
Fisheries and Livestock physical confirmation of B. anthracis
• Harmonization of Guidelines

WASH/IPC RCCE
• Decontamination at the homes • Communication Strategy
• Contact Precautions for the • Intensify community
patients sensitization on dangers of
• Environmental Health Scientists consuming meat from animals
• Reignite multisectoral response that have died on their own
• IEC Materials Printed
• Call Centre available
 Key messages

• What is anthrax
• Do not consume animal that died of unknown cause
• Ensure all cattle are vaccinated
• Report any livestock/wildlife that have died of unknown cause.
• Care points
• Avoid handling of affected animals
• Important to wear appropriate PPE when slaughtering/handling meat and
skins and ensure regular disinfection of the premisses
• Disposal of suspected animals should be done under the supervision of the
qualified personnel.
• Community to engage the qualified personnel to decontaminate the affected
site
THE END