1. Anthrax: Are You at Risk? Ann Herring-Lambert, LVT, BA, CVMN
Welcome to this presentation on the risks of anthrax infection and what you can do to minimize your chances of being exposed. My name is Ann Herring-Lambert and I am a Ph.D. student at Walden University.
Ann Herring-Lambert, LVT, BA, CVMN
Ph.D. Student, Walden University
PUBH : Environmental Health
Instructor: Dr. David Anderson
Term 4, Year 1

2. Purpose of Presentation The General Public will be able to:
Understand the cause and transmission of the disease
Identify signs and symptoms
Identify risk factors for exposure
Understand prophylactic and treatment measures
Implement preventive measures
Contact the appropriate authorities in the event of potential exposure or signs and symptoms
Share and discuss information with others
As a general audience, you should be able to understand the cause and transmission of this disease, how to identify the signs and symptoms in humans and animals, how to identify your personal risk factors for exposure, be aware of prophylactic and treatment measures for your situation, be able to implement preventive measures, and be able to contact the appropriate personnel and agencies in the event you feel you have been exposed.
You will also be able to share and discuss information with others in your family, your community, and workplace. This is important in that it increases awareness across a wide range of individuals.

3. Disease Agent: Bacillus anthracis
Overview
Disease Agent: Bacillus anthracis
Ancient bacterial pathogen
Single-celled, spore-forming bacteria
Reason for spore formation
Zoonosis
Anthrax is a disease that has been around throughout much of recorded history. It is generally seen in herbivorous mammals, especially livestock (WHO, 2012). The first descriptions of the disease came from Egypt and Mesopotamia in 1491 BC (SIU, 2010). In Europe, the first pandemic hit in 1613 AD and was commonly referred to as the “Black Bane” but it was not seen in the United States until the early 18th century (SIU, 2010). Immediately following the events of September 11, 2001 in the United States, anthrax was used as a bioweapon when letters containing the agent were sent through the U.S. Postal Service.
The cause, or infective agent, is Bacillus anthracis which is a single-celled, spore-forming bacteria. The bacteria form spores when environmental conditions are not ideal for survival. The spores consist of protective outer shells that contain the dormant bacteria and can remain in the environment for extended periods of time (NIAID, 2010). The bacteria can be re-activated under the right conditions such as: ingestion by herbivores (i.e. cattle, sheep, goats, etc.) or human ingestion, inhalation, or skin contact (CDC, 2011).
Anthrax is considered a zoonotic disease as it is primarily transmitted from animals or animal products to humans.
Bacillus anthracis spores.
Photo by Janice Haney Carr. CDC Public Health Image Library.

4. Transmission Zoonotic- Animals and Animal Products Soil & Water
Bioterrorism- Intentional Transmission
Centers for Disease Control and Prevention (CDC). (2011). Emergency preparedness and response: Anthrax. Retrieved from
Humans are generally exposed and infected while working with infected animals or by handling or consuming infected animal products (CDC, 2011). Not only are infected animals a source of infection, but their hides, wool and hair, milk, and meat can transmit the disease as well.
Soil and water are not typically considered sources of human infection but spores may be present in areas of endemic disease. Caution should be used when handling soil and when drinking untreated or unfiltered water in these areas.
Bioterrorism is another source of anthrax transmission. Spores in powdered form can be inhaled or ingested or can enter the body through cuts or other skin lesions (PubMed Health, 2012). The spores could be spread or released through a variety of methods and have the potential to infect large portions of the population.

5. Types of Anthrax Cutaneous (skin) Inhalation Gastrointestinal
There are three types of anthrax. Cutaneous anthrax involves the cutaneous tissues, more commonly known as skin.
Inhalation anthrax occurs when the pathogen is inhaled into the lungs.
And finally, gastrointestinal anthrax occurs when infected food (generally meat or other animal products such as milk) is ingested.
Bacillus anthracis bacteria. CDC Public Health Image Library.

6. Cutaneous Anthrax Contact with skin Lesions Prognosis Treatment
Centers for Disease Control and Prevention (CDC). (2011). Emergency preparedness and response: Anthrax. Retrieved from
Cutaneous anthrax occurs when the pathogen comes into contact with the skin. In 2001, mail contaminated with anthrax resulted in 11 cases of cutaneous anthrax infection (DHS, 2011). Infection usually occurs when the bacteria or spores enter breaks in the skin such as cuts, scrapes, sores, or other lesions (PubMed Health, 2012). It is the most common type of anthrax.
After infection, the incubation period is generally 1 to 7 days before lesions resembling insect bites or small sores will appear and then transform into blisters and eventually into ulcers that are black in the center (CDC, 2011). These lesions are typically not painful. The photographs show examples of cutaneous anthrax lesions.
It is important to treat this infection immediately. The prognosis is generally positive if antibiotic therapy is given. However, approximately 20% of infections may result in death if left untreated because the infection may enter the bloodstream (PubMed Health, 2012).
Oral antibiotics such as doxycycline and ciprofloxacin are typically given for 7 to 10 days. It is important to follow the recommendations of your health care provider. You should never resort to self-treatment or self-medication if cutaneous anthrax is suspected.
Cutaneous Lesions. CDC Public Image Health Library (PHIL).

7. Inhalation Anthrax Respiratory Prognosis Treatment
Centers for Disease Control and Prevention (CDC). (2011). Emergency preparedness and response: Anthrax. Retrieved from
Inhalation anthrax typically occurs when humans breathe in infectious spores. A person is considered to be exposed when this occurs, but does not necessarily mean he or she will develop the infection (PubMed Health, 2012). In 2001, anthrax was sent via U.S. mail and 11 people were infected with inhalation anthrax- 5 of those who were infected died (DHS, 2011). The incubation period is generally 1 to 6 days but has lasted as long as 43 days before symptoms occur (PubMed Health, 2012). This type of infection causes lesions and edema in the lungs (as seen in the photograph) and can also cause bleeding, swelling, and tissue necrosis (death). Typical symptoms can resemble those of other conditions and may include chest pain, difficulty breathing, cough, fever, headache, and a general sense of not feeling well (PubMed Health, 2012).
Prognosis is poor if left untreated. Without treatment, 80%-90% of infections result in death (SIU, 2010). With treatment, the prognosis improves. However, if second-stage infection is diagnosed, the prognosis remains poor, even with treatment.
Early and aggressive treatment is required in the case of inhalation infection. Those who are exposed are generally treated before symptoms occur. As this type of anthrax infection is more severe, combinations of antibiotics are often used. Intravenous antibiotics such a ciprofloxacin are given in combination according to standard protocols (PubMed Health, 2012). Supportive therapies such as intravenous fluids and oxygen may also be needed. Again, it is of the utmost importance that you seek medical attention immediately if you suspect you have been exposed to anthrax. You should never attempt self-treatment or self-medication. Always follow the recommendations of your health care provider.
Lesions and edema in the lungs. CDC Public Health Image Library (PHIL).

8. Gastrointestinal Anthrax
Digestive tract
Prognosis
Treatment
Centers for Disease Control and Prevention (CDC). (2011). Emergency preparedness and response: Anthrax. Retrieved from
Gastrointestinal anthrax involves the digestive tract, mainly the stomach and intestines. The general cause is ingestion of meat from infected animals. Symptoms can present in much the same way as other gastrointestinal illnesses and conditions. Symptoms may include fever, diarrhea, bloody diarrhea, abdominal pain and cramping, vomiting that may be normal or bloody, dehydration, and nausea (CDC, 2011). Sores may also develop in the mouth.
If left untreated, the prognosis may be poor. Approximately 25% to 60% of untreated infections result in death (CDC, 2011).
This type of infection is also treated with antibiotics and supportive therapy. Steroids may also be used to reduce inflammation.
It is important to seek medical treatment immediately if you suspect you have been exposed to this type of anthrax infection and follow the recommendations of your health care provider. Do not attempt self-treatment or self-medication.

9. Risk Factors Occupational Contact Incidental Contact Bioterrorism
Centers for Disease Control and Prevention (CDC). (2011). Emergency preparedness and response: Anthrax. Retrieved from
United States Department of Agriculture, Animal and Plant Health Inspection Service (USDA/APHIS). (2009). Epizootiology and ecology of anthrax. Retrieved from
Risk factors for exposure and infection can vary greatly. The most common risk factors are for those who directly or indirectly handle animals (especially livestock) and animal products or those who work in laboratories that handle anthrax (CDC, 2011; USDA/APHIS, 2009).
Incidental contact can occur if contaminated objects are handled.
Bioterrorism is a very real risk factor in that spores can be released and/or transported by various methods and can potentially infect large populations. Another risk factor in regards to bioterrorism is that livestock can become infected which results in a compromise of a nation’s food supply.

10. Examples of Potentially At-Risk Groups (Primarily Occupational)
Agricultural Workers
Hunters
Veterinary Professionals
Animal Caretakers
Taxidermists
Military Personnel
Laboratory Workers
Government/Public Servants (i.e. Postal Workers)
Researchers
Public Health Professionals
Law Enforcement Personnel
Zoo/Wildlife Professionals
Security Personnel
Hide/Leather Industry Workers
Shipping Industry Personnel
Food Industry Workers
Academia
The general public could potentially be at risk for exposure and infection in the case of bioterrorism. This is a listing of potentially at-risk groups. The risks are primarily occupational and often involve direct or indirect contact with animals or animal products or laboratory work and research associated with anthrax. Public servants such as public health professionals, military personnel, postal workers, and law enforcement personnel are listed due to the potential for bioterrorism and epidemics.

11. Prophylactic Measures
Vaccine- Available, but not to the general public
Antibiotics- Mainly used for treatment, but may be used in certain circumstances
Centers for Disease Control and Prevention (CDC). (2011). Emergency preparedness and response: Anthrax. Retrieved from
Prophylactic measures are available under certain circumstances. A vaccine is available to military personnel and individuals who work in close proximity to anthrax pathogens (i.e. laboratory personnel and public health professionals). It is not available to the general public unless there is a danger of epidemics either from bioterrorism or from naturally-occurring outbreaks.
Antibiotics are mainly used for treatment but they may be given in certain circumstances if an individual has an imminent danger of being exposed. Antibiotic stockpiling is highly discouraged and could result in an inadequate supply in the case of emergencies. The use of antibiotics should only take place under the supervision of a health care or veterinary professional in order to prevent resistance to current antibiotic therapies.

12. Preventive Measures
Do not handle live or dead animals suspected of having anthrax
Do not consume meat or other products from animals suspected of having anthrax
Do not handle hides, hair, or wool from animals suspected of having anthrax
Do not open suspicious packages or mail
Always wash hands thoroughly
Centers for Disease Control and Prevention (CDC). (2011). Emergency preparedness and response: Anthrax. Retrieved from
Preventive measures are the primary line of defense. Never handle live or dead animals that are suspected of having anthrax. If contact has occurred, immediately remove all clothing and footwear, place in a garbage bag and seal it. Wash/shower thoroughly with soap and water. Contact your local veterinarian so that he/she can examine the animal(s) and determine if further steps need to be taken.
Do not consume meat or other products from animals suspected of having anthrax.
Do not handle hides, hair, or wool from animals suspected of having anthrax. If you are in an occupation in which you have regular contact with these products it is recommended that you wear personal protective equipment such as gloves and masks to decrease the chances for exposure and infection.
Do not open suspicious packages or mail. Be careful when opening and handling mail and packages. Do not place mail or packages near your face and avoid shaking or waving it. If you receive suspicious mail or packages or see powder or dust-like substances, contact law enforcement immediately.
Always wash your hands thoroughly with soap and water in any situation.

13. Who to Contact if You Suspect Anthrax Exposure/Infection
Health care provider
Veterinarian
Law enforcement
Health departments
State departments of agriculture
Now we will discuss who to contact in the event of potential exposure and/or infection. The most important thing to remember is not to panic. You will be more helpful by remaining calm and thinking clearly.
If you suspect that you have been exposed or already have the infection, contact your health care provider immediately and follow his/her instructions. If the exposure is the result of contact with a potentially infected animal, contact your local veterinarian immediately and follow his/her instructions. If you are unable to contact a private veterinarian, you can contact your state department of agriculture and the public health veterinarians will assist you.
In the case of intentional exposure (i.e. bioterrorism), contact local law enforcement immediately. It is also recommended that you contact local law enforcement in the case of accidental exposure that occurs outside of licensed laboratories or research facilities.
Do not hesitate to contact the appropriate authorities if you suspect a potential exposure or infection. These individuals and agencies are trained to deal with this type of situation. Your local health department is also a point of contact in the event that you need immediate help.

14. Final Thoughts Educate Take Precautions Contacts List
Review Risk Factors
Remain Calm
Work on furthering your knowledge on anthrax and other similar diseases. Knowledge is power and it will help you to understand and prepare better in the event that you are faced with this type of situation.
Take precautions if you are in a high-risk or at-risk occupation
Prepare a list of contacts for your area in the event of exposure and infection. This will help to speed up the process of notification and you will not have to think of or look for names and numbers in a crisis situation.
Review your risk factors and be aware of steps you can take to minimize them.
Above all, remain calm. This presentation has provided you with information that you can use to make informed decisions in the event of exposure and/or infection. Be aware that in normal, daily activities the risks of exposure are minimal for most people. Discussing this information with family, friends, and colleagues will also serve to educate them. I encourage you to be proactive and gather further information to pass along as well.

15. Additional Resources
American Veterinary Medical Association (AVMA). Frequently Asked Questions About Anthrax.
Centers for Disease Control and Prevention (CDC). Emergency Preparedness and Response: Anthrax.
National Institutes of Health (NIH), National Institute of Allergy and Infectious Diseases (NIAID). Understanding Anthrax.
PubMed Health. Anthrax.

16. Additional Resources
United States Department of Agriculture, Animal and Plant Health Inspection Service (USDA/APHIS).
United States Department of Homeland Security (DHS). Biological Attack: The Danger.
World Health Organization (WHO). Guidance on Anthrax: Frequently Asked Questions.

17. References
Centers for Disease Control and Prevention (CDC). (2011). Emergency preparedness and response: Anthrax. Retrieved from
Centers for Disease Control and Prevention (CDC). (2008). Public Health Image Library (PHIL). Retrieved from
National Institute of Allergy and Infectious Diseases (NIAID). (2010). Anthrax. Retrieved from
PubMed Health. (2012). Anthrax. Retrieved from
Shadomy, S. V., & Smith, T. L. (July 1, 2008). Zoonosis update: Anthrax. Journal of the American Veterinary Medical Association, 233(1), Retrieved from

18. References
Southern Illinois University School of Medicine (SIU). (2010). Anthrax: Bacteriology , clinical presentations and management. Retrieved from
United States Department of Agriculture, Animal and Plant Health Inspection Service (USDA/APHIS). (2009). Epizootiology and ecology of anthrax. Retrieved from
United States Department of Homeland Security (DHS). (2011). Biological attack: The danger. Retrieved from
World Health Organization (WHO). (2012). Global alert and response: Anthrax. Retrieved from