1. Factors Associated with Contracting Anthrax in Makoni District Ward 22 and 23, 2014. Makurumidze R Gombe NT Magure T Tshimanga M Takundwa L Bangure D

2. Introduction Anthrax is a bacterial infection caused by the spore-forming bacteria, Bacillus Anthracis. A case of anthrax was reported in Makoni District on the 19 th of December 2013. Victim had consumed meat from cattle that had died on its own. District Veterinary Office reported cattle deaths in the area from the 6 th of December 2013. Veterinary Department investigation confirmed a diagnosis of anthrax.

3. Specific Objectives To describe the outbreak in person, time and place To determine factors associated with contracting anthrax To assess the community knowledge, attitudes and practices on anthrax To carry out an environmental assessment To asses anthrax prevention and control measures being implemented by the district To assess the preparedness of the district response to the outbreak

4. Methodology Study design: An unmatched 1:1 case-control study A case – was defined as any person in Makoni District Ward 22 and 23 who developed a disease which manifested by itching of the affected area, followed by a painful lesion which became papular, then vesiculated and eventually developed into a eschar between 19 June 2013 and 29 January 2014. A control –was defined as any person in Makoni District Ward 22 and 23 who never developed a disease which is manifested by itching of the affected area, followed by a painful lesion which became papular, then vesiculated and eventually developed into a eschar between 19 June 2013 and 29 January 2014

5. Methodology Sampling Cases – Obtained from the line list and through active case finding. Controls – Selected from the neighboring homesteads of cases.

6. Methodology Data Collection, Permission and Ethical Considerations

7. Results

8. Demographic Data of Study Participants VariableCases (n=37) (%)Controls (n=37)(%)P - Value Sex Male Female 27(73) 10(27) 26(70.3) 11(29.7) 0.7965 Level of Education Never Been to School Primary 2 Year Secondary 4 Year Secondary Tertiary College 2(5.4) 10(27) 3(8.1) 18(48.6) 4(10.8) 2(5.4) 13(35.1) 8(21.6) 13(35.1) 1(2.7) - Employment Not Employed Full time Self Employed Peasant Farmer Student 18(48.6) 6(16.2) 3(8.1) 6(16.2) 4(10.8) 19(51.4) 5(13.5) 0(0) 10(27) 3(8.1) Median Age in Years34(Q 1 =22, Q 3 =42)28(Q 1 =25, Q 3 =46) Average Monthly Income$54.05 (SD-105.72)$62.02(SD-118.86) Median Household Size6(Q 1 =6, Q 3 =7)5(Q 1 =4, Q 3 =6)

9. Signs and Symptoms

10. Site of Eschar

11. Epidemiological Curve First Animal Death Cattle Vaccination Human Anthrax Death Control Measures By DHE Outbreak Declared Over

12. Spot Map for Anthrax Outbreak in Makoni District Ward 22 and 23

13. Risk Factor Cases (n=37) Controls (n=37) Odds Ratio 95% CIP – Value Sex Male Female 27 10 26 11 1.140.42 – 3.120.797 Ate Meat of an Animal that died alone Yes No 33 4 20 17 7.012.06 – 23.820.000 Skinning Meat Yes No 22 15 8 29 5.321.91 – 14.770.000 Cutting Meat Yes No 30 17 20 5.041.77 -14.360.001 Cooking Meat Yes No 25 12 14 23 3.421.31 – 8.900.010 Factors Associated with Contracting Anthrax

14. Factor Cases (n=37) Controls (n=37) Odds Ratio 95% CIP – Value Cuts/Abrasions During Skinning Meat Yes No 14 23 3 34 6.901.78 -26.730.000 Belonging to a Religion which Permits Eating Animals that Die Alone Yes No 16 21 4 33 6.291.67-28.680.002 Cuts/Abrasions During Cutting Meat Yes No 13 24 3 34 6.141.56 – 23.910.005 Thinking Overcooking Meat Kills Anthrax Yes No 20 17 6 31 6.082.05 -18.030.001 Handling a Dead Animal Carcass Yes No 25 12 10 27 5.62.07 – 15.290.000 Hide Preparation Yes No 16 21 11 26 1.80.690 – 4.700.227 Heard of Anthrax Before Yes No 18 19 27 10 0.3510.133-0.930.032

15. Knowledge on Anthrax VariableCases (n=37) (%)Controls (n=37)(%) Heard of Anthrax Before18 (45.6)27(73) Signs and symptoms I don’t know Fever Eschar 33(89.2) 0(0) 4(10.8) 14(37.8) 7(18.9) 22(59.5) Transmission I don’t know Contact with spores Ingestion of infected meat Inhalation of spores 31(83.8) 4(10.8) 6(16.2) 0(0) 16(43.2) 1(2.7) 21(56.8) 0(0) Prevention I don’t know Vaccination Not eating meat from dead animals 27(73) 4(10.8) 6(16.2) 14(37.8) 10(27) 19(51.4)

16. Community Practices Practice Cases (n=37) Control (n=37) Odds Ratio 95%CIP- Value Handling carcass of animal that die on its own Yes No 22 14 29 8 0.4530.16 - 1.270.12 Skinning cattle that have died Alone Yes No 30 7 33 4 0.5200.10 - 2.310.26 Buying/selling meat from animals that have died on their own. Yes No 30 7 36 1 0.200.002 -1.040.028 Trading with hides of Animal that die Alone Yes No 30 7 31 6 0.830.21- 3.270.50

17. Environmental Assessment 180 cattle died and deaths of goats and pigs were reported. No anthrax outbreak before but an outbreak occurred in the adjacent Mutasa District during the previous year. Only 20 animal death sites were disinfected. Inadequate grazing land Cattle not dipping regularly Game Reserve near Osborne Dam Former Army Base in the area - ? Bioterrorism

18. Outbreak Control Measures Health Education – schools and community leaders Disinfectation of animal death sites Active community case finding Withholding slaughtering and selling of beef 5000 cattle vaccinated Outreach clinic

19. District Response Resources –Adequate drugs –No personal protective equipment –No IEC materials during early response –Allowances not provided for EHTs in field –Inadequate chloride of lime Emergency Preparedness Response –No EPR plan; no Zoonotic committees; cumulative period seven month; concrete response started after 6 months & line list incomplete

20. Discussion Eschar common in hands, similar to Mabaera et al (1999) and Gombe et al (2007) – Used for handling and increased risk of bruises Factors found to be associated with contracting anthrax included: eating, skinning, cutting and cooking meat of animals that will have died alone, having cuts/abrasions during skinning and belonging to a religion that permits eating meat of animals that die alone. –Consistent with other studies done locally by Gombe et al (2007), Chirundu et al (2010), Kuonza et al, (2007) and Mwenye et al (1996) –Similar local practices and backgrounds

21. Conclusion Dead animals were the source of infection while meat was the vehicle of transmission. All cases had cutaneous anthrax Having heard of anthrax before was protective The district delayed and was not prepared for the outbreak. Zoonotic committees were not functional and there was poor coordination

22. Recommendations Health worker training in Epidemic Preparedness and Response – DMO Improve surveillance efforts on anthrax during the high risk period – DMO Motorize the EHTs – DEHO Health education on anthrax in the community during high risk period- DHE/DVO Activation of Zoonotic committees -DEHO Vaccination of cattle this year - DVO

23. Limitations Small sample size No laboratory diagnosis of anthrax in humans. Recall bias

24. Acknowledgements Ministry of Health and Child Care, Health Studies Office University of Zimbabwe Department of Community Medicine National AIDS Council of Zimbabwe Center for Disease Control Zimbabwe Manicaland Province Medical Directorate Makoni District Medical Office

25. Thank you

26. Anthrax Eschar

29. Healed Anthrax Eschar

30. Meeting with Community Leaders

31. Health Education - Schools

35. Meat Confiscated from Butcheries

36. Challenges

37. Case Management