Anthrax
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Anthrax is a bacterial disease caused by the spore forming Bacillus anthraces, a gram positive, rod- shaped bacterium. It is a zoonotic disease whereby man is infected directly through contact with infected hides or inhalation of spores in the lungs or ingestion of infected meat. It can be manifest on the skin (Cutaneous Anthrax) in the lungs (Pulmonary/Inhalation Anthrax), and/or intestinal (Gastrointestinal Anthrax and Oropharyngeal anthrax) or CNS (Meningeal Anthrax).
Clinical Presentation Cutaneous Anthrax
- Itching
- Pruritic papule or vesicle
- Characteristic depressed black eschar surrounded by moderate to severe edema
- A malignant pustule
- Pyrexia
Inhalation Anthrax
- Mild inhalation Anthrax
- Cough, Fever, Fatigue, Myalgia, can resemble a viral respiratory illness, pulmonary and gastrointestinal signs may occur together
- Severe inhalation Anthrax
- Diaphoresis, Stridor, Dyspnea, Hypotension, Acute respiratory distress
- These patients may develop sepsis accompanied by cyanosis, shock, and hemorrhagic pneumonia. Hemorrhagic pleural effusions often develop.
Gastrointestinal Anthrax
- Fever, Abdominal pain, Vomiting, Diarrhea Bloody stool.
Oropharyngeal anthrax
- Signs of oropharyngeal anthrax may include dysphagia with posterior oropharyngeal necrotic ulcers, Unilateral neck swelling, Cervical adenopathy, Edema, Pharyngitis fever
Meningeal Anthrax
- Hemorrhagic meningoencephalitis that involves both
- Deep brain parenchymal hemorrhagic lesions
- Infection of the cerebrospinal fluid (CSF) in the subarachnoid space
Case Definition
Suspected Case: Any person with acute onset illness characterized by several clinical forms which are:
- 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.
- Gastro-intestinal: Any person with abdominal distress characterized by nausea, vomiting, anorexia and followed by fever
- 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
- 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
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
Laboratory Investigation
- Isolation of Bacillus anthracis from a clinical specimen (e.g. blood, lesions, discharges)
- Demonstration of B. anthracis in a clinical specimen by microscopic examination of stained smears (vesicular fluid, blood, cerebrospinal fluid, pleural fluid, stools)
- Positive serology (ELISA, Western blot, toxin detection, chromatographic assay, fluorescent antibody test)
- Detection of nucleic acid by PCR
Other supporting tests
- Measurement of antibodies or toxin in blood
- Chest X-ray
- Computerized tomography (CT) scan
- Detection of B. anthracis by nucleic acid test (NAT) covering the genes coding for capsule and virulence factors
Prevention: Post Exposure Prophylaxis
A: Initial 10-day exposure: ciprofloxacin (PO) 500 mg 12hourly for 5 days or doxycycline 100mg (PO) 12 hourly (or, if pathogens are documented to be susceptible phenoxymethyl penicillin may be used)
- Adults: phenoxymethyl penicillin (PO) 250-500 mg 6 hourly
- Children 1-5 years: phenoxymethyl penicillin (PO) 125 mg 6 hourly.
- 6-12 years: phenoxymethyl penicillin (PO) 250 mg 6 hourly 48 hours’ exposure:
OR
S: clindamycin (PO) 150 to 300 mg 6 hourly for 5days
OR
S: levofloxacin (PO) 500 mg 12hourly for 5 days are alternative antimicrobial prophylaxis to the local population within 48 hours of the initial exposure
Pharmacological Treatment
A: benzylpenicillin (IV) 0.6 MU 6 hourly until local oedema subsides then continue with
A: phenoxymethyl penicillin (IV) 250 mg 6 hourly for 7 days
If not responding, change to
A: doxycycline (PO) 200mg initial dose then 100mg 12 hourly for 7 days
OR
A: ciprofloxacin (PO) 500mg 12 hourly for 7 days
AND
A: paracetamol (PO) 15mg/kg 8 hourly for 5days
In severe forms ADD
Dexamethasone (PO) 0.6 mg/kg per day in divided doses every 8 hours for 4 days
Public Health Control Measures
- Standard infection control precautions (IPC) should be used when managing patients with particular attention to body fluid spills, as organisms which remain on surfaces may form spores which are infectious
- Personal protective equipment should be used in situations where there is potential for splashes and inoculation injuries.
- Mobilize the community for early detection and care
- Ensure proper burial or cremation (if practiced) of dead bodies (humans and animals)
- Conduct community education on the disease symptoms and signs, early reporting/seeking of medical care, disease transmission and prevention, application of infection prevention and control for home care setting
- Conduct active search for additional cases that may not come to the health care setting (older women or small children patients, for example) and provide a door to door information about prevention and when to seek care
- Ensure adequate collaboration with other sectors such as livestock, agriculture, environmental and sanitation, to ensure appropriate interventions are addressed
- Request additional help from district/regional/national levels as needed