| Nurses Continuing Education Institute Anthrax Bioterrorism & Health Care | Cour&e Number | LWN411 1830 | | Objectives | At the end of this course, you will 1) describe the characteristics of anthrax infections, 2) distinguish between the three anthrax forms, 3) analyze the effectiveness of anthrax vaccinations and 4) relate anthrax to bioterrorism . | | Credit Hours and Fee | 3.0 CE Credit Hours with a fee of $24.00 | | Instructor | Rudolf Klimes, PhD (Indiana University), MPH (Johns Hopkins University) Adjunct Professor, Folsom Lake College, Folsom, CA. |
Welcome to this 3-contact-hour Continuing Education course with instant online processing and certification 24/7. Study the course below, take the 12-question multiple-choice TEST, register and pay online. If you score 75% or above, you may print your CE certificate on your printer as soon as you finish. If you have difficulty printing your certificate,click here.You may retake the test once. Disclaimer: This course is for general background information for nurses and other health professionals. It was compiled mainly from existing CDC and university documents. It is a continuing education course and should not be used as an authorative document for treatment. Readers are invited to email updates and possible content additions to edu@learnwell.org. Questionsfor Self-study Do the following for self-study. Do not submit the answers. T F Anthrax infections can come through the nose, mouth or broken skin. T F Anthrax is a bacteria. T F Anthrax infection is mainly a human disease. T F Anthrax spores are found only in the laboratory or weapons. 
1.Anthrax Anthrax is an infectious bacterial disease spread by contact with infected animals, handling infected products, eating infected meat, or breathing weapon-dispersed anthrax spores. Bioterrorism is the intentional use of infectious biological agents, or germs, to cause illness. Bacillus anthracis, the etiologic agent of anthrax, is a large, gram-positive, nonmotile, spore-forming bacterial rod. The three virulence factors of B. anthracis are edema toxin, lethal toxin and a capsular antigen. B. anthracis is considered to be a likely agent for use in acts of biological terrorism. 
In the United States, incidence is extremely low. Gastrointestinal anthrax is rare but may occur as explosive outbreaks associated with ingestion of infected animals. Worldwide, the incidence is unknown, thoughB. anthracis is present in most of the world. For both livestock and humans, anthrax is a notifiable disease in the United States. Among humans, there has been no increase in naturally acquired infection in the United States. Recently, considerable attention has been focused on the potential for B. anthracis to be used in acts of biologic terrorism. Anthrax is primarily a disease of domesticated and wild animals, particularly herbivorous animals. Humans become infected incidentally when brought into contact with diseased animals, which includes their flesh, bones, hides, hair and excrement, or through bioterrorism.. If untreated, anthrax in all forms can lead to septicemia and death. Early treatment of cutaneous anthrax is usually curative. Without treatment, it has a 20% fatality rate. Early treatment of all forms is important for recovery. Patients with gastrointestinal anthrax have reported case- fatality rates ranging from 25% to 75%. Case-fatality rates for inhalational anthrax are thought to approach 90 to 100%.Source: CDC, Dec 2000. Anthrax is diagnosed by isolating B. anthracis from the blood, skin lesions, or respiratory secretions or by measuring specific antibodies in the blood of persons with suspected cases. Human anthrax has three major clinical forms, namely cutaneous, inhalation, and gastrointestinal. Cutaneous anthrax is a result of introduction of the spore through the skin; inhalation anthrax, through the respiratory tract; and gastrointestinal anthrax, by ingestion.
2. Cutaneous AnthraxCutaneous (skin) anthrax is an infection due to a bacterium (Bacillus anthracis) that is found in the environment and typically causes illlness in animals. Cutaneous anthrax is the most common manifestation of infection (about 95% of all cases) with B. anthracis. It is marked by a boil-like lesion that eventually forms an ulcer with a black center. The infection occurs when the bacteria enter a cut or scratch in the skin. Most cutaneous anthrax infections occur when people touch animal products (like wool, bone, hair, and hide) that come from an animal that died of anthrax. If you develop cutaneous anthrax, the drainage from the open sore presents alow risk of infection to others. The only way cutaneous anthrax can be transmitted is by direct contact with the drainage from an open sore. It is not spread from person to person by casual contact, sharing office space, or by coughing and sneezing. Human-to-human transmission is extremely rare and only reported with cutaneous anthrax. The cutaneous form of anthrax responds well to several antibiotics. The United States has a large supply of these antibiotics and can quickly manufacture more if needed. With treatment, complete recovery from cutaneous anthrax is usual. Cutaneous anthrax is diagnosed when the Bacillus anthracis bacterium is found in the skin lesion by a laboratory culture. It can also be diagnosed by measuring specific antibodies in the blood of persons who are suspected of having infection. Cutaneous anthrax is not usually fatal. If treated with appropriate antibiotics, most individuals make a full recovery. Source: New York State Dep of Health 10/12/01
3. Inhalation Anthrax Infection is spread by breathing in anthrax spores that germinate and cause pneumonia. The anthrax spores settle in the alvioli, the tiny air sacs in the lungs. The pneumonia develops very rapidly and leads to progressive respiratory distress. Death can result in less than 48 hours. Meningitis can also develop. Inhalation (pulmonary) anthrax occurs in persons working in certain occupations where spores may be forced into the air from contaminated animal products, such as animal hair processing. Occupational risk groups include those coming into contact with livestock or products from livestock, e.g., veterinarians, animal handlers, abattoir workers, and laboratorians.Source: CDC, Dec 2000. Inhalation anthrax has an usual incubation period of several days, but the range is from 1-60 days. Then symptoms appear in two stages Inhalation anthrax (also known as Woolsorter's disease) is a biphasic illness. The first phase occurs when the spores are carried to the mediastinal lymph nodes by pulmonary macrophages and cause a suppurative infection with edema and hemorrhage. This phase is characterized by nonspecific flu-like symptoms; fever from 100 to 103 degrees, malaise, fatigue, myalgia, nonproductive cough, and at times a sensation of chest oppression or pressure. Rhonchi may be heard with a stethoscope. The presence of such symptoms in a large number of personnel at once should raise the suspicion of anthrax. This phase can last for several days (usually 1-3 days), and can be followed by an asymptomatic period. A helpful radiographic sign is symmetrical enlargement of the superior mediastinum due to lymph node enlargement. The disease is treatable in this stage, but blood cultures are probably negative (no data on this). Sputum cultures might have a higher yield, particularly if anthrax is specifically looked for. It antibiotic treatment is started early in this phase, the survival rate is 25 % at best. The second phase develops suddenly with the development of severe shortness of breath and cyanosis. Hypotension and shock occur. The temperature may be elevated or subnormal due to shock, and perspiration is often profuse. Stridor may be present due to enlargement of the lymph nodes near the trachea. Chest exam shows moist, crepitant rales and signs of pleural effusion. Blood cultures are positive, and the bacteremia may be high enough for organisms to be visible on a Gram stained smear. The second, acute phase typically lasts less than 24 hours and usually ends in death despite therapy, due to the high number of toxin-producing organisms present by this stage in the illness. Bases mainly onAuthor: Sheldon Campbell MD, PhD 12/2/90 Antibiotics should be given to unvaccinated individuals exposed to inhalation anthrax. Penicillin, tetracyclines and fluoroquinolones (Cipro) are effective if administered before the onset of lymphatic spread or septicemia, estimated to be about 24 hours. Antibiotic treatment is also known to lessen the severity of disease in individuals who acquire anthrax through the skin. Inhaled Anthrax was formerly thought to be nearly 100% fatal despite antibiotic treatment, particularly if treatment is started after symptoms appear. A recent Army study resulted in successful treatment of monkeys with antibiotic therapy after being exposed to anthrax spores. The antibiotic therapy was begun one day after exposure.
4. Gastrointestinal Anthrax Gastrointestinal anthrax is rare but may occur as explosive outbreaks associated with ingestion of infected animals. Worldwide, the incidence is unknown, though B. anthracis is present in most of the world. Eating anthrax-infected meat can result in gastrointestinal infection (gastrointestinal anthrax). Gastrointestinal anthrax is generally not considered a threat to U.S. forces. Gastrointestinal infection is associated with ingestion of undercooked contaminated meat, usually that of goats, sheep and cows(1). There are 2 distinct syndromes of gastrointestinal anthrax: oral-pharyngeal and abdominal. The oral-pharyngeal form of the disease results from the deposition and germination of spores in the upper gastrointestinal tract. Locallymphadenopathy, edema, andsepsis develop after an oral or esophageal ulcer.Dysphagia and respiratory difficulties usually occur as a result. The abdominal form of the disease develops from the deposition and germination of spores in the lower gastrointestinal tract, which results in a primary intestinal lesion(6). Symptoms appear two to five days after ingestion, and include nausea, abdominal pain, vomiting, and malaise, eventually progressing to bloody diarrhea, acute abdomen, or sepsis(6 and 7). Massive edema and mucosal necrosis occur at the sites of infection. Due to the ulceration of the gastrointestinal mucosa, blood-tinged vomiting usually occurs.Ascites eventually develop two to four days after the onset of symptoms(7). Mortality rates are high in gastrointestinal anthrax because of the difficulty of early diagnosis(6). Intestinal perforation or anthrax toxemia are the usual causes of death. The morbidity of gastrointestinal anthrax is due to blood loss, electrolyte imbalance, and subsequent shock(7). Gastrointestinal anthrax cases are uncommon, however, there have been reported outbreaks in Africa and Asia(6). Abdominal anthrax is more common than the oral-pharyngeal form(7). The consumption of contaminated buffalo meat resulted in 24 cases of oral-pharyngeal anthrax in Thailand in 1982. Five years later, 14 cases were reported in Thailand with both oral-pharyngeal and abdominal disease occurring. Gastrointestinal anthrax has not been reported in the United States(6). Source Brown U
5. Immunization for Anthrax Currently, the anthrax vaccine is produced under contract to the Department of Defense, and only small quantities are made available as needed to civilians who are exposed to anthrax hazards in their work environment, such as veterinarians, lab workers and others. An attempt to immunize 2.5 million members of the military ended three years ago, but that policy is being reevaluated. If the manufacturer receives approval from the FDA, vaccine production will resume. The anthrax vaccine is a preparation of the protective antigen (a fraction of the toxin) recovered from the culture filtrate of an avirulent, nonencapsulated strain of Bacillus anthracis. Anthrax immunization consists of three subcutaneous injections given two weeks apart followed by three additional subcutaneous injections given at 6, 12, and 18 months. Annual booster injections of the vaccine are required to maintain a protective level of immunity. A segment of the U.S. military population has been vaccinated against anthrax. The first vaccine of the series must be given at least four weeks before exposure to the disease. This vaccine protects against anthrax that is acquired through the skin and it is believed that it would also be effective against inhaled spores in a biowarfare situation. Source: UW The CDC course of action for preventing anthrax after exposure in the civilian population would be with antibiotics. Vaccination is not recommended, and the vaccine is not available to health care providers or the general public. We do not recommend that physicians prescribe antibiotics for anthrax at this time. We currently have enough antibiotics to prevent the disease in 2 million persons exposed to anthrax, therefore we could rapidly get preventive medicine to those who may be affected by this disease, which cannot be transmitted between people. Source www.cdc.gov
6.Anthrax Bioterrorism The possibility of creating aerosols containing anthrax spores has made B. anthracis a chosen weapon of bioterrorism. Iraq, Russia and as many as ten nations have the capability to load spores of B. anthracis into weapons. Domestic terrorists may develop means to distribute spores via mass attacks or small-scale attacks at a local level. As an agent of biological warfare it is expected that a cloud of anthrax spores would be released at a strategic location to be inhaled by the individuals under attack. Spores of B. anthracis can be produced and stored in a dry form and remain viable for decades in storage or after release. There is no evidence of person-to person transmission of anthrax. Quarantine of affected individuals is not recommended. Anthrax spores may survive in the soil, water and on surfaces for many years. Spores can only be destroyed by steam sterilization or burning. Disinfection of contaminated articles may be accomplished using a 0.05% hypochlorite solution (1 tbsp. bleach per gallon of water). It has also been reported that boiling (100 degrees C) for two minutes kills endospores of B. anthracis. As far as getting dangerous mail with anthrax, there is first the logistics of sending out a large number of envelopes containing spores. Anthrax spores need to be dispersed in the air with very advanced equipment to become the dangerous form, pulmonary anthrax, that is lethal. But. (1) Check the address, is it someone you know? If it is someone you know, no problem (2) Check the post mark, where is it mailed from? (3) Is it a catalog? It is not likely that any retailer is going to send you something dangerous. (Note, glossy magazines will often put baby powder in between the pages to prevent them from sticking together. Keep that in mind.) If you are still worried and receive a suspicious package that does have a powder in it, report it to your local authorities and consult your physician. An infection of local animal populations such as sheep and cattle could follow a biological attack with spores. Infected animals could then transmit the disease to humans through the human's skin, mouth or nose. Dealing with Anthrax, a Summary: 1. If you think you have been exposed to anthrax, contact your doctor or health officials. If you need more information, search the links on this page or contact CDC at 888-246-2675 or 770-488-7100.
2. Anthrax spores can be washed off with soup and water or regular laundering.
3. Hard surfaces that may have been exposed to anthrax should be wiped down with a solution of one quart of water and 3 ounces of bleach.
4. If you think you may get exposed to anthrax, use disposable light-weight surgical gloves and N95 half-masks.
5. To guard against anthrax, open you mail carefully and wash your hands after opening the mail.
6. Never self-treat yourself for anthrax, seek professional help. CDC Health Advisory on Anthrax Ciprofloxacin is a broad-spectrum antibiotic agent active against several bacteria including anthrax. The use of ciprofloxacin is warranted only under the supervision of a physician. Ciprofloxacin is one antibiotic often recommended to prevent anthrax after a person has been exposed to B. anthracis.Supplementary information for general information only and not as a guide for treatment (The standard therapy for inhalation anthrax is intravenous penicillin G by continuous infusion, 50 mg/kg or 80,000 U/kg in the first hour, followed by 200 mg/kg or 320,000 U/kg over the following 24h. No data are available on the value on penicillin IM, but it would likely be less effective and larger doses might be required. Streptomycin, 1-2 g/24h IM has been described to be synergistic in combination with penicillin. An alternative regimen is erythromycin, 4g/24h by continuous infusion. In a biological warfare situation, however, it is recommend that vancomycin be a part of any regimen, in a dose of 500 mg every 6 hours. Intramuscular injection of vancomycin is painful. An inferior but possibly useful substitute for vancomycin would be oxacillin, methicillin, or nafcillin in appropriate dosages (use the PDR). Other drugs to which B. anthracis is generally considered susceptible include the first-generation cephalosporins, tetracycline, and chloramphenicol. Adjuvant therapy with hydrocortisone, 100-200 mg/day may be helpful in the case of malignant chest-wall and neck edema. As soon as in vitro susceptibility data are available, therapy should be adjusted to include effective drugs, and drugs to which the isolate is resistant should be eliminated.}Source: Sheldon Campbell
7.Anthrax Library Explore recent updates via More Deadly www.bt.cdc.gov - The most complete site for information on biological terrorism.http://www.dhs.ca.gov/Bioterrorism%20Headline/Revised%20BT%20Response%20master%20document.pdf -California Hospital Bioterrrorism Response Planning Guide DRAFT Turnbull PCB, Bohm R et al., 1993, Guidelines for the Surveillance and Control of Anthrax in Humans and Animals, Geneva. WHO/Zoon/93.170.
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