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3/20/2018 Anthrax

Anthrax
by Sarah Schoenfelder
Disease Etiology, Characteristics, and Identification:

Anthrax is a disease of microbial origin caused by the bacterium Bacillus anthracis, a Gram‐positive, endospore‐
forming rod. The word “nthrax”comes from the Greek word for coal; the origin of this word likely being the
coal‐black lesions cutaneous anthrax causes on victims’skin. (8) Gamma bacteriophage or enzyme‐linked
immunosorbent assay tests can identify B. anthracis. PCR (Polymerase Chain Reaction) testing is available now
in some, but not all lab settings and can accurately identify which specific anthrax strain is present. ELISA or
antibody tests can also confirm anthrax; they test for the antibodies our bodies create against anthrax once
infected but before clinical symptoms emerge (12). Lab testing (or cultures) can also confirm diagnosis of the
anthrax bacteria from lesions, blood, or serous fluid discharge but these can be slower to provide concrete
results, and result in the loss of precious time to treat a patient (12). Work is underway on nanotechnology tests
that might offer quicker anthrax identification. (9)

Disease Transmission:

Anthrax cannot directly transmitted from human‐to‐human contact. Rather, it is transmitted by the transfer of
spores from infected humans or animals to potential hosts or by exposure to airborne anthrax spores. (4) That
means it requires direct contact, inhalation, or ingestion of anthrax cells or spores to acquire an infection.
Unfortunately contact with anthrax bacterial cells or endospores can happen in a wide variety of ways: touching
or wearing infected clothing; contact with contaminated animal skins, hairs, hides, or bone products (1); being
exposed to spore reserves in soil; eating or touching infected wool or meat; inhaling airborne particles, etc.
Outside of acts of terror, contact with contaminated animal products or wool is the most single common source
of anthrax infections. In fact anthrax was once so common among workers who sorted sheep’’wool it was known
in the past as “woolsorters Disease.”(1, 7)

Reservoirs:

Other than intentional acts of bio‐terror in which anthrax was used as a terrorist agent, anthrax is primarily a
zoonotic, or animal‐born disease. The natural reservoirs of anthrax are domesticated herbivores, especially
cattle, sheep, and goats. (1)

Historical details:

Anthrax has plagued humankind for almost as long as history has been written and we have lived alongside
domesticated animals. It is even thought to have existed in early Egypt and Mesopotamia (7) and is even thought
to be referred to in the Old Testament of the Bible. (8) It continued to torment humans and caused mass
outbreaks in Europe during the Middle Ages up until the early Industrial Revolution. However, the most serious
human outbreak in recent times took place in Zimbabwe between 1978-1980; that epidemic infected nearly
10,000 and took 151 lives (8). Anthrax’ bacterial origin, Bacillus anthracis, was discovered by the famous
German microbiologist and physician Robert Koch, known best for his postulates which are still used to prove
microbial theory and disease etiology today. Koch’s theories and early work with anthrax later led to discovery
of germ theory. Koch isolated and identified Bacillus anthracis as the bacterial cause of anthrax in 1875. (2)

Signs and symptoms:

Anthrax can manifest in a variety of different ways, depending on how it enters the body. There are three main
varieties of anthrax: cutaneous anthrax (caused by skin exposure, usually through cuts); pulmonary anthrax
(caused by inhaling anthrax; this form affects the lungs and then attacks lymph nodes in the chest); and
gastrointestinal anthrax (caused by ingesting the bacteria through contaminated meat). Of the three types,
pulmonary anthrax is the most virulent and most frequently fatal if not treated. Oropharyngeal anthrax, the
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fourth and least common form of anthrax affects the throat and base of the tongue. (4) Cutaneous anthrax
manifests with dark ulcers or lesions on the skin that typically develop within a week of exposure. Pulmonary
anthrax symptoms set in faster, and can affect patients as soon as “1‐7 days”or up to a month after exposure (3).
Symptoms of pulmonary anthrax include trouble breathing, nausea, fever, vomiting, etc. Without treatment the
symptoms become worse and patient can go into shock, suffer toxemia, endure the collapse of lungs, or even die
(3). Pulmonary anthrax, left untreated, is quite often fatal. Gastrointestinal anthrax usually manifests with
stomach pain, fever, and loss of appetite, with symptoms increasing in severity if a patient is not treated with
antibiotics.

Virulence / Microbial Hardiness Factors:

Bacillus anthracis’ best weapon against its victims is the bacteria’s ability to form endospores, which allow it go
from a live cell state to an endospore state, which the National Institute of Allergy and Infectious Diseases’
summarizes as “a very hardy resting phase which can withstand extreme heat, cold, and drought, without
nutrients or air (3).” Once anthrax spores find themselves back in friendly climate or conditions, they can re-
germinate into an active state and can then infect a new set of potential hosts. Shockingly, anthrax spores can lay
dormant for up to 36 years and emerge viable!! (1 and 8). Additionally anthrax produces a trio of potent
exotoxins that boost the bacteria’ virulence (6). One toxin contributes to pulmonary edema in anthrax victims;
another boosts the bacteria’ “ethal factor;”a third disrupts host cells’molecular structure (3 and 6). Together these
three toxins are a deadly trio. As David Goodsell explains in his article on “anthrax Toxin,”each part of the trio
has its unique effect: “art of the toxin is a delivery mechanism that seeks out cells; another part is a toxic enzyme
that rapidly kills the cell…It delivers the other two parts, edema factor and lethal factor which are the toxic
components that attack cells,” (10). Further adding to anthrax’s virulence is its capsule, which is composed of
poly-Dglutamic acid (11). The capsule is negatively charged and aids in anthrax’s inhibition of host immune
defense; specifically the capsule prevents phagocytosis of the spores by macrophages (11). Ezzell and Welkos
further eludciate the capsule’s key role in anthrax’s virulence by stating, “In conjunction with lethal toxin and
oedema toxin, whose target cells include macrophages and neutrophils, respectively, the capsule allows virulent
anthrax bacilli to grow virtually unimpeded in the infected host,” (11).

Control and treatment:

Because of its ability to form endospores, the control of anthrax can be extremely challenging. Oxidizing agents,
including chlorine dioxide, formaldehyde, ethylene oxide, and peroxide have been found to kill anthrax with
prolonged, direct contact, but these agents are best utilized in enclosed areas where anthrax has been detected
(e.g. offices, laboratories, etc). Burning of contaminated objects is also effective but not always practical (1).
Anthrax contamination in outdoor areas such as farms or ranches is more difficult. Anthrax contaminated animal
corpses can be buried or burned, but burying does not destroy endospores, which can remain in the soil for long
periods of time even after the carcasses deteriorate. All told, anthrax is a tough bug to kill or control, primarily
because of its ability to form spores. And as the “Anthrax Fact Sheet” from the State of Georgia’s Health
Department notes, “B.anthracis spores are very resistant to harsh environmental conditions and disinfection, and
may remain viable in soil for many years.” (1)

If a human is known to be exposed to anthrax, they should be promptly treated with prophylactic antibiotics.
This is especially crucial in case of pulmonary (or inhaled) anthrax, which is often fatal if not treated. A variety
of antibiotics have been found to be effective against anthrax, including penicillin, fluroquinolones including
ciproflaxin and erythromycin, and vancomycin. (1 and 4) However, the disease must be treated in early stages
before levels of the toxin grow in a host’s body. Antibiotics only kill anthrax bacterial cells, and are not effective
against toxins. Since early anthrax symptoms resemble a variety of less virulent infections, many victims may
not even realize they need to be treated until the onset of severe symptoms, triggered by toxins. By the time
anthrax is diagnosed, exotoxin levels may have already killed the host (6). An anthrax vaccine was developed in
the mid‐1970s, mainly for use on militaryservice‐people and workers who come into frequent contact with
livestock or animal products including hides and wool. However due to side effects and relatively inconvenient
vaccine schedule (multiple doses are required for immunity) the vaccine has not been used or recommended to
the general public. Microbiologists and medical professionals continue to work on refining the anthrax vaccine
and therapies to treat anthrax infections including antitoxin therapies. (8) Additionally, according to Nature and
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other online journals, researchers have been working with bacteria‐killing viruses to see whether an anthrax‐
killing virus may be the next effective weapon against B.anthracis. (5)

Prevention:

The best way to prevent anthrax is to avoid or minimize contact with sources of contagion. This means
exercising caution when handling animals or animal products, and of course, absolute caution in laboratory
work. Meat from infected animals should never be sold, and carcasses should be carefully destroyed from any
animal suspected to suffer anthrax. Smart animal‐handling practices and policies regarding vaccinating livestock
have dropped the numbers of anthrax cases substantially (8). However, greater fears remain around anthrax’
potential as a bio‐weapon. As the attacks of 2001 illustrated, in the wrong hands, anthrax can be an extremely
potent, and difficult to detect weapon of terror. The bacteria’fearsome potential demands we be good stewards of
our vaccine, and refine potential treatments.

Global and Domestic Cases / Outbreaks:

While anthrax is endemic among livestock in some parts of the world and occasionally affects humans who
work with livestock or animal‐skins, outbreaks are usually quite rare, particularly in the Western World. It is
slightly more prevalent in the developing world. *Note: I hunted high and low for up-to-date global incidence
rates and neither the CDC, WHO.org, or NIH seemed to have published global incidence rates. I did find a on
older Public Health site that sited global case numbers for the 1950s and 1960s, but these would not be currently
useful. The most notorious outbreak in the United States in recent years was the post 9/11 bio-terror incident
when anthrax was mailed to US Senators’offices, affecting over 22 Americans. Before then, there had not been a
case in the United States of inhaled anthrax since 1976 (3). The published incidence rates for the United States
indicate approximately 1‐2 cases of cutaneous anthrax a year making it extremely rare. According to OSHA:
“rom January 1955 to December 1999, there were 236 reported cases of anthrax, most of them cutaneous, in 30
states and the District of Columbia,”(13). These “aturally occurring”anthrax cases were typically linked to work
with infected animals, or animal products like hides or yarn.

References:

(1) Georgia State of Health Department. Anon “nthrax Fact Sheet,”publication date not specified,
http://health.state.ga.us/pdfs/epi/notifiable/anthrax.fs.02.pdf 2/24/11

(2) Harvard University Library; Contagion: Historical Views of Diseases and Epidemics; Anon. “Robert Koch.”
Last updated 2011. http://ocp.hul.harvard.edu/contagion/koch.html 2/25/11

(3) National Institute of Allergy and Infectious Diseases, Anon. “Anthrax”


http://www.niaid.nih.gov/topics/anthrax/Pages/default.aspx

(4) Center for Disease Control, Anon, “Fact Sheet: Anthrax Information for Health Care Providers,” Last
updated March, 2002. http://www.bt.cdc.gov/agent/anthrax/anthrax‐hcp‐factsheet.asp#orop 2/26/11

(5) Nature. “Virus Deals Anthrax a Killer Blow,” Rosovitz, M.J. & Leppla, Stephen H.August, 2002
http://www.nature.com/nature/journal/v418/n6900/full/418825a_fs.html 2/25/11

(6) National Instiute of Health, Chvyrkova, Irina, Xuejan Zhang, and Simon Terzyan. "Lethal Factor of Anthrax
Toxin Binds Monomeric Form of Protective Antigen." July 3 2007,
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1986636/ 2/26/11

(7) Associated Content, “The History of Anthrax,” Dunkin, Daniel, last updated August 26,
2008,http://www.associatedcontent.com/article/953657/the_history_of_anthrax.html, 2/25/11.

(8) SIU Department of Medicine, Anon. “Anthrax: Bacteriology, Clinical Presentations, and Management,” last
updated January 27, 2011, http://www.siumed.edu/medicine/id/anthrax.htm 2/27/11.

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(9) US Food and Drug Administration, “Assessing Feasibility of Using Nanotechnology Test to Detect Anthrax
Following a Bioterrorist Attack,” last updated March 17, 2009,
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm14 9545.htm, 2/27/11.

(10) Protein Data Bank, Goodsell, David, “Anthrax Toxin,” (4/2002), http://www.pdb.org/pdb/101/motm.do?
momID=28 (4/28/11).

(11) Applied Microbiology, Ezzell, JW and Welkos, SL, “The Capsule of Bacillus anthracis: A Review,”
(8/2/98), http://www.ncbi.nlm.nih.gov/pubmed/10475959 (4/30/11).

(12) UCLA.edu, Johnson, T. “Anthrax Identification,” (10/19/01)


http://www.ph.ucla.edu/epi/bioter/anthapha_id_a.html#ELISA (5/1/11).

(13) OSHA.gov, Anon, “Anthrax: Protecting the Worksite Against Terrorism,” (date not provided on website)
“http://www.osha.gov/SLTC/etools/anthrax/disease_rec.html#incidence (5/1/11)

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