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Anthrax as an Agent of Bioterrorism

This document has been compiled from information from CDC and other international medical sources.

Introduction

Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. It most commonly occurs in hoofed mammals and can also infect humans. Symptoms of the disease vary depending on how the disease was contracted, but usually occur within 7 days after exposure. The serious forms of human anthrax are inhalation anthrax, cutaneous anthrax, and intestinal anthrax.

Initial symptoms of inhalation anthrax infection may resemble a common cold. After several days, the symptoms may progress to severe breathing problems and shock. Inhalation anthrax is often fatal.

The intestinal disease form of anthrax may follow the consumption of contaminated food and is characterized by an acute inflammation of the intestinal tract. Initial signs of nausea, loss of appetite, vomiting, and fever are followed by abdominal pain, vomiting of blood, and severe diarrhoea.

The lack of volatility of the disease, as well as the inability of bacterium to penetrate intact skin, should be taken into account when evaluating a threatened release of anthrax. These factors make it unlikely that individuals that come into contact with letters, packages, and other devices supposedly containing anthrax will be at risk for aerosol exposure.

Energy is required to aerosolize the spores and opening a letter containing anthrax, would be unlikely to place a person at substantial risk. Post-exposure prophylaxis may therefore not be necessary in many cases of threatened anthrax dissemination.

Direct person-to-person spread of anthrax is therefore extremely unlikely, if it occurs at all, and this is the most important factor to remember.

Incidents

Exposure

All persons exposed to a bio-terrorist incident involving anthrax should be started on one of the post-exposure prophylaxis regimens at the earliest possible opportunity.

In addition to receiving chemo-prophylaxis, exposed persons should be immunized only if the vaccine is available, which is unlikely to be the case in many countries including Indonesia.

Chemo-prophylaxis is best continued until the exposed persons have received at least three doses of vaccine (thus, for a minimum of 4 weeks).

If vaccine is not available, it is recommended that chemo-prophylaxis be continued for 8 weeks. As already stated the human form of the vaccine is not available within Indonesia.

Threatened or Suspected Anthrax Release

In cases of threatened or suspected release of anthrax, chemo-prophylaxis can be delayed 24 to 48 hours, until the threat is verified and should be discontinued if the threat is found to be false.

Laboratory Invetsigations

Laboratory investigations should be done immediately to confirm the diagnosis of anthrax by detecting gram-positive bacilli in skin biopsy material (in the case of cutaneous disease) or in blood smears. A preponderance of gram-positive bacilli in swabs of the nostrils or in appropriate environmental samples might support a diagnosis of anthrax where intentional release is suspected.

None of the major pathology laboratories in Indonesia are able to test for anthrax and the only facility currently able to test in the Jakarta area is the Balai Veterinary Department in Bogor.

Investigations that are not available in Indonesia should be sent to the nearest center in Singapore or Australia to confirm the diagnosis.

Chemo-Prophylaxis and Treatment

In persons exposed to anthrax, infection can be prevented with antibiotic treatment.

Early antibiotic treatment of anthrax is essential-delay lessens chances for survival. Anthrax usually is susceptible to antibiotics such as penicillin, doxycycline, and fluoroquinolones, all of which are widely available within Indonesia.

It is however emphasized that self-medication is not advisable and any person who wishes to start antibiotic treatment, for whatever reason, should seek prior medical advice before starting. The undisciplined use of antibiotics can lead to drug resistance later on. Drug-drug interactions and individual patient allergies should be considered when selecting an antibiotic for prophylaxis or treatment.

Careful consideration for the type of antibiotic prescribed should be taken for children, the aged and pregnant individuals.

Vaccination

The vaccine is prepared from a formalin-treated culture supernatant of an avirulent B. anthracis strain.

Direct person-to-person spread of anthrax is extremely unlikely, if it occurs at all. Therefore, there is no need to immunize or treat contacts of persons ill with anthrax, such as household contacts, friends, or co-workers, unless they also were also exposed to the same source of infection.

Vaccination against anthrax is not recommended for the general public to prevent disease and is not available for this purpose. At present its use is generally limited to military personnel and high-risk individuals.

Decontamination

In certain cases, such as exposure to a threat letter involving an unidentified substance, where anthrax cannot readily be ruled out by Gram stain or other rapid diagnostic procedures, decontamination may be warranted.

Remove all clothing, seal it in a plastic bag, and shower the plastic bag with copious amounts of soap and water.

Environmental surfaces and personal effects may be treated with 0.5% hypochlorite after the area in which the agent was released is investigated.

How to Handle Anthrax and Other Biological Agent Threats

Abbreviated from CDC Health Advisory

DO NOT PANIC!

A) Suspicious Unopened letter or PACKAGE MARKED WITH THREATENING MESSAGE SUCH AS "ANTHRAX":

  1. Notify your superior or senior management immediately.
  2. Do not shake or empty the contents of any suspicious envelope or package.
  3. PLACE the envelope or package in a plastic bag or some other type of container to prevent leakage of contents.
  4. If you do not have any container, then COVER the envelope or package with anything (e.g., clothing, paper, trash can, etc.) and do not remove this cover.
  5. Then LEAVE the room and CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away).
  6. WASH your hands with soap and water to prevent spreading any powder to your face.
  7. LIST all people who were in the room or area when this suspicious letter or package was recognized. This is for follow-up investigations and advice.
B) Envelope with powder and powder spills out onto surface:
  1. DO NOT try to CLEAN UP the powder. COVER the spilled contents immediately with anything (e.g., clothing, paper, trash can, etc.) and do not remove this cover!
  2. Then LEAVE the room and CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away).
  3. Notify available supervisor or senior management immediately.
  4. WASH your hands with soap and water to prevent spreading any powder to your face.
  5. REMOVE contaminated clothing as soon as possible and place in a plastic bag or some other container that can be sealed. This clothing bag should be given to the emergency responders for proper handling.
  6. SHOWER with soap and water as soon as possible. Do Not Use Bleach Or Other Disinfectant On Your Skin.
  7. If possible, list all people who were in the room or area, especially those who had actual contact with the powder so that proper instructions can be given for medical follow-up, and for further investigation.
C) Question of Room Contamination by Aerosolization::

For example: small device triggered, warning that air-handling system is contaminated, or warning that a biological agent released in a public space.

  1. Turn off local fans or ventilation units in the area.
  2. LEAVE area immediately.
  3. CLOSE the door, or section off the area to prevent others from entering (i.e., keep others away).
  4. Notify an available superior or senior management immediately.
  5. SHUT down air handling system in the building, if possible.
  6. If possible, list all people who were in the room or area, for further investigation.

How to Identify Suspicious Packages and Letters

Some characteristics of suspicious packages and letters include the following:
  • Excessive postage
  • Handwritten or poorly typed addresses
  • Incorrect titles
  • Title, but no name
  • Misspellings of common words
  • Oily stains, discolorations or odor
  • No return address
  • Excessive weight
  • Lopsided or uneven envelope
  • Protruding wires or aluminum foil
  • Excessive security material such as masking tape, string, etc.
  • Visual distractions
  • Ticking sound
  • Marked with restrictive endorsements, such as "Personal" or "Confidential"
  • Shows a city or state in the postmark that does not match the return address

Anthrax Testing in Indonesia

Anthrax testing is not available at any of the major laboratory companies in Indonesia and any lab samples will need to go to Singapore/Australia.

The only lab that is capable of testing locally is the veterinary laboratory which does the animal testing. Balai Veterinary Dept. Bogor, JL. RE Martadinata 30 Bogor (0251 - 331048; 334456). They can perform serological testing (Elisa) and blood culture on blood serum samples and also culture from skin lesions. They obviously have no experience of testing bioterrorism articles such as packages or envelopes containing suspicious materials. However, it is recommended that sophisticated testing such as this be done either in Singapore or Australia.

Additional information:

Info on Anthrax from the US Center for Disease Control

If you have any further questions about anthrax in Indonesia, see the Ask the Experts.

We trust this information will assist you in making correct choices regarding your health and welfare. However, it is not intended to be a substitute for personalized advice from your medical adviser.

Our appreciation to International SOS, An AEA Company who researched and contributed this article in response to inquiries about Anthrax threats in Indonesia.