Inhalation anthrax: a single case in North London Dr Sudy Anaraki North East and North Central Londo

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Inhalation anthraxa single case in North London
Dr Sudy Anaraki North East and North Central
LondonHealth Protection Unit
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Key participants in incident control

• Nigel Lightfoot
• Brian McCloskey
• Daniel Krahé
• Robert Gosh
• Sarah Addiman
• Grainne Nixon
• Roy Hitching
• Kate Harris
• Alison Cockerill

• Graham Lloyd
• Tim Brooks
• Robert C Spencer
• Bengu Said
• Hilary Kirkbride
• Amanda Walsh
• Helen Maguire
• Emily Collins
• And thanks to many others who supported the
  investigations

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Epidemiology of anthrax

• 1981 to 2006 18 possible cases of cutaneous
  anthrax in EW.
• Bacteria isolated in only one case
• Serological confirmation in another two
• The last case of pulmonary anthrax in EW in
  1974
• Linked to bonemeal fertilizer
• The previous case was in 1965
• A death from atypical inhalation anthrax in
  Scotland in 2006
• In a drummer and drum maker
• Possibly due to exposure to imported animal hides
  
• One case of naturally acquired inhalation anthrax
  in the US in 2006
• In a drum maker who used animal skins imported
  from Ivory Coast

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Anthrax the disease

• Cutaneous anthrax
• small papule or vesicle, ulcerates with central
  necrosis, painless, localized, non-pitting oedema
  surrounds ulcerated area, black eschar

• Bacillus anthracis
• large, non-motile, non-haemolytic gram-positive
  bacillus, forming endospores

Gram-positive, spore-forming rod
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Anthrax the disease

• Inhalation anthrax
• fever, chills, drenching sweats, cough, dyspnoea,
  respiratory distress
• CXR mediastinal widening, pleural effusion
• Intestinal anthrax
• fever, abdominal tenderness, diarrhoea, ascites,
  ulceration, haemorrhage, intestinal obstruction,
  or perforation

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Presentation of the case and investigations

• 21st Oct 08
• a patient presented with respiratory symptoms,
  rapidly deteriorated
• 23rd Oct 08
• respiratory failure, multiple organ failure,
  transferred to ITU
• CXR widening of mediastinum bilateral pleural
  effusion
• Investigations
• Blood culture grew Gram positive bacilli in 2
  hours
• Preliminary identification at the local lab
  anthrax
• Reported to HPU on Fri 24 Oct as possible anthrax
  
• Sample sent to the Laboratory for Novel and
  Dangerous Pathogens (NAPD), Porton Down on the
  same day
• Confirmed as anthrax at 930 pm on Friday

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Incident Control Team (ICT)

• Health Protection Agency
• NENC London Health Protection Unit
• Porton Down NADP
• Centre for Infection
• London Regional Epidemiology Unit
• Local services
• London Borough of Hackney
• City and Hackney PCT
• Local Emergency Services
• Other organisations involved
• DEFRA, GDS, etc.

• Working sub groups formed
• Clinical Team
• Epidemiological and Contacts Investigations Team
• Environmental Investigations Team
• Communications and Media team

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Case management and outcome

• Treatment Ciprofloxacin, Clindamycin and
  Rifampicin
• CDC, Atlanta consulted over the weekend
• Anthrax Immunoglobulin (AIG) flown in from USA on
  Monday 27th Oct
• AIG was administered according to protocol,
  tolerated well
• Supportive treatment and bilateral pleural fluid
  drainage
• On Sun 2nd November patient developed
  Disseminated Intravascular Coagulation, bleeding
  and seizure
• Arterial blood pressure dropped, cardiac arrest
  followed
• Patient died at 145 pm
• Body was bagged and buried in a lead lined,
  sealed coffin

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Post Mortem

• Post Mortem was carried out on Wednesday 05 Nov
  following infection control advice from Porton
  Down
• Pathological findings
• haemorrhagic pericardial effusion
• haemorrhagic pleural effusion
• pulmonary oedema
• bilateral hilar lymphadenopathy
• Cause of death sepsis and toxaemia due to
  inhalation anthrax
• A systematic review of 82 cases of inhalation
  anthrax describes a 45 mortality rate among 11
  cases of 2001 US bioterrorism attack, compared to
  a 92 mortality rate in cases reported before
  2001.
• The difference has been attributed to initiation
  of treatment during the prodromal stage, as well
  as multidrug antibiotic therapy and pleural fluid
  drainage

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Possible source of infection

• Patient made and played animal hide drums
• The main supplier of animal skins reported
  importing hides from the Gambia
• There were possibly other sources of skin but
  not known to the family
• HPA risk assessment
• The main risk drum making
• Shaving hair from infected animal skin results in
  aerosolised anthrax spores that can be inhaled

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Looking for those exposed

• Discussions with the family, friends and
  musicians re drum making with untreated animal
  skins
• Individuals who might have been present when the
  case was making drums in the 60 days before onset
  of symptoms, or were otherwise exposed included
• Immediate family
• The main supplier of the skins who also made
  drums
• A person who assisted the supplier of hides with
  drum making
• A staff member at the hospital who was concerned
  about potential exposure to aerosolised spores
• And Chica the cat!

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Prophylaxis

• 9 contacts identified as high risk
• All started prophylaxis with ciprofloxacin (500
  mg oral, twice daily for 60 days)
• Due to reported minor side effects, including
  stomach upset, the treatment was switched to
  doxycycline (100 mg oral, twice daily) in one,
  and to amoxicillin (500 mg oral, three times
  daily) in another
• The latter person stopped taking antibiotics
  after three weeks
• All other contacts completed their course of
  prophylaxis.

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Looking for spores

• Patient had two addresses
• Family home in Hackney where wife and children
  lived
• Studio flat in Hackney used as a workshop where
  he made drums
• Environmental testing included
• Samples from animal skins, drums, tools, surfaces
  and air at the studio flat
• Drums stored at the family home
• Animal skins and tools from the supplier of hides
  in Waltham Forest
• Environmental sampling of studio flat was carried
  out on Tuesday 04 Nov 08
• Well-organised operations
• Overseen/organised by the London Borough of
  Hackney
• Support from local emergency services
• Residents of the block informed
• Neighbours informed
• Media informed and were present

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Environmental testing results

• B. anthracis isolated from one drum removed from
  the studio flat
• Spores also isolated from some sections of 2 out
  of 5 animal hides found in the studio flat
• All samples taken from family home were negative
• Samples taken from the workshop of the supplier
  of the animal skins were also negative

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Genotyping

• Strain isolated from patient identical to those
  isolated from hides
• Origin of these hides and whether they were used
  by patient during the incubation period is
  unknown
• Spores recovered from the drum not related to
  strain isolated from patient
• This drum was not made by patient he bought it
  approximately 5 years ago and played it regularly

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Discussion

• Infection most likely due to handling and
  manipulating the contaminated hides rather than
  playing contaminated drum
• The source of contaminated animal skins were not
  found during the investigations
• Despite ongoing import of (untreated and
  uncertified) animal skins and popularity of
  animal hide drums the disease incidence in the UK
  remains very low
• HPAs advice to drummers and drum makers can be
  found on the HPA and Defras website

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The cat who did not have anthrax!

• Chica the only occupier of the flat after
  patients admission
• To carry out sampling and decontamination, Chica
  was removed
• A vet visited the flat in full PPE, washed and
  decontaminated Chica
• Transferred to Animal Reception Centre at
  Heathrow and received 60 days of CONVENIA
  injections (cefovecin, a third generation
  cephalosporin given every 14 days)
• She was later adopted by one of HPA staff!

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Acknowledgements

• Homerton University Hospital
• London Borough of Hackney
• NENC London HPU
• HPA, Centre for Infection
• HPA, London Region
• HPA, NADP, Porton Down
• City Hackney PCT
• London Borough of Waltham Forest
• Defra, Animal Health