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ANTHRAX REPORT FOR HEALTH CARE PROVIDERS

Despite multiple “scares,” there is currently no evidence that any person, business, or organization in Washington State has been the target of an anthrax threat. Testing for exposure to anthrax (nasal swabs or serologic testing) should only be done in the setting of an epidemiologic investigation following a known exposure to anthrax.  Prescribing antibiotics for a presumed exposure to anthrax should only occur after consultation with Communicable Disease Epidemiology at the State Health Department to determine the likelihood that the situation represents an exposure to anthrax. Testing at the Public Health Laboratory thus far has not found any evidence of anthrax in of the many specimens we have received. 

Frequently Asked Questions: 

My patient has no symptoms but is requesting to be tested and/or treated for anthrax.  What should I do? 

WE STRONGLY ADVISE AGAINST PRESCRIBING PROPHYLAXIS OR ORDERING NASAL SWABS OR ANY DIAGNOSTIC TESTING ON ASYMPTOMATIC PATIENTS WITHOUT EVIDENCE OF CONFIRMED OR HIGHLY LIKELY ANTHRAX EXPOSURE.  There are no useful tests to determine if persons are infected with anthrax before they become ill. A negative nasal swab and/or serologic testing cannot rule out exposure to anthrax and these tests are only useful as an epidemiologic tool in an investigation following a known exposure. If you suspect your patient may have been exposed, then local law enforcement and public health officials must be notified to investigate the situation. 

 Prophylaxis for anthrax would only be recommended following a confirmed or highly likely exposure to Bacillus anthracis.  The decision to prescribe prophylaxis should be made in consultation with your local health department or communicable disease epidemiology at the Department of Health. 

 What should we do if the asymptomatic person recalls past contact with powdery material from a letter or in the environment, but the material is no longer available for testing?

 Ask the person about the presence of a threatening message. If the letter contained wording suggesting a threat the patient should report the situation to their local law enforcement agency.  Also assess if inhalation or skin contact with material occurred.

·        If no contact, reassure the person.  No exposure, therefore no risk.  No further action needed.

·        If skin contact or inhalation occurred, reassure person that risk is extremely low in the absence of a threat in or on the letter or package.  It would be prudent to watch carefully for respiratory symptoms or fever, or development of skin lesions.

 What should we do if the asymptomatic person has had contact with powdery material from a letter or in the environment, and the material is currently available for testing?

If you suspect your patient may have been exposed, then local law enforcement and public health officials must be notified to investigate the situation.  Assess if inhalation or skin contact with material occurred.

·        If no contact, reassure the person.  No exposure, therefore no risk.  No further action needed.

·        If skin contact or inhalation occurred, reassure person that risk is extremely low in the absence of a threat in or on the letter or package.  It would be prudent to watch carefully for respiratory symptoms or fever, or development of skin lesions.

My patient gives a history of being at one of the building sites currently under active epidemiologic investigation for anthrax (such as FL, D.C. or NYC).  Do they need to have prophylaxis?

It depends on many factors and thus this decision should be in consultation with Communicable Disease Epidemiology at the Department of Health by calling 1-877-539-4344. 

My patient has flu-like symptoms and is worried that they may have anthrax. What should I do?

Unless there is a known or suspected exposure to anthrax, persons presenting for clinical evaluation of “flu-like” illness should be managed as usual.  The most critical aspect in making a diagnosis of anthrax is a high index of suspicion associated with compatible history of exposure.  Inhalational anthrax begins after an incubation period of one to six days with nonspecific symptoms of malaise, fatigue, myalgia, and fever. There may be an associated nonproductive cough and mild chest discomfort. These symptoms usually persist for two or three days, and in some cases there may be a short period of improvement. This is followed by the sudden onset of increasing respiratory distress with dyspnea, stridor, cyanosis, increased chest pain, and diaphoresis. There may be associated edema of the chest and neck. Chest X-ray examination usually shows the characteristic widening of the mediastinum and, often, pleural effusions.  Pneumonia is not typical of inhalation anthrax.

I have a high index of suspicion that my patient may have anthrax.  What specimens should I obtain for testing?

 Any confirmed or suspected case of B. anthracis must be reported to your local health department or Washington State Department of Health (DOH) IMMEDIATELY. The Washington State Public Health Laboratory is available for consultation 24 hours a day and can be reached through the DOH, Communicable Disease Epidemiology 24-hour emergency number: 1-877-539-4344.

 Obtain the appropriate laboratory specimens for culture based on the clinical form of anthrax that is suspected (inhalational, gastrointestinal, or cutaneous).

     - Inhalational anthrax: blood, CSF (if meningeal signs are present) or pleural
           fluid; and a chest X-ray

     - Gastrointestinal anthrax: blood

     -   Cutaneous anthrax: vesicular fluid and blood

 Evaluation of possible anthrax infection for individuals should be performed through standard laboratory tests, following the Laboratory Response Network (LRN) Level A Clinical Guidelines for rule-out and presumptive testing http://www.bt.cdc.gov (follow the link for Resources: Agents/Diseases – Bacillus anthracis) 

The microbiology laboratory has isolated an organism that is presumptive for Bacillus anthracis.  What should they do?

Any confirmed or suspected isolate of B. anthracis must be reported to your local health department or Washington State Department of Health (DOH) IMMEDIATELY. The Washington State Public Health Laboratory is available for consultation 24 hours a day and can be reached through the DOH, Communicable Disease Epidemiology 24-hour emergency number: 1-877-539-4344. Packaging and labeling specimens is the same as for any infectious substance. 

 More Information About Anthrax

Anthrax is an infection caused by the spore-forming bacterium Bacillus anthracis.  

There are three forms of anthrax infection:  (1) cutaneous – the result of anthrax spores coming into contact with skin; (2) inhalational, which occurs when a person breathes anthrax spores into their lungs, and (3) intestinal, which occurs when a person eats undercooked, anthrax-contaminated meat.  Most anthrax infections are cutaneous (skin).   

Inhalational (lung) anthrax is not spread from person to person, even after an infected person develops symptoms they are not contagious to others.  With cutaneous (skin) anthrax, the drainage from an open sore is a low risk of infection to others. Cutaneous (skin) anthrax can be spread only by direct contact with the drainage from an open sore.   Anthrax is not spread from person to person by casual contact, sharing office space, or by coughing and sneezing.   

Cutaneous Most anthrax infections occur when the bacterium enters a cut or abrasion on the skin, such as when handling contaminated wool, hides, leather or hair products (especially goat hair) of infected animals.  A boil-like lesion appears that eventually forms an ulcer, with a black center.  Adjacent lymph glands may swell.  With cutaneous anthrax, deaths are rare when appropriate anti-microbial therapy is administered. Cutaneous anthrax may be spread if someone comes into contact with fluid from an untreated,  draining anthrax sore on the skin.  

Inhalational:  With respiratory exposure, initial symptoms may resemble the common cold. After several days, the symptoms may progress to severe breathing problems and shock.  Without immediate treatment, inhalation anthrax is usually fatal.   

Intestinal:  The intestinal form of anthrax follows the consumption of contaminated meat and results in acute inflammation of the intestinal tract.  Initial symptoms of intestinal anthrax include nausea, loss of appetite, vomiting, and fever.  These symptoms are followed by abdominal pain, vomiting of blood, and severe diarrhea.  Death results in 25% to 60% of cases. 

The incubation period for anthrax is usually less than 7 days, and in most cases, symptoms appear within 48 hours of exposure.  In rare cases, the incubation period may be up to 60 days.

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Island County Health Department
6th & Main, P.O. Box 5000
Coupeville, WA 98239