I read this account last night about a woman contracting anthrax (which is rare, but cases have occurred from handling unprocessed imported hides).
STRAFFORD, N.H. — Investigators are trying to determine if a woman who took part in an African drumming circle got anthrax from her drum.
The woman from Strafford, New Hampshire got sick earlier in December, and is now in critical condition in the hospital.
State officials believe she may have breathed in anthrax spores, which can occur naturally in animal hides. Officials are asking anyone who attended drumming events at the Waysmeet Center between October and December to contact them.
She breathed in anthrax spores? That means she has inhalational anthrax, right?
CONCORD, N.H. — State and federal authorities are searching for the naturally occurring (Editor’s note: Naturally occurring? Says who?) source of anthrax that has left a New Hampshire woman in critical condition.
State public health director Dr. Jose Montero says the woman from Strafford County became ill in early December. Authorities have confirmed she is suffering from gastrointestinal anthrax and are investigating whether the anthrax spore came from an African drum she took to a drum circle event at the United Campus Ministry at the University of New Hampshire.
Montero says investigators are testing the drums because two recent anthrax cases in New York and Connecticut were related to animal hides. He says anthrax is not transmitted from person to person and the public is not at risk
Hunh. She clearly didn’t “breathe in” spores that caused her case of GI anthrax.
Disease from exposure to anthrax spores comes in three forms: Cutaneous anthrax (from spores entering the skin through a cut), inhalation anthrax (inhaling the spores), and intestinal anthrax (swallowing the spores in undercooked meat from diseased animals). Unless she was chewing on the drum or had recently been out of the country into an area where anthrax is endemic and eaten diseased, undercooked meat contaminated by anthrax spores, I have to wonder about the etiology of this. I also have to wonder about the sloppy reporting that gives the impression that inhaling spores causes GI/intestinal anthrax.
Per the CDC:
While the biowarfare and bioterrorist development of anthrax has focused on inhalation, ingestion has been considered as well. The Japanese experiments in China during the 1930s and 1940s included attempts to poison children with chocolate impregnated with anthrax (31). More recently, the apartheid government of South Africa had developed biological weapons, including another attempt at anthrax-containing chocolate (32). Given the large community outbreak of salmonellosis caused by an intentional contamination of restaurant salad bars the in United States by the Rajneeshees (33), awareness of the potential for GI anthrax due to bioterrorism is important.
In conclusion, GI anthrax is probably greatly underreported in rural disease-endemic areas of the world. The spectrum of disease, ranging from no symptoms to death, has not been fully appreciated. Awareness of anthrax in a differential diagnosis remains important in disease-endemic areas and also in settings of possible bioterrorism.
So, GI anthrax is rather rare even in rural disease-endemic areas of the world (where it may be underreported) and, when it appears outside those areas, we need to consider bioterrorism. Just how rare is it?
BACKGROUND: Bacillus Anthraces is a non-motile, rod like, gram-positive and aerobic bacillus that produces central oval-shaped spores and characterized by rough, irregular and often comma-shaped colonies in blood agar. About 95% of human anthrax is cutaneous and 5% respiratory. GI anthrax, a very rare type, has been reported in less than 1% of all cases. We thus report a case of GI anthrax with autopsy findings. CASE REPORT: A 15-year-old young adult man was admitted to our hospital with history of fever, abdominal pain and bloody diarrhea from 48 hours after ingestion of half-cooked sheep’s meat. In endoscopic exam of upper GI tract, the esophagus had been filled with fresh blood without any varices, stomach showed evidence of hemorrhage and had multiple erosion but no ulceration of duodenum. Penicillin G 24,000,000 U/day IV was started but unfortunately severe upper and lower GI hemorrhage developed, leading to hypotension and death. In autopsy, ascites, paraaortic and mesenteric lymphadenopathy was accident with some of them being hemorrhagic. The spleen was slightly enlarged with hemorrhagic congestion in some parts of it. In the blood sample drawn from the spleen, the filamentous bacillus was successfully found. CONCLUSIONS: Because of the fatal nature of the disease and the similarity of the signs and symptoms to the other gastrointestinal diseases, we should consider it as one of the probable differential diagnosis in the patients with upper and lower gastrointestinal bleeding with fever esp. in the endemic areas.
Less than 1% of anthrax cases are GI? Very rare indeed. Forty eight hours after ingestion, hunh? I suppose that would vary from person to person with the amount of infection present in the meat/spore count. The CDC, in investigating cases of GI anthrax in Thailand, found a mean time between ingestion and symptoms of @ 42 hours. Children in Africa that ingested undercooked contaminated meat in another reported case perished in @ 24 hours after ingestion.
So, how big of a risk could drums really pose for contracting GI anthrax? Not much, unless she ate the drum.
How is anthrax transmitted?
B. anthracis spores can live in the soil for many years, and humans can become infected with anthrax by handling products from infected animals or by inhaling anthrax spores from contaminated animal products. Anthrax can also be spread by eating undercooked meat from infected animals. It is rare to find infected animals in the United States .
Am I at risk for anthrax from animal hides or hair, or from making a drum from these products?
Animal hides pose a low risk of cutaneous (skin) anthrax, and an extremely low risk of inhalation anthrax. Exotic animal hides may pose a higher risk for exposure than domestic (U.S.-origin) hides. The risk of contracting Bacillus anthracis from handling individual hides is believed to be very low; however, the industrial processing of hides or hair has historically been associated with increased risk of anthrax. Such industrial handling of large numbers of hides or hair from multiple animals results in prolonged direct contact with contaminated materials, often in enclosed or poorly ventilated settings. Among the 236 cases of anthrax reported to CDC from 1955 to 1999, 153 (65%) were associated with industrial handling of animal hide or hair. Only 9 of the 153 cases (6%) associated with industrial handling of hair or hide were inhalation anthrax. (Editor’s note: Apparently none of those cases were GI anthrax.)
Am I at risk for anthrax from my souvenir animal hide drum?
The risk of acquiring anthrax from an animal hide drum is very low. Of 236 cases of anthrax reported to CDC from 1955 through 1999, only one case of cutaneous anthrax was associated with a goat hide bongo drum purchased in Haiti . No cases of inhalation anthrax in the US have ever been associated with animal hide drums. The New York patient’s exposure occurred when he was making and finishing drums made from untanned animal hides, and was not associated with playing finished drums. His exposure was similar to that experienced during industrial handling of hides, which has previously been associated with an increased risk of anthrax. CDC does not currently recommend prophylaxis for persons who have had contact with animal hide drums. However, drum owners or players should report any unexplained fever or new skin lesions to their healthcare provider, and describe their recent contact with animal hide drums.
Mayor Mark D. Boughton of Danbury said the house was being used to store untanned animal hides obtained from areas of the world where anthrax is known to be common.
At least one of the patients is believed to have contracted cutaneous anthrax from working with the hides, Mayor Boughton said. Local and state officials were examining the patient’s house in an effort to pinpoint the source of the anthrax, Mayor Boughton said.
It is the second time in two years that African drummers in the metropolitan region have contracted anthrax.
In both cases, untanned hides for drums were believed to be the source.
These cases were cutaneous anthrax.
To recap: It would appear that if the woman got anthrax from banging on a drum, it would be either cutaneous or inhalation anthrax. No cases of GI anthrax from drum banging. The most commonly contracted form of anthrax, cutaneous anthrax, was acquired from drumming. People working with/storing hides have come down with inhalational anthrax. Let’s review those causes of anthrax again:
In humans there are three possible forms of the disease anthrax. Historically, the most common form has been cutaneous anthrax, in which the organism enters through a break in the skin. The cutaneous form begins as a papule at the entry site that progresses over several days to a vesicle and then ulcerates. Edema, sometimes massive, surrounds the lesions, which then develop a characteristic black eschar. The patient may have fever, malaise and headache.4 A small percentage of cutaneous infections become systemic, and these can be fatal.
A more serious form is inhalation anthrax. Here the victim breathes in the organism and develops a severe respiratory disease. Systemic infection resulting from inhalation of Bacillus anthracis has a mortality rate approaching 100%. Initial symptoms are vague and flu-like, progressing to hypotension, shock and massive bacteremia and toxemia. The severe symptoms are believed to be the result of the bacillis exotoxins. Early antibiotic treatment is an absolute necessity and should be started during the incubation period if a person has been exposed.5 After acute symptoms have appeared, antibiotics can kill the organisms, but will not destroy the powerful toxins that have already been formed, and the person commonly dies in 2-3 days from respiratory failure, sepsis and shock.
The third form, intestinal anthrax, is contracted from the consumption of contaminated meat. In industrialized countries this is not usually a risk, although rare exceptions have been described. In August 2000, the Minnesota Department of Health was notified that Bacillus anthracis had been isolated from a steer on a farm in Roseau County. The infected steer was one of five dead cattle found in a pasture. On the basis of identification of the bacteria by phage typing of isolates cultured from tissues and blood samples by the North Dakota State University Veterinary Diagnostic Laboratory, anthrax was confirmed. A report of this incident described the management of and public health response to human exposure to meat contaminated with anthrax.
Instead of chasing drums, shouldn’t the question be “where did this woman eat anthrax-contaminated meat”? If she didn’t eat anthrax-contaminated meat, where did she acquire this disease? Until such time as the source of anthrax-infected meat is identified, this should be presumed to be bioterrorism. It should also be presumed that there are/will be more cases unless she was in an anthrax-endemic country shortly before becoming ill or ingested undercooked meat originating from said anthrax-endemic country. I certainly hope that hospitals/physicians have been alerted to BOLO for additional cases.
Concord – Two African drums stored at the United Campus Ministry in Durham have tested positive for anthrax, the state confirmed yesterday as it continues to investigate the nation’s first known case of gastrointestinal anthrax.
The young woman with the disease, who attended a drum circle at the center, remains in critical condition, state Public Health Director Jose Montero said.
The state ordered the ministry, which serves but is not part of the University of New Hampshire, closed for further testing. As many as 30 drums are stored at the 15 Mill Road building.
Montero continues to ask drum owners who attended the drum circle events since October to call his office for possible drum tests. The state lab has sent some samples, including DNA samples, for further testing at the U.S. Centers for Disease Control.
About a half-dozen attendees have contacted the state health officials since the anthrax case was announced Saturday, when more than 50 people may have attended the most recent drum circle.
Montero said the unidentified Strafford County woman brought her own drum, which had a synthetic covering and not one of animal skin typically used on an African drum.
Investigators have not yet confirmed that the two drums are the source of anthrax exposure. Technicians are still trying to match strains between the patient and the drums.
They are probing other possible sources of contamination, including soil, animal products, and food possibly ingested by the woman, who is in an undisclosed, out-of-state hospital.
“We have not yet been able to confirm that the drums are the cause of the patient’s illness and we are continuing to follow up many leads,” Montero said. “Anthrax is not an illness that you can catch from someone else.”
Montero and state Health and Human Services Commissioner Nicholas Toumpas emphasized that there is no risk to the public.
The state Division of Public Health has increased surveillance at hospitals and health care providers across the state.
It is possible tests may never fully identify the point of infection transmission, according to Montero.
Investigators are interviewing the woman’s family and her friends to try to identify eating habits and any other link for possible point of transmission.
Samples at the United Campus Ministry building were collected over the weekend by the New Hampshire National Guard, state Department of Environmental Services, and the U.S. Environmental Protection Agency. Additional samples will be collected and tested.
Anthrax is caused by a spore that is ingested, inhaled or enters the body through a cut in the skin. Gastrointestinal anthrax, an acute inflammation of the intestinal tract, has an incubation period of three to 60 days. Symptoms include nausea, fever and abdominal pain, vomiting of blood and severe diarrhea.
The African drum connection is a source under investigation after contaminated animal hides on drums were involved in anthrax infections in New York City in 2006 and in two Connecticut residents in 2007. Those cases were types of inhalation anthrax and cutaneous anthrax, not GI anthrax, according to the U.S. Centers for Disease Control.
Julie Corey of Village Drum Shop in Hooksett, who facilitated the most recent drum circle at the United Campus Ministry, said she has been in touch with the state and with the woman’s family.
Corey and the Rev. Larry Brickner-Wood, executive director of the United Campus Ministry, were alerted to the anthrax case and possible connection by investigators on Christmas eve.
“Obviously I’m very upset about the situation,” said Corey, who knows the woman and her family. “We need to pray for her and pray that she gets through this.”
Brickner-Wood said he has also reached out to participants of recent drum circles. He said his thoughts and prayers go out to the young woman and her family.
“It’s terrible and scary and all that,” he said.
There have been only 11 cases of naturally occurring anthrax in the country since 1957. The last anthrax cases in New Hampshire were nine involving employees at a textile mill in Manchester.
Montero said owners of drums played at the drum circles, as well as concerned residents, may call his office at 271-4496.
1. Her drum was made of synthetic materials.
2. Two African drums stored at the University where the drum circle took place tested positive for anthrax spores (if drums are made of hides imported from Africa or Haiti that are haired or untanned, they have a pretty good likelihood for being positive for anthrax, something that the immunocompromised should be aware of but probably are not).
3. Other people that were at the drumming circle (last month!) are being given antibiotic prophylaxis, although none have showed any symptoms.
4. The mean time between ingestion and symptom onset is @ 42 hours with a variation of 1 to 7 days. The longer periods of time between exposure and symptoms are for inhalation anthrax.
I agree with the antibiotic prophylaxis for the people at the drum circle because it can take 60 days from exposure for pulmonary anthrax to manifest, although people that have contracted pulmonary anthrax from drums were making drums and/or had multiple anthrax-spore-infested hides on the premises, and were exposed to a much higher spore count than what the average drummer/participant would be subject to. While the chance of infection from such an event is *very* low, the fatality rate is very high, and the prophylaxis is inexpensive.
I still wonder how it is that this woman (with the synthetic drum) is the only person that became ill. Did she (or anybody else) have an open drink at the event? Were anthrax-spore-covered cookies served afterwards? If so, how is it that only her drink/food were sufficiently covered in spores so as to cause illness?