HEALTH TRIBUNE Wednesday, October 24, 2001, Chandigarh, India
 


Anthrax: scare or problem of perception?

The human point of view
The dreaded powder is a very poor weapon of bioterrorism
Dr S.K. Jindal
T
he fear of biological warfare, more precisely, that of bioterrorism, has brought several microorganisms of the old times into sharp focus. It is a rather interesting fact that the old and forgotten organisms are likely to cause more extensive damage than the existing ones. 

An issue of concern
Protectors must be protected

Dr J.D. Wig
D
octors, nurses, technologists and other supporting staff that work in hospitals have committed themselves to a unique service programme. This programme does not work on fixed hours or for limited periods of the day, or for limited days of the week.

Ayurveda & total health
Honey is of help
Dr R. Vatsyayan, Ayurvedacharya
During these days of anthrax scare, honey's unstated value as a lung-rejuvenator and a giver of immunity should be seriously considered.

The veterinary angle
Causes & cure
Dr C.B. Singh
1. Anthrax is one of the most dreaded diseases of both man and animal. It is communicable from animal to man and exists in external (cutaneous) and internal (respiratory and gastro-enteric) form. In order of frequency, it occurs mainly in sheep, goats and horses. The disease has been reported in other domesticated animals and wild animals too.

 
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The human point of view
The dreaded powder is a very poor weapon of bioterrorism
Dr S.K. Jindal

The de facto disease is unlikely to turn into an epidemic but the terrorists' propaganda is doing psychological harm. Let us be cautious and unafraid.

The fear of biological warfare, more precisely, that of bioterrorism, has brought several microorganisms of the old times into sharp focus. It is a rather interesting fact that the old and forgotten organisms are likely to cause more extensive damage than the existing ones. This is largely attributed to the loss of herd-immunity, which occurs with time after the disease gets extinct or significantly diminished in incidence. In the past few weeks, it is the Bacillus anthracis which has alarmed the world in general and the physicians in particular. Colonies of Bacillus anthracis are aptly termed to resemble Medusa's head the Gorgon that had snakes in place of the hair and turned the beholders into stone. Anthrax was commonly called Beadford's Disease in the 19th and early 20th centuries.

This bacillus is a spore-forming organism which is endemic in countries such as Sudan, Pakistan, Turkey and Iran. Soil is the main reservoir of the spores. Grass-eating (herbivorous) animals, especially the cattle and the sheep, are commonly infected while grazing and pass on the infection to humans who handle these animals or their carcasses. It is for this manual handling that the skin is the most common organ which gets infected and diseased. There is the formation of skin sores or ulcers which are generally painless but potentially serious. The skin lesions is occasionally referred to as malignant sore although it is non-cancerous.

The more serious and more fearful form of anthrax, which is likely to occur frequently when the bacillus is used as a weapon of terror, is the pneumonic kind following the inhalation of organisms. This is especially so when the causative organisms are distributed in envelopes via postal mail as is being reported these days. The skin can also get infected if there are open cuts or wounds through which the bacilli gain entry.

The inhalational form of anthrax presents with general constitutional symptoms of malaise, fever, pain, headache and dry cough. The fever is generally low grade and the cough is non-productive. Once pneumonia occurs, the patient may develop severer symptoms of cough, sputum-production, blood in the sputum, breathlessness and respiratory failure.

The pneumonic form of anthrax is also called "wool-sorter's disease" since it is characteristically seen in people who sheer the infected sheep and handle their wool. It also occurs in butchers and skinners who rehandle carcasses.

Anthrax pneumonia can prove to be fatal in its severer forms. Infection can also spread into the surrounding structures in the mediastinum, i.e in between the two lungs, and the heart. Mediastinitis is a more common and dangerous problem. Sometimes, the brain and the meninges too may get involved. Gastrointestinal anthrax is also known, but is rare.

The diagnosis of anthrax is easily made whenever there is suspicion, as in the current scenario. But very few physicians have really diagnosed and treated anthrax in modern times. All the same, it continues to be taught in Medicine and Microbiology.

It is, however, difficult to differentiate from other pneumonias or febrile illnesses in sporadic cases which may occur occasionally. An occupational history is always helpful in all such cases. The bacilli may be seen in sputum or nasal secretions.

It is a fairly treatable disease whenever the diagnosis is made and treatment is instituted early in the course. Most of the available antibiotics are likely to be useful. Traditionally, heavy doses of penicillins have been used. Erythromycin can also be used. Tetracyclines, chloramphenicol, doxycycline, most drugs of the fluoroquoinolone group such as ciprofloxacin, sparfloxacin, ofloxacin, and cephalosporins of the second and third generations are also effective.

It may, however, be difficult to save patients with severer forms of pneumonia. Assisted ventilation is required for acute respiratory failure. Prevention is a more important step for workers involved in the animal-hide industry. Vaccination is useful for these high-risk groups. Importantly, carcasses of infected animals should be buried or burnt rather than cut and skinned.

In spite of exaggerated fears of an anthrax attack, it need not cause any panic. It is unlikely that anthrax will spread as an epidemic. No major anthrax epidemic has been reported in the past. A small epidemic form was reported in Sverdlovsk in the erstwhile USSRin 1979. The damage was rather limited. Another epidemic was reported from Zimbabwe in 1978-80. But this had occurred due to almost non-existent health-care facilities at that time. The chances of such a spread in India are rather few. It can certainly prove to be dangerous to an individual who gets infected. But it is a very poor weapon of a de facto terrorist attack. The psychological harm caused by the fear of anthrax is greater than anthrax itself.

Professor Jindal is the Head of the Department of Pulmonary Medicine at the PGI, Chandigarh. He has also worked as Professor of Medicine, including Nuclear Medicine.
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An issue of concern
Protectors must be protected

Dr J.D. Wig

Anthrax can come from inhalation or as an infection from cattle to man, who may per chance need surgery. With the era of hazards associated with the transmission of pathogens, health planners need to realise that health workers' health is also important.

Doctors, nurses, technologists and other supporting staff that work in hospitals have committed themselves to a unique service programme. This programme does not work on fixed hours or for limited periods of the day, or for limited days of the week. Health-care workers (HCWs) have frequently paid little attention to their own health and safety at work. They may thus be exposed to significant risks from the wide range of hazards prevalent in health-care. Risks to HCWs are underestimated and poorly understood. The employer has a duty towards the employee if he expects a high degree of devotion and commitment from HCW.

Health-care workers really became concerned about acquiring infections from patients in the 1980s. Hepatitis B was the first viral infection that was recognised to be transmitted in the healthcare setting. Then tuberculosis and, of course, AIDS were thought of. Now there is the anthrax talk.

HCWs are exposed to blood, tissue or fluids of patients.

HCWs are exposed to blood-borne viruses from percutaneous, mucocutaneous or other injuries. Transmission of infection via penetrating injuries (needlestick, cut with a blade or broken instruments) remains a significant hazard.

It is likely that, besides Hepatitis C, many more diseases will affect HCWs with serious and potentially fatal consequences.

Worldwide, the epidemic of HIV continues to spread and an increasing number of patients presenting themselves for surgery are going to be HIVseropositive or have AIDS. Anaesthetists and surgeons are at particular risk for occupational acquisition of HIV which can be transmitted from the infected patient to HCWs as a result of infected body fluids. Deep subcutaneous exposure with a blood-contaminated needle from a patient appears to be the worst type of contact. A single significant needlestick injury with HIV-infected blood may be associated with a 0.31% injury with HIV transmission. Conjunctival contamination with blood carries a slightly higher risk.

During an operation, intact gloves act as a protective barrier against these diseases. Accidents during surgery that cause the perforation of gloves and skin constitute the risk for the transmission of pathogens.

The Hepatitis B virus has been well established as an important occupational risk. The risk of acquiring the disease at work is up to 100 times greater than that of HIV. Hepatitis can be transmitted in the same way as HIV. Hepatitis B and C are well-documented hazards of needlestick injuries. The viruses are transmitted to the surgeons while they are operating, most likely through tissue-penetration by contaminated surgical instruments or materials. The prevalence of the Hepatitis C virus is greater than previously believed and there is a greater chance that a surgeon will operate on a patient infected with HCV. These HCV-infected individuals are not clinically ill and the surgeon may not know that they are infected.

Those surgeons who appear to have a especially significant risk for Hepatitis B viral infection include gynaecologists and oral surgeons. The reasons may be a high degree of infectivity of the virus, the large number of HBV particles present in infected individuals, and the lack of proper precautions taken by individuals at risk to prevent the transmission of the disease.

Tuberculosis remains an important occupational hazard. The current risk varies considerably. Workers involved in autopsies and cough-inducing procedures are at high risk. HIV-infected HCWs have a particularly high risk of tuberculosis. Inadequate ventilation has been identified as a contributing factor. A careful screening of patients for tuberculosis is essential and can dramatically reduce HCW exposure to tuberculosis. Anthrax can come from inhalation or as an infection from cattle to man, who may need surgery.

With the era of hazards associated with the transmission of pathogens, health planners need to realise that health workers' health is also important. There is a great need for good support to health workers and carers. All available technical resources should be used in ensuring maximal safety for HCWs. Universal precautions and specific prevention programmes have to be implemented. Since needle sticks represent the most frequent and potentially the single, most preventable hazard, the introduction of safer devices is one of the most important approaches for the reduction of occupational risks. Efforts should be made to train HCWs to comply strictly with infection control measures to replace hazardous devices with those with safer designs, and ensure a comfortable work environment. Compliance with recommendations in handling sharps is the mainstay of prevention.

Dr J.D. Wig, the concerned surgeon, is also a caring senior for students, resident surgeons and health-care workers. He is based at the PGI.
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Ayurveda & total health
Honey is of help
Dr R. Vatsyayan, Ayurvedacharya

During these days of anthrax scare, honey's unstated value as a lung-rejuvenator and a giver of immunity should be seriously considered.

Known as madhu in Sanskrit, honey has been described in detail in all ayurvedic texts including the works of Charaka and Sushruta. This golden liquid, which is nature's purest and sweetest food, has also been mentioned in the Rigveda.

Honey is sweet and astringent in taste having dry, subtle and light properties. While it alleviates all the three vitiating doshas, it has been described as cold in effect in its fresh form and is attributed to be yogvahi, a unique quality which enables it to adopt the properties of the basic medicine with which it is given as a vehicle. However, on storage, it turns hot in effect. Depending upon the source of collection, ayurveda classifies honey into four categories: makshika, bhramara, kshaudra and pouttika. These varieties resemble the colours of honey as yellow, white, raddish yellow and yellowish white, respectively. It has been described as a blood-purifier, wound-healer and cleanser of minute channels of the body. It also facilitates digestion and absorption.

Honey contains glucose, enzymes, amino acids, small amounts of protein, mineral salts like calcium, sodium, potassium, magnesium, iron, phosphorous, sulphur, iodine and organic acids. It also consists of a number of other substances which provide vitality to the cells, tissues and body organs.

All over the world, honey is consumed as a food item, but in India it is adopted more as a medicine. Used in countless ayurvedic preparations, it is considered to be the best anupan a (adjunct). Here are some medicinal tips: Honey is highly praised as a remedy for kapha diseases. The taking of half a gram of the powder of long pepper with one teaspoonful each of honey and ginger juice helps in acute asthmatic attack. Using occasionally a little of mulethi powder in honey also serves as a safe and effective expectorant. Patients suffering from eye diseases arising out of vitamin deficiency can take, once a day, carrot juice mixed with a teaspoonful of honey.

Though fresh honey is a tonic and a re-vitaliser, the one which is more than a year old is considered to be a reducing agent and is recommended in obesity. For this purpose, there is a common practice: take fresh lemon water mixed with honey in the morning. It is salutary as a medium in various face packs. Honey is also used externally in treating non-healing burns and scalds and also in chronic ophthalmic problems.

Ayurveda considers the honey extracted from the natural beehives to be the best. Apiaries usually add preservatives to it; this is sometimes responsible for unsavoury symptoms like nausea, abdominal cramps and skin rashes. Pure honey easily sinks into water, gets easily burnt like an oil and also doesn't stick to cloth. It should never be boiled. Diabetics can use honey of natural beehives in a small quantity and only as an adjunct to some basic medicine!

Dr R. Vatsyayan is an ayurvedic consultant based at Sanjivani Ayurvedic Centre, Ludhiana. (Phones 423500, 431500;e mail - sanjivni@satyam.net.in)
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The veterinary angle
Causes & cure
Dr C.B. Singh

1. Anthrax is one of the most dreaded diseases of both man and animal. It is communicable from animal to man and exists in external (cutaneous) and internal (respiratory and gastro-enteric) form. In order of frequency, it occurs mainly in sheep, goats and horses. The disease has been reported in other domesticated animals and wild animals too.

2. Anthrax is caused by a spore-forming bacteria called Bacilus anthracis (B anthracis) which, when seen under the microscope, grows in non-motile rod-shaped chains.

3. B. anthracis produces spores of great vitality as these retain their life for years in dry skin, soil and fleeces. While the bacillus is delicate and can be destroyed by ordinary chemicals, the spores are hard and can not be destroyed by boiling water, freezing, strong disinfectants or the gastric juices.

4. The disease is communicable from infected animal and animal products to man through a cut, an abrasion or a scratch in the skin, by inhalation or by swallowing. Anthrax can also be spread by eating undercooked meat from infected animals. Human-to-human transmission is extremely rare.

5. People who are involved with the animal industry like shepherds, butchers, woolsorters, veterinarians, animal-handlers, abattoir workers, and laboratorians are more at risk in contracting anthrax.

6. The disease is more prevalent in those parts of the world where the wool and hide industry is one of the major occupations like South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean, the Far-East and the Middle-East.

7. The affected body tissue (skin blisters) changes colour from greyish pink to jet black loaded with minute carbon-like particles which appear in the form of a fine dust.

8. This fine dust is full of spores which are highly infective when dry. The spores cannot be infective in the wet form.

9. Human anthrax has three major clinical forms: cutaneous, inhalation, and gastrointestinal. Cutaneous anthrax is a result of the introduction of the spore through the skin; inhalation anthrax, through the respiratory tract; and gastrointestinal anthrax by ingestion.

10. The external or cutaneous form is usually not fatal if treated in time and lasts about 10 days by causing skin blisters to black scrabs, prostration and high fever. The early treatment of cutaneous anthrax is usually curative.

11. The inhalation form may resemble the common cold. After several days, the symptoms may progress to take the shape of pneumonia with haemorrhages to severe breathing problems and shock. Inhalation anthrax is usually fatal (90 to 100%).

12. The initial signs of stomach and intestinal anthrax include nausea, loss of appetite, vomiting, fever followed by abdominal pain, vomiting and severe diarrhoea of blood, followed by death in 25% to 60% of the cases.

13. If untreated, anthrax in all forms can lead to septicaemia and death. Early treatment of all forms is important for recovery.

14. Direct person-to-person spread of anthrax is extremely unlikely to occur.

15. Anthrax is diagnosed by isolation B. anthracis from the blood, skin lesions, respiratory secretions, and by measuring specific antibodies in the blood of the suspected cases.

16. When the disease has been reported and identified, prevention by effective vaccination is more important than treatment. The vaccine is reported to be 93% effective in protecting one against anthrax.

17. The treatment consists of the administration of suitable antibiotics and the anti-serum. Once the toxins are produced, the treatment can go ineffective.

18. About 50 years ago, when the disease was not fully understood, treatment with high doses of penicillin and tetracycline was found to be effective. Today Ciprofloxacin is considered the best choice.

Dr C.B. Singh, M.V. Sc, is a widely known veterinarian. He has done immense work on diseases transmitted from animals to human beings. (Phone 602199; 1459, 44-B, Chandigarh.)
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