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

1. Inhalation anthrax:a single case in North London Dr Sudy Anaraki North East and North Central LondonHealth Protection Unit

2. 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… Key participants in incident control

3. Epidemiology of anthrax • 1981 to 2006: 18 possible cases of cutaneous anthrax in E&W. • Bacteria isolated in only one case • Serological confirmation in another two • The last case of pulmonary anthrax in E&W 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

4. Bacillus anthracis large, non-motile, non-haemolytic gram-positive bacillus, forming endospores Cutaneous anthrax small papule or vesicle, ulcerates with central necrosis, painless, localized, non-pitting oedema surrounds ulcerated area, black eschar Anthrax – the disease Gram-positive, spore-forming rod

5. 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 Anthrax – the disease

6. 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 9:30 pm on Friday

7. Health Protection Agency NE&NC 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 Incident Control Team (ICT)

8. 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 1:45 pm • Body was bagged and buried in a lead lined, sealed coffin

9. 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

10. 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 Possible source of infection

11. 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…!

12. 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.

13. 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

14. 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 Environmental testing results

15. 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

16. 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 • HPA’s advice to drummers and drum makers can be found on the HPA and Defra’s website

17. Chica the only occupier of the flat after patient’s 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! The cat who did not have anthrax!

18. Acknowledgements • Homerton University Hospital • London Borough of Hackney • NE&NC London HPU • HPA, Centre for Infection • HPA, London Region • HPA, NADP, Porton Down • City & Hackney PCT • London Borough of Waltham Forest • Defra, Animal Health