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Aerosolized Anthrax

What is anthrax?

Anthrax is an infectious disease caused by the spore-forming bacterium, Bacillus anthracis. Anthrax most commonly occurs in wild and domestic livestock (such as cattle, sheep and goats) but infections can occur in humans as well. Anthrax can be intentionally aerosolized causing inhalational anthrax that occurs when anthrax spores are inhaled into a person’s lungs. From the lungs, anthrax can spread into the lymph glands in the chest and from there into the bloodstream. Once in the bloodstream, anthrax can spread to all parts of the body. Inhalation anthrax is difficult to treat. Antibiotics should be started soon after symptoms begin.

What is inhalation (lung) anthrax?

Inhalation anthrax is a severe infection that occurs when anthrax spores are inhaled into a person’s lungs. From the lungs, anthrax can spread into the lymph glands in the chest and from there into the bloodstream. Once in the bloodstream, anthrax can spread to all parts of the body. Inhalation anthrax is difficult to treat. Antibiotics should be started soon after symptoms begin.

What are the symptoms of inhalation anthrax?

Symptoms usually occur within a few days, but may appear as late as two months after inhaling anthrax spores. Initial symptoms include flu-like symptoms, such as a low-grade fever, muscle aches, cough and general fatigue. Chest pain, severe breathing problems and shock follow within days, as the bacteria quickly spread through the bloodstream to the brain, kidneys, intestines and other critical organs. If untreated, inhalation anthrax is usually fatal.

Is anthrax contagious?

Anthrax is not spread from person to person by casual contact, sharing office space or by coughing or sneezing. Even after the symptoms of inhalation anthrax begin, persons are not contagious. Very rarely, drainage from an open sore of cutaneous (skin) anthrax may lead to a skin infection in another person.

When was the last time anthrax inhalation and disease affected anyone in New York City?

In the fall of 2001, an outbreak of cutaneous and inhalation anthrax in New York City, New Jersey, the Washington, D.C. area and Florida resulted from a still unsolved act of bioterrorism involving letters intentionally contaminated with anthrax spores. More than half of the persons infected with inhalation anthrax in 2001 survived.

In February 2006, a New York City resident was diagnosed with inhalation anthrax. He was infected after using a contaminated African animal skin to make an African drum. He was successfully treated and fully recovered.

How common is inhalation anthrax and how is it usually caused?

In the United States, inhalation anthrax is extremely rare. It most commonly affected textile workers through occupational exposure to contaminated animal hair or hides. Before the 2001 anthrax outbreak in New York City, there had not been an inhalation anthrax case reported in the United States since the 1970s.

What is bioterrorism?

Bioterrorism is the intentional use of biological agents, or germs, to cause illness. Bioterrorism has occurred in NYC only in 2001, when several media outlets received letters that were intentionally contaminated with anthrax bacteria.

Botulism can be caused by bioterrorism.

Are there other types of anthrax besides inhalation (lung)?

Cutaneous (skin) anthrax first appears as a boil-like, itchy pimple that feels like an insect bite. Over the next week or so, it changes into a fluid-filled blister, then an ulcer which eventually may have a black center. Cutaneous anthrax can cause significant swelling but is painless. While cutaneous anthrax infections account for about 95% of all human anthrax cases, there are other, more serious forms of anthrax: inhalation, gastrointestinal, meningeal and injectional.

Gastrointestinal (throat or abdomen) is the rarest form of anthrax. It can occur in the upper (throat) or lower (abdominal) intestinal tracts, typically after a person eats uncooked or undercooked food that is contaminated with anthrax spores or bacteria. Gastrointestinal anthrax causes severe inflammation of the intestinal tract. The first symptoms of include nausea, loss of appetite, vomiting and fever. These symptoms are followed by an extremely painful throat or abdominal pain, vomiting of blood, diarrhea, which can be bloody, or abdominal bloating. Unless antibiotic treatment is started shortly after symptoms begin, gastrointestinal anthrax is usually fatal.

Meningeal (brain) can occur if anthrax bacteria enter the bloodstream following cutaneous, inhalation, gastrointestinal or injectional anthrax infection. It then spreads to the brain. Symptoms include sudden headache, nausea, vomiting, muscle aches, chills and dizziness. Meningeal or brain anthrax disease usually cannot be treated successfully.

Injectional (blood) is a new type of anthrax caused when contaminated heroin is injected (usually in the skin). Between 2009 and 2010, more than 30 cases of injectional anthrax, including 11 deaths, were confirmed among heroin users in the United Kingdom. Severe infections of the skin and blood have been reported. Treatment is more effective when infections are diagnosed before they spread to the bloodstream. Investigators believe that the heroin was contaminated with anthrax spores at some point during transport of the drug by animals from Afghanistan, where anthrax occurs naturally, to Europe.

How soon after anthrax infection do symptoms appear?

Generally, the incubation period is seven days or less. However, it is possible for inhalation anthrax to develop up to two months after exposure to inhaled anthrax spores.

What should I do if I think I have anthrax symptoms?

Anyone with the symptoms of anthrax should contact their medical provider immediately. If you have symptoms of chest pain, breathing difficulty, severe headache or confusion, call 911.

Who usually gets anthrax when the disease occurs naturally?

Human anthrax is most common in agricultural areas where anthrax in animals occurs, including South and Central America, Southern and Eastern Europe, Asia and Africa. Anthrax occasionally occurs in animal herds in the United States as well, but until 2001, cases in humans were rare. Gastrointestinal anthrax sometimes occurs in areas of the world where infected animals are slaughtered and then eaten. Typically, when anthrax affects humans, it is from an occupational exposure to infected animals or animal products, such as wool, hides and/or hair. However, those at-risk during the 2001 outbreak included persons who had come into contact with contaminated mail. They were postal, news media, and government employees.

Contaminated African animal hides used to make African drums have been involved in a number of anthrax infections occurring from 2006 to 2009 in New York City, Connecticut and New Hampshire. To reduce the potential risk from contaminated animal hides, it is recommended that drum makers purchase domestic hides that have been treated by a professional to reduce the number of spores.

In 2009 and 2010, intravenous drug users in Europe were infected when they injected heroin that had been contaminated with anthrax spores. This probably occurred during transport of the heroin from Afghanistan – where anthrax naturally can infect animals – to Europe

How is anthrax spread?

Anthrax is almost never spread from one person to another person.

People are exposed to and infected by the anthrax bacteria in four ways:

  • Anthrax spores can enter the body through breaks in the skin causing cutaneous infection. This may occur when handling contaminated animal products, including hair, wool, or hides, or intentionally contaminated objects such as the letters/envelopes in fall 2001.

  • When anthrax spores are breathed into the lungs during manufacturing processes that used contaminated animal hides, wool or hair, and cause inhalation anthrax.

  • Eating uncooked or undercooked food that is contaminated with anthrax bacteria or spores can cause gastrointestinal anthrax. However anthrax is not found in animal milk.

  • Injecting heroin that is contaminated with anthrax spores can cause injectional anthrax.

How is anthrax diagnosed?

Depending on where the infection is located, anthrax bacteria can be cultured from blood, skin, and spinal fluid or from fluid that can collect in the abdominal cavity or around lungs (pleural fluid). Suspicious bacteria then can be tested and confirmed as the anthrax bacteria at governmental public health laboratories, such as the New York City Public Health Laboratory. Patients’ blood also can be tested for antibodies to the anthrax bacteria. These bacteria also can be seen and detected under a microscope, when looking at samples of infected human tissue. Lastly, there is a laboratory method called polymerase chain reaction (PCR) that can detect extremely small amounts of anthrax DNA.

What is the treatment for anthrax?

Doctors prescribe antibiotics to treat anthrax. To be effective, treatment should be started as soon as possible after anthrax infection is suspected. Cutaneous anthrax can be treated easily with antibiotics. However, anthrax may be fatal if not treated or if treatment is delayed. Inhalation (lung), gastrointestinal, meningeal (brain) and injection anthrax are much more severe infections. Successful treatment requires antibiotics, medical procedures such as removing fluid from around the lungs and potentially long hospital stays.

Is there an anthrax vaccine, and how can I get it?

There is an effective anthrax vaccine. The vaccine is currently available only for military personnel thought to be at higher risk for potential exposure to anthrax in combat settings. It is administered three times over one month. Periodic boosters might be recommended after that. It cannot be obtained from health care providers. The U.S. Centers for Disease Control and Prevention (CDC) maintains a supply of anthrax vaccine is available to state and local governments for emergency use.

What has New York City done to address the threat of anthrax?

Many federal, state, and city agencies, including the Department of Health and Mental Hygiene (DOHMH), have been working together for several years to prepare for the detection and response to a bioterrorism incident in the city and in a real event these agencies coordinate response. In cooperation with other emergency response agencies, DOHMH has set in place systems that improve our ability to detect and respond to public health emergencies caused by the intentional release of a biological agent. Public Health Laboratory has protocols in place to quickly test and detect anthrax. These protocols are regularly reviewed and drills are conducted to practice rapid response to an anthrax outbreak.

How Will I Cope?

Anthrax in New York City can be very stressful, especially if it is large scale outbreak. It can disrupt your everyday life and make you and those around you feel less safe. You may experience fear and uncertainty. Learning about stress and strategies to manage it can help you cope.

Prepare Today, Cope Better Tomorrow - Stress during Disasters provides basic information and practical advice on dealing with the stress and anxiety caused by disasters. It is available in seven languages.

If there is anthrax in the city and you feel overwhelmed and unable to cope, or if you are concerned about someone else, you can find help by calling 1-800-LIFENET. LIFENET is a free, confidential helpline for New York City residents, available 24/7, with trained staff ready to take your calls and offer advice: 1-800-LifeNet 1-800-543-3638 (English), 1-877-Ayudese 1-877-298-3373 (Spanish), 1-877-990-8585 (Chinese), 1-212-982-5284 (TTY).

Where can I get more information?

For more information about anthrax, visit:

Centers for Disease Control and Prevention (CDC)