THERAPEUTIC RECOMMENDATIONS FOR THE MANAGEMENT OF PATIENTS
EXPOSED TO BACILLUS ANTHRACIS IN NATURAL SETTINGS
L. Pirotha,i, J. Leroyb,i, O. Rogeauxc,i, JP Stahld,i, M. Mocke, B. Garin-Bastujif, N. Madanif,
C. Brezillone, A. Maillesg,i, Th Mayh,i,*
a
Department of Infectious and Tropical Diseases, Dijon Teaching Hospital, France
Department of Infectious and Tropical Diseases, Besançon Teaching Hospital, France
c
Department of Infectious and Tropical Diseases – Internal medicine, Chambéry Hospital, France
d
Department of Infectious and Tropical Diseases, Grenoble Teaching Hospital, France
e
Anthrax National Reference Center, Institut Pasteur, Paris, France
f
Anthrax National Reference Laboratory, ANSES Maisons-Alfort, France
g
National Institute for Public Health Surveillance InVS, Saint Maurice, France
h
Department of Infectious and Tropical Diseases, Nancy Teaching Hospital, France
i French Infectious Diseases Society (SPILF)
b
*
Corresponding author: t.may@chu-nancy.fr
INTRODUCTION Except in the context of bioterrorism, human anthrax infection is acquired after exposure to a sick
animal or to a contaminated animal product (wool, leather, etc.).
The sporulating bacterium Bacillus anthracis is considered as one of the most lethal potential
biological weapons. Since 2001, the risk of inhalation after a possible intentional dissemination has led
to numerous recommendations for a preemptive treatment both immediately after exposure and after
onset of symptoms [1-5]. But in the context of exposure to a natural source of the anthrax bacillus
(mainly farm animals), the management of potentially exposed individuals has never been the object of
therapeutic recommendations and there is very little published on the issue.
In 2005, the InVS had published a multidisciplinary report on the surveillance and prevention of
animal and human anthrax (or “anthrax fever”), but this document did not deal with the management
of individuals exposed to an animal infected or suspected to be infected by anthrax. It specifically
mentioned that “in case of exposure to a risk identified by the enquiry, individual chemoprophylaxis
could be suggested”, without any indication for the evaluation of the contamination risk, or any
indications for treatment, or any suggestions for a specific therapeutic regimen.
Nevertheless, every year foci of animal anthrax are reported in various French regions, and for each
focus individuals potentially exposed to the anthrax bacillus.
The objective of this document was to determine therapeutic recommendations for the evaluation and
management of patients potentially exposed to the anthrax bacillus, in “natural” settings.
I – METHOD The SPILF initiated a work group including infectiologists having been consulted during various
episodes of human exposure to infected animals or to their product (Côte d’Or, Doubs, Moselle,
Savoie), a microbiologist from the Pasteur Institute Anthrax National Reference Center in Paris, two
veterinarians specialized in microbiology from the ANSES Anthrax National Reference Laboratory in
Maisons Alfort, one veterinarian specialized in epidemiology from the Department of Infectious
Diseases at the InVS. This group drafted recommendations according to the following method:
1
i)
ii)
iii)
iv)
from recommendations on the surveillance and prevention of animal and human anthrax
issued by the InVS in 2005 [6]
by using published data when available (infecting inoculum, food borne epidemics, etc).
Searching on the Pub Med database using «post-exposure; anthrax; treatment» as keywords
brought up 26 articles 8 of which were related to antibiotherapy, 2 of which concerned
bioterrorism, 7 of which concerned vaccination or immunologic treatments, 4 of which
were general reviews. Using «human anthrax and antibiotic treatment» brought up 341
references, 68 of which published since 2006. 9 of these 68 references were non-redundant
with a «Post-exposure» search.
when there was no published data, recommendations were made according to experience
acquired by the various experts during previous episodes of animal anthrax.
after visiting a knackering and rendering facility and better understanding procedures and
potential occupational risks of various workstations in these settings.
Most evaluated settings with a weak level of proof were analyzed and drafted collectively by the
expert group, so that the resulting recommendation was a consensus between members of the work
group.
II - BACILLUS ANTHRACIS DATA B. anthracis is a sporulating Gram-positive bacterium, of the Bacillus cereus family. During its
biological cycle, B. anthracis presents in spore and vegetative form. The spore form is the one which
resists and persists in the environment. Sporulation is triggered in conditions of nutritional deficiency
with air oxygen (central position non deforming endospore) [7]. In its natural cycle, sporulation occurs
when the animal dies, after liberation of bacilli in the air, and the dissemination into the ground (via
body fluids or open carcasses). Spores also form in waste or by products of infected animals (bones,
skin, wool, etc).
The ground, when contaminated by spores, is the true reservoir of B. anthracis. The persistence of
spores in the ground for several decades, is responsible for the recurrent infection of animals on some
sites, «the cursed fields», known for ages.
The vegetative form, found inside the infected host’s organism, is a thick bacillus, with square ends,
immobile and capsulated. The virulence of B. anthracis is due to the presence of two plasmids, pXO1
and pXO2, coding respectively for the synthesis of two toxins and a capsule. The loss of one plasmid
or the other strongly decreases the strain’s virulence. This is the case for the Sterne vaccinal strain, non
capsulated by loss of pXO2, used in veterinarian medicine.
B. anthracis is aero-anaerobic and develops in 18 to 24 hours on common agarose, incubated at 37°C
in normal atmosphere, yielding large white to gray colonies, with a "jelly fish head" aspect, on a serum
enriched medium and in the presence of 5% CO2. The colonies are smooth because of the capsule
synthesis. Flakes can be observed in the broth, they sediment leaving a clear broth. In direct
microscopic examination, the bacillus appears isolated, in short chains or long bamboo stalk-like
associations. B. anthracis does not induce hemolysis on blood agarose and most strains are susceptible
to phage  and penicillin. The absence of mobility may be investigated with complementary tests.
Multiplex PCR, using specific markers of plasmids pXO1 and pXO2 and a chromosome marker,
allows confirming the bacteriologic identification of B. anthracis [8,9].
2
III - ANIMAL ANTHRAX (OR ANTHRAX FEVER) Anthrax fever (AF) due to B. anthracis usually occurs in the spring and summer, in animals grazing on
contaminated ground, after long periods of drought followed by episodes of rain. It mainly affects
herbivorous animals, more rarely omnivores or carnivores, domestic or wild animals. It usually
presents as an acute septicemic disease, evolving rapidly to death, with general digestive, respiratory,
and meningeal symptoms. The incubation usually lasts from 1 day in ovines to 3 up to 7 days, in
bovines (table 1).
Several forms de AF have been described in ruminants. The hyper acute form presents with a short
lasting tipsy gait, dyspnea, and convulsions. Death is sudden. In the acute form the onset of symptoms
is brutal, with fever, interruption of milk production, then respiratory disorders, and tachycardia,
digestive disorders (diarrhea, bloody diarrhea), and urinary disorders (hematuria). Death comes in very
rapidly (1 to 3 days). Most of the time, AF occurring in grazing animals presents as «sudden death»
and the discovery of the cadaver in the pasture without observing any symptom. In small ruminants,
the hyper acute form is the most frequent.
In horses, digestive disorders are more severe (diarrhea) and death occurs within 3 to 6 days. In Suidae
(pigs, boars), the edematous form or anthrax laryngitis is common: throat edema, fever, respiratory and
circulatory disorders, diarrhea sometimes hemorrhagic, sometimes congestive or hemorrhagic
cutaneous lesions. Death may occur in 2 to 4 days but cure is possible in this species.
In carnivores, symptoms are similar: hemorrhagic septicemia and throat edema.
In wild animals, symptoms would seem to be analogue to those of domestic animals. In birds, there are
very rare cases. Sporadic cases have been reported in ostriches and Barbary ducks.
The microbiologic diagnosis is made by culture and/or PCR. The most efficient samples are blood and
the spleen, as well as milk. Autopsy is forbidden if AF is suspected because of the great exposure risks
for the veterinarian and farm personnel, and risk of contaminating the environment.
In France, since 2002, 15 confirmed anthrax fever foci have been reported in 13 French subdivisions.
These cases are described in chapter 4.2.2
Table 1: clinical presentation of anthrax fever in bovines
Clinical description
- Incubation period from 1 to 5 days, usually
- Specific clinical signs
Acute form: septicemic anthrax
- After ingestion of B. anthracis, onset of acute febrile respiratory and circulatory disorders with
bleeding from natural orifices, petechia, and edema before death
Sub-acute form: external anthrax or «anthrax tumor»
- Edematous reaction often in the throat or in the upper respiratory tract before symptoms appear as in
the previous form
3
IV - ANTHRAX IN HUMANS 4.1 Modes of transmission to man and risk factors In “natural” transmission settings, a man can be contaminated by exposure to sick animals or to
contaminated animal products. There are 3 presentations of the human disease: cutaneous, inhalation,
or gastro-intestinal.
Transmission occurs:
• by skin or mucosal contact with spores on contaminated material, animals or animal products.
• by inhalation of spore aerosol penetrating in pulmonary alveoli and transported by lymph to
mediastinal lymph nodes. The germination of spores at this level frees toxins which trigger
hemorrhage, edema, and tissue necrosis;
• by ingestion of contaminated products. The germination of spores and then the multiplication of
bacilli free toxins at various levels of the digestive tract: mouth, esophagus; or intestine.
4.2 Epidemiological data: human cases and animal foci in France since 2002 [54].
4.2.1 Notified anthrax cases in France since 2002
Since 2002, 4 cases of human B. anthracis infection were reported.
In 2003, a case of cutaneous anthrax was diagnosed in a contaminated patient who had handled sheep
wool in Algeria.
In 2008, 3 cases of cutaneous anthrax were reported in Moselle; they concerned men who had cut-up
and gutted the same anthrax infected cow [10]. The diagnosis was made by PCR on skin biopsies made
next to the lesions [11]. The strain was isolated from a human case and from the infected bovine. The 3
cases had a favorable outcome without complications.
4.2.2 Animal anthrax foci and management of exposed persons
Since 2002, 61 confirmed foci of animal anthrax1 were reported in 12 French subdivisions (Aveyron,
Cantal, Côte d’Or, Doubs, Isère, Jura, Meurthe-and-Moselle, Moselle, Puy de Dôme, Saône et Loire,
and Savoie). Three other foci were reported but without bacteriological confirmation in 3 other
subdivisions (Aube, Loire Atlantique and Vienne) (figure 1).
In all, data on the number of exposed individuals is documented for 11 foci. During these episodes,
150 patients received post-exposure prophylactic treatment to (PEPT), average 14 per animal anthrax
focus [0 to 108] (table 2).
Individuals considered as exposed to the bacterium or to its spores were most often farmers and
owners of the anthrax infected animals and people working on these farms, the veterinarian having
examined the animal or animals, and knackering and rendering facility personnel having processed the
animal cadavers. Less frequently, they were subdivision veterinarian laboratory personnel (SVL),
members of the farmer’s family, or relatives having helped to move the anthrax infected animal
cadavers. The reported types of exposure were direct contact with cadavers, or exposure to aerosols
possibly generated by moving the cadaver or processing it at the knackering and rendering facility.
More rarely, consumption of raw milk, meat, or offal from anthrax-infected animals, was responsible
for contamination. Finally, for SVL personnel, unprotected contact with diagnostic samples of animals
suspected to be infected by anthrax, and in one cases, the spattering of samples during the accidentally
brutal opening of a package were considered to be the source of exposure.
4
Table 2: foci of animal anthrax and management of exposed patients in France since 2003
Date
Subdivision
Animal(s) involved
Bovine (milk)
(Comte cheese with raw
milk)
Bovine (meat)
Bovine (meat)
(Charolais)
Management of exposed individuals
Veterinarian and farmer: doxycycline 8 d
SVL technicians: ciprofloxacin 60 d
Veterinarian intern: no treatment, anthrax blood test
Veterinarian and 2 farmers: amoxicillin 10 d
One of the 2 farmers consulted, management not
documented
Farmer, 8 close relatives, 4 DDSV(veterinarian subdivision
agency) agents, 8 SVL agents: amoxicillin 12 d
Farmer and veterinarian: no treatment
June 2003
Doubs
June 2003
Côte d’Or
2004
Saône and Loire
August 2005
Aube
Bovine (milk)
August 2006
Vienne
August 2006
Cantal
August 2006
Sept. 2006
Cantal
Savoie
5 bovines
5 bovines (meat)
1 horse
3 bovines (Salers)
1 bovine (Montbeliard)
June 2007
Lozere
3 bovine herds (Aubrac)
August 2007
Jura
1 bovine (Montbeliard)
August 2007
Meurthe and
Moselle
Bovines
October 2007
Cantal
2 bovines (Aubrac)
August 2008
Doubs
37 bovines (milk and meat)
(21 herds in 10 towns)
Dec. 2008
Moselle
1 bovine (meat)
July 2009
Puy de Dôme
5 bovines (milk)
(Saint-Nectaire AOC)
5 non treated exposed individuals (refusal)
July 2009
Côte d’Or
3 bovines (meat)
Farmer + 5 family members, a veterinarian and an SVL
agent: fluoroquinolone then doxycycline after antibiogram,
Comments
Consumption of raw milk non considered at risk
Clinical diagnosis only, not confirmed in bovines
Clinical diagnosis without biological confirmation for
bovines
Badly documented episode
Not documented
No individual considered as potentially contaminated
3 individuals: fluoroquinolone 10 d
5 SVL agents: amoxicillin 10 d
Farmer and 2 neighbors having helped him to move the
bovine cadavers: prescription not documented
Not documented
Farmer: fluoroquinolone (length of treatment not
documented)
3 knackering and rendering facility personnel: amoxicillin
(length of treatment not documented)
Veterinarian: no treatment
No individual considered as potentially contaminated
108 known patients assessed at the Besançon teaching
hospital and treated most frequently for cutaneous and
digestive exposure (consumption of anthrax infected cow
milk)
10 individuals treated with fluoroquinolone and 1 with
amoxicillin because of a contra-indication for
fluoroquinolones
Nature of exposure not documented
Episode having occurred after earthworks in a pasture
Possibly community practice prescribed treatments, but not
documented
7 other non treated exposed individuals because of the
delay between latest risk exposure and consultation
5
total length 2 months
Farmer + 4 close relatives, a veterinarian, a milk, collection
technician, knackering and rendering facility personnel:
prescription made but not documented
July 2009
Aveyron
5 bovines (meat) and 15
dairy goats
July 2009
Savoie/Isere
Around 20 bovines
belonging to 12 herds
38 individuals: fluoroquinolone 15 or 21 d
Sept. 2009
Loire Atlantique
8 bovines (meat)
Veterinarian: antibiotic self prescription
Farmer and a neighbor: no treatment
A second veterinarian wearing gloves and a mask during
his intervention did not receive any treatment
Fluoroquinolone was chosen because a penicillin resistant
strain was isolated from an anthrax infected bovine in 1997
in the same town
Anthrax without biological confirmation but episode having
occurred on a previously “cursed” field
No human case occurred after discovering these animal anthrax foci.
In the Moselle 2008 episode, the 3 human cases led to discovering the animal focus and occurred before implementing any preemptive treatment.
6
Figure 1: geographical distribution of animal anthrax foci identified in France from 2003 to 2010
Legend
Number of animal anthrax foci
0, 87.5, 175, 250 kilometers
7
Table 3: clinical presentation of human anthrax
Clinical description
- Incubation period from an average of 1 to 10 days (after cutaneous-mucosal contact or ingestion) up
to 60 days (after inhalation)
- Non-specific clinical signs
Inhalation anthrax
- After inhalation of B. anthracis and a short prodrome, acute febrile respiratory distress, complicated
by hypoxia, dyspnea, and radiological observation of mediastinal enlargement associated to septicemia
Cutaneous anthrax
- After contact with a sick animal or infected products of animal origin, skin lesion with first a papula,
then a vesicle, and finally a black sore surrounded by edema. The lesion is usually painless but it may
be complicated by fever and malaise, which can be associated to septicemia
Gastro-intestinal anthrax
- After consuming a contaminated raw product, syndrome with sharp abdominal pain, diarrhea, fever,
and septicemia
4.3 Clinical course
4.3.1 Length of incubation
The length of incubation (between exposure and onset of symptoms) after cutaneous and/or mucosal
contact or ingestion is 1 to 10 days, rarely more. Nevertheless, after inhalation of spores, incubation
has been reported to last up to 60 days (table 3).
4.3.2 Cutaneous anthrax
The exposed cutaneous zones (arms, hands, face, and neck) are the most frequently affected (figure 2).
The disease begins with a macula or pruritic papula which develops into a circular shaped ulcer on the
second day. Small vesicles from 1 to 3 mm may appear, discharging a clear or bloody fluid containing
numerous bacilli. The lesion then changes to a black sore, often associated to local and severe edema.
The sore dries and disappears in 1 to 2 weeks without leaving any scar. Lymphangitis, painful lymph
nodes, and severe edema may develop and the disease may be complicated by bacteremia. An adapted
antibiotic oral treatment is effective.
Without treatment, the death rate may reach 20% (in case of sepsis). With an early treatment, it is
inferior to 1%.
8
Figure 2: cutaneous anthrax (picture courtesy of Bacillus anthracis NRC, Institut Pasteur)
4.3.3 Gastro-intestinal anthrax
It begins with acute gastroenteritis which can evolve rapidly to bacteremia with bloody diarrhea.
Death may occur within a few hours (estimated death rate between 25% and 60%).
Oropharyngeal presentations with lymph node involvement and sub-lingual edema have been
described.
4.3.4 Inhalation anthrax
It is improperly called “pulmonary” form: it is not really pneumonia but a first involvement of
mediastinal lymph nodes.
According to available data, the disease could includes two stages:
1) an initial pseudo-influenza syndrome with catarrhal rhinitis which may last from a few hours to a
few days;
2) a secondary and fulminant respiratory failure associated to bacteremia.
Thoracic X-ray reveals mediastinal enlargement often related to lymph node involvement very often
associated to pleural and parenchymal involvement. In half of the cases, patients develop a
hemorrhagic meningeal form.
If very early antibiotic treatment is not initiated (in the early phase of the disease), the death rate
ranges between 80% and 100%. The mean delay between onset of des symptoms and death is 3 days.
4.3.5 Meningeal anthrax
It may be a complication of all the other presentations. The initial site may also be directly ethmoidal
after spore inhalation. This severe hemorrhagic meningitis rapidly evolves to coma and death [12].
4.4 Microbiologic diagnosis
The microbiologic diagnosis is performed by:
 isolation and identification of Bacillus anthracis from clinical samples (hemocultures, skin
swabs, CSF, lymph node biopsies, etc.) which should be collected before any antibiotherapy;
 specific PCR (Polymerase Chain Reaction) ;
 blood tests (ELISA). Serodiagnosis is useful only for a retrospective diagnosis in case of
antibiotic treatment before sampling.
9
The following are available in all laboratories
- direct examination: non-mobile Gram positive bacilli;
- culture: positive in 6 to 24 h, identification in 24 to 48 h (non hemolytic, depending on culture
medium either in short chains of 2 to 3 consecutive elements, or in very dense reticulation of
long mycelium-like chains);
- antibiogram: to be required systematically (penicillin, doxycycline, ciprofloxacin).
Samples must be managed by a P3 laboratory if anthrax is suspected. Nevertheless, incidental
identification of the bacillus in culture by a non-P3 laboratory may be possible.
Laboratories in the biotox-piratox network (reference laboratories in defense zones) may perform
culture and antibiogram, as well as PCR.
The Paris Institut Pasteur Anthrax National Reference Center and the Anthrax National Reference
Laboratory (Anses, Maisons Alfort) will perform PCR for confirmation (results in 24 h after receiving
samples), the antibiogram of strains, and blood tests.
V - EVALUATION OF RISK DEPENDING ON THE CONTACT
The risk of developing human anthrax depends on the contact with a sick animal, living or dead. The
risk of person-to-person transmission, if it has sometimes been suggested, is not significant. The risk of
developing human anthrax after contact with a sick animal depends of the source bacterial inoculum
and of the contact type.
5.1 Estimation of the source inoculum
The vegetative form is present at very high concentrations in all tissues of the living animal or in the
non open carcass during the first days (cf. infra) [13]. It may be a source of infection for man only in
case of direct contact direct with a sick animal, during care giving for example, or with bacterial
culture in the laboratory [5].
The spore form is most often responsible for human contamination. Spores develop only in the
presence of oxygen. This condition explains why sporulation develops only once the animal is dead
and the carcass opened. Thus, if the carcass is not opened, anaerobic breakdown and ambient acidity
will kill vegetative forms en 4 days without allowing spore formation.
Sporulation is a process the length of which depends on temperature and humidity conditions [14] and
which ranges from several hours to several days. For example, in laboratory conditions, the sporulation
rate of bacilli reaches 100% in 12 hours at 37°C if relative humidity is 100%, but if it is only at 50%,
this rate only reaches 35% after 34 hours. Sporulation is less important if the temperature does not
exceed 15 to 21°C. There is none below 9°C [15]. Thus, only contact with an anthrax infected carcass
which was opened or soiled by biological fluids exposes to spores. The source spore inoculum to
which is exposed an individual in contact with this carcass is thus variable and dependant on
environmental conditions (humidity, temperature, oxygen) and on the delay after the animal’s death.
5.2 Estimation of the transmission risk depending on the type of contact
5.2.1 Respiratory
The available data comes almost exclusively from preparation of response plans to bioterrorism and of
the experience of malevolent exposure in the USA in 2001. It allows estimating that the 50% lethal
10
dose (LD50) ranges from 8,000 to 10,000 inhaled spores [16]. Experimental studies in primates have
nevertheless reported lower LD50s [17]. This estimated LD50 is probably much more important than
the inoculum potentially inhaled after opening an animal carcass. Indeed, circumstances in which
spores are aerosolized from a carcass are rare [18]. Furthermore, if an aerosol is created from a
carcass, the density of spores would certainly be inferior to that of aerosols from envelopes of powder
de malevolently distributed during the 2001 American episode.
Indeed, no human case of “respiratory” anthrax has ever been reported after exposure to anthraxinfected animals. This risk could be under estimated, either because the diagnosis of such cases is not
made in countries with weak medical means, or because the prescription of preemptive treatment in
developed countries prevented such cases. These hypotheses remain weakly probable because of the
rarity of settings leading to aerosol formation.
The only cases of reported non malevolent respiratory anthrax are cases of occupational anthrax in the
wool industry [19, 20] and anecdotal cases in bongo manufacturers or African drum players [20].
Nevertheless, an old study made in several New Hampshire goat wool processing manufactures
(United States) proved that workers exposed daily to several hundreds of spores did not develop
respiratory anthrax [21].
Thus it may be said that the contamination risk via the respiratory tract on contact with an anthraxinfected animal is null to negligible, except for a few very specific circumstances generating an
aerosol (using a high pressure cleaner or compressed air in a confined atmosphere to clean a building
or strip the skin of a sick animal). In these cases, upstream prevention measures must be observed by
using individual protection equipment (including wearing a mask, gown, and gloves) and banning the
use of high pressure cleaner when possible [18].
5.2.2 Digestive
Cases of digestive anthrax are rare, and due to the ingestion of raw or sometimes cooked meat [22-26].
This meat may come from animals dead or infected before being slaughtered. The infecting dose after
ingestion is unclear but probably more important than the one for the respiratory tract. A study
performed in Kazakhstan in 2004 showed that the risk of developing anthrax was more important if
meat was consumed raw or grilled and less if it was boiled [27]. In this study, cooking the meat was
not itself a risk factor to develop non-cutaneous anthrax. In France, in individuals exposed both
cutaneously and by ingestion of meat coming from an anthrax infected animal, the cutaneous form
only was observed [11].
The probability to consume meat from an anthrax-infected animal is very weak in France because of
the rapid evolution of the disease in an animal, and because of veterinarian surveillance in knackering
and rendering facilities. But the consumption of non-controlled meat (illegal butchering or
importation) or that of wild animals infected or found dead is not without risks.
Finally, if the bacillus or des may be found in the milk of infected animals, no case of digestive
anthrax has ever been documented after the exclusive consumption of milk, even if a risk remains
possible.
5.2.3 Cutaneous
Cutaneous anthrax is by far the most frequent form of «farm» human anthrax [27-30].
Incubation is always inferior to 12 days and no case of cutaneous anthrax has ever been reported after
a prolonged latency period, contrary to respiratory anthrax [11]. If any direct handling of an anthrax
infected animal may involve a risk of cutaneous anthrax (a fortiori in case of hand wounds), cutting up
the cadaver or the carcass is the greatest risk [27,31].
Some very rare cases of human-to-human transmission by direct contact direct with skin lesions have
been reported but never any digestive or respiratory forms. Usual hygiene precautions should be
respected [5,32,33,34].
11
The risk of vectorial transmission sometimes suggested is highly improbable [31].
VI – RECOMMENDATIONS CONCERNING PREVENTION MEASURES
6.1 Reminders on investigation and management of an animal focus
As soon as an anthrax animal focus is suspected, the ARS (regional heath agency) identifies potentially
exposed individuals, along with the Subdivision Direction of population protection (DDPP previously
Subdivision Direction of Veterinarian Services) and InVS/CIRE. Exposure to screen for includes:
direct contacts with the sick animal(s), and products from these animals, among individuals living and
working on the farm, and among outside individuals such as the farm veterinarian, knackering and
rendering facility personnel, etc. Once the contact is proved, these individuals will be referred to a
physician who will determine if antibiotic treatment is necessary, and eventually prescribed.
If the animal focus is proved or suspected, a July 2010 ANSES recommendation specifies that animals
sharing the infected animal’s pasture should not be moved so as to prevent spore displacement and not
opening the cadaver to limit human exposure [18]. Clinical samplings of the suspicious animal or
animals are sent to the national reference laboratory or to the subdivision veterinarian laboratory (if it
is a P3 level) to confirm the animal diagnosis. If the focus is confirmed, vaccination or
antibioprophylactic measures are implemented for animals by the ministry of agriculture and its local
services to prevent other animal cases.
6.2 Preemptive treatment regimen and indications
6.2.1 Preemptive treatment objective
The aim of this treatment is to prevent evolution to disease after a potentially contaminating exposure
[32,35]. The work group recommends initiating the treatment as soon as possible after exposure.
It is not possible to use preventive vaccination in man because there is no available vaccine in France.
[5]
Human cases of anthrax after contact with an sick animal are rare. The indications for preemptive
treatment must be specific and restricted [36].
6.2.2 Recommended antibiotics
In vitro, the bacterium is susceptible to several molecules: penicillins, fluoroquinolones, cyclines,
phenicoles, aminosides, macrolides, penemes, rifampicin, and vancomycin [35-40]. B. anthracis is
resistant to cephalosporins, trimethoprim, and sulfonamide [37,38,41].
Because of a possible inducible beta-lactam secretion, penicillin or amoxicillin monotherapy is not
recommended without a prior antibiogram [32,40]. There is no natural resistance to ciprofloxacin or la
doxycycline but the selection of resistant strains under treatment remains possible [32,37,39,43].
Determining the susceptibility of the isolated strains is always necessary [34,39]. Ciprofloxacin or
doxycycline are the two first-line molecules to initiate treatment before performing an antibiogram
[4,12,32,36,42,44,45,46].
6.2.3 Length of preemptive treatment
There is no human study on this issue, comparing molecules together or against placebo [32,35,41].
The length of preemptive treatment thus takes into account the disease’s physiopathology, animal
experimental studies (primate), and modelization [32,47,48,49]. The length of preemptive treatment
12
should be twice the average incubation time of the disease, that is 10 days for cutaneous or digestive
exposure.
For airborne exposure, incubation may be longer. In case of bioterrorism, the recommendation is to
treat for 60 days, but in case of “natural” or non-malevolent contamination, 35 days seem enough.
Indeed, in a macaque receiving a respiratory inoculum, 10 days of prophylaxis are enough to prevent
the onset of the disease [48]. But in a primate model exposed to a respiratory inoculum, the
germination of spores into pathogenic bacilli may occur up to 60 days after exposure to [36].
Finally, in a Monte Carlo simulation, Drusano et al showed that 30 days would be enough to prevent
the onset of the disease, always in case of significant respiratory exposure [49].
Furthermore, a long term treatment prescription exposes to observance problems as demonstrated in
mailmen exposed to envelopes of powder potentially containing spores, malevolently distributed in the
USA in 2001 [50,51].
Clinical surveillance remains recommend during preemptive treatment [39].
6.2.4 Treatment indications and modalities
Precise indications were established for each type of exposure, they are specified in figure 3 and table
4.
Ciprofloxacin or doxycycline are recommended in first line. If the antibiogram of the B. anthracis
focus strain is documented and if the susceptibility to beta-lactams is demonstrated, amoxicillin may
be used.
Cyclines cannot be used in pregnant women or in children under 8 years of age, except when no other
antibiotic can be prescribed and should be defined case by case [52,53].
Preemptive treatment is not recommended for healthcare personnel or for morgue personnel if standard
precautions are observed, when dealing with patients infected by anthrax [3].
13
Figure 3: management for human exposure after contact with an animal with suspected or confirmed anthrax
Any animal with suspected or confirmed infection, dead or alive
Cutaneous or mucosal exposure by handling
or spattering on the skin or mucosa 1, 2
Cadaver not opened,
no biological fluid
discharge
Food-borne exposure
Respiratory exposure
Cadaver opened, or biological
fluid discharge
(animal dead or alive) no
individual protective equipment
(IPE)
Workstation with
risk of aerosol
exposure
In knackering and
rendering facilities
4
Using a high
pressure cleaner
in confined settings
(truck, livestock van,
stable, etc.)
Cleaning stable area
without
IPE, 5
milk
Meat (even cooked)
Exposure within 72h
before signs or animal
death and
consultation in the 10
days following the
latest exposure
Treatment
10 days
Other cases
Animal infected
or dead
Treatment
35 days
No treatment
Mixed milk or milked 72h
before signs or animal death
Individual milk or slightly
mixed milk (<5 animals)
within 72h before signs or
animal death
Other animal in the
herd or from another
herd 3
No treatment
No gloves
Gloves worn
No treatment.
Clinical surveillance
and updating the
family physician
Exposure within 72h
before signs or animal
death and consultation
in the 10 days following
the latest exposure
Treatment
10 days
Other cases
Exposure
dating back to
more than 10
days at
consultation
No treatment
Exposure dating
back to 10 days or
less at consultation
Treatment
10 days
Exposure dating
back to more than
10 days at
consultation
No treatment
Exposure dating back
to 10 days or less at
consultation
14
Treatment
10 days
The settings listed in the flowchart were considered by the workgroup as being the only ones with a
risk for human contamination. Settings and/or activities not mentioned are thus considered as not being
at risk.
If the diagnosis of anthrax on one or several suspected animals is refuted, treatment must be stopped.
1 - Handling and spattering to skin or mucosa were considered as risk for a local form of anthrax
(especially cutaneous). These activities are not considered as potentially aerosol generating.
Handling pieces of animal meat and offal, surfaces, material or documents strongly soiled by blood or
other biological fluids from the animal with suspected or confirmed infection is considered at risk as
well as handling the whole animal. Contact with work wear or boots having been in contact with the
animal is not considered at risk except if work wear is soiled by blood or biological fluids from the
animal with suspected or confirmed infection.
2 - Accidental exposure to blood of animal with suspected or confirmed infection, within 72h before
the onset of signs or death of the animal, during care giving for example, is considered as risk
exposure, on the same level as handling, and is an indication for treatment.
3 – There is a negligible risk of B. anthracis transmission when ingesting products from animals which
may have been gutted and cut up with the same instruments as those used for an animal(s) with
suspected or confirmed infection, or products which may have been in direct contact with products
from an animal with suspected or confirmed infection, as in a refrigerator fro example. Treatment is
not recommended for individuals having ingested these products but clinical surveillance is.
4 – Knackering and rendering facility specificities.
Visiting and analyzing the various works stations in knackering and rendering facility enabled
determining risk exposure taking into account the type of exposure and wearing or not protective
equipment (cf. Addendum 1). Globally, individual protective measures (gloves, protective hood)
should be implemented permanently on risk works stations, and should be reinforced as soon as the
first case of animal anthrax is reported so as to prevent recurrent exposure in case of a growing focus.
-
Collecting animals: direct handling of the cadaver without gloves is a risk for cutaneous
requiring treatment. Pulling out a cadaver from inside a truck if the truck is equipped with a
winch (driver at the back of the truck pulling out a cadaver from inside) is a risk for respiratory
exposure except if a mask or protective hood is worn. Cleaning the truck without protective
equipment (mask or protective hood) is a risk for respiratory exposure requiring treatment.
-
Administration: individuals who may have handled documents strongly soiled by blood or
other biological fluids are considered as cutaneous exposure cases by handling, requiring
treatment. These documents should be placed rapidly under a plastic protection, using
disposable gloves.
-
Triage of animals to retrieve hides and BSE decapitation: cutaneous contamination is possible,
treatment is required if gloves were not worn, there is no risk of respiratory contamination a
priori.
-
Decapitation with a knife to screen for BSE: no treatment is needed a priori unless protective
equipment was not worn (hood, gloves) and there were spattering of biological fluid toward the
face or direct skin contact.
15
-
Cutting up cadavers: treatment for a possible cutaneous contamination if no compressed air
was used, and gloves were not worn, treatment for a possible respiratory contamination if no
compressed air was used to dissect sub-cutaneous conjunctive tissue (if no mask or hood was
used).
-
Cleaning the decapitation, cutting up, and triage area with a high pressure cleaner: cleaning up
the area without adequate protection (mask or hood) is a respiratory exposure requiring
treatment.
-
Chopping cadavers and cooking: no treatment. Nevertheless, cleaning the chopper with a high
pressure cleaner, in case of diagnosed anthrax, is not necessary because the permanent forward
motion prevents a long-lasting contamination of the chopper and this type of cleaning would
probably not ensure an effective decontamination of the cadaver-processing device if it were
required. Furthermore, this type of cleaning presents a non-negligible risk for the operator
(accident, spattering of decaying organic matter, etc.) to be compared with the expected
benefit.
5 – An animal infected or dead in a farm building (stable), will probably contaminate the floor by
dejections and biologic fluid discharge. In these settings, the risk to have airborne spores when
cleaning the floor cannot be excluded (removing the straw and dejections packed on the floor requiring
«scraping» the animal position area in the building). This scraping should be performed wearing
individual protective equipment if an animal was diagnosed with anthrax. Airborne contamination
cannot be excluded if individual protective equipment is not worn.
16
Table 4: suggested antibiotic regimen after risk exposure to anthrax
Cutaneous or food exposure: 10 days per os
Individuals
Antibiotic susceptibility
Respiratory exposure: 35 days per os (2)
- Doxycycline 100 mg x 2/day
Adults
Before antibiogram
or
- Ciprofloxacin 500mg x 2/ day
If the strain is susceptible to
penicillin (1)
Before antibiogram
Pregnant women
If the strain is susceptible to
penicillin (1)
Amoxicillin 500 mg x 3/ day
Ciprofloxacin 500 mg x 2/day
Amoxicillin 500 mg x 3/ day
Ciprofloxacin 10-15mg/kg x 2/ day not exceeding 1 g/ day
or
- Doxycycline
Child >8 years of age and >45 kg:
Children
Before antibiogram
100mg x 2/ day
Child >8 years of age and < 45kg:
2.2 mg/kg x 2/ day not exceeding 200 mg/day
Child <8 years of age:
avoid using doxycycline
(1)
In case of extended focus on several herds, the susceptibility of isolated strains should be checked during the episode to detect the emergence of possible resistance to
penicillins as soon as possible. At least one antibiogram should be performed for each new infected herd.
(2)
For long-term treatments (35 days), the prescription should be modified and switched to amoxicillin if the strain is susceptible, if there is no allergy or contraindication.
The referent infectious diseases department or ARS should be contacted to document antibiogram results for the animal strain. For short-term treatments, the prescription should
not be modified.
17
References
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Bossi P, Tegnell A, Baka A and al. Recommendations Bichat sur la management clinique des
patients présentant une maladie du Charbon liée or non à un acte bioterrorisme. Euro Surveill.
2004;9(12):E3-4.
Inglesby T, O’Toole T, Henderson D and al. Anthrax as a biological weapon-2002: updated
recommendations for management. JAMA. 2002;287(17):2236-52. Erratum in: JAMA
2002;288(15):1849.
Brook I. The prophylaxis and treatment of anthrax. Int J Antimicrob Agents. 2002;20(5):320-5.
Stern EJ, Uhde KB, Shadomy SV, Messonier N. Conference report on public health and clinical
guidelines for anthrax. Emerg. Inf. Dis. 2008;14(4), pii: 07-0969.
Schmid G, Kaufmann A. Anthrax in Europe: its epidemiology, clinical characteristics, and role
in bioterrorism. Clin Microbiol Infect 2002;8(8):479-488.
InVS. Recommendations pour la surveillance and la lutte contre le charbon animal and humain.
Guide
méthodologique.
Saint
Maurice,
June
2005:35pp.
http://www.invs.sante.fr/publications/2005/guide_charbon/guide_charbon.pdf
Accédé
le
10/08/2010.
Mock M, Fouet A. Anthrax. Annu Rev Microbiol. 2001;55:647-71.
Ramisse V, Patra G, Garrigue H, Guesdon JL, Mock M. Identification and characterization of
Bacillus anthracis by multiplex PCR analysis of sequences on plasmids pXO1 and pXO2 and
chromosomal DNA. FEMS Microbiol Lett. 1996;145(1):9-16.
WHO/OIE/FAO (2008) Anthrax in humans and animals. 4ème édition. OMS, Genève, Suisse,
208 p
InVS. Cas groupés de charbon cutané humain en Moselle – Décembre 2008. Saint-Maurice,
février 2010 : 4 pp.
http://www.invs.sante.fr/publications/2010/charbon_cutane_moselle/plaquette_charbon_cutane
_moselle.pdf. Accédé le 10/08/2010.
Cinquetti G, Banal F, Dupuy AL and al. Three related cases of cutaneous anthrax in France:
clinical and laboratory aspects. Medicine (Baltimore). 2009;88(6):371-5.
Swartz M. Current concepts: recognition and management of anthrax – an update. N Engl J
Med. 2001;345(22):1621-6. Erratum in: N Engl J Med 2002 Feb 21;346(8):634.
Koehler TM. Bacillus anthracis physiology and genetics. Mol Aspects Med 2009;30:386-96.
Driks A. The Bacillus anthracis spore. Mol Aspects Med 2009;30:368-73.
Beyer W, Turnbull PC. Anthrax in animals. Mol Aspects Med 2009;30:481-9.
Fennelly KP, Davidow AL, Miller SL, Connell N, Ellner JJ. Airborne infection with Bacillus
anthracis--from mills to mail. Emerg Infect Dis 2004;10:996-1002.
Peters CJ, Hartley DM. Anthrax inhalation and lethal human infection. Lancet 2002;359:710711.
ANSES. Avis de l’Agence nationale de sécurité sanitaire de l’alimentation, de l’environnement
and du travail relatif à une demande d'avis sur les mesures de gestion en santé animale and en
sécurité sanitaire des aliments lors de suspicions and de confirmations de cas de fièvre
charbonneuse.
Maisons-Alfort,
13
juillet
2010.
http://www.afssa.fr/Documents/SANT2010sa0007.pdf. Accédé le 10/08/2010
Carter T. The dissemination of anthrax from imported wool: Kidderminster 1900-14. Occup
Environ Med 2004;61:103-7.
18
20 Centers for Disease Control and Prevention (CDC).Inhalation anthrax associated with dried
animal hides--Pennsylvania and New York City, 2006.MMWR Morb Mortal Wkly Rep. 2006
Mar 17;55(10):280-2.
21 Dahlgren CM, Buchanan LM, Decker HM, Freed SW, Phillips CR, Brachman PS. Bacillus
anthracis aerosols in goat hair processing mills. Am J Hyg 1960;72:24-31.
22 Doganay M, Almac A, Hanagasi R. Primary throat anthrax. A report of six cases. Scand J Infect
Dis 1986;18:415-9.
23 Sirisanthana T, Brown AE. Anthrax of the gastrointestinal tract. Emerg Infect Dis 2002;8:649651.
24 Sirisanthana T, Navachareon N, Tharavichitkul P, Sirisanthana V, Brown AE. Outbreak of oraloropharyngeal anthrax: an unusual manifestation of human infection with Bacillus anthracis.
Am J Trop Med Hyg 1984;33:144-50.
25 Anonymous. From the Centers for Disease Control and Prevention. Human ingestion of
Bacillus anthracis-contaminated meat--Minnesota, August 2000. Jama 2000;284:1644-6.
26 Hugh-Jones M. 1996-97 Global Anthrax Report. J Appl Microbiol 1999;87:189-91.
27 Woods CW, Ospanov K, Myrzabekov A, Favorov M, Plikaytis B, Ashford DA. Risk factors for
human anthrax among contacts of anthrax-infected livestock in Kazakhstan. Am J Trop Med
Hyg 2004;71:48-52.
28 Ozcan H, Kayabas U, Bayindir Y, Bayraktar MR, Ay S. Evaluation of 23 cutaneous anthrax
patients in eastern Anatolia, Turkey: diagnosis and risk factors. Int J Dermatol 2008;47:1033-7.
29 Davies JC. A major epidemic of anthrax in Zimbabwe. The experience at the Beatrice Road
Infectious Diseases Hospital, Harare. Cent Afr J Med 1985;31:176-80.
30 Doganay M, Metan G. Human anthrax in Turkey from 1990 to 2007. Vector Borne Zoonotic
Dis 2009;9:131-40.
31 Doganay M. Anthrax. In: Cohen J, Powderly WG, Eds., Infectious diseases. 2nd ed. Edinburg
Mosby Elsevier; 2004. 1685-1689.
32 Brook I. The prophylaxis and treatment of anthrax. Intern J Antimicrob Agents 2002;20:320-5.
33 Yakupogullari Y, Koroglu M. Nosocomial spread of Bacillus anthracis. J Hospit Infect
2007;66:401-2.
34 Weber DJ, Rutala WA. Risks and prevention of nosocomial transmission of rare zoonotic
diseases. Clin Infect Dis 2001; 32: 446-56.
35 Kyriacou DN, Adamski A, Khardori N. Anthrax: from antiquity and obscurity to a front-runner
in bioterrorism. Infect Dis Clin N Am 2006;20:227-51.
36 Spencer RC. Bacillus anthracis. J Clin Pathol 2003; 56: 182-7.
37 Bryskier A. Bacillus anthracis and antibacterial agents. Clin Microbiol Infect. 2002;8:467-78.
38 Luna V, King DS, Gulledge J, and al. Susceptibility of Bacillus anthracis, Bacillus cereus,
Bacillus mycoides, Bacillus pseudomycoides and Bacillus thuringiensis to 24 antimicrobials
using Sensititre® automated microbroth dilution and Etest® agar gradient diffusion methods. J
antimicrob Chemother 2007;60: 555-67.
39 IDSA. Anthrax: current, comprehensive information on pathogenesis, microbiology,
epidemiology, diagnosis, treatment, and prophylaxis. Last updated July 2010;
http://www.cidrap.umn.edu/idsa/bt/anthrax/biofacts/anthraxfactsheet.html.
Accédé
le
10/08/2010
40 Turnbull PCB, Sirianni NM, LeBron CI, and al. MICs of selected antibiotics for Bacillus
anthracis, Bacillus cereus, Bacillus thuringiensis, and bacillus mycoides from a range of
clinical and environmental sources as determined by Etest. J Clin Microbiol 2004; 42:3626-34.
41 Centers for Disease Control and Prevention (CDC).Update: Investigation of bioterrorismrelated anthrax and interim guidelines for exposure management and antimicrobial therapy,
19
42
43
44
45
46
47
48
49
50
51
52
53
54
October 2001.MMWR Morb Mortal Wkly Rep. 2001;50(42):909-19.Erratum in: MMWR Morb
Mortal Wkly Rep 2001;50(43):962.
Bartlett JG., Inglesky TV., Borio L. Management of anthrax. Clin Infect Dis 2002; 35: 851-848
Athamna A, Athamna M, Abu-Rashed N, and al. Selection of Bacillus anthracis isolates
resistant to antibiotics. J Antimicrob Chemother 2004; 54: 424-8.
Ministère de la Santé and des Sports. Agents de la menace biologique. Stratégies de réponse
face a une menace d’agression par les agents de la peste, du charbon or de la tularémie.
http://www.sante-sports.gouv.fr/IMG/pdf/Guide_Peste_-_Charbon_-_Tularemie_PCT.pdf.
Accédé le 10/08/2010.
Centers for Disease Control and Prevention (CDC).Update: Interim recommendations for
antimicrobial prophylaxis for children and breastfeeding mothers and treatment of children with
anthrax.MMWR Morb Mortal Wkly Rep. 2001 Nov 16;50(45):1014-6.
ACOG Committee on obstetric practice. ACOG Committee Opinion number 268, February
2002. Management of asymptomatic pregnant or lactating women exposed to anthrax. Obset
Gynecol 2002; 99: 366-8.
Deziel MR, Heine H, Louie A, and al. Effective antimicrobial regimens for use in humans for
therapy of Bacillus anthracis infections and postexposure prophylaxis. Antimicrob Agents
Chemother. 2005 ;49(12):5099-106.
Vietri NJ, Purcell BK, Tobery SA, and al. A short course of antibiotics treatment is effective in
preventing death from experimental inhalational anthrax after discontinuing antibiotics. J.
Infect. Dis. 2009;199:336-41.
Drusano GL, Okusanya OO, Okusanya A, and al. Is 60 days of ciprofloxacin administration
necessary for postexposure prophylaxis for Bacillus anthracis. Antimicrob. Agents Chemother
2008;52:3973-9.
Williams JL, Noviello SS, Griffith KS, and al. Anthrax postexposure prophylaxis in postal
workers, Connecticut, 2001. Emerg Infect Dis 2002; 8: 1133-7.
Shepard CW, Soriano-Gabarro M, Zell ER, and al.Antimicrobial postexposure prophylaxis for
anthrax: adverse events and adherence.Emerg Infect Dis. 2002 Oct;8(10):1124-32.
Kadanali A, Taysyaran MA, Kadanali S. Anthrax during pregnancy: case report and review.
Clin Infect Dis 2003; 36: 1343-6.
Centers for Disease Control and Prevention (CDC).Updated recommendations for antimicrobial
prophylaxis among asymptomatic pregnant women after exposure to Bacillus
anthracis.MMWR Morb Mortal Wkly Rep. 2001;50(43):960.
Madani N, Mendy C, Moutou F, Garin-Bastuji B, 2010. La fièvre charbonneuse en France.
Épisodes de l’été 2009 and foyers enregistrés sur la dernière décennie (1999-2009). BEH Horssérie / 14 septembre 2010, 15-17.
20
Work group
The SPILF drafted these recommendations from the evaluations of a multidisciplinary group of experts
chaired by Th. MAY, infectiologist (Nancy) including:
-
C. BREZILLON, microbiologist (Institut Pasteur)
B. GARIN-BASTUJI, veterinarian microbiologist (Anses - Maisons Alfort)
J. LEROY, infectious diseases physician (Besançon)
N. MADANI, veterinarian microbiologist (Anses - Maisons Alfort)
A. MAILLES, epidemiologist (InVS)
M. MOCK, microbiologist (Institut Pasteur)
L. PIROTH, infectious diseases physician (Dijon)
O. ROGEAUX, infectious diseases physician (Chambéry)
JP. STAHL, infectious diseases physician (Grenoble)
21
Addendum 1 - Knackering and rendering organization
All the knackering and rendering facilities in France treat around 2.5 million tons of biomass per year.
40% of this mass is made up of animal cadavers.
The cadavers that are processed come from farm animals dead after disease accident unfit for
consumption, as well as from wild animals (pigeons, rats, etc.), or pets dead or killed by veterinarians,
marine mammals run aground, cadavers from research laboratories, etc. Knackering and rendering
facilities also process waste from agri-food industries, milk unfit for consumption, etc.
Usually, if the facility is warned that anthrax fever was suspected (AF) before collecting a cadaver, the
protective measures which are implemented should be sufficient to prevent exposure. There is a risk
for the facility personnel only if the facility was not warned, or warned too late after having already
processed several cadavers (in case the diagnosis of AF was late).
1 Collecting cadavers
According to the current legislation, knackering and rendering facilities may collect only closed
cadavers (not having undergone autopsy) or sutured. Nevertheless, this law may be overruled in some
cases, and this increases the risks of exposure to infected biological fluids.
The collecting trucks are not allowed to enter pastures and must remain on the road (including in city
streets), thus limiting contamination of truck wheels and the role of trucks in spreading spores and
bacteria.
Two types of trucks may perform picking up cadavers at the pasture side.
- Trucks with an articulated arm and a remote controlled «clamp», with a roof opening: no
handling of the cadaver by the par personnel, no leak of fluids from the cadaver.
- Trucks with a winch and opening at the rear: handling of the cadaver by the truck driver is
needed to attach the cadaver before pulling it inside the truck and biological fluids may leak
during traction. Furthermore, this type of equipment requires the driver’s coming inside the
truck to detach the animal (confined space).
In case of prior information on the suspicion of anthrax and request from the competent authority
(Local veterinarian health authorities for the protection of populations), a specific collection may be
organized directly from the facility. Protective kits including gloves and hoods are given to drivers in
this case protection.
If no prior information is available, cadavers are collected during routine rounds at various distances
from the facility. If the distance is great, the round may start from another collecting spot other than
the facility with change of truck and driver, thus with potentially more handling of the cadaver. In this
case, sub-contractors may be used for knackering.
2 Processing cadavers of bovines
Bovines, killed or dead by accident, more than 24 months of age, are systematically screened for
Bovine Spongiform Encephalopathy (BSE) during knackering. They are triaged on arrival and
decapitated with knives. The worker in charge of cutting-up the cadaver wears steel mesh gloves, but
not systematically a mask or hood. But, the veterinarian mandated to perform the sampling for ESB
(who is not affiliated as facility personnel but with the DDPP) wears gloves, protective glasses and
hood most often but not systematically.
Bovines under 24 months of age, the skin of which is in a satisfactory state, are also table-cut. Before
table cutting, the hide may be detached from the sub-cutaneous conjunctiva by using compressed air
and then traction. Hides are the sent to a tanning facility after a stabilizing pre-treatment brine curing.
22
All the cadavers are put in a grinder hopper (or a crusher) around 10 by 5 meters, featuring a feed
screw which performs a first course crushing. The grinder is never completely emptied and it is the
permanent forward motion which plays the role of a prophylactic device (year round function).
The crushed meat is then transferred to closed tanks, without risk of exposure, and is submitted to
transformation (grinding into a given granulometry then sanitized by heat treatment) as defined in
paragraph III of addendum V of the 1774/2002 European Regulations.
The room in which triage, sampling for SBE, and table cutting are performed is cleaned superficially
with a high pressure cleaner daily at the end of the workday.
3 Cleaning trucks
Trucks are cleaned with a high pressure cleaner (open or confined space), and soiled water is collected
and sent to a wastewater treatment station. The person responsible for cleaning up is usually the truck
driver who may use a hood protecting him from spattering.
4 Protective measures for workers
Boot and hand washers are installed on the site for disinfection outside of work zones and previously
mentioned individual protective equipment is issued to the personnel (gloves, goggles, hoods).
Workers are given occupational wear and must shower and change on the work before going home.
Passive spreading of spores outside of facilities is thus theoretically impossible.
23