Anthrax Policy

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Chapter 31

Anthrax Policy

Version 6
Document Summary

This policy provides guidance for the appropriate actions and responsibilities for the management of patients with anthrax or exposed to anthrax spores. It also details the procedure which must be followed in the event of receipt of a letter/parcel containing possible anthrax




Patient Safety Council


10 September 2014


1 October 2014


1 October 2017


Sue Redfern, Director of Nursing, Midwifery & Governance


Karen Allen, Director of Infection Prevention & Control


All Trust staff


Anthrax, suspect parcel, bioterrorism

Important Note:
The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as “uncontrolled” and, as such, may not necessarily contain the latest updates and amendments
Document Version History



Summary of key changes

Author Designation

November 2001



1st December 2004



1st December 2006



1st November 2008



1st October 2011


Format changed.

Page 7-8: Treatment of inhalation/ingestion anthrax amended.

Page 11: Advice on removal of pacemaker after death has been added.

Page 13: Flow chart for responding to suspect packages has been replaced by current HPA version.

Page 16: Appendix 2 added.


1 October 2014


Format changed.


1st October 2017

Review date



Item No.


Page No.








Statement of Intent






Duties, Accountabilities and Responsibilities






















Clinical presentation




Decontamination of victims



If death occurs




Bio-terrorist attacks

How to handle receipt of possible anthrax























Monitoring compliance



Key Performance Indicators of the Policy



Performance Management of the Policy



References and Bibliography



Related Policies and Procedures



Equality analysis




Appendix 1:

Clinical evaluation and management of persons with possible

cutaneous anthrax


Appendix 2:

Clinical evaluation and management of persons with possible

inhalational anthrax


1. Scope

This policy applies to all staff within St Helens and Knowsley Teaching Hospitals NHS Trust. This policy provides information to staff on the management of:

  • patients with anthrax

  • patients exposed to anthrax spores and

  • what to do in the event of receipt of a letter/parcel containing possible anthrax

2. Introduction

Anthrax is an acute bacterial disease caused by Bacillus anthracis. Normally it is a zoonotic disease (caught from animals). However the organism has been used as a bioterrorist weapon. Anthrax is potentially fatal. Therefore it is essential that this policy is followed.

3. Statement of Intent

This policy aims to ensure that patients with anthrax or exposed to anthrax are managed correctly in order to minimise transmission, morbidity and mortality. It also aims to ensure that suspicious letters/parcels are dealt with correctly in order to minimise spread of contamination and limit the number of potential casualties.

4. Definitions

Anthrax is an acute bacterial disease caused by the bacterium Bacillus anthracis.

5. Duties Accountabilities and Responsibilities

For full details of infection control responsibilities see Infection Control Policy, Chapter 28B Infection Control Manual.

5.1. Staff

It is the responsibility of all clinical staff to:

  • be aware of the current guidelines.

  • put these guidelines into practice.

  • bring to the attention of the Unit Manager or Infection Prevention and Control Team any problems in applying these guidelines

Breaches of this policy may lead to disciplinary action being taken against the individual.

5.2. Unit managers (person in charge of a ward or department) must ensure that

  • The policy is readily accessible to all staff.

  • The required facilities and equipment are available to enable compliance with the policies.

  • All staff within their area of responsibility have received training in the appropriate procedures with respect to infection control.

6. Process

6.1 Introduction

Anthrax is an acute bacterial disease caused by Bacillus anthracis. It is a zoonosis i.e. it is a disease usually acquired by humans from animals, most commonly herbivorous animals e.g. cattle, sheep, goats, camels, antelopes. It can also occur in carrion birds. It is not naturally occurring in the UK. Areas of the world where anthrax occurs include South and Central America, Southern and Eastern Europe, Asia, Africa, the Caribbean and the Middle East.

6.2 Transmission

Humans can be infected by:

  • Contact with infected animals

  • Contact with contaminated animal products e.g. wool, hide, bonemeal

  • Ingestion of meat from infected animals

  • Exposure to bioterrorist attack

Airborne person-to-person spread has not been described, but cutaneous anthrax may be acquired from direct contact with skin lesions.

In 2001, letters containing anthrax spores were sent through the USA postal system resulting in 22 cases of cutaneous and inhalational anthrax.
In view of the links with bioterrorism, cases must be notified urgently, both locally and nationally (see p9).
6.3 Clinical presentation

6.3.1 Incubation period

Usually 1-6 days (depending on the number of spores exposed to). However cases may occur up to 60 days after exposure, due to delayed germination of spores within macrophages.

6.3.2 Presentation

Anthrax occurs in 3 forms:




Cutaneous anthrax

This accounts for about 95% of anthrax infections. The bacteria enter the skin through a cut or abrasion. Skin infection begins as an itchy bump that resembles an insect bite but within 1-2 days develops into a vesicle and then a painless ulcer, usually 1-3cm diameter with a characteristic black necrotic eschar in the centre. Pronounced oedema often occurs due to the release of oedema toxin by the organism. Adjacent lymph nodes may swell. If untreated 20% of cases will result in death. With antibiotic treatment, death is rare, the lesions are cleared of organism within 24 hours and lesions resolve within several weeks.

Inhalational anthrax

Initial symptoms may resemble a common cold. Fever, malaise, fatigue, non-productive cough and mild chest discomfort may occur. These initial symptoms are often followed by a short period of improvement (from several hours to days). This is followed by the abrupt development of severe respiratory distress with shortness of breath, sweats, stridor, and cyanosis (blue skin colour). Shock and death usually occur 1-2 days after onset of respiratory distress. Mortality approaches 100% despite aggressive treatment at this stage. Chest X ray often shows widened mediastinum, pleural effusions, but typically without infiltrates.

Intestinal anthrax

This may follow ingestion of contaminated meat. The patient may have nausea, loss of appetite, vomiting, fever, abdominal pain, and diarrhoea. 25-60% of cases are fatal

6.4 Diagnosis

Culture of:

Blood (routine blood cultures)


Pus/tissue/swabs e.g., skin lesion, nose, throat

Faeces (intestinal anthrax only)
Specimens for culture must be marked as possible anthrax and High risk so that appropriate containment facilities will be used in the laboratory. Specimens should only be collected after the patient has been decontaminated (see page 9).

Take care to avoid external contamination of the specimen container. Seal it inside a plastic bag (do not use staples or metal clips) with attached request form. Use a separate request form for each specimen.

The laboratory must be informed in advance of specimens being sent. A responsible person must take the specimen to the laboratory. Do NOT use the vacuum tube system.

6.5 Treatment

With empirical therapy, when anthrax is a remote possibility, it is important to make sure that other more common causes of infection are also covered. Do NOT use ciprofloxacin alone for possible, unconfirmed inhalational anthrax as it will not cover Streptococcus pneumoniae, the most common cause of community-acquired pneumonia (use amoxicillin in addition as per Hospital Antibiotic Policy instead).
Usual sensitivity patterns

B anthracis is sensitive to tetracycline (doxycycline is best), ciprofloxacin and clarithromycin.

It may also be sensitive to penicillin, ampicillin, clindamycin, gentamicin, vancomycin and erythromycin. Due to concerns about constitutive and inducible β-lactamases in B. anthracis, penicillin and ampicillin should not be used alone for the treatment of inhalation anthrax.

It is resistant to cephalosporins e.g. cefuroxime, ceftazidime, cefotaxime and also to trimethoprim

Although the Russians have engineered a strain which is resistant to tetracycline, the strain currently used by terrorists has been fully sensitive.

Cutaneous anthrax

(See Appendix 1 for algorithm on clinical evaluation & management)

Ciprofloxacin 500mg 12 hourly orally for 7 days or

Doxycycline 100mg 12 hour orally for 7 days or

Amoxicillin 500mg 8 hourly orally for 7 days (if the organism is sensitive)

N.B. 60 days may be required if inhalation of spores has occurred (e.g. deliberate release).

Severe cases of cutaneous anthrax with signs of systemic involvement, extensive oedema, or lesions on the head or neck requires intravenous therapy and a multi-drug approach is recommended.

Inhalation/ingestion anthrax

Initial Therapy


Adults (including pregnant women)

Ciprofloxacin 400mg IV every 12hr (switching to 500mg oral twice daily when patient improves)


Doxycycline 100mg oral twice daily (when appropriate)


One or two additional antibiotics (agents with in vitro activity include rifampicin, vancomycin, gentamicin, chloramphenicol, penicillin, amoxicillin, imipenem, meropenem and clindamycin)

60 days

to cover delayed germination of spores


Ciprofloxacin 10mg/kg IV every 12hr, not to exceed adult dose of 1500mg per day (change to oral therapy, 15mg/kg PO not to exceed1500mg per day, when appropriate)


Doxycycline 100mg oral twice daily (NB: only for children > 8yrs and >45kg)


One or two additional antibiotics (agents with in vitro activity include rifampicin, vancomycin, gentamicin, chloramphenicol, penicillin, amoxicillin, imipenem, meropenem and clindamycin)

60 days

NB Benzylpenicillin or amoxicillin should not be used alone for initial treatment.

Tetracyclines and ciprofloxacin are normally avoided in children and pregnant/breast feeding women. However, if antibiotic sensitivity testing, exhaustion of antibiotic supplies and/or allergic sensitivity preclude the use of safer alternatives these may be used during a confirmed anthrax attack (consider the balance of risks).

It there is a high probability of the diagnosis of anthrax please contact the duty Microbiologist for up-to-date advice on treatment.

6.6. Prophylaxis

There is no need to give prophylaxis to contacts of the victim, unless these contacts were also exposed to a bioterrorist attack. Staff involved in decontamination of exposed persons or handling of exposed patients prior to decontamination will also require prophylaxis.

Prophylaxis must be given for at least 60 days because of the possibility of delayed germination of spores. They should be advised to seek medical attention in the event of any suspicious symptoms. Otherwise their daily life is not restricted. Ciprofloxacin is the drug of choice and can be used in children and pregnant women. Alternatives are given below.

Adult doses:

Ciprofloxacin 500mg bd orally

or Doxycycline 100mg bd orally

or Amoxicillin 500mg tds orally if organism confirmed sensitive

Vaccination is also recommended because of the uncertainty of when the sensitive spores may germinate. If vaccination is given, the duration of prophylaxis may be reduced to 30 days. Advice must be obtained from the Immunisation Division of Public Health England (PHE) Colindale (020 8200 6868). There is no need to quarantine victims.

6.7 Decontamination of victims

After immediate exposure to a bio-terrorist attack with anthrax, the patient will be decontaminated, either prior to arrival at hospital, or in the Emergency Department Decontamination Room i.e. all clothing removed and sealed in a double plastic bag, showered thoroughly with soap and water and dressed in paper suit and disposable slippers. Use minimum handling of clothing to avoid creation of aerosols of spores. Clothing must be stored securely (in labelled double plastic bags) and will be returned if exposure to anthrax is ruled out. If anthrax is confirmed, all contaminated clothing must be incinerated or autoclaved.

Personnel assisting in decontamination must wear appropriate protection i.e. gowns mask and gloves. After decontamination protective clothing must be removed carefully and hands must be thoroughly washed.

Staff who attend the patient after decontamination has been completed do not need to take any special precautions.

6.8 Isolation

There is no evidence of airborne person-to-person transmission of anthrax. Therefore isolation in side room is not necessary. However direct contact with the skin lesions in cutaneous anthrax may result in cutaneous infection. Gowns, mask and gloves must be worn. Hands must be washed on removal of gloves.

6.9 Disinfection

Contaminated environmental surfaces should be cleaned with 1% hypochlorite (10,000 ppm). As per Disinfection Policy (see Chapter 9 Infection Control Manual), wear plastic aprons (or gowns) and gloves when cleaning up spillages.

6.10 If death occurs

A body bag must be used. Viewing by relatives is not permitted. Nor is embalming or hygienic preparation by the undertaker. Embalming of bodies should not be undertaken because the body fluids are likely to contain large numbers of the causative bacteria and therefore the process exposes the embalmer to an unacceptable risk. Standard precautions for the disposal of bodies infected with Containment Level 3 pathogens should be observed and the undertaker should be informed. Cremation, rather than burial is the preferred method for disposal of the deceased.

Pacemaker removal is permitted. Pacemaker should be treated with hypochlorite solution (10,000 ppm available chlorine), bagged and disposed of appropriately (not by incineration).

Post mortem examination

Full post mortem is discouraged because of the risk of release of anthrax spores. If an autopsy is necessary expert advice must be sought from the PHE. The Pathologist must be informed of the known or suspected diagnosis. Standard precautions for post-mortem examinations on patients infected with Containment Level 3 organisms are appropriate. If post mortem is performed, all related instruments should be autoclaved or incinerated. Post mortem samples may include blood cultures, nasal swabs, cutaneous lesion swabs and swabs or samples of lung, spleen or lymph node if indicated.

6.11 Notification

Anthrax is a notifiable disease. Confirmed and suspected cases must be notified to the Consultant in Communicable Disease Control (CCDC) for the District of which the patient is resident. Cases must also be reported to the duty doctor at CDSC (020 8200 6868- 24 hour service)

6.12 Vaccination

The PHE is the sole manufacturer of the UK anthrax vaccine. The vaccine is manufactured for and on behalf of the UK Government. Vaccination is not recommended for the general public. It is not produced commercially and cannot be purchased.

Advice must be obtained from the Immunisation Division of PHE Colindale (020 8200 6868).

PHE Colindale may advise 5 doses of vaccination 0, 3 and 6 weeks then 6 months and 1 year after exposure in addition to antibiotic prophylaxis for certain contacts e.g. those frontline workers entering an exposed zone where anthrax has been released. With vaccination, antibiotic prophylaxis may be given for only 30 instead of 60 days.

6.13 Laboratory

B anthracis is a hazard Group 3 pathogen (ACDP Categorisation of biological agents according to hazard). Microbiological procedures should be performed within the Class 2 safety cabinet in the TB laboratory. B anthracis will grow on blood agar (but not MacConkey) within 18-24h of incubation at 37oC. Positive isolates must be confirmed by the reference laboratory (telephone first):

Special Pathogens Laboratory

PHE - Porton

Porton Down


Wiltshire, SP4 0JG

Tel 01980 612100 (24 hours)

10% (100,000ppm) hypochlorite is required for decontaminating laboratory surfaces that have been exposed to B anthracis spores. See laboratory SOP for methods of identification and parcelling of specimens sent to other laboratories.

6.14 Bio-terrorist attacks

Although anthrax is readily obtained by terrorist groups, none have yet achieved the technology required to aerosolise it in order to produce a weapon that can attack large numbers of people. So far, successful attacks have been limited to powder sent in letters/parcels to individuals. The terrorist group who released sarin gas in the Tokyo subway station in 1995 are known to have attempted to disperse anthrax and botulism throughout Tokyo on at least 8 occasions but failed to produce illness. Accidental release of anthrax spores from a military Microbiology laboratory in Sverdlovsk in 1979 caused 79 cases of anthrax (68 died). In 1970 a WHO expert committee estimated that aircraft release of 50Kg of anthrax over an urban population of 5 million would result in 250,000 cases of anthrax. In 1993 a US group estimated that if 100Kg of anthrax spores were to be aerosolised and released upwind of Washington, between 130,000 and 3 million deaths could follow.

6.15 What to do if you receive a letter/parcel containing possible anthrax.

Types of letters/parcels that may be suspect:

Any letter/parcel that has suspicious/threatening messages written on it.

Letters with oily stains.

Unexpected letters from foreign countries.

No postage or non-cancelled postage.

Improper spelling of common names, places or titles.

Envelopes that are lop-sided, rigid, bulky, discoloured, have a strange odour or feel like they contain powder.
If still unopened (e.g. feels like it contains powder, labelled with threatening message e.g. “Anthrax”)

Do NOT open.

Do NOT shake.

Place it into plastic bag or some other container to prevent leakage. Leave it in the room. Do NOT take it to the police.

Shut doors and windows and switch off air conditioning.

Leave the room.

Close the door.

Do not allow anyone to enter the room.

Wash your hands with soap and water to prevent you from spreading the powder to your face.

Keep yourself separate from others and available for medical examination

Inform your line manager.

Telephone the police.

List all the people who were in the room when this suspicious letter/parcel was recognised.

If opened letter/parcel contains suspicious powder

Do NOT try to clean up the powder.

COVER the powder immediately and carefully with anything to hand e.g. clothing, paper, waste bin to prevent the powder from dispersing. Do NOT remove this cover.

Shut doors and windows and switch off air conditioning.

Leave the room.

Close the door.

Do not allow anyone to enter the room.

Wash your hands with soap and water to prevent you from spreading the powder to your face.

Keep yourself separate from others who may have not been exposed. Remain available for medical examination.

Inform your line manager.

Telephone the police.

Do not attempt to brush powder off clothing.

Remove contaminated clothing as soon as possible and place it carefully in a plastic bag (or some other container that can be sealed). This should be given to emergency responders for proper handling.

Shower with soap and water as soon as possible. Do NOT use bleach or disinfectants on your skin.

List all the people who were in the room when this suspicious letter/parcel was opened/recognised.

Sequence of actions following discovery of Suspect Packages and Materials

6.16 Glossary

ACDP: Advisory Committee on Dangerous Pathogens

CCDC: Consultant in Communicable Disease Control

CDSC: Communicable Disease Surveillance Centre

ED: Emergency Department

ERD: Emergency Response Division

HPU: Health Protection Unit

PHE: Public Health England

WHO: World Health Organisation
7. Training

Training required to fulfil this policy will be provided in accordance with the Trust’s Induction Mandatory and Risk Management Training Policy - Training Needs Analysis.

8. Monitoring compliance with this document

8.1 Key performance Indicators of the Policy

Describe Key Performance Indicators (KPIs)

Frequency of Review


None specific to this policy (see related Infection Control Manual chapters) referenced in section 10.

8.2 Performance Management of the Policy

Aspect of compliance or effectiveness being monitored

Monitoring method

Individual responsible for the monitoring

Frequency of the monitoring activity

Group / committee which will receive the findings / monitoring report

Group / committee / individual responsible for ensuring that the actions are completed







9. References/ bibliography


9.1. Anthrax: HPA guidelines for action in the event of a deliberate release

9.2. Inglesby et al Anthrax as a biological weapon. 1999 JAMA 281 1735-1745

10. Related trust policy/procedures

Associated Infection Control Manual chapters:

Chapter 21

Hand decontamination policy

Chapter 5

Personal protective equipment

Chapter 9

Disinfection policy

11. Equality analysis

Please refer to the overarching document which covers all chapters of the Infection Control Manual.

Appendix 1: Clinical evaluation and management of persons with possible cutaneous anthrax

Appendix 2: Clinical evaluation and management of persons with possible inhalational anthrax

* Standard Universal Precautions should be used when microbiological specimens are taken. Samples should be labelled as ‘High Risk’ and handled according to local protocols. The microbiology laboratory and reference laboratory should be notified of the suspected diagnosis and told to expect the sample.

1 Microbiological specimens to local laboratory; if Gram-positive bacilli are isolated, or bacterial colonies are grown, these should be sent to the Reference laboratory.

2 Microbiological specimens to Reference laboratory.

Infection Control Manual - Chapter 31- Anthrax policy – Version 6 (clinical) Page of

Issue Date: 1st October 2014 Policy Reference number: STHK0290

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