Cutaneous Anthrax Associated with Drum Making Using Goat Hides from West Africa --- Connecticut, 2007

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On August 29, 2007, the Connecticut Department of Public Health was notified by a physician of suspect cutaneous anthrax involving a drum maker and one of his three children. The drum maker had been working with untreated goat hides from Guinea in West Africa. This report summarizes results of the joint epidemiologic and environmental investigation conducted by public health officials, environmental agencies, and law enforcement authorities. The investigation revealed that the drum maker was exposed while working with a contaminated goat hide from Guinea and that his workplace and home were contaminated with anthrax. His child was most likely exposed from cross-contamination of the home. The findings underscore the potential hazard of working with untreated animal hides from areas with epizootic anthrax and the potential for secondary cases from environmental contamination.

On July 22, while sanding a newly assembled goat-hide drum in his backyard shed, the drum maker felt a sting on his right forearm. He then proceeded to an upstairs bathroom in his house to wash his arm. Two days later, a painless 2 cm papular lesion with surrounding edema developed at the site. The man sought medical attention and was prescribed cephalexin and then clindamycin for a presumptive infected spider bite. On August 28, after the skin lesion progressed to an eschar with lymphangitic spread, the man consulted an infectious disease practitioner, who sent a biopsy specimen of the lesion to the Connecticut State Laboratory. Culture was negative, but Bacillus anthracis was detected by polymerase chain reaction (PCR). The patient received ciprofloxacin for suspect cutaneous anthrax.

On August 31, the Connecticut Department of Public Health was notified of a second suspect case of cutaneous anthrax in the drum maker's child aged 8 years, who developed a painless, 1 cm ulcer of 3 days' duration over the scapula that did not improve under treatment with amoxicillin-clavulanate. Culture of the lesion was negative, but biopsy specimens tested positive for B. anthracis by PCR at the Connecticut State Laboratory and by PCR and immunohistochemistry assay at CDC. The patient was treated with penicillin.

Also on August 31, an epidemiologic investigation was initiated to identify the primary source of exposure and the extent of dissemination of B. anthracis spores. The investigation included interviews with the index patient and his family and environmental testing. The family had moved into their house in December 2006. The index patient made traditional West African drums (known as djembe drums) by soaking animal hides in water, stretching them over the drum body, then scraping and sanding them. At the end of June, a contact in New York City told the index patient that he had some new goat hides from Guinea. Shortly thereafter, the index patient purchased 10 of them, making the transaction on a street corner in New York City. Whether these goat hides were imported legally is unknown. The index patient used three of these hides to make drums during the time he developed anthrax.

All animal hides and drums in progress were stored in a backyard shed. Drum making usually occurred at the shed entrance. The affected child never participated in any drum making and had no known exposure to animal hides. He played indoors on carpeted floors and was prohibited from entering the shed.

Since childhood, the drum maker had been taught by his father, who also made djembe drums, to routinely use latex gloves and wear tight-fitting goggles when drum making. He also was taught to use designated work clothes with long sleeves, which were laundered periodically. In addition, the drum maker wore disposable facemasks to avoid the strong odor associated with animal hides. He always removed his work clothes and shoes before entering the house. One exception to these practices occurred on July 22, when the drum maker wore short sleeves and went indoors to an upstairs bathroom without removing his work attire. Although he kept all drum making equipment in the shed, the drum maker sometimes brought other items from the shed into the house.

On September 5 and 6, targeted environmental sampling was conducted collaboratively by the Federal Bureau of Investigation (FBI), the Environmental Protection Agency, and the Connecticut Department of Environmental Protection. The FBI chose to participate because anthrax is a select bioterrorism agent.* On the basis of initial positive results for B. anthracis in several areas of the house, extensive testing was performed a week later to guide decontamination efforts.^† Specimens included swabs of all hides and drum heads (Figure) after transport to the state laboratory, seven of which underwent additional wipes and punch biopsies; 16 wipe samples of the shed, including table surfaces and coat hooks 5 feet above the ground; and a swab sample of the car used for transporting the recently purchased hides. House testing included vacuum samples from carpeted areas and composite wipe samples from selected hard surfaces in all regularly used areas.

The following were culture positive for B. anthracis: six (24%) of 25 drum heads, including the recently sanded drum; 15 (42%) of 35 hides, some of which were exposed to ambient dust in the shed; all 16 shed samples, many indicating heavy growth; the car trunk; and 18 (26%) of 72 house specimens, including vacuum samples from the upstairs hallway and both affected patients' bedrooms and swab and wipe samples from the laundry room and upstairs bathroom. DNA from all environmental isolates of B. anthracis and the cutaneous biopsy specimens were sent to CDC for genotyping using multiple-locus variable-number tandem repeat analysis (MLVA) (1). All isolates were MLVA genotype 1, as was the B. anthracis DNA detected in the child's biopsy specimen.

Federal, state, and local officials completed a comprehensive remediation process that included fumigation of the house with chlorine dioxide. The house and shed were cleared for occupancy on December 22, 2007, after all post-remediation samples had tested negative for anthrax. Because of exposure to aerosolized spores in the shed from drum making, the drum maker was continued on ciprofloxacin for a total of 60 days from the date of last presumed exposure based on recommendations established by CDC for postexposure prophylaxis against inhalation anthrax (2). No other contacts were identified with potential inhalation exposure. With the exception of lymphangitic scarring of the drum maker's arm, the illnesses in both patients resolved without sequelae.

Reported by: J Stratidis, MD, Danbury Hospital; S LeRoy, MPH, Danbury Health Dept; D Barden, MT (HHS), K Kelley, PhD, J Fontana, PhD, K Purviance, MPH, M Cartter, MD, J Hadler, MD, Connecticut Dept of Public Health. K Glynn, DVM, A Hoffmaster, PhD, M Guerra, DVM, S Shadomy, DVM, T Smith, MD, C Marston, National Center for Zoonotic, Vector-Borne, and Enteric Diseases; K Martinez, MSEE, National Institute for Occupational Safety and Health; A Guh, MD, EIS Officer, CDC.

Editorial Note:

This report highlights the individual and environmental risks for anthrax from using contaminated goat hides brought from West Africa for drum making. It also describes the first case in the United States of naturally acquired cutaneous anthrax in a personal contact caused by cross-contamination from drum making.

Since 2006, three unrelated cases of anthrax, including the first case described in this report, have been reported from direct occupational association with djembe drums made from untreated animal hides from West Africa. The first two cases were inhalation anthrax. One occurred in a New York City drum maker exposed while making a djembe drum from contaminated hides, and the other occurred in a man in Scotland who died of anthrax septicemia after playing or handling djembe drums newly made from contaminated hides (3,4). The Connecticut cases and the New York City case were caused by B. anthracis of MLVA genotype 1, a different genotype than the Ames strain used in the 2001 mail-related anthrax attacks (1). Although MLVA genotypes from West Africa have not been systematically studied, the widespread nature of genotype 1 (1) and its presence in the West African hides implicated in the New York City and Connecticut cases suggest that genotype 1 might be commonly found in West Africa.

The drum making process of stretching, scraping, and sanding animal hides could have released and potentially aerosolized any B. anthracis spores present on untreated hides, exposing the drum maker and contaminating the surrounding environment. However, despite direct exposure, the drum maker described in this report did not develop inhalation anthrax. He developed cutaneous anthrax only after wearing short sleeves and experiencing a penetrating injury or insect bite, which could have served to inoculate spores into the skin.

The Connecticut drum maker routinely wore personal protective equipment (PPE). His wearing a facemask might have reduced the amount of inhalation exposure. However, even if he had worked with all recommended precautions (3), such as working in a well-ventilated area using PPE that included a N95 respirator, his risk for cutaneous and inhalation exposure would have been lessened but not necessarily eliminated, and environmental contamination would still have occurred and required remediation.

In this investigation, environmental sampling indicated tracking of spores into the house by the drum maker, either through his work clothes or objects brought from the shed, leading to exposure and subsequent development of cutaneous anthrax in his child. Few cases of anthrax have been reported in children in the United States because most exposures are acquired occupationally. However, household members can be exposed through cross-contamination of living areas. In 1978, dust samples from vacuum cleaners in the houses of textile mill workers tested positive for B. anthracis, suggesting that workers carried spores into their homes (5). A case series of cutaneous anthrax in a Pennsylvania mill town indicated that 4% of all cases during a 22-year period occurred in household members of mill workers, including their children (6).

Decontamination of affected areas to minimize the risk for secondary cases of anthrax can be time-consuming and expensive. The cost of environmental cleanups on Capitol Hill in the District of Columbia and in postal facilities affected by the 2001 anthrax attacks ranged from $464,000 to $200 million (7).

To eliminate individual and environmental risks for anthrax in drum making, public health agencies have long advised that animal hides of unknown origin or from areas of epizootic anthrax should not be used. However, imported animal hides from West Africa, particularly goat hides, remain in demand because they are prized by drum makers for their acoustical quality. Because anthrax outbreaks in livestock frequently occur in West Africa, hides brought into the United States might contain B. anthracis spores. The Animal and Plant Health Inspection Service (APHIS) of the U.S. Department of Agriculture has the authority to regulate importation of all animal hides, mainly to prevent the introduction of foreign animal diseases of agricultural importance into the United States. However, APHIS does not mandate screening of imported hides for B. anthracis (8), and potentially contaminated hides might continue to be imported. In addition, importation can bypass legal channels (3). Currently, the World Health Organization recommends the use of sporicidal treatments to disinfect all contaminated animal hides, including ethylene oxide fumigation, gamma irradiation, preservation in a 5% formaldehyde solution, or chemical treatment with hydrochloric acid or salt in appropriate concentrations and durations (9,10).

Although safer practice in djembe drum making is needed to protect drum makers and others who might be exposed inadvertently, the best preventive measure is to use animal hides known to be free of anthrax spores. The use of PPE is not considered a safe alternative to the use of anthrax-free hides. Until a process exists for certifying that imported hides from West Africa are free of anthrax, drum makers should follow current disinfection guidelines to reduce the risk for disease (9,10).

This report is based, in part, on contributions by the Town of Danbury; Danbury Mayor's Office; Connecticut State Police; Connecticut State Laboratory; Connecticut Dept of Environmental Protection; Federal Bur of Investigation; US Environmental Protection Agency; and T Gomez, DVM, T Butler, DVM, US Dept of Agriculture.

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