'We dry contaminated meat to make it safe': An assessment of knowledge, attitude and practices on anthrax during an outbreak, Kisumu, Kenya, 2019.

INTRODUCTION: Anthrax is the highest-ranked priority zoonotic disease in Kenya with about ten human cases annually. Anthrax outbreak was reported in Kisumu East Sub County after some villagers slaughtered and ate beef from a cow suspected to have died of anthrax. We aimed at establishing the magnitude of the outbreak, described associated factors, and assessed community knowledge, attitude, and practices on anthrax. METHODS: We reviewed human and animal records, conducted case search and contact tracing using standard case definitions in the period from July 1through to July 28, 2019. A cross-sectional study was conducted to assess community knowledge, attitude, and practices towards anthrax. The household selection was done using multistage sampling. We cleaned and analyzed data in Ms. Excel and Epi Info. Descriptive statistics were carried out for continuous and categorical variables while analytical statistics for the association between dependent and independent variables were calculated. RESULTS: Out of 53 persons exposed through consumption or contact with suspicious beef, 23 cases (confirmed: 1, probable: 4, suspected: 18) were reviewed. The proportion of females was 52.17% (12/23), median age 13.5 years and range 45 years. The attack rate was 43.4% (23/53) and the case fatality rate was 4.35% (1/23). Knowledge level, determined by dividing those considered to be 'having good knowledge' on anthrax (numerator) by the total number of respondents (denominator) in the population regarding cause, transmission, symptoms and prevention was 51% for human anthrax and 52% for animal anthrax. Having good knowledge on anthrax was associated with rural residence [OR = 5.5 (95% CI 2.1-14.4; p<0.001)], having seen a case of anthrax [OR = 6.2 (95% CI 2.8-14.2; p<0.001)] and among those who present cattle for vaccination [OR = 2.6 (95% CI 1.2-5.6; p = 0.02)]. About 23.2% (26/112) would slaughter and sell beef to neighbors while 63.4% (71/112) would bury or burn the carcass. Nearly 93.8% (105/112) believed vaccination prevents anthrax. However, 5.4% (62/112) present livestock for vaccination. CONCLUSION: Most anthrax exposures were through meat consumption. Poor knowledge of the disease might hamper prevention and control efforts.

Knowledge, attitude and practice towards anthrax in northern Ethiopia: a mixed approach study.

BACKGROUND: Anthrax is the second most highly prioritized zoonotic disease in Ethiopia due to its negative impact at the household level, causing disease and production losses in livestock and severe disease in humans. This study seeks to assess the knowledge of, attitudes towards, and practices addressing (KAPs) anthrax in the communities of Eastern Tigray, Northern Ethiopia. METHODS: A cross-sectional survey was conducted concurrently with focus group discussions (FGDs) and key informant interviews (KIIs) between May 2019 and April 2020. A total of 862 respondents participated in the questionnaire survey. Of these, 800 were local community members while 62 were professionals working at health service institutions. In addition, qualitative data were collected using six FGDs and 11 KIIs. RESULTS: Sixty-two percent (496/800) of the community respondents said that they were aware of anthrax while 38% (304/800) of them did not. Only 9.3% (74/800) of the respondents reported that the causative agent of anthrax is germs/microbial. About 56.5% (35/62) of professional respondents said that it is bacterial. More than 60% (64.1%, 513/800) of the respondents did not know that whether the disease was zoonotic or not. Regarding clinical signs, 26.3 (210/800) and 36.8% (294/800) of the respondents could identify at least one in animals and humans, respectively, while 21.3 (170/800) and 20.1% (161/800) knew one or more transmission routes in animals and humans, respectively. Moreover, 43.4% (347/800) and 45.6% (365/800) of the respondents mentioned one or more control/prevention method(s) in animals and humans, respectively. Regarding qualitative results, some of the participants knew the disease (in animals) by their local names: Lalish and Tafia (splenomegaly), and Gulbus (abdominal cramps and shivering). Some reported that anthrax was exclusively a human disease while others recognized its zoonotic potential after the clinical signs in both animals and humans were listed. CONCLUSION: The KAP of the participants regarding anthrax was low. There was no consistent understanding of the disease among the participants. The study also revealed that the participants did not receive consistent, adequate, and continuous education regarding the disease.

Comparative knowledge, attitudes, and practices regarding anthrax, brucellosis, and rabies in three districts of northern Tanzania.

BACKGROUND: Knowledge, attitudes, and practices (KAP) surveys regarding zoonotic diseases are crucial to understanding the extent of knowledge among citizens and for guiding health-related education programs. METHOD: Employing a structured questionnaire, we interviewed residents (n = 388) in three districts of northern Tanzania (Karatu n = 128, Monduli n = 114, Babati n = 146) to assess knowledge, attitudes and reported practices regarding three zoonotic diseases that occur in the region (anthrax, brucellosis, and rabies). We used generalized linear mixed effects models and multi-model inference to identify demographic correlates of knowledge. RESULTS: Proportional average district- and disease- specific knowledge scores ranged from 0.14-0.61. We found positive correlations between age and knowledge of symptoms, causes and treatments of anthrax (three districts), brucellosis (three districts), and rabies (one district). Gender, ethnic identity, formal education and ownership of livestock or dogs had variable effects on knowledge among the interviewed population. Risk perceptions regarding different diseases varied across districts and were positively correlated with knowledge of the specific diseases. Direct interactions with livestock and domestic dogs were reported to occur across all demographic groups, suggesting that most people living in rural settings of our study area are potentially exposed to zoonotic diseases. Behaviors which may favor transmission of specific pathogens (such as consumption of raw milk or meat) were occasionally reported and varied by district. Wildlife was generally regarded as negative or neutral with regard to overall veterinary and human health. CONCLUSION: The combination of variable knowledge about zoonotic diseases in the three districts, reported occurrence of practices that are conducive to pathogen transmission, and previously documented circulation of pathogens causing anthrax, brucellosis and rabies in our study system, call for health education programs embedded in a holistic One Health approach.

Perceptions of anthrax in livestock from Victorian dairy farmers in the Goulburn-Murray region of Victoria, Australia.

To inform future anthrax surveillance and response activities and to revitalise the communication strategy for producers and their communities, seven dairy farmers in the Goulburn-Murray region of Victoria participated in a Design Thinking process to create a better method to share information about the annual probability of anthrax in their region. Design Thinking is a structured, user-centric design process that begins with intentionally un-structured interviews. Following each interview, transcripts are disassembled into common themes identified by clustering similar statements from these interviews. This short contribution presents these themes re-framed into eight core statements. These statements provide a framework for the remainder of the Design Thinking process but in isolation provide a reference for stake-holding agencies seeking to maximise farmer participation in surveillance programs for early anthrax detection, to encourage active farmer participation during a response and to minimise any anthrax-associated stigma by affected farmers post-response.

Medical Spending for the 2001 Anthrax Letter Attacks.

ABSTRACTIntroductionThis paper assesses the total medical costs associated with the US anthrax letter attacks of 2001. This information can be used to inform policies, which may help mitigate the potential economic impacts of similar bioterrorist attacks. METHODS: Journal publications and news reports were reviewed to establish the number of people who were exposed, were potentially exposed, received prophylactics, and became ill. Where available, cost data from the anthrax letter attacks were used. Where data were unavailable, high, low, and best cost estimates were developed from the broader literature to create a cost model and establish economic impacts. RESULTS: Medical spending totaled approximately $177 million. CONCLUSIONS: The largest expenditures stemmed from self-initiated prophylaxis (worried well): people who sought prophylactic treatment without any indication that they had been exposed to anthrax letters. This highlights an area of focus for mitigating the economic impacts of future disasters. (Disaster Med Public Health Preparedness. 2019;13:539-546).

Lay perceptions, beliefs and practices linked to the persistence of anthrax outbreaks in cattle in the Western Province of Zambia.

Anthrax, a neglected zoonotic disease that is transmitted by a spore-forming, rod-shaped bacterium, Bacillus anthracis, has reached endemic proportions in the Western Province of Zambia. Transmission of anthrax from the environment as well as between cattle has been observed to be partly because of entrenched beliefs, perceptions and traditional practices among cattle farmers in the known outbreak areas. This study was aimed at exploring lay perceptions, beliefs and practices that influence anthrax transmission in cattle of the Western Province. A mixed-methods study was conducted from August to December 2015. Quantitative data were collected using a cross-sectional survey. Qualitative data were generated by interviewing professional staff and community members. Five focus group discussions and five key informant interviews were conducted. Thematic analysis of interview data was performed using NVivo software. The findings suggested that cattle anthrax was biologically as well as culturally maintained. Cattle farmers were reluctant to have their livestock vaccinated against anthrax because of perceived low efficacy of the vaccine. Also, the cattle farmers did not trust professional staff and their technical interventions. Popular cultural practices that involved exchange of animals between herds contributed to uncontrolled cattle movements between herds and subsequent transmission of anthrax. These findings imply the need for professional staff to be culturally competent in handling socio-cultural issues that are known to be barriers for disease control in animals. There is a need to develop a policy framework that will foster integrated control of anthrax across disciplines.

Awareness and attitude toward zoonoses with particular reference to anthrax among cattle owners in selected rural communities of Zimbabwe.

We conducted a cross-sectional study to assess cattle owners' awareness, perceptions, and attitudes toward zoonoses, with particular emphasis regarding anthrax. Data on awareness of zoonoses, clinical signs of anthrax in animals and human, its routes of transmission and methods of prevention, the families' consumption habits of anthrax-infected carcasses, and other family activities that increase exposure to anthrax were collected using an interviewer-administered questionnaire. A total of 41.4% (135/326) of the farmers were from high-anthrax-risk districts, whereas 28.5% and 30.1% were from medium- and low-risk districts, respectively. Overall, the level of awareness amongst the farmers for the named zoonoses were rabies (88.7%), anthrax (71.5%), and brucellosis (20.9%). Except for anthrax, awareness of other zoonoses did not differ significantly (p>0.05) among the district categories. Farmers from anthrax high-risk districts were significantly more aware of anthrax compared to those from moderate- (p=0.000) and low- (p=0.000) risk districts. All of the farmers were aware that anthrax occurs in cattle, and 73% indicated the presence of unclotting blood oozing from natural orifices as a consistent finding in cattle that died of anthrax, whereas 86.7% of them indicated the presence of skin lesions as the most common sign of the disease in humans. The good efficacy of human anthrax treatment (58.3%), slaughter of moribund cattle and selling of meat from cattle found dead to unsuspecting consumers (59.8%), reluctance to lose animals (47.9%), and forgetting about anthrax (41.1%) were cited as the major reasons for consuming anthrax-infected carcasses. Given that 75.2% of cattle owners indicated that they would not consume meat from cattle found dead, because they were discouraged by veterinary authorities, introducing meat inspection services is likely to have a positive impact in preventing human anthrax outbreaks in Zimbabwe.

Public response to an anthrax attack: a multiethnic perspective.

The 2001 anthrax attacks emphasized the need to develop outreach that would more effectively support racial/ethnic minority populations during a bioterrorism incident. Given the importance of antibiotic prophylaxis in a future anthrax attack, it should be a priority to better support racial/ethnic minorities in mass dispensing programs. To examine the needs and perspectives of racial/ethnic minorities, this study used a nationally representative poll of 1,852 adults, including 1,240 whites, 261 African Americans, and 282 Hispanics. The poll examined public reactions to a ''worst-case scenario'' in which cases of inhalation anthrax are discovered without an identified source and the entire population of a city or town is asked to receive antibiotic prophylaxis within 48 hours. Findings suggest willingness across all racial/ethnic groups to comply with recommendations to seek prophylaxis at dispensing sites. However, findings also indicate possible barriers for racial/ethnic minorities, including greater concern about pill safety and multiple attacks as well as lesser knowledge about inhalation anthrax. Across all racial/ethnic groups, roughly half would prefer to receive antibiotics at mass dispensing sites rather than through the US Postal Service. People in racial/ethnic minority groups were more likely to say this preference stems from a desire to speak with staff or to exchange medication formulation or type. Findings suggest the need for tailored outreach to racial/ethnic minorities through, for example, emphasis on key messages and enhanced understandability in communications, increased staff for answering questions in relevant dispensing sites, and long-term trust building with racial/ethnic minority communities.

Determinants of emergency response willingness in the local public health workforce by jurisdictional and scenario patterns: a cross-sectional survey.

BACKGROUND: The all-hazards willingness to respond (WTR) of local public health personnel is critical to emergency preparedness. This study applied a threat-and efficacy-centered framework to characterize these workers' scenario and jurisdictional response willingness patterns toward a range of naturally-occurring and terrorism-related emergency scenarios. METHODS: Eight geographically diverse local health department (LHD) clusters (four urban and four rural) across the U.S. were recruited and administered an online survey about response willingness and related attitudes/beliefs toward four different public health emergency scenarios between April 2009 and June 2010 (66% response rate). Responses were dichotomized and analyzed using generalized linear multilevel mixed model analyses that also account for within-cluster and within-LHD correlations. RESULTS: Comparisons of rural to urban LHD workers showed statistically significant odds ratios (ORs) for WTR context across scenarios ranging from 1.5 to 2.4. When employees over 40 years old were compared to their younger counterparts, the ORs of WTR ranged from 1.27 to 1.58, and when females were compared to males, the ORs of WTR ranged from 0.57 to 0.61. Across the eight clusters, the percentage of workers indicating they would be unwilling to respond regardless of severity ranged from 14-28% for a weather event; 9-27% for pandemic influenza; 30-56% for a radiological 'dirty' bomb event; and 22-48% for an inhalational anthrax bioterrorism event. Efficacy was consistently identified as an important independent predictor of WTR. CONCLUSIONS: Response willingness deficits in the local public health workforce pose a threat to all-hazards response capacity and health security. Local public health agencies and their stakeholders may incorporate key findings, including identified scenario-based willingness gaps and the importance of efficacy, as targets of preparedness curriculum development efforts and policies for enhancing response willingness. Reasons for an increased willingness in rural cohorts compared to urban cohorts should be further investigated in order to understand and develop methods for improving their overall response.

Facilitation of risk communication during the anthrax attacks of 2001: the organizational backstory.

The anthrax attacks of 2001 created risk communication problems that cannot be fully understood without appreciating the dynamics among organizations. Case studies of communication in New Jersey, consisting of interviews with a range of participants, found that existing organizational and professional networks facilitated trust among decisionmakers. This interpersonal trust improved communication among agencies and thereby risk communication with the public. For example, "white powder scares" were a problem even in places without contamination. Professionals' trust in each other was vital for responding productively. Conversely, organizational challenges, including conflict among agencies, hindered communication with key audiences. Although centralization and increased control are often seen as the remedy for communicative confusion, they also can quash the improvisational responses needed during crises.

Neurologists and the threat of bioterrorism.

Neurologists are most likely to become involved in primarily diagnosing those bioterrorist attacks utilising botulinum toxin. Oral ingestion, or possibly inhalation, are likely routes of delivery. The characteristic descending paralysis starts in the extraocular and bulbar muscles, with associated autonomic features. Repetitive nerve stimulation usually shows an incremental muscle response. Treatment is supportive. The differential diagnosis is from naturally occurring paralysing illnesses such as Guillain-Barré syndrome, myasthenic crisis or diphtheria, from paralysing seafood neurotoxins (tetrodotoxin, saxitoxin), snake envenomation, and from chemical warfare poisoning by organophosphates. Primary neurological infections are less feasible for use as bioweapons. There are theoretical possibilities of Venezuelan equine encephalitis transmission by inhalation and secondary zoonotic transmission cycles sustained by horses and mosquitoes. Severe haemorrhagic meningitis regularly occurs in anthrax, usually in the aftermath of severe systemic disease likely to have been transmitted by spore inhalation. Panic and psychologically determined 'me-too' symptomatology are likely to pose the biggest diagnostic and management burden on neurologists handling bioterrorist attack on an institution or a random civilian population. Indeed civilian panic and disablement of institutional operations are likely to be prominent intentions of any bioterrorist attack.

Bioterrorism and its aftermath: dealing individually and organizationally with the emotional reactions to an anthrax attack.

From September 2001 through April 2004, the United States Postal Service (USPS) dealt, for the first time, with bioterrorism resulting in employee deaths and the closure of a large mail processing plant in Washington, D.C. The Employee Assistance Program (EAP) partnered with the USPS throughout this tumultuous time to meet the multiple and evolving behavioral health needs of the employees and facilitate the employees' emotional preparedness for their return to work at the closed facility. This paper discusses the reactions manifested by the employees during this extended period, as well as the EAP activities in the recovery process.

Postal workers' perspectives on communication during the anthrax attack.

In 2001, the nation experienced its first bioterrorism attack, in the form of anthrax sent through the U.S. Postal Service, and public health professionals were challenged to communicate with a critical audience, U.S. postal workers. Postal workers, the first cohort to receive public health messages during a bioterrorist crisis, offer a crucial viewpoint that can be used in the development of best practices in crisis and emergency risk communication. This article reports results of qualitative interviews and focus groups with 65 postal workers employed at three facilities: Trenton, New Jersey; New York City; and Washington, DC. The social context and changing messages were among the factors that damaged trust between postal workers and public health professionals. Lessons learned from this attack contribute to the growing body of knowledge available to guide communications experts and public health professionals charged with crisis and emergency risk communication with the public.

Concerns of Capitol Hill staff workers after bioterrorism: focus group discussions of authorities' response.

Systematic studies of mental health effects of bioterrorism on exposed populations have not been carried out. Exploratory focus groups were conducted with an exposed population to provide qualitative data and inform empirical research. Five focus groups of 28 political worker volunteers were conducted 3 months after the October 15, 2001, anthrax attack on Capitol Hill. More than 2000 transcribed focus group passages were categorized using qualitative software. The category with the most items was authorities' response (23% passages), and much of this discussion pertained to communication by authorities. The category with the fewest items was symptoms (4%). Identified issues were less within individuals and more between them and authorities. Risk communication by authorities regarding safety and medical issues was a prominent concern among Capitol Hill office staff workers regarding the anthrax incident on Capitol Hill. This suggests focus on risk communication in developing interventions, but more systematic investigation is needed.

Media exposure to bioterrorism: stress and the anthrax attacks.

This study examined media exposure and adjustment to anthrax bioterrorism attacks and the terrorist attacks on 9/11 in a sample of 300 people who lived distant from the attacks. Measures of direct and indirect exposure to terrorism, perceived risk of anthrax exposure, psychological distress, and outlook were assessed at 2 to 3 months and at 8 months after the first reported anthrax attack. Initial anthrax media exposure was a powerful predictor of distress, whereas subsequent anthrax media exposure only predicted negative changes in outlook over time. Perceived risk of anthrax exposure predicted distress and outlook but did not appear to mediate the effects of media exposure. Determining the nature and consequences of media exposure to threatening and frightening events like terrorism will help predict and manage response to future bioterrorism.

In their own words: lessons learned from those exposed to anthrax.

OBJECTIVES: We evaluated perceptions of workers at the US Postal Service Brentwood Processing and Distribution Center and US Senate employees regarding public health responses to the anthrax mailings of October 2001. We generated recommendations for improving responses to bioterrorism on the basis of the perceptions we recorded. METHODS: Transcripts from focus groups conducted with Brentwood and US Senate employees were examined, and qualitative analysis identified common domains. RESULTS: Brentwood focus groups consisted of 36 participants (97% African American and 19% hearing impaired). US Senate focus groups consisted of 7 participants (71% White and 0% hearing impaired). The focus groups revealed that participants' trust in public health agencies had eroded and that this erosion could threaten the effectiveness of communication during future public health emergencies. Among Brentwood participants, lack of trust involved the perception that unfair treatment on the basis of race/ethnicity and socioeconomic status had occurred; among US Senate participants, it derived from perceptions of inconsistent and disorganized messages. CONCLUSIONS: Effective communication during a public health emergency depends on the provision of clear messages and close involvement of the affected community. Diverse populations may require individualized approaches to ensure that messages are delivered appropriately. Special attention should be given to those who face barriers to traditional modes of communication.

One-year health assessment of adult survivors of Bacillus anthracis infection.

CONTEXT: Little is known about potential long-term health effects of bioterrorism-related Bacillus anthracis infection. OBJECTIVE: To describe the relationship between anthrax infection and persistent somatic symptoms among adults surviving bioterrorism-related anthrax disease approximately 1 year after illness onset in 2001. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 15 of 16 adult survivors from September through December 2002 using a clinical interview, a medical review-of-system questionnaire, 2 standardized self-administered questionnaires, and a review of available medical records. MAIN OUTCOME MEASURES: Health complaints summarized by the body system affected and by symptom categories; psychological distress measured by the Revised 90-Item Symptom Checklist; and health-related quality-of-life indices by the Medical Outcomes Study 36-Item Short-Form Health Survey (version 2). RESULTS: The anthrax survivors reported symptoms affecting multiple body systems, significantly greater overall psychological distress (P<.001), and significantly reduced health-related quality-of-life indices compared with US referent populations. Eight survivors (53%) had not returned to work since their infection. Comparing disease manifestations, inhalational survivors reported significantly lower overall physical health than cutaneous survivors (mean scores, 30 vs 41; P =.02). Available medical records could not explain the persisting health complaints. CONCLUSION: The anthrax survivors continued to report significant health problems and poor life adjustment 1 year after onset of bioterrorism-related anthrax disease.