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What do you think about Mobipocket Reader Desktop? Although there were no gastrointestinal anthrax cases identified, illnesses might have been missed at health facilities or otherwise unreported based on the GI symptoms reported. Adult males were most affected in this cluster of infections. This is unsurprising, as this group is most likely to be engaged in exposures to animal carcasses. However, two case-patients were under five years of age. For these case-patients, the only two not involved in direct contact with livestock carcasses, infection may have occurred when spores were brought into the house by a parent or other contact involved in skinning, carrying, butchering, or preparing the meat.

This type of exposure has been described previously with pediatric anthrax cases [ 28 ] and may explain the illnesses among the youngest case-patients. Although probable cases had been occurring throughout the study period, the Ministry of Health was only alerted to these cases in mid Anthrax testing is possible in Uganda, but it is infrequent because of incomplete reporting in veterinary surveillance systems, knowledge gaps among healthcare workers about anthrax and limited access to laboratory services.

Because of the infrequent testing, both human and veterinary anthrax are almost certainly underreported in Uganda. Investigation of probable cases over a longer period i. The epidemic curve showed noticeable peaks in human cases for two years during March-May, which corresponds with the dry season in Uganda. In addition, stressors, such as poor nutrition or overheating and reduced resource availability, may lead to increased animal density in localized areas, such as along river banks, and increase the possibility of getting infected [ 15 , 30 ].

For humans, food scarcity during the dry season may also force them to seek alternate sources of food, which could lead to their eating meat that they might otherwise avoid. Cutaneous anthrax cases have been reported at the animal-human interface in several other regions globally including Bhutan, the Republic of Georgia, Kenya, and Tanzania [ 21 , 24 , 26 , 31 ]. In some cases, the outbreaks have been related to chronic food insecurity [ 32 ]. Although we did not systematically collect data on this, several respondents reported to us anecdotally that they could not afford butchery-sourced meat.

Although this therapy is readily available in Uganda, anecdotal evidence suggests that not all physicians are familiar with the presentation, and misdiagnosis can lead to delays in appropriate treatment. The late care-seeking behavior and subsequent difficulty with diagnosis of Mr. A likely contributed to his eventual death. Although most patients in this outbreak reported that they sought and received treatment, apart from Mr.

A, we were unable to assess whether or not they were diagnosed and treated correctly. The number of human cases and the time period over which they occurred also suggest more widespread livestock anthrax in this region, something that could potentially be prevented by animal vaccination.

During an outbreak, all livestock in areas around the affected area should be vaccinated [ 34 ]. Despite anthrax being considered a priority zoonotic disease in Uganda [ 35 ], mass animal vaccinations are not currently done, primarily due to the low number of reported cases, nor are reactive vaccinations done during an outbreak.

While farmers can choose to vaccinate their animals privately, many do not. There are unpublished draft national guidelines currently in place requiring livestock vaccination. In Zimbabwe, the government previously conducted national annual anthrax vaccination campaigns for livestock, but currently vaccinations are restricted to high-risk areas only.

In spite of this, livestock producers in Zimbabwe are advised to ensure that farm animals are vaccinated against anthrax annually [ 34 ]. Because we conducted the investigation retrospectively, there is a possibility of recall bias including symptoms and date of onset, hence masking the actual anthrax prevalence in the district. In addition, it is likely that some cases were missed, which would have led to an underestimation of the magnitude of the outbreak.

Therefore to minimize on missing out case-patients because of the long period, every interviewee was asked about others with similar symptoms and key informant interviews were conducted in order to pick out as much as possible. It is also possible that some were not true anthrax, leading to an overestimation. However all the case-patients had skin lesions and the black eschar which is pathognomonic for cutaneous anthrax therefore they were taken to be anthrax cases.

Also the case definition included skin lesions and black eschar so that cutaneous anthrax case-patients were picked out. We had sparse data about the livestock deaths, preventing certainty that they were due to anthrax.

However the case-patients mentioned that they had symptoms following contact with livestock that had died suddenly hence the linkage stated. In addition, we could not confirm the vast majority of cases, nor did we identify any cases of gastrointestinal anthrax. Although some patients had nonspecific gastrointestinal illnesses at the time of investigation, many were already taking antibiotic therapy, rendering sample testing ineffective. It is possible that gastrointestinal anthrax occurred and was missed.

The cutaneous anthrax cases occurring over a 3-year period in Uganda were associated with handling carcasses of animals that died suddenly. The key findings of this study presented proof of infected livestock carcasses within human vicinity and risky human behavior of handling and consuming infected livestock carcasses that caused a case-patient to succumb.

The district set up a One Health structure a collaboration between human and veterinary health departments, including a single laboratory that processes both human and veterinary samples to facilitate epidemic preparedness and response as a result of this outbreak. These maps show the location of the two sub-counties affected by the cutaneous anthrax outbreak.

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