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From wool-sorters’ to mail-sorters’ disease
In this issue of OEM, an article by Tim Carter documents the experience of cutaneous, pulmonary, and abdominal anthrax among wool sorters and others in a rural town (Kidderminster, Worcestershire) in the UK in the early twentieth century.1 At the start of the twenty first century anthrax was an esoteric topic of study, mostly for those interested in zoonoses. This position changed radically following the deliberate anthrax releases in the USA in the autumn of 2001.2 Medline searches for articles on human health relating to anthrax revealed only 57 articles published in 2000, but 414 for 2002 (accessed 28/04/03). The American experience has been extensively documented.2–9 In summary, in September and October 2001 salvoes of sealed envelopes of very fine (weaponised) anthrax powder were posted in sealed envelopes from a New Jersey (USA) postal address to newspaper and broadcast media offices and two senators in the Eastern USA. At least 22 cases of anthrax resulted; 11 cutaneous and 11 pulmonary cases, with five deaths among the latter. The majority of victims were not those to whom the envelopes were addressed but US postal service mail sorters. Though the envelopes were sealed the exquisitely fine powder leaked from the envelopes en route when passing through mechanical sorting machines.3,4 There were also at least two “ectopic” fatal pulmonary cases in persons where it seems the exposure was indirect, probably through a powder containing letter contaminating others within the postal system.5,6 The impact of these attacks is hard to overstate. The US postal service almost stopped. Decontamination of buildings has been difficult as there is no consensus on the minimum safe level of contamination with anthrax spores (some of the affected buildings remain sealed off). No other anthrax was released but there followed worldwide epidemics of hoax postings of white powders and false alarms as fine powders discovered in the mail and public places has to be assessed for the risk of being weaponised anthrax.10
The events described a century ago give lessons for the present day. Though most of the victims in Kidderminster in the early 1900s were occupationally exposed, there were at least two cases among their wives, suggesting that it is possible for anthrax to be brought home from the workplace and cause disease.1 It was considered useful to produce guidance in poster form telling professionals and workers what cutaneous anthrax looked like and what to do when it was found: a technique rediscovered by the Centers for Disease Control and Prevention in 2001 after September 11th through the US Health Alerting Network and CDSC’s Health Alert System.11
Anthrax is uncommon in the UK. The last occupationally acquired case was reported in November 2001 in a 55 year old man who handled animal hides, and between 1981 and 2000 there were only 14 cases reported in the UK, all cutaneous.12 However, it is quite possible that a few other cutaneous cases could be being misdiagnosed and so missed. Raised awareness during and immediately after the American anthrax releases brought forward some patients with anthrax-like skin lesions. It seems less likely that pulmonary cases would be missed with the characteristic widened mediastinum and severe course.
It will be difficult to deal with the deliberate dissemination of lethal biological materials such as anthrax spores in any country.13 Options available to terrorist groups are wide and include, in addition to biological substances, chemicals and radioactive materials. The Tokyo subway incident in 1995 showed that a well organised group could produce a very toxic compound, sarin, in significant quantities and then release it in a crowded space to lethal effect.14 Complete defence against such outrages is impossible, though the UK is probably better prepared than any other European country. For the health sector, UK authoritative information, including tips for clinicians and pictures, are provided on one website.15 Supplies of antidotes equipment and vaccines are available in all parts of the country,16 and vaccination of key staff against smallpox is underway.17 However, there is an immense task for training and awareness so that any attack is detected early. Occupational physicians are likely to be as well informed as any about potential hazards as similar problems arise from time to time in the occupational setting. Dr Carter’s paper is both timely and disturbing.
From wool-sorters’ to mail-sorters’ disease