One night in June, 48-year-old Janni Gundu cried out in pain caused by the large lesions that had come to cover his hands over the past day or two. Despite this, the farmer from Kodupunjuvalasa village in the Araku valley in Andhra Pradesh’s Visakhapatnam district did not want to see a doctor. It was sowing season and he had a lot of work.
Ignoring his protests, his daughter Padma took him to the Araku Area Hospital about 25 kms away. The doctors suspected that Gundu had anthrax and told him to go to the King George Hospital in Visakhapatnam city. Instead, Gundu went to the community health centre at the neighbouring district Vizianagaram and got some antibiotics.
But his daughter Padma, an IAS aspirant and an engineer, began to look for details about anthrax online using her smartphone.
Anthrax is an infection caused by the bacterium Bacillus anthracis that normally infects animals. It is a major cause of fatalities in cattle, sheep, goats, camels, horses and pigs around the world. Humans get this disease from infected animals, either by handling the animal or when exposed to contaminated animal products. Anthrax is not known to spread from person to person.
When four other people in Kodupunjuvalasa were also found to have the same infection, Padma asked a local politician to contact the Integrated Tribal Development Agency headquarters in Paderu to come to the village and help them.
On June 24, the agency sent an ambulance to take the five anthrax-infected patients to the Visakhapatnam Hospital. Two days later, three more patients – one from the neighbouring village Padmapuram – were also taken to the hospital.
Andhra Pradesh has an outbreak of anthrax almost every year, mostly often in Adivasi areas. Anthrax spores remain in soil for long periods of time in areas where the disease is endemic. Cattle that consume grass, water or soil containing the spores become infected. The only way to prevent the spread of the disease is to vaccinate the domesticated animals that come in contact with people.
But officials at the state’s Integrated Tribal Development Agency admitted that they rarely undertake vaccination of animals in all Adivasi areas. Dr Gurunadar Rao, additional district medical and health officer, said that the government conducts anthrax vaccinations once a year in the areas with suspected human anthrax cases.
For instance, the animal husbandry department vaccinated animals in Kodupunjuvalasa and four other villages within a 10-km radius only after Gundu and his neighbours went to hospital with anthrax infections.
“They think that because we are tribals, we need not be treated well,” said Padma.
The district administration said that the villagers developed skin infections after they ate the meat of a goat infected with anthrax. But the villagers claimed that not everyone who was infected had eaten the goat meat. Besides, all eight suspected anthrax cases were skin infections.
There are three forms of anthrax infections – cutaneous anthrax that causes infection in the skin, ingestion anthrax that is caused by eating contaminated food, and inhalation anthrax that occurs when spores of the bacteria are inhaled. All three forms of the disease are dangerous to different degrees.
According to the World Health Organisation, cutaneous anthrax accounts for more than 95% of the cases worldwide. If left untreated, cutaneous anthrax is fatal in about 20% of cases. Gastrointestinal or ingestion anthrax kills about of those infected who do not get treatment. However, with proper treatment, 60% of patients survive. Inhalation anthrax is the most deadly form of the disease, and only about 10%-15% of patients survive without treatment, while about 55% survive with treatment.
Gundu and his fellow villagers had cutaneous anthrax.
Dr B Balachandrudu, the head of dermatology at the King George Hospital, has seen and treated anthrax infections over many years. Spores present in animal meat die if the meat is cooked in high temperatures, he pointed out.
“Gastrointestinal presentation of the disease is rare in India,” he said.
Little anthrax awareness
Balachandrudu sent the samples of the eight patients to the Defence Research and Development Establishment laboratory in Gwalior, Madhya Pradesh. Seven were confirmed as positive for anthrax, while one patient’s test was inconclusive. All the eight patients were given antibiotics – treatment to which they responded well – and were sent home in a fortnight.
“Every year we get some case or other,” said Balachandrudu. “This disease has been here for hundreds of years and has been treatable with antibiotics for more than 60 years.” He said that the disease can be managed at the primary health centre level and need not be brought to the medical college every year.
Balachandrudu has seen how common and easily treatable cutaneous anthrax is. But for most people, the word “anthrax” conjures up the spectacle of fatal infections linked to bio-terrorism. After the attack and collapse of the World Trade Centre towers in New York in 2001, powdered anthrax spores were deliberately put into letters and mailed through the United States postal system. Twenty two people contracted anthrax by opening these envellopes and five people died.
The more common and less dangerous forms of anthrax around us have got little attention compared to the post-9/11 cases. A number of people in Andhra Pradesh have died of anthrax in the last decade. Some research papers point to the underreporting of anthrax cases.
“Fatality takes place only if there is an accumulation of toxins in the blood,” said Professor Rakesh Bhatnagar of the School of Biotechnology at Jawaharlal Nehru University who has been working on anthrax for more than two decades.
Balachandrudu said that anthrax can be be fatal if there is a co-infection of cholera or malaria. “But there are not many studies done on the subject,” he said.
No preventive measures
While Andhra Pradesh’s health and tribal welfare authorities do not conduct preventive vaccination of animals in adivasi areas, residents of these villages have only intermittent access to any kind of healthcare that could help catch early stages of infection.
Padma complained that Kodupunjuvalasa village has no primary health centre. The village has an Accredited Social Health Activist or ASHA, but the Auxiliary Nurse and Midwife or ANM manages to come to the village only once a month. The ANM did not visit the village in June when the anthrax infections occurred.
After the incident, many officials including the State Health Minister Kamineni Srinivas visited the village.
“We complained about the lack of drinking water,” said Padma. “He told us: ‘Do not tell me about problems. I have only come to see the patients.’”