Anthrax is caused by the bacteria, bacillus anthracis. It is a spore-forming bacterium that in its natural state is commonly found in the soil of agricultural areas and is best known as an animal disease. It was formerly known as "wool sorter's disease" because it was commonly seen in workers exposed to wool and sheep skins infected with the disease producing agent. It is commonly found in Asia and Africa, but is also common in rural soils of Texas, Oklahoma, and the Mississippi Valley.

The bacterium has been around for a long time and in fact was used by German bacteriologist Robert Koch in 1877, when he discovered the basic principles of infectious diseases.

The bacterium causes three distinct forms of the disease we call anthrax.

The cutaneous, or skin form of the disease is the least serious. It occurs when the agent penetrates the skin through a cut or from skin contact with the spores on tissues or hides of infected animals. 95% of all anthrax cases reported are cutaneous.

The lesion that results is an itchy red bump that looks much like an insect bite. Within 1-2 days, it develops into a vesicle and then a painless ulcer. Its unique characteristic is a black necrotic area that develops in the center of the lesion. Headaches, muscle aches and general flu-like symptoms commonly develop. Swollen lymph glands are also common.

Antibiotic treatment is very successful and death is rare. Even left totally untreated, the fatality rate is about 20%.

The second form of anthrax is gastrointestinal. It results from eating undercooked meat from an infected animal.

The symptoms are nausea, vomiting, fever, abdominal pain, severe diarrhea and vomiting of blood. Again, antibiotic treatment is very successful in treating the disease, especially when diagnosed early. Without any treatment, the disease is 25-60% fatal.

The third form of anthrax, respiratory, is the most serious. It results from the inhalation of the anthrax spores.

It causes flu-like symptoms including fever, cough, difficulty in breathing, and general malaise. Left untreated, the patient develops septicemia, goes into shock, coma and eventually dies. Unless diagnosed quickly and treated with an aggressive course of antibiotics, the fatality rate is about 90%.

While anthrax is often referred to as a potential weapon for a bio-terrorist, it does have its problems.

In order to cause respiratory infection, the spores first must be inhaled in a large enough number to actually cause infection. It takes at least 8,000 to 30,000 spores to cause an infection. In fact in one study, goat workers inhaling 500 spores per hour during their 8-hour shift did not contract the disease.

To be an effective weapon then, the spores must remain airborne long enough and in sufficient concentration to allow potential victims to inhale large numbers of the spores.

A standard ventilation system filter in a home or office will routinely remove about 97% of the spores on the first pass through the system, making residual infection unlikely. The more efficient HEPA type filters will remove 99.9% of the spores on the first pass through.

Secondly, the spores must be inhaled deep into the lungs to cause infection.

The bacterium is approximately 1 micron in size (a human hair is 25-50 microns in width). In its natural state the spores clump together. Once these clumps become 5 microns or more in size, they are usually trapped in the upper respiratory system and can not infiltrate the lungs where they can cause the disease.

Making "weapons grade" anthrax requires a sophisticated laboratory where the spores may be genetically altered and refined so they will remain separated and smaller than 5 microns. They are then placed in a powder to increase the time they can remain airborne and to prevent the spores from clumping again before they can be inhaled.

There are about 4 dozen labs worldwide that store anthrax cultures where terrorists could obtain b.anthracis. Many of these countries are not friendly to the U.S., most notably, Iran, Iraq, China, and several states of the former Soviet Union.

With this information, we can put some of the news reports into perspective. One person who "tested positive" for anthrax, indeed had a single spore on his cheek. He was technically "infected", but far from being in any danger.

The unsettling part of the current news reports is that the anthrax we are dealing with certainly appears to be professionally prepared. It is unlikely it comes from a "natural" source and is being sent by an amateur or other "terrorist wannabe."

The real danger from anthrax does not lie in a contaminated envelope, however. A terrorist with an airplane could indeed infect an entire city with a mist of anthrax which would be undetected until symptoms developed and the fatality rate would make the World Trade Center disaster seem like a minor incident. Worse yet would be the use of small pox as a bio-terrorist weapon, which is highly transmissible. Possible scenarios there could exceed any horror movie Hollywood has ever thought of.

Enough of those unpleasant thoughts… and back to the situation at hand.

For the embalmer, anthrax is not the worst disease they could be presented with.

We can assume that most casualties will be of the respiratory type. Anthrax is not considered transmissible. That is, there is no concern of contracting anthrax from an infected person either from normal casual contact or by inhalation.

Nevertheless, an embalmer making the removal of an anthrax patient should use universal precautions and standard barrier isolation. Since anthrax is opportunistic (is especially infectious) to persons who already have respiratory infections, removal personnel should be suspicious of transmissible respiratory infections and should utilize a face mask on the deceased as well as on themselves.

Gloves should be used on all removals, and in the event of an anthrax patient where cutaneous anthrax may be present, gloves become critical and contact with the lesions should be avoided.

Standard embalming with universal precautions should not present a particular risk to the embalmer. Formaldehyde kills b. anthracis, but since it is a spore-forming bacterium, the spore is not killed on contact with embalming fluid. The spores may survive for minutes or even hours.

Aspiration of the lungs should be done in such manner to minimize any chance of creating an aerosol. Again, this should already be common practice, but in the case of anthrax, this becomes even more important. Do not assume that arterial embalming has destroyed the spores by the time aspiration is done since formaldehyde contact in the lungs is limited and because of the time it takes for the spores to be destroyed. Instruments should be autoclaved or disposed of.

Any lesions should be treated with a topical embalming product and covered to avoid any possible contact.

Many disinfectants can be used for general cleaning and disinfection purposes. Sodium hypochlorite (Clorox) is an effective disinfectant.

There are no additional health concerns with cremation of a body infected with anthrax.

Finally, however, it should also be noted that articles in the Journal of the American Medical Association and in The Control of Communicable Disease Manual discourage embalming because embalming creates "other concerns." They do not say what those concerns might be.

But I think I know what those concerns are. A careful professional embalmer can safely prepare an anthrax case, but an embalmer that routinely takes shortcuts, fails to understand and utilize the concept of "universal precautions" or is simply careless, should think twice before attempting preparation of the anthrax case-- or any other case for that matter.