SENTINEL LEVEL CLINICAL LABORATORY GUIDELINES FOR SUSPECTED AGENTS OF BIOTERRORISM AND EMERGING INFECTIOUS DISEASES Bacillus anthracis and Bacillus cereus biovar anthracis American Society for Microbiology (ASM) Revised August 2017 For last revision, see website below https://www.asm.org/Articles/Policy/Laboratory-Response-Network-LRN-Sentinel-Level-C ASM Subject Matter Experts: James W. Snyder, Ph.D. Steven D. Mahlen, Ph.D. University of Louisville Affiliated Laboratory, Inc. Louisville, KY Bangor, ME [email protected] [email protected] ASM Sentinel Level Laboratory Protocol Working Group APHL Advisory Committee Vickie Baselski, Ph.D. Barbara Robinson-Dunn, Ph.D. Patricia Blevins, MPH University of Tennessee at Department of Clinical San Antonio Metro Health Memphis Pathology District Laboratory Memphis, TN Beaumont Health System [email protected] [email protected] Royal Oak, MI BRobinson- Erin Bowles David Craft, Ph.D. [email protected] Wisconsin State Laboratory of Penn State Milton S. Hershey Hygiene Medical Center Michael A. Saubolle, Ph.D. [email protected] Hershey, PA Banner Health System [email protected] Phoenix, AZ Christopher Chadwick, MS Mike.Saubolle@bannerh Association of Public Health Peter H. Gilligan, Ph.D. ealth.com Laboratories University of North [email protected] Carolina Hospitals/ Susan L. Shiflett Clinical Microbiology and Michigan Department of Mary DeMartino, BS, Immunology Labs Community Health MT(ASCP)SM Chapel Hill, NC Lansing, MI State Hygienic [email protected] [email protected] Laboratory at the University of Iowa Larry Gray, Ph.D. Alice Weissfeld, Ph.D. [email protected] TriHealth Laboratories and Microbiology Specialists Inc. University of Cincinnati Houston, TX Harvey Holmes, PhD College of Medicine alice@microbiologyspecialist. Centers for Disease Cincinnati, OH com Control and Prevention [email protected] [email protected] David Welch, Ph.D. Major Todd Kijek, Ph.D. Medical Microbiology Kara MacKeil US Army Medical Research Consulting Association of Public Institute for Infectious Diseases Dallas, TX Health Laboratories Ft. Detrick, MD [email protected] [email protected] [email protected] Mary K. York, Ph.D. Chris Mangal, MPH Michael J. Loeffelholz, Ph.D. MKY Microbiology Association of Public Department of Pathology Consultants Health Laboratories Univ. Texas Medical Branch Walnut Creek, CA [email protected] Galveston, TX [email protected] [email protected] Amanda Moore, BS Coordinating Editor: South Carolina Department of Judith C. Lovchik, Ph.D. Health and Environmental Indiana State Department of Steven D. Mahlen, Ph.D. Control Health Laboratories Affiliated Laboratory, Inc. [email protected] Indianapolis, IN Bangor, ME [email protected] [email protected] James Rudrik, PhD, Michigan Department of Scott W. Riddell, Ph.D. Administrative Support Community Health Department of Pathology [email protected] SUNY Upstate Medical Kimberly E. Walker, Ph.D. University American Society for Maureen Sullivan, MPH Syracuse, NY Microbiology Minnesota Department [email protected] [email protected] of Health [email protected] PREANALYTICAL CONSIDERATIONS I. PRINCIPLE A. Introduction Bacillus anthracis, the agent of anthrax, is a zoonotic disease that is transmissible to humans through consumption or handling of contaminated products, is an aerobic, spore-forming, nonmotile, large Gram-positive bacterium (4). Bacillus cereus biovar anthracis strains were identified in the early 2000’s in Cameroon (strains CA) and Côte d’Ivoire (strains CI) (1,17). These strains were recovered from gorillas and chimpanzees with anthrax-like disease. The organism has since been recovered from an elephant and goats in other countries of Africa (1). B. cereus biovar anthracis CA strains are non-hemolytic, motile, and resistant to penicillin G, while B. cereus biovar anthracis CI strains are non-hemolytic, motile, and sensitive to pencillin G (17); some B. cereus biovar anthracis strains may exhibit weak beta-hemolysis upon extended incubation (48 h) and may be more hemolytic when incubated in CO2 at 48 h (see Table 1). B. anthracis and B. cereus biovar anthracis strains are classified as Tier I, Category A agents because of their suitability for use as biothreat agents in an attack or commission of a biocrime. At this time no human infections caused by B. cereus biovar anthracis have been described. This procedure describes steps to recognize, presumptively identify, and rule out these organisms from clinical specimens in Sentinel Clinical Laboratories. Such laboratories are defined as those who are certified to perform high complexity testing under the Clinical Laboratory Improvement Amendment of 1988 (CLIA’88) by the Centers for Medicare and Medicaid Services (CMS) for the applicable Microbiology specialty. Laboratory in-house testing includes Gram stains, and at least one of the following: lower respiratory tract, wound, or blood cultures. Sentinel clinical laboratories are not required to register with the Select Agent Program to conduct diagnostic testing for Select Agents, both Tier I and non-Tier 1. Testing for Select Agents may be performed by laboratories as long as the laboratory follows the policies listed in the reporting section of this document when a Select Agent cannot be ruled out. Consult with your designated LRN Reference Laboratory or refer to the CDC Division of Select Agents and Toxins website at http://www.selectagents.gov for questions. NOTE: To rule out B. anthracis and B. cereus biovar anthracis requires a combination of morphological assessment including Gram stain characteristics, and three simple, conventional tests. Automated systems and manual multi-test kit identification methods have no place in the identification of this organism due to the danger of misidentification and its close relationship to other species within the Bacillus genera. Table 1. Comparison of B. anthracis, B. cereus, and B. cereus biovar anthracis characteristics (adapted from reference 17) Characteristic B. B. cereus B. cereus biovar B. cereus biovar anthracis anthracis CI1 anthracis CA2 Hemolysis3 - + - - Motility4 - + +/- +/- Gamma-phage + - - - susceptibility5 Penicillin G6 S R S R Capsule + Absent in + + vitro 1: CI = Côte d’Ivoire strains, from chimpanzees 2: CA = Cameroon strains, from gorillas/chimpanzees 3: Hemolysis: + = beta hemolytic on sheep blood agar; - = non-hemolytic 4: Motility: + = motile; - = non-motile. +/- = B. cereus biovar anthracis strains are usually motile, including those recovered from gorillas, chimpanzees, and elephants; B. cereus biovar anthracis goat strains from Democratic Republic of the Congo were non-motile (3). 5: Gamma phage susceptibility: + = susceptible; - = resistant. 6: S= susceptible; R = resistant B. Geographic distribution Anthrax is endemic in southern Europe, parts of Africa, Australia, Asia, and North and South America. Its persists in arid deserts of the Middle East, Asia, Africa, Australia and South America with the majority of cases reported from Iran, Turkey, Pakistan, and Sudan. Although relatively rare in the United States, over 500 cases in Texas were reported in White Tailed Deer since 2006. Cases have also been reported in livestock in South Dakota, Nebraska, Arkansas, Mississippi, Louisiana, and California. Currently, B. cereus biovar anthracis strains have only been found in certain African countries, including Cameroon and Côte d’Ivoire. These strains are known to cause an anthrax-like disease in gorillas and chimpanzees, and have been isolated from other animals, including elephants and goats. B. cereus biovar anthracis strains are genetically similar to B. anthracis and produce all of the primary B. anthracis virulence factors, thus, they are now considered to be select agents in the United States. The use of B. anthracis as a bioterrorism agent to inflict disease and death following contact with or inhalation of spores has dominated recorded history for centuries (6, 19). Primarily used by many countries, including the United States, for military purposes in the conduct of biowarfare, it gained notoriety in the commission of biocrimes, determined to be hoaxes, throughout the 1990s. Although the LRN was created in late 1999, its role and responsibilities in preparing for, and responding to bioterrorism increased dramatically during and after the 2001 outbreak. The lessons learned from this national event demonstrated the serious need for training Sentinel Level Clinical Laboratories and preparing them to play a key role in the LRN. Three naturally occurring cases of anthrax have been reported within the past five years, one case respectively of gastrointestinal, cutaneous, and inhalational (20, 22, 23). These incidences are examples in which Sentinel Level Clinical Laboratories will be challenged by ensuring that all suspicious Bacillus spp., have been ruled out based on the use of the LRN designated tests and algorithm for B. anthracis and B. cereus biovar anthracis discussed in this protocol. C. Diseases and Clinical Presentation Anthrax is a zoonotic disease that occurs most frequently in herbivorous animals (e.g., cattle, sheep, and goats), which acquire endospores from contaminated soil. Human disease is less common and results from contact with infected animals or with commercial products derived from them, such as wool and hides. Infection can occur in one of three forms: 1. Cutaneous, responsible for >95% of naturally occurring cases, is initiated when