Applying the One Health Approach to Understand a Gastrointestinal Anthrax Outbreak in Koraput, Odisha, India, 2023: A Case-Control Study

Applying the One Health Approach to Understand a Gastrointestinal Anthrax Outbreak in Koraput, Odisha, India, 2023: A Case-Control Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Applying the One Health Approach to Understand a Gastrointestinal Anthrax Outbreak in Koraput, Odisha, India, 2023: A Case-Control Study Dharmesh Arya, Amit Pritam Swain, Hanul Thukral, Nivethitha N, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9365102/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Introduction: Anthrax is a neglected zoonotic disease worldwide. In Odisha, outbreaks have been reported annually since 2009, with four hotspot districts – Koraput, Sundergarh, Rayagada, and Deogarh. While supporting the response efforts at the district level, an undetected cluster of acute diarrhoeal disease (ADD) was identified at one of the blocks and was investigated for gastrointestinal anthrax with the objective of confirming the outbreak and identifying risk factors. Methods We defined a probable human anthrax case as acute painless cutaneous lesions or acute fever, gastrointestinal illness, regional lymphadenopathy, and contact with dead livestock within 7 days of onset in a Sakiaguda resident during 15 March–22 May 2023. A laboratory-confirmed case was a probable case with Bacillus anthracis detected by RT-PCR in blood or stool. We did a 1:2 unmatched case-control study with asymptomatic neighbourhood controls. We calculate adjusted odds ratios (aOR) with 95% CI. We collected data on livestock anthrax vaccination from the district animal husbandry department. Results We identified 38 cases (median age and IQR in years 38 [20–50]; 60% females, 100% from indigenous tribe), of these, two were laboratory confirmed, with zero case fatality. Among cases, 97% (37/38) had gastrointestinal manifestations and 3% (1/38) had cutaneous manifestation. Among 38 cases and 76 controls, we identified that consumption of dead livestock meat (AOR: 51.88; 95% CI: 11.5–234) was significantly associated with case status. For the affected village, the routine anthrax vaccination coverage in livestock for 2021 was 50% (314/633); it was missed in 2022. Following the confirmation of human anthrax cases, ring vaccination of the livestock with 54% (314/633) coverage was done in 2023. Conclusion This was a confirmed human gastrointestinal anthrax outbreak associated with the consumption of dead livestock meat. There were gaps in routine anthrax vaccination for livestock and in reporting of sudden livestock deaths. We recommended health education with behaviour change communication for dead livestock disposal practices, and strengthening anthrax vaccination programme for livestock. Figures Figure 1 Figure 2 Introduction Anthrax is one of the major neglected zoonotic diseases worldwide. It is estimated that a global total of 63.8 million poor livestock keepers and 1.1 billion livestock live within vulnerable regions for anthrax risk. ( 1 ) India is endemic for animal anthrax due to a large unvaccinated livestock population. It primarily affects domestic herbivores during grazing via ingestion of spores shed in the soil from dead infected animals, leading to high mortality among livestock during epizootics. ( 2 ) In humans, anthrax primarily develops following exposure to infected animals, tissues, or products from infected animals. ( 3 ) The human anthrax cases in India are reported under the Integrated Disease Surveillance Program – Integrated Health Information Platform (IDSP-IHIP), which facilitates real-time reporting of anthrax cases and outbreaks. ( 4 ) The animal anthrax cases are reported through the National Animal Disease Reporting System. Despite an established surveillance, human anthrax is widely underreported in India due to lack of awareness for seeking health care among communities that live in proximity with livestock that are largely at risk of illness acquisition. Human anthrax outbreaks in India are concentrated in Eastern and east central parts comprising the states of Odisha, West Bengal, Andhra Pradesh and Jharkhand. In Odisha specifically, outbreaks have been reported annually since 2009, with four hotspot districts, namely, Koraput, Sundergarh, Rayagada, and Deogarh. Koraput district has reported mostly cutaneous anthrax cases for the last 10 years. ( 5 ) The prevention and control of zoonotic diseases like anthrax require a concerted One Health (OH) approach with multisectoral effort among various sectors, including public health, veterinary, wildlife institutions, and environmental health. This joint effort strengthens outbreak response, integrated disease surveillance, and comprehensive prevention programmes targeting human and animal sectors. ( 6 , 7 ) The IDSP received a media alert on 8 May 2023 about clustering of anthrax cases in Koraput district, Odisha. A multidisciplinary team of two EIS officers and a veterinary consultant were deployed to support response efforts. Surveillance data review and interaction with livestock officials revealed a cluster of acute diarrhoeal disease (ADD) and indeterminate livestock deaths in a village of the same district during the first week of May 2023. We investigated this cluster of ADD cases with the suspicion of gastrointestinal anthrax with the objective to confirm the outbreak, identify risk factors, and recommend control measures. Methodology Outbreak setting and Confirmation We investigated this outbreak in Sakiaguda village of Koraput district with a population of 336. The IDSP human anthrax case data for the last 10 years and anthrax-suspected livestock death data from the District Animal Husbandry department, Koraput district, was reviewed to understand the pattern of cases reported from the block and confirm the outbreak. We interacted with the district rapid response team (RRT) for information on the initial outbreak response. Case definition We defined a probable human anthrax case as acute painless cutaneous lesions (papule, vesicle, ulcer, or eschar) or acute fever, gastrointestinal illness (abdominal pain, vomiting, diarrhoea), regional lymphadenopathy; and contact with dead livestock within 7 days before onset in a resident of Sakiaguda village during 15 March–22 May 2023. We defined a laboratory-confirmed case as a probable case positive for Bacillus anthracis by reverse transcriptase polymerase chain reaction (RT-PCR) in a blood or stool specimen. We defined a livestock death as sudden death in livestock (including cattle, bulls, buffaloes, sheep, goats, equines, and pigs) or death accompanied by bleeding from body orifices (such as the nose, mouth, or anus) in village A between March 15, 2023, and May 22, 2023. Case search and data collection House-to-house active case search was done by the team and field staff after orientation on the case definition. We reviewed the OPD register of the health and wellness centre and the community health centre for passive case search from 15 March to 22 May 2023. We described cases by demographic characteristics, location, date of symptoms onset, clinical symptoms and exposures (livestock deaths and handling). Case-Control Study Based on the descriptive epidemiology of cases, we formed a hypothesis that consumption of ill livestock meat led to anthrax cases in residents of Sakiaguda village, we conducted a 1:2 unmatched case-control investigation. We defined control as the absence of all the symptoms of a cutaneous or gastrointestinal form of anthrax in a resident of Sakiaguda village during the period from 15th March to 25th May 2023. We recruited all cases and two asymptomatic, unmatched neighbourhood controls per case (1:2). We used a content validated questionnaire to interview cases and controls for demographic data, livestock deaths and livestock handling. The district rapid response team collected the rectal swabs to aid their clinical care. The samples were tested at the District Public Health Laboratory (DPHL), Koraput and Regional Medical Research Centre (RMRC), Bhubaneshwar using RT-PCR. We collected additional samples (blood, rectal swab, skin lesion swab) for public health response and sent for testing at, National Centre for Disease Control, Delhi. Trace-back animal investigation We interviewed the cases to trace back any epidemiological link with exposure to sudden livestock death in the same household or the neighbouring household between 15 March to 25 May 2023. We visited the entire village to identify households with livestock, farmland, slaughtering sites, and grazing sites of livestock. Environmental investigation We collected livestock samples (bone and meat samples from dead livestock) and environmental specimens (soil samples from farmland and slaughtering sites located around the village randomly). The samples were tested by RT-PCR at the College of Veterinary Science and Animal Husbandry, Odisha University of Agriculture and Technology, Bhubaneshwar, Odisha. Anthrax vaccination of livestock We enquired about the livestock anthrax vaccination of the village from the animal husbandry department of Koraput district. To estimate the current livestock population of the village, we interviewed households based on availability regarding the number and type of livestock owned. By extrapolation we estimated the total livestock population of the village. Data analysis Descriptive analysis was performed with frequency and percentage for categorical variables and median and interquartile range (IQR) for continuous variables. We used Epi Info v 7.2 (CDC, USA) to compute the odds ratio at 95% confidence interval between exposure and outcome. A multivariate logistic regression model was applied to determine the adjusted odds ratios (ORs) and 95% confidence intervals (CIs). We added the exposure variables that were considered as known confounders, did not have high collinearity and had a significant association (p < 0.05) in the univariate model in the multivariate analysis. We also considered various exposures of cooking and handling the livestock as combined exposures to consider if there was a dose-response relationship. Results Brief about the initial response : In the background of a large confirmed human anthrax outbreak in the Dasmanthpur block of Koraput district, predominantly cutaneous in nature, an event alert was generated on May 3rd for a cluster of 25 acute diarrheal diseases in Sakiaguda village of the neighbouring Semiliguda block of the same district. The district RRT responded as per protocol by treating the reported cases (providing ciprofloxacin tablets and oral rehydration sachets). They collected 03 rectal swabs, being a cholera endemic area. Initially these rectal swabs were tested negative for Vibrio Cholerae . In context of the human anthrax outbreak that was ongoing in the district, these samples were additionally sent for testing for anthrax on 10th May. One of the three samples tested positive for anthrax on 17th May. Outbreak confirmation . The district reported 689 human anthrax cases from 2002 to 2022, with no cases reported in 2015, 2016, or 2020. The Similiguda block did not report any cases from the 2017. We could not confirm the outbreak of human anthrax as per the outbreak threshold, as the ADD cases were not reported as human anthrax cases in IDSP. We then proceeded to confirm the outbreak based on the presence of clustering of ADD cases along with animal deaths and lab confirmation. Descriptive epidemiology : The village had a total population of 336, with tribal residents comprising 57% (192/336). There were 38 cases from the indigenous tribes (100%) with zero case fatality. Among the tribal residents, the overall attack rate was 20% (38/192) and household attack rate was 44% (25/57). The median age (IQR) of the cases was 38 (20–50) years, with 60% females. Of the cases, 76% were farmers by occupation, and 60% had no formal education. Out of total cases, 97% (37/38) had gastrointestinal manifestation and 3% (1/38) had cutaneous manifestation. Out of the total cases, 90% (34/38) had diarrhoea, 76% (29/38) cases had pain in the abdomen, 66% (25/38) cases had a fever, and one case had a vesicle lesion on the left thumb. (Table 1 ) Table 1 Sociodemographic details of Anthrax cases, in Sakiaguda village, Koraput District, Odisha, 15th March to 25th May 2023 (N = 38) Sociodemographic variables Frequency (N = 38) Percentage Median age (IQR) years 38 (20–50) Sex Female 23 60 Male 15 40 Indigenous tribe 38 100 Education No Formal Education 23 60 Primary 09 24 Secondary 6 16 Occupation Farmer 29 76 Daily Wager 3 9 Driver 1 2 Student 5 13 Clinical Symptoms* Diarrhoea 34 90 Abdominal Pain 29 76 Vomiting 14 37 Fever 25 66 Bulla on left thumb 1 3 Vesicle lesion 0 0 Eschar 0 0 Inhalational Symptoms 0 0 Fever with cough 0 0 Fever with shortness of breath 0 0 * multiple response The first livestock death occurred on 28th May 2023; however, the first case became ill on 29th April 2023. The last livestock death was reported on 16th June, and the last case was reported on 21st June (Fig. 1 ). Case-Control (univariate and multivariate) : A total of 38 cases and 76 controls were enrolled. Significant risk factors for the cases were consumption of dead livestock meat (OR: 69, 95% CI: 18.03–263.5), involvement in slaughtering and disposal (OR: 31,95% CI: 3.76–247.9), cooking (OR: 13, 95% CI: 4.8–34), both cooking and consumption (OR: 10.5, 95% CI: 3.6–29.9), consumption of dried meat (OR: 11.2, 95% CI: 2.93–42.9). In the multivariate model, we found that only consumption of dead livestock meat (AOR: 51.88; 95% CI: 11.5–234) had significantly higher odds of being a case (Table 2 ). Since the cases who gave history of eating meat also gave history of cooking and handling the meat, we considered cooking as an individual risk factor and removed the combined exposures from the model. Table 2 Risk factor analysis of exposures among anthrax cases and controls, Sakiaguda, Koraput district, Odisha 15th March to 22nd May 2023 Exposure Case (N = 38) Control (N = 76) Odds Ratio 95% CI Adjusted Odds Ratio 95% CI Individuals owned livestock 28 61 0.68 0.27–1.7 Sudden death of livestock in family/neighbourhood 17 25 1.6 0.74–3.6 Handling of dead livestock Disposal # 12 3 11.23 2.9–43 3.2 0.05–219 Slaughtering # 11 1 31 3.76–248 8.36 0.08–804 Practices with Dead Livestock Mea t Consumption of dead livestock meat # 35 11 69 18.03–263 51.88 11.5–234 Involved in both cooking and consumption 18 6 10.5 3.6–30 Involved in cooking 23 8 13.03 4.8–34 Consumption of dried meat 32 7 11.2 2.93-43 General practice of cooking meat by boiling (> 30 mins) 14 34 0.72 0.32–1.6 Practice of hand wash with soap after handling dead livestock 3 11 0.5 0.13–1.9 # Risk factors considered for multivariate regression analysis along with age, gender and occupation Lab investigation : One stool sample tested positive for anthrax. Out of three blood samples of probable human anthrax cases collected by our team, one tested positive for plasmid pOX1 (pag gene), plasmid pXO2 (cap gene), and chromosomal sap gene of Bacillus anthracis by RT-PCR. Trace-back livestock death investigation : A total of 24 livestock deaths occurred between 15 March and 25 May 2023, including two cattle and 22 sheep in 77% (20/28) case households (Fig. 2 ). Overall, 47% (18/38) of cases had livestock deaths in their own household, and 53% (20/38) reported livestock deaths in a neighbouring household (Fig. 2 ). Four grazing sites, three farmlands, and one slaughtering site (piles of dead livestock remains) were within 500 metres of the centre of the village. A lack of awareness and communication about anthrax in both humans and livestock was observed among the Indigenous community. The community reported that there was no provision for compensating for the dead livestock. Environmental investigation : Seven livestock samples (bone and meat samples from dead livestock that were buried in a common burial ground and were available) were collected by our team during the investigation. We were not able to determine whether the collected samples belonged to animal deaths linked with this outbreak. All samples tested negative for B. anthracis by RT-PCR. Analysis of anthrax vaccination of livestock : The animal husbandry department informed that routine vaccination for livestock anthrax is done in April and May in endemic areas on a priority basis. The department lacked livestock census data. However, they had data available for the number of vaccine doses administered to livestock in various years. To assess vaccination coverage, we estimated a total livestock population of 633 for 92 households based on a rapid livestock survey for 78 households. For the affected village, the routine vaccination coverage for 2021 was 50% (314/633); however, it was missed in 2022. Following reports of human anthrax cases, ring vaccination among 54% (314/633) livestock was conducted on 13 May 2023. Discussion This is a confirmed outbreak of gastrointestinal (GI) anthrax in the Similuguda block, Koraput district. We found that all the affected case-patients belonged to a tribal population associated with the consumption or handling of dead livestock meat. The absence of reported anthrax cases in the block over the preceding five years, followed by the 2023 outbreak, suggests a sustained transmission of the disease involving humans, livestock, and the environment within the Koraput district. This resurgence highlights that the Bacillus anthracis persists in the local ecology, and the sudden occurrence of the cases is likely driven by the pathogen's ability to form highly resilient endospores, which remain dormant in the soil for many years. ( 8 ) The current outbreak was initially treated as an ADD outbreak by the district RRT, who responded quickly to manage ADD cases within one day. The treatment regimen was similar to that for anthrax. ( 9 ) This might explain the zero mortality in humans, despite previously reported gastrointestinal anthrax in India having 100% mortality. ( 5 ) A similar outbreak with a greater number of gastrointestinal anthrax cases and no case fatality was reported in Tengwe, Zimbabwe,2022. ( 10 ) The district RRT treating this as an ADD outbreak also suggests a low index of suspicion for gastrointestinal anthrax among healthcare workers. In the past, Odisha has reported predominantly cutaneous anthrax in the district.( 11 ) This finding in the context of high background rates of ADD highlights a gap in risk communication for gastrointestinal anthrax. We identified one case of cutaneous anthrax in our outbreak. This may be due to fewer skin breaches among case patients, as cutaneous anthrax manifests when anthrax spores are inoculated into a skin breech while handling infected livestock or contaminated livestock. However, outbreaks reported from other blocks in Koraput district during the same time period were mainly cutaneous anthrax, similar to past outbreaks. ( 11 , 12 ) One-fourth of case-patients processed the dead livestock; however, all case-patients had a history of consumption of dead livestock meat. This may be due to meat-sharing practices of tribal communities among neighbours and relatives, which potentially resulted in human exposure and illness. A study by Pattnaik et al. on socio-behavioral practices in the Koraput district highlighted similar practice of distributing meat from dead livestock among community members. ( 13 ) The district is endemic for livestock anthrax and has faced livestock death due to anthrax in previous years. Despite this, there was rampant practice of slaughtering and consumption of ill livestock meat. The lack of financial assistance coupled with low income could have led the residents to resort to consumption of the dead livestock. Our findings underscore the critical role of livestock vaccination in mitigating anthrax outbreaks and preventing spillover to human populations. The observed livestock anthrax cases following a decline in vaccination coverage align with previous research demonstrating a clear association between inadequate vaccination and heightened disease risk. ( 14 ) The potential for zoonotic transmission is further emphasized by the presence of unprotected cattle herds, adjoining burial and grazing fields, and subsequent human anthrax cases in this outbreak. These results reinforce that routine vaccination programmes for livestock are a cornerstone of anthrax prevention and control. There was a delay in testing the samples for anthrax, which suggests a lack of alertness in both human and animal sectors for gastrointestinal anthrax despite the region being endemic. The lack of awareness in the community about animal anthrax coupled with lack of information from the animal sector to the human sector may have caused a continuation of livestock meat consumption in the community, leading to the outbreak. A One Health approach is needed to address the proper disposal of dead livestock, increasing awareness of the community, and early detection and treatment of case-patients. Limitations Our investigation has potentially two limitations. We were not able to collect samples and test all cases for anthrax because IDSP mandate for stool sampling in ADD outbreaks is to collect samples from 10% of all cases. We addressed this by epidemiologically linking the cases (including the non-lab confirmed) with dead livestock meat consumption. We could not establish lab confirmation of animal deaths due to anthrax as we could not determine conclusively that the samples (which eventually tested negative for anthrax) were taken from the dead livestock linked to this outbreak. Conclusions Anthrax is typically suspected only when human cases arise, which is not ideal, as outbreaks initially occur in the livestock population and should act as an early warning for human infections. In this outbreak, factors such as the lack of veterinary anthrax surveillance, gaps in routine livestock vaccination, and a low level of suspicion regarding anthrax likely contributed to the disease spillover. Additionally, behaviours such as consuming ill livestock meat, skinning livestock without protective measures, and having a history of dead cattle in households were identified as risk factors for contracting anthrax. We identified gaps in coordination between human health and veterinary sector. To effectively prevent and respond to anthrax outbreaks, coordinated efforts between the human and animal health sectors is crucial. Strengthening surveillance at human-animal interface to quickly detect and report cases in both populations can significantly improve early response measures. Implementing comprehensive vaccination programs for livestock in endemic regions, along with public awareness campaigns on safe handling practices, can help lower transmission risks. Enhancing laboratory capabilities for accurate anthrax diagnosis at district leve and conducting joint training for veterinarians and healthcare professionals will improve outbreak detection and response. Moreover, fostering collaboration among public health authorities, veterinary services, and environmental agencies will support a holistic One Health approach, recognizing the interconnectedness of human, animal, and environmental health. Abbreviations GI – Gastro-Intestinal ADD – Acute Diarrhoeal Disease IDSP-IHIP – Integrated Disease Surveillance Platform-Integrated Health Information Portal OH – One Health RT-PCR – Reverse Transcriptase-Polymerase Chain Reaction Declarations Ethics approval and consent to participate All methods in this investigation were carried out in accordance with government of India guidelines and regulations. This study was conducted in response to a public health event under the mandate of the National Centre for Disease Control. Ethical approval was exempted and not applicable, as the investigation was conducted as part of a public health response and consistent with applicable state and central government law (Epidemic Diseases Act no. 3, 1897). Verbal informed consent was obtained from all respondents (or their parents/guardians for those <18 years of age) prior to participation. Strict data protection protocols reviewed by NCDC, ethical principles and guidelines by the Government of India, and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards were followed during data handling. Consent to publication: Not Applicable Clinical trial no.: Not Applicable Competing interest: None of the authors have any conflicts of interest that could inappropriately influence or bias the findings presented in this study. Data Availability: All data generated or analysed during this study are included in this published article and its supplementary information files. Funding: The authors declare that no funds, grants, or other financial support were received during the preparation of this manuscript. The investigation was conducted using existing institutional resources and without external financial assistance. Acknowledgements: We acknowledge Dr. Arti Bahl, Dr. Himanshu Chauhan, Dr. Sanket Kulkarni, Dr. Monil Singhai, Dr. Irum Tabasum, Dr. Mohan Kumar, Dr. Satish Kumar, Dr. Suchitra Samal, Dr. Nilam Somalkar, Dr. Niranjan Mishra, Dr. Ashok Paikray, Dr. Sasmita Mallick, Dr. Debdutta Battacharya, Dr. Arun Kumar Padhi, Dr. Rabinaryan Panda, Dr. Bichitra, Dr. Sudarshan Sahoo, Dr. Sunita Jena, Mr. Jitendra, Ms. Rahel Kadam, Mrs. Babita Panda, Mrs. Geeta Pradhan, Mrs. Malati Nandibali for their support during our investigation. Author contribution: DA and APS conceptualized the study, performed data collection and analysis, and shared equal responsibility in drafting the manuscript. HT conducted the investigation and interpretation of the animal component. NN and TD provided formal supervision and technical guidance throughout the data analysis and manuscript preparation. Administrative and logistical support was coordinated by SP, RC, and ST. All authors have read and approved the final version of the manuscript. References Carlson CJ, Kracalik IT, Ross N, Alexander KA, Hugh-Jones ME, Fegan M, et al. The global distribution of Bacillus anthracis and associated anthrax risk to humans, livestock and wildlife. Nat Microbiol. 2019;4(8):1337–43. World Health Organization, Food and Agriculture Organization of the United Nations, World Organisation for Animal Health. Anthrax in humans and animals [Internet]. 4th ed. Geneva: World Health Organization. 2008 [cited 2024 Jul 2]. 208 p. Available from: https://iris.who.int/handle/10665/97503 shadomy2008. Weekly Outbreaks:. Integrated Disease Surveillance Programme(IDSP) [Internet]. [cited 2025 Mar 20]. Available from: https://idsp.mohfw.gov.in/index4.php?lang=1&level=0&linkid=406&lid=3689 Jayaprakasam M, Chatterjee N, Chanda MM, Shahabuddin SM, Singhai M, Tiwari S, et al. Human anthrax in India in recent times: A systematic review & risk mapping. One Health Amst Neth. 2023;16:100564. 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A cutaneous Anthrax outbreak in Koraput District of Odisha-India 2015. BMC Public Health. 2019;19(S3):470. Parai D, Pattnaik M, Choudhary HR, Padhi AK, Pattnaik S, Jena S, et al. Investigation of human anthrax outbreak in Koraput district of Odisha, India. Travel Med Infect Dis. 2023;56:102659. Pattnaik M, Kshatri JS, Choudhary HR, Parai D, Shandilya J, Mansingh A, et al. Assessment of socio-behavioural correlates and risk perceptions regarding anthrax disease in tribal communities of Odisha, Eastern India. BMC Infect Dis. 2022;22(1):53. Navdarashvili A, Doker TJ, Geleishvili M, Haberling DL, Kharod GA, Rush TH, et al. Human anthrax outbreak associated with livestock exposure: Georgia, 2012. Epidemiol Infect. 2016;144(1):76–87. Additional Declarations No competing interests reported. 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Control","correspondingAuthor":false,"prefix":"","firstName":"Simmi","middleName":"","lastName":"Tiwari","suffix":""},{"id":626771784,"identity":"f3f9c515-155a-4b1b-862b-6a0265cd8439","order_by":7,"name":"Tanzin Dikid","email":"","orcid":"","institution":"National Center for Disease Control","correspondingAuthor":false,"prefix":"","firstName":"Tanzin","middleName":"","lastName":"Dikid","suffix":""}],"badges":[],"createdAt":"2026-04-09 07:57:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9365102/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9365102/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107651821,"identity":"afd5f487-36a8-47ed-9180-dfb11cd4769d","added_by":"auto","created_at":"2026-04-23 15:10:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30232,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of probable human anthrax cases and Livestock deaths by date of onset of symptoms from 15\u003csup\u003eth\u003c/sup\u003e March 2023 to 25\u003csup\u003eth\u003c/sup\u003e May 2023, Sakiaguda village, Koraput, Odisha\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9365102/v1/7ee751167642362dfebe1c80.png"},{"id":107651791,"identity":"7c3df264-0e6b-4ada-b187-d8213c3d3edb","added_by":"auto","created_at":"2026-04-23 15:10:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":619684,"visible":true,"origin":"","legend":"\u003cp\u003eSpot map of Sakiaguda village, Koraput district, Odisha households showing human cases and animal deaths with animal grazing and butchering sites\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9365102/v1/4a717c92b2720be09067fb4e.png"},{"id":107652003,"identity":"84ac4839-a134-4335-9fbd-9c5776629f45","added_by":"auto","created_at":"2026-04-23 15:11:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":723024,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9365102/v1/cf9eb87b-1e02-4510-942a-28c51c30af1d.pdf"},{"id":107651757,"identity":"c15d2aa8-f38d-46f1-a7ed-dc3a8dcbe788","added_by":"auto","created_at":"2026-04-23 15:10:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16203,"visible":true,"origin":"","legend":"","description":"","filename":"SuppTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-9365102/v1/dcdf5872479b30ddfa2dfeb7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Applying the One Health Approach to Understand a Gastrointestinal Anthrax Outbreak in Koraput, Odisha, India, 2023: A Case-Control Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnthrax is one of the major neglected zoonotic diseases worldwide. It is estimated that a global total of 63.8\u0026nbsp;million poor livestock keepers and 1.1\u0026nbsp;billion livestock live within vulnerable regions for anthrax risk. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) India is endemic for animal anthrax due to a large unvaccinated livestock population. It primarily affects domestic herbivores during grazing via ingestion of spores shed in the soil from dead infected animals, leading to high mortality among livestock during epizootics. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) In humans, anthrax primarily develops following exposure to infected animals, tissues, or products from infected animals. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe human anthrax cases in India are reported under the Integrated Disease Surveillance Program \u0026ndash; Integrated Health Information Platform (IDSP-IHIP), which facilitates real-time reporting of anthrax cases and outbreaks. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) The animal anthrax cases are reported through the National Animal Disease Reporting System.\u003c/p\u003e \u003cp\u003eDespite an established surveillance, human anthrax is widely underreported in India due to lack of awareness for seeking health care among communities that live in proximity with livestock that are largely at risk of illness acquisition. Human anthrax outbreaks in India are concentrated in Eastern and east central parts comprising the states of Odisha, West Bengal, Andhra Pradesh and Jharkhand. In Odisha specifically, outbreaks have been reported annually since 2009, with four hotspot districts, namely, Koraput, Sundergarh, Rayagada, and Deogarh. Koraput district has reported mostly cutaneous anthrax cases for the last 10 years. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe prevention and control of zoonotic diseases like anthrax require a concerted One Health (OH) approach with multisectoral effort among various sectors, including public health, veterinary, wildlife institutions, and environmental health. This joint effort strengthens outbreak response, integrated disease surveillance, and comprehensive prevention programmes targeting human and animal sectors. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe IDSP received a media alert on 8 May 2023 about clustering of anthrax cases in Koraput district, Odisha. A multidisciplinary team of two EIS officers and a veterinary consultant were deployed to support response efforts. Surveillance data review and interaction with livestock officials revealed a cluster of acute diarrhoeal disease (ADD) and indeterminate livestock deaths in a village of the same district during the first week of May 2023.\u003c/p\u003e \u003cp\u003eWe investigated this cluster of ADD cases with the suspicion of gastrointestinal anthrax with the objective to confirm the outbreak, identify risk factors, and recommend control measures.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOutbreak setting and Confirmation\u003c/h2\u003e \u003cp\u003eWe investigated this outbreak in Sakiaguda village of Koraput district with a population of 336. The IDSP human anthrax case data for the last 10 years and anthrax-suspected livestock death data from the District Animal Husbandry department, Koraput district, was reviewed to understand the pattern of cases reported from the block and confirm the outbreak. We interacted with the district rapid response team (RRT) for information on the initial outbreak response.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCase definition\u003c/h3\u003e\n\u003cp\u003eWe defined a probable human anthrax case as acute painless cutaneous lesions (papule, vesicle, ulcer, or eschar) or acute fever, gastrointestinal illness (abdominal pain, vomiting, diarrhoea), regional lymphadenopathy; and contact with dead livestock within 7 days before onset in a resident of Sakiaguda village during 15 March\u0026ndash;22 May 2023.\u003c/p\u003e \u003cp\u003eWe defined a laboratory-confirmed case as a probable case positive for \u003cem\u003eBacillus anthracis\u003c/em\u003e by reverse transcriptase polymerase chain reaction (RT-PCR) in a blood or stool specimen.\u003c/p\u003e \u003cp\u003eWe defined a livestock death as sudden death in livestock (including cattle, bulls, buffaloes, sheep, goats, equines, and pigs) or death accompanied by bleeding from body orifices (such as the nose, mouth, or anus) in village A between March 15, 2023, and May 22, 2023.\u003c/p\u003e\n\u003ch3\u003eCase search and data collection\u003c/h3\u003e\n\u003cp\u003eHouse-to-house active case search was done by the team and field staff after orientation on the case definition. We reviewed the OPD register of the health and wellness centre and the community health centre for passive case search from 15 March to 22 May 2023. We described cases by demographic characteristics, location, date of symptoms onset, clinical symptoms and exposures (livestock deaths and handling).\u003c/p\u003e\n\u003ch3\u003eCase-Control Study\u003c/h3\u003e\n\u003cp\u003eBased on the descriptive epidemiology of cases, we formed a hypothesis that consumption of ill livestock meat led to anthrax cases in residents of Sakiaguda village, we conducted a 1:2 unmatched case-control investigation. We defined control as the absence of all the symptoms of a cutaneous or gastrointestinal form of anthrax in a resident of Sakiaguda village during the period from 15th March to 25th May 2023. We recruited all cases and two asymptomatic, unmatched neighbourhood controls per case (1:2). We used a content validated questionnaire to interview cases and controls for demographic data, livestock deaths and livestock handling.\u003c/p\u003e\n\u003cp\u003eThe district rapid response team collected the rectal swabs to aid their clinical care. The samples were tested at the District Public Health Laboratory (DPHL), Koraput and Regional Medical Research Centre (RMRC), Bhubaneshwar using RT-PCR. We collected additional samples (blood, rectal swab, skin lesion swab) for public health response and sent for testing at, National Centre for Disease Control, Delhi.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTrace-back animal investigation\u003c/h2\u003e \u003cp\u003eWe interviewed the cases to trace back any epidemiological link with exposure to sudden livestock death in the same household or the neighbouring household between 15 March to 25 May 2023. We visited the entire village to identify households with livestock, farmland, slaughtering sites, and grazing sites of livestock.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEnvironmental investigation\u003c/h3\u003e\n\u003cp\u003eWe collected livestock samples (bone and meat samples from dead livestock) and environmental specimens (soil samples from farmland and slaughtering sites located around the village randomly). The samples were tested by RT-PCR at the College of Veterinary Science and Animal Husbandry, Odisha University of Agriculture and Technology, Bhubaneshwar, Odisha.\u003c/p\u003e\n\u003ch3\u003eAnthrax vaccination of livestock\u003c/h3\u003e\n\u003cp\u003eWe enquired about the livestock anthrax vaccination of the village from the animal husbandry department of Koraput district. To estimate the current livestock population of the village, we interviewed households based on availability regarding the number and type of livestock owned. By extrapolation we estimated the total livestock population of the village.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eDescriptive analysis was performed with frequency and percentage for categorical variables and median and interquartile range (IQR) for continuous variables. We used Epi Info v 7.2 (CDC, USA) to compute the odds ratio at 95% confidence interval between exposure and outcome. A multivariate logistic regression model was applied to determine the adjusted odds ratios (ORs) and 95% confidence intervals (CIs). We added the exposure variables that were considered as known confounders, did not have high collinearity and had a significant association (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in the univariate model in the multivariate analysis. We also considered various exposures of cooking and handling the livestock as combined exposures to consider if there was a dose-response relationship.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBrief about the initial response\u003c/span\u003e: In the background of a large confirmed human anthrax outbreak in the Dasmanthpur block of Koraput district, predominantly cutaneous in nature, an event alert was generated on May 3rd for a cluster of 25 acute diarrheal diseases in Sakiaguda village of the neighbouring Semiliguda block of the same district. The district RRT responded as per protocol by treating the reported cases (providing ciprofloxacin tablets and oral rehydration sachets). They collected 03 rectal swabs, being a cholera endemic area. Initially these rectal swabs were tested negative for \u003cem\u003eVibrio Cholerae\u003c/em\u003e. In context of the human anthrax outbreak that was ongoing in the district, these samples were additionally sent for testing for anthrax on 10th May. One of the three samples tested positive for anthrax on 17th May.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eOutbreak confirmation\u003c/span\u003e. The district reported 689 human anthrax cases from 2002 to 2022, with no cases reported in 2015, 2016, or 2020. The Similiguda block did not report any cases from the 2017. We could not confirm the outbreak of human anthrax as per the outbreak threshold, as the ADD cases were not reported as human anthrax cases in IDSP. We then proceeded to confirm the outbreak based on the presence of clustering of ADD cases along with animal deaths and lab confirmation.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDescriptive epidemiology\u003c/span\u003e: The village had a total population of 336, with tribal residents comprising 57% (192/336). There were 38 cases from the indigenous tribes (100%) with zero case fatality. Among the tribal residents, the overall attack rate was 20% (38/192) and household attack rate was 44% (25/57). The median age (IQR) of the cases was 38 (20\u0026ndash;50) years, with 60% females. Of the cases, 76% were farmers by occupation, and 60% had no formal education. Out of total cases, 97% (37/38) had gastrointestinal manifestation and 3% (1/38) had cutaneous manifestation. Out of the total cases, 90% (34/38) had diarrhoea, 76% (29/38) cases had pain in the abdomen, 66% (25/38) cases had a fever, and one case had a vesicle lesion on the left thumb. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic details of Anthrax cases, in Sakiaguda village, Koraput District, Odisha, 15th March to 25th May 2023 (N\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (N\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian age (IQR) years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e38 (20\u0026ndash;50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndigenous tribe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo Formal Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarmer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDaily Wager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDriver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical Symptoms*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiarrhoea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBulla on left thumb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVesicle lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEschar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInhalational Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever with cough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever with shortness of breath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* multiple response\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe first livestock death occurred on 28th May 2023; however, the first case became ill on 29th April 2023. The last livestock death was reported on 16th June, and the last case was reported on 21st June (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCase-Control (univariate and multivariate)\u003c/span\u003e: A total of 38 cases and 76 controls were enrolled. Significant risk factors for the cases were consumption of dead livestock meat (OR: 69, 95% CI: 18.03\u0026ndash;263.5), involvement in slaughtering and disposal (OR: 31,95% CI: 3.76\u0026ndash;247.9), cooking (OR: 13, 95% CI: 4.8\u0026ndash;34), both cooking and consumption (OR: 10.5, 95% CI: 3.6\u0026ndash;29.9), consumption of dried meat (OR: 11.2, 95% CI: 2.93\u0026ndash;42.9). In the multivariate model, we found that only consumption of dead livestock meat (AOR: 51.88; 95% CI: 11.5\u0026ndash;234) had significantly higher odds of being a case (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Since the cases who gave history of eating meat also gave history of cooking and handling the meat, we considered cooking as an individual risk factor and removed the combined exposures from the model.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factor analysis of exposures among anthrax cases and controls, Sakiaguda, Koraput district, Odisha 15th March to 22nd May 2023\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExposure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase (N\u0026thinsp;=\u0026thinsp;38)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (N\u0026thinsp;=\u0026thinsp;76)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOdds Ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividuals owned livestock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.27\u0026ndash;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSudden death of livestock in family/neighbourhood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.74\u0026ndash;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHandling of dead livestock\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisposal\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e11.23\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.9\u0026ndash;43\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e3.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.05\u0026ndash;219\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlaughtering\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e31\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.76\u0026ndash;248\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e8.36\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.08\u0026ndash;804\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePractices with Dead Livestock Mea\u003c/b\u003et\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsumption of dead livestock meat\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e69\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e18.03\u0026ndash;263\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e51.88\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e11.5\u0026ndash;234\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolved in both cooking and consumption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e10.5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3.6\u0026ndash;30\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolved in cooking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e13.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e4.8\u0026ndash;34\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsumption of dried meat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e11.2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2.93-43\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral practice of cooking meat by boiling (\u0026gt;\u0026thinsp;30 mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.32\u0026ndash;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePractice of hand wash with soap after handling dead livestock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.13\u0026ndash;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e# Risk factors considered for multivariate regression analysis along with age, gender and occupation\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eLab investigation\u003c/span\u003e: One stool sample tested positive for anthrax. Out of three blood samples of probable human anthrax cases collected by our team, one tested positive for plasmid pOX1 (pag gene), plasmid pXO2 (cap gene), and chromosomal sap gene of Bacillus anthracis by RT-PCR.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTrace-back livestock death investigation\u003c/span\u003e: A total of 24 livestock deaths occurred between 15 March and 25 May 2023, including two cattle and 22 sheep in 77% (20/28) case households (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Overall, 47% (18/38) of cases had livestock deaths in their own household, and 53% (20/38) reported livestock deaths in a neighbouring household (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Four grazing sites, three farmlands, and one slaughtering site (piles of dead livestock remains) were within 500 metres of the centre of the village. A lack of awareness and communication about anthrax in both humans and livestock was observed among the Indigenous community. The community reported that there was no provision for compensating for the dead livestock.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEnvironmental investigation\u003c/span\u003e: Seven livestock samples (bone and meat samples from dead livestock that were buried in a common burial ground and were available) were collected by our team during the investigation. We were not able to determine whether the collected samples belonged to animal deaths linked with this outbreak. All samples tested negative for B. anthracis by RT-PCR.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAnalysis of anthrax vaccination of livestock\u003c/span\u003e: The animal husbandry department informed that routine vaccination for livestock anthrax is done in April and May in endemic areas on a priority basis. The department lacked livestock census data. However, they had data available for the number of vaccine doses administered to livestock in various years. To assess vaccination coverage, we estimated a total livestock population of 633 for 92 households based on a rapid livestock survey for 78 households.\u003c/p\u003e \u003cp\u003eFor the affected village, the routine vaccination coverage for 2021 was 50% (314/633); however, it was missed in 2022. Following reports of human anthrax cases, ring vaccination among 54% (314/633) livestock was conducted on 13 May 2023.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is a confirmed outbreak of gastrointestinal (GI) anthrax in the Similuguda block, Koraput district. We found that all the affected case-patients belonged to a tribal population associated with the consumption or handling of dead livestock meat.\u003c/p\u003e \u003cp\u003eThe absence of reported anthrax cases in the block over the preceding five years, followed by the 2023 outbreak, suggests a sustained transmission of the disease involving humans, livestock, and the environment within the Koraput district. This resurgence highlights that the \u003cem\u003eBacillus anthracis\u003c/em\u003e persists in the local ecology, and the sudden occurrence of the cases is likely driven by the pathogen's ability to form highly resilient endospores, which remain dormant in the soil for many years. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe current outbreak was initially treated as an ADD outbreak by the district RRT, who responded quickly to manage ADD cases within one day. The treatment regimen was similar to that for anthrax. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) This might explain the zero mortality in humans, despite previously reported gastrointestinal anthrax in India having 100% mortality. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) A similar outbreak with a greater number of gastrointestinal anthrax cases and no case fatality was reported in Tengwe, Zimbabwe,2022. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) The district RRT treating this as an ADD outbreak also suggests a low index of suspicion for gastrointestinal anthrax among healthcare workers. In the past, Odisha has reported predominantly cutaneous anthrax in the district.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) This finding in the context of high background rates of ADD highlights a gap in risk communication for gastrointestinal anthrax.\u003c/p\u003e \u003cp\u003eWe identified one case of cutaneous anthrax in our outbreak. This may be due to fewer skin breaches among case patients, as cutaneous anthrax manifests when anthrax spores are inoculated into a skin breech while handling infected livestock or contaminated livestock. However, outbreaks reported from other blocks in Koraput district during the same time period were mainly cutaneous anthrax, similar to past outbreaks. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOne-fourth of case-patients processed the dead livestock; however, all case-patients had a history of consumption of dead livestock meat. This may be due to meat-sharing practices of tribal communities among neighbours and relatives, which potentially resulted in human exposure and illness. A study by Pattnaik et al. on socio-behavioral practices in the Koraput district highlighted similar practice of distributing meat from dead livestock among community members. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe district is endemic for livestock anthrax and has faced livestock death due to anthrax in previous years. Despite this, there was rampant practice of slaughtering and consumption of ill livestock meat. The lack of financial assistance coupled with low income could have led the residents to resort to consumption of the dead livestock.\u003c/p\u003e \u003cp\u003eOur findings underscore the critical role of livestock vaccination in mitigating anthrax outbreaks and preventing spillover to human populations. The observed livestock anthrax cases following a decline in vaccination coverage align with previous research demonstrating a clear association between inadequate vaccination and heightened disease risk. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) The potential for zoonotic transmission is further emphasized by the presence of unprotected cattle herds, adjoining burial and grazing fields, and subsequent human anthrax cases in this outbreak. These results reinforce that routine vaccination programmes for livestock are a cornerstone of anthrax prevention and control.\u003c/p\u003e \u003cp\u003eThere was a delay in testing the samples for anthrax, which suggests a lack of alertness in both human and animal sectors for gastrointestinal anthrax despite the region being endemic. The lack of awareness in the community about animal anthrax coupled with lack of information from the animal sector to the human sector may have caused a continuation of livestock meat consumption in the community, leading to the outbreak. A One Health approach is needed to address the proper disposal of dead livestock, increasing awareness of the community, and early detection and treatment of case-patients.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOur investigation has potentially two limitations. We were not able to collect samples and test all cases for anthrax because IDSP mandate for stool sampling in ADD outbreaks is to collect samples from 10% of all cases. We addressed this by epidemiologically linking the cases (including the non-lab confirmed) with dead livestock meat consumption. We could not establish lab confirmation of animal deaths due to anthrax as we could not determine conclusively that the samples (which eventually tested negative for anthrax) were taken from the dead livestock linked to this outbreak.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAnthrax is typically suspected only when human cases arise, which is not ideal, as outbreaks initially occur in the livestock population and should act as an early warning for human infections. In this outbreak, factors such as the lack of veterinary anthrax surveillance, gaps in routine livestock vaccination, and a low level of suspicion regarding anthrax likely contributed to the disease spillover. Additionally, behaviours such as consuming ill livestock meat, skinning livestock without protective measures, and having a history of dead cattle in households were identified as risk factors for contracting anthrax. We identified gaps in coordination between human health and veterinary sector.\u003c/p\u003e \u003cp\u003eTo effectively prevent and respond to anthrax outbreaks, coordinated efforts between the human and animal health sectors is crucial. Strengthening surveillance at human-animal interface to quickly detect and report cases in both populations can significantly improve early response measures. Implementing comprehensive vaccination programs for livestock in endemic regions, along with public awareness campaigns on safe handling practices, can help lower transmission risks. Enhancing laboratory capabilities for accurate anthrax diagnosis at district leve and conducting joint training for veterinarians and healthcare professionals will improve outbreak detection and response. Moreover, fostering collaboration among public health authorities, veterinary services, and environmental agencies will support a holistic One Health approach, recognizing the interconnectedness of human, animal, and environmental health.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGI \u0026ndash; Gastro-Intestinal\u003c/p\u003e\n\u003cp\u003eADD \u0026ndash; Acute Diarrhoeal Disease\u003c/p\u003e\n\u003cp\u003eIDSP-IHIP \u0026ndash; Integrated Disease Surveillance Platform-Integrated Health Information Portal\u003c/p\u003e\n\u003cp\u003eOH \u0026ndash; One Health\u003c/p\u003e\n\u003cp\u003eRT-PCR \u0026ndash; Reverse Transcriptase-Polymerase Chain Reaction\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods in this investigation were carried out in accordance with government of India guidelines and regulations. This study was conducted in response to a public health event under the mandate of the National Centre for Disease Control. Ethical approval was exempted and not applicable, as the investigation was conducted as part of a public health response and consistent with applicable state and central government law (Epidemic Diseases Act no. 3, 1897). Verbal informed consent was obtained from all respondents (or their parents/guardians for those \u0026lt;18 years of age) prior to participation. Strict data protection protocols reviewed by NCDC, ethical principles and guidelines by the Government of India, and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards were followed during data handling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial no.:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors have any conflicts of interest that could inappropriately influence or bias the findings presented in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other financial support were received during the preparation of this manuscript. The investigation was conducted using existing institutional resources and without external financial assistance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge Dr. Arti Bahl, Dr. Himanshu Chauhan, Dr. Sanket Kulkarni, Dr. Monil Singhai, Dr. Irum Tabasum, Dr. Mohan Kumar, Dr. Satish Kumar, Dr. Suchitra Samal, Dr. Nilam Somalkar, Dr. Niranjan Mishra, Dr. Ashok Paikray, Dr. Sasmita Mallick, Dr. Debdutta Battacharya, Dr. Arun Kumar Padhi, Dr. Rabinaryan Panda, Dr. Bichitra, Dr. Sudarshan Sahoo, Dr. Sunita Jena, Mr. Jitendra, Ms. Rahel Kadam, Mrs. Babita Panda, Mrs. Geeta Pradhan, Mrs. Malati Nandibali for their support during our investigation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDA and APS conceptualized the study, performed data collection and analysis, and shared equal responsibility in drafting the manuscript. HT conducted the investigation and interpretation of the animal component. NN and TD provided formal supervision and technical guidance throughout the data analysis and manuscript preparation. Administrative and logistical support was coordinated by SP, RC, and ST. All authors have read and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCarlson CJ, Kracalik IT, Ross N, Alexander KA, Hugh-Jones ME, Fegan M, et al. The global distribution of Bacillus anthracis and associated anthrax risk to humans, livestock and wildlife. Nat Microbiol. 2019;4(8):1337\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization, Food and Agriculture Organization of the United Nations, World Organisation for Animal Health. Anthrax in humans and animals [Internet]. 4th ed. Geneva: World Health Organization. 2008 [cited 2024 Jul 2]. 208 p. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/handle/10665/97503\u003c/span\u003e\u003cspan address=\"https://iris.who.int/handle/10665/97503\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eshadomy2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeekly Outbreaks:. Integrated Disease Surveillance Programme(IDSP) [Internet]. [cited 2025 Mar 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://idsp.mohfw.gov.in/index4.php?lang=1\u0026amp;level=0\u0026amp;linkid=406\u0026amp;lid=3689\u003c/span\u003e\u003cspan address=\"https://idsp.mohfw.gov.in/index4.php?lang=1\u0026amp;level=0\u0026amp;linkid=406\u0026amp;lid=3689\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJayaprakasam M, Chatterjee N, Chanda MM, Shahabuddin SM, Singhai M, Tiwari S, et al. Human anthrax in India in recent times: A systematic review \u0026amp; risk mapping. One Health Amst Neth. 2023;16:100564.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDasgupta R, Tomley F, Alders R, Barbuddhe SB, Kotwani A. Adopting an intersectoral One Health approach in India: Time for One Health Committees. Indian J Med Res. 2021;153(3):281\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational One Health Mission [Internet]. [cited 2025 Mar 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.psa.gov.in/oneHealthMission\u003c/span\u003e\u003cspan address=\"https://www.psa.gov.in/oneHealthMission\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSangwan N, Gangwal A, Jain P, Langtso C, Srivastava S, Dhawan U, et al. Anthrax: Transmission, Pathogenesis, Prevention and Treatment. Toxins. 2025;17(2):56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTreatment. and prophylaxis. In: Anthrax in Humans and Animals 4th edition [Internet]. World Health Organization; 2008 [cited 2025 Mar 23]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK310491/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK310491/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamutyinei Dhliwayo T, Chonzi P, Madembo C, Juru TP, Chadambuka A, Gombe NT, et al. Anthrax outbreak investigation in Tengwe, Mashonaland West Province, Zimbabwe, 2022. PLoS ONE. 2022;17(12):e0278537.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNayak P, Sodha SV, Laserson KF, Padhi AK, Swain BK, Hossain SS, et al. A cutaneous Anthrax outbreak in Koraput District of Odisha-India 2015. BMC Public Health. 2019;19(S3):470.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParai D, Pattnaik M, Choudhary HR, Padhi AK, Pattnaik S, Jena S, et al. Investigation of human anthrax outbreak in Koraput district of Odisha, India. Travel Med Infect Dis. 2023;56:102659.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePattnaik M, Kshatri JS, Choudhary HR, Parai D, Shandilya J, Mansingh A, et al. Assessment of socio-behavioural correlates and risk perceptions regarding anthrax disease in tribal communities of Odisha, Eastern India. BMC Infect Dis. 2022;22(1):53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNavdarashvili A, Doker TJ, Geleishvili M, Haberling DL, Kharod GA, Rush TH, et al. Human anthrax outbreak associated with livestock exposure: Georgia, 2012. Epidemiol Infect. 2016;144(1):76\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9365102/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9365102/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eAnthrax is a neglected zoonotic disease worldwide. In Odisha, outbreaks have been reported annually since 2009, with four hotspot districts \u0026ndash; Koraput, Sundergarh, Rayagada, and Deogarh. While supporting the response efforts at the district level, an undetected cluster of acute diarrhoeal disease (ADD) was identified at one of the blocks and was investigated for gastrointestinal anthrax with the objective of confirming the outbreak and identifying risk factors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe defined a probable human anthrax case as acute painless cutaneous lesions or acute fever, gastrointestinal illness, regional lymphadenopathy, and contact with dead livestock within 7 days of onset in a Sakiaguda resident during 15 March\u0026ndash;22 May 2023. A laboratory-confirmed case was a probable case with \u003cem\u003eBacillus anthracis\u003c/em\u003e detected by RT-PCR in blood or stool. We did a 1:2 unmatched case-control study with asymptomatic neighbourhood controls. We calculate adjusted odds ratios (aOR) with 95% CI. We collected data on livestock anthrax vaccination from the district animal husbandry department.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe identified 38 cases (median age and IQR in years 38 [20\u0026ndash;50]; 60% females, 100% from indigenous tribe), of these, two were laboratory confirmed, with zero case fatality. Among cases, 97% (37/38) had gastrointestinal manifestations and 3% (1/38) had cutaneous manifestation. Among 38 cases and 76 controls, we identified that consumption of dead livestock meat (AOR: 51.88; 95% CI: 11.5\u0026ndash;234) was significantly associated with case status. For the affected village, the routine anthrax vaccination coverage in livestock for 2021 was 50% (314/633); it was missed in 2022. Following the confirmation of human anthrax cases, ring vaccination of the livestock with 54% (314/633) coverage was done in 2023.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis was a confirmed human gastrointestinal anthrax outbreak associated with the consumption of dead livestock meat. There were gaps in routine anthrax vaccination for livestock and in reporting of sudden livestock deaths. We recommended health education with behaviour change communication for dead livestock disposal practices, and strengthening anthrax vaccination programme for livestock.\u003c/p\u003e","manuscriptTitle":"Applying the One Health Approach to Understand a Gastrointestinal Anthrax Outbreak in Koraput, Odisha, India, 2023: A Case-Control Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 15:09:49","doi":"10.21203/rs.3.rs-9365102/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-14T07:00:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-12T17:22:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40450282415154177990153576135508826352","date":"2026-05-12T08:55:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14421455413590481467811846124080214744","date":"2026-05-10T15:42:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284204039168011126838792287978676694425","date":"2026-05-10T12:01:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259906013324700373463295216952687719036","date":"2026-05-10T11:30:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"249399254507979238813040136513415628146","date":"2026-05-08T05:17:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"335725296785907652129329528460225205282","date":"2026-04-24T13:45:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105093115009795088909128961353759728901","date":"2026-04-21T05:56:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"42031615904257399277076079654883477225","date":"2026-04-16T05:35:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-16T01:21:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-16T01:18:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-13T08:06:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-10T12:57:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-04-10T11:37:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"44f62bbf-a416-4e7b-864a-096a4919e83c","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-14T07:00:59+00:00","index":117,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-12T17:22:54+00:00","index":116,"fulltext":""},{"type":"reviewerAgreed","content":"40450282415154177990153576135508826352","date":"2026-05-12T08:55:36+00:00","index":115,"fulltext":""},{"type":"reviewerAgreed","content":"14421455413590481467811846124080214744","date":"2026-05-10T15:42:51+00:00","index":113,"fulltext":""},{"type":"reviewerAgreed","content":"284204039168011126838792287978676694425","date":"2026-05-10T12:01:00+00:00","index":112,"fulltext":""},{"type":"reviewerAgreed","content":"259906013324700373463295216952687719036","date":"2026-05-10T11:30:26+00:00","index":111,"fulltext":""},{"type":"reviewerAgreed","content":"249399254507979238813040136513415628146","date":"2026-05-08T05:17:19+00:00","index":105,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T15:09:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 15:09:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9365102","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9365102","identity":"rs-9365102","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}