Development and experience with an algorithm to evaluate suspected smallpox cases in the United States, 2002-2004.

Concerns that smallpox, an eradicated disease, might reappear because of a bioterror attack and limited experience with smallpox diagnosis in the United States prompted us to design a clinical algorithm. We used clinical features of classic smallpox to classify persons presenting with suspected smallpox rashes into 3 categories: those with high, those with moderate, and those with low risk of having smallpox. The classification guides subsequent diagnostic strategies, limiting smallpox laboratory testing to high-risk persons to minimize the number of false-positive test results. From January 2002 through June 2004, the Centers for Disease Control and Prevention (CDC) received 43 consultations regarding suspected smallpox cases. No patient was at high risk for having smallpox. One patient was tested for the presence of variola virus. Varicella was the diagnosis for 23 cases (53%). The algorithm worked well to guide clinical and public health responses to suspected smallpox cases. The poster is available from CDC, and an interactive version and laboratory protocol are available at http://www.bt.cdc.gov/agent/smallpox/diagnosis/riskalgorithm/index.asp. We recommend use of the algorithm in the United States and elsewhere.

Vaccinia (smallpox) vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001.

These revised recommendations regarding vaccinia (smallpox) vaccine update the previous Advisory Committee on Immunization Practices (ACIP) recommendations (MMWR 1991;40; No. RR-14:1-10) and include current information regarding the nonemergency use of vaccinia vaccine among laboratory and health-care workers occupationally exposed to vaccinia virus, recombinant vaccinia viruses, and other Orthopoxviruses that can infect humans. In addition, this report contains ACIP's recommendations for the use of vaccinia vaccine if smallpox (variola) virus were used as an agent of biological terrorism or if a smallpox outbreak were to occur for another unforeseen reason.

Fort Chaffee revisited: the epidemiology of tick-borne rickettsial and ehrlichial diseases at a natural focus.

A retrospective cohort study was conducted among troops training at Fort Chaffee, Arkansas, from May through June 1997, to identify infections caused by tick-borne pathogens. Serum samples were tested by IFAs for antibodies to selected Rickettsia and Ehrlichia species and by an investigational EIA for spotted fever group Rickettsia lipopolysaccharide antigens. Of 1,067 guardsmen tested, 162 (15.2%) had antibodies to one or more pathogens. Of 93 guardsmen with paired serum samples, 33 seroconverted to Rickettsia rickettsii or spotted fever group rickettsiae (SFGR) and five to Ehrlichia species. Most (84.8%) of the personnel who seroconverted to SFGR were detected only by EIA, and seropositivity was significantly associated with an illness compatible with a tick-borne disease. In addition, 34 (27%) of 126 subjects with detectable antibody titers reported a compatible illness. The primary risk factor for confirmed or probable disease was finding > 10 ticks on the body. Doxycycline use and rolling up of long sleeves were protective against seropositivity. The risk of transmission of tick-borne pathogens at Fort Chaffee remains high, and use of the broadly reactive EIA suggests that previous investigations may have underestimated the risk for infection by SFGR. Measures to prevent tick bite and associated disease may require reevaluation.

Bioterrorism preparedness: planning for the future.

The release of nerve gas in a Tokyo subway and attempted releases of biological agents by the Aum Shinrikyo cult have demonstrated the willingness and ability of modern-day terrorists to use unconventional weapons. Unlike explosive weapons, the use of biologic weapons may only become apparent once people become ill. The detection and response to these man-made outbreaks will occur initially at the medical and public health levels. Therefore, the Centers for Disease Control and Prevention and its partners are strengthening their response, disease detection, diagnostic, and communication capabilities to better protect the nation's citizens against biological or chemical terrorism.

An investigation into the possibility of transmission of tick-borne pathogens via blood transfusion. Transfusion-Associated Tick-Borne Illness Task Force.

BACKGROUND: Tick-borne illnesses were diagnosed in a group of National Guard members, including some who had donated blood a few days before the onset of symptoms. A voluntary recall of those blood components was issued and a multistate investigation was conducted to determine if transfusion-transmitted illness had occurred. STUDY DESIGN AND METHODS: Donors and recipients were asked to complete questionnaires regarding symptoms and risk factors for infection and to provide blood samples for laboratory analysis. RESULTS: Among National Guard personnel who donated blood, 12 individuals were found to have a confirmed or probable case of Rocky Mountain spotted fever or ehrlichiosis. A total of 320 units (platelets or packed red cells) from 377 donors were transfused into 129 recipients. Although 10 recipients received units from National Guard personnel with confirmed or probable infection, none became ill. CONCLUSION: Transfusion-transmitted illness did not occur. Despite the awareness of the risk for tick-borne diseases and the use of tick-preventive measures, many National Guard personnel reported exposure to ticks. In addition to augmenting current tick-preventive measures, scheduling blood drives before rather than after field exercises could further reduce the potential for transmission of tick-borne pathogens.

An outbreak of acute bartonellosis (Oroya fever) in the Urubamba region of Peru, 1998.

During May 1998, we conducted a case-control study of 357 participants from 60 households during an outbreak of acute bartonellosis in the Urubamba Valley, Peru, a region not previously considered endemic for this disease. Blood and insect specimens were collected and environmental assessments were done. Case-patients (n = 22) were defined by fever, anemia, and intra-erythrocytic coccobacilli seen in thin smears. Most case-patients were children (median age = 6.5 years). Case-patients more frequently reported sand fly bites than individuals of neighboring households (odds ratio [OR] = 5.8, 95% confidence interval [CI] = 1.2-39.2), or members from randomly selected households > or = 5 km away (OR = 8.5, 95% CI = 1.7-57.9). Bartonella bacilliformis isolated from blood was confirmed by nucleotide sequencing (citrate synthase [g/tA], 338 basepairs). Using bacterial isolation (n = 141) as the standard, sensitivity, specificity, and positive predictive value of thin smears were 36%, 96%, and 44%, respectively. Patients with clinical syndromes compatible with bartonellosis should be treated with appropriate antibiotics regardless of thin-smear results.

Electrically evoked potentials recorded in adult and pediatric CLARION implant users.

The purpose of this study was to record electrical auditory brain stem responses (EABRs) and electrical middle latency responses (EMLRs) in the clinic from 3 adult CLARION Multi-Strategy Cochlear Implant subjects and to record EABRs in the operating room from 3 pediatric subjects. For 2 of the 3 adult subjects, EABR thresholds were within the subject's behavioral dynamic range, whereas 1 adult subject's EABR thresholds were either absent or, when present, exceeded the upper limit of the dynamic range. For this subject, EMLRs were absent or of poor morphology for the channels tested. Moreover, this subject was not able to understand speech in an open-set, auditory-only format. The EABR thresholds obtained with children were within the behavioral dynamic range for 2 of the 3 subjects, but exceeded comfortable loudness levels for 1 subject. Although the EABR thresholds were measured at stimulus levels that were audible for all subjects, the relationship of the EABR threshold levels to behavioral measures of loudness varied. Evoked potentials that originate more centrally, such as the EMLR, should be investigated further to determine the possible relationship to postimplant performance.

Importancia de la Lutzomia peruensis en la transmisión de la enfermedad de Carrión en el Valle Sagrado de los incas. Urubamba Cusco, Perú / Importance of Lutzomyia peruensis in the transmission of the Carrionïs disease in the Incaïs Sacred Valley. Urubamba Cusco, Peru

En el valle Sagrado de los Incas (Valle del Río Urubamba) encontramos una sola de Lutzomyia, nos referimos a la Lutzomyia suele compartir su habitat con el vector de la enfermedad de Carrión, la Lutzomyia verrucarum. Los aspectos entomológicos fueron levados a cabo, en Mayo de 1998. Las colectas entomológicas se realizaron utilizando trampas de luz CDC toda la noche y en capturas diurnas en las viviendas.Se muestra la importancia de Lutzomyia peruensis incriminándola epidemiológicamente y se detectó Bartonella bacilliformis mediante PCR y haciendo secuenciamiento de ADN. Se presenta también la estimación del riesgo entomólogico de transmisión de bartonelosis por Lutzomyia peruensis, mediante el índice de inoculación de Bartonella bacilliformis

An epidemiologic and entomologic investigation of a cluster of Rocky Mountain spotted fever cases in Delaware.

BACKGROUND: Rocky Mountain spotted fever (RMSF) continues to be the most common fatal tick-borne illness in the United States. In August of 1996, four children attending a summer camp in Delaware were diagnosed with RMSF. This report summarizes the results of the epidemiologic and entomologic investigation conducted by the Delaware Division of Public Health and the Centers for Disease Control and Prevention regarding this cluster of RMSF cases. Epidemiologic and clinical aspects of RMSF, as well as previously reported clusters of the disease, are also reviewed. METHODS: A questionnaire regarding symptoms and activities was administered via telephone to 163 (73 percent) of the 223 attendees. A suspected case was defined as an illness in a person attending the camp between August 11 and 17 that occurred during the two-week period following the session, characterized by either 1) fever with one or more symptoms (i.e., headache, rash, myalgia, or fatigue) or 2) no fever with two or more symptoms. Cases of RMSF were confirmed by serologic evaluation. RESULTS: Seven of 13 patients with suspected RMSF submitted sera for testing. Four patients had confirmed RMSF; three were males, and the median age was 12.5 years compared with 12 years for all attendees. All confirmed patients reported fever, headache, fatigue, and rash. An increased risk of becoming ill was associated with overnight camping at site A (Odds Ratio (OR) undefined, p = 0.02), visiting or overnight camping at site B (OR undefined, p = 0.003 and 0.002), and leaving the trails when hiking (OR undefined, p = 0.02). CONCLUSIONS: These data suggest that development of RMSF was associated with visiting or camping at specific sites and behavior likely to increase contact with ticks. Camp supervisors were advised to educate campers regarding tick bite prevention measures, reduce underbrush around campsites, and encourage campers to remain on the trails. Health care providers should remain aware of the increased risk for RMSF during the spring, summer, and fall months.

Large-scale human exposures to rabid or presumed rabid animals in the United States: 22 cases (1990-1996).

OBJECTIVE: To identify common elements of large-scale human exposures to rabid or presumed rabid animals in the United States from 1990 to 1996. DESIGN: Retrospective study. PROCEDURE: Health departments in 50 states and the District of Columbia were contacted regarding episodes of large-scale human exposures to rabid animals occurring between 1990 and 1996. A large-scale exposure was defined as administration of postexposure prophylaxis (PEP) to 25 or more people after an exposure to a rabid or presumed rabid animal or littermates. Incident-specific information was obtained through questionnaires sent to states reporting episodes. Data are reported as medians. RESULTS: Fifteen of 51 (29.4%) health departments reported 22 episodes; 72.7% involved companion animals or livestock. Twenty-six animals were involved in these 22 episodes, including 10 (38.5%) dogs, 4 (15.4%) livestock, 4 (15.4%) raccoons, 3 (11.5%) cats, 3 (11.5%) bats, and 2 (7.7%) ferrets. Schools (36.4%) and public places (22.7%) were the most common settings for exposures. Reportedly, 1,908 people received PEP. The cost for 10 episodes was $61,547/episode (range, $14,199 to $1,500,000). An episode-specific written algorithm for recommending PEP had been developed for use in only 4 (18.2%) episodes. CLINICAL IMPLICATIONS: Large-scale exposures most commonly involved a single companion animal. Exposures attributable to improper handling of wildlife and unrestricted access of animals in schools and public areas can be potentially remedied by targeted education. Use of an episode-specific algorithm to determine need for PEP may also reduce the number of unnecessary treatments.

Overwhelming sepsis with Vibrio vulnificus: a coastal pathogen in Oklahoma.

Vibrio vulnificus has been associated with three main clinical syndromes; primary septicemia; wound infection, and gastroenteritis. This organism has increased virulence for persons with underlying medical conditions that predispose to iron overload or an impaired immune system. Since the organism proliferates more readily in warm, coastal waters, such infections are more commonly found in those regions. Infection can result from the ingestion of contaminated, undercooked seafood; contact of a wound with seawater; or a puncture wound sustained from a contaminated surface. Vibrio infections rarely occur in inland areas, but when they do occur, they are usually a result of the contact of wounds with contaminated, brackish water or the ingestion of raw shellfish. Because infections with this organism occur less frequently in non-coastal regions, the diagnosis may not be suspected initially in susceptible individuals and a delay of treatment may result. We present a case of V. vulnificus sepsis occurring in a man with underlying liver disease and a history of row oyster consumption in Oklahoma and discuss the clinical manifestations of primary sepsis with this organism as well as prevention strategies.