In October 2001, the first inhalational anthrax case in the United States since 1976 was identified in a media company worker in Florida. A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis. Surveillance was enhanced through health-care facilities, laboratories, and other means to identify cases, which were defined as clinically compatible illness with laboratory-confirmed B. anthracis infection. From October 4 to November 20, 2001, 22 cases of anthrax (11 inhalational, 11 cutaneous) were identified; 5 of the inhalational cases were fatal. Twenty (91%) case-patients were either mail handlers or were exposed to worksites where contaminated mail was processed or received. B. anthracis isolates from four powder-containing envelopes, 17 specimens from patients, and 106 environmental samples were indistinguishable by molecular subtyping. Illness and death occurred not only at targeted worksites, but also along the path of mail and in other settings. Continued vigilance for cases is needed among health-care providers and members of the public health and law enforcement communities.

Malaria remains a diagnostic and treatment challenge for US clinicians as increasing numbers of persons travel to and emigrate from malarious areas. A strong evidence base exists to help clinicians rapidly initiate appropriate therapy and minimize the major mortality and morbidity burdens caused by this disease.

Lyme disease, caused by the tick-transmitted bacterium Borrelia burgdorferi, is the most common vector-borne disease in the United States. We surveyed residents of three Connecticut health districts to evaluate the impact of intensive community-wide education programs on knowledge, attitudes, and behaviors to prevent Lyme disease. Overall, 84% of respondents reported that they knew a lot or some about Lyme disease, and 56% felt that they were very or somewhat likely to get Lyme disease in the coming year. During 2002-2004, the percentage of respondents who reported always performing tick checks increased by 7% and the percentage of respondents who reported always using repellents increased by 5%, whereas the percentage of respondents who reported avoiding wooded areas and tucking pants into socks decreased. Overall, 99% of respondents used personal protective behaviors to prevent Lyme disease. In comparison, 65% of respondents reported using environmental tick controls, and increased use of environmental tick controls was observed in only one health district. The majority of respondents were unwilling to spend more than $100 on tick control. These results provide guidance for the development of effective Lyme disease prevention programs by identifying measures most likely to be adopted by residents of Lyme disease endemic communities.

As part of a fatal human plague case investigation, we showed that the plague bacterium, Yersinia pestis, can survive for at least 24 days in contaminated soil under natural conditions. These results have implications for defi ning plague foci, persistence, transmission, and bioremediation after a natural or intentional exposure to Y. pestis.

We describe the 11th case of bioterrorism-related inhalational anthrax reported in the United States. The presenting clinical features of this 94-year-old woman were subtle and nondistinctive. The diagnosis was recognized because blood cultures were obtained prior to administration of antibiotics, emphasizing the importance of this diagnostic test in evaluating ill patients who have been exposed to Bacillus anthracis. The patient's clinical course was characterized by progression of respiratory insufficiency, pleural effusions and pulmonary edema, and, ultimately, death. Although her B anthracis bacteremia was rapidly sterilized after initiation of antibiotic therapy, viable B anthracis was present in postmortem mediastinal lymph node specimens. The source of exposure to B anthracis in this patient is not known. Exposure to mail that was cross-contaminated as it passed through postal facilities contaminated with B anthracis spores is one hypothesis under investigation.

Abstract. Plague, a life-threatening flea-borne zoonosis caused by Yersinia pestis , has most commonly been reported from eastern Africa and Madagascar in recent decades. In these regions and elsewhere, prevention and control efforts are typically targeted at fine spatial scales, yet risk maps for the disease are often presented at coarse spatial resolutions that are of limited value in allocating scarce prevention and control resources. In our study, we sought to identify sub-village level remotely sensed correlates of elevated risk of human exposure to plague bacteria and to project the model across the plague-endemic West Nile region of Uganda and into neighboring regions of the Democratic Republic of Congo. Our model yielded an overall accuracy of 81%, with sensitivities and specificities of 89% and 71%, respectively. Risk was higher above 1,300 meters than below, and the remotely sensed covariates that were included in the model implied that localities that are wetter, with less vegetative growth and more bare soil during the dry month of January (when agricultural plots are typically fallow) pose an increased risk of plague case occurrence. Our results suggest that environmental and landscape features play a large part in classifying an area as ecologically conducive to plague activity. However, it is clear that future studies aimed at identifying behavioral and fine-scale ecological risk factors in the West Nile region are required to fully assess the risk of human exposure to Y. pestis .

The West Nile region of Uganda represents an epidemiologic focus for human plague in east Africa. However, limited capacity for diagnostic laboratory testing means few clinically diagnosed cases are confirmed and the true burden of disease is undetermined. The aims of the study were 1) describe the spatial distribution of clinical plague cases in the region, 2) identify ecologic correlates of incidence, and 3) incorporate these variables into predictive models that define areas of plague risk. The model explained 74% of the incidence variation and revealed that cases were more common above 1,300 m than below. Remotely-sensed variables associated with differences in soil or vegetation were also identified as incidence predictors. The study demonstrated that plague incidence can be modeled at parish-level scale based on environmental variables and identified parishes where cases may be under-reported and enhanced surveillance and preventative measures may be implemented to decrease the burden of plague.

Tularemia is frequently initially misdiagnosed. A thorough exposure history, particularly for tick bites, and awareness of clinical features may prompt clinicians to consider tularemia and facilitate appropriate testing. Promising success with oral fluoroquinolones could provide an acceptable alternative to intravenous aminoglycosides or long courses of tetracyclines where clinically appropriate.