Ehrlichiosis.

HGE and HME have been recognized as distinct clinical conditions for only 5 and 10 years, respectively, and much information regarding their ecology and epidemiology remains uncertain. The nonspecific character of the illness complicates this incomplete knowledge, as an unknown percentage of infections are likely misdiagnosed. Ehrlichiosis should be considered in any patient presenting with flu-like illness and history of a tick bite. Although expanding, diagnostic support for human ehrlichioses is currently limited to a few regional academic and public health laboratories. Healthcare providers should educate themselves regarding the clinical presentation of ehrlichioses and the availability of diagnostic resources in their area.

Epidemic of dengue-4 virus in Yap State, Federated States of Micronesia, and implication of Aedes hensilli as an epidemic vector.

A dengue fever/dengue hemorrhagic fever (DF/DHF) outbreak in Yap State caused by dengue-4 virus was confirmed serologically and by virus isolation from serum samples collected on each of three island groups. Most DF/DHF cases occurred during a three-month period between mid-May and early August 1995. Five fatal cases, three of which were in children between the ages of four and 11, occurred between June 20 and July 26. A serosurvey conducted in late August revealed anti-dengue IgM prevalence rates of 18% on Yap, 36% on Eauripik, and 6% on Woleai. The majority of residents (93-100%) on the three islands were positive for anti-dengue IgG antibodies, indicating widespread exposure to dengue viruses. The IgG titers indicative of secondary antibody response were noted on Eauripik (6.5%) and Woleai (17%), but were rare on Yap (0.7%). Entomologic investigations implicated the native mosquito species, Aedes hensilli, a member of the Scutellaris Group of Aedes (Stegomyia), as a previously unrecognized epidemic vector of dengue viruses. Aedes hensilli was the most abundant and widespread member of Ae. (Stegomyia) in Yap State, the only species of Ae. (Stegomyia) on Woleai, and the only mosquito species present on Eauripik. New distribution records for mosquito species are reported.

The incubation period of hantavirus pulmonary syndrome.

In 1993 Sin Nombre virus was recognized as the cause of hantavirus pulmonary syndrome (HPS) and the deer mouse (Peromyscus maniculatus) was identified as the reservoir host. Surveillance by the Centers for Disease Control and Prevention and state health departments includes investigation to determine the likely site(s) and activities that led to infection, an environmental assessment of the home and workplace, and possibly rodent trappings at these sites. As of December 31, 1998, there were 200 confirmed cases from 30 states (43% case-fatality ratio). The national HPS case registry was examined to determine the incubation period of HPS. Review of 11 case-patients with well-defined and isolated exposure to rodents suggests that the incubation period of HPS is 9 to 33 days, with a median of 14-17 days. Case investigations allow a better understanding of the incubation time of HPS and may define high-risk behaviors that can be targeted for intervention.

Spatial analysis of Yersinia pestis and Bartonella vinsonii subsp. berkhoffii seroprevalence in California coyotes (Canis latrans).

Zoonotic transmission of sylvatic plague caused by Yersinia pestis occurs in California, USA. Human infections with various Bartonella species have been reported recently. Coyotes (Canis latrans) are ubiquitous throughout California and can become infected with both bacterial agents, making the species useful for surveillance purposes. This study examined the geographic distribution of 863 coyotes tested for Y. pestis and Bartonella vinsonii subsp. berkhoffii serologic status to gain insight into the natural history of B. vinsonii subsp. berkhoffii and to characterize the spatial distribution of the two agents. We found 11.7% of specimens positive to Y. pestis and 35.5% positive to B. vinsonii subsp. berkhoffii. The two pathogens had distinct spatial clusters: Y. pestis was more prevalent in eastern portions of the state and B. vinsonii subsp. berkhoffii in coastal regions. Prevalence of Y. pestis increased with increasing elevation, whereas prevalence of B. vinsonii subsp. berkhoffii decreased with increasing elevation. There were differences in the proportions of positive animals on a yearly basis to both pathogens.

An overview of plague in the United States and a report of investigations of two human cases in Kern county, California, 1995.

Plague was confirmed in the United States from nine western states during 1995. Evidence of Yersinia pestis infection was identified in 28 species of wild or domestic mammals. Thirteen of the plague positive species were wild rodents; 15 were predators/carnivores. Yersinia pestis was isolated from eight species of fleas. Seven confirmed cases of human plague were reported in 1995 (New Mexico 3; California 2; Arizona and Oregon 1 each). Five of the seven cases were bubonic; one was septicemic and one a fatal pneumonic case. Months of onset ranged from March through August. In California, during 1995, plague was recorded from 15 of the 58 counties. Over 1,500 animals were tested, of which 208 were plague positive. These included 144 rodents and 64 predators/carnivores. Two confirmed human cases (one bubonic and one fatal pneumonic) occurred, both in Kern County. Case No. 1 was reported from the town of Tehachapi. The patient, a 23 year-old male resident, died following a diagnosis of plague pneumonia. The patient's source of plague infection could not be determined precisely. Field investigations revealed an extensive plague epizootic surrounding Tehachapi, an area of approximately 500-600 square miles (800-970 square kilometers). Case No. 2 was a 57 year-old female diagnosed with bubonic plague; she was placed on an antibiotic regimen and subsequently recovered. The patient lives approximately 20 miles (32 km) north of Tehachapi. Field investigations revealed evidence of a plague epizootic in the vicinity of the victim's residence and adjacent areas. Overall results of the joint field investigations throughout the entire Kern county area revealed a high rate of plague positive animals. Of the numerous samples submitted, 48 non-human samples were plague positive.

Correlation among three psychological scales used in research of caregivers for patients with Alzheimer's disease.

This study was conducted to assess whether three scales commonly used in psychological research of Alzheimer's disease caregivers-Caregiver Burden Interview, Life Satisfaction Index-Z, and Geriatric Depression Scale-measure similar or different aspects of mental health. Responses from 244 nonprofessional caregivers were used to estimate factor structure, intercorrelation, and independent variables associated with the three scales. Self-rated health was the only variable significantly associated with scores on all three scales. Financial concern and number of weekly telephone calls were associated with total scores on the Satisfaction and Depression scales. Factor models of five, three, and six factors were fitted for the Burden, Satisfaction, and Depression scales, respectively. Correlations of factor scores and canonical variables among the scales did not yield strong associations between subsets of items. Although a few common aspects of caregiving influence scores of all three techniques, the facets of caregivers' psychology assessed by the three scales appear to be different.

Companion animals and the psychological health of Alzheimer patients' caregivers.

A sample of 244 persons in northern California who provided care for individuals with possible or probable Alzheimer's disease was studied to examine the effect of association with companion animals on three indices of psychological health. 124 caregivers had regular contact with pets; 120 caregivers did not. Men who were attached to dogs scored better on some measures of psychological health than did men who had no pets. Women less than 40 years old who were attached to cats scored better on some measures of psychological health than did the same-age women who had no pets. Women aged 40 to 59 years who were attached to dogs scored worse on measures of life satisfaction and depression than did the same-age women who had no pets. The data suggested a positive indirect effect on caregivers' mental health through interaction between the pet and the patient, but small strata numbers precluded definitive conclusions. Association with pets appeared to temper some of the psychological stress associated with caring for a cognitively impaired adult among young female and male caregivers but not among middle-aged female caregivers.

Tick infestation and spotted-fever group Rickettsia in shelter dogs, California, 2009.

In response to an outbreak of Rocky Mountain spotted fever (RMSF) in Baja California in early 2009, dogs at two shelters in neighbouring Imperial County, California, were evaluated for ectoparasites. Brown dog ticks (Rhipicephalus sanguineus), a recognized vector for RMSF, were found on 35 (30%) of 116 dogs but all ticks tested negative for Rickettsia rickettsii by PCR.

Association with companion animals and the expression of noncognitive symptoms in Alzheimer's patients.

Interactions with companion animals have been shown to have socializing and calming effects for Alzheimer's patients in an institutional setting. Sixty-four Alzheimer's patients living in the private home were studied, through medical records and information provided by caregivers, to determine what effect association with a companion animal had on the progression of cognitive decline and the manifestation of concomitant noncognitive symptoms. Prevalence of episodes of verbal aggression and anxiety was reported less frequently in 34 patients who were exposed to companion animals compared with patients who were not exposed. Significantly fewer mood disorders were reported in patients who were attached to their pets compared with patients who were not attached. There was no significant difference in the rate of cognitive decline between pet-exposed and nonexposed patients as measured by three standard indices. This study lends preliminary support to the belief that interaction with pets can aid in tempering feelings of agitation and aggression in Alzheimer's patients.

Surveillance for pneumonic plague in the United States during an international emergency: a model for control of imported emerging diseases.

In September 1994, in response to a reported epidemic of plague in India, the Centers for Disease Control and Prevention (CDC) enhanced surveillance in the United States for imported pneumonic plague. Plague information materials were rapidly developed and distributed to U.S. public health officials by electronic mail, facsimile, and expedited publication. Information was also provided to medical practitioners and the public by recorded telephone messages and facsimile transmission. Existing quarantine protocols were modified to effect active surveillance for imported plague cases at U.S. airports. Private physicians and state and local health departments were relied on in a passive surveillance system to identify travelers with suspected plague not detected at airports. From September 27 to October 27, the surveillance system identified 13 persons with suspected plague; no case was confirmed. This coordinated response to an international health emergency may serve as a model for detecting other emerging diseases and preventing their importation.

Estimation of the incidence of Lyme disease.

The incidence of Lyme disease in most endemic areas is unknown but will be an important factor in determining the cost-effectiveness of Lyme disease vaccines in those areas. The authors developed a deterministic model with nine components to estimate the frequency of Ixodes scapularis tick bites and the resulting incidence of Lyme disease in residents of endemic areas. For each component, best point estimates and plausible ranges of values were based on the published literature, unpublished data, expert opinion, or a combination of the above. By using the mean, crude, annual total of 3,827 Lyme disease cases reported from the endemic county of Westchester, New York, in 1991-1994, a mean of 178,889 I. scapularis bites (20.4 per 100 person-years) and a mean of 10,632 incident Lyme disease cases (1.2 per 100 person-years) were estimated to have occurred per year. Results of a sensitivity analysis that used two different methods suggested that this deterministic model is reasonably robust. In conclusion, according to this model, the incidence of Lyme disease in Westchester County is several-fold higher than suggested by the current passive reporting system.

Predominant kidney involvement in a fatal case of hantavirus pulmonary syndrome caused by Sin Nombre virus.

A 27-year-old woman presented to a hospital with symptoms resembling pyelonephritis; respiratory distress did not develop until nearly a day after admission and she subsequently died. The Unexplained Deaths and Critical Illnesses Project of the Centers for Disease Control and Prevention confirmed Sin Nombre virus infection by the results of serological testing and sequencing of the viral genome; staining of Sin Nombre virus antigen in the pulmonary capillaries was relatively weak.

Seroepidemiology of emerging tickborne infectious diseases in a Northern California community.

A seroprevalence and risk factor study of emerging tickborne infectious diseases (Lyme disease, ehrlichiosis, and babesiosis) was conducted among 230 residents of a semirural community in Sonoma County, California. Over 50% of residents reported finding a tick on themselves in the preceding 12 months. Samples from 51(23%) residents were seroreactive to antigens from one or more tickborne disease agents: 1.4% to Borrelia burgdorferi, 0.4% to Ehrlichia equi, 4.6% to Ehrlichia chaffeensis, and 17.8% to the Babesia-like piroplasm WA1. Only 14 (27%) of these seroreactive residents reported one or more symptoms compatible with these diseases. Seroreactivity was significantly associated with younger age (<16 years), longer residence in the community (11-20 years), and having had a physician's diagnosis of Lyme disease. In northern California, the risk of infection with these emerging tickborne diseases, particularly in children, may be greater than previously recognized.

Cases of cat-associated human plague in the Western US, 1977-1998.

Exposure to cats infected with Yersinia pestis is a recently recognized risk for human plague in the US. Twenty-three cases of cat-associated human plague (5 of which were fatal) occurred in 8 western states from 1977 through 1998, which represent 7.7% of the total 297 cases reported in that period. Bites, scratches, or other contact with infectious materials while handling infected cats resulted in 17 cases of bubonic plague, 1 case of primary septicemic plague, and 5 cases of primary pneumonic plague. The 5 fatal cases were associated with misdiagnosis or delays in seeking treatment, which resulted in overwhelming infection and various manifestations of the systemic inflammatory response syndrome. Unlike infections acquired by flea bites, the occurrence of cat-associated human plague did not increase significantly during summer months. Plague epizootics in rodents also were observed less frequently at exposure sites for cases of cat-associated human plague than at exposure sites for other cases. The risk of cat-associated human plague is likely to increase as residential development continues in areas where plague foci exist in the western US. Enhanced awareness is needed for prompt diagnosis and treatment.

Acute Sin Nombre hantavirus infection without pulmonary syndrome, United States.

Hantavirus pulmonary syndrome (HPS) occurs in most infections with Sin Nombre virus and other North American hantaviruses. We report five cases of acute hantavirus infection that did not fit the HPS case definition. The patients had characteristic prodromal symptoms without severe pulmonary involvement. These cases suggest that surveillance for HPS may need to be expanded.