Correction: Convergent evolution of diverse Bacillus anthracis outbreak strains toward altered surface oligosaccharides that modulate anthrax pathogenesis.

[This corrects the article DOI: 10.1371/journal.pbio.3001052.].

Convergent evolution of diverse Bacillus anthracis outbreak strains toward altered surface oligosaccharides that modulate anthrax pathogenesis.

Bacillus anthracis, a spore-forming gram-positive bacterium, causes anthrax. The external surface of the exosporium is coated with glycosylated proteins. The sugar additions are capped with the unique monosaccharide anthrose. The West African Group (WAG) B. anthracis have mutations rendering them anthrose deficient. Through genome sequencing, we identified 2 different large chromosomal deletions within the anthrose biosynthetic operon of B. anthracis strains from Chile and Poland. In silico analysis identified an anthrose-deficient strain in the anthrax outbreak among European heroin users. Anthrose-deficient strains are no longer restricted to West Africa so the role of anthrose in physiology and pathogenesis was investigated in B. anthracis Sterne. Loss of anthrose delayed spore germination and enhanced sporulation. Spores without anthrose were phagocytized at higher rates than spores with anthrose, indicating that anthrose may serve an antiphagocytic function on the spore surface. The anthrose mutant had half the LD50 and decreased time to death (TTD) of wild type and complement B. anthracis Sterne in the A/J mouse model. Following infection, anthrose mutant bacteria were more abundant in the spleen, indicating enhanced dissemination of Sterne anthrose mutant. At low sample sizes in the A/J mouse model, the mortality of ΔantC-infected mice challenged by intranasal or subcutaneous routes was 20% greater than wild type. Competitive index (CI) studies indicated that spores without anthrose disseminated to organs more extensively than a complemented mutant. Death process modeling using mouse mortality dynamics suggested that larger sample sizes would lead to significantly higher deaths in anthrose-negative infected animals. The model was tested by infecting Galleria mellonella with spores and confirmed the anthrose mutant was significantly more lethal. Vaccination studies in the A/J mouse model showed that the human vaccine protected against high-dose challenges of the nonencapsulated Sterne-based anthrose mutant. This work begins to identify the physiologic and pathogenic consequences of convergent anthrose mutations in B. anthracis.

Coalescence modeling of intrainfection Bacillus anthracis populations allows estimation of infection parameters in wild populations.

Bacillus anthracis, the etiological agent of anthrax, is a well-established model organism. For B. anthracis and most other infectious diseases, knowledge regarding transmission and infection parameters in natural systems, in large part, comprises data gathered from closely controlled laboratory experiments. Fatal, natural anthrax infections transmit the bacterium through new host-pathogen contacts at carcass sites, which can occur years after death of the previous host. For the period between contact and death, all of our knowledge is based upon experimental data from domestic livestock and laboratory animals. Here we use a noninvasive method to explore the dynamics of anthrax infections, by evaluating the terminal diversity of B. anthracis in anthrax carcasses. We present an application of population genetics theory, specifically, coalescence modeling, to intrainfection populations of B. anthracis to derive estimates for the duration of the acute phase of the infection and effective population size converted to the number of colony-forming units establishing infection in wild plains zebra (Equus quagga). Founding populations are small, a few colony-forming units, and infections are rapid, lasting roughly between 1 d and 3 d in the wild. Our results closely reflect experimental data, showing that small founding populations progress acutely, killing the host within days. We believe this method is amendable to other bacterial diseases from wild, domestic, and human systems.

Spatiotemporal Patterns of Anthrax, Vietnam, 1990-2015.

Anthrax is a priority zoonosis for control in Vietnam. The geographic distribution of anthrax remains to be defined, challenging our ability to target areas for control. We analyzed human anthrax cases in Vietnam to obtain anthrax incidence at the national and provincial level. Nationally, the trendline for cases remained at ≈61 cases/year throughout the 26 years of available data, indicating control efforts are not effectively reducing disease burden over time. Most anthrax cases occurred in the Northern Midlands and Mountainous regions, and the provinces of Lai Chau, Dien Bien, Lao Cai, Ha Giang, Cao Bang, and Son La experienced some of the highest incidence rates. Based on spatial Bayes smoothed maps, every region of Vietnam experienced human anthrax cases during the study period. Clarifying the distribution of anthrax in Vietnam will enable us to better identify risk areas for improved surveillance, rapid clinical care, and livestock vaccination campaigns.

Malaria transmission in Nepal under climate change: anticipated shifts in extent and season, and comparison with risk definitions for intervention.

BACKGROUND: Climate and climate change affect the spatial pattern and seasonality of malaria risk. Season lengths and spatial extents of mapped current and future malaria transmission suitability predictions for Nepal were assessed for a combination of malaria vector and parasites: Anopheles stephensi and Plasmodium falciparum (ASPF) and An. stephensi and Plasmodium vivax (ASPV) and compared with observed estimates of malaria risk in Nepal. METHODS: Thermal bounds of malaria transmission suitability for baseline (1960-1990) and future climate projections (RCP 4.5 and RCP 8.5 in 2030 and 2050) were extracted from global climate models and mapped for Nepal. Season length and spatial extent of suitability between baseline and future climate scenarios for ASPF and ASPV were compared using the Warren's I metric. Official 2010 DoHS risk districts (DRDs) and 2021 DoHS risk wards (DRWs), and spatiotemporal incidence trend clusters (ITCs) were overlaid on suitability season length and extent maps to assess agreement, and potential mismatches. RESULTS: Shifts in season length and extent of malaria transmission suitability in Nepal are anticipated under both RCP 4.5 and RCP 8.5 scenarios in 2030 and 2050, compared to baseline climate. The changes are broadly consistent across both future climate scenarios for ASPF and ASPV. There will be emergence of suitability and increasing length of season for both ASPF and ASPV and decreasing length of season for ASPV by 2050. The emergence of suitability will occur in low and no-risk DRDs and outside of high and moderate-risk DRWs, season length increase will occur across all DRD categories, and outside of high and moderate-risk DRWs. The high and moderate risk DRWs of 2021 fall into ITCs with decreasing trend. CONCLUSIONS: The study identified areas of Nepal where malaria transmission suitability will emerge, disappear, increase, and decrease in the future. However, most of these areas are anticipated outside of the government's current and previously designated high and moderate-risk areas, and thus outside the focus of vector control interventions. Public health officials could use these anticipated changing areas of malaria risk to inform vector control interventions for eliminating malaria from the country, and to prevent malaria resurgence.

Geographical distribution and space-time clustering of human illnesses with major Salmonella serotypes in Florida, USA, 2017-2018.

Nontyphoidal salmonellosis is the leading reported foodborne illness in Florida. Although the diversity of Salmonella serotypes circulating in Florida has been identified, the geographical characteristics of the major serotypes are poorly described. Here we examined the geospatial patterns of 803 whole-genome sequenced Salmonella isolates within seven major serotypes (Enteritidis, Newport, Javiana, Sandiego, Braenderup, Typhimurium and I 4,[5],12:i:-) with the metadata obtained from Florida Department of Health during 2017-2018. Geographically, the distribution of incidence rates varied distinctively between serotypes. Illnesses with Enteritidis and Newport serotypes were widespread in Florida. The incidence rate for Javiana was relatively higher in the north compared to the south. Typhimurium was concentrated in the northwest, while I 4,[5],12:i:-, the monophasic variant of Typhimurium was limited to the south. We also evaluated space-time clustering of isolates at the zip code level using scan statistic models. Space-time clusters were detected for each major serotype during 2017-2018. The multinomial scan statistic found the risk of illness with Javiana was higher in the north and southwest in the fall of 2017 compared to other major serotypes. This serotype-specific clustering analysis will assist in further unpacking the associations between distinct reservoirs and illnesses with major serotypes in Florida.

High Case-Fatality Rate for Human Anthrax, Northern Ghana, 2005-2016.

The human cutaneous anthrax case-fatality rate is ≈1% when treated, 5%-20% when untreated. We report high case-fatality rates (median 35.0%; 95% CI 21.1%-66.7%) during 2005-2016 linked to livestock handling in northern Ghana, where veterinary resources are limited. Livestock vaccination and access to human treatment should be evaluated.

Sex-Specific Elk Resource Selection during the Anthrax Risk Period.

Anthrax, caused by the spore-forming bacterium Bacillus anthracis, is a zoonosis affecting animals and humans globally. In the United States, anthrax outbreaks occur in wildlife and livestock, with frequent outbreaks in native and exotic wildlife species in Texas, livestock outbreaks in the Dakotas, and sporadic mixed outbreaks in Montana. Understanding where pathogen and host habitat selection overlap is essential for anthrax management. Resource selection and habitat use of ungulates may be sex-specific and lead to differential anthrax exposure risks across the landscape for males and females. We evaluated female elk (Cervus canadensis) resource selection in the same study areas as male elk in a previous anthrax risk study to identify risk of anthrax transmission to females and compare transmission risk between females and males. We developed a generalized linear mixed-effect model to estimate resource selection for female elk in southwest Montana during the June to August anthrax transmission risk period. We then predicted habitat selection of female and male elk across the study area and compared selection with the distribution of anthrax risk to identify spatial distributions of potential anthrax exposure for the male and female elk. Female and male elk selected different resources during the anthrax risk period, which resulted in different anthrax exposure areas for females and males. The sex-specific resource selection and habitat use could infer different areas of risk for anthrax transmission, which can improve anthrax and wildlife management and have important public health and economic implications.

EVIDENCE OF EPIZOOTIC HEMORRHAGIC DISEASE VIRUS AND BLUETONGUE VIRUS EXPOSURE IN NONNATIVE RUMINANT SPECIES IN NORTHERN FLORIDA.

Epizootic hemorrhagic disease virus (EHDV) and bluetongue virus (BTV) are vector-borne viruses of ruminants nearly worldwide. They can affect white-tailed deer (WTD; Odocoileus virginianus), the ranching industry, and nonindigenous hoof stock species managed for conservation. One potential risk factor for ranched WTD is commingling with nonindigenous species on high-fenced properties. Nonindigenous species provide novel viewing and hunting opportunities; however, their presence may create disease hazards. Furthermore, animals within conservation properties may be at a risk from commingling exotics and adjacent wild WTD. Currently, knowledge about EHDV and BTV seroprevalence and transmission is limited in nonindigenous populations in the southeastern United States. The authors conducted a serological survey of 10 Bovidae and 5 Cervidae species residing within two properties in northern Florida. The first site was a conservation property breeding threatened nonindigenous species for conservation. The second property was a private high-fenced game preserve managing WTD and nonindigenous species for breeding, sale, and harvest. Blood samples were tested for titers to three EHDV serotypes (1, 2, and 6) and active circulating viral EHDV and BTV. The private ranch had evidence of EHDV or BTV in one of three (33.3%) Bovidae species and four of five (80%) Cervidae species sampled. At the conservation property, evidence of EHDV infection was found in four of seven (57.1%) Bovidae and one of one (100%) Cervidae species sampled. The presence of antibodies in many nonindigenous species sampled might indicate these species are potential viral hosts and may be a risk to ranched WTD and other species within the same property. Nonindigenous species within the private ranch and conservation properties are at risk of contracting EHDV and BTV, and herd managers should reduce vector-host interactions and consider increased biosecurity measures when translocating animals.

Nucleotide polymorphism assay for the identification of west African group Bacillus anthracis: a lineage lacking anthrose.

BACKGROUND: The exosporium of the anthrax-causing Bacillus anthracis endospores display a tetrasaccharide composed of three rhamnose residues and an unusual sugar termed anthrose. Anthrose is a proposed potential target for immunotherapy and for specific detection of B. anthracis. Although originally thought to be ubiquitous in B. anthracis, previous work identified an anthrose negative strain from a West African lineage isolated from cattle that could represent a vaccine escape mutant. These strains carry genes required for expression of the anthrose operon but premature stop codons resulting from an 8-bp insertion in BAS3320 (an amino-transferase) and a C/T substitution at position 892 of the BAS3321 (a glycosyltransferase) gene prevent anthrose expression. Various other single nucleotide polymorphisms (SNPs) have been identified throughout the operon and could be the basis for detection of anthrose-deficient strains. RESULTS: In this study, we evaluated rhAmp genotypic assays based on SNPs at positions 892 and 1352 of BAS3321 for detection and differentiation of anthrose negative (Ant-) West African strains. Discrimination of anthrose negative West African isolates was achieved with as low as 100 fg of DNA, whereas consistent genotyping of Sterne necessitated at least 1 pg of DNA. CONCLUSIONS: Screening of a global panel of B. anthracis isolates showed anthrose-expressing alleles are prevalent worldwide whereas the anthrose-deficient phenotype is to date limited to West Africa. Our work also revealed a third, previously unreported anthrose genotype in which the operon is altogether missing from a Polish B. anthracis isolate.

A network analysis framework to improve the delivery of mosquito abatement services in Machala, Ecuador.

BACKGROUND: Vector-borne disease places a high health and economic burden in the American tropics. Comprehensive vector control programs remain the primary method of containing local outbreaks. With limited resources, many vector control operations struggle to serve all affected communities within their districts. In the coastal city of Machala, Ecuador, vector control services, such as application of larvicides and truck-mounted fogging, are delivered through two deployment facilities managed by the Ecuadorian Ministry of Health. Public health professionals in Machala face several logistical issues when delivering mosquito abatement services, namely applying limited resources in ways that will most effectively suppress vectors of malaria, dengue, and encephalitis viruses. METHODS: Using a transportation network analysis framework, we built models of service areas and optimized delivery routes based on distance costs associated with accessing neighborhoods throughout the city. Optimized routes were used to estimate the relative cost of accessing neighborhoods for mosquito control services in Machala, creating a visual tool to guide decision makers and maximize mosquito control program efficiency. Location-allocation analyses were performed to evaluate efficiency gains of moving service deployment to other available locations with respect to distance to service hub, neighborhood population, dengue incidence, and housing condition. RESULTS: Using this framework, we identified different locations for targeting mosquito control efforts, dependent upon management goals and specified risk factors of interest, including human population, housing condition, and reported dengue incidence. Our models indicate that neighborhoods on the periphery of Machala with the poorest housing conditions are the most costly to access. Optimal locations of facilities for deployment of control services change depending on pre-determined management priorities, increasing the population served via inexpensive routes up to 34.9%, and reducing overall cost of accessing neighborhoods up to 12.7%. CONCLUSIONS: Our transportation network models indicate that current locations of mosquito control facilities in Machala are not ideal for minimizing driving distances or maximizing populations served. Services may be optimized by moving vector control operations to other existing public health facilities in Machala. This work represents a first step in creating a spatial tool for planning and critically evaluating the systematic delivery of mosquito control services in Machala and elsewhere.

Elk Resource Selection and Implications for Anthrax Management in Montana.

Anthrax, caused by the spore-forming bacterium Bacillus anthracis, is a zoonotic disease that affects humans and animals throughout the world. In North America, anthrax outbreaks occur in livestock and wildlife species. Vaccine administration in wildlife is untenable; the most effective form of management is surveillance and decontamination of carcasses. Successful management is critical because untreated carcasses can create infectious zones increasing risk for other susceptible hosts. We studied the bacterium in a re-emerging anthrax zone in southwest Montana. In 2008, a large anthraxepizootic primarily affected a domestic bison (Bison bison) herd and the male segment of a free-ranging elk (Cervus elaphus) herd in southwestern Montana. Following the outbreak, we initiated a telemetry study on elk to evaluate resource selection during the anthrax season to assist with anthrax management. We used a mixed effects generalized linear model (GLM) to estimate resource selection by male elk, and we mapped habitat preferences across the landscape. We overlaid preferred habitats on ecological niche model-based estimates of B. anthracis presence. We observed significant overlap between areas with a high predicted probability of male elk selection and B. anthracis potential. These potentially risky areas of elk and B. anthracis overlap were broadly spread over public and private lands. Future outbreaks in the region are probable, and this analysis identified the spatial extent of the risk area in the region, which can be used to prioritize anthrax surveillance.

Mapping Resource Selection Functions in Wildlife Studies: Concerns and Recommendations.

Predicting the spatial distribution of animals is an important and widely used tool with applications in wildlife management, conservation, and population health. Wildlife telemetry technology coupled with the availability of spatial data and GIS software have facilitated advancements in species distribution modeling. There are also challenges related to these advancements including the accurate and appropriate implementation of species distribution modeling methodology. Resource Selection Function (RSF) modeling is a commonly used approach for understanding species distributions and habitat usage, and mapping the RSF results can enhance study findings and make them more accessible to researchers and wildlife managers. Currently, there is no consensus in the literature on the most appropriate method for mapping RSF results, methods are frequently not described, and mapping approaches are not always related to accuracy metrics. We conducted a systematic review of the RSF literature to summarize the methods used to map RSF outputs, discuss the relationship between mapping approaches and accuracy metrics, performed a case study on the implications of employing different mapping methods, and provide recommendations as to appropriate mapping techniques for RSF studies. We found extensive variability in methodology for mapping RSF results. Our case study revealed that the most commonly used approaches for mapping RSF results led to notable differences in the visual interpretation of RSF results, and there is a concerning disconnect between accuracy metrics and mapping methods. We make 5 recommendations for researchers mapping the results of RSF studies, which are focused on carefully selecting and describing the method used to map RSF studies, and relating mapping approaches to accuracy metrics.

Spatio-temporal patterns of an anthrax outbreak in white-tailed deer, Odocoileus virginanus, and associated genetic diversity of Bacillus anthracis.

BACKGROUND: Anthrax, a soil-borne zoonosis caused by the bacterium Bacillus anthracis, is enzootic in areas of North America with frequent outbreaks in west Texas. Despite a long history of study, pathogen transmission during natural outbreaks remains poorly understood. Here we combined case-level spatio-temporal analysis and high resolution genotyping to investigate anthrax transmission dynamics. Carcass locations from a single white-tailed deer, Odocoileus virginanus, outbreak were analyzed for spatial clustering using K-function analysis and directionality with trend surface analysis and the direction test. RESULTS: The directionalities were compared to results of high resolution genotyping. The results of the spatial clustering analyses, combined with deer movement data, suggest anthrax transmission events occur within limited spatial areas, with carcass locations occurring within the activity space of adjacent cases. The directionality of the outbreak paralleled adjacent dry river beds. Isolates from the outbreak were represented by a single genotype based on multiple locus variable number tandem repeat analysis (MLVA); four sub-genotypes were identified using single nucleotide repeat (SNR) analysis. CONCLUSIONS: Areas of high transmission agreed spatially with areas of higher SNR genetic diversity; however, SNRs did not provide clear evidence of linear transmission. Overlap of case home ranges provides spatial and temporal support for localized transmission, which may include the role of necrophagous or hematophagous flies in outbreaks in this region. These results emphasize the need for active surveillance and prompt cleanup of anthrax carcasses to control anthrax both during outbreaks and between seasons.

Human cutaneous anthrax, Georgia 2010-2012.

We assessed the occurrence of human cutaneous anthrax in Georgia during 2010--2012 by examining demographic and spatial characteristics of reported cases. Reporting increased substantially, as did clustering of cases near urban centers. Control efforts, including education about anthrax and livestock vaccination, can be directed at areas of high risk.

Household-level spatiotemporal patterns of incidence of cholera, Haiti, 2011.

A cholera outbreak began in Haiti during October, 2010. Spatiotemporal patterns of household-level cholera in Ouest Department showed that the initial clusters tended to follow major roadways; subsequent clusters occurred further inland. Our data highlight transmission pathway complexities and the need for case and household-level analysis to understand disease spread and optimize interventions.

Culicoides Midge Abundance across Years: Modeling Inter-Annual Variation for an Avian Feeder and a Candidate Vector of Hemorrhagic Diseases in Farmed Wildlife.

(1) Background: Epizootic hemorrhagic disease virus (EHDV) and bluetongue virus (BTV) are orbiviruses that cause hemorrhagic disease (HD) with significant economic and population health impacts on domestic livestock and wildlife. In the United States, white-tailed deer (Odocoileus virginianus) are particularly susceptible to these viruses and are a frequent blood meal host for various species of Culicoides biting midges (Diptera: Ceratopogonidae) that transmit orbiviruses. The species of Culicoides that transmit EHDV and BTV vary between regions, and larval habitats can differ widely between vector species. Understanding how midges are distributed across landscapes can inform HD virus transmission risk on a local scale, allowing for improved animal management plans to avoid suspected high-risk areas or target these areas for insecticide control. (2) Methods: We used occupancy modeling to estimate the abundance of gravid (egg-laden) and parous (most likely to transmit the virus) females of two putative vector species, C. stellifer and C. venustus, and one species, C. haematopotus, that was not considered a putative vector. We developed a universal model to determine habitat preferences, then mapped a predicted weekly midge abundance during the HD transmission seasons in 2015 (July-October) and 2016 (May-October) in Florida. (3) Results: We found differences in habitat preferences and spatial distribution between the parous and gravid states for C. haematopotus and C. stellifer. Gravid midges preferred areas close to water on the border of well and poorly drained soil. They also preferred mixed bottomland hardwood habitats, whereas parous midges appeared less selective of habitat. (4) Conclusions: If C. stellifer is confirmed as an EHDV vector in this region, the distinct spatial and abundance patterns between species and physiological states suggest that the HD risk is non-random across the study area.

Spatial clusters of human and livestock anthrax define high-risk areas requiring intervention in Lao Cai Province, Vietnam 1991-2022.

Anthrax, a widespread zoonosis in low and middle-income countries with low disease awareness and insufficient livestock vaccination coverage, has been known in Lao Cai Province in northern Vietnam for years before its apparent absence in 2009, which requires investigation as this infection is frequently reported from neighbouring provinces and countries. We aimed to describe the seasonal patterns of anthrax (1991-2008), compare livestock anthrax vaccine coverage to disease occurrence (1991- 2022), and delineate the high-risk areas to inform local disease surveillance in the province. We illustrated the seasonal pattern of anthrax and provided a comparison between livestock vaccine coverage and disease occurrence by purely spatial SaTScan (Poisson model, 25% population at risk) to detect spatial clusters of human and livestock anthrax using population derived from zonal statistics routines. The number of cases, crude cumulative incidence, and spatial clusters of human and livestock anthrax were mapped in QGIS. Results indicate peak anthrax incidence from May to October. Buffalo, domestic cattle, and horses accounted for 75% of total animal cases. Horse anthrax was more common in Lao Cai than in its neighbours and often occurred in years with human mortality. Vaccination covered less than 30% of the livestock population. We found an apparent pattern where anthrax was controlled from 1998-2003 with higher vaccine coverage (>20%) and identified spatial clusters of human and livestock anthrax in Muong Khuong, Bao Thang, and Bac Ha districts of Lao Cai. The local public health and veterinary agencies are recommended to revisit the high-risk areas and communicate with neighbouring provinces for a regional approach to anthrax surveillance and control.

Spatial epidemiology of human anthrax in Son La province, Vietnam, 2003-2022.

AIMS: Anthrax is reported with frequency but poorly understood in Southeast Asian countries including Vietnam. In Vietnam, anthrax surveillance is national. However, case detection, prevention, and control are implemented locally at the provincial level. Here, we describe the epidemiological characteristics, identify spatial clusters of human anthrax, and compare the variation in livestock anthrax vaccine coverage to disease incidence in humans and livestock using historical data in Son La province, Vietnam (2003-2020). METHODS AND RESULTS: Most human cases occurred between April and September. Most of the patients were male, aged 15-54 years old. The human cases were mainly reported by public district hospitals. There was a delay between disease onset and hospitalization of ~5 days. We identified spatial clusters of high-high incidence communes in the northern communes of the province using the local Moran's I statistic. The vaccine coverage sharply decreased across the study period. The province reported sporadic human anthrax outbreaks, while animal cases were only reported in 2005 and 2022. CONCLUSIONS: These results suggest underreporting for human and livestock anthrax in the province. Intersectoral information sharing is needed to aid livestock vaccination planning, which currently relies on reported livestock cases. The spatial clusters identify areas for targeted surveillance and livestock vaccination, while the seasonal case data suggest prioritizing vaccination campaigns for February or early March ahead of the April peak. A regional approach for studying the role of livestock trading between Son La and neighbouring provinces in anthrax occurrence is recommended.

Spatial analysis of human and livestock anthrax in Lai Chau province, Vietnam (2004-2021).

Anthrax is reported globally with varying disease intensity and seasonality among countries. In Vietnam, anthrax epidemiology and ecology remain understudied. We used historical data of human and livestock anthrax from 2004 to 2021 in Lai Chau province, to identify spatial clusters of human and livestock anthrax, describe epidemiological characteristics, and compare livestock anthrax vaccine coverage to human and livestock disease incidence. Local Moran's I (LISA) using spatial Bayes smoothed commune-level cumulative incidence (per 10,000) for the study period, epidemiological descriptive statistics, livestock vaccine coverage data, and annual incidence rates (per 10,000) at provincial level were used. LISA identified a human anthrax hotspot (high-high) in the southeast which did not overlap spatially with livestock anthrax hotspots in southeastern and northeastern communes. Most human cases were male, aged 15-59 years, handled sick animals, and/or consumed contaminated meat. Almost all cases were reported by grassroot health facilities with a delay of 6.3 days between exposure and case notification to the national surveillance system. 80 % of human cases were reported from June-October. The increase in disease incidence occurred shortly after livestock anthrax vaccine coverage decreased. This study informs vaccination strategy and targeted surveillance and control measures in newly identified high-risk areas and seasons of anthrax.