Molecular characterisation of Histoplasma capsulatum sensu lato from Ethiopian horses reveals two distinct phylogenetic clades.

Epizootic lymphangitis (EL) is a highly prevalent and contagious infectious disease affecting horses in many parts of Ethiopia caused by Histoplasma capsulatum sensu lato ('var. farciminosum'). In this study, 12 suspected isolates of H. capsulatum sensu lato or yeasts unidentified by conventional biochemical tests isolated from Ethiopian horses with EL were characterised by internal transcribed spacer sequencing. Six of the 12 isolates were identified to be members of H. capsulatum sensu lato and the other six were Pichia kudriavzevii (synonym: Candida krusei) (n = 3), Trichosporon asahii (n = 1), Geotrichum silvicola (n = 1) and Moesziomyces aphidis (n = 1), respectively. The six H. capsulatum sensu lato isolates were further characterised by multilocus sequence analysis. Four distinct gene loci (arf [462 bases], H-anti [410 bases], ole1 [338 bases] and tub1 [272 bases]) of these six isolates as well as those of two H. capsulatum sensu lato ('var. farciminosum') reference strains (ATCC 58332 and ATCC 28798) were polymerase chain reaction (PCR)-amplified and sequenced. Phylogenetic analyses of their concatenated nucleotide sequences showed that three of the isolates and the reference strain ATCC 58332 were identical and belonged to the Eurasia clade within Latin American (LAm) A (H. suramericanum), and those of the other three isolates and the reference strain ATCC 28798 were identical and belonged to the Africa clade. At least two distinct phylogenetic clades of H. capsulatum sensu lato were circulating in Ethiopian horses with EL. Advanced molecular technologies and bioinformatics tools are crucial for the accurate identification and typing of pathogens as well as the discovery of novel microorganisms in veterinary microbiology.

Using multilocus sequence analysis with four concatenated housekeeping gene loci, at least two distinct phylogenetic clades, namely Eurasia clade and Africa clade, of Histoplasma capsulatum sensu lato were confirmed to be circulating in Ethiopian horses with epizootic lymphangitis.

Characterization of ophthalmic lesions and normal ocular parameters in a flock of captive MacQueen's (houbara) bustards (Chlamydotis macqueenii).

OBJECTIVES: To determine normal ocular parameters of the MacQueen's bustard (Chlamydotis macqueenii) and describe ophthalmic lesions in a captive bred population. ANIMALS STUDIED: Captive breeding population of 257 Macqueen's bustards. METHODS: All birds were screened for ocular abnormalities using direct ophthalmoscopy. Abnormalities were photographed. Normative values for Schirmer tear test-1 (STT-1), applanation tonometry, aerobic and anaerobic bacterial culture, fungal culture, and transcorneal ocular ultrasonography were derived from multiple cohorts of clinically normal adult birds. Five birds with ocular pathology also underwent transcorneal ultrasonography. Statistical comparisons for normative values between OD and OS, and males and females were made using a paired t-test or Mann-Whitney U-test, with a significance level of p < .05. RESULTS: Mean tear production based on Schirmer tear test 1 (STT-1) was 10.16 ± 4.61 mm/min (3-21 mm/min). Mean intraocular pressure (IOP) was 12.42 ± 4.94 mm Hg (5-26 mm Hg). Staphylococcus species were the most isolated bacteria from the conjunctival surfaces of normal birds (85%). Significant differences were found in transcorneal ultrasonographic measurements between males and females for axial globe length (p = .032), vitreous body depth (p = .049) and lens thickness (p = .0428). Corneal fibrosis was the most observed ocular abnormality amongst eyes with pathological changes (39%). CONCLUSIONS: Schirmer tear testing, tonometry and transcorneal ultrasound can easily be utilized in MacQueen's bustards and provide reproducible results. Normal parameters for these tests were determined, and common pathological ocular changes were described in this species.

Comparative investigations into the growth details of Histoplasma capsulatum var farciminosum on four different agar media.

Epizootic equine lymphangitis (EEL) is a chronic fungal disease that affects equids. The causative agent is a dimorphic fungus called Histoplasma capsulatum var farciminosum. Histoplasmacapsulatum var farciminosum field strain 7 (D 2878/2023) isolated from the eye socket of an EEL Ethiopian horse was sub-cultured on four different solid media and incubated at 26°C and 37°C for 6 weeks. Details of growth morphology were recorded and shown in images during 6 weeks of incubation. Histoplasmacapsulatum var farciminosum grew best at 26°C on all four agars, but only on sheep blood agar at 37°C as small, white dry colonies.

Histoplasma capsulatum var farciminosum was isolated from the eye socket of an equine epizootic lymphangitis infected Ethiopian horse on Mycosel agar, which was sub-cultured on four different solid media at two different temperatures for 6 weeks to show its growth pattern.

Perceptions on the impact of a structured community-based training model in undergraduate medical training during the first phase of clinical exposure: A qualitative study from Kerala.

The new competency-based undergraduate medical curriculum advocates early clinical exposure in medical training for adequate orientation to societal and patient needs. The present study aimed to explore the experiences of medical students about community-based training in rural hospitals during the first phase of clinical exposure. An exploratory qualitative study was conducted among 75 Bachelor of Medicine and Bachelor of Surgery students who underwent the training program as part of their undergraduate medical training using "most significant change" technique. The responses collected were analyzed using the inductive approach of thematic analysis. Majority of the participants opined that the program not only has enabled them to better understand their academic learning but also has provided a social learning experience. The student feedback throws light on the potential of such community-based learning programs to inspire the students to become a more humane version of themselves. This study observed that the remote hospital-based training has positively influenced the students.

Ignatzschineria cameli sp. nov., isolated from necrotic foot tissue of dromedaries (Camelus dromedarius) and associated maggots (Wohlfahrtia species) in Dubai.

Five bacterial strains, UAE-HKU57T, UAE-HKU58, UAE-HKU59, UAE-HKU60 and UAE-HKU61, were isolated in Dubai, UAE, from necrotic foot tissue samples of four dromedaries (Camelus dromedarius) and associated maggots (Wohrlfartia species). They were non-sporulating, Gram-negative, non-motile bacilli. They grew well under aerobic conditions at 37 °C, but not anaerobically. The pH range for growth was pH 7.0-9.0 (optimum, pH 7.5-8.0) and the strains could tolerate NaCl concentrations (w/v) up to 2 % (optimum, 0.5 %). They were catalase- and cytochrome oxidase-positive, but caseinase-, gelatinase- and urease-negative. Their phenotypic characters were distinguishable from other closely related species. Phylogenetic analyses of the almost-complete 16S rRNA gene and partial 23S rRNA gene, gyrB, groEL and recA sequences revealed that the five isolates were most closely related to undescribed Ignatzschineria strain F8392 and Ignatzschineria indica, but in most phylogenies clustered separately from these close relatives. Average nucleotide identity analysis showed that genomes of the five isolates (2.47-2.52 Mb, G+C content 41.71-41.86 mol%) were 98.00-99.97% similar to each other, but ≤87.18 % similar to other Ignatzschineriaspecies/strains. Low DNA relatedness between the five isolates to other Ignatzschineriaspecies/strains was also supported by Genome-to-Genome Distance Calculator analysis. The chemotaxonomic traits of the five strains were highly similar. They were non-susceptible (intermediate or resistant) to tetracycline and resistant to trimethoprim/sulphamethoxazole. The name Ignatzschineria cameli sp. nov. is proposed to accommodate these five strains, with strain UAE-HKU57T (=CCOS1165T=NBRC 113042T) as the type strain.

Serodiagnosis of aspergillosis in falcons (Falco spp.) by an Afmp1p-based enzyme-linked immunosorbent assay.

Aspergillosis in falcons may be associated with high mortality and difficulties in clinical and laboratory diagnosis. We previously cloned an immunogenic protein, Afmp1p, in Aspergillus fumigatus and showed that anti-Afmp1p antibodies were present in human patients with A. fumigatus infections. In this study, we hypothesise that a similar Afmp1p-based enzyme-linked immunosorbent assay (ELISA) could be applied to serodiagnose falcon aspergillosis. A specific polyclonal antibody was first generated to detect falcon serum IgY. Horseradish peroxidase-conjugate of this antibody was then used to measure anti-Afmp1p antibodies in sera collected from falcons experimentally infected with A. fumigatus, and the performance of the Afmp1p-based ELISA was evaluated using sera from healthy falcons and falcons with documented A. fumigatus infections. All four experimentally infected falcons developed culture- and histology-proven invasive aspergillosis. Anti-Afmp1p antibodies were detected in their sera. For the Afmp1p-based ELISA, the mean ± SD OD450 nm using sera from 129 healthy falcons was 0.186 ± 0.073. Receiver operating characteristics curve analysis showed an absorbance cut-off value of 0.407. One negative serum gave an absorbance outside the normal range, giving a specificity of 99.2%. For the 12 sera from falcons with confirmed aspergillosis, nine gave absorbance values ≥ cut-off, giving a sensitivity of 75%. The Afmp1p-based ELISA is useful for serodiagnosis of falcons with aspergillosis.

Osmoregulation requires brain expression of the renal Na-K-2Cl cotransporter NKCC2.

The Na-K-2Cl cotransporter 2 (NKCC2) was thought to be kidney specific. Here we show expression in the brain hypothalamo-neurohypophyseal system (HNS), wherein upregulation follows osmotic stress. The HNS controls osmotic stability through the synthesis and release of the neuropeptide hormone, arginine vasopressin (AVP). AVP travels through the bloodstream to the kidney, where it promotes water conservation. Knockdown of HNS NKCC2 elicited profound effects on fluid balance following ingestion of a high-salt solution-rats produced significantly more urine, concomitant with increases in fluid intake and plasma osmolality. Since NKCC2 is the molecular target of the loop diuretics bumetanide and furosemide, we asked about their effects on HNS function following disturbed water balance. Dehydration-evoked GABA-mediated excitation of AVP neurons was reversed by bumetanide, and furosemide blocked AVP release, both in vivo and in hypothalamic explants. Thus, NKCC2-dependent brain mechanisms that regulate osmotic stability are disrupted by loop diuretics in rats.

New hepatitis E virus genotype in camels, the Middle East.

In a molecular epidemiology study of hepatitis E virus (HEV) in dromedaries in Dubai, United Arab Emirates, HEV was detected in fecal samples from 3 camels. Complete genome sequencing of 2 strains showed >20% overall nucleotide difference to known HEVs. Comparative genomic and phylogenetic analyses revealed a previously unrecognized HEV genotype.

Diet and Lifestyle Modifications for Fibromyalgia.

Fibromyalgia (FM) is a complex, widespread pain disorder characterized by symptoms such as fatigue, sleep deprivation, mental fog, mood swings, and headaches. Currently, there are only three FDA-approved medications for FM patients: duloxetine, milnacipran, and pregabalin, with outcomes frequently being inadequate. This research team aims to investigate the effects of diet and lifestyle modifications on FM, with emphasis on anti-inflammatory diet, antioxidants, and gluten-free diets, as well as supplementation with Magnesium, CQ10, and Vitamin D, microbiome, sleep, exercise, and cognitive behavioral therapy. We reviewed the pathophysiology of certain foods that can be proinflammatory with the release of cytokines leading to activation of pain, fatigue and aggravation of the majority of Fibromyalgia symptoms. A literature review was performed by identifying FM articles published between 1994 and 2022 via PubMed and EMBASE databases, with particular emphasis on randomized controlled trials, meta-analysis, and evidence-based treatment guidelines. This review article was completed by a comprehensive narrative review process, in which our team systematically examined relevant scientific literature to provide a comprehensive overview of the significant role that diet and other lifestyle modifications play in mediating symptoms of Fibromyalgia. We propose that diet modifications and lifestyle changes, such as sleep, exercise, and weight loss, can be important steps in managing FM.

An overview of various stages and morphology of Histoplasma capsulatum var. farciminosum in the horse.

This article describes the development of the pathogenic dimorphic fungus Histoplasma capsulatum var. farciminosum (HCF), which is the causative agent of Equine epizootic lymphangitis (EEL), from the mycelial form in the soil to the yeast form in the horse. In this study, the stages and morphology of HCF were identified through histopathological analysis and culture with various samples collected in Ethiopia from 15 horses showing clinical signs of EEL. In equids, especially cart horses in Ethiopia, poor-quality harnesses cause cutaneous wounds, which often attract flies facilitating the transmission of the fungus. Also, HCF infection occurs through open wounds or ocular mucous membranes when horses roll on contaminated damp soil. Respiratory histoplasmosis can occur through inhaling fungal spores, which is rare. HCF microconidia enter the lungs and skin wounds and are phagocytized by tissue-resident macrophages. The spores undergo intracellular replication within the macrophages transitioning into yeasts. The infected macrophages undergo lysis releasing pathogenic yeast cells into the surrounding tissue. Consequently, yeast-rich purulent exudate is produced, contaminating the soil in stables where yeast cells germinate into the mycelial form, and the entire process starts from the beginning.

Comprehensive metabolic investigation of dopamine reuptake inhibitor HDMP-28 in equine liver microsomes and Cunninghamella elegans for doping control.

A dopamine reuptake inhibitor is a type of medication or substance that works by blocking the reuptake of dopamine in the brain. Dopamine reuptake inhibitors offer multiple effects, including increased alertness, improved mood, and therapeutic potential for conditions like depression, ADHD, and Parkinson's disease. HDMP-28, or methylnaphthidate, is a potent synthetic stimulant from the phenyltropane class. It surpasses methylphenidate in both dopamine reuptake inhibition and half-life. As a dopamine reuptake inhibitor, it boosts dopamine levels by hindering reuptake into nerve cells, resulting in heightened stimulation and increased energy. In order to comprehensively address both the tangible and potential repercussions of the unauthorized utilization of the aforementioned substance in sports, it is imperative to establish analytical methodologies for the identification of the parent drug and its primary metabolites. Additionally, a comprehensive analysis of the metabolic characteristics of HDMP-28 in both human and animal subjects has yet to be published. This study explores the metabolic conversion of HDMP-28 mediated by equine liver microsomes and Cunninghamella elegans. An extraction and detection method was developed, optimized, and validated for doping assessment in equine urine and plasma. Liquid chromatography-high-resolution mass spectrometry was employed to determine metabolite structures. The study identified 31 (22 phase I and 9 phase II) metabolites of HDMP-28, including hydroxylated, hydrogenated, and hydrolyzed analogs. Glucuronic acid-conjugated metabolites were also detected. This manuscript describes metabolites based on the in vitro studies, which might not be the same in vivo. These findings aid in the detection and understanding of the illicit use of HDMP-28 in equestrian sports.

Appropriateness of Levothyroxine Prescription: A Multicenter Retrospective Study.

CONTEXT: Levothyroxine is one of the most prescribed medications in the United States. OBJECTIVE: This study explores the appropriateness of levothyroxine prescriptions. METHODS: A retrospective multicenter study was conducted on adult patients who were prescribed levothyroxine for the first time between 2017 and 2020 at three academic centers in the United States. We classified each case of levothyroxine initiation into one of three mutually exclusive categories: appropriate (clinically supported), indeterminate (clinically unclear), or nonevidence based (NEB, not clinically supported). RESULTS: A total of 977 participants were included. The mean age was 55 years (SD 19), there was female (69%) and White race predominance (84%), and 44% had possible hypothyroid symptoms. Nearly half of the levothyroxine prescriptions were considered NEB (528, 54%), followed by appropriate (307, 31%) and indeterminate (118, 12%). The most common reason for NEB prescription was an index thyrotropin (TSH) value of less than 10 mIU/L without previous TSH or thyroxine values (131/528, 25%), for appropriate prescription, was overt hypothyroidism (163/307, 53%), and for an indeterminate prescription was a nonconfirmed subclinical hypothyroidism with TSH greater than or equal to 10 mIU/L (no confirmatory testing) (51/118, 43%). In multivariable analysis, being female (odds ratio [OR]: 1.3; 95% CI, 1.0-1.7) and prescription by a primary care provider (OR: 1.5; 95% CI, 1.2-2.0) were associated with NEB prescriptions. CONCLUSION: There is a considerable proportion of NEB levothyroxine prescriptions. These results call for additional research to replicate these findings and to explore the perspective of those prescribing and receiving levothyroxine.

Comparison of five basal compositions of selective chocolate agar media for isolation of Taylorella equigenitalis.

The gold standard method to isolate and identify Taylorella equigenitalis, the contagious agent of equine metritis, is the culture method according to the World Organisation for Animal Health Terrestrial Manual. No selective T. equigenitalis chocolate agar medium has been developed since the 1980s and the existing media show limited performances due to the fastidious nature of T. equigenitalis and the presence of interfering bacteria in the genital tract of equines. Here, the growth rates of 6 T. equigenitalis strains and 7 non-T. equigenitalis strains were compared on Timoney's selective medium formulated with 5 different basal agars (Columbia, Eugon, Blood, Mueller-Hinton and Tryptose Blood) provided by 2 to 4 suppliers per basal agar. The impact of glucose and/or Vitox supplementation was also investigated. Overall, the performance of selective T. equigenitalis media could be improved by substituting Eugon or Columbia agar with Blood, Mueller-Hinton or Tryptose Blood agar. It is nevertheless essential to validate the basal agar/supplier pair using a panel of T. equigenitalis strains. Furthermore, our findings confirm the need to supplement the selective media with a mixture of amino acids, nucleotides, and organic, mineral and vitamin compounds, translated here by Vitox supplementation.

Subcategories of Fibromyalgia: A New Concept.

Fibromyalgia has previously been categorized as primary, secondary, and juvenile fibromyalgia. However, these definitions do not adequately explain the etiopathology of disease, nor do they help direct new specific therapies. Herein, we review the previously known categorizations of fibromyalgia. Based on common patient characteristics and previously studied pathophysiologies, we propose new subcategorizations of fibromyalgia that we have self-narrated, including hormonal fibromyalgia, neuroendocrine fibromyalgia, psychologic fibromyalgia, inflammatory fibromyalgia, and lastly, neuropathic fibromyalgia. Future research needs to be done to verify, add to, and fully describe these self-narrated categories of fibromyalgia that we have proposed.

Genetic diversity and spatial distribution of Burkholderia mallei by core genome-based multilocus sequence typing analysis.

Burkholderia mallei is the etiological agent of glanders, a highly contagious and often fatal disease in equids. Due to the high genetic clonality of B. mallei, high-resolution typing assays are necessary to differentiate between individual strains. Here we report on the development and validation of a robust and reproducible core genome-based Multi Locus Sequence Typing Assay (cgMLST) for B. mallei, which is based on 3328 gene targets and enables high-resolution typing at the strain level. The assay was validated using a set of 120 B. mallei genomes from public databases and 23 newly sequenced outbreak strains from in-house strain collections. In this cgMLST analysis, strains from different geographic regions were clearly distinguished by at least 70 allele differences, allowing spatial clustering while closely related and epidemiologically related strains were separated by only zero to three alleles. Neither the different sequencing technologies nor the assembly strategies had an influence on the cgMLST results. The developed cgMLST is highly robust, reproducible and can be used for outbreak investigations, source tracking and molecular characterization of new B. mallei isolates.

Natural Burkholderia mallei infection in Dromedary, Bahrain.

We confirm a natural infection of dromedaries with glanders. Multilocus variable number tandem repeat analysis of a Burkholderia mallei strain isolated from a diseased dromedary in Bahrain revealed close genetic proximity to strain Dubai 7, which caused an outbreak of glanders in horses in the United Arab Emirates in 2004.

Understanding reporting practices and perceptions of barriers in adverse events following immunisation surveillance: A cross-sectional survey of paediatricians in Kerala, India.

PURPOSE: The role of health care professionals (HCPs) is central to adverse event following immunisation (AEFI) surveillance. A cross-sectional survey was conducted among paediatricians practising in Kerala, India, to assess their knowledge and reporting behaviour in AEFI surveillance as well as to identify barriers to reporting. RESULTS: A random sample of 380 paediatricians were contacted of whom, 243 (63.9%) participated in the survey. The understanding scores were distributed as follows: 30.9% very high or high, 40.3% moderate, and 28.8% low. Formal training was significantly associated with higher understanding scores, and increased AEFI detection and reporting. Only 42.0% of respondents had formal training; paediatricians in the public sector had higher access to training than those in the private sector. There were 141 respondents (58.0%) who identified an AEFI in the previous year, of whom 66 (46.8%) reported it. The main barriers to AEFI reporting were: difficulties with reporting process (28.9%); fear of raising public alarm (28.1%); time constraints (22.3%); fear of personal consequences (15.7%); and belief that health authorities rarely take useful action (11.6%). CONCLUSION: Training in AEFI surveillance should be prioritised for HCPs with greater emphasis in medical education programmes. Study showed that a user-friendly reporting mechanism and a blame-free culture are crucial to improve AEFI reporting practices.

Assessment of Squalor in Migrant Colonies of Thiruvalla Province of Kerala, India using Rapid Survey Technique.

BACKGROUND: Domestic squalor refers to households that are extremely cluttered, in a filthy condition, and where the accumulation of items such as personal possessions, rubbish, excrement and decomposing food creates an environment that jeopardizes the health and wellbeing of the occupant(s). In India, an estimated 258 million are migrants. They are more likely to live in squalor due to inferior socio-economic status and no permanent residence. This poses a threat to the health of the migrants and the neighbors. OBJECTIVE: To assess the squalor and morbidity pattern among the migrants of Migrant colonies in Thiruvalla using Rapid survey technique. METHODOLOGY: The state of squalor in migrant colonies was assessed by Lot Quality Assurance Sampling Methodology using the Environment Cleanliness and Clutter Scale (ECCS). The sample size for each lot/colony was '14' dwellings according to LQAS table. The details were collected from 14 inhabitants of different dwellings of the same colony. The inhabitants were selected randomly and were excluded if he belonged to the same dwelling. Fifteen colonies were randomly selected to achieve the sample size of 210 (15*14). The study was done in Tiruvalla municipality. RESULTS AND CONCLUSION: Only two colonies (n = 15) were squalor free. Majority of the dwellings (n = 210) were having an ECCS score between 13 and 15. Common ailments affecting migrants include Common cold, Skin disorders, and dental caries and gastritis. Squalor was found in most of the migrant colonies as they are living in inhuman conditions.

A new strain of Taylorella asinigenitalis shows differing pathogenicity in mares and Jenny donkeys.

BACKGROUND: Three horse mares inadvertently inseminated with semen from a Tayorella asinigenitalis-positive Jack donkey developed severe, purulent endometritis whereas two Jenny donkeys mated naturally to the same Jack donkey did not develop clinical signs of infection. OBJECTIVES: To isolate and identify the causative agent. STUDY DESIGN: Case report. METHODS: Endometrial swabs from the infected mares were cultured on selective and non-selective media under aerobic and microaerophilic conditions. Isolates were subjected to Gram staining, oxidase and catalase tests, the Monotayl Latex Agglutination test and PCR to test for both T. equigenitalis and T. asinigenitalis. In vitro antimicrobial susceptibility testing was performed and the bacterial isolate was genotyped using MLST. RESULTS: A new sequence type of T. asinigenitalis was confirmed. MAIN LIMITATIONS: A limited numbers of mares and donkeys are described. CONCLUSIONS: This strain of T. asinigenitalis causes a severe venereal infection in mares but not in Jenny donkeys.

Together let us confront it: An outbreak investigation of hepatitis B in Pathanamthitta district, Kerala.

INTRODUCTION: Hepatitis B is a potentially life-threatening liver infection caused by the Hepatitis B virus (HBV). The established routes of transmission are from mother to infant, sexual contact, and exposure to blood or body fluids. Though HBV is preventable by vaccine and robust infection control practices, outbreaks of HBV infection do occur in India. However, the state of Kerala with its health parameters, one among the best in the country, cannot afford to have continuing outbreaks. An unusual increase in the reported cases of Hepatitis B in a rural area of Pathanamthitta district of Kerala, called for an outbreak investigation. AIMS: To describe the epidemiological features, to determine the risk factors associated with HBV transmission, and to suggest measures to prevent future transmission. METHODS: A community-based case-control study (1:2) was undertaken. A total of 162 participants (54 cases and 108 age, gender, and neighborhood matched controls) took part in the study. Focus group discussions were conducted with subject experts to develop an interview schedule assessing 40 risk factors. It was further reviewed by the University of Sydney. Data was collected by trained Junior Health Inspectors and Junior Public Health Nurses of the Primary Health Centers. Data was analyzed using SPSS v. 20. Proportions were compared by Univariate analysis, sub-group analysis, and logistic regression. Population Attributable Risk (PAR) was also calculated. RESULTS AND CONCLUSION: More than 90% of the infections were IgM anti-HBc positive, suggesting a recent infection. Interventions during hospitalization [OR: 7.98 (95% CI - 2.17--29.4)], family history of Hepatitis B [OR. 4.14 (95%CI - 1.73--9.9)], and laboratory investigations [OR: 3.99 (1.72--9.31)] were found to be significant risk factors. PAR was highest for laboratory interventions (32%). Vaccinating household contacts and strict enforcement of infection control practices could substantially reduce the burden of this fatal disease.