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Volume 18, Number 1—January 2012

Volume 18, Number 1—January 2012   PDF Version [PDF - 7.63 MB - 207 pages]


  • Medscape CME Activity
    Intestinal Toxemia Botulism in 3 Adults, Ontario, Canada, 2006–2008 PDF Version [PDF - 208 KB - 6 pages]
    Y. D. Sheppard et al.
    View Summary

    An underlying gastrointestinal condition is a risk factor for this disease.

        View Abstract

    Five cases of intestinal toxemia botulism in adults were identified within an 18-month period in or near Toronto, Ontario, Canada. We describe findings for 3 of the 5 case-patients. Clinical samples contained Clostridium botulinum spores and botulinum neurotoxins (types A and B) for extended periods (range 41–61 days), indicative of intestinal toxemia botulism. Patients’ clinical signs improved with supportive care and administration of botulinum antitoxin. Peanut butter from the residence of 1 case-patient yielded C. botulinum type A, which corresponded with type A spores found in the patient’s feces. The food and clinical isolates from this case-patient could not be distinguished by pulsed-field gel electrophoresis. Two of the case-patients had Crohn disease and had undergone previous bowel surgery, which may have contributed to infection with C. botulinum. These cases reinforce the view that an underlying gastrointestinal condition is a risk factor for adult intestinal toxemia botulism.


  • Serious Invasive Saffold Virus Infections in Children, 2009 PDF Version [PDF - 245 KB]
    A. Nielsen et al.
    View Summary

    This virus might have caused previously unexplained cerebral infections and deaths in children.

        View Abstract

    The first human virus in the genus Cardiovirus was described in 2007 and named Saffold virus (SAFV). Cardioviruses can cause severe infections of the myocardium and central nervous system in animals, but SAFV has not yet been convincingly associated with disease in humans. To study a possible association between SAFV and infections in the human central nervous system, we designed a real-time PCR for SAFV and tested cerebrospinal fluid (CSF) samples from children <4 years of age. SAFV was detected in 2 children: in the CSF and a fecal sample from 1 child with monosymptomatic ataxia caused by cerebellitis; and in the CSF, blood, and myocardium of another child who died suddenly with no history of illness. Virus from each child was sequenced and shown to be SAFV type 2. These findings demonstrate that SAFV can cause serious invasive infection in children.

  • Modeling Insights into Haemophilus influenzae Type b Disease, Transmission, and Vaccine Programs PDF Version [PDF - 444 KB - 8 pages]
    M. L. Jackson et al.
    View Summary

    Flexible simulation model use can optimize vaccination programs and response to changes in vaccine supply.

        View Abstract

    In response to the 2007–2009 Haemophilus influenzae type b (Hib) vaccine shortage in the United States, we developed a flexible model of Hib transmission and disease for optimizing Hib vaccine programs in diverse populations and situations. The model classifies population members by age, colonization/disease status, and antibody levels, with movement across categories defined by differential equations. We implemented the model for the United States as a whole, England and Wales, and the Alaska Native population. This model accurately simulated Hib incidence in all 3 populations, including the increased incidence in England/Wales beginning in 1999 and the change in Hib incidence in Alaska Natives after switching Hib vaccines in 1996. The model suggests that a vaccine shortage requiring deferral of the booster dose could last 3 years in the United States before loss of herd immunity would result in increasing rates of invasive Hib disease in children <5 years of age.

  • Assessing Prion Infectivity of Human Urine in Sporadic Creutzfeldt-Jakob Disease PDF Version [PDF - 800 KB - 8 pages]
    S. Notari et al.
    View Summary

    Intracerebral inoculation of transgenic mice failed to demonstrate prion disease transmission.

        View Abstract

    Prion diseases are neurodegenerative conditions associated with a misfolded and infectious protein, scrapie prion protein (PrPSc). PrPSc propagate prion diseases within and between species and thus pose risks to public health. Prion infectivity or PrPSc presence has been demonstrated in urine of experimentally infected animals, but there are no recent studies of urine from patients with Creutzfeldt-Jakob disease (CJD). We performed bioassays in transgenic mice expressing human PrP to assess prion infectivity in urine from patients affected by a common subtype of sporadic CJD, sCJDMM1. We tested raw urine and 100-fold concentrated and dialyzed urine and assessed the sensitivity of the bioassay along with the effect of concentration and dialysis on prion infectivity. Intracerebral inoculation of transgenic mice with urine from 3 sCJDMM1 patients failed to demonstrate prion disease transmission, indicating that prion infectivity in urine from sCJDMM1 patients is either not present or is <0.38 infectious units/mL.

  • High Prevalence of Multidrug-Resistant Tuberculosis, Swaziland, 2009–2010 PDF Version [PDF - 294 KB]
    E. Sanchez-Padilla et al.
    View Summary

    One third of previously treated patients had MDR TB.

        View Abstract

    In Africa, although emergence of multidrug-resistant (MDR) tuberculosis (TB) represents a serious threat in countries severely affected by the HIV epidemic, most countries lack drug-resistant TB data. This finding was particularly true in the Kingdom of Swaziland, which has the world’s highest HIV and TB prevalences. Therefore, we conducted a national survey in 2009–2010 to measure prevalence of drug-resistant TB. Of 988 patients screened, 420 new case-patients and 420 previously treated case-patients met the study criteria. Among culture-positive patients, 15.3% new case-patients and 49.5% previously treated case-patients harbored drug-resistant strains. MDR TB prevalence was 7.7% and 33.8% among new case-patients and previously treated case-patients, respectively. HIV infection and past TB treatment were independently associated with MDR TB. The findings assert the need for wide-scale intervention in resource-limited contexts such as Swaziland, where diagnostic and treatment facilities and health personnel are lacking.

  • Medscape CME Activity
    Accelerating Control of Pertussis in England and Wales PDF Version [PDF - 330 KB - 10 pages]
    H. Campbell et al.
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    Pertussis incidence among infants can be reduced by early completion of the primary vaccination schedule.

        View Abstract

    Results of an accelerated pertussis vaccination schedule for infants introduced in 1990 in England and Wales were examined. Earlier scheduling and sustained high vaccine coverage resulted in fewer reported cases of pertussis among infants, reinforcing the World Health Organization drive for on-time completion of the infant vaccination schedule. As determined by using the screening method, the first dose of vaccine was 61.7% effective in infants <6 months of age, and effectiveness increased with subsequent doses. Three doses of a good whole-cell pertussis vaccine were 83.7% effective in children 10–16 years of age; a preschool booster vaccination further reduced pertussis incidence in children <10 years of age. As in other industrialized countries, surveillance data during 1998–2009 showed that pertussis in England and Wales mainly persists in young infants (i.e., <3 months of age), teenagers, and adults. Future vaccine program changes may be beneficial, but additional detail is required to inform such decisions.

  • The 1918–19 Influenza Pandemic in Boyacá, Colombia PDF Version [PDF - 454 KB]
    G. Chowell et al.
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    Timing of pandemic onset and prior immunity of populations varied by region.

        View Abstract

    To quantify age-specific excess-mortality rates and transmissibility patterns for the 1918–20 influenza pandemic in Boyacá, Colombia, we reviewed archival mortality records. We identified a severe pandemic wave during October 1918–January1919 associated with 40 excess deaths per 10,000 population. The age profile for excess deaths was W shaped; highest mortality rates were among infants (<5 y of age), followed by elderly persons (>60 y) and young adults (25–29 y). Mean reproduction number was estimated at 1.4–1.7, assuming 3- or 4-day generation intervals. Boyacá, unlike cities in Europe, the United States, or Mexico, experienced neither a herald pandemic wave of deaths early in 1918 nor a recrudescent wave in 1920. In agreement with reports from Mexico, our study found no death-sparing effect for elderly persons in Colombia. We found regional disparities in prior immunity and timing of introduction of the 1918 pandemic virus across populations.

  • Use of Lean Response to Improve Pandemic Influenza Surge in Public Health Laboratories PDF Version [PDF - 469 KB]
    J. L. Isaac-Renton et al.
    View Summary

    These tools enabled laboratory response to the 10-fold increase in testing demands.

        View Abstract

    A novel influenza A (H1N1) virus detected in April 2009 rapidly spread around the world. North American provincial and state laboratories have well-defined roles and responsibilities, including providing accurate, timely test results for patients and information for regional public health and other decision makers. We used the multidisciplinary response and rapid implementation of process changes based on Lean methods at the provincial public health laboratory in British Columbia, Canada, to improve laboratory surge capacity in the 2009 influenza pandemic. Observed and computer simulating evaluation results from rapid processes changes showed that use of Lean tools successfully expanded surge capacity, which enabled response to the 10-fold increase in testing demands.

  • Invasive Meningococcal Capsular Group Y Disease, England and Wales, 2007–2009 PDF Version [PDF - 322 KB - 8 pages]
    S. N. Ladhani et al.
    View Summary

    Increases may result from mutations that allow the organism to evade the immune system.

        View Abstract

    Enhanced national surveillance for invasive meningococcal disease in England and Wales identified an increase in laboratory-confirmed capsular group Y (MenY) disease from 34 cases in 2007 to 44 in 2008 and 65 in 2009. For cases diagnosed in 2009, patient median age at disease onset was 60 years; 39% of patients had underlying medical conditions, and 19% died. MenY isolates causing invasive disease during 2007–2009 belonged mainly to 1 of 4 clonal complexes (cc), cc23 (56% of isolates), cc174 (21%), cc167 (11%), and cc22 (8%). The 2009 increase resulted primarily from sequence type 1655 (cc23) (22 cases in 2009, compared with 4 cases each in 2007 and 2008). cc23 was associated with lpxL1 mutations and meningitis in younger age groups (<25 years); cc174 was associated with nonmeningitis, particularly pneumonia, in older age groups (>65 years). The increase in MenY disease requires careful epidemiologic and molecular monitoring.

Historical Review

  • Differential Mortality Rates by Ethnicity in 3 Influenza Pandemics Over a Century, New Zealand PDF Version [PDF - 260 KB]
    N. Wilson et al.
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    The persistent excess in adverse outcomes by ethnicity highlights the need for improved public health responses.

        View Abstract

    Evidence suggests that indigenous populations have suffered disproportionately from past influenza pandemics. To examine any such patterns for Māori in New Zealand, we searched the literature and performed new analyses by using additional datasets. The Māori death rate in the 1918 pandemic (4,230/100,000 population) was 7.3× the European rate. In the 1957 pandemic, the Māori death rate (40/100,000) was 6.2× the European rate. In the 2009 pandemic, the Māori rate was higher than the European rate (rate ratio 2.6, 95% confidence interval 1.3–5.3). These findings suggest some decline in pandemic-related ethnic inequalities in death rates over the past century. Nevertheless, the persistent excess in adverse outcomes for Māori, and for Pacific persons residing in New Zealand, highlights the need for improved public health responses.

  • Daily Newspaper View of Dengue Fever Epidemic, Athens, Greece, 1927–1931 PDF Version [PDF - 213 KB]
    C. Louis
    View Summary

    Controversy remains about possible dengue hemorrhagic fever during the epidemic.

        View Abstract

    During the late summers of 1927 and 1928, a biphasic dengue epidemic affected the Athens, Greece, metropolitan area; >90% of the population became sick, and >1,000 persons (1,553 in the entire country) died. This epidemic was the most recent and most serious dengue fever epidemic in Europe. Review of all articles published by one of the most influential Greek daily newspapers (I Kathimerini) during the epidemic and the years that followed it did not shed light on the controversy about whether the high number of deaths resulted from dengue hemorrhagic fever after sequential infections with dengue virus types 1 and 2 or to a particularly virulent type 1 virus. Nevertheless, study of the old reports is crucial considering the relatively recent introduction of Aedes albopictus mosquitoes and the frequent warnings of a possible reemergence of dengue fever in Europe.


  • Unexpected Result of Hendra Virus Outbreaks for Veterinarians, Queensland, Australia PDF Version [PDF - 205 KB]
    D. H. Mendez et al.
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    A qualitative study of equine veterinarians and allied staff from Queensland, Australia, showed that veterinarians are ceasing equine practice because of fears related to Hendra virus. Their decisions were motivated by personal safety and legal liability concerns.

  • Candida spp. with Acquired Echinocandin Resistance, France, 2004–2010 PDF Version [PDF - 261 KB]
    E. Dannaoui et al.
        View Abstract

    We report 20 episodes of infection caused by acquired echinocandin-resistant Candida spp. harboring diverse and new Fksp mutations. For 12 patients, initial isolates (low MIC, wild-type Fksp sequence) and subsequent isolates (after caspofungin treatment, high MIC, mutated Fksp) were genetically related.

  • Outbreak of Leptospirosis after Flood, the Philippines, 2009 PDF Version [PDF - 160 KB]
    A. T. Amilasan et al.
        View Abstract

    After a typhoon in September 2009, an outbreak of leptospirosis occurred in Metro Manila, the Philippines; 471 patients were hospitalized and 51 (10.8%) died. A hospital-based investigation found risk factors associated with fatal infection to be older age, hemoptysis, anuria, jaundice, and delayed treatment with antimicrobial drugs.

  • Legionella longbeachae and Endocarditis PDF Version [PDF - 249 KB - 3 pages]
    N. Leggieri et al.
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    We report a case of infectious endocarditis attributable to Legionella longbeachae. L. longbeachae is usually associated with lung infections. It is commonly found in composted waste wood products. L. longbeachae should be regarded as an agent of infectious endocarditis, notably in the context of gardening involving handling of potting soils.

  • Emergence of Blastoschizomyces capitatus Yeast Infections, Central Europe PDF Version [PDF - 226 KB]
    T. Birrenbach et al.
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    We report 5 cases of disseminated infection caused by Blastoschizomyces capitatus yeast in central Switzerland. The emergence of this yeast in an area in which it is not known to be endemic should alert clinicians caring for immunocompromised patients outside the Mediterranean region to consider infections caused by unfamiliar fungal pathogens.

  • Asymmetric Type F Botulism with Cranial Nerve Demyelination PDF Version [PDF - 311 KB]
    A. Filozov et al.
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    We report a case of type F botulism in a patient with bilateral but asymmetric neurologic deficits. Cranial nerve demyelination was found during autopsy. Bilateral, asymmetric clinical signs, although rare, do not rule out botulism. Demyelination of cranial nerves might be underrecognized during autopsy of botulism patients.

  • MRSA USA300 at Alaska Native Medical Center, Anchorage, Alaska, USA, 2000–2006 PDF Version [PDF - 203 KB - 4 pages]
    M. Z. David et al.
        View Abstract

    To determine whether methicillin-resistant Staphylococcus aureus (MRSA) USA300 commonly caused infections among Alaska Natives, we examined clinical MRSA isolates from the Alaska Native Medical Center, Anchorage, during 2000–2006. Among Anchorage-region residents, USA300 was a minor constituent among MRSA isolates in 2000–2003 (11/68, 16%); by 2006, USA300 was the exclusive genotype identified (10/10).

  • Mutations I117V and I117M and Oseltamivir Sensitivity of Pandemic (H1N1) 2009 Viruses PDF Version [PDF - 313 KB - 4 pages]
    A. C. Hurt et al.
        View Abstract

    Analysis of mutations I117V and I117M in the neuraminidase of influenza A pandemic (H1N1) 2009 viruses showed that I117V confers a mild reduction in oseltamivir sensitivity and has a synergistic effect of further increasing resistance when combined with H275Y. Contrary to recent reports, the I117M mutation does not alter oseltamivir sensitivity.

  • Multistate Outbreak of MDR TB Identified by Genotype Cluster Investigation PDF Version [PDF - 247 KB - 4 pages]
    P. M. Barry et al.
    View Summary

    In the United States, more than half the cases of tuberculosis (TB) occur in people born outside this country. Many immigrants are assumed to have been infected before coming to the United States; however, genotype matching shows that they can be infected after arrival. Genotype matching compares the genetic make-up of TB isolates from different patients. This article reports on multidrug resistant tuberculosis in patients that were born on different continents and who worked together in the United States. They had TB isolates that shared the same genotype, so their TB probably came from the United States. Nationwide use of genotype matching should help identify the source of other, previously unknown, TB outbreaks.

        View Abstract

    In 2008, diagnosis and investigation of 2 multidrug-resistant tuberculosis cases with matching genotypes led to identification of an outbreak among foreign-born persons who performed short-term seafood production work in Alaska during 2006. Tuberculosis control programs should consider the possibility of domestic transmission even among foreign-born patients.

  • Spoligotyping of Mycobacterium africanum, Burkina Faso PDF Version [PDF - 190 KB]
    M. K. Gomgnimbou et al.
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    Using Ziehl-Neelsen–positive slides collected from tuberculosis diagnostic centers in Burkina Faso, we showed that 20% of 80 spoligotyping-positive DNA samples had a characteristic Mycobacterium africanum–specific genomic signature. This result suggests that M. africanum is still present in Burkina Faso at almost the same prevalence as 15–20 years ago.

  • Molecular Evolution of Respiratory Syncytial Virus Fusion Gene, Canada, 2006–2010 PDF Version [PDF - 356 KB]
    J. Papenburg et al.
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    To assess molecular evolution of the respiratory syncytial virus (RSV) fusion gene, we analyzed RSV-positive specimens from 123 children in Canada who did or did not receive RSV immunoprophylaxis (palivizumab) during 2006–2010. Resistance-conferring mutations within the palivizumab binding site occurred in 8.7% of palivizumab recipients and none of the nonrecipients.

  • Colpodella spp.–like Parasite Infection in Woman, China PDF Version [PDF - 278 KB]
    C. L. Yuan et al.
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    The phylum Apicomplexa comprises intracellular protozoa that include many human pathogens. Their nearest relatives are chromerids and colpodellids. We report a case of a Babesia spp.–like relapsing infection caused by a newly described microorganism related to the Apicomplexa. This case is highly suggestive of a previously undescribed type of colpodellid that infects vertebrates.

  • Babesiosis among Elderly Medicare Beneficiaries, United States, 2006–2008 PDF Version [PDF - 266 KB]
    M. Menis et al.
    View Summary

    In the United States, recently, there has been an increase in the number of reported clinical and transfusion-transmitted babesiosis cases. Human babesiosis is a tick-borne disease that is generally mild but may cause life-threatening anemia in people at high risk, such as the elderly, who are also likely to receive blood transfusions. Review of the Medicare databases confirmed that most cases recorded in claims data occurred in the northeastern United States, during peak tick season, and also suggested that the disease may be spreading to other regions. Among potential causes for disease expansion are human encroachment into tick and deer habitat, growing deer populations, climatic effects and travel to disease-endemic areas.

        View Abstract

    We used administrative databases to assess babesiosis among elderly persons in the United States by year, sex, age, race, state of residence, and diagnosis months during 2006–2008. The highest babesiosis rates were in Connecticut, Rhode Island, New York, and Massachusetts, and findings suggested babesiosis expansion to other states.

  • Foodborne Outbreak and Nonmotile Salmonella enterica Variant, France PDF Version [PDF - 171 KB - 3 pages]
    S. Le Hello et al.
        View Abstract

    We report a food-related outbreak of salmonellosis in humans caused by a nonmotile variant of Salmonella enterica serotype Typhimurium in France in 2009. This nonmotile variant had been circulating in laying hens but was not considered as Typhimurium and consequently escaped European poultry flock regulations.

  • Dengue Outbreak in Key West, Florida, USA, 2009 PDF Version [PDF - 158 KB - 3 pages]
    E. G. Radke et al.
    View Summary

    For more than 60 years, no cases of dengue had been acquired in the continental United States outside the Texas-Mexico border; therefore, a reported suspect case in Florida in 2009 was cause for concern. An investigation, consisting of a survey and blood testing, found 13 Key West residents in the sampled area who had been infected with dengue virus in 2009 and reported no travel outside the United States. From the survey results, researchers estimated that 5% of people in the surveyed area had been infected, which would mean that more infections occurred in 2009 than were reported. Factors that put people at risk for dengue infections included having windows frequently open, using air conditioning less frequently and having yards with large amounts of vegetation or bird baths. Preventing future cases will require personal protection against mosquitoes, mosquito control, early diagnosis, appropriate testing, and prompt reporting of suspected cases. A total of 27 and 66 cases of locally acquired dengue were reported in Key West in 2009 and 2010, respectively. There were no cases of locally acquired dengue in 2011, which is indicative of the success that local health authorities, mosquito control and the public are having in controlling dengue in Key West.

        View Abstract

    After 3 dengue cases were acquired in Key West, Florida, we conducted a serosurvey to determine the scope of the outbreak. Thirteen residents showed recent infection (infection rate 5%; 90% CI 2%–8%), demonstrating the reemergence of dengue in Florida. Increased awareness of dengue among health care providers is needed.

  • Rabies in Captive Deer, Pennsylvania, USA, 2007–2010 PDF Version [PDF - 396 KB - 4 pages]
    B. W. Petersen et al.
    View Summary

    Rabies is almost always fatal, unless preventive treatment is received soon after exposure. Although usually associated with small wild animals, rabies has recently been found in large captive animals—farmed deer that probably became infected through contact with wildlife. Four deer farmers in Pennsylvania were potentially exposed to rabies and received vaccination against rabies. More cases could be prevented by vaccinating deer against rabies, decreasing wildlife contact with captive deer, and educating deer farmers about their risks.

        View Abstract

    Since January 2007, a total of 11 rabid deer from 4 deer farms have been identified in 2 neighboring Pennsylvania counties. Vaccination of deer against rabies, decreasing wildlife animal contact with deer, and education of deer farmers may prevent further cases of rabies in captive deer and exposures to humans.

  • Oral Transmission of L-type Bovine Spongiform Encephalopathy in Primate Model PDF Version [PDF - 361 KB - 4 pages]
    N. Mestre-Francés et al.
        View Abstract

    We report transmission of atypical L-type bovine spongiform encephalopathy to mouse lemurs after oral or intracerebral inoculation with infected bovine brain tissue. After neurologic symptoms appeared, transmissibility of the disease by both inoculation routes was confirmed by detection of disease-associated prion protein in samples of brain tissue.

  • Early Detection of Pandemic (H1N1) 2009, Bangladesh PDF Version [PDF - 239 KB]
    E. Azziz-Baumgartner et al.
        View Abstract

    To explore Bangladesh’s ability to detect novel influenza, we examined a series of laboratory-confirmed pandemic (H1N1) 2009 cases. During June–July 2009, event-based surveillance identified 30 case-patients (57% travelers); starting July 29, sentinel sites identified 252 case-patients (1% travelers). Surveillance facilitated response weeks before the spread of pandemic (H1N1) 2009 infection to the general population.

  • Human Herpesvirus 8 Seroprevalence, China PDF Version [PDF - 174 KB - 3 pages]
    N. He et al.
        View Abstract

    To summarize the seroprevalence of human herpesvirus 8 (HHV-8) in mainland China, we conducted a systematic review and meta-analysis based on available literature. Data show that differences in HHV-8 prevalence vary considerably among different ethnic groups and geographic regions. Blood-borne transmission could be a potential route for HHV-8 infection in China.

Another Dimension

  • The Plague of Thebes, a Historical Epidemic in Sophocles’ Oedipus Rex PDF Version [PDF - 195 KB - 5 pages]
    A. A. Kousoulis et al.
    View Summary

    Brucella abortus may have been the etiologic agent.

        View Abstract

    Sophocles, one of the most noted playwrights of the ancient world, wrote the tragedy Oedipus Rex in the first half of the decade 430–420 bc. A lethal plague is described in this drama. We adopted a critical approach to Oedipus Rex in analyzing the literary description of the disease, unraveling its clinical features, and defining a possible underlying cause. Our goals were to clarify whether the plague described in Oedipus Rex reflects an actual historical event; to compare it with the plague of Athens, which was described by Thucydides as occurring around the same time Sophocles wrote; and to propose a likely causative pathogen. A critical reading of Oedipus Rex and a comparison with Thucydides’ history, as well as a systematic review of historical data, strongly suggests that this epidemic was an actual event, possibly caused by Brucella abortus.


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