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Volume 9, Number 6—June 2003

Volume 9, Number 6—June 2003   PDF Version [PDF - 8.38 MB - 155 pages]

Perspective

  • An Ounce of Prevention is a Ton of Work: Mass Antibiotic Prophylaxis for Anthrax, New York City, 2001 PDF Version [PDF - 199 KB - 8 pages]
    S. Blank et al.
        View Abstract

    Protocols for mass antibiotic prophylaxis against anthrax were under development in New York City beginning in early 1999. This groundwork allowed the city’s Department of Health to rapidly respond in 2001 to six situations in which cases were identified or anthrax spores were found. The key aspects of planning and lessons learned from each of these mass prophylaxis operations are reviewed. Antibiotic distribution was facilitated by limiting medical histories to issues relevant to prescribing prophylactic antibiotic therapy, formatting medical records to facilitate rapid decision making, and separating each component activity into discrete work stations. Successful implementation of mass prophylaxis operations was characterized by clarity of mission and eligibility criteria, well-defined lines of authority and responsibilities, effective communication, collaboration among city agencies (including law enforcement), and coordination of staffing and supplies. This model can be adapted for future planning needs including possible attacks with other bioterrorism agents, such as smallpox.

        Cite This Article
    EID Blank S, Moskin LC, Zucker JR. An Ounce of Prevention is a Ton of Work: Mass Antibiotic Prophylaxis for Anthrax, New York City, 2001. Emerg Infect Dis. 2003;9(6):615-622. https://dx.doi.org/10.3201/eid0906.030118
    AMA Blank S, Moskin LC, Zucker JR. An Ounce of Prevention is a Ton of Work: Mass Antibiotic Prophylaxis for Anthrax, New York City, 2001. Emerging Infectious Diseases. 2003;9(6):615-622. doi:10.3201/eid0906.030118.
    APA Blank, S., Moskin, L. C., & Zucker, J. R. (2003). An Ounce of Prevention is a Ton of Work: Mass Antibiotic Prophylaxis for Anthrax, New York City, 2001. Emerging Infectious Diseases, 9(6), 615-622. https://dx.doi.org/10.3201/eid0906.030118.

Synopses

  • Inactivation of Bacillus anthracis Spores PDF Version [PDF - 173 KB - 5 pages]
    E. A. Whitney et al.
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    After the intentional release of Bacillus anthracis through the U.S. Postal Service in the fall of 2001, many environments were contaminated with B. anthracis spores, and frequent inquiries were made regarding the science of destroying these spores. We conducted a survey of the literature that had potential application to the inactivation of B. anthracis spores. This article provides a tabular summary of the results.

        Cite This Article
    EID Whitney EA, Beatty ME, Taylor TH, Weyant R, Sobel J, Arduino MJ, et al. Inactivation of Bacillus anthracis Spores. Emerg Infect Dis. 2003;9(6):623-627. https://dx.doi.org/10.3201/eid0906.020377
    AMA Whitney EA, Beatty ME, Taylor TH, et al. Inactivation of Bacillus anthracis Spores. Emerging Infectious Diseases. 2003;9(6):623-627. doi:10.3201/eid0906.020377.
    APA Whitney, E. A., Beatty, M. E., Taylor, T. H., Weyant, R., Sobel, J., Arduino, M. J....Ashford, D. A. (2003). Inactivation of Bacillus anthracis Spores. Emerging Infectious Diseases, 9(6), 623-627. https://dx.doi.org/10.3201/eid0906.020377.

Research

  • Children with Respiratory Disease Associated with Metapneumovirus in Hong Kong PDF Version [PDF - 211 KB - 6 pages]
    J. M. Peiris et al.
        View Abstract

    Human metapneumovirus (HMPV) is a newly discovered pathogen thought to be associated with respiratory disease. We report the results of a study of 587 children hospitalized with respiratory infection over a 13-month period. HMPV was detected in the nasopharyngeal aspirates from 32 (5.5%) children by reverse transcription-polymerase chain reaction. HMPV infection was associated with clinical diagnoses of pneumonia (36%), asthma exacerbation (23%), or acute bronchiolitis (10%). When compared to those with respiratory syncytial virus infection, children with HMPV infection were older, and wheezing was more likely to represent asthma exacerbation rather than acute bronchiolitis. HMPV viral activity peaked during the spring-summer period in Hong Kong. Phylogenetically, all HMPV virus strains from Hong Kong belonged to one of the two genetic lineages previously described. HMPV contributed to 441.6 hospital admissions per 100,000 population <6 years of age.

        Cite This Article
    EID Peiris JM, Tang W, Chan K, Khong P, Guan Y, Lau Y, et al. Children with Respiratory Disease Associated with Metapneumovirus in Hong Kong. Emerg Infect Dis. 2003;9(6):628-633. https://dx.doi.org/10.3201/eid0906.030009
    AMA Peiris JM, Tang W, Chan K, et al. Children with Respiratory Disease Associated with Metapneumovirus in Hong Kong. Emerging Infectious Diseases. 2003;9(6):628-633. doi:10.3201/eid0906.030009.
    APA Peiris, J. M., Tang, W., Chan, K., Khong, P., Guan, Y., Lau, Y....Chiu, S. S. (2003). Children with Respiratory Disease Associated with Metapneumovirus in Hong Kong. Emerging Infectious Diseases, 9(6), 628-633. https://dx.doi.org/10.3201/eid0906.030009.
  • Human Metapneumovirus Infections in Hospitalized Children PDF Version [PDF - 401 KB - 7 pages]
    G. Boivin et al.
        View Abstract

    We evaluated the percentage of hospitalizations for acute respiratory tract infections in children <3 years of age attributable to human metapneumovirus (HMPV) and other respiratory viruses in a prospective study during winter and spring 2002. We used real-time polymerase chain assays and other conventional diagnostic methods to detect HMPV, human respiratory syncytial virus (HRSV), and influenza viruses in nasopharyngeal aspirates of children. HMPV was detected in 12 (6%) of the 208 children hospitalized for acute respiratory tract infections, HRSV in 118 (57%), and influenza A in 49 (24%). Bronchiolitis was diagnosed in 8 (68%) and pneumonitis in 2 (17%) of HMPV-infected children; of those with HRSV infection, pneumonitis was diagnosed in 99 (84%) and bronchiolitis in 30 (25%). None of the HMPV-infected children was admitted to an intensive-care unit, whereas 15% of those with HRSV or influenza A infections were admitted. HMPV is an important cause of illness in young children with a similar, although less severe, clinical presentation to that of HRSV.

        Cite This Article
    EID Boivin G, De Serres G, Côté S, Gilca R, Abed Y, Rochette L, et al. Human Metapneumovirus Infections in Hospitalized Children. Emerg Infect Dis. 2003;9(6):634-640. https://dx.doi.org/10.3201/eid0906.030017
    AMA Boivin G, De Serres G, Côté S, et al. Human Metapneumovirus Infections in Hospitalized Children. Emerging Infectious Diseases. 2003;9(6):634-640. doi:10.3201/eid0906.030017.
    APA Boivin, G., De Serres, G., Côté, S., Gilca, R., Abed, Y., Rochette, L....Déry, P. (2003). Human Metapneumovirus Infections in Hospitalized Children. Emerging Infectious Diseases, 9(6), 634-640. https://dx.doi.org/10.3201/eid0906.030017.
  • Dead Bird Clusters as an Early Warning System for West Nile Virus Activity PDF Version [PDF - 299 KB - 6 pages]
    F. Mostashari et al.
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    An early warning system for West Nile virus (WNV) outbreaks could provide a basis for targeted public education and surveillance activities as well as more timely larval and adult mosquito control. We adapted the spatial scan statistic for prospective detection of infectious disease outbreaks, applied the results to data on dead birds reported from New York City in 2000, and reviewed its utility in providing an early warning of WNV activity in 2001. Prospective geographic cluster analysis of dead bird reports may provide early warning of increasing viral activity in birds and mosquitoes, allowing jurisdictions to triage limited mosquito-collection and laboratory resources and more effectively prevent human disease caused by the virus. This adaptation of the scan statistic could also be useful in other infectious disease surveillance systems, including that for bioterrorism.

        Cite This Article
    EID Mostashari F, Kulldorff M, Hartman JJ, Miller JR, Kulasekera V. Dead Bird Clusters as an Early Warning System for West Nile Virus Activity. Emerg Infect Dis. 2003;9(6):641-646. https://dx.doi.org/10.3201/eid0906.020794
    AMA Mostashari F, Kulldorff M, Hartman JJ, et al. Dead Bird Clusters as an Early Warning System for West Nile Virus Activity. Emerging Infectious Diseases. 2003;9(6):641-646. doi:10.3201/eid0906.020794.
    APA Mostashari, F., Kulldorff, M., Hartman, J. J., Miller, J. R., & Kulasekera, V. (2003). Dead Bird Clusters as an Early Warning System for West Nile Virus Activity. Emerging Infectious Diseases, 9(6), 641-646. https://dx.doi.org/10.3201/eid0906.020794.
  • Gnathostomiasis: An Emerging Imported Disease PDF Version [PDF - 243 KB - 4 pages]
    D. A. Moore et al.
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    As the scope of international travel expands, an increasing number of travelers are coming into contact with helminthic parasites rarely seen outside the tropics. As a result, the occurrence of Gnathostoma spinigerum infection leading to the clinical syndrome gnathostomiasis is increasing. In areas where Gnathostoma is not endemic, few clinicians are familiar with this disease. To highlight this underdiagnosed parasitic infection, we describe a case series of patients with gnathostomiasis who were treated during a 12-month period at the Hospital for Tropical Diseases, London.

        Cite This Article
    EID Moore DA, McCrodden J, Dekumyoy P, Chiodini P. Gnathostomiasis: An Emerging Imported Disease. Emerg Infect Dis. 2003;9(6):647-650. https://dx.doi.org/10.3201/eid0906.020625
    AMA Moore DA, McCrodden J, Dekumyoy P, et al. Gnathostomiasis: An Emerging Imported Disease. Emerging Infectious Diseases. 2003;9(6):647-650. doi:10.3201/eid0906.020625.
    APA Moore, D. A., McCrodden, J., Dekumyoy, P., & Chiodini, P. (2003). Gnathostomiasis: An Emerging Imported Disease. Emerging Infectious Diseases, 9(6), 647-650. https://dx.doi.org/10.3201/eid0906.020625.
  • Histopathologic Features of Mycobacterium ulcerans Infection PDF Version [PDF - 977 KB - 6 pages]
    J. Guarner et al.
        View Abstract

    Because of the emergence of Buruli ulcer disease, the World Health Organization launched a Global Buruli Ulcer Initiative in 1998. This indolent skin infection is caused by Mycobacterium ulcerans. During a study of risk factors for the disease in Ghana, adequate excisional skin-biopsy specimens were obtained from 124 clinically suspicious lesions. Buruli ulcer disease was diagnosed in 78 lesions since acid-fast bacilli (AFB) were found by histopathologic examination. Lesions with other diagnoses included filariasis (3 cases), zygomycosis (2 cases), ulcerative squamous cell carcinomas (2 cases), keratin cyst (1 case), and lymph node (1 case). Thirty-seven specimens that did not show AFB were considered suspected Buruli ulcer disease cases. Necrosis of subcutaneous tissues and dermal collagen were found more frequently in AFB-positive specimens compared with specimens from suspected case-patients (p<0.001). Defining histologic criteria for a diagnosis of Buruli ulcer disease is of clinical and public health importance since it would allow earlier treatment, leading to less deforming sequelae.

        Cite This Article
    EID Guarner J, Bartlett J, Whitney EA, Raghunathan PL, Stienstra Y, Asamoa K, et al. Histopathologic Features of Mycobacterium ulcerans Infection. Emerg Infect Dis. 2003;9(6):651-656. https://dx.doi.org/10.3201/eid0906.020485
    AMA Guarner J, Bartlett J, Whitney EA, et al. Histopathologic Features of Mycobacterium ulcerans Infection. Emerging Infectious Diseases. 2003;9(6):651-656. doi:10.3201/eid0906.020485.
    APA Guarner, J., Bartlett, J., Whitney, E. A., Raghunathan, P. L., Stienstra, Y., Asamoa, K....Ashford, D. A. (2003). Histopathologic Features of Mycobacterium ulcerans Infection. Emerging Infectious Diseases, 9(6), 651-656. https://dx.doi.org/10.3201/eid0906.020485.
  • Clinical Implications of Varying Degrees of Vancomycin Susceptilibity in Methicillin-Resistant Staphylococcus aureus Bacteremia PDF Version [PDF - 345 KB - 8 pages]
    M. J. Schwaber et al.
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    We conducted a retrospective study of the clinical aspects of bacteremia caused by methicillin-resistant Staphylococcus aureus (MRSA) with heterogeneously reduced susceptibility to vancomycin. Bloodstream MRSA isolates were screened for reduced susceptibility by using brain-heart infusion agar, including 4 mg/L vancomycin with and without 4% NaCl. Patients whose isolates exhibited growth (case-patients) were compared with those whose isolates did not (controls) for demographics, coexisting chronic conditions, hospital events, antibiotic exposures, and outcomes. Sixty-one (41%) of 149 isolates exhibited growth. Subclones from 46 (75%) of these had a higher MIC of vancomycin than did their parent isolates. No isolates met criteria for vancomycin heteroresistance. No differences in potential predictors or in outcomes were found between case-patients and controls. These data show that patients with vancomycin-susceptible MRSA bacteremia have similar baseline clinical features and outcomes whether or not their bacterial isolates exhibit growth on screening media containing vancomycin.

        Cite This Article
    EID Schwaber MJ, Wright SB, Carmeli Y, Venkataraman L, DeGirolami PC, Gramatikova A, et al. Clinical Implications of Varying Degrees of Vancomycin Susceptilibity in Methicillin-Resistant Staphylococcus aureus Bacteremia. Emerg Infect Dis. 2003;9(6):657-664. https://dx.doi.org/10.3201/eid0906.030001
    AMA Schwaber MJ, Wright SB, Carmeli Y, et al. Clinical Implications of Varying Degrees of Vancomycin Susceptilibity in Methicillin-Resistant Staphylococcus aureus Bacteremia. Emerging Infectious Diseases. 2003;9(6):657-664. doi:10.3201/eid0906.030001.
    APA Schwaber, M. J., Wright, S. B., Carmeli, Y., Venkataraman, L., DeGirolami, P. C., Gramatikova, A....Gold, H. S. (2003). Clinical Implications of Varying Degrees of Vancomycin Susceptilibity in Methicillin-Resistant Staphylococcus aureus Bacteremia. Emerging Infectious Diseases, 9(6), 657-664. https://dx.doi.org/10.3201/eid0906.030001.
  • Serogroup W-135 Meningococcal Disease during the Hajj, 2000 PDF Version [PDF - 249 KB - 7 pages]
    J. R. Lingappa et al.
        View Abstract

    An outbreak of serogroup W-135 meningococcal disease occurred during the 2000 Hajj in Saudi Arabia. Disease was reported worldwide in Hajj pilgrims and their close contacts; however, most cases were identified in Saudi Arabia. Trends in Saudi meningococcal disease were evaluated and the epidemiology of Saudi cases from this outbreak described. Saudi national meningococcal disease incidence data for 1990 to 2000 were reviewed; cases from January 24 to June 5, 2000 were retrospectively reviewed. The 2000 Hajj outbreak consisted of distinct serogroup A and serogroup W-135 outbreaks. Of 253 identified cases in Saudi Arabia, 161 (64%) had serogroup identification; serogroups W-135 and A caused 93 (37%) and 60 (24%) cases with attack rates of 9 and 6 cases per 100,000 population, respectively. The 2000 Hajj outbreak was the first large serogroup W-135 meningococcal disease outbreak identified worldwide. Enhanced surveillance for serogroup W-135, especially in Africa, is essential to control this emerging epidemic disease.

        Cite This Article
    EID Lingappa JR, Al-Rabeah AM, Hajjeh R, Mustafa T, Fatani A, Al-Bassam T, et al. Serogroup W-135 Meningococcal Disease during the Hajj, 2000. Emerg Infect Dis. 2003;9(6):665-671. https://dx.doi.org/10.3201/eid0906.020565
    AMA Lingappa JR, Al-Rabeah AM, Hajjeh R, et al. Serogroup W-135 Meningococcal Disease during the Hajj, 2000. Emerging Infectious Diseases. 2003;9(6):665-671. doi:10.3201/eid0906.020565.
    APA Lingappa, J. R., Al-Rabeah, A. M., Hajjeh, R., Mustafa, T., Fatani, A., Al-Bassam, T....Rosenstein, N. E. (2003). Serogroup W-135 Meningococcal Disease during the Hajj, 2000. Emerging Infectious Diseases, 9(6), 665-671. https://dx.doi.org/10.3201/eid0906.020565.
  • Molecular Subtyping to Detect Human Listeriosis Clusters PDF Version [PDF - 295 KB - 9 pages]
    B. D. Sauders et al.
        View Abstract

    We analyzed the diversity (Simpson’s Index, D) and distribution of Listeria monocytogenes in human listeriosis cases in New York State (excluding New York City) from November 1996 to June 2000 by using automated ribotyping and pulsed-field gel electrophoresis (PFGE). We applied a scan statistic (p<0.05) to detect listeriosis clusters caused by a specific Listeria monocytogenes subtype. Of 131 human isolates, 34 (D=0.923) ribotypes and 74 (D=0.975) PFGE types were found. Nine (31% of cases) clusters were identified by ribotype or PFGE; five (18% of cases) clusters were identified by using both methods. Two of the nine clusters (13% of cases) identified corresponded with investigated multistate listeriosis outbreaks. While most human listeriosis cases are considered sporadic, highly discriminatory molecular subtyping approaches thus indicated that 13% to 31% of cases reported in New York State may represent single-source clusters. Listeriosis control and reduction efforts should include broad-based subtyping of human isolates and consider that a large number of cases may represent outbreaks.

        Cite This Article
    EID Sauders BD, Fortes ED, Morse DL, Dumas N, Kiehlbauch JA, Schukken Y, et al. Molecular Subtyping to Detect Human Listeriosis Clusters. Emerg Infect Dis. 2003;9(6):672-680. https://dx.doi.org/10.3201/eid0906.20702
    AMA Sauders BD, Fortes ED, Morse DL, et al. Molecular Subtyping to Detect Human Listeriosis Clusters. Emerging Infectious Diseases. 2003;9(6):672-680. doi:10.3201/eid0906.20702.
    APA Sauders, B. D., Fortes, E. D., Morse, D. L., Dumas, N., Kiehlbauch, J. A., Schukken, Y....Wiedmann, M. (2003). Molecular Subtyping to Detect Human Listeriosis Clusters. Emerging Infectious Diseases, 9(6), 672-680. https://dx.doi.org/10.3201/eid0906.20702.
  • Bioterrorism-related Inhalational Anthrax in an Elderly Woman, Connecticut, 2001 PDF Version [PDF - 369 KB - 8 pages]
    K. S. Griffith et al.
        View Abstract

    On November 20, 2001, inhalational anthrax was confirmed in an elderly woman from rural Connecticut. To determine her exposure source, we conducted an extensive epidemiologic, environmental, and laboratory investigation. Molecular subtyping showed that her isolate was indistinguishable from isolates associated with intentionally contaminated letters. No samples from her home or community yielded Bacillus anthracis, and she received no first-class letters from facilities known to have processed intentionally contaminated letters. Environmental sampling in the regional Connecticut postal facility yielded B. anthracis spores from 4 (31%) of 13 sorting machines. One extensively contaminated machine primarily processes bulk mail. A second machine that does final sorting of bulk mail for her zip code yielded B. anthracis on the column of bins for her carrier route. The evidence suggests she was exposed through a cross-contaminated bulk mail letter. Such cross-contamination of letters and postal facilities has implications for managing the response to future B. anthracis–contaminated mailings.

        Cite This Article
    EID Griffith KS, Mead P, Armstrong GL, Painter J, Kelley KA, Hoffmaster AR, et al. Bioterrorism-related Inhalational Anthrax in an Elderly Woman, Connecticut, 2001. Emerg Infect Dis. 2003;9(6):681-688. https://dx.doi.org/10.3201/eid0906.020728
    AMA Griffith KS, Mead P, Armstrong GL, et al. Bioterrorism-related Inhalational Anthrax in an Elderly Woman, Connecticut, 2001. Emerging Infectious Diseases. 2003;9(6):681-688. doi:10.3201/eid0906.020728.
    APA Griffith, K. S., Mead, P., Armstrong, G. L., Painter, J., Kelley, K. A., Hoffmaster, A. R....Hadler, J. L. (2003). Bioterrorism-related Inhalational Anthrax in an Elderly Woman, Connecticut, 2001. Emerging Infectious Diseases, 9(6), 681-688. https://dx.doi.org/10.3201/eid0906.020728.
  • Isolated Case of Bioterrorism-related Inhalational Anthrax, New York City, 2001 PDF Version [PDF - 398 KB - 8 pages]
    T. H. Holtz et al.
        View Abstract

    On October 31, 2001, in New York City, a 61-year-old female hospital employee who had acquired inhalational anthrax died after a 6-day illness. To determine sources of exposure and identify additional persons at risk, the New York City Department of Health, Centers for Disease Control and Prevention, and law enforcement authorities conducted an extensive investigation, which included interviewing contacts, examining personal effects, summarizing patient’s use of mass transit, conducting active case finding and surveillance near her residence and at her workplace, and collecting samples from co-workers and the environment. We cultured all specimens for Bacillus anthracis. We found no additional cases of cutaneous or inhalational anthrax. The route of exposure remains unknown. All environmental samples were negative for B. anthracis. This first case of inhalational anthrax during the 2001 outbreak with no apparent direct link to contaminated mail emphasizes the need for close coordination between public health and law enforcement agencies during bioterrorism-related investigations.

        Cite This Article
    EID Holtz TH, Ackelsberg J, Kool JL, Rosselli R, Marfin A, Matte T, et al. Isolated Case of Bioterrorism-related Inhalational Anthrax, New York City, 2001. Emerg Infect Dis. 2003;9(6):689-696. https://dx.doi.org/10.3201/eid0906.020668
    AMA Holtz TH, Ackelsberg J, Kool JL, et al. Isolated Case of Bioterrorism-related Inhalational Anthrax, New York City, 2001. Emerging Infectious Diseases. 2003;9(6):689-696. doi:10.3201/eid0906.020668.
    APA Holtz, T. H., Ackelsberg, J., Kool, J. L., Rosselli, R., Marfin, A., Matte, T....Layton, M. (2003). Isolated Case of Bioterrorism-related Inhalational Anthrax, New York City, 2001. Emerging Infectious Diseases, 9(6), 689-696. https://dx.doi.org/10.3201/eid0906.020668.
  • Relapsing Fever–Like Spirochetes Infecting European Vector Tick of Lyme Disease Agent PDF Version [PDF - 180 KB - 5 pages]
    D. Richter et al.
        View Abstract

    To determine whether relapsing fever–like spirochetes associated with hard ticks may infect Ixodes ricinus ticks in central Europe, we screened questing ticks for 16S rDNA similar to that of Asian and American relapsing fever–like spirochetes. We compared the prevalence of these spirochetes to that of Lyme disease spirochetes transmitted by the same vector. Relapsing fever-like spirochetes infect 3.5% of questing vector ticks in our three central European sites near the Rhein Valley. These spirochetes differ genetically from their American and Asian analogs while being relatively homogeneous in the region we sampled. The Lyme disease genospecies most commonly detected in central Europe are distributed broadly, whereas those that are less frequently found appear to be place-specific. The absence of co-infected ticks suggests that relapsing fever–like and Lyme disease spirochetes may not share hosts. Exposure risk for relapsing fever–like spirochetes is similar to that of certain Lyme disease genospecies. Although many persons may be bitten by ticks infected by relapsing fever–like spirochetes, health implications remain unknown.

        Cite This Article
    EID Richter D, Schlee DB, Matuschka F. Relapsing Fever–Like Spirochetes Infecting European Vector Tick of Lyme Disease Agent. Emerg Infect Dis. 2003;9(6):697-701. https://dx.doi.org/10.3201/eid0906.020459
    AMA Richter D, Schlee DB, Matuschka F. Relapsing Fever–Like Spirochetes Infecting European Vector Tick of Lyme Disease Agent. Emerging Infectious Diseases. 2003;9(6):697-701. doi:10.3201/eid0906.020459.
    APA Richter, D., Schlee, D. B., & Matuschka, F. (2003). Relapsing Fever–Like Spirochetes Infecting European Vector Tick of Lyme Disease Agent. Emerging Infectious Diseases, 9(6), 697-701. https://dx.doi.org/10.3201/eid0906.020459.
  • Leptospirosis in “Eco-Challenge” Athletes, Malaysian Borneo, 2000 PDF Version [PDF - 200 KB - 6 pages]
    J. Sejvar et al.
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    Adventure travel is becoming more popular, increasing the likelihood of contact with unusual pathogens. We investigated an outbreak of leptospirosis in “Eco-Challenge” multisport race athletes to determine illness etiology and implement public health measures. Of 304 athletes, we contacted 189 (62%) from the United States and 26 other countries. Eighty (42%) athletes met our case definition. Twenty-nine (36%) case-patients were hospitalized; none died. Logistic regression showed swimming in the Segama River (relative risk [RR]=2.0; 95% confidence interval [CI]=1.3 to 3.1) to be an independent risk factor. Twenty-six (68%) of 38 case-patients tested positive for leptospiral antibodies. Taking doxycycline before or during the race was protective (RR=0.4, 95% CI=0.2 to 1.2) for the 20 athletes who reported using it. Increased adventure travel may lead to more frequent exposure to leptospires, and preexposure chemoprophylaxis for leptospirosis (200 mg oral doxycycline/week) may decrease illness risk. Efforts are needed to inform adventure travel participants of unique infections such as leptospirosis.

        Cite This Article
    EID Sejvar J, Bancroft E, Winthrop KL, Bettinger J, Bajani M, Bragg S, et al. Leptospirosis in “Eco-Challenge” Athletes, Malaysian Borneo, 2000. Emerg Infect Dis. 2003;9(6):702-707. https://dx.doi.org/10.3201/eid0906.020751
    AMA Sejvar J, Bancroft E, Winthrop KL, et al. Leptospirosis in “Eco-Challenge” Athletes, Malaysian Borneo, 2000. Emerging Infectious Diseases. 2003;9(6):702-707. doi:10.3201/eid0906.020751.
    APA Sejvar, J., Bancroft, E., Winthrop, K. L., Bettinger, J., Bajani, M., Bragg, S....Rosenstein, N. (2003). Leptospirosis in “Eco-Challenge” Athletes, Malaysian Borneo, 2000. Emerging Infectious Diseases, 9(6), 702-707. https://dx.doi.org/10.3201/eid0906.020751.
  • Community Reaction to Bioterrorism: Prospective Study of Simulated Outbreak PDF Version [PDF - 232 KB - 5 pages]
    C. DiGiovanni et al.
        View Abstract

    To assess community needs for public information during a bioterrorism-related crisis, we simulated an intentional Rift Valley fever outbreak in a community in the southern part of the United States. We videotaped a series of simulated print and television “news reports” over a fictional 9-day crisis period and invited various groups (e.g., first-responders and their spouses or partners, journalists) within the selected community to view the videotape and respond to questions about their reactions. All responses were given anonymously. First-responders and their spouses or partners varied in their reactions about how the crisis affected family harmony and job performance. Local journalists exhibited considerable personal fear and confusion. All groups demanded, and put more trust in, information from local sources. These findings may have implications for risk communication during bioterrorism-related outbreaks.

        Cite This Article
    EID DiGiovanni C, Reynolds B, Harwell R, Stonecipher EB, Burkle FM. Community Reaction to Bioterrorism: Prospective Study of Simulated Outbreak. Emerg Infect Dis. 2003;9(6):708-712. https://dx.doi.org/10.3201/eid0906.020769
    AMA DiGiovanni C, Reynolds B, Harwell R, et al. Community Reaction to Bioterrorism: Prospective Study of Simulated Outbreak. Emerging Infectious Diseases. 2003;9(6):708-712. doi:10.3201/eid0906.020769.
    APA DiGiovanni, C., Reynolds, B., Harwell, R., Stonecipher, E. B., & Burkle, F. M. (2003). Community Reaction to Bioterrorism: Prospective Study of Simulated Outbreak. Emerging Infectious Diseases, 9(6), 708-712. https://dx.doi.org/10.3201/eid0906.020769.

Dispatches

  • Severe Acute Respiratory Syndrome (SARS) in Singapore: Clinical Features of Index Patient and Initial Contacts PDF Version [PDF - 337 KB - 5 pages]
    L. Hsu et al.
        View Abstract

    Severe acute respiratory syndrome (SARS) is an emerging viral infectious disease. One of the largest outbreaks of SARS to date began in Singapore in March 2003. We describe the clinical, laboratory, and radiologic features of the index patient and the patient’s initial contacts affected with probable SARS.

        Cite This Article
    EID Hsu L, Lee C, Green JA, Ang B, Paton NI, Lee L, et al. Severe Acute Respiratory Syndrome (SARS) in Singapore: Clinical Features of Index Patient and Initial Contacts. Emerg Infect Dis. 2003;9(6):713-717. https://dx.doi.org/10.3201/eid0906.030264
    AMA Hsu L, Lee C, Green JA, et al. Severe Acute Respiratory Syndrome (SARS) in Singapore: Clinical Features of Index Patient and Initial Contacts. Emerging Infectious Diseases. 2003;9(6):713-717. doi:10.3201/eid0906.030264.
    APA Hsu, L., Lee, C., Green, J. A., Ang, B., Paton, N. I., Lee, L....Leo, Y. (2003). Severe Acute Respiratory Syndrome (SARS) in Singapore: Clinical Features of Index Patient and Initial Contacts. Emerging Infectious Diseases, 9(6), 713-717. https://dx.doi.org/10.3201/eid0906.030264.
  • Control Measures for Severe Acute Respiratory Syndrome (SARS) in Taiwan PDF Version [PDF - 185 KB - 3 pages]
    S. Twu et al.
        View Abstract

    As of April 14, 2003, Taiwan had had 23 probable cases of severe acute respiratory syndrome (SARS), all imported. Taiwan isolated these first 23 patients with probable SARS in negative-pressure rooms; extensive personal protective equipment was used for healthcare workers and visitors. For the first 6 weeks of the SARS outbreak, recognized spread was limited to one healthcare worker and three household contacts.

        Cite This Article
    EID Twu S, Chen T, Chen C, Olsen SJ, Lee L, Fisk T, et al. Control Measures for Severe Acute Respiratory Syndrome (SARS) in Taiwan. Emerg Infect Dis. 2003;9(6):718-720. https://dx.doi.org/10.3201/eid0906.030283
    AMA Twu S, Chen T, Chen C, et al. Control Measures for Severe Acute Respiratory Syndrome (SARS) in Taiwan. Emerging Infectious Diseases. 2003;9(6):718-720. doi:10.3201/eid0906.030283.
    APA Twu, S., Chen, T., Chen, C., Olsen, S. J., Lee, L., Fisk, T....Dowell, S. F. (2003). Control Measures for Severe Acute Respiratory Syndrome (SARS) in Taiwan. Emerging Infectious Diseases, 9(6), 718-720. https://dx.doi.org/10.3201/eid0906.030283.
  • Human Rabies: A Reemerging Disease in Costa Rica? PDF Version [PDF - 349 KB - 3 pages]
    X. Badilla et al.
        View Abstract

    Two human rabies cases caused by a bat-associated virus variant were identified in September 2001 in Costa Rica, after a 31-year absence of the disease in persons. Both patients lived in a rural area where cattle had a high risk for bat bites, but neither person had a definitive history of being bitten by a rabid animal. Characterization of the rabies viruses from the patients showed that the reservoir was the hematophagous Vampire Bat, Desmodus rotundus, and that a sick cat was the vector.

        Cite This Article
    EID Badilla X, Pérez-Herra V, Quirós L, Morice A, Jiménez E, Sáenz E, et al. Human Rabies: A Reemerging Disease in Costa Rica?. Emerg Infect Dis. 2003;9(6):721-723. https://dx.doi.org/10.3201/eid0906.020632
    AMA Badilla X, Pérez-Herra V, Quirós L, et al. Human Rabies: A Reemerging Disease in Costa Rica?. Emerging Infectious Diseases. 2003;9(6):721-723. doi:10.3201/eid0906.020632.
    APA Badilla, X., Pérez-Herra, V., Quirós, L., Morice, A., Jiménez, E., Sáenz, E....Rupprecht, C. E. (2003). Human Rabies: A Reemerging Disease in Costa Rica?. Emerging Infectious Diseases, 9(6), 721-723. https://dx.doi.org/10.3201/eid0906.020632.
  • Accidental Infection of Laboratory Worker with Vaccinia PDF Version [PDF - 248 KB - 3 pages]
    N. Moussatché et al.
        View Abstract

    We report the accidental needlestick inoculation of a laboratory worker with vaccinia virus. Although the patient had previously been vaccinated against smallpox, severe lesions appeared on the fingers. Western blot and polymerase chain reaction–restriction fragment length polymorphism were used to analyze the virus recovered from the lesions. The vaccinia virus–specific immunoglobulin G levels were measured by enzyme-linked immunosorbent assay. Our study supports the need for vaccination for laboratory workers that routinely handle orthopoxvirus.

        Cite This Article
    EID Moussatché N, Tuyama M, Kato SE, Castro AP, Njaine B, Peralta RH, et al. Accidental Infection of Laboratory Worker with Vaccinia. Emerg Infect Dis. 2003;9(6):724-726. https://dx.doi.org/10.3201/eid0906.020732
    AMA Moussatché N, Tuyama M, Kato SE, et al. Accidental Infection of Laboratory Worker with Vaccinia. Emerging Infectious Diseases. 2003;9(6):724-726. doi:10.3201/eid0906.020732.
    APA Moussatché, N., Tuyama, M., Kato, S. E., Castro, A. P., Njaine, B., Peralta, R. H....Barroso, P. F. (2003). Accidental Infection of Laboratory Worker with Vaccinia. Emerging Infectious Diseases, 9(6), 724-726. https://dx.doi.org/10.3201/eid0906.020732.
  • Anthroponotic Cutaneous Leishmaniasis, Kabul, Afghanistan PDF Version [PDF - 249 KB - 3 pages]
    R. Reithinger et al.
        View Abstract

    A prevalence survey in Kabul City showed that 2.7% and 21.9% of persons have active leishmaniasis lesions or scars, respectively. Incidence of disease was estimated to be 2.9% (29 cases/1,000 persons per year; 95% confidence interval 0.018 to 0.031). Disease was associated with age and gender; logistic regression analyses showed significant clustering of cases.

        Cite This Article
    EID Reithinger R, Mohsen M, Aadil K, Sidiqi M, Erasmus P, Coleman PG, et al. Anthroponotic Cutaneous Leishmaniasis, Kabul, Afghanistan. Emerg Infect Dis. 2003;9(6):727-729. https://dx.doi.org/10.3201/eid0906.030026
    AMA Reithinger R, Mohsen M, Aadil K, et al. Anthroponotic Cutaneous Leishmaniasis, Kabul, Afghanistan. Emerging Infectious Diseases. 2003;9(6):727-729. doi:10.3201/eid0906.030026.
    APA Reithinger, R., Mohsen, M., Aadil, K., Sidiqi, M., Erasmus, P., & Coleman, P. G. (2003). Anthroponotic Cutaneous Leishmaniasis, Kabul, Afghanistan. Emerging Infectious Diseases, 9(6), 727-729. https://dx.doi.org/10.3201/eid0906.030026.
  • Fluoroquinolone Use and Clostridium difficile–Associated Diarrhea PDF Version [PDF - 286 KB - 4 pages]
    M. E. McCusker et al.
        View Abstract

    We performed a case-control study to evaluate the association between antibiotic use and Clostridium difficile–associated diarrhea (CDAD), matching for admission unit and time at risk for CDAD. A multivariable regression model showed that treatment with fluoroquinolones (odds ratio 12.7; 95% confidence interval 2.6 to 61.6) was the strongest risk factor for CDAD.

        Cite This Article
    EID McCusker ME, Harris AD, Perencevich EN, Roghmann M. Fluoroquinolone Use and Clostridium difficile–Associated Diarrhea. Emerg Infect Dis. 2003;9(6):730-733. https://dx.doi.org/10.3201/eid0906.020385
    AMA McCusker ME, Harris AD, Perencevich EN, et al. Fluoroquinolone Use and Clostridium difficile–Associated Diarrhea. Emerging Infectious Diseases. 2003;9(6):730-733. doi:10.3201/eid0906.020385.
    APA McCusker, M. E., Harris, A. D., Perencevich, E. N., & Roghmann, M. (2003). Fluoroquinolone Use and Clostridium difficile–Associated Diarrhea. Emerging Infectious Diseases, 9(6), 730-733. https://dx.doi.org/10.3201/eid0906.020385.
  • Absence of Neisseria meningitidis W-135 Electrophoretic Type 37 during the Hajj, 2002 PDF Version [PDF - 417 KB - 4 pages]
    A. Wilder-Smith et al.
        View Abstract

    We document the absence of carriage of Neisseria meningitidis W-135 of the sequence type 11 in returning pilgrims after the Hajj 2002. This finding contrasts with the 15% carriage rate we previously reported in pilgrims returning from the Hajj 2001. The epidemiology of carriage may be changing or may have been controlled by vaccination and a policy of administering antibiotics to pilgrims from countries with a high incidence of meningococcal disease.

        Cite This Article
    EID Wilder-Smith A, Barkham TM, Chew SK, Paton NI. Absence of Neisseria meningitidis W-135 Electrophoretic Type 37 during the Hajj, 2002. Emerg Infect Dis. 2003;9(6):734-737. https://dx.doi.org/10.3201/eid0906.020725
    AMA Wilder-Smith A, Barkham TM, Chew SK, et al. Absence of Neisseria meningitidis W-135 Electrophoretic Type 37 during the Hajj, 2002. Emerging Infectious Diseases. 2003;9(6):734-737. doi:10.3201/eid0906.020725.
    APA Wilder-Smith, A., Barkham, T. M., Chew, S. K., & Paton, N. I. (2003). Absence of Neisseria meningitidis W-135 Electrophoretic Type 37 during the Hajj, 2002. Emerging Infectious Diseases, 9(6), 734-737. https://dx.doi.org/10.3201/eid0906.020725.
  • Laboratory Surveillance of Dengue in Argentina, 1995–2001 PDF Version [PDF - 216 KB - 5 pages]
    G. Avilés et al.
        View Abstract

    Local transmission of dengue fever virus in Argentina is increased by the presence of Aedes aegypti mosquitoes and dengue outbreaks in neighboring countries. From 1995 to 2001, a laboratory-based active surveillance program detected 922 dengue cases. Indigenous transmission involving dengue-1 and -2 serotypes was confirmed only in subtropical areas in northern Argentina.

        Cite This Article
    EID Avilés G, Paz MV, Rangeon G, Ranaivoarisoa MY, Verzeri N, Roginski S, et al. Laboratory Surveillance of Dengue in Argentina, 1995–2001. Emerg Infect Dis. 2003;9(6):738-742. https://dx.doi.org/10.3201/eid0906.020483
    AMA Avilés G, Paz MV, Rangeon G, et al. Laboratory Surveillance of Dengue in Argentina, 1995–2001. Emerging Infectious Diseases. 2003;9(6):738-742. doi:10.3201/eid0906.020483.
    APA Avilés, G., Paz, M. V., Rangeon, G., Ranaivoarisoa, M. Y., Verzeri, N., Roginski, S....Enria, D. (2003). Laboratory Surveillance of Dengue in Argentina, 1995–2001. Emerging Infectious Diseases, 9(6), 738-742. https://dx.doi.org/10.3201/eid0906.020483.
  • Tick-Borne Encephalitis with Hemorrhagic Syndrome, Novosibirsk Region, Russia, 1999 PDF Version [PDF - 253 KB - 4 pages]
    V. A. Ternovoi et al.
        View Abstract

    Eight fatal cases of tick-borne encephalitis with unusual hemorrhagic syndrome were identified in 1999 in the Novosibirsk Region, Russia. To study these strains, we sequenced cDNA fragments of protein E gene from six archival formalin-fixed brain samples. Phylogenetic analysis showed tick-borne encephalitis variants clustered with a Far Eastern subtype (homology 94.7%) but not with the Siberian subtype (82%).

        Cite This Article
    EID Ternovoi VA, Kurzhukov GP, Sokolov YV, Ivanov GY, Ivanisenko VA, Loktev AV, et al. Tick-Borne Encephalitis with Hemorrhagic Syndrome, Novosibirsk Region, Russia, 1999. Emerg Infect Dis. 2003;9(6):743-746. https://dx.doi.org/10.3201/eid0906.030007
    AMA Ternovoi VA, Kurzhukov GP, Sokolov YV, et al. Tick-Borne Encephalitis with Hemorrhagic Syndrome, Novosibirsk Region, Russia, 1999. Emerging Infectious Diseases. 2003;9(6):743-746. doi:10.3201/eid0906.030007.
    APA Ternovoi, V. A., Kurzhukov, G. P., Sokolov, Y. V., Ivanov, G. Y., Ivanisenko, V. A., Loktev, A. V....Loktev, V. B. (2003). Tick-Borne Encephalitis with Hemorrhagic Syndrome, Novosibirsk Region, Russia, 1999. Emerging Infectious Diseases, 9(6), 743-746. https://dx.doi.org/10.3201/eid0906.030007.
  • Poor Potential Coverage for 7-Valent Pneumococcal Conjugate Vaccine, Malawi PDF Version [PDF - 194 KB - 3 pages]
    S. B. Gordon et al.
        View Abstract

    Streptococcus pneumoniae infections can be prevented by using new conjugate vaccines, but these vaccines have limited serogroup coverage. We report the first serogrouping data from carried and invasive isolates obtained from children and adults in Malawi. The 7-valent vaccine would cover 41% of invasive isolates from children and 25% from adults. A 9-valent vaccine, including types 1 and 5, would cover 66% of invasive isolates from children and 55% from adults.

        Cite This Article
    EID Gordon SB, Kanyanda S, Walsh AL, Goddard K, Chaponda M, Atkinson V, et al. Poor Potential Coverage for 7-Valent Pneumococcal Conjugate Vaccine, Malawi. Emerg Infect Dis. 2003;9(6):747-749. https://dx.doi.org/10.3201/eid0906.030020
    AMA Gordon SB, Kanyanda S, Walsh AL, et al. Poor Potential Coverage for 7-Valent Pneumococcal Conjugate Vaccine, Malawi. Emerging Infectious Diseases. 2003;9(6):747-749. doi:10.3201/eid0906.030020.
    APA Gordon, S. B., Kanyanda, S., Walsh, A. L., Goddard, K., Chaponda, M., Atkinson, V....Graham, S. M. (2003). Poor Potential Coverage for 7-Valent Pneumococcal Conjugate Vaccine, Malawi. Emerging Infectious Diseases, 9(6), 747-749. https://dx.doi.org/10.3201/eid0906.030020.

Letters

  • Imported West Nile Virus Infection in Europe PDF Version [PDF - 152 KB - 1 page]
    P. Charles et al.
            Cite This Article
    EID Charles P, Zeller H, Bonnotte B, Decasimacker A, Bour J, Chavanet P, et al. Imported West Nile Virus Infection in Europe. Emerg Infect Dis. 2003;9(6):750. https://dx.doi.org/10.3201/eid0906.020723
    AMA Charles P, Zeller H, Bonnotte B, et al. Imported West Nile Virus Infection in Europe. Emerging Infectious Diseases. 2003;9(6):750. doi:10.3201/eid0906.020723.
    APA Charles, P., Zeller, H., Bonnotte, B., Decasimacker, A., Bour, J., Chavanet, P....Lorcerie, B. (2003). Imported West Nile Virus Infection in Europe. Emerging Infectious Diseases, 9(6), 750. https://dx.doi.org/10.3201/eid0906.020723.
  • Rift Valley Fever Virus Infection among French Troops in Chad PDF Version [PDF - 196 KB - 2 pages]
    J. P. Durand et al.
            Cite This Article
    EID Durand JP, Bouloy M, Richecoeur L, Peyrefitte CN, Tolou HJ. Rift Valley Fever Virus Infection among French Troops in Chad. Emerg Infect Dis. 2003;9(6):751-752. https://dx.doi.org/10.3201/eid0906.020647
    AMA Durand JP, Bouloy M, Richecoeur L, et al. Rift Valley Fever Virus Infection among French Troops in Chad. Emerging Infectious Diseases. 2003;9(6):751-752. doi:10.3201/eid0906.020647.
    APA Durand, J. P., Bouloy, M., Richecoeur, L., Peyrefitte, C. N., & Tolou, H. J. (2003). Rift Valley Fever Virus Infection among French Troops in Chad. Emerging Infectious Diseases, 9(6), 751-752. https://dx.doi.org/10.3201/eid0906.020647.
  • Corynebacterium ulcerans Diphtheria in Japan PDF Version [PDF - 168 KB - 2 pages]
    A. Hatanaka et al.
            Cite This Article
    EID Hatanaka A, Tsunoda A, Okamoto M, Ooe K, Nakamura A, Miyakoshi M, et al. Corynebacterium ulcerans Diphtheria in Japan. Emerg Infect Dis. 2003;9(6):752-753. https://dx.doi.org/10.3201/eid0906.020645
    AMA Hatanaka A, Tsunoda A, Okamoto M, et al. Corynebacterium ulcerans Diphtheria in Japan. Emerging Infectious Diseases. 2003;9(6):752-753. doi:10.3201/eid0906.020645.
    APA Hatanaka, A., Tsunoda, A., Okamoto, M., Ooe, K., Nakamura, A., Miyakoshi, M....Takahashi, M. (2003). Corynebacterium ulcerans Diphtheria in Japan. Emerging Infectious Diseases, 9(6), 752-753. https://dx.doi.org/10.3201/eid0906.020645.
  • Salmonella in Birds Migrating through Sweden PDF Version [PDF - 172 KB - 3 pages]
    J. Hernandez et al.
            Cite This Article
    EID Hernandez J, Bonnedahl J, Waldenström J, Palmgren H, Olsen B. Salmonella in Birds Migrating through Sweden. Emerg Infect Dis. 2003;9(6):753-755. https://dx.doi.org/10.3201/eid0906.030072
    AMA Hernandez J, Bonnedahl J, Waldenström J, et al. Salmonella in Birds Migrating through Sweden. Emerging Infectious Diseases. 2003;9(6):753-755. doi:10.3201/eid0906.030072.
    APA Hernandez, J., Bonnedahl, J., Waldenström, J., Palmgren, H., & Olsen, B. (2003). Salmonella in Birds Migrating through Sweden. Emerging Infectious Diseases, 9(6), 753-755. https://dx.doi.org/10.3201/eid0906.030072.
  • Parachlamydiaceae as Rare Agents of Pneumonia PDF Version [PDF - 167 KB - 2 pages]
    G. Greub et al.
            Cite This Article
    EID Greub G, Berger P, Papazian L, Raoult D. Parachlamydiaceae as Rare Agents of Pneumonia. Emerg Infect Dis. 2003;9(6):755-756. https://dx.doi.org/10.3201/eid0906.020613
    AMA Greub G, Berger P, Papazian L, et al. Parachlamydiaceae as Rare Agents of Pneumonia. Emerging Infectious Diseases. 2003;9(6):755-756. doi:10.3201/eid0906.020613.
    APA Greub, G., Berger, P., Papazian, L., & Raoult, D. (2003). Parachlamydiaceae as Rare Agents of Pneumonia. Emerging Infectious Diseases, 9(6), 755-756. https://dx.doi.org/10.3201/eid0906.020613.
  • Hantaviruses in the Czech Republic PDF Version [PDF - 159 KB - 2 pages]
    M. Pejčoch and B. Kříž
            Cite This Article
    EID Pejčoch M, Kříž B. Hantaviruses in the Czech Republic. Emerg Infect Dis. 2003;9(6):756-757. https://dx.doi.org/10.3201/eid0906.020772
    AMA Pejčoch M, Kříž B. Hantaviruses in the Czech Republic. Emerging Infectious Diseases. 2003;9(6):756-757. doi:10.3201/eid0906.020772.
    APA Pejčoch, M., & Kříž, B. (2003). Hantaviruses in the Czech Republic. Emerging Infectious Diseases, 9(6), 756-757. https://dx.doi.org/10.3201/eid0906.020772.
  • Antibiotics and Airline Emergency Medical Kits PDF Version [PDF - 229 KB - 2 pages]
    B. Bar-Oz and B. Loughran
            Cite This Article
    EID Bar-Oz B, Loughran B. Antibiotics and Airline Emergency Medical Kits. Emerg Infect Dis. 2003;9(6):757-758. https://dx.doi.org/10.3201/eid0906.030097
    AMA Bar-Oz B, Loughran B. Antibiotics and Airline Emergency Medical Kits. Emerging Infectious Diseases. 2003;9(6):757-758. doi:10.3201/eid0906.030097.
    APA Bar-Oz, B., & Loughran, B. (2003). Antibiotics and Airline Emergency Medical Kits. Emerging Infectious Diseases, 9(6), 757-758. https://dx.doi.org/10.3201/eid0906.030097.

About the Cover

  • Pablo Picasso (1881–1973). Guernica (1937). PDF Version [PDF - 193 KB - 2 pages]
    P. Potter
            Cite This Article
    EID Potter P. Pablo Picasso (1881–1973). Guernica (1937). . Emerg Infect Dis. 2003;9(6):760-761. https://dx.doi.org/10.3201/eid0906.AC0906
    AMA Potter P. Pablo Picasso (1881–1973). Guernica (1937). . Emerging Infectious Diseases. 2003;9(6):760-761. doi:10.3201/eid0906.AC0906.
    APA Potter, P. (2003). Pablo Picasso (1881–1973). Guernica (1937). . Emerging Infectious Diseases, 9(6), 760-761. https://dx.doi.org/10.3201/eid0906.AC0906.
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