The human ehrlichioses in the United States.The emerging tick-borne zoonoses Zoonoses Infections of humans caused by the transmission of disease agents that naturally live in animals. People become infected when they unwittingly intrude into the life cycle of the disease agent and become unnatural hosts. human monocytic ehrlichiosis human monocytic ehrlichiosis Infectious disease An infection by Ehrlichia chaffeensis Vector Lone Star tick–Amblyomma americanum, possibly also Dermacentor variabilis (HME HME Home Medical Equipment HME Home Media Engine (TiVo) HME Heat and Moisture Exchange HME Hierarchical Mixtures-of-Experts HME Happy Meal Ethernet (UNIX driver) HME Honeymoon Experience ) and human granulocytic ehrlichiosis human granulocytic ehrlichiosis: see ehrlichiosis. (HGE HGE hemorrhagic gastroenteritis. ) are underreported in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . From 1986 through 1997, 1,223 cases (742 HME, 449 HGE, and 32 not ascribed to a specific ehrlichial agent) were reported by state health departments. HME was most commonly reported from southeastern and southcentral states, while HGE was most often reported from northeastern and upper midwestern states. The annual number of reported cases increased sharply, from 69 in 1994 to 364 in 1997, coincident co·in·ci·dent adj. 1. Occupying the same area in space or happening at the same time: a series of coincident events. See Synonyms at contemporary. 2. with an increase in the number of states making these conditions notifiable notifiable /no·ti·fi·a·ble/ (no?ti-fi´ah-b'l) necessary to be reported to a government health agency. notifiable necessary to be reported to the relevant government authority. Said of individual diseases. . From 1986 through 1997, 827 probable and confirmed cases were diagnosed by serologic testing serologic test Lab medicine A test that measures components–eg, antibodies, complement, and reactions–eg, complement fixation, agglutination, precipitation, etc, that reflect immune status, especially antibody titers. Cf Seroconversion. at the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. , although how many of these cases were also reported by states is not known. Improved national surveillance would provide a better assessment of the public health importance of ehrlichiosis. First recognized in the United States in 1986, the human ehrlichioses are considered emerging zoonotic diseases Zoonotic diseases Diseases caused by infectious agents that can be transmitted between (or are shared by) animals and humans. This can include transmission through the bite of an insect, such as a mosquito. Mentioned in: West Nile Virus . Two etiologically and epidemiologically distinct forms of illness are recognized: human monocytic ehrlichiosis (HME), caused by Ehrlichia chaffeensis (1), and human granulocytic ehrlichiosis (HGE), caused by an agent similar or identical to the veterinary pathogens E. equi and E. phagocytophila (2). A third species, E. ewingii, can also cause human illness (3). The bacteria that cause ehrlichiosis are transmitted to humans through the bite of infected ticks, which acquire the agents after feeding on infected animal reservoirs. During infection, ehrlichiae form distinctive membrane-bound, intracytoplasmic intracytoplasmic /in·tra·cy·to·plas·mic/ (-si?to-plaz´mik) within the cytoplasm of a cell. bacterial aggregates (morulae) in white blood cells White blood cells A group of several cell types that occur in the bloodstream and are essential for a properly functioning immune system. Mentioned in: Abscess Incision & Drainage, Bone Marrow Transplantation, Complement Deficiencies . HME is characterized by morulae in monocytes monocytes, n.pl the largest of the white blood cells. They have one nucleus and a large amount of grayish-blue cytoplasm. Develop into macrophages and both consume foreign material and alert T cells to its presence. , HGE by morulae in granulocytes Granulocytes White blood cells. Mentioned in: Blood Donation and Registry granulocytes (granˑ·y . Clinically, HME and HGE are nearly indistinguishable and are characterized by one or more of the following symptoms: fever, headache, myalgia myalgia /my·al·gia/ (mi-al´jah) muscular pain.myal´gic epidemic myalgia see under pleurodynia. my·al·gia n. , thrombocytopenia Thrombocytopenia Definition Thrombocytopenia is an abnormal drop in the number of blood cells involved in forming blood clots. These cells are called platelets. , leukopenia leukopenia /leu·ko·pe·nia/ (-pe´ne-ah) reduction of the number of leukocytes in the blood below about 5000 per cubic mm.leukope´nic basophilic leukopenia basophilopenia. , and elevated liver enzyme levels (4-8). A rash occurs in approximately one third of patients with HME (8) but is less common in patients with HGE (4,9). Most cases of ehrlichiosis are characterized by mild illness. However, complications such as adult respiratory distress syndrome Adult Respiratory Distress Syndrome Definition Adult respiratory distress syndrome (ARDS), also called acute respiratory distress syndrome, is a type of lung (pulmonary) failure that may result from any disease that causes large amounts of fluid to , renal failure renal failure n. Acute or chronic malfunction of the kidneys resulting from any of a number of causes, including infection, trauma, toxins, hemodynamic abnormalities, and autoimmune disease, and often resulting in systemic symptoms, especially edema, , neurologic neurologic /neu·ro·log·ic/ (-loj´ik) pertaining to neurology or to the nervous system. Neurologic Having to do with the nervous system. disorders, and disseminated intravascular coagulation disseminated intravascular coagulation n. Abbr. DIC A hemorrhagic disorder that occurs following the uncontrolled activation of clotting factors and fibrinolytic enzymes throughout small blood vessels, resulting in tissue necrosis and can occur (6,10). Case-fatality ratios case-fatality ratio Epidemiology A value calculated as 100 cases of a disease 'X', divided by the number of persons with the disease who died in a given period of time; the resulting ratio is equal to the rate of a disease's occurrence. See Cause-fatality ratio. are as high as 5% for HME and 10% for HGE (10), although more serious cases are probably overrepresented o·ver·rep·re·sent·ed adj. Represented in excessive or disproportionately large numbers: "Some groups, and most notably some races, may be overrepresented and others may be underrepresented" in these estimates. Other studies have reported case-fatality ratios of <5% for these diseases (4,7). HME and HGE are most often diagnosed by indirect immunofluorescence Noun 1. indirect immunofluorescence - a method of using fluorescence microscopy to detect the presence of an antigen indirectly fluorescence microscopy - light microscopy in which the specimen is irradiated at wavelengths that excite fluorochromes assay (IFA Immunofluorescent assay (IFA) A blood test sometimes used to confirm ELISA results instead of using the Western blotting. In an IFA test, HIV antigen is mixed with a fluorescent compound and then with a sample of the patient's blood. ), although polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is (PCR PCR polymerase chain reaction. PCR abbr. polymerase chain reaction Polymerase chain reaction (PCR) ) assays are increasingly used (11). A confirmed case is defined as a fourfold fourfold Adjective 1. having four times as many or as much 2. composed of four parts Adverb by four times as many or as much Adj. 1. change in antibody titer antibody titer The amount of a specific antibody present in the serum, usually as a result of an acquired infection; titers for IgM usually rise abruptly at the time of infection–acute phase and fall slowly; during the 'convalescent' phase, IgG ↑ and is by IFA in acute- and convalescent-phase serum samples, PCR amplification of ehrlichial DNA DNA: see nucleic acid. DNA or deoxyribonucleic acid One of two types of nucleic acid (the other is RNA); a complex organic compound found in all living cells and many viruses. It is the chemical substance of genes. from a clinical sample, or detection of intraleukocytic morulae and a single IFA titer titer /ti·ter/ (ti´ter) the quantity of a substance required to react with or to correspond to a given amount of another substance. of [is greater than or equal to] 64. A probable case is defined as a single IFA titer of [is greater than or equal to] 64 or the presence of morulae within infected leukocytes. Laboratory data are only used to support clinical suspicion clinical suspicion A working hypothesis about a Pt's diagnosis, which is then tested with appropriately targeted tests to arrive at a definitive diagnosis; a CS is based on a constellation of findings in a Pt that suggests to the physician a limited palette of ; the designation of a confirmed or probable case of ehrlichiosis is interpreted in the context of compatible illness (11). The public health importance of the ehrlichioses has not been well defined, largely because these diseases are newly recognized. Because ehrlichiae are present in blood, concerns have been raised about the risk for perinatal perinatal /peri·na·tal/ (-na´t'l) relating to the period shortly before and after birth; from the twentieth to twenty-ninth week of gestation to one to four weeks after birth. per·i·na·tal adj. and blood-transfusion transmission (12,13). Ehrlichiae are susceptible to tetracyclines Tetracyclines Definition Tetracyclines are medicines that kill certain infection-causing microorganisms. Purpose Tetracyclines are called "broad-spectrum" antibiotics, because they can be used to treat a wide variety of , so rapid and effective treatment is possible (8). However, the nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik) 1. not due to any single known cause. 2. not directed against a particular agent, but rather having a general effect. nonspecific 1. signs and symptoms of these diseases may interfere with timely clinical diagnosis. Ehrlichial infections can be life-threatening. Raising disease awareness and educating physicians and the public about clinical manifestations and proper treatment are indicated. A national ehrlichiosis surveillance program does not exist, so national incidence rates have not been determined because of wide variability in state surveillance activities. The Council of State and Territorial Epidemiologists The Council of State and Territorial Epidemiologists (CSTE) was organized in the USA in the early 1950s in response to the need to have at least one person in each state and territory responsible for public health surveillance of diseases and conditions of public health recommended that human ehrlichiosis be made nationally notifiable in 1998, but many states do not have a system for surveillance and do not test for ehrlichiosis in state diagnostic laboratories. We summarize the scope of state-supported surveillance efforts and present data on ehrlichiosis cases reported to state health departments from 1986 through 1997. In addition, we include data on ehrlichiosis cases diagnosed by serologic testing at the Centers for Disease Control and Prevention (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ). Reported Ehrlichiosis Cases in the United States From 1986 through 1997, 1,223 ehrlichiosis cases were reported by 30 state health departments in the United States. Data were reported from 19 states that considered ehrlichiosis notifiable as of August 1998, five that routinely collected information on cases, and six that occasionally received reports of ehrlichiosis cases (Appendix I) (14-17). For states where ehrlichiosis was not notifiable, the designation routine reporting versus occasional reporting was based on the completeness of data provided. Because some states did not differentiate between probable and confirmed cases in their records, both categories were considered cases for the purposes of this report. Of the 1,223 reported ehrlichiosis cases, 742 (60.7%) were categorized cat·e·go·rize tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es To put into a category or categories; classify. cat as HME, 449 (36.7%) as HGE, and 32 (2.6%) as not ascribed to a specific ehrlichial agent. Using data from 20 states that reported information on deaths, we found case-fatality ratios of 2.7% (8 of 299) for HME and 0.7% (3 of 448) for HGE. HME and HGE Incidence Data provided through 1997 were used to calculate state-specific average annual incidence rates for 16 of the 19 states that considered ehrlicjiosis notifiable and the five states that routinely collected surveillance data (Table). Although Missouri, South Carolina South Carolina, state of the SE United States. It is bordered by North Carolina (N), the Atlantic Ocean (SE), and Georgia (SW). Facts and Figures Area, 31,055 sq mi (80,432 sq km). Pop. (2000) 4,012,012, a 15. , and Tennessee considered ehrlichiosis notifiable, average annual incidence rates could not be calculated because these states did not differentiate between HME and HGE. Average annual incidence per one million population was calculated by dividing the number of reported cases by the number of years a state collected data (Table). When possible, average annual incidence by county was determined for HME and HGE (Figures 1-2) (15,17). [Figures 1-2 ILLUSTRATION OMITTED] Table. Average annual ehrlichiosis incidence (per one million population) for reporting states(a) on the basis of 1995 census data (18)
Incidence
Human Human
monocytic granulocytic
State ehrlichiosis ehrlichiosis
Arkansas 5.53 0
Arizona 0.12 0
California 0.02 0.03
Connecticut 0.92 15.90
Florida 0.74 0
Illinois 0.11 0.03
Indiana 0.91 0
Kentucky 0.40 0
Maine 0 0
Minnesota 0.22 3.90
Missouri 3.05 0
North Carolina 4.72 0.05
New Hampshire 0 0
New Jersey 1.47 0.17
New York 0.38 2.68
Oklahoma 2.90 0
Pennsylvania 0.01 0.03
Rhode Island 0 0.67
Texas 0.20 0
Virginia 0.68 0
Wisconsin 0 8.79
(a) Includes states that consider ehrlichiosis notifiable, as well as five states where data are routinely collected. Michigan, South Carolina, and Tennessee did not differentiate between cases of human monocytic ehrlichiosis and human granulocytic ehrlichiosis and are not included in this table. Most HME cases were reported from the southeastern and southcentral areas of the United States (Table, Figure 1). The highest reported average annual incidence rates of HME were in Arkansas (5.53 per million), North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures Area, 52,586 sq mi (136,198 sq km). Pop. (4.72 per million), Missouri (3.05 per million), and Oklahoma (2.90 per million). In contrast, the highest reported average annual incidence rates of HGE were in the northeastern and upper midwestern areas of the United States--Connecticut (15.90 per million), Wisconsin (8.79 per million), Minnesota (3.90 per million), and New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of (2.68 per million) (Figure 2). The county reporting the highest; average annual incidence of HME was Searcy, Arkansas Searcy (local pronunciation: SUR see) is the largest city and county seatGR6 of White County, Arkansas, United States. According to 2006 Census Bureau estimates, the population of the city is 20,663. (64.80 per million), and the county with the highest annual incidence of HGE was Jackson, Wisconsin
Jackson is a village in Washington County, Wisconsin, United States. The population was 4,938 at the 2000 census. The village is located partially within the Town of Jackson. (521.68 per million). These incidence rates follow the expected geographic distribution of tick vectors for each type of ehrlichiosis. E. chaffeensis is primarily transmitted by the lone star tick lone star tick see amblyommaamericanum. Lone Star tick Amblyomma americanum A 3-host–wild animal, domestic animal, hard tick native to southern US, Central and South America, which is a vector of RMSF and occasionally Lyme disease. (Amblyomma americanum Amblyomma americanum, or lone star tick, is a species of tick in the genus Amblyomma. It is very wide-spread in the United States ranging from Texas to Iowa in the Midwest and east to the coast where it can be found as far north as Maine. ), which is common in the southeastern United States (].9). The black-legged tick black-legged tick see ixodes. (Ixodes scapularis Ixodes scapularis Deer tick A tick with a 2-yr life cycle, and 3 feeding seasons; the cycle begins in spring with soil deposition of fertilized eggs; by summer, larvae emerge and imbibe a blood meal from small vertebrates–eg, white-footed mouse– ) transmits the causative caus·a·tive adj. 1. Functioning as an agent or cause. 2. Expressing causation. Used of a verb or verbal affix. caus agent of HGE in the northeastern United States (20,21) and the western black-legged tick (I. pacificus) in the western coastal United States (22). Reporting Trends The annual number of ehrlichiosis cases reported by the state health departments was calculated with data from 18 states that considered ehrlichiosis notifiable as of August 1998 (yearly summaries were not available for Missouri) and the five additional states that routinely collected information on ehrlichiosis cases (Figure 3). The annual number of reported ehrlichiosis cases increased sharply, from 69 in 1994 to 364 in 1997. This increase may be explained by the addition of ehrlichiosis as a notifiable disease no·ti·fi·a·ble disease n. A disease that must be reported to public health authorities at the time it is diagnosed because it is potentially dangerous to human or animal health. Also called reportable disease. in 10 states during this same 4-year interval, the discovery of HGE in 1994, increased availability of diagnostic tests, and increased awareness of ehrlichiosis. [Figure 3 ILLUSTRATION OMITTED] Ehrlichioses Cases Diagnosed at CDC At CDC, antigen from E. chaffeensis, Arkansas strain, is used to diagnose HME by IFA. Before E. chaffeensis was isolated in 1991, E. canis was used as a surrogate antigen (23). During 1995 to 1996, antigen from E. equi obtained from infected horse neutrophils neutrophils (ner·ō·trōˑ·filz), n.pl white blood cells with cytoplasmic granules that consume harmful bacteria, fungi, and other foreign materials. was used, but cases submitted to CDC after 1996 were diagnosed by IFA using cell culture--derived antigen from the HGE agent (24). Antibody from patients with ehrlichial infection may cross-react with both E. chaffeensis and the HGE agent (24,25). For patients with significant antibody titers to both Ehrlichia species, the causative agent is assumed to be the one with a fourfold or greater change in antibody titer between paired serum samples. If both agents show a fourfold difference, the one with the highest titer is considered the causative agent. If neither shows a fourfold difference, the causative agent is usually not ascribed to a specific ehrlichial species (25). Of 827 probable and confirmed ehrlichiosis cases diagnosed by IFA from serum or plasma specimens submitted to CDC through the end of 1997, 754 were HME, 44 were HGE, and 29 could not be differentiated because of antibody cross-reactivity. The geographic distribution was widespread (Figures 4, 5), and cases of ehrlichiosis were diagnosed from every state except North Dakota North Dakota, state in the N central United States. It is bordered by Minnesota, across the Red River of the North (E), South Dakota (S), Montana (W), and the Canadian provinces of Saskatchewan and Manitoba (N). and South Dakota South Dakota (dəkō`tə), state in the N central United States. It is bordered by North Dakota (N), Minnesota and Iowa (E), Nebraska (S), and Wyoming and Montana (W). (Appendix 2). Imported disease acquired by travel to disease-endemic areas may explain cases reported from states without the recognized tick vectors, including Hawaii and Alaska. Because information about clinical manifestations was not always provided with specimens, whether all cases had compatible clinical illness is unknown. Of 754 HME cases, 423 (56.1%) were classified as probable and 331 (43.9%) as confirmed on the basis of serologic se·rol·o·gy n. pl. se·rol·o·gies 1. The science that deals with the properties and reactions of serums, especially blood serum. 2. criteria established by CSTE CSTE Council of State and Territorial Epidemiologists CSTE Certified Software Test Engineer CSTE Centre for the Study of Teacher Education (University of British Columbia, Vancouver) and CDC (11). In contrast, of 44 HGE cases, 39 (88.6%) were classified as probable and 5 (11.4%) as confirmed. [Figures 4-5 ILLUSTRATION OMITTED] Conclusions Although a few state health departments have published information on local ehrlichiosis surveillance (14-17,26-28), comprehensive national surveillance data had not been collected until this review. This review further defines the public health problem posed by the ehrlichioses in the United States. These diseases have incidence rates comparable with or exceeding those of Rocky Mountain spotted fever Rocky Mountain spotted fever, infectious disease caused by a rickettsia. The germ is harbored by wild rodents and other animals and is carried by infected ticks that attach themselves to humans. in some states (29). These state-reported data have several limitations. State health departments provided information on ehrlichiosis cases in different ways. For example, some states provided only data compiled after ehrlichiosis became notifiable, while others provided information as far back as data were available. The ehrlichiosis cases in this article represent a compilation of existing (albeit incomplete) surveillance datasets and probably underestimate the true prevalence of the disease in the United States. Moreover, the accuracy of HME and HGE case-fatality ratios presented here is uncertain. The number of deaths may be underreported because diagnosis of ehrlichiosis requires laboratory confirmation. However, serious or complicated cases, more likely to end in death, are more likely to be investigated and reported to state health departments. The case-fatality ratios described in this article are compatible with findings from other studies (4,7). Finally, the state-reported data include some cases from areas where ehrlichiosis is not commonly diagnosed. For example, a single case of HME was reported from Arizona, although the recognized distribution of the lone star tick does not include this state. Ehrlichiosis cases are usually reported from the patient's county and state of residence at the time of diagnosis; however, ehrlichiosis may be acquired during travel to an area with Ehrlichia-infected ticks. Imported cases of ehrlichiosis in states where the disease is not common or tick vectors are absent underscores the need to consider this diagnosis even in areas of low risk. Diagnostic serologic testing has been offered at CDC since 1986 for HME, and since 1995 for HGE. Records show that from 1986 through 1997 more than 800 ehrlichiosis cases were diagnosed from 48 states. This finding contrasts sharply with state-reported surveillance data, which identified specific geographic regions where ehrlichiosis was most likely to occur. The number of cases diagnosed at CDC from each state may not accurately reflect expected regional incidence patterns; for example, states with public health laboratories that offer in-house diagnostic tests or states that frequently use commercial laboratories may be less likely to submit samples to CDC for testing. Some cases of ehrlichiosis diagnosed at CDC may also have been reported by state surveillance systems; these reporting systems cannot be regarded as mutually exclusive Adj. 1. mutually exclusive - unable to be both true at the same time contradictory incompatible - not compatible; "incompatible personalities"; "incompatible colors" . The numbers of serologically diagnosed cases of ehrlichiosis reported here may differ from numbers published in other CDC reports because other reports include samples obtained for specific studies (7), whereas most of the cases in this report were submitted for routine diagnostic tests. As of August 1998, only 19 states considered ehrlichiosis notifiable, and fewer than one fourth of state health departments offered in-house diagnostic assays for HME or HGE. Average annual incidence rates, an important indicator of disease prevalence, could be calculated for only 21 states. These data underscore The underscore character (_) is often used to make file, field and variable names more readable when blank spaces are not allowed. For example, NOVEL_1A.DOC, FIRST_NAME and Start_Routine. (character) underscore - _, ASCII 95. the need for better nationwide surveillance of ehrlichiosis. Acknowledgments We thank the state health departments for sharing these data and gratefully acknowledge the contributions of Bob England, Thomas McChesney, Dennis Berry, Thomas Tsang, Mark Starr, David Schnurr, John Poppy, Jim Meek meek adj. meek·er, meek·est 1. Showing patience and humility; gentle. 2. Easily imposed on; submissive. , Cathy Rebmann, Lisa Conti Conti (kôNtē`), cadet branch of the French royal house of Bourbon. Although the title of prince of Conti was created in the 16th cent. , Valerie Mock, Jeff Chapman, Mike Loeffelholz, Carl Langkop, Robert Teclaw, Pam Judson, Mike Auslander aus·land·er n. A foreigner. [German Ausländer, from Ausland, foreign country : aus-, away (from Middle High German , Louise McFarland, Mike McGuill, David Blythe, Linda Traviti, Jeff Beckett, Mary Grace Stobierski, Sheril Arndt, Dave Neitzel, Mary Currier, Melissa Johnson, Faye Sorhage, Lorna Lynch, Paul Edistat, Philip Kurpiel, Susan Wong, Todd McPherson, Leslie Wolf, Mike Crutcher, Maria Moll, Ted Donnelly, Ted LeBlanc, Steve McLaughlin For the musician and producer, see . Steve McLaughlin (born October 2, 1971) was an American football player. Born in 1971 in Tucson Arizona, Steve McLaughlin had a long career growing up playing soccer. , Robert Taylor Robert Taylor or Bob Taylor may refer to:
We thank Joseph Singleton sin·gle·ton n. An offspring born alone. singleton Medtalk One baby. Cf Triplet, Twin. for help in collecting data on confirmed and probable ehrlichiosis cases diagnosed at CDC. References (1.) Anderson BE, Dawson JE, Jones DC, Wilson KH. Ehrlichia chaffeensis, a new species associated with human ehrlichiosis. J Clin Microbiol 1991;29:2838-42. (2.) Chen S, Dumler JS, Bakken JS, Walker DH. Identification of a granulocytotropic, Ehrlichia species as the etiologic agent of human disease. J Clin Microbiol 1994;32:589-95. (3.) Hmiel SP, Buller R, Arens M, Gaudreault-Keener M, Storch GA. Human infection with Ehrlichia ewingii, the agent of Ozark canine granulocytic granulocytic pertaining to granulocytes. granulocytic leukemia see myelocytic leukemia. granulocytic sarcoma extramedullary growth of multiple, focal granulocytic neoplasm. They may be neutrophilic or eosinophilic. ehrlichiosis. Proceedings of the First International Conference on Emerging Infectious Diseases The ICEID or International Conference on Emerging Infectious Diseases is a conference for public health professionals on the subject of emerging infectious diseases. ; 1998 Mar 8-11; Atlanta, Georgia; Addendum addendum n. an addition to a completed written document. Most commonly this is a proposed change or explanation (such as a list of goods to be included) in a contract, or some point that has been subject of negotiation after the contract was originally proposed by :4. [Abstract]. (4.) Bakken JS, Krueth J, Wilson-Nordskog C, Tilden RL, Asanovich K, Dumler JS. Clinical and laboratory characteristics of human granulocytic ehrlichiosis. JAMA JAMA abbr. Journal of the American Medical Association 1996;275:199~205. (5.) Dawson JE, Warner CK, Standaert S, Olson JG. The interface between research and the diagnosis of an emerging tick-berne disease, human ehrlichiosis due to Ehrlichia chaffeensis. 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Bureau of Census Bureau of Census A division of the federal government of the United States Bureau of Commerce that is responsible for conducting the national census at least once every 10 years, in which the population of the United States is counted. . Intercensual estimates of the population of counties by age, sex, and race: 1995. Washington: The Bureau; 1996. (19.) Anderson BE, Sims KG, Olson JG, Childs JE, Piesman JR, Happ CM, et al. Amblyomma americanum: a potential vector of human ehrlichiosis. Am J Trop Med Hyg 1993;49:239-44. (20.) Magnarelli LA, Stafford KC, Mather TN, Yeh M, Horn KD, Dumler JS. Hemocytic rickettsia-like organisms in ticks: serologic reactivity with antisera to Ehrlichiae and detection of DNA of the agent of human granulocytic ehrlichiosis by PCR. J Clin Microbiol 1995;33:2710-4. (21.) Pancholi P, Kolbert CP, Mitchell PD, Reed KD, Dumler JS, Bakken JS, et al. Ixodes dammini Ixodes dam·mi·ni n. A species of Ixodes that is a vector of Lyme disease and human babesiosis in the United States. tick as a potential vector of human granulocytic ehrlichiosis. J Infect Dis 1995;172:1007-12. (22.) Richter PJ Jr, Kimsey RB, Madigan JE, Barlough JE, Dumler JS, Brooks DL. Ixodes pacificus (Acari: Ixodidae) as a vector of Ehrlichia equi (Rickettsiales: Ehrlichieae). J Med Entomol 1996;33:1-5. (23.) Dawson JE, Rikihisa Y, Ewing SA, Fishbein DB. Serologic diagnosis of human ehrlichiosis using two Ehrlichia canis isolates. J Infect Dis 1991;163:564-7. (24.) Nicholson WL, Comer JA, Sumner JW, Gingrich-Baker C, Coughlin RT, Magnarelli LA, et al. An indirect immunofluorescence assay using a cell culture-derived antigen for detection of antibodies to the agent of human granulocytic ehrlichiosis. J Clin Microbiol 1997;35:1510-6. (25.) Comer JA, Nicholson WL, Olson JG, Childs JE. Serologic testing for human granulocytic ehrlichiosis at a national referral center. J Clin Microbiol 1999;37:558-64. (26.) Centers for Disease Control and Prevention. Human ehrlichiosis--Maryland, 1994. MMWR Morb Mortal Wkly Rep 1996;45:798-802. (27.) Centers for Disease Control and Prevention. Human granulocytic ehrlichiosis--New York, 1995. MMWR Morb Mortal Wkly Rep 1995;44:593-5. (28.) Centers for Disease Control and Prevention. Statewide surveillance for ehrlichiosis--Connecticut and New York, 1994-1997. MMWR Morb Mortal Wkly Rep 1998;47:476-80. (29.) Dalton MJ, Clarke MJ, Holman RC, Krebs JW, Fishbein DB, Olson JG, et al. National surveillance for Rocky Mountain spotted fever, 1981-1992: epidemiologic summary and evaluation of risk factors for fatal outcome fatal outcome, n a consequence that results in death. The course of a disease that results in the death of the patient. . Am J Trop Med Hyg 1995;52:405-13. Appendix I: Ehrlichiosis surveillance by state health departments as of August 1998 and total number of cases reported through 1997.
Laboratory
First year Tests
State reportable offered
Alabama Not reportable None available
Alaska Not reportable None available
Arizona 1997 None available
Arkansas 1993 None available
California 1996 IFA for both; PCR for both
Colorado Not reportable(a) None available
Connecticut 1995 IFA for both; PCR for both
Delaware Not reportable None available
District of Not reportable None available
Columbia
Florida 1996 IFA for HME only
Georgia Not reportable None available
Hawaii Not reportable None available
Idaho Not reportable None available
Illinois Not reportable(b) None available
Indiana Not reportable(b) IFA for HME only
Iowa Not reportable IFA for both; PCR for both
Kansas Not reportable None available
Kentucky 1989 None available
Louisiana Not reportable(a) None available
Maine 1996 None available
Maryland Not reportable IFA for both
Massachusetts Not reportable(a) None available
Michigan 1993 None available
Minnesota 1996 None available
Mississippi Not reportable(a) None available
Missouri Reportable, date None available
unknown
Montana Not reportable None available
Nebraska Not reportable None available
Nevada Not reportable None available
New Hampshire 1996 None available
New Jersey 1995 IFA for both; PCR for both
New Mexico Not reportable(a) None available
New York 1996 IFA for both; PCR for both
North Carolina 1998 IFA for HME only
North Dakota Not reportable None available
Ohio Not reportable None available
Oklahoma Not reportable(b) None available
Oregon Not reportable None available
Pennsylvania 1992 None available
Rhode Island 1996 None available
South Carolina 1990 None available
South Dakota Not reportable None available
Tennessee 1996 IFA for HME only
Texas 1996 IFA for HME only;
PCR for both
Utah Not reportable None available
Vermont Not reportable None available
Virginia Not reportable(b) None available
Washington Not reportable None available
West Virginia Not reportable None available
Wisconsin Not reportable(b) IFA for both; PCR
for HGE only
Wyoming Not reportable None available
Total n/a n/a
Human Human
monocytic granulocytic Ehrlichial
ehrlichiosis ehrlichiosis agent not Total
State cases cases specified cases
Alabama -- -- -- --
Alaska -- -- -- --
Arizona 1 0 0 1
Arkansas 55 0 0 55
California 2 3 0 5
Colorado -- -- 3 3
Connecticut 9 156 9 174
Delaware -- -- -- --
District of
Columbia -- -- -- --
Florida 21 0 0 21
Georgia -- -- -- --
Hawaii -- -- -- --
Idaho -- -- -- --
Illinois 5 1 2 8
Indiana 21 0 0 21
Iowa -- -- -- --
Kansas -- -- -- --
Kentucky 14 0 0 14
Louisiana -- -- 1 1
Maine 0 0 0 0
Maryland 6 0 1 7
Massachusetts 0 5 0 5
Michigan -- -- 2 2
Minnesota 2 36 0 38
Mississippi -- -- 1 1
Missouri 162 0 0 162
Montana -- -- -- --
Nebraska -- -- -- --
Nevada -- -- -- --
New Hampshire 0 0 0 0
New Jersey 35 4 0 39
New Mexico 1 0 0 1
New York 28 195 0 223
North Carolina 204 1 0 205
North Dakota -- -- -- --
Ohio -- -- -- --
Oklahoma 76 0 0 76
Oregon -- -- -- --
Pennsylvania 1 1 1 3
Rhode Island 0 2 0 2
South Carolina -- -- 5 5
South Dakota -- -- -- --
Tennessee -- -- 7 7
Texas 45 0 0 45
Utah -- -- -- --
Vermont -- -- -- --
Virginia 54 0 0 54
Washington -- -- -- --
West Virginia -- -- -- --
Wisconsin 0 45 0 45
Wyoming -- -- -- --
Total 742 449 32 1,223
(a) Occasionally received reports of ehrlichiosis cases. (b) Routinely collected information on ehrlichiosis cases. HME, human monocytic ehrlichiosis; HGE, human granulocytic ehrlichiosis; -- not reported by states; IFA, indirect immunofluorescence assay; PCR, polymerase chain reaction; n/a, not applicable. Appendix II: Probable and confirmed ehrlichiosis cases diagnosed by indirect immunfluorescence assay (IFA), Centers for Disease Control and Prevention, 1986 through 1997.
Human monocytic
ehrlichiosis
State Prob(b) Conf(c) Total
Alabama 8 4 12
Alaska 2 0 2
Arizona 0 1 1
Arkansas 32 20 52
California 15 9 24
Colorado 6 1 7
Connecticut 9 4 13
Delaware 1 1 2
District of Columbia 4 8 12
Florida 15 7 22
Georgia 30 25 55
Hawaii 2 4 6
Idaho 3 0 3
Illinois 3 5 8
Indiana 9 0 9
Iowa 19 5 24
Kansas 1 2 3
Kentucky 5 2 7
Louisiana 5 2 7
Maine 2 1 3
Maryland 18 7 25
Massachusetts 10 3 13
Michigan 4 2 6
Minnesota 5 3 8
Mississippi 0 2 2
Missouri 61 84 145
Montana 2 0 2
Nebraska 17 1 18
Nevada 0 1 1
New Hampshire 1 0 1
New Jersey 4 9 13
New Mexico 1 0 1
New York 13 3 16
North Carolina 28 5 33
North Dakota 0 0 0
Ohio 4 0 4
Oklahoma 4 7 11
Oregon 0 1 1
Pennsylvania 2 6 8
Rhode Island 2 0 2
South Carolina 4 4 8
South Dakota 0 0 0
Tennessee 15 22 37
Texas 22 31 53
Utah 0 1 1
Vermont 2 0 2
Virginia 17 29 46
Washington 13 6 19
West Virginia 0 0 0
Wisconsin 3 1 4
Wyoming 0 2 2
Total 423 331 754
Human granulocytic
ehrlichiosis
State Prob(b) Conf(c) Total
Alabama 0 0 0
Alaska 0 0 0
Arizona 0 0 0
Arkansas 8 0 8
California 0 0 0
Colorado 0 0 0
Connecticut 0 1 1
Delaware 0 0 0
District of Columbia 0 0 0
Florida 0 1 1
Georgia 1 0 1
Hawaii 0 0 0
Idaho 1 0 1
Illinois 0 0 0
Indiana 0 0 0
Iowa 8 0 8
Kansas 0 0 0
Kentucky 0 0 0
Louisiana 0 0 0
Maine 0 0 0
Maryland 0 0 0
Massachusetts 5 1 6
Michigan 0 0 0
Minnesota 0 0 0
Mississippi 0 0 0
Missouri 0 1 1
Montana 1 0 1
Nebraska 1 0 1
Nevada 1 0 1
New Hampshire 0 0 0
New Jersey 1 0 1
New Mexico 0 0 0
New York 2 0 2
North Carolina 0 0 0
North Dakota 0 0 0
Ohio 0 0 0
Oklahoma 3 0 3
Oregon 0 0 0
Pennsylvania 0 0 0
Rhode Island 0 0 0
South Carolina 0 0 0
South Dakota 0 0 0
Tennessee 4 0 4
Texas 0 0 0
Utah 0 0 0
Vermont 0 0 0
Virginia 1 0 1
Washington 0 0 0
West Virginia 0 0 0
Wisconsin 2 1 3
Wyoming 0 0 0
Total 39 5 44
Ehrlichial agent
not determined(a) Total
State Prob(b) Conf(c) Total cases
Alabama 0 1 1 13
Alaska 0 0 0 2
Arizona 0 0 0 1
Arkansas 1 1 2 62
California 0 0 0 24
Colorado 0 0 0 7
Connecticut 0 0 0 14
Delaware 0 0 0 2
District of Columbia 1 0 1 13
Florida 2 1 3 26
Georgia 1 0 1 57
Hawaii 0 0 0 6
Idaho 0 0 0 4
Illinois 0 0 0 8
Indiana 0 0 0 9
Iowa 2 0 2 34
Kansas 0 0 0 3
Kentucky 0 0 0 7
Louisiana 0 0 0 7
Maine 0 0 0 3
Maryland 1 1 2 27
Massachusetts 1 1 2 21
Michigan 0 0 0 6
Minnesota 0 0 0 8
Mississippi 0 0 0 2
Missouri 2 2 4 150
Montana 0 0 0 3
Nebraska 0 1 1 20
Nevada 0 0 0 2
New Hampshire 0 0 0 1
New Jersey 0 0 0 14
New Mexico 0 0 0 1
New York 0 0 0 18
North Carolina 1 1 2 35
North Dakota 0 0 0 0
Ohio 0 0 0 4
Oklahoma 0 1 1 15
Oregon 0 0 0 1
Pennsylvania 0 0 0 8
Rhode Island 0 0 0 2
South Carolina 0 0 0 8
South Dakota 0 0 0 0
Tennessee 2 0 2 43
Texas 0 0 0 53
Utah 0 0 0 1
Vermont 0 0 2 4
Virginia 2 0 2 49
Washington 0 0 0 19
West Virginia 0 1 1 1
Wisconsin 1 1 2 9
Wyoming 0 0 0 2
Total 17 12 29 827
(a) Includes cases that could not be ascribed to a specific ehrlichial agent because of antibody cross-reactivity. (b) Probable case (single antibody titer of [is greater than or equal to] 64 by IFA). (c) Confirmed case (fourfold change in antibody titer in paired serum by samples by IFA). Dr. McQuiston, a veterinarian veterinarian /vet·er·i·nar·i·an/ (vet?er-i-nar´e-an) a person trained and authorized to practice veterinary medicine and surgery; a doctor of veterinary medicine. vet·er·i·nar·i·an n. , is serving as an Officer in the Epidemic Intelligence Service The Epidemic Intelligence Service is a program of the United States' Centers for Disease Control and Prevention. Established in 1951 due to biological warfare concerns arising from the Korean War, it has become a hands-on two-year postgraduate training program in epidemiology, with , Centers for Disease Control and Prevention. Her research focuses on the epidemiologic investigation of several zoonotic Zoonotic A disease which can be spread from animals to humans. Mentioned in: Zoonosis pathogens, including rabies virus rabies virus n. A rather large, bullet-shaped virus of the genus Lyssavirus that causes rabies. , ehrlichioses, and Rickettsia rickettsii Rickettsia rick·ett·si·i n. A bacterium that causes a variety of spotted fevers throughout the world including Rocky Mountain spotted fever. . Address for correspondence: J.E. Childs, Centers for Disease Control and Prevention, Mail Stop G13, 1600 Clifton Road Clifton Road is main street in Clifton neighborhood of Saddar Town in Karachi, Sindh, Pakistan. Its name dates from the British Colonial rule, and its market is posh areas of Karachi. , Atlanta, GA 30333, USA; fax: 404-639-2778; e-mail: jfc5@cdc.gov. |
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