An Outbreak of Primary Pneumonic Tularemia on Martha's Vineyard
Katherine A. Feldman, D.V.M., M.P.H., Russell E. Enscore, M.S., Sarah L. Lathrop, D.V.M., Ph.D., Bela T. Matyas, M.D., M.P.H., Michael McGuill, D.V.M., M.P.H., Martin E. Schriefer, Ph.D., Donna Stiles-Enos, R.N., David T. Dennis, M.D., M.P.H., Lyle R. Petersen, M.D., M.P.H., and Edward B. Hayes, M.D.
Background In the summer of 2000, an outbreak of primary pneumonictularemia occurred on Martha's Vineyard, Massachusetts. Theonly previously reported outbreak of pneumonic tularemia inthe United States also occurred on the island in 1978.
Methods We conducted a case–control study of adults withpneumonic tularemia and investigated the environment to identifyrisk factors for primary pneumonic tularemia. Patients withconfirmed cases were residents of or visitors to Martha's Vineyardwho had symptoms suggestive of primary pneumonic tularemia,were ill between May 15 and October 31, 2000, and had a positivelaboratory test for tularemia. Controls were adults who hadspent at least 15 days on Martha's Vineyard between May 15 andSeptember 28, 2000.
Results We identified 15 patients with tularemia; 11 of thesecases were primary pneumonic tularemia. Francisella tularensistype A was isolated from blood and lung tissue of the one manwho died. Patients were more likely than controls to have useda lawn mower or brush cutter in the two weeks before the illness(odds ratio, 9.2; 95 percent confidence interval, 1.6 to 68.0)and during the summer (odds ratio, undefined; 95 percent confidenceinterval, 1.8 to ). Lawn mowing and brush cutting remained significantrisk factors after adjustment for other potentially confoundingvariables. Only one patient reported being exposed to a rabbitwhile cutting brush. Of 40 trapped animals, 1 striped skunkand 1 Norway rat were seropositive for antibodies against F.tularensis.
Conclusions Study of this outbreak of primary pneumonic tularemiaimplicates lawn mowing and brush cutting as risk factors forthis infection.
Source Information
From the Epidemic Intelligence Service (K.A.F., S.L.L.) and the National Center for Infectious Diseases (R.E.E., M.E.S., D.T.D., L.R.P., E.B.H.), Centers for Disease Control and Prevention, Fort Collins, Colo.; the Massachusetts Department of Public Health, Boston (B.T.M., M.M.); and the Martha's Vineyard Hospital, Oak Bluffs, Mass. (D.S.-E.).
Address reprint requests to Dr. Feldman at the Centers for Disease Control and Prevention, P.O. Box 2087, Rampart Rd., Fort Collins, CO 80522, or at kfeldman{at}cdc.gov.
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). Lawn mowing and brush cutting remained significant risk factors after adjustment for other potentially confounding variables. Only one patient reported being exposed to a rabbit while cutting brush. Of 40 trapped animals, 1 striped skunk and 1 Norway rat were seropositive for antibodies against F. tularensis. 
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