Table Of Content

Electronic Access Retrieve the journal electronically on the World Wide Web (WWW) at http://www.cdc.gov/eid or from the CDC home page (http://www.cdc.gov). Announcements of new table of contents can be automatically e-mailed to you. To subscribe, send an e-mail to [email protected] with the follow- ing in the body of your message: subscribe EID-TOC. Editors Editorial Board D. Peter Drotman, Editor-in-Chief Dennis Alexander, Addlestone Surrey, United Kingdom Philip P. Mortimer, London, United Kingdom Atlanta, Georgia, USA Ban Allos, Nashville, Tennessee, USA Fred A. Murphy, Davis, California, USA David Bell, Associate Editor Michael Apicella, Iowa City, Iowa, USA Barbara E. Murray, Houston, Texas, USA Atlanta, Georgia, USA Ben Beard, Atlanta, Georgia, USA P. Keith Murray, Ames, Iowa, USA Barry J. Beaty, Ft. Collins, Colorado, USA Stephen Ostroff, Atlanta, Georgia, USA Brian W.J. Mahy, Associate Editor Martin J. Blaser, New York, New York, USA Rosanna W. Peeling, Geneva, Switzerland Atlanta, Georgia, USA David Brandling-Bennet, Washington, D.C., USA David H. Persing, Seattle, Washington, USA David Morens, Associate Editor Donald S. Burke, Baltimore, Maryland, USA Gianfranco Pezzino, Topeka, Kansas, USA Washington, DC, USA Charles H. Calisher, Ft. Collins, Colorado, USA Richard Platt, Boston, Massachusetts, USA Patricia M. Quinlisk, Associate Editor Arturo Casadevall, New York, New York, USA Didier Raoult, Marseille, France Des Moines, Iowa, USA Patrice Courvalin, Paris, France Leslie Real, Atlanta, Georgia, USA Thomas Cleary, Houston, Texas, USA David Relman, Palo Alto, California, USA Polyxeni Potter, Managing Editor Anne DeGroot, Providence, Rhode Island, USA Pierre Rollin, Atlanta, Georgia, USA Atlanta, Georgia, USA Vincent Deubel, Providence, Rhode Island, USA Nancy Rosenstein, Atlanta, Georgia, USA Joseph E. McDade, Founding Editor Ed Eitzen, Washington, D.C., USA Connie Schmaljohn, Frederick, Maryland, USA Atlanta, Georgia, USA Duane J. Gubler, Fort Collins, Colorado, USA Tom Schwan, Hamilton, Montana, USA Richard L. Guerrant, Charlottesville, Virginia, USA Ira Schwartz, Valhalla, New York, USA Scott Halstead, Arlington, Virginia, USA Tom Shinnick, Atlanta, Georgia, USA David L. Heymann, Geneva, Switzerland Robert Shope, Galveston, Texas, USA Production Editors Sakae Inouye, Tokyo, Japan Bonnie Smoak, Bethesda, Maryland, USA Charles King, Cleveland, Ohio, USA Rosemary Soave, New York, New York, USA Mary Anne Castranio Keith Klugman, Atlanta, Georgia, USA P. Frederick Sparling, Chapel Hill, North Carolina, USA Carolyn P. Collins Takeshi Kurata, Tokyo, Japan Jan Svoboda, Prague, Czech Republic Teresa M. Hood S.K. Lam, Kuala Lumpur, Malaysia Bala Swaminathan, Atlanta, Georgia, USA Ann Kitchen Bruce R. Levin, Atlanta, Georgia, USA Robert Swanepoel, Johannesburg, South Africa Myron Levine, Baltimore, Maryland, USA Phillip Tarr, Seattle, Washington, USA Anne D. Mather Stuart Levy, Boston, Massachusetts, USA Timothy Tucker, Cape Town, South Africa Carol D. Snarey John S. MacKenzie, Brisbane, Australia Elaine Tuomanen, Memphis, Tennessee, USA Reginald S. Tucker Tom Marrie, Edmonton, Alberta, Canada David Walker, Galveston, Texas, USA Cathy E. Young John E. McGowan, Jr., Atlanta, Georgia, USA Mary E. Wilson, Cambridge, Massachusetts, USA Stephen S. Morse, New York, New York, USA Emerging Infectious Diseases Emerging Infectious Diseases is published monthly All material published in Emerging Infectious (cid:106) Emerging Infectious Diseases is printed on acid- by the National Center for Infectious Diseases, Cen- Diseases is in the public domain and may be free paper that meets the requirements of ANSI/ ters for Disease Control and Prevention (CDC), 1600 used and reprinted without special permission; NISO 239.48-1992 (Permanence of Paper) Clifton Road, Mailstop D61, Atlanta, GA 30333, USA. proper citation, however, is required. Telephone 404-371-5329, fax 404-371-5449, e-mail [email protected]. Use of trade names is for identification only The opinions expressed by authors contributing to and does not imply endorsement by the Public this journal do not necessarily reflect the opinions of Health Service or by the U.S. Department of the Centers for Disease Control and Prevention or the Health and Human Services. institutions with which the authors are affiliated. (cid:1)(cid:2)(cid:3)(cid:3)(cid:4)(cid:5)(cid:6)(cid:7)(cid:5)(cid:4)(cid:8)(cid:9)(cid:6)(cid:6)(cid:4)(cid:10)(cid:11)(cid:3)(cid:12)(cid:11)(cid:6)(cid:4)(cid:13)(cid:5) (cid:14)(cid:14)(cid:14)(cid:15)(cid:16)(cid:17)(cid:16)(cid:15)(cid:18)(cid:10)(cid:19)(cid:20)(cid:6)(cid:12)(cid:17) The print journal is available at no charge to public health professionals YES, I would like to receive Emerging Infectious Diseases. Please print your name and business address in the box and return by fax to 404-371-5449 or mail to EID Editor CDC/NCID/MS D61 1600 Clifton Road, NE Atlanta, GA 30333 Moving? Please give us your new address (in the box) and print the number of your old mailing label here______________ Emerging Infectious Diseases • Vol. 9, No. 1, January 2003 On the Cover: Molecular Typing of IberoAmerican Frida Kahlo (1910–1954). Cryptococcus neoformans Isolates......................................189 Self-Portrait with Monkey (1938). W. Meyer et al. Oil on masonite, 16'' x 12'' Albright-Knox Art Gallery, Health and Economic Impact of Surgical Site Buffalo, New York, USA Infections Diagnosed after Hospital Discharge....................196 Copyright 2003 Banco de México E.N. Perencevich et al. Diego Rivera & Frida Kahlo Museums Trust. Av. Cinco de Mayo No. 2, Col. Centro, Del. Cuauhtémoc 06059, Applying Network Theory to Epidemics: México, D.F. Control Measures for Mycoplasma pneumoniae Outbreaks........................................................204 About the Cover, see pg 281 L. Ancel Meyers et al. Research Using Hospital Antibiogram Data To Assess Regional Pneumococcal Emerging Pattern of Rabies Deaths Resistance to Antibiotics......................................................211 and Increased Viral Infectivity..............................................151 C.R. Stein et al. S.L. Messenger et al. Influence of Role Models and Hospital Araçatuba Virus: A Vaccinialike Virus Design on Hand Hygiene of Health-care Workers...............217 Associated with Infection in Humans and Cattle.................155 M.G. Lankford et al. G. de Souza Trindade et al. Aeromonas Isolates from Human Equine Amplification and Virulence of Diarrheic Stool and Groundwater Subtype IE Venezuelan Equine Compared by Pulsed-Field Gel Electrophoresis..................224 Encephalitis Viruses Isolated during M.A. Borchardt et al. the 1993 and 1996 Mexican Epizootics...............................161 D. Gonzalez-Salazar et al. Risk Factors for Sporadic Giardiasis: A Case-Control Study in Southwestern England.................229 Elimination of Epidemic Methicillin-Resistant J.M. Stuart et al. Staphylococcus aureus from a University Hospital and District Institutions, Finland.............................169 Viral Encephalitis in England, P. Kotilainen et al. 1989–1998: What Did We Miss?..........................................234 K.L. Davison et al. Annual Mycobacterium tuberculosis Infection Risk and Interpretation of Clustering Statistics....................176 Perspective E. Vynnycky et al. Preparing for a Bioterrorist Attack: Endemic Babesiosis in Another Legal and Administrative Strategies.....................................241 Eastern State: New Jersey..................................................184 R.E. Hoffman B.L. Herwaldt et al. Synopsis B-Virus (Cercopithecine herpesvirus 1) This issue of Emerging Infectious Diseases was made possible Infection in Humans and Macaques: through a partnership with the CDC Foundation with financial Potential for Zoonotic Disease.............................................246 support provided by The Ellison Medical Foundation. J.L. Huff and P.A. Barry Dispatches Fluoroquinolone Resistance in Campylobacter jejuni Isolates in Travelers Photorhabdus Species: Bioluminescent Returning to Finland: Association of Bacteria Emerging as Human Pathogens?..........................251 Ciprofloxacin Resistance to Travel Destination...................267 J.G. Gerrard et al. A. Hakanen et al. Life-Threatening Infantile Diarrhea from Letters Fluoroquinolone-Resistant Salmonella enterica Typhimurium with Mutations in Both gyrA and parC............255 Dual Infection by Dengue Virus and H. Nakaya et al. Shigella sonnei in Patient Returning from India..................271 R.N. Charrel et al. Invasive Type e Haemophilus influenzae Disease in Italy.....................................................................258 St. Louis Encephalitis in Argentina: The M. Cerquetti et al. First Case Reported in the Last Seventeen Years..............271 L. Spinsanti et al. Public Health Surveillance for Australian Bat Lyssavirus in Queensland, Australia, 2000–2001..........262 Streptomyces bikiniensis Bacteremia..................................273 D. Warrilow et al. W.J. Moss et al. Infection of Cultured Human and Monkey Drug-Resistant Mycobacterium tuberculosis Cell Lines with Extract of Penaeid among New Tuberculosis Patients Shrimp Infected with Taura Syndrome Virus........................265 Yangon, Myanmar...............................................................274 J. Audelo-del-Valle et al. S. Phyu et al. Pneumocystis carinii vs. Pneumocystis jiroveci: Another Misnomer (Response to Stringer et al.).................276 W. T. Hughes IMPORTANT ANNOUNCEMENT A New Name (Pneumocystis jiroveci) for NEW MANUSCRIPT SUBMISSION PROCESS Pneumocystis from Humans (Response to Hughes)...........277 Beginning January 2003, all Emerging Infectious Diseases J.R. Stringer et al. manuscripts must be handled through Manuscript Central, a Web- based system for manuscript submission and peer review. The system Correction, Vol.9, No.1........................................................277 allows authors, reviewers, editors, and editorial office staff direct access to journal operations through the Web. For more information Book Review on the new system and the advantages it offers, visit http:// www.scholarone.com/home_flash.html. Field Epidemiology, 2nd Edition (Michael B. Gregg, editor)................................280 To submit a manuscript using Manuscript Central M.A. Strassburg 1. Access the Emerging Infectious Diseases Web site (www.cdc.gov/eid). News and Notes 2. Click on Submit Manuscript (upper right screen), which takes you to the Manuscript Central Web site. 3. Click the Create a New Account button on the upper left of About the Cover..................................................................281 the screen. P. Potter 4. Create an account and choose a log in ID. 5. Once you have an ID and password, Log in. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the Centers for Disease Control and Prevention or the institutions with which the authors are affiliated. RESEARCH Emerging Pattern of Rabies Deaths and Increased Viral Infectivity Sharon L. Messenger,* Jean S. Smith,* Lillian A. Orciari,* Pamela A. Yager,* and Charles E. Rupprecht* Most human rabies deaths in the United States can be determined that although other bat species occasionally are attributed to unrecognized exposures to rabies viruses associ- infected with L. noctivagans and P. subflavus variants, the fre- ated with bats, particularly those associated with two infre- quency of such spillover is low (6,10). A survey of rabid quently encountered bat species (Lasionycteris noctivagans “house bats” (i.e., Eptesicus fuscus and Myotis lucifugus) in and Pipistrellus subflavus). These human rabies cases tend to the United States revealed that only 2 of 117 E. fuscus and 4 of cluster in the southeastern and northwestern United States. In 15 M. lucifugus were infected with L. noctivagans and P. sub- these regions, most rabies deaths associated with bats in non- flavus variants (6). The sample size of M. lucifugus is notably human terrestrial mammals are also associated with virus vari- small because this species is rarely found rabid, despite sub- ants specific to these two bat species rather than more missions of thousands of individual bats each year (11). Thus, common bat species; outside of these regions, more common bat rabies viruses contribute to most transmissions. The pre- all available data suggest that L. noctivagans and P. subflavus ponderance of rabies deaths connected with the two uncom- variants are rare. mon L. noctivagans and P. subflavus bat rabies viruses is best Given that L. noctivagans and P. subflavus variants appear explained by their evolution of increased viral infectivity. to be infrequently encountered, two explanations have been proposed to explain their prevalence among cryptic human rabies deaths associated with bats. The small vector hypothesis suggests a failure to recognize that a bite has occurred when a Bites by rabid dogs are the source of 35,000–50,000 human small bat is involved (7,12). Absence of a bite history may rabies deaths each year globally (1), yet most human result from inaccurate documentation when a patient could not rabies deaths in the United States are attributed to unrecog- be questioned directly or was not lucid. In 18 of 34 cases with nized exposures to rabid bats. Particular attention has focused no bite history, however, documented contact with a poten- upon two relatively rare bat species (Lasionycteris noctiva- tially rabid animal could have contributed to an unrecognized gans and Pipistrellus subflavus) because rabies variants asso- bite (i.e., physical contact with bats in 11 cases, bats in resi- ciated with these species account for approximately 70% of dence in 4 cases, and contact with a known sick domestic ani- human cases and 75% of cryptic rabies deaths (2–6). mal in 3 cases). Among these contacts, 11 involved L. Molecular typing (i.e., phylogenetic analysis of DNA data) noctivagans and P. subflavus variants. In addition, bites by has shown that rabies viruses associated with insectivorous smaller bat species, such as Eastern Pipistrelles, may be more bats (L. noctivagans and P. subflavus variants in particular) are likely to go unnoticed than bites by larger bats, which may the culprits in what otherwise would have been unsolved cryp- explain why more cases are associated with this species. tic human rabies deaths. However, phylogenetic analyses of Wounds from the teeth of small bat species are not easily seen human rabies cases have not provided insights into why an without careful examination (13,14), possibly leading to the unexpectedly large proportion of human rabies deaths involve impression that a bite has not occurred. the uncommon L. noctivagans and P. subflavus variants. Pas- A second hypothesis was suggested by results from experi- sive surveillance systems used by state public health depart- mental data comparing rabies virus isolates from Silver-haired ments confirm that human encounters with Eastern Pipistrelle Bats with those from domestic dogs and a coyote (15,16). bats (P. subflavus) and Silver-haired Bats (L. noctivagans) are These data showed that, although both viruses replicated rare. Neither species exceeded 5% of all bats submitted for equally well in neuroblastoma cells, rabies viruses from Sil- rabies testing in the southeastern United States, and Silver- ver-haired Bats replicated to higher titers in fibroblast and epi- haired Bats account for <12% of all bats submitted in the thelial cells, particularly at low temperatures of 34°C. Such Northwest (7). Moreover, the prevalence of rabid individual growth characteristics might facilitate successful infection bats within each species is also low and similar to the esti- after a superficial bite. Thus, superficial contact may occur fre- mated prevalence in other, more common, bat species (8,9). quently between bats and terrestrial mammals (including While these surveillance studies are known to produce biased humans), but may be unlikely to result in a productive infec- estimates of the true prevalence of rabies in natural bat popula- tion unless L. noctivagans and P. subflavus variants are tions, they should accurately reflect the prevalence of rabies in involved (the increased infectivity hypothesis). Although these bat species encountered by the public. In addition, we have experimental data suggest that L. noctivagans and P. subflavus variants have evolved increased infectivity, comparison *Centers for Disease Control and Prevention, Atlanta, Georgia, USA between viruses associated with Silver-haired Bats and dogs Emerging Infectious Diseases • Vol. 9, No. 2, February 2003 151 RESEARCH (including one coyote) is not sufficient to pinpoint whether (n=27). Additional analyses (not shown) that included incom- increased infectivity evolved in the common ancestor of L. plete taxa (formalin-fixed human case samples) did not alter noctivagans and P. subflavus variants and, thereby, is relevant tree topology but decreased nonparametric bootstrap propor- to the noted prevalence of these variants among human rabies tions for nodes including formalin-fixed taxa. deaths. We proposed a novel test of the increased infectivity Results and Discussion hypothesis using a comparative phylogenetic approach in Phylogenetic analysis (Figure 1) links 20 of 27 bat-associ- which we characterized transmission patterns from bats to ated human cases (24/32 cases, including formalin-fixed sam- nonhuman terrestrial mammals. Transmission of bat rabies to ples not shown in Figure 1) with L. noctivagans and P. terrestrial mammals can be viewed as a natural experiment that subflavus variants. In contrast to the patterns seen in humans removes the confounding effects of vector size and, therefore, (Figures 1 and 2A), a wide variety of bat rabies variants are can be used as a control in understanding transmission patterns implicated in the terrestrial mammal cases across a broad geo- between bats and humans. That is, such comparisons take graphic area and largely correspond to the most common bat advantage of a fundamental difference between rabies expo- rabies virus variants in that geographic region (Figures 1 and sures in humans and rabies exposures in other terrestrial mam- 2B). Two notable exceptions to this general geographic pattern mals (nonhuman terrestrial mammals cannot initiate occur in the northwestern and the southeastern United States postexposure prophylaxis even if they are aware of a bite). (Figure 2B). In these two regions, L. noctivagans and P. sub- Given that size of the vector species is not a factor in terrestrial flavus variants account for a substantially larger percentage of mammal deaths, we can control for the effect of bat vector size transmission events to terrestrial mammals than expected, in our comparison. Therefore, a disproportionate number of L. given the rarity of the host bat species and L. noctivagans and noctivagans and P. subflavus cases among terrestrial mammals P. subflavus variants in those geographic areas (Figure 2C) would be consistent with increased infectivity of the L. nocti- (because spillover of these variants to other bat species is rare, vagans and P. subflavus variants. If these variants are not over- we used the prevalence of rabid Silver-haired Bats and East- represented in terrestrial mammal rabies cases, we can reject ern Pipistrelles as a surrogate for the prevalence of L. noctiva- the increased infectivity hypothesis, leaving the small vector gans and P. subflavus variants). These two geographic regions hypothesis as the most plausible alternative. also match very closely the geographic distribution of human rabies deaths in the United States associated with these vari- Methods ants (Figure 2A). In the northwest region, delimited by the human cases associated with Silver-haired Bats (clade 1), the Sequence Data L. noctivagans rabies virus variant accounted for 57% of bat- Sequences were obtained from reverse transcriptase poly- associated cases in terrestrial mammals and 80% of bat-associ- merase chain reaction (RT-PCR)–amplified portions of the ated cases in humans, despite the fact that rabies-positive Sil- nucleoprotein (positions 1,157–1,477), based on the reference ver-haired Bats account for only 5% of all bats submitted for strain M13215 (17). The taxa include 32 rabies virus samples testing. Similarly, in the southeast region, delimited by human obtained between 1958 and 2000 from frozen (n=27) and for- cases associated with Eastern Pipistrelles (clade 2), where nei- malin-fixed (n=5) U.S. human brain tissue specimens, 17 of 41 ther Eastern Pipistrelles nor Silver-haired Bats exceed an aver- U.S. bat species (n=54), and 98 nonhuman terrestrial mam- age of 2% of all rabies-positive bats submitted, the P. mals (24 cats, 3 dogs, 5 cattle, 9 horses, 1 sheep, 1 llama, 42 subflavus variant accounted for 63% of bat-associated cases in foxes [grey, red, and kit], 1 raccoon, 1 ringtail cat, and 11 terrestrial mammals and 89% of bat-associated cases in striped skunks), determined to have been infected by a bat humans. The high prevalence of L. noctivagans and P. subfla- rabies virus by using monoclonal antibody screening. Reser- vus variants among terrestrial mammals in the same regions voir species from the eight U.S. terrestrial rabies-endemic where human cases have occurred suggests that a similar regions (n=24) were included as outgroups. Nucleotide mechanism, such as increased infectivity of these rabies virus sequences included in this study will be deposited in GenBank variants, is responsible for both epidemiologic patterns. but are also available as an aligned matrix (batrabies.nex). Our study included 13 terrestrial mammal species, both domesticated and wild, suggesting that exposure to bat species Phylogenetic Analyses likely occurred in a variety of habitats, including more remote Phylogenetic analyses used PAUP* 4.0b2 (18), employing forest habitats. Our data set was comprised mostly of foxes the neighbor-joining search algorithm (minimum evolution) and cats (two species likely to capture and feed upon bats), but using maximum likelihood to estimate Ti:Tv ratio and nucle- we had no reason to suspect that their behavior would create a otide base frequencies (settings correspond to Hasegawa-Kish- disproportionate opportunity for infection by L. noctivagans ino-Yano [HKY] 1985 model of nucleotide sequence and P. subflavus variants compared with other bat variants. evolution). We assessed tree support using the nonparametric While our data do not invalidate the small vector hypothe- bootstrap method (1,000 replicates). Phylogenetic analyses sis, the terrestrial mammal data show that even when vector presented here included only frozen human brain samples size does not play a role in determining whether bat bites are 152 Emerging Infectious Diseases • Vol. 9, No. 2, February 2003 RESEARCH Figure 1. Phylogenetic tree of bat-associated rabies cases. Taxa represent 203 rabies virus variants from 27 human rabies cases (formalin-fixed taxa removed) and 98 terrestrial mammals infected with a bat rabies virus, 54 bat samples representing 17 species, and 24 terrestrial mammal outgroup taxa. Each circle represents a case (terrestrial mammal = closed circles, human = open circles) associated with the monophyletic clade in the phy- logeny to the left. Numbers at tree nodes indicate nonparametric bootstrap proportions. recognized, L. noctivagans and P. subflavus variants are still the tively whether L. noctivagans and P. subflavus variants have most prevalent rabies virus variants among bat-associated ter- evolved genetic changes associated with increased infectivity. restrial mammal deaths in the northwestern and southeastern Nonetheless, comparisons of phylogenetic patterns between United States. For human rabies cases, small vector size may independent datasets in which one data set can be used to con- still play a role in the probability of detecting a bat bite, while trol for one or more potentially relevant parameters offers a the increased infectivity of L. noctivagans and P. subflavus valid method of hypothesis testing. Additionally, through phy- variants enhances the likelihood of a successful infection fol- logenetic analyses such as these, we can target those taxa and lowing a superficial bite. Additional experimental data (e.g., genomic regions that warrant further investigation. site-directed mutagenesis) will be necessary to show defini- Emerging Infectious Diseases • Vol. 9, No. 2, February 2003 153 RESEARCH trol and Prevention. Her work includes training, development of rapid diagnostics laboratory procedures, and rapid diagnostic testing of clinical and environmental samples. She continues to employ the tools of molecular genetic and phylogenetic analyses to investigate the evolution and ecology of infectious disease pathogens and how that knowledge can be applied to improved detection, surveillance, and forensic technologies. References 1. World Health Organization. World survey of rabies. 1996;32:1–27. Avail- able from: Rabnet, WHO rabies electronic data bank, URL: http:// oms.b3e.jussieu.fr/rabnet/ 2. Anderson LJ, Nicholson MB, Tauxe RV, Winkler WG. Human rabies in the United States, 1960 to 1979: epidemiology, diagnosis, and prevention. Ann Intern Med 1984;100:728–35. 3. Noah DL, Drenzek CL, Smith JS, Krebs JW, Orciari L, Shaddock J, et al. Epidemiology of human rabies in the United States, 1980–1996. Ann Intern Med 1998;128:922–30. 4. Johnson HN. In: Rivers TM, editor. Viral and rickettsial infections of man. Philadelphia: J. B. Lippincott Co.; 1952. 5. Rupprecht CE, Smith JS, Fekadu M, Childs JE. The ascension of wildlife rabies: a cause for public health concern or intervention. Emerg Infect Dis 1995;1:107–14. 6. Smith, JS. Molecular epidemiology. In: Jackson AC, Wunner WH, editors. Rabies. San Diego: Academic Press; 2002. p. 79–111. 7. Smith JS, Orciari LA, Yager PA. Molecular epidemiology of rabies in the United States. Seminars in Virology 1995;6:387–99. 8. Smith JS. Monoclonal antibody studies of rabies in insectivorous bats of the United States. Rev Infect Dis 1988;10:S637–43. 9. Smith JS. Rabies virus epitopic variation: use in ecologic studies. Adv Virus Res 1989;36:215–53. 10. McQuiston JH, Yager PA, Smith JS, Rupprecht CE. Epidemiologic char- Figure 2. Geographic distribution of (A) human (including 5 formalin- acteristics of rabies virus variants in dogs and cats in the United States, fixed samples not shown in Figure 1) and (B) terrestrial mammal cases identified by rabies virus variant isolated. Minimum length polygons 1999. J Am Vet Med Assoc 2001;218:1939–42. delimiting human cases associated with Silver-haired Bats (clade 1) 11. Childs JE, Trimarchi CV, Krebs JW. The epidemiology of bat rabies in and Eastern Pipistrelles (clade 2) shown in (A) and superimposed in New York State, 1988–92. Epidemiol Infect 1994;113:501–14. (B). (C) Prevalence of Lasionycteris noctivagans (Ln) and Pipistrellus 12. Rupprecht CE. Rethinking rabies risks: sharpening clinical skills for a subflavus (Ps) variants in regions delimited by clades 1 and 2. Preva- lence of variants in bats was estimated from unpublished state public reemerging threat. In: SCIENS Worldwide Medical Education. New health department reports that determined the percentage of rabies- York; 2000. p. 8–12. positive Silver-haired or Eastern Pipistrelle bats from the total number 13. Feder HM Jr, Nelson R, Reiher HW. Bat bite? Lancet 1997;350:1300. of bats submitted (7, unpub. data). Prevalence of L. noctivagans and P. 14. Jackson AC, Fenton MB. Human rabies and bat bites. Lancet subflavus variants in terrestrial mammals and humans is estimated as the percentage of all spillover cases in each clade region infected with 2001;357:1714. L. noctivagans or P. subflavus. 15. Morimoto K, Patel M, Corisdeo S, Hooper DC, Fu ZF, Rupprecht CE, et al. Characterization of a unique variant of bat rabies virus responsible for Acknowledgments newly emerging human cases in North America. Proc Natl Acad Sci U S We thank the staff members at the U.S. and foreign state health A 1996;93:5653–8. departments for their submissions of invaluable samples included in 16. Dietzschold B, Morimoto K, Hooper DC, Smith JS, Rupprecht CE, Koprowski H. Genotypic and phenotypic diversity of rabies virus variants our analyses. We also thank J. Bull, F. Burbrink, J. Childs, M. Hell- involved in human rabies: implications for postexposure prophylaxis. J berg, B. Mahy, J. McGuire, M. Noor, J. O’Connor, D. Pollock, and Hum Virol 2000;3:50–7. the scientific staff in Viral and Rickettsial Zoonoses Branch, Division 17. Tordo N, Poch O, Ermine A, Keith G, Rougeon F. Walking along the of Viral and Rickettsial Diseases, National Center for Infectious Dis- rabies genome: is the the large G-L intergenic region a remnant gene? eases, Centers for Disease Control and Prevention for their fruitful Proc Natl Acad Sci U S A 1986;83:3914-8. 18. Swofford, DL. PAUP*. Phylogenetic Analysis Using Parsimony (*and discussions and helpful suggestions. Other Methods), Version 4. Sunderland (MA): Sinauer Associates; 2000. S.L.M. was supported by the American Society for Microbiol- ogy–National Center for Infectious Diseases postdoctoral research Address for correspondence: Charles Rupprecht, National Center for Infec- associates program. tious Diseases, Mailstop G33, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA; fax: 404-639-1564; e-mail: Dr. Messenger has worked on bioterrorism preparedness pro- [email protected] grams at Louisiana State University and the Centers for Disease Con- 154 Emerging Infectious Diseases • Vol. 9, No. 2, February 2003 RESEARCH Araçatuba Virus: A Vaccinialike Virus Associated with Infection in Humans and Cattle Giliane de Souza Trindade,* Flávio Guimarães da Fonseca,† João Trindade Marques,* Maurício Lacerda Nogueira,† Luiz Claudio Nogueira Mendes,‡ Alexandre Secorun Borges,‡§ Juliana Regina Peiró,‡ Edviges Maristela Pituco,¶ Cláudio Antônio Bonjardim,* Paulo César Peregrino Ferreira,* and Erna Geessien Kroon* We describe a vaccinialike virus, Araçatuba virus, associ- bovine herpes mammillitis, pseudocowpox, and cowpox infec- ated with a cowpoxlike outbreak in a dairy herd and a related tions (9–12). case of human infection. Diagnosis was based on virus growth After clinical and initial laboratory analysis, cowpox virus characteristics, electron microscopy, and molecular biology (CPXV) was considered to be the obvious etiologic agent techniques. Molecular characterization of the virus was done causing this human and cattle infection. CPXV (genus Ortho- by using polymerase chain reaction amplification, cloning, and poxvirus) is the causative agent of localized and painful vesic- DNA sequencing of conserved orthopoxvirus genes such as ular lesions. The virus is believed to persist in wild host the vaccinia growth factor (VGF), thymidine kinase (TK), and reservoirs (including mammals, birds, and rodents), cattle, zoo hemagglutinin. We used VGF-homologous and TK gene nucle- animals, and domestic animals, including cats in parts of otide sequences to construct a phylogenetic tree for comparison with other poxviruses. Gene sequences showed 99% Europe and Asia. Contact of these reservoirs with susceptible homology with vaccinia virus genes and were clustered animals and people can trigger the onset of disease (13,14). together with the isolated virus in the phylogenetic tree. When humans are affected, the lesions occur on the hands and Araçatuba virus is very similar to Cantagalo virus, showing the sometimes on the arms, usually followed by axillary adenopa- same signature deletion in the gene. Araçatuba virus could be thy (15). However, CPXV isolation has not been reported from a novel vaccinialike virus or could represent the spread of Can- cattle or humans in Brazil, which led investigators to consider tagalo virus. the possibility that infections were caused by vaccinia virus (VACV), since VACV was used as a live smallpox vaccine throughout the country until the late 1970s. The poxviruses comprise a family of large DNA viruses The occurrence of VACV-infected animals (domestic or wild species) is believed to be a result of contact with people capable of infecting vertebrate and invertebrate hosts (1). recently vaccinated against smallpox. In fact, during mass Viruses from this family have caused naturally occurring or smallpox vaccination campaigns, VACV infections were occa- introduced infections in all populated continents (2). In Brazil, sionally transmitted from the vesicular lesion on the vaccinee as in other parts of South America, little is known about the to domestic animals, usually cattle. In turn, infected animals occurrence and circulation of poxvirus in the wild (3–6). After transmitted VACV to susceptible people (14,16,17). Such the worldwide elimination of smallpox in the 1970s, a few infections were shown to be reproducible in experimental con- reports of poxvirus isolation in South America have been pub- ditions (18). lished, including scattered reports of parapoxvirus outbreaks in Vaccinialike viruses have been isolated from the wild in sheep and goat herds and virus isolation from wild or captive Brazil; at least one of these viruses, the Cantagalo virus, was animals (7,8). The existence of mousepox outbreaks in animal specifically obtained from infected cattle and humans after an facilities is also known, but most cases remain unpublished. outbreak of a cowpoxlike disease (6,14,19). These facts indi- In recent years, however, many cases of unidentified dis- cate the long-term establishment and active circulation of dif- eases in dairy cattle with similar pathology have been reported ferent vaccinialike viruses in the wild in South America, in rural areas of Brazil, and some human infections have been similar to the well-documented establishment of buffalopox associated with these illnesses in herds. Such diseases, charac- virus in India (19,20). terized by the appearance of nodular and pustular lesions on We describe the isolation and characterization of a vaccini- bovine teats, are frequently related to viral infections such as alike strain linked to a cowpoxlike outbreak affecting a dairy herd and associated with human infection; a similar outbreak *Universidade Federal de Minas Gerais, Belo Horizonte, Brasil; attributed to Cantagalo virus infection was recently described †National Institutes of Health, Bethesda, Maryland, USA; ‡Univer- (14). The virus reported here, named Araçatuba virus, was sidade Estadual Paulista–Araçatuba, São Paulo, Brasil; §Universidade readily identified as a poxvirus by conventional methods, Estadual Paulista–Botucatu, São Paulo, Brasil; and ¶Instituto Biológico, São Paulo, Brasil including characterization of pock morphology on the chorio- Emerging Infectious Diseases • Vol. 9, No. 2, February 2003 155 RESEARCH allantoic membrane of chick embryos and electronic microscopy, which allows a quick differentiation between CPXV, pseudocowpox virus, and herpesvirus. However, such techniques do not differentiate between closely related viruses such as CPXV and VACV. To obtain accurate phylogenetic information, we detected poxvirus-conserved genes, such as thymidine kinase (TK), vaccinia growth factor (VGF), and hemagglutinin (HA), in the genome of Araçatuba virus using polymerase chain reaction (PCR). These genes were sequenced and the data used to generate phylogenetic trees. We also analyzed the A-type gene (ATI) based on restriction length polymorphism, which is a phylogenetic tool used to differentiate and classify orthopoxviruses (13). Based on these techniques, Araçatuba virus was shown to be similar to VACV–Western Reserve (WR) strain, the prototype member of the poxvirus family and the Orthopoxvirus genus. In addition, in relation to the HA gene, Araçatuba virus was very similar to Cantagalo virus, showing the same signature deletion in the gene. Such findings specifically point to the ubiquity of VACV circulating in the wild in Brazil as well as to the public health problems that may arise from the presence of this virus. Methods Case Report Five adult Girolanda cows from a herd of 40 animals were sent to the Veterinary Teaching Hospital at Unesp-Araçatuba, São Paulo State, Brazil; they had painful lesions on their teats, which interfered with milking. Lesions initially appeared on 2 cows and spread quickly to 35 animals, as well as the milker’s Figure 1. Lesions from suspected Araçatuba virus on hand of dairy farm hands (Figure 1). Starting as a red focal area, the lesions devel- worker (milker) (A) and teats of cow (B). oped quickly into a wound that healed with difficulty. No such episode had previously occurred on that farm. The cows had an advanced healing process; however, all affected cows pro- these symptoms for approximately 8 days before being taken duced substantially less milk. to the veterinary surgeon. During the clinical examination, lesions in different stages were recognized; in most of the Virus Isolation and Electron Microscopy cows, nodular ulcerative wounds of 2–6 mm in diameter were The material collected was prepared in 20% suspension of predominant. Lesions were localized only on teats and udder, Eagle minimal essential medium (MEM) with 1% antibiotic to and many of them had dark, raw crusts. The teats had isolate the virus by inoculations in bovine fetal kidney cell increased local temperature and were sensitive to touch. monolayers at the Instituto Biológico, São Paulo. Samples that Because of the pain, cows avoided their suckling calves. At the showed cytopathic effects were analyzed by transmission elec- farm, the only manual milker was also affected. The milker tronic microscopy. Material isolated from bovine fetal kidney had approximately 10 lesions on both hands and arms, but he cell monolayers was spread on the chorioallantoic membrane did not initially accept any medical help and did not consent to of embryonated chicken eggs and incubated at 37°C for 72 h examination. Because asepsic measures were not carried out, (21). contact between the cows’ teats and the milker’s hands during milking probably enhanced the rapid spread of virus within the Cells and Viruses herd. Oral vesicles were not observed on calves’ muzzles or on VACV, WR strain, was obtained from the National Insti- buccal mucosae. Sterile samples of the vesicles and crusts tute for Medical Research (Mill Hill, London, U.K.) and were collected and sent to the Laboratório de Viroses de CPXV, Brighton strain, was provided by Dr. C. Jungwirth, Bovídeos, Instituto Biológico, São Paulo for analysis. The ani- Würzburg, Germany. Viruses were propagated in Vero cells mals were isolated from the herd, and teat lesions were treated and purified in a sucrose gradient as described (22). Vero cells with glycerine and a topical antibiotic, while the milker were propagated at 37°C in MEM, supplemented with 5% received medication at a nearby hospital. Three months after fetal calf serum. Vero cells were also used for viral titration onset of infection, the remaining lesions on the cows were in (23). 156 Emerging Infectious Diseases • Vol. 9, No. 2, February 2003