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Solving a rare epidemiological puzzle

By Jennifer Durgin

A drum like this was to blame in a case of anthrax.

On December 5, 2009, a 24-year-old southern New Hampshire woman fell ill with what she thought was the flu. But when fever, muscle aches, and sweating were joined by pain in her head, neck, and back, then by vomiting, cramps, and dizziness, she sought medical help.

Test: On December 14, she went to a walk-in clinic and was immediately transported to a nearby hospital. A blood test showed that her white blood cell count was at least four times higher than normal, and a CT scan of her abdomen revealed swollen lymph nodes, very irregular-looking bowels, and a massive accumulation of fluid.

Doctors removed the diseased parts of her intestines, stabilized her, and transferred her to Massachusetts General Hospital, where her condition fluctuated as doctors struggled to identify her mysterious illness. It was not until December 24 that they reached a definitive diagnosis: gastrointestinal anthrax, a rare bacterial infection. But how had she been exposed? And was anyone else at risk? These questions led to a multiagency, multistate investigation.

Effort: Elizabeth Talbot, M.D., a DH infectious disease specialist and former deputy epidemiologist in New Hampshire, led the effort. She was assisted by Jodie Dionne-Odom, M.D., also a DH physician and the current deputy epidemiologist, and colleagues in the state's Department of Health and Human Services.

Talbot interviewed the patient's family and friends to piece together how she might have contracted the disease. She learned that the patient had attended a drumming circle near the University of New Hampshire on December 4, the day before she fell ill. Among the more than 50 drums at the event were several with tops made of animal hides—a potential source of anthrax spores. Testing confirmed that two drums were contaminated with the same strain of anthrax that the patient had. (A full account of the investigation was published in the September 8, 2010, Journal of the American Medical Association.)

How had she been exposed? And was anyone else at risk?

Infected: "It was very difficult," says Dionne-Odom of the quest. The investigators wanted to protect the woman's privacy, but dozens of other people had also attended the drumming circle and could have also been infected. "For the first couple of weeks, we didn't know if there were a lot of other cases out there that had just been missed," Dionne-Odom says.

The team worked quickly to identify and contact everyone who'd attended the event. They interviewed 187 people and determined that 84 had potentially been exposed; all 84 were offered antimicrobial medications and an anthrax vaccine.

A year later, with no other cases having been reported, Talbot and Dionne-Odom can reflect on a job well done and on the young woman's good fortune. "The mortality of gastrointestinal anthrax is about 60% to 80%," explains Dionne-Odom, "so her prognosis was not good." But fortunately she survived and is doing fine, she adds. "We're very, very happy about that."

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