Chapter Notes

Introduction

  1.   Dr. Lederberg’s saying is quoted in: Shalala DE. Collaboration in the fight against infectious diseases. Emerg Infect Dis. 1998 Jul-Sep;4(3):354-7. His ideas about “Our Wits Versus Their Genes” may be found in: Lederberg J. Infectious history. Science. 2000 Apr 14;288(5464):287-93.

  2.   This saying is variously attributed to Irving J. Selikoff (1915–92), who pioneered occupational medicine, and Sir Austin Bradford Hill (1897–1991), who pioneered the use of random clinical trials.

Chapter 1. Dead Crows Falling from the Sky

Chapter 1 draws on interviews with Marci Layton, Annie Fine, and Duane Gubler.

  1.   In most years, the NYS Arthropod-Borne Disease Program performs viral isolation studies by culturing material from statewide (or multi-county) mosquito surveillance pools in Vero cells, a line of African green monkey cells that supports the growth of many mosquito-borne viruses, including SLE virus. However, due to budget constraints, analysis of mosquito surveillance pools in 1998 and 1999 was limited to molecular (RT-PCR) testing for two encephalitis viruses: eastern equine encephalitis virus and California encephalitis virus (John Howard, NYS health department, personal communication). The last time SLE had been detected in New York State was in 1975, a year in which SLE was also detected in several other states.

  2.   See: Kennedy R., “Man Versus Mosquito.” New York Times. September 17, 2000.

  3.   In recent years, “syndromic surveillance” has acquired a second, specialized meaning in the public health community, referring to the use of electronic data to monitor increases in syndromes of interest.

  4.   United States General Accounting Office. Report to Congressional Requesters. West Nile Virus Outbreak. Lessons for Public Health Preparedness. GAO/HEHS-00-180, September 11, 2000. Page 41. Appendix II of this report provides a detailed chronology of the animal and human outbreaks. A timeline of the outbreak is also provided in West Nile Fever: A Medical Detective Story. Bio Bulletin of the American Museum of Natural History (http://www.amnh.org/education/resources/rfl/web/bulletins/bio/biobulletin/story1378.htm)

  5.   Jacobs A. “Exotic Virus is Identified in 3 Deaths.” New York Times. September 26, 1999.

  6.   The minimum WNV infection rate in Culex mosquitoes in Brooklyn in fall 1999, may have been as high as 57 per 1000. See: Nasci RS, White DJ, Sterling H, Oliver JA, Daniels TJ, Falco RC, Campbell S, Crans WJ, Savage HM, Lanciotti RS, Moore CG, Godsev MS, Gottfried KL, Mitchell CJ. “West Nile virus isolates from mosquitos in New York and New Jersey, 1999.” Emerg Infect Dis, 2001 Jul–Aug; 7(4): 626–30.

  7.   Hauer accused anti-spraying protesters of “irresponsible environmental hysteria and stupidity” [Newsday, 10/9/99, “Bugged by Spraying,” by Dan Morrison], and Giuliani said that the protestors were “in the business of wanting to frighten people to death” [Newsday, 4/14/2000, “City Nixes Malathion Spraying,” by Curtis L. Taylor and Dan Morrison].

  8.   ArboNET currently monitors 14 arboviral diseases, including West Nile, dengue, and SLE. See: Lindsey NP, Brown JA, Kightlinger L, Rosenberg L, Fischer M; ArboNET Evaluation Working Group. “State health department perceived utility of and satisfaction with ArboNET, the U.S. National Arboviral Surveillance System.” Public Health Rep. 2012 Jul–Aug; 127(4): 383–90.

  9.   Lee BY, Biggerstaff BJ. “Screening the United States blood supply for West Nile Virus: a question of blood, dollars, and sense.” PLoS Med. 2006 Feb; 3(2): e99.

10.   Roehr B. “Texas records worst outbreak of West Nile virus on record.” BMJ. 2012 Sep 6; 345: e6019.

11.   A retrospective analysis of data collected in New York State in 2000 confirmed that the crow deaths are a reliable marker for early detection of WNV: Eidson M, Kramer L, Stone W, Hagiwara Y, Schmit K; New York State West Nile Virus Avian Surveillance Team. “Dead bird surveillance as an early warning system for West Nile virus.” Emerg Infect Dis. 2001 Jul–Aug; 7(4): 631–5.

12.   Steinhauer J, Miller J. “In New York Outbreak, Glimpse of Gaps in Biological Defenses.” New York Times, October 11, 1999

13.   See: Jones KE, Patel NG, Levy MA, Storeygard A, Balk D, Gittleman JL, Daszak P. “Global trends in emerging infectious diseases.” Nature. 2008 Feb 21; 451(7181): 990–3; Also: Taylor LH, Latham SM, Woolhouse ME. “Risk factors for human disease emergence.” Philos Trans R Soc Lond B Biol Sci. 2001 Jul 29; 356(1411): 983–9.

14.   In 2007, the American Veterinary Medical Association and the American Medical Association formed a task force that helped launch the One Health Initiative, which promotes an integrated approach to protecting human and animal health in the United States and around the world. See: King LJ, Anderson LR, Blackmore CG, Blackwell MJ, Lautner EA, Marcus LC, Meyer TE, Monath TP, Nave JE, Ohle J, Pappaioanou M, Sobota J, Stokes WS, Davis RM, Glasser JH, Mahr RK. “Executive summary of the AVMA One Health Initiative Task Force report.” J Am Vet Med Assoc. 2008 Jul 15; 233(2): 259–61.

Chapter 2. The McConnon Strain

Chapter 2 draws on interviews with Patrick McConnon.

  1.   Six years later, in 1988, Patpong and other red-light districts in Thailand became local epicenters of an outbreak of a previously unknown illness called acquired immunodeficiency syndrome (AIDS). AIDS-inspired efforts to promote safe sex in Patpong are described in: Timm M. “Deadly serious humour for the ‘go-go girls’.” “Thailand. AIDS Action. 1989; Dec: 4. See also Hanenberg R, Rojanapithayakorn W. “Changes in prostitution and the AIDS epidemic in Thailand. “AIDS Care 1998; 10: 69–79.

  2.   P. vivax parasites, though rarely causing death, can remain dormant in the liver of humans for months or years, erupting into the bloodstream intermittently to cause episodes of severe illness.

  3.   Llamzon BS, Gordon RM. Horyo: Memoir of an American POW. London: Continuum International Publishing Group; 1999.

  4.   P. falciparum mutations that confer CQ-resistance apparently emerged independently in four places: in the Thailand–Cambodia border region, in two places in South America (Colombia and Venezuela), and in Papua New Guinea. (See: Wernsdorfer WH, Payne D. “The dynamics of drug resistance in Plasmodium falciparum.” Pharmacol Ther 1991; 50: 95–121; Ebisawa I, Fukuyama T, Kawamura Y. “Additional foci of chloroquine-resistant falciparum malaria in East Kalimantan and West Irian, Indonesia.” Trop Geogr Med 1976; 28: 349–54; and Van Dijk WJ. “Mass chemoprophylaxis with chloroquine additional to DDT indoor spraying; report on a pilot project in the Demta area, Netherlands New Guinea.” Trop Geogr Med 1958; 10: 379–84.)

  5.   Packard RM. The Making of a Tropical Disease: A Short History of Malaria. Baltimore, MD: Johns Hopkins University Press; 2008. Author’s Note: I contacted Dr. Packard to confirm the location of Pailin. It is located within Cambodia, not far from the Cambodia-Thailand border.

  6.   Some authorities include a section of Yunnan Province, China, as part of the Golden Triangle. In recent years the Thai tourist industry has begun using the term “Golden Triangle” to denote the meeting point of the Thailand, Laos, and Myanmar borders, at the junction of the Mekong and Ruark Rivers.

  7.   Information about the spread of drug-resistant malaria strains from Cambodia and Thailand may be found in the following articles:

•   Sulfadoxine-pyrimethamine (SP): Roper C, Pearce R, Nair S, Sharp B, Nosten F, Anderson T. “Intercontinental spread of pyrimethamine-resistant malaria.” Science 2004; 305: 1124.

•   Chloroquine (CQ): Ariey F, Fandeur T, Durand R, Randrianariv-elojosia M, Jambou R, Legrand E, et al. “Invasion of Africa by a single PFCRT allele of South East Asian type.” Malar J 2006; 26(5): 34.

•   Artesunate-mefloquine: Wongsrichanalai C, Meshnick SR. “Declining artesunate-mefloquine efficacy against falciparum malaria on the Cambodia–Thailand border.” Emerg Infect Dis 2008; 14: 716–9. This article describes the detection in Cambodia and Thailand of mutations that confer resistance to newer drugs, such as mefloquine and artemisinin.

Chapter 3. Sorrow and Statistics

Chapter 3 drew on interviews with James W. Buehler and Steve Solomon

  1.   Fullfillment. Memoirs of a Criminal Court Judge by David Vanek. Dundurn Press, Toronto and Oxford, and the Osgoode Society for Canadian Legal History. 1999. Page 290.

  2.   Cardiac Arrest, A True Account of Stolen Lives, by Sarah Spinks. Doubleday Canada Limited, Toronto, 13985. Page 83.

  3.   Solomon SL, Wallace EM, Ford-Jones EL, Baker WM, Martone WJ, Kopin IJ, Critz AD, Allen JR. “Medication errors with inhalant epinephrine mimicking an epidemic of neonatal sepsis.” Engl J Med. 1984 Jan 19; 310(3): 166–70.

  4.   Transcript of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Transcript of Evidence for January 24, 1984. Volume 91. Pages 418.

  5.   This saying is variously attributed to Irving J. Selikoff (1915–92), who pioneered occupational medicine, and Sir Austin Bradford Hill (1897–1991), who pioneered the use of random clinical trials.

  6.   Buehler JW, Smith LF, Wallace EM, Heath CW Jr, Kusiak R, Herndon JL. “Unexplained deaths in a children’s hospital. An epidemiologic assessment.” N Engl J Med. 1985 Jul 25; 313(4): 211–6.

  7.   Report of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Ministry of the Attorney General, 1984. Page 41.

  8.   Some doctors who participated in the June 1980 slowdown also went on strike for a week during the fall, from October 30 to November 5. During that week, clinical fellows and staff cardiologists served on the cardiology ward as substitutes for the strikers. See: Mortality on the Cardiology Service of a Children’s Hospital in Toronto, Canada (the “Atlanta Report”), page 3. This report was submitted to the Canadian Minister of Health on February 16, 1983, by Clark W. Heath, Jr., Lesbia F. Smith, James W. Buehler, and Evelyn M. Wallace. Its conclusions are summarized in Buehler JW, Smith LF, Wallace EM, Heath CW Jr, Kusiak R, Herndon JL. “Unexplained deaths in a children’s hospital. An epidemiologic assessment.” N Engl J Med. 1985 Jul 25; 313(4): 211–6.

  9.   Of patients with a known room number, the location was the Ward 4A infant room for 22 of 27 babies (81.5%) and the 4B infant room for 3 of 6 (50%). Mortality on the Cardiology Service of a Children’s Hospital in Toronto, Canada (the “Atlanta Report”), page 15.

10.   Berkelman RL, Martin D, Graham DR, Mowry J, Freisem R, Weber JA, Ho JL, Allen JR. “Streptococcal wound infections caused by a vaginal carrier.” JAMA. 1982 May 21; 247(19): 2680–82.

11.   During the Grange Commission, David Hunt, Counsel for the Attorney General and Solicitor General of Ontario (Crown Attorneys and the Coroner’s Office) reviewed the sequence and timing of the deaths as part of his cross-examination of Phyllis Trayner. See: Cardiac Arrest, A True Account of Stolen Lives, by Sarah Spinks. Doubleday Canada Limited, Toronto, 1985. Page 163.

12.   Death Shift by Ted Bissland, Methuen & Company, 1984. Chapter 8.

13.   Transcript of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Transcript of Evidence for January 24, 1984. Volume 91. Page 577.

14.   Transcript of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Transcript of Evidence for January 24, 1984. Volume 91. Pages 427–428.

15.   Transcript of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Transcript of Evidence for January 24, 1984. Volume 91. Pages 536–544 (data on access to the cardiology ward by doctors) and pages 556–560 (data on access by nursing supervisors and teaching team leaders). The lawyer for Nurse Trayner continued this line of questioning, especially in regard to nursing supervisors (see: Transcript of Evidence for January 25, 1984. Volume 92. Pages 794–809).

16.   Transcript of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Transcript of Evidence for January 25, 1984. Volume 92. Pages 776–779.

17.   Transcript of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Transcript of Evidence for January 26, 1984. Volume 93. Pages 870–71.

18.   Transcript of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Transcript of Evidence for January 24, 1984. Volume 91. Page 553.

19.   Transcript of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Transcript of Evidence for January 25, 1984. Volume 92. Page 650–1.

20.   Report of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Ministry of the Attorney General, 1984. Page 222.

21.   Inaccurate digoxin measurements in infants caused by cross-reaction with naturally occurring chemicals have been documented by David Seccombe and his colleagues at the Shaughnessey and Vancouver General Hospitals. (See: Seccombe DW, Pudek MR. “Digoxin-like immunoreactive substances in the perinatal period.” Lancet. 1987 Apr 25; 1[8539]: 983.) In the Report of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters, Justice Grange acknowledged Secommbe’s findings but concluded that “the greatest amount of the [cross-reactive] substance detected in anyone’s research to date (4.1 ng/ml in Dr. Seccombe’s tests) is miniscule compared with some of the readings . . . encountered in the children whose deaths we are investigating” (Page 26). Justice Grange also stated that, due to difficulties in measuring digoxin levels, “the results of the tests on exhumed tissue were never offered as proof of an overdose of digoxin, only as proof of the presence of digoxin” (Page 31).

22.   The theory linking Charles Smith to the autopsies of the infants who died on the cardiology ward at Sick Kids is laid out in: Hamilton G. The Nurses Are Innocent. The Digoxin Poisoning Fallacy. Dundurn, Toronto. 2011. Chapter 25. The implications of a 2005–2007 review of 45 cases of criminally suspicious child deaths involving testimony from Charles Smith are discussed in: Glancey GD, Regehr C. “From Schadenfreude to Contemplation: Lessons for Forensic Experts.” J Am Acad Psychiatry Law 40: 81–8, 2012.

23.   Contemporary accounts include: Death Shift, by Ted Bissland (Methuen & Company, 1984) and Cardiac Arrest, A True Account of Stolen Lives, by Sarah Spinks (Doubleday Canada Limited, Toronto, Canada, 1985).

24.   Hamilton G. The Nurses Are Innocent. The Digoxin Poisoning Fallacy. Dundurn, Toronto. 2011

25.   Transcript of the Royal Commission of Inquiry into Certain Deaths at the Hospital for Sick Children and Related Matters. Transcript of Evidence for January 24, 1984. Volume 91. Page 499.

26.   Yorker BC, Kizer KW, Lampe P, Forrest AR, Lannan JM, Russell DA. “Serial murder by healthcare professionals.” Forensic Sci. 2006 Nov; 51(6): 1362–71. In a discussion of “Intervention and Prevention” the article notes that hospitals are favorable environments for healthcare serial killer events, due to “easy access to injectable medications, availability of patients with intravenous lines, reduced oversight during evening and night shifts, the frequent use of float nursing personnel, and less than routine quality assurance activities that may increase the likelihood of these crimes going undetected.”

27.   Yorker BC. “Hospital epidemics of factitious disorder by proxy.” In The spectrum of factitious disorders. Washington, DC. American Psychiatric Press, 1996.

28.   Possible motives of firefighters who set fires are considered in: The National Volunteer Fire Council Report on the Firefighter Arson Problem. Contexts, Considerations, and Best Practices, 2011 (http://www.nvfc.org/files/documents/FF_Arson_Report_FINAL.pdf) and Special Report: Firefighter Arson, U.S. Fire Administration/Technical Report Series, USFA-TR-141/January 2003. Federal Management Association, U.S. Department of Homeland Security (http://www.usfa.fema.gov/downloads/pdf/publications/tr-141.pdf).

29.   “Sick Kids Cold Case Getting Colder.” Michele Mandel, Toronto Sun. March 5, 2011 (http://www.torontosun.com/news/columnists/michele_mandel/2011/03/05/17507076.html).

Chapter 4. Obession or Inspiration

Chapter 4 drew on interviews with James S. Marks and Joseph McDade

  1.   Founded as the Communicable Disease Center in 1947, CDC’s name was changed in 1970 to the Center for Disease Control and in 1992 to the Centers for Disease Control and Prevention. Its acronym has always been “CDC.”

  2.   “In vitro” refers to tests conducted in test tubes and laboratory dishes; “in vivo” refers to tests conducted in animals.

  3.   John Adams, by David McCullough. Simon & Schuster, New York, NY, 2001. Page 446.

  4.   Dr. Shepard, who headed the CDC Leprosy and Rickettsia Branch for more than 30 years, died on February 18, 1985. The Charles C. Shepard Science Award—which can be given for scientific publications or for lifetime scientific achievement—was established in his honor in 1986.

  5.   The Bellevue-Stratford Hotel re-opened in 1979 under a new name.

  6.   The association between swine flu vaccination and Guillain-Barré syndrome (GBS) was further confirmed by a CDC study published in 1979 (Schonberger LB, Bregman DJ, Sullivan-Bolyai JZ, Keenlyside RA, Ziegler DW, Retailliau HF, Eddins DL, Bryan JA. “Guillain-Barre syndrome following vaccination in the National Influenza Immunization Program, United States, 1976–1977.” Am J Epidemiol. 1979 Aug; 110(2): 105–23). A reassessment performed in 1991 came to the same conclusion (Safranek TJ, Lawrence DN, Kurland LT, Culver DH, Wiederholt WC, Hayner NS, Osterholm MT, O’Brien P, Hughes JM. “Reassessment of the association between Guillain-Barré syndrome and receipt of swine influenza vaccine in 1976–1977: results of a two-state study. Expert Neurology Group. Am J Epidemiol. 1991 May 1; 133(9): 940–51). The 1979 study found that the period of increased risk was primarily within the first five weeks after vaccination, with some risk remaining for nine to ten weeks.” The reassessment study found no increased risk beyond the first six weeks after vaccination.

The reasons for the association between GBS and the 1976 swine flu vaccine remain unknown. Vaccine production methods and safety standards have changed since 1976, resulting in fewer adverse reactions. Today’s seasonal flu vaccines have excellent safety profiles (see: Vellozzi C et al. “Safety of trivalent inactivated influenza vaccines in adults: background for pandemic influenza vaccine safety monitoring.” Vaccine 2009; 27: 2114–20). Moreover, no increase in adverse events following vaccination was observed during the 2009–2010 H1N1 pandemic (Centers for Disease Control and Prevention. Safety of Influenza A [H1N1] 2009 Monovalent Vaccines—United States, October 1–November 24, 2009. Morbidity and Mortality Weekly Report, December 11, 2009 / 58(48); 1351–56).

  7.   Thirty-two years later, on April 30, 2009, during the H1N1 influenza pandemic, Dr. Sencer told a CNN reporter that in 1976 health officials “acted on the best knowledge that we had and believed that we were doing the right thing. . . . [But] we know a lot more about viruses than we did then.” See also: Sencer DJ, Millar JD. “Reflections on the 1976 swine flu vaccination program.” Emerg Infect Dis. Volume 12, Number 1—January 2006.

  8.   Marks JS, Tsai TF, Martone WJ, Baron RC, Kennicott J, Holtzhauer FJ, Baird I, Fay D, Feeley JC, Mallison GF, Fraser DW, Halpin TJ. “Nosocomial Legionnaires’ disease in Columbus, Ohio.” Ann Intern Med. 1979 Apr; 90(4): 565–69. An LD outbreak was also reported in 1977 in Burlington, Vermont (Broome CV, Goings SA, Thacker SB, Vogt RL, Beaty HN, Fraser DW. “The Vermont epidemic of Legionnaires’ disease.” Ann Intern Med. 1979 Apr; 90(4): 573–77).

  9.   An ehrlichial species that causes a human infection called Sennetsu fever, characterized by fever and swollen lymph nodes, was identified in Japan in 1953 and later reported in the Far East and Southeast Asia.

10.   Ganguly S, Mukhopadhayay SK. “Tick-borne ehrlichiosis infection in human beings.” J Vector Borne Dis. 2008 Dec; 45(4): 273–80.

11.   A list of pathogens discovered between 1972 and 2004 may be found in: Cohen & Powderly: Infectious Diseases, 2nd ed. Volume 1, Section 1, Chapter 4. “Emerging and re-emerging pathogens and diseases.” Levitt AM, Khan S, Hughes JM. 2004. Mosby, an imprint of Elsevier. Pathogens discovered since 2004 include: a human bocavirus identified in Sweden that causes acute respiratory illness in children (2005); a transplant-associated arenavirus identified in Australia that killed three recipients of liver or kidney transplants from a single donor (2008); a new tickborne phlebovirus identified in Missouri (the Heartland virus) that causes a severe febrile illness (2012); and a new SARS-like coronavirus identified in the Middle East (2012).

Chapter 5. Dangerous Desserts

Chapter 5 drew on interviews with Richard N. Danila, Craig W. Hedberg, Thomas Hennessy, and Michael T. Osterholm.

  1.   Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson MA, Roy SL, Jones JL, Griffin PM. Foodborne illness acquired in the United States—major pathogens. Emerg Infect Dis. 2011 Jan; 17(1): 7-15.

  2.   Hedberg CW, Angulo FJ, White KE, Langkop CW, Schell WL, Stobierski MG, Schuchat A, Besser JM, Dietrich S, Helsel L, Griffin PM, McFarland JW, Osterholm MT. “Outbreaks of salmonellosis associated with eating uncooked tomatoes: implications for public health.” The Investigation Team. Epidemiol Infect. 1999 Jun; 122(3): 385–93.

  3.   Hedberg CW, Korlath JA, D’Aoust JY, White KE, Schell WL, Miller MR, Cameron DN, MacDonald KL, Osterholm MT. “A multistate outbreak of Salmonella javiana and Salmonella oranienburg infections due to consumption of contaminated cheese.” JAMA. 1992 Dec 9; 268(22): 3203–07.

  4.   Hedberg CW, Fishbein DB, Janssen RS, Meyers B, McMillen JM, MacDonald KL, White KE, Huss LJ, Hurwitz ES, Farhie JR, Simmons JL, Braverman LE, Ingbar SH, Schonberger LB, Osterholm MT. “An outbreak of thyrotoxicosis caused by the consumption of bovine thyroid gland in ground beef.” N Engl J Med. 1987 Apr 16; 316(16): 993–98.

  5.   Berton Roueché. Annals of Medicine. “A Lean Cusine.” New Yorker, June 27, 1988, pg. 70–78.

  6.   Case Studies in Crisis Communication. Lessons Learned About Protecting America’s Food Supply. Edited by Timothy L. Sellnow and Robert S. Littlefield. Institute for Regional Studies, North Dakota State University, P.O. Box 5075, Fargo ND 58105. 2005. See Chapter 2: “Social Responsibility: Lessons Learned from Schwan’s Salmonella Crisis.” J.J. McIntyre. (http://www.fooddefense.org/Ncfpd/assets/File/pdf/RC_Lessons_Learned_2005.pdf).

  7.   Rose Farley. Tainted Love. Twin Cities Reader. January 18–24, 1995.

  8.   Hennessy TW, Hedberg CW, Slutsker L, White KE, Besser-Wiek JM, Moen ME, Feldman J, Coleman WW, Edmonson LM, MacDonald KL, Osterholm MT. “A national outbreak of Salmonella enteritidis infections from ice cream.” The Investigation Team. N Engl J Med. 1996 May 16; 334(20): 1281–86.

  9.   Mahon BE, Slutsker L, Hutwagner L, Drenzek C, Maloney K, Toomey K, and Griffin PM. “Consequences in Georgia of a nationwide outbreak of Salmonella infections: what you don’t know might hurt you.” Am J Public Health. 1999 January; 89(1): 31–35.

10.   See: Food Safety from Farm to Table: a National Food Safety Initiative Report to the President. May 1997. Food and Drug Administration, U.S. Department of Agriculture, U.S. Environmental Protection Agency, Centers for Disease Control. (http://www.cdc.gov/ncidod/foodsafe/report.htm)

11.   Emerging Infections: Microbial Threats to Health in the United States. Joshua Lederberg, Robert E. Shope, and Stanley C. Oaks, Jr., eds. Institute of Medicine, National Academies Press, Washington, D.C. 1992.

12.   Blaser MJ. “How safe is our food? Lessons from an outbreak of salmonellosis.” N Engl J Med. 1996 May 16; 334(20): 1324–25. Infection with Salmonella Enteriditis has been has been called a “disease of civilization,” and Legionnaires’ Disease has been called “a disease of technology” (Chapter 4). In both cases, disease spread is facilitated by modern factors.

13.   FoodNet is hosted by the CDC Emerging Infections Program (EIP). Information about FoodNet and EIP may be found at: http://www.cdc.gov/ncezid/dpei/eip/index.html and http://www.cdc.gov/foodnet/

14.   Information on PulseNet is available at http://www.cdc.gov/pulsenet/, and information on PulseNet International is available at http://www.pulsenetinternational.org/Pages/default.aspx.

Chapter 6. The Red Mist

Chapter 6 drew on interviews with Ruth Lynfield, Aaron DeVries, Stacy Holzbauer, Richard N. Danila, and James Sejvar.

  1.   The role of the Spanish interpreter is mentioned in three news reports: Brown, David. “Inhaling pig brains may be cause of new illness.” Washingtonpost.com. February 4, 2008 (http://www.national-toxic-encephalopathy-foundation.org/PigBrain.pdf); Gajilan, A. “Medical mystery solved in slaughterhouse.” CNNHealth. February 28, 2008 (http://articles.cnn.com/2008-02-28/health/medical.mystery_1_doctors-pig-brain-slaughterhouse?_s=PM:HEALTH); and Cassels C. “Findings in pork workers with novel neurological illness reported for the first time.” Medscape Medical News. April 17, 2008. (http://www.medscape.com/viewarticle/573193_print).

  2.   Grady D. “A medical mystery unfolds in Minnesota.” New York Times. February 5, 2008.

  3.   Said G. “Infectious neuropahties.” Neurol Clin 2007; 25: 115–37. Infectious causes of polyneuropathy include HIV/AIDS, Lyme disease, leprosy, herpes zoster, and hepatitis B and C.

  4.   Kennedy ED, Hall RL, Montgomery SP, Pyburn DG, Jones JL. “Trichinellosis Surveillance—United States, 2002–2007.” MMWR Surveillance Summary 2009 Dec 4; 58(9): 1–7.

  5.   Whitfield JT, Pako WH, Collinge J, Alpers MP. “Mortuary rites of the South Fore and kuru.” Philos Trans R Soc Lond B Biol Sci. Nov 27 2008; 363(1510): 3721–24.

  6.   The index patient is referred to as “Case 1” in: Lachance DH, Lennon VA, Pittock SJ, Tracy JA, Krecke KN, Amrami KK, Poeschla EM, Orenstein R, Scheithauer BW, Sejvar JJ, Holzbauer S, DeVries AS, Dyck PJ. “An outbreak of neurological autoimmunity with polyradiculoneuropathy in workers exposed to aerosolised porcine neural tissue: a descriptive study.” Lancet Neurol. 2010 Jan; 9(1): 55–66.

  7.   Genoways T. “The Spam Factory’s Dirty Secret.” Mother Jones. July/August 2011 (http://www.motherjones.com/politics/2011/06/hormel-spam-pig-brains-disease)

  8.   Brown, David. “Inhaling pig brains may be cause of new illness.” Washingtonpost.com. February 4, 2008 (http://www.national-toxic-encephalopathy-foundation.org/PigBrain.pdf).

  9.   The history of the Hormel Corporation through the 1980s is described in: Hage D and Klauda P. No Retreat, No Surrender: Labor’s War at Hormel. William Morrow & I Co. 1989.

10.  The QPP holding pen was continuously filled with animals who moved along for several hours, giving them sufficient time to acclimate and calm down before they entered the room where they were stunned by electric shock and killed. These procedures—designed in accordance with the ideas of Temple Grandin, the animal expert and autism activist, are both humane and protective of the meat, whose flavor can be affected by high levels of stress-induced lactic acid.

11.   Taylor LH, Latham SM, Woolhouse ME. “Risk Factors for human disease emergence.” Philos Trans R Soc Lond B Biol Sci. 2001 Jul 29; 356(1411): 983–89.

12.   Holzbauer SM, DeVries AS, Sejvar JJ, Lees CH, Adjemian J, McQuiston JH, Medus C, Lexau CA, Harris JR, Recuenco SE, Belay ED, Howell JF, Buss BF, Hornig M, Gibbins JD, Brueck SE, Smith KE, Danila RN, Lipkin WI, Lachance DH, Dyck PJ, Lynfield R. “Epidemiologic investigation of immune-mediated polyradiculoneuropathy among abattoir workers exposed to porcine brain.” PLoS One. 2010 Mar 19; 5(3): e9782 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841649/).

13.   The exchange between Lynfield and Wadding is also described in Grady D. “A medical mystery unfolds in Minnesota.” New York Times. February 5, 2008. (Reference 2.)

14.   Gajilan, A. “Medical mystery solved in slaughterhouse.” CNNHealth. February 28, 2008 (http://articles.cnn.com/2008-02-28/health/medical.mystery_1_doctors-pig-brain-slaughterhouse?_s=PM:HEALTH).

15.   Eurosurveillance Editorial Team. “Progressive inflammatory neuropathy (PIN) among swine slaughterhouse workers in Minnesota, United States, 2007–2008.” Euro Surveill. 2008 Feb 21; 13(8). pii: 8047.

16.   Adjemian JZ, Howell J, Holzbauer S, Harris J, Recuenco S, McQuiston J, Chester T, Lynfield R, DeVries A, Belay E, Sejvar. “A clustering of immune-mediated polyradiculoneuropathy among swine abattoir workers exposed to aerosolized porcine brains, Indiana, United States.” Int J Occup Environ Health. 2009 Oct–Dec; 15(4): 331–88.

17.   Collins TR. “Surveillance Continues on Pork Plant Workers Diagnosed with ‘Mystery’ Neuropathy.” Neurology Today. 16 October 2008; Volume 8(20), p 18–20. (http://www.aan.com/elibrary/neurologytoday/?event=home.showArticle&id=ovid.com:/bib/ovftdb/00132985-200810160-00009)

18.   Bell H. “Inspector Lachance.” Minnesota Medicine, November 2008 (http://www.minnesotamedicine.com/Default.aspx?tabid=2712)

19.   Cassels C. “Findings in pork workers with novel neurological illness reported for the first time.” Medscape Medical News. April 17, 2008. (http://www.medscape.com/viewarticle/573193_print).

20.   Centers for Disease Control and Prevention (CDC). “Update: outbreak of Nipah virus—Malaysia and Singapore, 1999.” Morb Mortal Wkly Rep. 1999 Apr 30; 48(16): 335–37.

21.   Paton NI, Leo YS, Zaki SR, Auchus AP, Lee KE, Ling AE, Chew SK, Ang B, Rollin PE, Umapathi T, Sng I, Lee CC, Lim E, Ksiazek TG. “Outbreak of Nipah-virus infection among abattoir workers in Singapore.” Lancet. 1999 Oct 9; 354(9186): 1253–56.

22.   Carrieri MP, Tissot-Dupont H, Rey D, Brousse P, Renard H, Obadia Y, Raoult D. “Investigation of a slaughterhouse-related outbreak of Q fever in the French Alps.” Eur J Clin Microbiol Infect Dis. 2002 Jan; 21(1): 17–21.

23.   Marmion BP, Ormsbee RA, Kyrkou M, Wright J, Worswick D, Cameron S, Esterman A, Feery B, Collins W. “Vaccine prophylaxis of abattoir-associated Q fever.” Lancet. 1984 Dec 22; 2(8417–18): 1411–14.

24.   Wilson LE, Couper S, Prempeh H, Young D, Pollock KG, Stewart WC, Browning LM, Donaghy M. “Investigation of a Q fever outbreak in a Scottish co-located slaughterhouse and cutting plant.” Zoonoses Public Health. 2010 Dec; 57(7–8): 493–8.

25.   Dijkstra F, van der Hoek W, Wijers N, Schimmer B, Rietveld A, Wijkmans CJ, Vellema P, Schneeberger PM. “The 2007–2010 Q fever epidemic in The Netherlands: characteristics of notified acute Q fever patients and the association with dairy goat farming.” FEMS Immunol Med Microbiol. 2012 Feb; 64(1): 3–12.

26.   Centers for Disease Control and Prevention (CDC). “Q fever among slaughterhouse workers—California.” MMWR Morb Mortal Wkly Rep. 1986 Apr 11; 35(14): 223–6.

27.   Lachance DH, Lennon VA, Pittock SJ, Tracy JA, Krecke KN, Amrami KK, Poeschla EM, Orenstein R, Scheithauer BW, Sejvar JJ, Holzbauer S, DeVries AS, Dyck PJ. “An outbreak of neurological autoimmunity with polyradiculoneuropathy in workers exposed to aerosolised porcine neural tissue: a descriptive study.” Lancet Neurol. 2010 Jan; 9(1): 55–66.

28.   The Sign of the Four (1890) by Sir Arthur Conan Doyle.

29.   Gamaleia N. “Etude sur la rage paralytique chez l’homme. (Study of human rabies.)” Ann Inn Pasteur 1887; 1: 63–83.

30.   Rivers T, Schwenker F. “Encephalomyelitis accompanied by myelin destruction experimentally produced in monkeys.” J Exp Med 1935; 61: 689–702. In 1955, scientists also induced allergic neuritis (inflammation of the nerves) in laboratory animals through injection of emulsified brain tissue. See: Waksman BH and Adams RD. “Allergic neuritis: an experimental disease of rabbits induced by the injection of peripheral nervous tissue and adjuvants.” J Exp Med. 1955 Aug 1; 102(2): 213–36.

31.   Hemachuda T, Griffin D, Giffels B, Johnson R, Moser A, Phanuphak P,” “Myelin basic protein as an encephalitogen in encephalomyelitis and polyneuritis following rabies vaccination.” N Engl J Med 1987; 316: 369–74.

32.   Figueras A, Morales-Olivas FJ, Capella D, Palop V, Laporte JR. “Bovine gangliosides and acute motor polyneuropathy.” BMJ 1992; 305. The implications of this study are discussed in: Willison HJ, Wraith DC. “A hazardous vapour trail from abattoir to neuropathy clinic.” Lancet Neurol. 2010 Jan; 9(1): 22–4.

33.   Oldstone MB. “Molecular mimicry and immune-mediated diseases.” FASEB J. 1998 Oct; 12(13): 1255–65.

34.   Tracy JA and Dyck PJB. “Auto-immune polyradiculoneuropathy and a novel IgG biomarker in workers exposed to aerosolized porcine brain.” Journal of the Peripheral Nervous System. Volume 16, Issue s1, June 2011, Pages: 34–37.

35.   Cajigal S. “Antibody pattern discovered for pork plant illness.” Neuro Today. 5 June 2008; Volume 8(11); p 3 (http://www.aan.com/elibrary/neurologytoday/?event=home.showArticle&id=ovid.com:/bib/ovftdb/00132985-200806050-00004).

36.   Centers for Disease Control and Prevention (CDC). “Investigation of progressive inflammatory neuropathy among swine slaughterhouse workers–Minnesota, 2007–2008.” MMWR Morb Mortal Wkly Rep. 2008 Feb 8; 57(5): 122–4.

37.   DeAngelis TM and Shen L. “Outbreak of progressive inflammatory neuropathy following exposure to aerosolized porcine neural tissue.” Mt Sinai J Med. 2009 Oct; 76(5): 442–7.

38.   Because progressive inflammatory neuropathy (PIN) did not turn out to be a progressive disease, as first believed, the Mayo Clinic neurologists prefer to call it an “occupational autoimmune polyradiculoneuropathy,” a term that reflects its discovery in an occupational setting, its autoimmune causation, and its impact on the peripheral nerves and nerve roots. (A “polyradiculoneuropathy” is a disease of the peripheral nerves and the nerve roots.) See: Rukovets O. “Animal Model Mirrors Human Form of Occupational Neuropathy in Pork Plant Workers.” Neurology Today. 19 January 2012; Volume 12(2); pp 24–27. (Reference 40)

39.   Meeusen JW, Klein CJ, Pirko I, Haselkorn KE, Kryzer TJ, Pittock SJ, Lachance DH, Dyck PJ, Lennon VA. “Potassium channel complex autoimmunity induced by inhaled brain tissue aerosol.” Ann Neurol. 2012 Mar; 71(3): 417–26.

40.   Rukovets O. “Animal Model Mirrors Human Form of Occupational Neuropathy in Pork Plant Workers.” Neurology Today. 19 January 2012; Volume 12(2); pp 24–27

41.   Frolov, RV Bagati A, Casino B, Singh S. “Potassium Channels in Drosphila: Historical Breakthroughs, Significance, and Perspectives.” J. Neurogenetics, 26(3–4): 275–290, 2012; Kamb A, Iverson LE, Tanouye MA. “Molecular characterization of Shaker, a Drosophila gene that encodes a potassium channel.” Cell 50, 40513, 1987.

42.   The patients’ recoveries correlated with decreasing levels (or titers) of neuronal self-antibodies. For most patients, the titers fell below the detection level within three to eighteen months after exposure to the brain-mist ended (see Reference 39). Additional data indicating that the level of anti-VGPC self-antibodies correlates with the level of a patient’s symptoms is provided in: Meeusen JW, Lennon VA, Klein CJ. “Immunotherapy-responsive pain in an abattoir worker with fluctuating potassium channel-complex IgG.” Neurology. 2012 Oct 23; 79(17): 1824–25.

43.   Fitzgerald S. “Condition of pork plant workers improving after developing neuropathy.” Neurol Today 2009; 9: 18–20.

44.   Baier E. “Workers sickened at pork plant still wait for compensation.” MPRnews. Minnesota Public Radio, March 31, 2010 (http://minnesota.publicradio.org/display/web/2010/03/31/pork-illness-compensation).

Chapter 7. A Normal Spring

Chapter 7 drew on interviews with Jay Butler, Jamie Childs, Thomas Hennessy, James Hughes, Patrick McConnon, and Stuart Nichol. Information about the activities of Bruce Tempest, Mack Sewell, and James Cheek was gathered by the author in 1995 as part of an internal CDC evaluation of the HPS outbreak response.

  1.   Peters CJ, Olshaker M. Virus Hunter. Thirty Years of Battling Hot Viruses Around the World. Anchor Books. Doubleday. 1997. Page 8.

  2.   Harper DR, Meyer AS. Of Mice, Men, and Microbes: Hantavirus. (1999) San Diego: Academic Press.

  3.   Duchin JS, Koster FT, Peters CJ, Simpson GL, Tempest B, Zaki SR, Ksiazek TG, Rollin PE, Nichol S, Umland ET, et al. “Hantavirus pulmonary syndrome: a clinical description of 17 patients with a newly recognized disease.” The Hantavirus Study Group. N Engl J Med. 1994 Apr 7; 330(14): 949–55.

  4.   Grady D. “Death at the Corners.” Discover Magazine. December 1993 Issue.

  5.   The phosgene theory is described in: Garrett L. The Coming Plague. Newly Emerging Diseases in a World Out of Balance. Farrar, Straus and Giroux, New York, 1994, pgs. 530–31, and in: Peters CJ, Olshaker M. Virus Hunter. Thirty Years of Battling Hot Viruses Around the World. Anchor Books. Doubleday, 1997, p.10.

  6.   A detailed description of the irradiation of the clinical specimens and the antibody testing may be found in: Peters CJ, Olshaker M. Virus Hunter. Thirty Years of Battling Hot Viruses Around the World. Anchor Books. Doubleday. 1997. Pgs. 26–27 and 31.

  7.   Lee PW, Amyx HL, Yanagihara R, Gajdusek DC, Goldgaber D, Gibbs CJ Jr. “Partial characterization of Prospect Hill virus isolated from meadow voles in the United States.” J Infect Dis. 1985 Oct; 152(4): 826–9.

  8.   Childs JE, Korch GW, Glass GE, LeDuc JW, Shah KV. “Epizootiology of Hantavirus infections in Baltimore: isolation of a virus from Norway rats, and characteristics of infected rat populations.” Am J Epidemiol. 1987 Jul; 126(1): 55–68.

  9.   Childs and his colleagues found that some individuals had antibodies to the Seoul virus in their blood sera, suggesting that they had been exposed but had not been sick (see Reference 8). Decades later, two cases of human disease were attributed to infection with Seoul virus, one in the United States and one in the United Kingdom. See: Woods Palekar R, Kim P, Blythe D, de Senarclens O, Feldman K, Farnon EC, Rollin PE, Albariño CG, Nichol ST, Smith M. “Domestically acquired Seoul virus causing hemorrhagic fever with renal syndrome-Maryland, 2008.” Clin Infect Dis. 2009 Nov 15; 49(10): e109–12, and Jameson LJ, Logue CH, Atkinson B, Baker N, Galbraith SE, Carroll MW, Brooks T, Hewson R. “The continued emergence of hantaviruses: isolation of a Seoul virus implicated in human disease, United Kingdom, October 2012.” Euro Surveill. 2013 Jan 3; 18(1): 4–7.

10.   Rodriguez LL, Letchworth GJ, Spiropoulou CF, Nichol ST. “Rapid detection of vesicular stomatitis virus New Jersey serotype in clinical samples by using polymerase chain reaction.” J Clin Microbiol. 1993 Aug; 31(8): 2016–20.

11.   Nichol ST, Spiropoulou CF, Morzunov S, Rollin PE, Ksiazek TG, Feldmann H, Sanchez A, Childs J, Zaki S, Peters CJ. “Genetic identification of a hantavirus associated with an outbreak of acute respiratory illness.” Science. 1993 Nov 5; 262(5135): 914–7.

12.   Zaki SR, Greer PW, Coffield LM, Nolte KB, Zumwalt R, Umiand ET, Feddersen RM, Foucar K, Ruo SL, Rollin P, Ksiazek T, Nichol S, Peters CJ. “Outbreak of hantavirus-associated illness in the United States: immunohistochemical localization of viral nucleoproteins to endothelial cells in human tissues.” Lab Invest 1994, 70: 129A (Abstract)

13.   Zaki SR, Greer PW, Coffield LM, Goldsmith CS, Nolte KB, Foucar K, Feddersen RM, Zumwalt RE, Miller GL, Khan AS. “Hantavirus pulmonary syndrome. Pathogenesis of an emerging infectious disease.” Am J Pathol. 1995 Mar; 146(3): 552–79.

14.   Saltzstein. “Southwest’s ‘Navajo Flu’ Deadly But Not Navajo.” American Journalism Review, October 1993.

15.   Leovy J, Cheevers J. Los Angeles Times. June 2, 1993. “Visiting Navajo Children Barred From L.A. School : Health: Officials feared students would be exposed to deadly illness. Medical authorities say they overreacted.”

16.   Zeitz PS, Butler JC, Cheek JE, Samuel MC, Childs JE, Shands LA, Turner RE, Voorhees RE, Sarisky J, Rollin PE, et al. “A case-control study of hantavirus pulmonary syndrome during an outbreak in the southwestern United States.” J Infect Dis. 1995 Apr; 171(4): 864–70

17.   Childs JE, Krebs JW, Ksiazek TG, Maupin GO, Gage KL, Rollin PE, Zeitz PS, Sarisky J, Enscore RE, Butler JC, et al. “A household-based, case-control study of environmental factors associated with hantavirus pulmonary syndrome in the southwestern United States.” Am J Trop Med Hyg. 1995 May; 52(5): 393–7.

18.   Childs JE, Ksiazek TG, Spiropoulou CF, Krebs JW, Morzunov S, Maupin GO, Gage KL, Rollin PE, Sarisky J, Enscore RE, et al. “Serologic and genetic identification of Peromyscus maniculatus as the primary rodent reservoir for a new hantavirus in the southwestern United States.” J Infect Dis. 1994 Jun; 169(6): 1271–80.

19.   Childs JE, Kaufmann AF, Peters CJ, Ehrenberg RL. “Hantavirus infection–southwestern United States: interim recommendations for risk reduction.” Centers for Disease Control and Prevention. MMWR Recomm Rep. 1993 Jul 30; 42(RR-11): 1–13.

20.   The advice and concerns of the Navajo medicine men are also described in: Peters CJ, Olshaker M. Virus Hunter. Thirty Years of Battling Hot Viruses Around the World. Anchor Books. Doubleday. 1997. Pgs. 24–25.

21.   Parmenter RR, Brunt JW, Moore DI, Ernest S. (1993). “The hantavirus epidemic in the Southwest: Rodent population dynamics and the implications for transmission of hantavirus-associated adult respiratory distress syndrome (HARDS) in the Four Corners region (Univ. of New Mexico, Albuquerque),” Sevilleta Long-Term Ecological Research Site Pub. No 41.

22.   Yates TL, Mills JN, Parmenter CA, Ksaizek TG, Parmenter RR, Vande Castle JR, Calisher CH, Nichol ST, Abbott KD, Young JC, Morrison ML, Beaty BJ, Dunnum JL, Baker RJ, Salazar-Bravo J, Peters CJ. “The Ecology and Evolutionary History of an Emergent Disease: Hantavirus Pulmonary Syndrome.” BioScience 52(11): 989–98. 2002.

23.   McCormick JB, King IJ, Webb PA, Scribner CL, Craven RB, Johnson KM, Elliott LH, Belmont-Williams R. “Lassa fever. Effective therapy with ribavirin.” N Engl J Med. 1986 Jan 2; 314(1): 20–6.

24.   Huggins JW, Hsiang CM, Cosgriff TM, Guang MY, Smith JI, Wu ZO, LeDuc JW, Zheng ZM, Meegan JM, Wang QN, et al. “Prospective, double-blind, concurrent, placebo-controlled clinical trial of intravenous ribavirin therapy of hemorrhagic fever with renal syndrome.” J Infect Dis. 1991 Dec; 164(6): 1119–27.

25.   The initial ribavirin trial was inconclusive, and the drug was not shown to be effective against HPS in later studies. See: Chapman LE, Mertz GJ, Peters CJ, Jolson HM, Khan AS, Ksiazek TG, Koster FT, Baum KF, Rollin PE, Pavia AT, Holman RC, Christenson JC, Rubin PJ, Behrman RE, Bell LJ, Simpson GL, Sadek RF. “Intravenous ribavirin for hantavirus pulmonary syndrome: safety and tolerance during 1 year of open-label experience.” Ribavirin Study Group. Antivir Ther. 1999; 4(4): 211–9, and Mertz GJ, Miedzinski L, Goade D, Pavia AT, Hjelle B, Hansbarger CO, Levy H, Koster FT, Baum K, Lindemulder A, Wang W, Riser L, Fernandez H, Whitley RJ; Collaborative Antiviral Study Group. “Placebo-controlled, double-blind trial of intravenous ribavirin for the treatment of hantavirus cardiopulmonary syndrome in North America.” Clin Infect Dis. 2004 Nov 1; 39(9): 1307–13.

26.   Crowley MR, Katz RW, Kessler R, Simpson SQ, Levy H, Hallin GW, Cappon J, Krahling JB, Wernly J. “Successful treatment of adults with severe Hantavirus pulmonary syndrome with extracorporeal membrane oxygenation.” Crit Care Med. 1998 Feb; 26(2): 409–14.

27.   Dietl CA, Wernly JA, Pett SB, Yassin SF, Sterling JP, Dragan R, Milligan K, Crowley MR. “Extracorporeal membrane oxygenation support improves survival of patients with severe Hantavirus cardiopulmonary syndrome.” J Thorac Cardiovasc Surg. 2008 Mar; 135(3): 579–84.

28.   Christian MD, Poutanen SM, Loutfy MR, Muller MP, Low DE. “Severe acute respiratory syndrome.” Clin Infect Dis. 2004 May 15; 38(10): 1420–27.

29.   Zaki SR, Khan AS, Goodman RA, Armstrong LR, Greer PW, Coffield LM, Ksiazek TG, Rollin PE, Peters CJ, Khabbaz RF. “Retrospective diagnosis of hantavirus pulmonary syndrome, 1978-1993: implications for emerging infectious diseases.” Arch Pathol Lab Med. 1996 Feb; 120(2): 134–9.

30.   As of December 31, 1993, 53 cases of HPS had been detected in 14 states. See: CDC. “Hantavirus pulmonary syndrome—United States, 1993.” MMWR. 1994 Jan 28; 43(3): 45–8. In 1994, additional cases were reported in Florida, Virginia, and the northeastern United States. See: CDC. “Newly identified hantavirus—Florida, 1994.” 1994 Feb 18; 43(6): 99, 105; CDC. “Hantavirus pulmonary syndrome–Virginia, 1993.” MMWR. 1994 Dec 2; 43(47): 876–7; and CDC. “Hantavirus pulmonary syndrome—Northeastern United States, 1994.” MMWR. 1994 Aug 5; 43(30): 548-9, 555–66).

31.   Centers for Disease Control and Prevention (CDC). “Hantavirus pulmonary syndrome in visitors to a national park—Yosemite Valley, California, 2012.” MMWR 2012 Nov 23; 61(46): 952.

32.   In 1997, fifteen years before the 2012 HPS outbreak, Childs, Peters, Ksiazek, and other CDC colleagues conducted a study in Yosemite and two other national parks (Sequoia/Kings Canyon National Parks in California and Shenandoah National Park in Virginia) to identify ways to keep mice from entering homes and cabins in rural areas during the fall and winter. They found that even minor repairs help prevent rodents from entering homes. (See: Mills JN, Johnson JM, Ksiazek TG, Ellis BA, Rollin PE, Yates TL, Mann MO, Johnson MR, Campbell ML, Miyashiro J, Patrick M, Zyzak M, Lavender D, Novak MG, Schmidt K, Peters CJ, Childs JE. “A survey of hantavirus antibody in small-mammal populations in selected United States National Parks.” Am J Trop Med Hyg. 1998 Apr; 58[4]: 525–32.) Also in 1997, they conducted a survey to evaluate hantavirus activity among small mammals in 39 national parks in the eastern and central United States. Antibody reactive to the HPS virus was found in deer mice, white-footed mice, rice rats, cotton rats, western harvest mice, three species of voles, and one species of chipmunk. Antibody prevalence among deer mice was highest in the northeast. (See: Mills JN, Johnson JM, Ksiazek TG, Ellis BA, Rollin PE, Yates TL, Mann MO, Johnson MR, Campbell ML, Miyashiro J, Patrick M, Zyzak M, Lavender D, Novak MG, Schmidt K, Peters CJ, Childs JE. “A survey of hantavirus antibody in small-mammal populations in selected United States National Parks.” Am J Trop Med Hyg. 1998 Apr; 58[4]: 525–32.)

33.   Renewed U.S. concern about infectious diseases was spurred by the emergence of AIDS and the re-emergence of TB, which demonstrated that viruses and bacteria had not been “conquered” by modern medicine. See: Institute of Medicine. Emerging Infections: Microbial Threats to Health in the United States. National Academies Press. Washington, DC. 1992.

34.   The CDC Special Pathogens Laboratory isolated Sin Nombre virus (SNV) from a deer mouse trapped near the New Mexico home of an HPS patient. Shortly afterwards and independently, USAMRIID isolated SNV from an HPS patient in New Mexico and a mouse trapped in California. See: Marshall E, Stone R. “Race to grow hantavirus ends in tie.” Science. 1993 Dec 3; 262(5139): 1509; and Elliott LH, Ksiazek TG, Rollin PE, Spiropoulou CF, Morzunov S, Monroe M, Goldsmith CS, Humphrey CD, Zaki SR, Krebs JW, Maupin G, Gage K, Childs JE, Nichol ST, Peters CJ. “Isolation of the causative agent of hantavirus pulmonary syndrome.” Am J Trop Med Hyg 1994, 51: 102–8.

Epilogue. June 2013

  1.   In late 2013, Chikungunya virus was found for the first time in the Americas, on islands in the Caribbean. Since then, it has spread to forty-four countries and territories throughout the Americas, including the United States, where cases of Chikungunya virus disease have been reported in Florida, Puerto Rico, and the U.S. Virgin Islands.