LETTERS compare the results of seroepidemio- Pneumonic Plague, and hemoptysis. A total of 16 cases logic investigations among cats living were reported from 3 hospitals in the in sites contaminated by avian viruses. Northern India, area: a local civil hospital, the state 2002 medical college, and a regional terti- This work was supported by the ary care hospital. Clinical material University of Milan grant F.I.R.S.T. To the Editor: A small outbreak collected from the case-patients and of primary pneumonic plague took their contacts was initially processed Saverio Paltrinieri,* place in the Shimla District of in the laboratories of these hospitals. Valentina Spagnolo,* Himachal Pradesh State in northern Wayson staining provided immediate Alessia Giordano,* India during February 2002. Sixteen presumptive diagnosis, and confirma- Ana Moreno Martin,† cases of plague were reported with a tory tests were performed at NICD. and Andrea Luppi† case-fatality rate of 25% (4/16). The Diagnosis of plague was confirmed infection was confirmed to the molec- *University of Milan, Milan, Italy; and for 10 (63%) of 16 patients (1). †Istituto Zooprofilattico Sperimentale della ular level with PCR and gene NICD conducted the following Lombardia e dell’Emilia, Brescia, Italy sequencing (1). A previous outbreak laboratory tests on 2 suspected culture in this region during 1983 was sug- References isolates, 2 sputum specimens, 1 lung gestive of pneumonic plague (22 autopsy material specimen, and 1 lung 1. Hopp M. Germany: H5N1 in domestic cats. cases, 17 deaths) but was not con- lavage sample (Table): 1) direct fluo- ProMed. 2006 Mar 1. [cited 2006 Mar 1]. firmed. In India, the last laboratory- rescent antibody test for Yersinia Available from http://www.promedmail. confirmed case of plague was report- org, archive no: 20060301.0656. pestis; 2) culture and bacteriophage 2. Kuiken T, Rimmelzwaan G, van Riel D, van ed in 1966 from Karnataka State (2). lysis test; and 3) PCR and gene Amerongen G, Baars M, Fouchier R, et al. The index patient for the 2002 sequencing to detect Y. pestis–specif- Avian H5N1 influenza in cats. Science. outbreak lived in a hamlet in the ic genes (pla and F1). All these tests 2004;306:241. Himalayas. He went hunting on 3. van Riel D, Munster VJ, de Wit E, confirmed that isolates were Y. pestis Rimmelzwaan GF, Fouchier RA, Osterhaus January 28, 2002, in a nearby forest at ≈ and met all the World Health Organi- AD, et al. H5N1 Virus attachment to lower a height of 500–600 m from his zation’s recommended criteria (2). respiratory tract. Science. 2006;312:399. house. There, he killed a sick wild cat Antibodies against F1 antigen of 4. Paniker CK, Nair CM. Infection with A2 and skinned it. He returned home on Hong Kong influenza virus in domestic Y. pestis were detected by passive cats. Bull World Health Organ. February 2 and sought treatment for hemagglutination testing of paired 1970;43:859–62. fever, chills, and headache. On serum samples. Although 5 patients 5. Butler D. Can cats spread avian flu? Nature. February 4, breathlessness, chest pain, showed a >4-fold rise, 1 patient 2006;440:135. and hemoptysis developed; radiologic 6. Songsermn T, Amonsin A, Jam-on R, Sae- showed a >4-fold fall in antibody titer. Heng N, Meemak N, Pariyothorn N, et al. findings were suggestive of lobar In contrast, samples from 6 patients Avian influenza H5N1 in naturally infected pneumonia, and treatment with aug- were negative for Y. pestis, and no domestic cat. Emerg Infect Dis. mentin was begun. He died the next change was found in the titers from 1 2006;12:681–3. day. Subsequently, 13 of his relatives 7. Butler D. Thai dogs carry bird-flu virus, but patient. No serum sample was collect- will they spread it? Nature. 2006;439:773. exhibited a similar illness, although 2 ed from the index patient; for the 2 8. Eurosurveillance.com. [homepage on the additional patients acquired infection other patients who died, 1 of the sin- Internet]. Stockholm. European Center for in the hospital. The incubation period gle serum samples became contami- Disease Prevention and Control. [cited for those patients was 1–4 days, 2006 Apr 13]. Available from http://www. nated, and the other was positive for eurosurveillance.org which is consistent with that of pneu- Y. pestis (3). Paired serum samples 9. De Boer GF, Back W, Osterhaus AD. An monic plague. from the case-patients were collected ELISA for detection of antibodies against A team of microbiologists, epi- on a single day 4 weeks apart during influenza A nucleoprotein in humans and demiologists, and entomologists visit- various animal species. Arch Virol. the visit of the NICD team, regardless 1990;115:47–61. ed the village after 7 more cases were of the duration of symptoms. 10. Capua I, Marangon S. Avian influenza in reported until February 12, 2002, fol- Antimicrobial drug sensitivity Italy (1999–2000): a review. Avian Pathol. lowed by a team from the National 2000;29:289–94. testing was carried out by the Kirby- Institute of Communicable Diseases Bauer disk diffusion method. All iso- (NICD), New Delhi. The following Address for correspondence: Saverio lates were sensitive to doxycycline, case-patient definition was used: a Paltrinieri, University of Milan, Department of tetracycline, chloramphenicol, strep- person who sought treatment for fever Veterinary Pathology, Hygiene and Public tomycin, ciprofloxacin, gentamicin, of rapid onset, chills, chest pain, Health, Via Celoria 10, Milan, Italy 20133; and amikacin but were resistant to breathlessness, headache, prostration, email: [email protected] penicillin. 664 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 13, No. 4, April 2007 LETTERS No fleas or other ectoparasites cats resulted in 17 cases of bubonic the relative of the index case-patient were found on the 6 cats, 8 dogs, 6 plague, 1 case of primary septicemic who had accompanied him to the for- cows, 4 calves or 2 trapped rodents in plague, and 5 cases of primary pneu- est survived the infection; whereas, the village. One serum sample, with monic plague (5). the wife and sister of the index patient pooled blood from 3 dogs was nega- In our report, close and pro- died. No spread to healthcare workers tive for antibodies against F1 antigen. longed contact with the index patient was noted. Before these infections occurred, a while providing care (for example, When plague was suspected heavy snowfall in the region had wiping his face during hemoptysis, immediate preventive measures were reduced the activity of rodents and supporting him during a bout of taken, for example, fumigation of the was unfavorable for the survival and coughing, taking him to the hospital index patient’s residence and any multiplication of rat fleas. The snow in a vehicle) resulted in secondary vehicles used for transporting the also helped restrict the spread of the cases. Because of the severe winter, patients; active surveillance and edu- infection because of reduced move- poor ventilation in houses further cation; standard work precautions; ment of the local population (1). helped the illness spread. All patients chemoprophylaxis for patient contacts Primary pneumonic plague is acquired infection before plague was and paramedics; and isolation and acquired by inhaling infective suspected. Initially, patients were treatment of patients (1). The trans- droplets from persons or animals and treated for community-acquired pneu- mission rate for primary pneumonic rarely by accidental aerosol exposure. monia, which delayed the proper plague is relatively low compared Y. pestis is a category A agent of treatment and led to deaths. A patient with that of many other communica- bioterrorism (4). It is not truly air- admitted for status epilepticus was ble diseases; the average number of borne; person-to-person transmission infected by her attendant, who in turn, secondary cases per primary case is requires face-to-face exposure within acquired infection from a terminally 1.3, according to a study done by Gani 2 m of a coughing patient (2). During ill plague patient for whom he provid- and Leach (6). 1977–1998, in the western United ed some care. The patient with epilep- The key element in the control of States, 23 cases of cat-associated sy and her attendant shared a common small outbreaks of primary pneumon- human plague were reported. Bites, room with the terminally ill wife of ic plague could be the intensity of dis- scratches, or other contact with infec- the index patient, which was small ease surveillance system (6). As a tious material while handling infected and poorly ventilated. Surprisingly, result, the state government has estab- Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 13, No. 4, April 2007 665 LETTERS lished a Plague Surveillance Unit in Francisella were subjected to electrophoresis on District Shimla of Himachal Pradesh 0.8% low-melt agarose gels (Roche in 2002 (1). tularensis, Portugal Diagnostics GmbH, Mannheim, To the Editor: Tularemia is a Germany), and the bands were puri- Acknowledgments zoonosis caused by Francisella fied by using the QIAquick gel extrac- We thank B.D. Negi for his selfless tularensis. Recently, tularemia has tion kit (QIAGEN GmbH) and service in collecting and processing sam- emerged in new locations, popula- sequenced with the BigDye ples from patients and their contacts in tions, and settings (1). After an out- Terminator Cycle Sequencing kit harsh field conditions. We are also thank- break in Spain in 1997 (2), it was (Applied Biosystems, Foster City, ful to NICD, New Delhi, for confirming expected that the disease would CA, USA) on an ABI 377 DNA Y. pestis in the culture isolates and serum spread toward Portugal, a country sequencer. The sequences were samples. with an extended area that borders the aligned with other sequences from affected areas.