Modes of Transmission: In Progress
Discussions on Transmission always include a healthy portion of debate. That debate can be a real help or hindrance, depending on your point of view. Personally, I think that as long as the debate remains open, it is never a negative thing... it is only at that time, that the debate closes, that we also risk closing our minds to new viewpoints.
It is important here to make a clear distinction between Proven Transmission and Possibility of Transmission... as this seems to stay in the heart of the debate. Proven Transmission is basically a reproducible scientific experiment. Where as Possibility of Transmission is basically a theory based on other factors not yet scientifically reproduced and published.
I use the qualifier 'YET' because it is my great confidence that eventually, funding will be acquired, studies will be conducted and what we have experienced as TBD patients will be validated scientifically in the laboratory.
Anaplasmosis
Human Granulocytic Anaplasmosis (HGA) is caused by the bacterium Anaplasma phagocytophilum. It is contracted with the bite of infected ticks (Amblyomma americanum, Ixodes pacificus, Ixodes scapularis, Ixodes spinipalpis and Ixodes Dermacentor variabilis). It has also been documented to transmit congenitally, through blood transfusion and through direct contact with blood or respiratory secretions.Human Granulocytic Ehrlichiosis (HGE) is caused by the bacterium Ehrlichia ewingii. It is typically contracted with the bite of infected ticks (Amblyomma americanum, Amblyomma maculatum, Ixodes scapularis, Ixodes Dermacentor variabilis and Rhipicephalus sanguineus), however, it has also been transmitted through contact with blood of fresh venison.
The Fatality rate is 2-5%.
Nosocomial Transmission of Human Granulocytic Anaplasmosis in China.
Lijuan Zhang, MD, PhD et al.
JAMA. 2008;300(19):2263-2270.
Human Granulocytic Anaplasmosis During Pregnancy: Case Series and Literature Review.
Dhand A, Nadelman R et al.
Clinical Infectious Diseases 2007;45:589–593.
Anaplasma phagocytophilum Transmitted Through Blood Transfusion
Morbidity and Mortality Weekly Report, October 24, 2008
MMWR 57(42);1145-1148
Exposure to deer blood may be a cause of human granulocytic ehrlichiosis.
Bakken JS, Krueth J, Lund T, Malkovitch D, Asanovich K, Dumler JS.
Clin Infect Dis 1996; 23:198.
The human ehrlichioses in the United States.1999.
McQuiston, J. H., C. D. Paddock, R. C. Holman, and J. E. Childs.
Emerg. Infect. Dis. 5:635-642
(Fatality rate)
Babesiosis
Babesia is caused by several species of protozoan parasites. It is known to transfer through blood transfusion and ingestion, organ transplant and by congenital means. Transmission also occurs with the bite of infected ticks (Boophilus annulatus, Boophilus decoloratus, Boophilus microplus, Ixodes pacificus, Ixodes scapularis, Ixodes Dermacentor nitens and Rhipicephalus sanguineus).The Fatality rate is 5-10%.
Probable congenital babesiosis in infant, New Jersey, USA.
Sethi S, Alcid D, Kesarwala H, Tolan, RW Jr.
Emerg Infect Dis [serial on the Internet]. 2009 May.
Experimental transmission of Babesia microti infection by the oral route.
Malagon F, Tapia JL.
Parasitol Res 1994;80(8):645-8.
Transfusion-Associated Babesia after Heart Transplant.
Lux JZ, Weiss D, Linden JV, Kessler D, Herwaldt BL, Wong SJ, et al.
Emerg Infect Dis [serial online] 2003 Jan.
Babesiosis and blood transfusion: flying under the radar.
Leiby DA.
Vox Sang. 2006 Apr;90(3):157-65.
Fatal experimental transplacental Babesia gibsoni infections in dogs.
Fukumoto S, Suzuki H, Igarashi I, Xuan X.
Int J Parasitol 2005 Aug;35(9):1031-5.
Human babesiosis in New York state: an epidemiologic description of 136 cases.
Meldrum, SC, Birkhead GS, White DJ, et al.
Clin Infect Dis 1992; 15:1019 23.
(Fatality rate)
Bartonella
Bartonella is caused by several species of bacteria. It is known to be transmitted by vectors such as fleas, biting flies, body louse, mosquitoes and ticks (Argasidae Carios kelleyi, Ixodes pacificus, Ixodes ricinus, Ixodes scapularis and Rhipicephalus sanguineus).
Bartonella has also been associated with the saliva of dogs and cats, normally passed on through scratches, bites or everyday grooming. Congenital transmission is also documented.Some species of Bartonella have a Fatality rate of 10-90%.
Transmission of Bartonella henselae by Ixodes ricinus.
Cotté V, Bonnet S, Le Rhun D, et al.
Emerg Infect Dis 2008 Jul; 14(7):1074-1080.
Experimental Transmission of Bartonella henselae by the Cat Flea.
Chomel B, Kasten R, Floyd-Hawkins K, Chi B, Yamamoto K, Roberts-Wilson J, Nikos Gurfield A et al.
Journal Of Clinical Microbiology, Aug. 1996, p. 1952–1956.
Bartonella spp. DNA associated with biting flies from California.
Chung CY, Kasten RW, Paff SM, Van Horn BA, Vayssier-Taussat M, Boulouis H-J et al.
Emerg Infect Dis. 2004 Jul.
Role of Hippoboscidae Flies as Potential Vectors of Bartonella spp. Infecting Wild and Domestic Ruminants.
Halos L, Jamal T, Maillard R, Girard B, Guillot J, Chomel B, Vayssier-Taussat M, Boulouis HJ.
Appl Environ Microbiol. 2004 Oct;70(10):6302-5.
Experimental Model of Human Body Louse Infection Using Green Fluorescent Protein-Expressing Bartonella quintana.
Pierre-Edouard Fournier, Michael F. Minnick, Hubert Lepidi, Eric Salvo, and Didier Raoult
Infect Immun. 2001 March; 69(3): 1876–1879.
Infection of Ixodes Ticks, Mosquitoes and Patients with Borrelia, Bartonella, Rickettsia, Anaplasma, Ehrlichia and Babesia in Western Siberia, Russia.
Molecular Biology of Spirochetes
FC Cabrello et al.
IOS Press, 2006.
Isolation of Bartonella quintana from a Woman and a Cat following Putative Bite Transmission.
Edward B. Breitschwerdt, Ricardo G. Maggi, Betsy Sigmon, and William L. Nicholson.
J Clin Microbiol. 2007 January; 45(1): 270–272.
Bartonella DNA in dog saliva.
Duncan AW, Maggi RG, Breitschwerdt EB.
Emerg Infect Dis. 2007 Dec;13(12):1948-50.
Isolation or Molecular Detection of Bartonella henselae and Bartonella vinsonii subsp. berkhoffii from Dogs with Idiopathic Cavitary Effusions.
Cherry NA, Diniz PP, Maggi RG, Hummel JB, Hardie EM, Behrend EN, Rozanski E, Defrancesco TC, Cadenas MB, Breitschwerdt EB
Intracellular Pathogens Research Laboratory and the Veterinary Teaching Hospital, Department of Clinical Sciences, North Carolina State University, Raleigh, NC, USA.
J Vet Intern Med 2009 Jan-Feb; 23(1):186-9.
Identification of Bartonella henselae in an Aborted Equine Fetus.
Johnson R, Ramos-Vara J, Vemulapalli R
Vet Pathol 2009 Mar; 46(2):277-81.
Kinetics of Bartonella birtlesii Infection in Experimentally Infected Mice and Pathogenic Effect on Reproductive Functions.
Henri J. Boulouis et al.
Infection and Immunity, September 2001, p. 5313-5317, Vol. 69, No. 9.
BARTONELLOSIS New and Old.
C . Maguiña , E . Gotuzzo
Infectious Disease Clinics of North America , Volume 14 , Issue 1 , Pages 1 - 22
(Fatality rate)
Brucellosis
Brucellosis is caused by several species of the bacterium Brucella. It is contracted through ingestion of contaminated milk products, direct blood contact with an infected animal and inhalation of the organism. Brucellosis is the most commonly reported laboratory-associated bacterial infection. Transmission has been documented by sexual contact, tissue transplant, congenital means and through breast-feeding. It is also contracted through flies and with the bite of an infected tick (Ixodes ricinus) .
Brucellosis is classified as a class B bioterrorism agent.The Fatality rate is less than 5%.
Brucellosis
CDC Division of Bacterial and Mycotic Diseases
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/brucellosis_g.htm
The Experimental Infection of Ticks with Brucellosis under Laboratory Conditions.
Zotova AA, Boldicina KS.
Defense Technical Information Center 06 FEB 1951.
Department of Natural Resources
http://www.michigan.gov/dnr/0,1607,7-153-10370_12150_12220-26503--,00.html
"These flies are primary thought of as the primary transmission vector associated with the bacteria Moraxella bovis that can cause pinkeye, but have also been associated with mechanically transmitting brucella abortus..."
http://www.cattlenetwork.com/content.asp?contentid=58759
Probable Transmission of Brucellosis by Breast Milk.
Ignacio Arroyo Carrera et al.
Journal of Tropical Pediatrics 2006 52(5):380-381.
Transplacentally Transmitted Congenital Brucellosis Due to Brucella abortus.
I. Giannacopoulos.
Journal of Infection, Volume 45, Issue 3, Pages 209-210.
Backgrounder: Brucellosis
AVMA February 16, 2007
(Fatality rate)
Colorado Tick Fever
Colorado Tick Fever is caused by the Colorado tick fever virus, a member of the Coltivirus genera. Some cases have been associated with exposures to the virus in laboratory settings and transfusion associated cases have been reported. Typically, it is contracted with the bite of infected ticks (Argasidae Otobius megnini, Ixodes Dermacentor andersoni, Ixodes Dermacentor occidentalis, Ixodes Dermacentor variabilis and Rhipicephalus sanguineus)
Colorado Tick Fever is classified as a Biosafety Level 2 arbovirus. Although prompt recovery is the expected outcome, rare fatalities are reported.
"Transfusion-associated cases from viremic patients have occurred."
http://www.emedicine.com/emerg/topic586.htm
CDC Biosafety Levels
http://www.cdc.gov/OD/OHS/biosfty/bmbl/sect7f.htm
Ehrlichiosis
Human Monocytic Ehrlichiosis (HME) is caused by the bacterium Ehrlichiosis chaffeensis. It is contracted with the bite of an infected tick (Amblyomma americanum).25% of all patients require intensive care therapy. The Fatality rate is 5-10%.
Transmission of ehrlichia chaffeensis from lone star ticks (amblyomma americanum ) to white-tailed deer (odocoileus virginianus).
Varela-Stokes AS
J Wildl Dis 2007 Jul; 43(3):376-81.
The human ehrlichiosis in the United States.
McQuiston JH, Paddock CD, Holman RC, Childs JE.
Emerg Infect Dis 1999;5:635–42.
(Fatality rate)
Lyme disease
Lyme disease is caused by the bacterium Borrelia burgdorferi. While it is still the most common vector-borne disease in the country, it is also transmitted in other ways. Infection occurs through blood transfusion, organ transplant, direct contact and by congenital means.
Typically, it is contracted with the bite of infected ticks (Amblyomma americanum, Amblyomma maculatum, Haemaphysalis leporispalustris, Ixodes affinis, Ixodes angustus, Ixodes cookei, Ixodes dentatus, Ixodes neotomae, Ixodes pacificus, Ixodes ricinus, Ixodes scapularis, Ixodes spinipalpis, Ixodes texanus, Ixodes Dermacentor albipictus, Ixodes Dermacentor andersoni, Ixodes Dermacentor occidentalis and Ixodes Dermacentor variabilis), however it has also been contracted through infected biting flies, mosquitoes, mites and fleas.
Survival of Borrelia burgdorferi in human blood stored under blood banking conditions.
Nadelman RB, Sherer C, Mack L, Pavia CS, Wormser GP.
Transfusion 1990 30(4):298-301.
Experimental inoculation of Peromyscus spp. with Borrelia burgdorferi: evidence of contact transmission.
Burgess EC, Amundson TE, Davis JP, Kaslow RA, Edelman R.
Am J Trop Med Hyg. 1986 Mar;35(2):355-9.
Erythema migrans in solid-organ transplant recipients.
Maraspin V, Cimperman J, Lotric-Furlan S, Logar M, Ruzic-Sabljic E, Strle F.
Clin Infect Dis. 2006 Jun 15;42(12):1751-4.
Borrelia burgdorferi in a newborn despite oral penicillin for Lyme borreliosis during pregnancy.
Weber K, Bratzke HJ, Neubert U, Wilske B, Duray PH.
Pediatric Infectious Disease Journal, 7:286-9. 1988.
Lyme disease transmitted by a biting fly.
Luger SW.
N Engl J Med 1990 Jun 14;322(24):1752.
Ticks and mosquitoes as vectors of Borrelia burgdorferi s. l. in the forested areas of Szczecin.
Kosik-Bogacka DI, Kuźna-Grygiel W, Jaborowska M.
Folia Biol (Krakow). 2007;55(3-4):143-6.
Isolation of the spirochaete Borrelia afzelii from the mosquito Aedes vexans in the Czech Republic.
Halouzka J, Postic D, Hubalek Z.
Med Vet Entomol 1998 Jan;12(1):103-5.
Presence of Borrelia burgdorferi sensu lato in mites parasitizing small rodents.
Netusil J, Zakovska A, Horvath R, Dendis M, Janouskovcova E.
Vector Borne Zoonotic Dis. 2005 Fall;5(3):227-32.
The spirochetal isolates were from several tick and one flea species, including Amblyomma americanum, A. maculatum, Ixodes scapularis, and Ctenocephalides felis.
Teltow GJ, Fournier PV, Rawlings JA.
Am J Trop Med Hyg 1991 May;44(5):469-74.
MycoplasmaMycoplasma infections are caused by several specific and unique species of cell-wall deficient bacteria. Mycoplasmas are transmitted through respiratory secretions, congenital means and the bite of infected ticks (Ixodes pacificus, Haemaphysalis leporispalustris and Argasidae Ornithodoros parkeri).
Diagnostic Assessment of Mycoplasma genitalium in Culture-Positive Women.
Joel B Baseman et al.
Journal of Clinical Microbiology, Jan 2004, p. 203-211, Vol 42, No 1.
Mycoplasmas: Sophisticated, reemerging, and burdened by their notoriety.
Baseman JB, Tully JG.
Emerging Infectious Diseases, 1997 1(3), 21-32.
In utero transmission of Mycoplasma pulmonis in experimentally infected Sprague-Dawley rats.
Steiner DA, Uhl EM, Brown MB.
Infect Immun. 1993 July; 61(7): 2985-2990.
A Search for Mycoplasmas in Ornithodoros parkeri Ticks Collected from the Desert Tortoise in the Mojave, Colorado, and Sonoran Deserts.
Joseph G Tully et al.
Desert Tortoise Council, April 3-5, 1998.
Mycoplasmas- Stealth Pathogens
http://www.rain-tree.com/myco.htm
Query Fever
Q fever is caused by the rickettsia Coxiella burnetii. Because infected animals shed this organism in urine, feces, birth products, and milk; transmission occurs by inhalation of dust, ingestion of infected milk and the bite of infected ticks (Amblyomma americanum, Argasidae Otobius megnini, Ixodes Dermacentor andersoni, Ixodes Dermacentor occidentalis, Ixodes Dermacentor variabilis and Rhipicephalus sanguineus). Infection can also be transmitted congenitally.Coxiella burnetii could be developed for use in biological warfare and is considered a potential terrorist threat.
The Fatality rate may approach 65% for chronic cases.
The Infectious Origins of Stillbirth.
Goldenberg RL, Thompson C.
Am J Obstet Gynecol. 2003 Sep; 189(3):861-73. 2003.
Coxiella burnetii shedding by dairy cows.
Guatteo R, Beaudeau F, Joly A, et al.
Vet Res 2007 Nov-Dec; 38(6):849-60.
Evaluation of low concentration aerosol for infecting humans with the Q fever pathogen.
Vorobeychikov E, Vasilenko A, Tokarevich N, et al.
Ann N Y Acad Sci 2005 Dec.:466-70.
Studies probe microbes in raw milk, swine.
Stephenson J
JAMA 2007 Sep 26; 298(12):1388.
Centers for Disease Control and Prevention- Q Fever
http://www.cdc.gov/ncidod/dvrd/qfever/#Significance%20for%20Bioterrorism
UC Entomology
http://www.entomology.ucr.edu/ebeling/ebel9-3.html#ticks
Backgrounder: Q Fever
AVMA November 20, 2006
(Fatality rate)
Relapsing Fever
Relapsing fever is caused by several species of the bacterium Borrelia. Most commonly, it is contracted with the bite of infected ticks (Amblyomma americanum, Argasidae Ornithodoros hermsi, Argasidae Ornithodoros parkeri, Argasidae Ornithodoros talaje and Argasidae Ornithodoros turicata). Infection can also be transmitted through the blood of rodents, the bite of infected lice or take place by contamination of a wound in the skin. It is also known to be transmitted congenitally.The Fatality rate may approach 10% in untreated patients.
Complications of pregnancy and transplacental transmission of relapsing-fever borreliosis.
Larsson C, Anderson M, Guo BP, Nordstrand A, Hagerstrand I, Carlsson S, Bergstrom S.
J Infect Dis. 2006 Nov 15;194(10):1367-74. Epub 2006 Oct 3.
Louse-borne relapsing fever and malaria co-infection in Ethiopia.
Reyes F, Tesfamariam A, Malmierca E.
Trop Doct 2007 Apr; 37(2):121-2.
UC Entomology
http://www.entomology.ucr.edu/ebeling/ebel9-3.html#ticks
CDC MMWR
August 29, 2003/ 52(34);809-812
(Fatality rate)
Rocky Mountain Spotted Fever
Rocky Mountain spotted fever is caused by the bacterium Rickettsia rickettsii. Typically, it is contracted with the bite of infected ticks (Amblyomma americanum, Amblyomma cajennense, Amblyomma maculatum, Argasidae Ornithodoros parkeri, Argasidae Otobius megnini, Haemaphysalis leporispalustris, Ixodes pacificus, Ixodes Dermacentor andersoni, Ixodes Dermacentor occidentalis, Ixodes Dermacentor variabilis and Rhipicephalus sanguineus), but has also been acquired through blood transfusion and contamination of the skin with tick blood or feces.
The fatality rate is 20% or more and up to 30% in untreated patients.
An Outbreak of Rocky Mountain Spotted Fever Associated with a Novel Tick Vector, Rhipicephalus sanguineus, in Arizona, 2004: Preliminary Report.
Demma LJ, Eremeeva M, Nicholson WL, et al.
Ann N Y Acad Sci 2006 Oct.:342-3.
Rocky mountain spotted fever caused by blood transfusion.
Wells GM, Woodward TE, Fiset P, Hornick RB.
JAMA. 1978 Jun 30;239(26):2763-5.
American Veterinary Medical Association
"...human infection has occurred much less often following transdermal or inhalation exposure to tick fluids (hemolymph), tick feces, or crushed tick tissues."
http://www.avma.org/reference/zoonosis/znrockymountain.asp
CDC
http://www.cdc.gov/ncidod/dvrd/rmsf/overview.htm
New York State Department Of Health RMSF Fact Sheet
UC Entomology
http://www.entomology.ucr.edu/ebeling/ebel9-3.html#ticks
NYC Dept of Health Communicable Diseases
http://www.nyc.gov/html/doh/html/cd/cdrmsf.shtml
(Fatality rate)
STARI
Southern Tick Associated Rash Illness, also known as Master's disease, is caused by the bacterium Borrelia lonestari. It is contracted with the bite of infected ticks (Amblyomma americanum and Argasidae Carios capensis).
First culture isolation of Borrelia lonestari, putative agent of southern tick-associated rash illness.
Varela AS, Luttrell MP, Howerth EW, et al.
J Clin Microbiol 2004 Mar; 42(3):1163-9.
Borrelia, Coxiella, and Rickettsia in Carios capensis (Acari: Argasidae) from a brown pelican (Pelecanus occidentalis) rookery in South Carolina, USA.
Reeves WK, Loftis AD, Sanders F, et al.
Exp Appl Acarol 2006 Jul 5.
Tick Paralysis
Tick paralysis is a loss of muscle function that results from an unidentified protein toxin in tick saliva (Amblyomma americanum, Amblyomma maculatum, Amblyomma rotundatum, Argasidae Otobius megnini, Ixodes brunneus, Ixodes pacificus, Ixodes Dermacentor andersoni, Ixodes Dermacentor variabilis and Rhipicephalus sanguineus). Ticks attach to the skin to feed on blood and it is during this feeding process that the toxin enters the bloodstream. The paralysis is ascending; meaning it starts in the lower body moving up and death by respiratory failure may result.
The fatality rate is 11.7%, despite the fact that there is usually a latent period of about 5 days before the ticks can produce enough toxin to cause paralysis, and paralysis can be avoided by removal of the ticks during that period.
Cluster of tick paralysis cases--Colorado, 2006.
MMWR Morb Mortal Wkly Rep 2006 Sep 1; 55(34):933-5.
Biochemical perspectives on paralysis and other forms of toxicoses caused by ticks.
Mans BJ, Gothe R, Neitz AW
Parasitology 2004.:S95-111.
Tick paralysis in the United States: a photographic review.
Felz MW, Swift TR, Hobbs W.
Arch Neurol 2000 Jul; 57(7):1071-2.
UC Entomology
http://www.entomology.ucr.edu/ebeling/ebel9-3.html#ticks
Tularemia
Tularemia is caused by the bacterium Francisella tularensis. It is a highly infectious, invasive and potentially dangerous pathogen. So much so that the CDC has it listed as a possible bio-weapon.
Tularemia has many modes of transmission. Typically, contraction occurs with the bite of an infected vector such as the deerfly, the horsefly, the mosquito, the flea or the tick (Amblyomma americanum, Amblyomma maculatum, Argasidae Otobius megnini, Haemaphysalis leporispalustris, Ixodes pacificus, Ixodes Dermacentor andersoni, Ixodes Dermacentor occidentalis and Ixodes Dermacentor variabilis). In addition, it is transmitted through contaminated water, food and soil.
Handling infected animals and ingesting infected game puts many at risk. Organisms can be transmitted directly through a bite from pets and wild animals, such as raccoons, snakes, and coyotes, which have bitten a sick or dead rabbit and thus have the bacteria in their mouths. Tularemia has also been acquired through inhalation of airborne particulates.
Tularemia is classified as a Category A disease/agent. The fatality rate is 5-15% in untreated patients, and when spread by aerosol, the rate increases to 30-60%.
F. tularensis: an arthropod-borne pathogen.
Petersen JM, Mead PS, Schriefer ME
Vet Res 2008 Oct 28; 40(2):7.
Tularemia transmitted by insect bites--Wyoming, 2001-2003.
MMWR Morb Mortal Wkly Rep 2005 Feb 25; 54(7):170-3.
A small water-borne tularemia outbreak.
Meriç M, Sayan M, Willke A, Gedikoğlu S.
Mikrobiyol Bul 2008 Jan; 42(1):49-59.
Two unusual glandular presentations of tick-borne tularemia.
Charles P, Stumpf P, Buffet P, et al.
Med Mal Infect 2008 Jan 9.
An outbreak of airborne tularaemia in France, August 2004.
Siret V, Barataud D, Prat M, et al.
Euro Surveill 2006 Feb 20; 11(2)
Tularemia outbreak in the province of Cuenca associated with crab handling.
Díaz de Tuesta AM, Chow-Quan , Geijo Martínez MP, et al.
Rev Clin Esp 2001 Jul; 201(7):385-9
A milk-borne outbreak of tularemia in Moscow.
Manenkova GM, Rodina LV, Tsvil' LA, et al.
Zh Mikrobiol Epidemiol Immunobiol 1996 Sep-Oct; (5):123-4.
Detection of diverse new Francisella-like bacteria in environmental samples.
Barns SM, Grow CC, Okinaka RT, et al.
Appl Environ Microbiol 2005 Sep; 71(9):5494-500.
Tularemia associated with a hamster bite--Colorado, 2004.
MMWR Morb Mortal Wkly Rep 2005 Jan 7; 53(51):1202-3.
First reported prairie dog–to-human tularemia transmission, Texas, 2002.
Avashia SB, Petersen JM, Lindley CM, Schriefer ME, Gage KL, Cetron M, et al.
Emerg Infect Dis 2004 Mar
Medline
http://www.nlm.nih.gov/medlineplus/ency/article/000856.htm
CDC
http://www.bt.cdc.gov/agent/tularemia/facts.asp
NEJM
http://content.nejm.org/cgi/content/full/345/22/1637
Medical Entomology Purdue
http://www.entm.purdue.edu/publichealth/diseases/tabanid/tularemia.html
American College of Physicians- Tularemia
STOP
http://www.stopticks.org/ticks/tularemia.asp
GlobalSecurity WMD Tularemia
http://www.globalsecurity.org/wmd/intro/bio-tularemia-att.htm
(Fatality rate)
"Absence of Proof is not Proof of Absence."
- William Cowper
© 2006 The National Lyme Disease Memorial Park Project
