title: An epidemiologic and entomologic investigation of a cluster of Rocky Mountain spotted fever cases in Delaware.
abstract: BACKGROUND
  Rocky Mountain spotted fever (RMSF) continues to be the most common fatal tick-borne illness in the United States. In August of 1996, four children attending a summer camp in Delaware were diagnosed with RMSF. This report summarizes the results of the epidemiologic and entomologic investigation conducted by the Delaware Division of Public Health and the Centers for Disease Control and Prevention regarding this cluster of RMSF cases. Epidemiologic and clinical aspects of RMSF, as well as previously reported clusters of the disease, are also reviewed.
  
  
  METHODS
  A questionnaire regarding symptoms and activities was administered via telephone to 163 (73 percent) of the 223 attendees. A suspected case was defined as an illness in a person attending the camp between August 11 and 17 that occurred during the two-week period following the session, characterized by either 1) fever with one or more symptoms (i.e., headache, rash, myalgia, or fatigue) or 2) no fever with two or more symptoms. Cases of RMSF were confirmed by serologic evaluation.
  
  
  RESULTS
  Seven of 13 patients with suspected RMSF submitted sera for testing. Four patients had confirmed RMSF; three were males, and the median age was 12.5 years compared with 12 years for all attendees. All confirmed patients reported fever, headache, fatigue, and rash. An increased risk of becoming ill was associated with overnight camping at site A (Odds Ratio (OR) undefined, p = 0.02), visiting or overnight camping at site B (OR undefined, p = 0.003 and 0.002), and leaving the trails when hiking (OR undefined, p = 0.02).
  
  
  CONCLUSIONS
  These data suggest that development of RMSF was associated with visiting or camping at specific sites and behavior likely to increase contact with ticks. Camp supervisors were advised to educate campers regarding tick bite prevention measures, reduce underbrush around campsites, and encourage campers to remain on the trails. Health care providers should remain aware of the increased risk for RMSF during the spring, summer, and fall months.
authors.affiliation: Delaware Division of Public Health.
authors.forename: L
authors.initials: L
authors.lastname: Rotz
authors.forename: L
authors.initials: L
authors.lastname: Callejas
authors.forename: D
authors.initials: D
authors.lastname: McKechnie
authors.forename: D
authors.initials: D
authors.lastname: Wolfe
authors.forename: E
authors.initials: E
authors.lastname: Gaw
authors.forename: L
authors.initials: L
authors.lastname: Hathcock
authors.forename: J
authors.initials: J
authors.lastname: Childs
mesh_terms: D000818:Animals; D016009:Chi-Square Distribution; D002648:Child; D003691:Delaware / Q000453:epidemiology; D004196:Disease Outbreaks; D005260:Female; D006801:Humans; D008297:Male; D016017:Odds Ratio; D016133:Polymerase Chain Reaction; D012281:Rickettsia / Q000302:isolation & purification; D012373:Rocky Mountain Spotted Fever / Q000453:epidemiology* / Q000635:transmission; D018709:Statistics, Nonparametric; D011795:Surveys and Questionnaires; D013987:Ticks / Q000382:microbiology