title: Water-borne outbreak of oropharyngeal and glandular tularemia in Georgia: investigation and follow-up.
abstract: BACKGROUND
  In November 2006, an outbreak of waterborne tularemia occurred in an eastern region in the Republic of Georgia. Outbreak investigation revealed 26 cases: 21 oropharyngeal and 5 glandular tularemia cases.
  
  
  METHODS
  The presentation of the index case triggered an outbreak investigation involving the collection of clinical/ epidemiological data, application of tularine skin test, and laboratory confirmation of the possible cases using the tube agglutination test and polymerase chain reaction (PCR) testing. Serology results were verified by enzyme-linked immunosorbent assay (ELISA) and Western blot. A case- control study along with follow-up was conducted 4 months after the index case presentation.
  
  
  RESULTS
  Exudative pharyngitis, predominantly laterocervical adenitis, fever, and headache were the most prevalent clinical signs/symptoms observed. Depressed mood, concentration difficulties, and sleep disturbance were also detected. Bubo aspirates tested by PCR were positive in 4/4 cases and pharyngeal swabs also tested by PCR were positive in 2/3 cases. Francisella tularensis was isolated from the water samples. Comparison of the cases and controls did not reveal any statistically significant risk factors. A follow-up investigation revealed cases with protracted symptoms of fatigue, headache, and sleep disturbance. Additionally, 8/26 cases still had cervical adenopathy of prominent size. A delay in diagnosis was associated with persistent lymphadenopathy on follow-up examination (p = 0.05).
  
  
  CONCLUSIONS
  We observed unique features of persistent neuropsychiatric symptoms and lymphadenopathy 5 months after tularemia infection which were associated with delayed diagnosis and the lack of prompt response to therapy. This outbreak of oropharyngeal tularemia emphasizes the importance of a rapid diagnostic and investigative response to tularemia. This type of response can prevent ongoing exposure, as well as provide expeditious treatment to mitigate persistent symptoms.
authors.affiliation: National Center for Disease Control and Public Health, Tbilisi, Georgia.
authors.forename: N
authors.initials: N
authors.lastname: Chitadze
authors.forename: T
authors.initials: T
authors.lastname: Kuchuloria
authors.forename: D V
authors.initials: DV
authors.lastname: Clark
authors.forename: E
authors.initials: E
authors.lastname: Tsertsvadze
authors.forename: M
authors.initials: M
authors.lastname: Chokheli
authors.forename: N
authors.initials: N
authors.lastname: Tsertsvadze
authors.forename: N
authors.initials: N
authors.lastname: Trapaidze
authors.forename: A
authors.initials: A
authors.lastname: Lane
authors.forename: L
authors.initials: L
authors.lastname: Bakanidze
authors.forename: S
authors.initials: S
authors.lastname: Tsanava
authors.forename: M J
authors.initials: MJ
authors.lastname: Hepburn
authors.forename: P
authors.initials: P
authors.lastname: Imnadze
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000818:Animals; D016022:Case-Control Studies; D004269:DNA, Bacterial / Q000235:genetics; D004196:Disease Outbreaks; D005604:Francisella tularensis / Q000302:isolation & purification*; D005846:Georgia (Republic) / Q000453:epidemiology; D006801:Humans; D008199:Lymphadenitis / Q000382:microbiology; D008297:Male; D051379:Mice; D008875:Middle Aged; D010612:Pharyngitis / Q000382:microbiology; D016133:Polymerase Chain Reaction; D012307:Risk Factors; D014406:Tularemia / Q000453:epidemiology* / Q000473:pathology; D014871:Water Microbiology; D055815:Young Adult
chemical_list: D004269:DNA, Bacterial