title: Tularaemia outbreaks in Sakarya, Turkey: case-control and environmental studies.
abstract: BACKGROUND
  Tularaemia is an important zoonotic disease that leads to outbreaks. This study aimed to compare the epidemiological characteristics of two tularaemia outbreaks that occurred in the Sakarya region of Turkey, analyse the risk factors for the development of outbreaks and identify Francisella (F.) tularensis in the water samples.
  
  
  METHODS
  Two tularaemia outbreaks occurred in the Kocadongel village in 2005 and 2006. A field investigation and a case-control study with 47 cases and 47 healthy households were performed during the second outbreak. Clinical samples from the patients and filtrated water samples were analysed for F. tularensis via real-time polymerase chain reaction.
  
  
  RESULTS
  From the two outbreaks, a total of 58 patients were diagnosed with oropharyngeal tularaemia based on their clinical and serological results. Both outbreaks occurred between the months of January and April, and the number of patients peaked in February. Logistic regression analysis revealed that the consumption of natural spring water was the only significant risk factor for tularaemia infection (odds ratio 3.5, confidence interval 1.23-10.07). F. tularensis was detected in eight clinical samples and in the filtrated natural spring water.
  
  
  CONCLUSIONS
  This study is the first report of tularaemia from this region. The results show that both tularaemia outbreaks were related to the consumption of untreated natural spring water. To prevent waterborne tularaemia, community water supplies should be treated and checked periodically.
authors.affiliation: Kocaeli University, Medical Faculty, Department of Clinical Bacteriology and Infectious Diseases, Umuttepe/Kocaeli 41380, Turkey. drmelihameric@gmail.com
authors.forename: M
authors.initials: M
authors.lastname: Meric
authors.forename: M
authors.initials: M
authors.lastname: Sayan
authors.forename: D
authors.initials: D
authors.lastname: Dundar
authors.forename: A
authors.initials: A
authors.lastname: Willke
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D005260:Female; D005604:Francisella tularensis / Q000302:isolation & purification; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D010038:Otorhinolaryngologic Diseases / Q000453:epidemiology / Q000382:microbiology; D010608:Pharyngeal Diseases / Q000453:epidemiology / Q000382:microbiology; D014406:Tularemia / Q000453:epidemiology*; D014421:Turkey / Q000453:epidemiology; D014871:Water Microbiology; D014881:Water Supply; D055815:Young Adult