title: Contact investigation of melioidosis cases reveals regional endemicity in Puerto Rico.
abstract: BACKGROUND
  Melioidosis results from infection with Burkholderia pseudomallei and is associated with case-fatality rates up to 40%. Early diagnosis and treatment with appropriate antimicrobials can improve survival rates. Fatal and nonfatal melioidosis cases were identified in Puerto Rico in 2010 and 2012, respectively, which prompted contact investigations to identify risk factors for infection and evaluate endemicity.
  
  
  METHODS
  Questionnaires were administered and serum specimens were collected from coworkers, neighborhood contacts within 250 m of both patients' residences, and injection drug user (IDU) contacts of the 2012 patient. Serum specimens were tested for evidence of prior exposure to B. pseudomallei by indirect hemagglutination assay. Neighborhood seropositivity results guided soil sampling to isolate B. pseudomallei.
  
  
  RESULTS
  Serum specimens were collected from contacts of the 2010 (n = 51) and 2012 (n = 60) patients, respectively. No coworkers had detectable anti-B. pseudomallei antibody, whereas seropositive results among neighborhood contacts was 5% (n = 2) for the 2010 patient and 23% (n = 12) for the 2012 patient, as well as 2 of 3 IDU contacts for the 2012 case. Factors significantly associated with seropositivity were having skin wounds, sores, or ulcers (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.2-17.8) and IDU (OR, 18.0; 95% CI, 1.6-194.0). Burkholderia pseudomallei was isolated from soil collected in the neighborhood of the 2012 patient.
  
  
  CONCLUSIONS
  Taken together, isolation of B. pseudomallei from a soil sample and high seropositivity among patient contacts suggest at least regional endemicity of melioidosis in Puerto Rico. Increased awareness of melioidosis is needed to enable early case identification and early initiation of appropriate antimicrobial therapy.
authors.affiliation: Epidemic Intelligence Service Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Doker
authors.affiliation: Dengue Branch, Centers for Disease Control and Prevention.
authors.forename: Tyler M
authors.initials: TM
authors.lastname: Sharp
authors.affiliation: Puerto Rico Department of Health, San Juan.
authors.forename: Brenda
authors.initials: B
authors.lastname: Rivera-Garcia
authors.affiliation: Dengue Branch, Centers for Disease Control and Prevention.
authors.forename: Janice
authors.initials: J
authors.lastname: Perez-Padilla
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Tina J
authors.initials: TJ
authors.lastname: Benoit
authors.affiliation: Epidemic Intelligence Service Dengue Branch, Centers for Disease Control and Prevention.
authors.forename: Esther M
authors.initials: EM
authors.lastname: Ellis
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Mindy G
authors.initials: MG
authors.lastname: Elrod
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Jay E
authors.initials: JE
authors.lastname: Gee
authors.affiliation: Infectious Diseases Pathology Branch.
authors.forename: Wun-Ju
authors.initials: WJ
authors.lastname: Shieh
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Cari A
authors.initials: CA
authors.lastname: Beesley
authors.affiliation: Puerto Rico Department of Health, San Juan.
authors.forename: Kyle R
authors.initials: KR
authors.lastname: Ryff
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Rita M
authors.initials: RM
authors.lastname: Traxler
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Renee L
authors.initials: RL
authors.lastname: Galloway
authors.affiliation: Prion and Public Health Office, Centers for Disease Control and Prevention.
authors.forename: Dana L
authors.initials: DL
authors.lastname: Haberling
authors.affiliation: Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Lance A
authors.initials: LA
authors.lastname: Waller
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Sean V
authors.initials: SV
authors.lastname: Shadomy
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: William A
authors.initials: WA
authors.lastname: Bower
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Alex R
authors.initials: AR
authors.lastname: Hoffmaster
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Henry T
authors.initials: HT
authors.lastname: Walke
authors.affiliation: Bacterial Special Pathogens Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: David D
authors.initials: DD
authors.lastname: Blaney
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000907:Antibodies, Bacterial / Q000097:blood; D016957:Burkholderia pseudomallei / Q000276:immunology* / Q000302:isolation & purification*; D002648:Child; D002675:Child, Preschool; D016358:Contact Tracing; D019353:Endemic Diseases; D005260:Female; D006386:Hemagglutination Tests; D006801:Humans; D008297:Male; D008554:Melioidosis / Q000453:epidemiology*; D008875:Middle Aged; D011647:Puerto Rico / Q000453:epidemiology; D012307:Risk Factors; D012988:Soil Microbiology; D011795:Surveys and Questionnaires; D055815:Young Adult
chemical_list: D000907:Antibodies, Bacterial
keywords: Burkholderia pseudomallei; Puerto Rico; emerging infectious disease; melioidosis