An Outbreak of Primary Pneumonic Tularemia on Martha's Vineyard

N Engl J Med. 2001 Nov 29;345(22):1601-6. doi: 10.1056/NEJMoa011374.


Background: In the summer of 2000, an outbreak of primary pneumonic tularemia occurred on Martha's Vineyard, Massachusetts. The only previously reported outbreak of pneumonic tularemia in the United States also occurred on the island in 1978.

Methods: We conducted a case-control study of adults with pneumonic tularemia and investigated the environment to identify risk factors for primary pneumonic tularemia. Patients with confirmed cases were residents of or visitors to Martha's Vineyard who had symptoms suggestive of primary pneumonic tularemia, were ill between May 15 and October 31, 2000, and had a positive laboratory test for tularemia. Controls were adults who had spent at least 15 days on Martha's Vineyard between May 15 and September 28, 2000.

Results: We identified 15 patients with tularemia; 11 of these cases were primary pneumonic tularemia. Francisella tularensis type A was isolated from blood and lung tissue of the one man who died. Patients were more likely than controls to have used a lawn mower or brush cutter in the two weeks before the illness or before an interview, for controls (odds ratio, 9.2; 95 percent confidence interval, 1.6 to 68.0) and during the summer (odds ratio, undefined; 95 percent confidence interval, 1.8 to infinity). Lawn mowing and brush cutting remained significant risk factors after adjustment for other potentially confounding variables. Only one patient reported being exposed to a rabbit while cutting brush. Of 40 trapped animals, 1 striped skunk (Mephitis mephitis) and 1 Norway rat (Rattus norvegicus) were seropositive for antibodies against F. tularensis.

Conclusions: Study of this outbreak of primary pneumonic tularemia implicates lawn mowing and brush cutting as risk factors for this infection.

MeSH terms

  • Adolescent
  • Adult
  • Animals
  • Antibodies, Bacterial / blood*
  • Case-Control Studies
  • Disease Outbreaks*
  • Female
  • Francisella tularensis / immunology*
  • Francisella tularensis / isolation & purification
  • Humans
  • Male
  • Massachusetts / epidemiology
  • Mephitidae / microbiology
  • Pneumonia, Bacterial / epidemiology*
  • Rats / microbiology
  • Risk Factors
  • Tularemia / epidemiology*


  • Antibodies, Bacterial