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as other forms of raw milk tested; therefore, in this outbreak, the risk for human illness from consuming either product was probably similar. Exemption of colostrum from state dairy regulations is not supported by the findings in this outbreak investigation.

From 1998 to May 2005, raw milk or raw milk products have been implicated in 45 foodborne illness outbreaks in the United States, accounting for more than 1,000 cases of illness (CDC, unpublished data, 2007). Because illnesses associated with raw milk continue to occur, additional efforts are needed to educate consumers and dairy farmers about illnesses associated with raw milk and raw colostrum. To reduce the risk for E. coli O157 and other infections, consumers should not drink raw milk or raw milk products.

Acknowledgments This report is based, in part, on data contributed by D Buglino, MPH, K Smith-Sayer, Nevada County Public Health Dept; S Fortino, Riverside County Dept of Public Health; J Van Meter, MPH, County of San Diego Health and Human Sves Administration; E Frykman, MD, San Bernardino County Dept of Public Health; L Crawford-Miksza, PhD, C Myers, S Himathongkham, DVM, M Palumbo, PhD, J Atwell, T Chang, D Csuti, S Fontanoz, Y Gerbremichael, J Glover, DVM, J O'Connell, B Sun, DVM, C Wheeler, MD, Y Zhao, California Dept of Public Health; California Dept of Food and Agriculture; and M Lynch, MD, Div of Foodborne, Bacterial, and Mycotic Diseases, CDC. References 1. CDC. Ongoing multistate outbreak of Escherichia coli serotype 0157:H7

infections associated with consumption of fresh spinach—United States,

September 2006. MMWR 2006;55:1045–6. 2. Hyytiä-Trees E, Smole SC, Fields PA, Swaminathan B, Ribot EM.

Second generation subtyping: a proposed PulseNet protocol for multiple-locus variable-number tandem repeat analysis of Shiga toxinproducing Escherichia coli O157 (STEC 0157). Foodborne Pathog Dis

2006;3:118-31. 3. CDC. Foodborne diseases active surveillance network (FoodNet): population

survey atlas of exposures, 2002. Atlanta, GA: US Department of Health and Human Services, CDC; 2004:205. Available at http://www.

cdc.gov/foodnet/surveys/pop/2002/2002atlas.pdf. 4. Rangel JM, Sparling PH, Crowe C, Griffin PM, Swerdlow DL. Epide

miology of Escherichia coli O157:H7 outbreaks, United States, 1982–

2002. Emerg Infect Dis 2005;11:603–9. 5. Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the

United States. Emerg Infect Dis 1999;5:607–25. 6. Dundas S, Todd WT, Stewart Al, et al. The central Scotland Escherichia

coli O157:H7 outbreak: risk factors for the hemolytic uremic syndrome

and death among hospitalized patients. Clin Infect Dis 2001;33:923–31. 7. Food and Drug Administration. Grade “A” pasteurized milk ordinance:

2003 revision. Rockville, MD: US Department of Health and Human Services; 2004. Available at http://www.cfsan.fda.gov/ -ear/pmo03toc.

html. 8. Headrick ML, Korangy S, Bean NH, et al. The epidemiology of raw

milk-associated foodborne disease outbreaks reported in the United States, 1973 through 1992. Am J Public Health 1998;88:1219–21.

Cutaneous Anthrax Associated
with Drum Making Using Goat
Hides from West Africa

Connecticut, 2007 On August 29, 2007, the Connecticut Department of Pue lic Health was notified by a physician of suspect cutancoanthrax involving a drum maker and one of his three di dren. The drum maker had been working with untreated gohides from Guinea in West Africa. This report summar:: results of the joint epidemiologic and environmental inve. gation conducted by public health officials, environme.. agencies, and law enforcement authorities. The investigacio revealed that the drum maker was exposed while working we a contaminated goat hide from Guinea and that his works place and home were contaminated with anthrax. His child was most likely exposed from cross-contamination of the home. The findings underscore the potential hazard of wo.1ing with untreated animal hides from areas with epizconc anthrax and the potential for secondary cases from envirormental contamination.

On July 22, while sanding a newly assembled goat-hide drut in his backyard shed, the drum maker felt a sting on his right forearm. He then proceeded to an upstairs bathroom in his house to wash his arm. Two days later, a painless 2 cm papu'a lesion with surrounding edema developed at the site. The man sought medical attention and was prescribed cephalexin and then clindamycin for a presumptive infected spider bite. On August 28, after the skin lesion progressed to an eschar with lymphangitic spread, the man consulted an infectious disease practitioner, who sent a biopsy specimen of the lesion to the Connecticut State Laboratory. Culture was negative, bu Bacillus anthracis was detected by polymerase chain reaction (PCR). The patient received ciprofloxacin for suspect cutane ous anthrax.

On August 31, the Connecticut Department of Pub Health was notified of a second suspect case of cutane. anthrax in the drum maker's child aged 8 years, who den oped a painless, 1 cm ulcer of 3 days' duration over the scap > that did not improve under treatment with amoxicil. clavulanate. Culture of the lesion was negative, but biorst specimens tested positive for B. anthracis by PCR at the C3necticut State Laboratory and by PCR and immunohistoch: istry assay at CDC. The patient was treated with penicillir.

Also on August 31, an epidemiologic investigation was 11tiated to identify the primary source of exposure and the extent of dissemination of B. anthracis spores. The investigate tion included interviews with the index patient and his family and environmental testing. The family had moved into the FIGURE. Bacillus anthracis-contaminated drum head made from goat hide from Guinea — Connecticut, 2007

se in December 2006. The index patient made traditional t African drums (known as djembe drums) by soaking nal hides in water, stretching them over the drum body,

scraping and sanding them. At the end of June, a contact New York City told the index patient that he had some

goat hides from Guinea. Shortly thereafter, the index ent purchased 10 of them, making the transaction on a Et corner in New York City. Whether these goat hides were orted legally is unknown. The index patient used three of e hides to make drums during the time he developed

[graphic]

rax.

Photo/Connecticut State Department of Public Health Laboratory

I animal hides and drums in progress were stored in a yard shed. Drum making usually occurred at the shed ance. The affected child never participated in any drum ing and had no known exposure to animal hides. He played ors on carpeted floors and was prohibited from entering shed. nce childhood, the drum maker had been taught by his er, who also made djembe drums, to routinely use latex es and wear tight-fitting goggles when drum making. He was taught to use designated work clothes with long ies, which were laundered periodically. In addition, the n maker wore disposable facemasks to avoid the strong - associated with animal hides. He always removed his --* clothes and shoes before entering the house. One excepto these practices occurred on July 22, when the drum -er wore short sleeves and went indoors to an upstairs bath

without removing his work attire. Although he kept all 'n making equipment in the shed, the drum maker some

s brought other items from the shed into the house. ---- September 5 and 6, targeted environmental sampling - conducted collaboratively by the Federal Bureau of Invesion (FBI), the Environmental Protection Agency, and the necticut Department of Environmental Protection. The chose to participate because anthrax is a select bioterrorism

t.* On the basis of initial positive results for B. anthracis cveral areas of the house, extensive testing was performed ek later to guide decontamination efforts. Specimens ided swabs of all hides and drum heads (Figure) after trans

to the state laboratory, seven of which underwent addial wipes and punch biopsies; 16 wipe samples of the shed, iding table surfaces and coat hooks 5 feet above the

nd; and a swab sample of the car used for transporting ecently purchased hides. House testing included vacuum yles from carpeted areas and composite wipe samples from ted hard surfaces in all regularly used areas.

The following were culture positive for B. anthracis: six (24%) of 25 drum heads, including the recently sanded drum; 15 (42%) of 35 hides, some of which were exposed to ambient dust in the shed; all 16 shed samples, many indicating heavy growth; the car trunk; and 18 (26%) of 72 house specimens, including vacuum samples from the upstairs hallway and both affected patients' bedrooms and swab and wipe samples from the laundry room and upstairs bathroom. DNA from all environmental isolates of B. anthracis and the cutaneous biopsy specimens were sent to CDC for genotyping using multiple-locus variable-number tandem repeat analysis (MLVA) (1). All isolates were MLVA genotype 1, as was the B. anthracis DNA detected in the child's biopsy specimen.

Federal, state, and local officials completed a comprehensive remediation process that included fumigation of the house with chlorine dioxide. The house and shed were cleared for occupancy on December 22, 2007, after all post-remediation samples had tested negative for anthrax. Because of exposure to aerosolized spores in the shed from drum making, the drum maker was continued on ciprofloxacin for a total of 60 days from the date of last presumed exposure based on recommendations established by CDC for postexposure prophylaxis against inhalation anthrax (2). No other contacts were identified with potential inhalation exposure. With the exception of lymphangitic scarring of the drum maker's arm, the illnesses in both patients resolved without sequelae.

mation on selected agents and toxins available from the CDC Select Agent ram at http://www.cdc.gov/od/sap/docs/salist.pdf. 1os and additional information available at http://www.epa.gov/region1/ es/danbury

Reported by: J Stratidis, MD, Danbury Hospital; S Le Roy, MPH, Danbury Health Dept; D Barden, MT (HHS), K Kelley, PhD, J Fontana, PhD, K Purviance, MPH, M Cartter, MD, J Hadler, MD, Connecticut Dept of Public Health. K Glynn, DVM, A Hoffmaster, PhD, M Guerra, DVM, S Shadomy, DVM, T Smith, MD, C Marston, National Center for Zoonotic, Vector-Borne, and Enteric Diseases; K Martinez, MSEE, National Institute for Occupational Safety and Health; A Guh, MD, EIS Officer, CDC. Editorial Note: This report highlights the individual and environmental risks for anthrax from using contaminated goat hides brought from West Africa for drum making. It also describes the first case in the United States of naturally acquired cutaneous anthrax in a personal contact caused by cross-contamination from drum making.

Since 2006, three unrelated cases of anthrax, including the first case described in this report, have been reported from direct occupational association with djembe drums made from untreated animal hides from West Africa. The first two cases were inhalation anthrax. One occurred in a New York City drum maker exposed while making a djembe drum from contaminated hides, and the other occurred in a man in Scotland who died of anthrax septicemia after playing or handling djembe drums newly made from contaminated hides (3,4). The Connecticut cases and the New York City case were caused by B. anthracis of MLVA genotype 1, a different genotype than the Ames strain used in the 2001 mail-related anthrax attacks (1). Although MLVA genotypes from West Africa have not been systematically studied, the widespread nature of genotype 1 (1) and its presence in the West African hides implicated in the New York City and Connecticut cases suggest that genotype 1 might be commonly found in West Africa.

The drum making process of stretching, scraping, and sanding animal hides could have released and potentially aerosolized any B. anthracis spores present on untreated hides, exposing the drum maker and contaminating the surrounding environment. However, despite direct exposure, the drum maker described in this report did not develop inhalation anthrax. He developed cutaneous anthrax only after wearing short sleeves and experiencing a penetrating injury or insect bite, which could have served to inoculate spores into the skin.

The Connecticut drum maker routinely wore personal protective equipment (PPE). His wearing a facemask might have reduced the amount of inhalation exposure. However, even if he had worked with all recommended precautions (3), such as working in a well-ventilated area using PPE that included a N95 respirator, his risk for cutaneous and inhalation exposure would have been lessened but not necessarily eliminated, and environmental contamination would still have occurred and required remediation.

In this investigation, environmental sampling indice tracking of spores into the house by the drum maker, ein through his work clothes or objects brought from the cra leading to exposure and subsequent development of cuti ous anthrax in his child. Few cases of anthrax have x reported in children in the United States because most az sures are acquired occupationally. However, household me bers can be exposed through cross-contamination of live areas. In 1978, dust samples from vacuum cleaners in houses of textile mill workers tested positive for B. anthan suggesting that workers carried spores into their homes 07: case series of cutaneous anthrax in a Pennsylvania mill to: indicated that 4% of all cases during a 22-year per.o. occurred in household members of mill workers, includ. their children (6).

Decontamination of affected areas to minimize the risk or secondary cases of anthrax can be time-consuming and expensive. The cost of environmental cleanups on Capitol H. in the District of Columbia and in postal facilities affected by the 2001 anthrax attacks ranged from $464,000 to $ million (7).

To eliminate individual and environmental risks for anthra in drum making, public health agencies have long advised that animal hides of unknown origin or from areas of

TE zootic anthrax should not be used. However, imported anmal hides from West Africa, particularly goat hides, remain in demand because they are prized by drum makers for thes acoustical quality. Because anthrax outbreaks in livestock trequently occur in West Africa, hides brought into the United States might contain B. anthracis spores. The Animal and Por: Health Inspection Service (APHIS) of the U.S. Departmen of Agriculture has the authority to regulate importation of animal hides, mainly to prevent the introduction of forean animal diseases of agricultural importance into the Ur.com States. However, APHIS does not mandate screening of imported hides for B. anthracis (8), and potentially contri nated hides might continue to be imported. In addit3 importation can bypass legal channels (3). Currently, the With Health Organization recommends the use of sporicidal traments to disinfect all contaminated animal hides, including ethylene oxide fumigation, gamma irradiation, preservation in a 5% formaldehyde solution, or chemical treatment : hydrochloric acid or salt in appropriate concentrations and durations (9,10).

Although safer practice in djembe drum making is nezvad to protect drum makers and others who might be exposed inadvertently, the best preventive measure is to use anima hides known to be free of anthrax spores. The use of PPE not considered a safe alternative to the use of anthrax-ret

- s. Until a process exists for certifying that imported hides -- West Africa are free of anthrax, drum makers should

w current disinfection guidelines to reduce the risk for itse (9,10).

Acknowledgments nis

report is based, in part, on contributions by the Town of bury; Danbury Mayor's Office; Connecticut State Police; Concut State Laboratory; Connecticut Dept of Environmental Proon; Federal Bur of Investigation; US Environmental Protection cy; and T Gomez, DVM, T Butler, DVM, US Dept of Agri

re. .

rences

eim P, Price LB, Klevytska AM, et al. Multiple-locus variable-numer tandem repeat analysis reveals genetic relationships within Bacillus uthracis. J Bacteriol 1999;182:298–336. DC. Update: investigation of bioterrorism-related anthrax and terim guidelines for exposure management and antimicrobial therapy, 'ctober 2001. MMWR 2001;50:909–19. DC. Inhalation anthrax associated with dried animal hidesennsylvania and New York City, 2006. MMWR 2006;55:280–2. HS Borders. Report on the management of an anthrax incident in le Scottish borders, July 2006 to May 2007. Available at http:// ews.bbc.co.uk/1/shared/bsp/hi/pdfs/13_12_07_anthrax.pdf. ales ME, Dannenberg AL, Brachman PS, et al. Epidemiologic sponse to anthrax outbreaks: field investigations, 1950–2001. Emerg fect Dis 2002;8:1163–74. old H. Anthrax: a report of one hundred seventeen cases. Arch Interil Med 1955:96:387–96. anter DA, Gunning D, Rodgers P, et al. Remediation of Bacillus athracis contamination in the U.S. Department of Justice mail facil-- Biosecur Bioterror 2005;3:119-27. S Department of Agriculture. Animal product manual. 2nd edition. ashington, DC: US Department of Agriculture; 2008. Available at -tp://www.aphis.usda.gov/import_export/plants/manuals/ports/ ownloads/apm.pdf. ussell AD, Yarnych VS, Koulikovskii A (eds). Guidelines on disinfecon in animal husbandry for prevention and control of zoonotic disses. Geneva, Switzerland: World Health Organization; 1984. Available http://whqlibdoc.who.int/hq/pre-wholis/who_vph_84.4.pdf. irnbull PCB. Guidelines for the surveillance and control of anthrax

humans and animals. Geneva, Switzerland: World Health Organi: tion; 1986. Available at http://www.who.int/csr/resources/publica

ons/anthrax/WHO_EMC_ZDI_98_6.

prevalence rate of 2%, one of the highest AIDS prevalence rates in the United States (2). Accurate death ascertainment is an important part of HIV/AIDS surveillance. Manual methods can substantially underestimate deaths by missing death certificates that do not mention HIV infection or deaths of residents that occur in other states. CDC and the Council of State and Territorial Epidemiologists (CSTE) recommend performing electronic record linkages to ascertain deaths annually as part of routine HIV/AIDS surveillance activities (3). In 2007, to identify all deaths that occurred during 2000– 2005 among persons with AIDS who resided or received their diagnosis in DC, the HIV/AIDS Administration of the DC Department of Health, with assistance from CDC, performed an electronic record linkage. This report summarizes the results of that linkage, which determined that 54% of deaths among persons with AIDS had not been reported previously to the DC HIV/AIDS Reporting System (HARS). The results indicated that electronic record linkage for death ascertainment is necessary to more accurately estimate the prevalence of persons living with HIV/AIDS.

HARS is a confidential, name-based reporting system developed by CDC to manage HIV/AIDS surveillance data. HARS contains vital status information but does not contain information on cause of death. Until November 2006, DC records in HARS were limited to AIDS patients because nonAIDS patients with HIV infection were not reported by name in DC. To perform the electronic record linkage, Link Plus, a free program developed at CDC (4), was used to link AIDS patients in the HARS data file to records in two other computer data files: 1) the DC Vital Records Division's electronic death certificate file (DCF) and 2) the Social Security Administration's Death Master File (SSDMF). The eDCF includes all deaths that occur in DC, regardless of state of residence, and some deaths of DC residents that occur in Maryland or Virginia. The SSDMF contains information on all deaths reported to the Social Security Administration, regardless of state of residence or where the death occurred. The eDCF has information on causes of death, but the SSDMF does not.

Analysis was limited to deaths that occurred during 2000– 2005. The variables used for record linkage were name, date of birth, Social Security number, and sex. Three linkages were performed (Figure). Linkage 1 and linkage 2 matched the HARS file to eDCF and SSDMF records, respectively, to identify deaths among persons listed in HARS with reported AIDS. HARS cases that were successfully linked to eDCF or SSDMF records were categorized by whether the death had been

previously reported to HARS.

ctronic Record Linkage to Identify aths Among Persons with AIDS – District of Columbia, 2000–2005 mestimated 1 million persons in the United States are liv

vith human immunodeficiency virus (HIV)/acquired unodeficiency syndrome (AIDS); approximately 500,000 ins with AIDS have died since 1981 (1,2). In 2005, the ict of Columbia (DC) had an estimated adult AIDS

Total AIDS deaths. 2,557

Linkage 3: HARS linked to the subset of eDCF
records for which HIV infection was reported
as a cause of death.

Linkage 1: DC HIV/AIDS Reporting System (HARS) linked
to electronic death certificate file (DCF)
Linkage 2: HARS linked to Social Security Death Master
file (SSDMF)
Result: 2,460 deaths, including 1,123 previously reported
to DC HARS

Result: 97 deaths of persons newly identified from
HIV-specific death certificates that had not been
matched to known persons with AIDS in HARS

HARS deaths not

linked to either SSDMF or eDCF: 140

HARS deaths linked
to both SSDMF and

eDCF: 921

HARS deaths linked
only to eDCF: 641

HARS deaths linked
only to DMF: 758

Deaths of persons with cause of death information

available: 1,562

FIGURE. Electronic linkages used to ascertain deaths among persons with tificates mentioned HIV infection as a core
AIDS — District of Columbia (DC), 2000–2005

uting (but not underlying) cause of death. Le
ing causes of the 506 deaths inclut:
cardiovascular disease (112 (22%]); cancer
(19%]); infectious diseases other than
infection (72 (14%); homicide, suicide
unintentional injury (52 (10%]); and chros
liver disease (30 (6%]). In a multiple logice
regression analysis, previously unrepor:
deaths were associated with an underlying a
of death other than HIV infection (adius
odds ratio: 7.53) but not with race/ethnic
transmission category, sex, or age (Table 2;

Electronic linkage 3 identified 216 death tificates in eDCF that mentioned HIV in tion as a cause of death but did not electronics match that information with reported AIDS

patients in the HARS data file and thus mg To identify potential new AIDS cases never previously represent previously unreported HIV/AIDS cases. Overall, reported to HARS, linkage 3 identified those death certifi- (45%) cases were confirmed as new HIV/AIDS cases based, cates within eDCF that indicated HIV infection as a cause of on information from medical records. Of the other porencalzi, death but had not been linked to HARS via linkage 1. To cases, 69 (32%) were matched manually to HARS patents: ensure that these HIV-specific death certificates did not match (and therefore represented previously reported cases missct , any previously reported AIDS cases in HARS, a manual search by linkage 1); 29 (13%) had only death certificate evidence et of HARS records was conducted for matches after not find- HIV infection available and thus remained unconfirmed: and ing them by electronic linkage. The remaining nonmatching 21 (10%) had no mention of HIV on the printed death HIV-specific death certificates were then matched to associ- tificate or medical records and were assumed to be erroneou. ated medical records to confirm that decedents met the sur- Reported by: T Jolaosho, MHS, J Gauntt, MS, T West-Ojo. 15 veillance case definition for HIV infection (5,6). If medical MSPH, HIVIAIDS Admin, District of Columbia Dept of Health records were unavailable to corroborate the death certificate AD Castel, MD, Dept of Epidemiology and Biostatistics

, Germany information, HIV/AIDS remained unconfirmed for the

Washington Univ School of Public Health and Health Szucs, Disc

Columbia. RM Selik, MD, T Durant, PhD, Div of HIVA decedent because the surveillance case definition for HIV

Prevention, National Center for HIV, Viral Hepatitis, STD, ans 3 infection cannot be met by a death certificate alone (3). Mul- Prevention; PJ Peters, MD, E Tai, MD, EIS officers, CDC. tiple logistic regression was performed, and adjusted odds

Editorial Note: This report provides the first compariso, di ratios were calculated to examine factors independently asso

electronic record linkage with manual methods of AIDS de ciated with whether a death was previously unreported to

ascertainment in the United States. More than half (549. HARS before the electronic record linkage.

deaths among AIDS patients during 2000–2005 in DC Linkage 1 and linkage 2 identified 2,460 deaths that

not been reported to HARS and were discovered by electroca occurred during 2000–2005 among persons with AIDS. Of

record linkage with eDCF and SSDMF. This suggests these deaths, 1,337 (54%) had not been reported previously to HARS (Table 1). Among these previously unreported

electronic record linkage is essential for complete ascerat

ment of deaths among persons with HIV/AIDS and accurate deaths, 320 (24%) were linked only to eDCF, 577 (43%) were

estimations of HIV/AIDS prevalence. linked only to SSDMF, and 440 (33%) were linked to both

Death ascertainment in DC has relied on vital records stat (Table 1).

members manually reviewing death certificates and sending Cause of death information was available for 1,562 (63%)

records that mention HIV to HIV/AIDS surveillance start of the 2,460 deaths. The underlying cause of death was HIV

members, who then manually matched the death certificates infection in 1,056 deaths (68%) and other causes (not HIV

to HARS. Because this manual method is dependent unzi infection) in 506 deaths (32%) (Table 2). Of those 506 deaths

death certificates mentioning HIV infection, deaths with ncm attributed to other underlying causes, 112 (22%) death cer

HIV underlying causes were less likely to be reported as !

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