Facility A’s purchasing and shipping records were reviewed and the staff interviewed. All involved states and countries were notified of the outbreak, asked to identify the status of prairie dogs from the suspected shipments, and submit tissue samples for testing.

All prairie dogs at facility A, prairie dogs distributed within Texas from facility A since June 2002, and other dead and free-roaming exotic species at facility A were retrieved; live animals were euthanized, and all were tested for F. tularensis by direct fluorescence assay (DFA) and culture on cysteine heart agar with 9% chocolatized blood media (9). All recovered isolates were subtyped by using a polymerase chain reaction (PCR) assay (9).

Trappers who supplied prairie dogs to facility A in May and June 2002 were interviewed, and prairie dogs from their respective facilities in Texas and South Dakota were euthanized and tested for tularemia. South Dakota trapping sites suspected to be a potential source of the outbreak were also investigated.

Investigation of facility A on August 2 indicated a variety of exotic species crowded within a 2,500 square foot building. We found 163 remaining prairie dogs in four groups: sick and dying prairie dogs (bin 1), healthy-appearing prairie dogs (bin 2 and cages), prairie dog carcasses (frozen), and escaped prairie dogs roaming free around the facility. The bins were metal, uncovered, 2.5 feet tall and 5 feet in diameter, with 50–100 prairie dogs per bin. In addition, several other exotic animals were found roaming free or dead.

According to shipping records, approximately 3,600 prairie dogs passed through facility A during January through July 2002. In July, an estimated 250 prairie dog deaths occurred compared with approximately 25 deaths over the previous 6 months (Figure 2). On August 1, shipments to and from facility A were halted.

Necropsies on all 163 prairie dogs remaining in facility A indicated clinical signs of oropharyngeal tularemia in all the dead and most of the euthanized sick animals, suggesting transmission through ingestion. Many of the dead animals had been cannibalized. F. tularensis was isolated from 61 animals (Table 1). Of these, 60 isolates came from prairie dogs remaining in facility A, including one prairie dog roaming free in the facility, and one isolate came from a privately owned prairie dog purchased from a Texas pet shop supplied by facility A. All of the isolates were identified as type B.

During June through July 2002, more than 1,000 prairie dogs were distributed from facility A to locations in 10 U.S. states and 7 other countries (Table 2). By early August, 100 prairie dogs, those shipped to the Czech Republic, remained unsold: of these, approximately 30 were dead on arrival, 30 were ill, and evidence of cannibalism had been noted within the shipment. All living animals were euthanized.

Of the prairie dogs distributed from facility A to other U.S. states, specimens were received from two prairie dogs sent to Michigan; serum samples from both tested negative for tularemia (Table 1). The Netherlands and Belgium retrieved 4 and 10 prairie dogs, respectively, for serologic testing and culture of tissue samples; all were reported to be negative. The Czech Republic tested six prairie dogs for tularemia: one was positive by isolation of F. tularensis in culture, and five were presumptively positive by polymerase chain reaction (PCR). The Czech F. tularensis isolate was identified as type B, indistinguishable from the Texas isolates by restriction fragment length polymorphism analysis (9).

All healthy-appearing prairie dogs in bin 2 and cages, as well as other exotic animals roaming free or found dead in facility A tested negative for tularemia, demonstrating that outbreak propagation required direct contact with infected prairie dogs. Prairie dogs collected from Texas trappers, South Dakota trappers, and trapping sites all tested negative.

A human case was defined as a fourfold change in serial F. tularensis antibody titers from serum samples obtained at least 14 days apart, with at least one titer ≥1:128, in an exposed person. Paired serum samples were tested with an F. tularensis microagglutination assay. Anyone who transported, handled, bought, or cleaned the cages of prairie dogs from facility A since June 2002 was considered exposed. Exposed persons in Texas and other U.S. states were given a standardized questionnaire to assess infection risk factors and symptoms during the 2 weeks after their exposure. To enhance case finding, periodic follow-up was maintained with health authorities in involved U.S. states and foreign countries.

Twenty-two exposed persons were identified in Texas: 5 worked at facility A, 13 worked at other Texas facilities supplied by facility A, 3 worked at a veterinary care center and necropsied a prairie dog originating from facility A, and 1 privately owned an infected prairie dog originating from facility A. In interviews with 20 of 22 exposed persons, 6 (32%) reported recent prairie-dog bites, 7 (37%) ate or drank without handwashing after contact with prairie dogs, and 13 (67%) handled prairie dogs or cleaned cages barehanded. Although gloves and soap were available to employees, none of the involved Texas facilities had formal written policies enforcing proper handwashing, wearing gloves, or prohibiting eating or drinking in animal care areas.

During their exposure interval, 14 of 20 exposed persons interviewed reported having >2 nonspecific symptoms that can be consistent with tularemia: headache, sore throat, myalgias, stiff neck, fever, chills, cough, and swollen glands. Initial serologic testing on blood samples obtained 1 week to 2 months after initial exposure from 19 of 22 persons in Texas identified a positive F. tularensis titer of 1:128 in a 24-year-old man, who was an animal handler at facility A. All other persons tested negative, and no new positive titers were identified from follow-up samples obtained 1–2 months later from 9 of 19 persons. Except for the animal handler, other symptomatic persons had spontaneous resolution of symptoms or other diagnoses for their symptoms. The animal handler’s 1-month follow-up titer persisted at 1:128; however, a fourfold decline in titer, from 1:128 to 1:32, was documented for samples obtained 4 and 6 months after the initial titer, indicating recent exposure to F. tularensis. The animal handler had begun working at facility A in June 2002 and had handled dead and dying prairie dogs barehanded. He denied prior potential tularemia exposures, such as hunting, having tick bites, or owning a pet. Additionally, he denied having received a tularemia vaccine, which could have explained the elevated titer. During our investigation, the animal handler reported having an afebrile upper respiratory infection-like illness atypical of tularemia, with sore throat, cough productive of green sputum, and mild chest discomfort but no interruption of work or leisure activities. His symptoms began 12 days after the last prairie dog shipment arrived at facility A and 1 week before the die-off, and they resolved after oral fluoroquinolone therapy.

Health authorities in other states and countries reported no illness in exposed persons. Six months after the outbreak occurred, follow-up calls to health authorities in the involved U.S. states indicated no new human cases. No serologic testing was performed on exposed persons outside of Texas.