Measles and rubella were common infectious diseases in Egypt during the prevaccine era. Monovalent measles vaccine was introduced in 1977, and measles vaccination coverage increased from <50% to >90% from 1980 to 1999; however, measles outbreaks continued to occur at 2- to 4-year intervals during this period. After the introduction of a second routine dose of measles vaccine as a combined measles-mumps-rubella (MMR) vaccine in 1999 and the implementation of measles immunization campaigns targeting 6- to 16-year-old children during 2000-2003, reported measles cases dramatically decreased by 2003. In 2002, Egypt established a goal to eliminate measles and rubella and to prevent congenital rubella syndrome (CRS) by 2010. Large-scale rubella and measles outbreaks in 2005-2007, however, led to a revision of the plan of action to achieve the 2010 goals. A nation-wide measles-rubella immunization campaign, targeting children, adolescents, and young adults 2-20 years old, was conducted in 2 phases during 2008-2009 and achieved coverage >95%. With the decrease to record low levels of cases of measles and rubella in 2009 and 2010, Egypt should achieve measles and rubella elimination in the near future, but high coverage(>95%) with 2 doses of measles-rubella vaccine needs to be maintained, measles-rubella surveillance strengthened, and CRS surveillance developed.

The availability of vaccines that contain both measles and rubella components allows for the elimination of both diseases. Although routine infant vaccination with rubella vaccine has had profound effects on the incidence of both acquired and congenital rubella, mass vaccination rapidly stops circulation of the virus and prevents paradoxical increases in susceptibility of women that might result from decreased exposure in childhood. Whereas routine rubella vaccination has eliminated the infection from many developed countries, mass vaccination has rapidly accomplished the same goal in Latin America and the Caribbean, and is being applied in other developing country areas.

CONTEXTOn January 24, 2003, the US Department of Health and Human Services (DHHS) implemented a preparedness program in which smallpox (vaccinia) vaccine was administered to federal, state, and local volunteers who might be first responders during a bioterrorism event.OBJECTIVETo describe results from the comprehensive DHHS smallpox vaccine safety monitoring and response system.DESIGN, SETTING, AND PARTICIPANTSDescriptive study of adverse event reports from the DHHS smallpox vaccine safety monitoring and response system received between January 24 and October 31, 2003, through the Vaccine Adverse Event Reporting System (VAERS) and the Centers for Disease Control and Prevention. A total of 37,901 volunteers in 55 jurisdictions received at least 1 dose of smallpox vaccine.MAIN OUTCOME MEASURESNumber of vaccinations administered and description of adverse events and reporting rates.RESULTSA total of 38,885 smallpox vaccinations were administered, with a take rate of 92%. VAERS received 822 reports of adverse events following smallpox vaccination (overall reporting rate, 217 per 10,000 vaccinees). A total of 590 adverse events (72%) were reported within 14 days of vaccination. Nonserious adverse events (n = 722) included multiple signs and symptoms of mild and self-limited local reactions. One hundred adverse events (12%) were designated as serious, resulting in 85 hospitalizations, 2 permanent disabilities, 10 life-threatening illnesses, and 3 deaths. Among the serious adverse events, 21 cases were classified as myocarditis and/or pericarditis and 10 as ischemic cardiac events that were not anticipated based on historical data. Two cases of generalized vaccinia and 1 case of postvaccinial encephalitis were detected. No preventable life-threatening adverse reactions, contact transmissions, or adverse reactions that required treatment with vaccinia immune globulin were identified. Serious adverse events were more common among older revaccinees than younger first-time vaccinees.CONCLUSIONSRigorous smallpox vaccine safety screening, educational programs, and older vaccinees may have contributed to low rates of preventable life-threatening adverse reactions. Other rare, clinically significant, or unexpected cardiac adverse events were detected by timely review of VAERS data and intensive clinical case investigation.

To contribute to the development of a rubella vaccination strategy, we conducted a study to determine age-specific susceptibility among women aged 15-39 years by testing for rubella-specific IgG antibodies. Of 964 women, 13% were found to be susceptible to rubella. Significantly higher susceptibility among women >25 years old was observed. Susceptibility data are important but are not sufficient to develop a vaccination strategy. After considering all available information, we suggested vaccination of women aged <35 years and selective vaccination of older women who were planning pregnancy.

Entre 2002 et 2003, une epidemie importante de rubeole s'est declaree en Roumanie avec plus de 115 000 cas notifies dans le pays, et une incidence de 531 cas pour 100 000 habitants. L'incidence la plus elevee concernait les enfants d'âge scolaire. Les cohortes d'adolescentes vaccinees en 1998 et en 2002 (lorsqu'un vaccin anti-rubeoleux etait disponible) presentaient des incidences significativement plus basses (pl0,001) que celles de garcons du meme âge non vaccines. En 2003, sur les 150 cas suspects de syndrome de rubeole congenitale (SRC), sept (4,6%) ont ete confirmes par la presence d'anticorps IgM anti-rubeole. En l'absence de vaccin pour lutter contre l'epidemie, un plan de reponse a l'alerte a ete mis en place pour ameliorer la detection des cas et limiter la transmission du virus de la rubeole. Les activites suivantes ont ete mises en œuvre : surveillance des femmes enceintes avec une suspicion de rubeole ou des antecedents d'exposition au virus de la rubeole et suivi des issues de grossesses, renforcement de la surveillance des SRC ainsi que des recommandations existantes relatives au controle de l'infection pour prevenir la transmission de la maladie dans les etablissements de soins, et mise en place d'une campagne grand public. Le vaccin combine Rougeole-Oreillons-Rubeole sera introduit en mai 2004 en Roumanie pour la vaccination en routine des enfants de 12 a 15 mois, tandis que la vaccination des jeunes filles de 13-14 ans avec un vaccin monovalent contre la rubeole sera maintenue.

Since the early 1990s, rubella disproportionately affected non-US-born Hispanic persons in the United States. In 2000, 149 (78%) of the 192 rubella cases were among Hispanics, and 23 (77%) of the 30 infants with congenital rubella syndrome reported between 1997 and 2000 were born to non-US-born Hispanic mothers.1–5 The US childhood rubella vaccination program was started in 19691; however, many other countries do not have, or have recently implemented, rubella vaccination programs.6 Foreign-born workers in certain US industries (e.g., meat- and poultry-processing plants) appear to be at increased risk for rubella, suggesting higher susceptibility rates.7–9 In 2000, a varicella outbreak occurring among Mexican-born adults, most of whom worked in a poultry-processing plant in southern Alabama, provided an opportunity to test for rubella susceptibility.10 Vaccine was offered to susceptible persons. We describe risk factors for susceptibility among these workers.

CONTEXT:In 1989, the United States established a goal to eliminate indigenous rubella and congenital rubella syndrome (CRS) by 2000. Reported rubella cases are at record low levels; however, cases and outbreaks have occurred, primarily among unvaccinated foreign-born adults.OBJECTIVE:To evaluate the current epidemiology of rubella and CRS and assess progress toward elimination.DESIGN, SETTING, AND SUBJECTS:Analysis of rubella cases reported to the National Notifiable Diseases Surveillance System from 1990 through 1999 and CRS cases reported to the National Congenital Rubella Syndrome Registry from 1990 through 1999. Since 1996, US and international viral isolates have been sequenced.MAIN OUTCOME MEASURES:Incidence and characteristics of rubella and CRS cases; molecular typing of virus isolates.RESULTS:Annually from 1990 through 1999, the median number of reported rubella cases was 232 (range, 128-1412), and between 1992 and 1999, fewer than 300 rubella cases were reported annually, except in 1998. During the 1990s, the incidence of rubella in children younger than 15 years decreased (0.63 vs 0.06 per 100 000 in 1990 vs 1999), whereas the incidence in adults aged 15 to 44 years increased (0.13 vs 0.24 per 100 000). In 1992, incidence among Hispanics was 0.06 per 100 000 and increased to a high in 1998 of 0.97 per 100 000. From 1997 through 1999, 20 (83%) of 24 CRS infants were born to Hispanic mothers, and 21 (91%) of 23 CRS infants were born to foreign-born mothers. Molecular typing identified 3 statistically distinct genotypic groups. In group 1, the close relatedness of viruses suggests that a single imported source seeded an outbreak that did not spread beyond the Northeast. Similarly, within groups 2 and 3, relatedness of viruses obtained from clusters of cases suggests that single imported sources seeded each one. Diversity of viruses found in 1 state is consistent with the conclusion that several viruses were imported. Moreover, the similarity of viruses found across the country, combined with a lack of epidemiologic evidence of endemic transmission, support the conclusion that some viruses that are common abroad, particularly in Latin America and the Caribbean, were introduced into the United States on several separate occasions.CONCLUSIONS:The epidemiology of rubella and CRS has changed significantly in the last decade. These changes and molecular typing suggest that the United States is on the verge of elimination of the disease. To prevent future rubella outbreaks and CRS, current strategies must be enhanced and new strategies developed.

The worldwide use of vaccines has resulted not only in significant achievements in controlling disease but also in disease eradication; smallpox was eradicated in 1977 and there is a global goal for polio eradication by 2005. Additionally, global efforts are already underway towards accelerated measles control. In 1992, mumps disease was recognized as one of six potentially eradicable diseases by the International Task Force for Disease Eradication (ITFDE). 1 The ITFDE is a group of scientists convened through the Carter Center of Emory University in Atlanta, GA, that met from 1989 to 1992 to evaluate the potential for eradication of more than 90 diseases. The ITFDE also recognized the potential for the eradication of rubella and suggested that the effort to eradicate measles, mumps and rubella be combined through the use of the trivalent MMR (measles-mumps-rubella) vaccine. Today, as many countries embark on accelerated measles control or elimination activities, there is a unique opportunity to control mumps and rubella diseases and to work towards the ITFDE goal of eradication through use of the MMR vaccine. However, this opportunity is being missed while debate continues concerning the safety profiles of the different mumps vaccine strains to be incorporated in MMR formulations. Opportunities for control are also affected by differences in the cost of vaccines prepared with the different strains. The present paper 2 adds to the debate by contributing additional data on the safety profile of the Leningrad Zagreb strain of the mumps vaccine and discussing the issues of cost as they relate to national immunization programmes. Both safety and cost have implications for the global use of mumps-containing vaccines and the control of mumps disease worldwide. The most frequent serious complication following wild mumps infection is aseptic meningitis. 3 Wild virus mumps infection leads to aseptic meningitis in up to 10% of patients. The attenuated vaccine-strain virus poses a much lower risk of aseptic meningitis following vaccination, however the risk varies from strain to strain. Estimates ranging from 1 case in 150 000 doses of vaccine administered for the Jeryl Lynn strain, developed in the US, 4 to 1 case in 1000 for the Leningrad-3 strain, developed in Russia, have been found. 5 In the early 1990s, use of the Urabe strain of mumps vaccine virus, developed in Japan, was discontinued in many countries (Japan, Canada and the UK) due to the occurrence of aseptic meningitis following vaccination. 6 It is important to note that cases of aseptic meningitis following vaccination resolve completely and without sequelae. The Rubini strain of mumps vaccine virus, developed in Switzerland, is a strain about which there is no debate concerning its use; the use of vaccines made with this strain are not recommended by WHO for use in national programmes due to their low effectiveness. This risk of aseptic meningitis following vaccination has caused some countries to elect not to use the MMR vaccine made with either the Urabe strain or one of the two Leningrad series of strains (the Leningrad-3 vaccine virus was further attenuated to the Leningrad-Zagreb strain, which was developed in Croatia) for mass vaccination campaigns. These countries have elected to use either the bivalent measles-rubella vaccine or the monovalent measles vaccine rather than use the more expensive Jeryl Lynn MMR vaccine. An opportunity to control mumps disease is thus lost.

To the Editor—Zimmerman and Reef’s report regarding congenital rubella syndrome (CRS)1 did not address the challenging infection control issues posed when the diagnosis of CRS is considered. Our recent experience may be instructive for others.In October 2000, a neonate with a patent ductus arteriosus was admitted to a multi-bed room at our hospital. The infant’s mother reported a febrile illness with rash during the 5th week of her pregnancy in Honduras, which she identified as “rubeola.” The infant was managed by cardiology and seen in consultation by hematology, infectious diseases, ophthalmology, and neurology. Although CRS was mentioned in the differential diagnoses of several physicians, the patient was not isolated until the 7th day of hospitalization. This may in part be because early prenatal records were unavailable and that those involved in the patient’s care did not recognize that “rubeola” is Spanish for rubella. On the 14th day of hospitalization rubella-specific immunoglobulin M was reported in the patient’s serum. Later, cultures of the patient’s nasopharyngeal secretions grew rubella.Five infants who shared the multi-bed room with the case patient and 261 staff including employees, volunteers, and medical contract staff were potentially exposed. Of the patients, 3 were aged 3 days to 2 months and were born at term to rubella immune mothers. The remaining 2 were born at 31 weeks’ gestation and were therefore followed for a month after exposure to confirm rubella seronegativity. Initially, baseline immune status was known on 213 (82%) of the staff. Ultimately, 251 (96%) were documented to be rubella-immune. One seronegative employee was furloughed and a second was immunized and allowed to continue working. The rubella status of the remaining 8, all nonemployee physicians, remains undocumented. No secondary cases were identified.Over the past 3 years in Washington State, there have been seven documented cases of postnatal rubella. Six of 7 occurred in individuals born in Russia or Thailand (personal communication, Epidemiology and Immunization Section, Public Health King County, Seattle, WA). In addition, 83.3% of laboratory-confirmed cases of CRS in the United States between 1997 and 1999 were born to Hispanic mothers.2 When evaluating for congenital infection, CRS should be considered in infants of foreign-born mothers from countries that do not routinely immunize for rubella. When the diagnosis of CRS is considered, patients should be placed in contact isolation until CRS can be ruled out. While 96% of exposed employees and volunteers were confirmed as immune, lack of documentation for certain groups, notably physicians, hampered efforts to perform postexposure investigation. Immune status documentation should be required for all personnel who have direct patient contact within health care institutions, including physicians.In Reply—We thank the correspondents for sharing their experience related to the challenges of infection control issues posed when the diagnosis of congenital rubella syndrome (CRS) is considered. We also underscore the importance of performing rubella-specific immunoglobulin M testing as soon as CRS is suspected. If CRS is suspected in an infant but tests performed shortly after birth are negative, the infant should be retested at age 1 month. Efforts should also be made to obtain clinical specimens for virus isolation from all cases. The infant discussed by Zerr and colleagues was not laboratory-confirmed for rubella infection until the 14th day of hospitalization, allowing for multiple exposures of other infants and hospital staff and resulting in a significant amount of time and intensive effort in investigation of these contacts. Studies show that infants with CRS can shed virus for prolonged periods of time, up to a year in some cases, representing a source of infection to susceptible individuals. The Advisory Committee on Immunization Practices recommends that all health care workers are immune to rubella. As Zerr and colleagues discuss, although the incidence of CRS is low in the United States, CRS should be considered in all infants with manifestations consistent with CRS, particularly in infants of foreign-born women from countries who do not vaccinate against rubella or from countries who have only recently instituted rubella vaccination programs. It is crucial then to place these infants in contact isolation until CRS is ruled out or confirmed. If CRS is confirmed, the infant is considered infectious until 1 year of age or until 2 cultures of pharyngeal and urine specimens obtained at least 1 month apart are negative for virus after age 3 months.

OBJECTIVEThe current epidemiology of rubella reveals an increase in the number of cases among adult Hispanics and an increase in the number of congenital rubella syndrome (CRS) cases among infants of Hispanic mothers. Recent rubella outbreaks have occurred primarily among adult Hispanics, many of whom are foreign-born natives of countries where rubella vaccination is not routine or has only recently been implemented. The objective of this study was to estimate the incidence of CRS in a hospital serving a predominantly Hispanic population.METHODSHospital charts of infants <1 year old discharged between January 1, 1994 and December 31, 1996 with International Classification of Diseases, Ninth Revision (ICD-9) discharge codes consistent with CRS were reviewed; we looked for cataracts, deafness, congenital heart defects, dermal erythropoiesis, microcephaly, meningoencephalitis, and other defects associated with CRS. We abstracted data on maternal and infant ethnicity, maternal age, gestational age, infants' birth weight, infants' clinical characteristics, and laboratory evaluation. Cases were categorized according to the Council of State and Territorial Epidemiologists' case classification for CRS.RESULTSOf the 182 infants with 1 or more ICD-9 codes consistent with CRS, 6 (3.3%) met either the confirmed or probable case definition for CRS. Two infants met the definition for confirmed CRS. Although laboratory tests for rubella immunoglobulin M antibodies were positive for both of these infants, only 1 of the cases had been reported to the state health department. Four other infants had clinical presentations that met the definition for a probable case. One of these had been tested for rubella immunoglobulin M antibodies, and the test was negative. The other 3 had not been tested. The rate of infants meeting the definition of confirmed and probable CRS was 3.1 per 10 000 hospital births. All confirmed and probable cases were among infants born to Hispanic mothers. Maternal country of origin was Mexico for the 2 confirmed cases and 1 of the probable cases, and unknown for the remaining 3 probable cases.CONCLUSIONThe rate of confirmed and probable CRS among infants in this predominantly Hispanic population is higher than the reported rate in the United States in the vaccine era, which has been reported to range from approximately 0.01-0.08 per 10 000 live births. These findings indicate a need for heightened awareness of CRS among physicians who serve populations at risk for rubella. Physicians should report all confirmed and probable CRS cases to the state health department. The lack of appropriate laboratory testing in 3 infants with probable CRS indicates that physicians should consider a diagnosis of CRS in infants with some signs consistent with CRS, particularly in areas serving high numbers of individuals at risk for rubella.

Journal of Women's Health & Gender-Based MedicineVol. 10, No. 7 Observations from the CDCPreventing Congenital Rubella Syndrome (CRS) through Vaccination of Susceptible Women of Childbearing AgeM. Carolina Danovaro-Holliday, Laura Zimmerman, and Susan E. ReefM. Carolina Danovaro-HollidaySearch for more papers by this author, Laura ZimmermanSearch for more papers by this author, and Susan E. ReefSearch for more papers by this authorPublished Online:7 Jul 2004https://doi.org/10.1089/15246090152563489AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byViral Infections of the Fetus and NewbornCongenital Rubella SyndromeInfectious Diseases in Clinical Practice, Vol. 20, No. 3Viral Infections of the Fetus and Newborn and Human Immunodeficiency Virus Infection during PregnancyCommonly Encountered Medical Problems in PregnancyViral Infections of the Fetus and NewbornIdentifying Risk Factors for Rubella Susceptibility in a Population at Risk in the United StatesAmerican Journal of Public Health, Vol. 93, No. 2 Volume 10Issue 7Sep 2001 To cite this article:M. Carolina Danovaro-Holliday, Laura Zimmerman, and Susan E. Reef.Preventing Congenital Rubella Syndrome (CRS) through Vaccination of Susceptible Women of Childbearing Age.Journal of Women's Health & Gender-Based Medicine.Sep 2001.617-619.http://doi.org/10.1089/15246090152563489Published in Volume: 10 Issue 7: July 7, 2004PDF download

The goal of eliminating indigenous rubella and congenital rubella syndrome (CRS) in the United States in the near future is now within reach, because rubella incidence has been sustained at record-low levels since the mid-1990s. Effective prevention strategies to eliminate CRS and rubella require improvement in the surveillance of CRS and congenital rubella infection (CRI). The purpose of the workshop was to review rubella and CRS epidemiology, as well as current clinical, diagnostic, and laboratory practices, to determine whether new strategies are needed to achieve and document CRS elimination. Workshop participants agreed that surveillance for CRS must be strengthened, particularly through augmented laboratory capabilities, and the case definition for CRS must be revised to reflect the current scientific information available. Further studies of methods are needed to identify high-risk populations and geographic areas for rubella and CRS and to enhance identification of infants with CRS.

CONTEXT:Childhood vaccination has reduced rubella disease to low levels in the United States, but outbreaks continue to occur. The largest outbreak in the past 5 years occurred in Nebraska in 1999.OBJECTIVES:To examine risk factors for disease, susceptibility of the risk population, role of vaccine failure, and the need for new vaccination strategies in response to the Nebraska rubella outbreak.DESIGN, SETTING, AND PATIENTS:Investigation of 83 confirmed rubella cases occurring in Douglas County, Nebraska, between March 23 and August 24, 1999; serosurvey of 413 pregnant women in the outbreak locale between October 1998 and March 1999 (prior to outbreak) and April and November 1999 (during and after outbreak).MAIN OUTCOME MEASURES:Case characteristics, compared with that of the general county population; area childhood rubella vaccination rates; and susceptibility among pregnant women before vs during and after the outbreak.RESULTS:All 83 rubella cases were unvaccinated or had unknown vaccination status and fell into 3 groups: (1) 52 (63%) were young adults (median age, 26 years), 83% of whom were born in Latin American countries where rubella vaccination was not routine. They were either employed in meatpacking plants or were their household contacts. Attack rates in the plants were high (14.4 per 1000 vs 0. 19 per 1000 for general county population); (2) 16 (19%), including 14 children (9 of whom were aged <12 months) and 2 parents, were US-born and non-Hispanic, who acquired the disease through contacts at 2 day care facilities (attack rate, 88.1 per 1000); and (3) 15 (18%) were young adults (median age, 22 years) whose major disease risk was residence in population-dense census tracts where meatpacking-related cases resided (R(2) = 0.343; P<.001); 87% of these persons were born in Latin America. Among pregnant women, susceptibility rates were 13% before the outbreak and 11% during and after the outbreak. Six (25%) of 24 susceptible women tested were seropositive for rubella IgM. Rubella vaccination rates were 90.2% for preschool children and 99.8% for school-aged children.CONCLUSIONS:A large rubella outbreak occurred among unvaccinated persons in a community with high immunity levels. Crowded working and living conditions facilitated transmission, but vaccine failure did not. Workplace vaccination could be considered to prevent similar outbreaks. JAMA. 2000;284:2733-2739.

To describe clinical presentation and epidemiology of US infants with congenital rubella syndrome (CRS) and to identify missed opportunities for maternal vaccination, data from CRS cases reported to the National Congenital Rubella Syndrome Registry (NCRSR) from 1985 through 1996 were analyzed. Missed opportunities for maternal vaccination were defined as missed postpartum, premarital, and occupational opportunities, that is, times when rubella vaccination is recommended but was not given. From 1985 through 1996, 122 CRS cases were reported to the NCRSR. The most frequent CRS-related defect was congenital heart disease. Of the reported infants with CRS, 44% were Hispanic. Of 121 known missed opportunities for rubella vaccination among 94 mothers of infants with indigenous CRS, 98 (81%) were missed postpartum opportunities. CRS continues to occur in the United States. Hispanic infants have an increased risk of CRS. Missed opportunities for postpartum rubella vaccination were identified for 52% of indigenous CRS cases.

ABSTRACT Nosocomial Candida albicans infections have become a major cause of morbidity and mortality in neonates in neonatal intensive care units (NICUs). To determine the possible modes of acquisition of C. albicans in hospitalized neonates, we conducted a prospective study at Grady Memorial Hospital, Atlanta, Ga. Clinical samples for fungal surveillance cultures were obtained at birth from infants (mouth, umbilicus, and groin) and their mothers (mouth and vagina) and were obtained from infants weekly until they were discharged. All infants were culture negative for C. albicans at birth. Six infants acquired C. albicans during their NICU stay. Thirty-four (53%) of 64 mothers were C. albicans positive (positive at the mouth, n = 26; positive at the vagina, n = 18; positive at both sites, n = 10) at the time of the infant’s delivery. A total of 49 C. albicans isolates were analyzed by restriction endonuclease analysis and restriction fragment length polymorphism analysis by using genomic blots hybridized with the CARE-2 probe. Of the mothers positive for C. albicans , 3 of 10 were colonized with identical strains at two different body sites, whereas 7 of 10 harbored nonidentical strains at the two different body sites. Four of six infants who acquired C. albicans colonization in the NICU had C. albicans -positive mothers; specimens from all mother-infant pairs had different restriction endonuclease and CARE-2 hybridization profiles. One C. albicans -colonized infant developed candidemia; the colonizing and infecting strains had identical banding patterns. Our study indicates that nonperinatal nosocomial transmission of C. albicans is the predominant mode of acquisition by neonates in NICUs at this hospital; mothers may be colonized with multiple strains of C. albicans simultaneously; colonizing C. albicans strains can cause invasive disease in neonates; and molecular biology-based techniques are necessary to determine the epidemiologic relatedness of maternal and infant C. albicans isolates and to facilitate determination of the mode of transmission.

OBJECTIVE:To describe a coccidioidomycosis outbreak in Ventura County following the January 1994 earthquake, centered in Northridge, Calif, and to identify factors that increased the risk for acquiring acute coccidioidomycosis infection.DESIGN:Epidemic investigation, population-based skin test survey, and case-control study.SETTING:Ventura County, California.RESULTS:In Ventura County, between January 24 and March 15, 1994, 203 outbreak-associated coccidioidomycosis cases, including 3 fatalities, were identified (attack rate [AR], 30 cases per 100,000 population). The majority of cases (56%) and the highest AR (114 per 100,000 population) occurred in the town of Simi Valley, a community located at the base of a mountain range that experienced numerous landslides associated with the earthquake. Disease onset for cases peaked 2 weeks after the earthquake. The AR was 2.8 times greater for persons 40 years of age and older than for younger persons (relative risk, 2.8; 95% confidence interval [CI], 2.1-3.7; P<.001). Environmental data indicated that large dust clouds, generated by landslides following the earthquake and strong aftershocks in the Santa Susana Mountains north of Simi Valley, were dispersed into nearby valleys by northeast winds. Simi Valley case-control study data indicated that physically being in a dust cloud (odds ratio, 3.0; 95% CI, 1.6-5.4; P<.001) and time spent in a dust cloud (P<.001) significantly increased the risk for being diagnosed with acute coccidioidomycosis.CONCLUSIONS:Both the location and timing of cases strongly suggest that the coccidioidomycosis outbreak in Ventura County was caused when arthrospores were spread in dust clouds generated by the earthquake. This is the first report of a coccidioidomycosis outbreak following an earthquake. Public and physician awareness, especially in endemic areas following similar dust cloud-generating events, may result in prevention and early recognition of acute coccidioidomycosis.