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Background Chagas disease affects an estimated 326 000–347 000 people in the United States and is severely underdiagnosed. Lack of awareness and clarity regarding screening and diagnosis is a key barrier. This article provides straightforward recommendations, with the goal of simplifying identification and testing of people at risk for US healthcare providers. Methods A multidisciplinary working group of clinicians and researchers with expertise in Chagas disease agreed on 6 main questions, and developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, after reviewing the relevant literature on Chagas disease in the United States. Results Individuals who were born or resided for prolonged time periods in endemic countries of Mexico and Central and South America should be tested for Trypanosoma cruzi infection, and family members of people who test positive should be screened. Women of childbearing age with risk factors and infants born to seropositive mothers deserve special consideration due to the risk of vertical transmission. Diagnostic testing for chronic T. cruzi infection should be conducted using 2 distinct assays. Conclusions Increasing provider-directed screening for T. cruzi infection is key to addressing this neglected public health challenge in the United States.

Background:Urgent care centers (UCCs) have become frontline healthcare facilities for individuals with acute infectious diseases. Additionally, UCCs could potentially support the healthcare system response during a public health emergency. Investigators sought to assess NYC UCCs’ implementation of nationally-recommended IPC and EP practices.Methods:Investigators identified 199 eligible UCCs based on criteria defined by the Urgent Care Association of America. Multiple facilities under the same ownership were considered a network. As part of a cross-sectional analysis, an electronic survey was sent to UCC representatives assessing their respective facilities’ IPC and EP practices. Representatives of urgent care networks responded on behalf of all UCCs within the network if all sites within the network used the same policies and procedures.Results:Of the respondents, 18 representing 144 UCCs completed the survey. Of these, 8 of them (44.4% of the respondents) represented more than 1 facility that utilized standardized practices (range = 2-60 facilities). Overall, 81.3% have written IPC policies, 75.0% have EP policies, 80.6% require staff to train on IPC, and 75.7% train staff on EP.Conclusion:Most UCCs reported implementation of IPC and EP practices; however, the comprehensiveness of these activities varied across UCCs. Public health can better prepare the healthcare system by engaging UCCs in planning and executing of IPC and EP-related initiatives.

Staphylococcus pseudintermedius commonly colonizes companion animals, including canines. This microbe is a major opportunistic pathogen responsible for pyogenic and necrotizing skin and soft tissue infection in canines. Infection with S. pseudintermedius is increasingly being recognized in humans, especially in those who are immunocompromised. This microbe is quite similar to Staphylococcus aureus, expressing several analogous virulence factors and a variety of toxins. Furthermore, S. pseudintermedius has variants that display multi-drug resistance comparable to methicillin-resistant S. aureus. We report a 50-year-old female with bilateral lung transplant on immunosuppression who presents with signs of sepsis and pneumonia. Initial blood cultures grew Gram-positive cocci that were not initially identified via molecular diagnostics as Staphylococcus species but were later confirmed as S. pseudintermedius through mass spectrometry. Antimicrobial susceptibility testing demonstrated multi-drug resistance, including methicillin. Despite aggressive medical and antimicrobial treatment, our patients succumbed to the infection. The source of infection likely came from her companion canine at home as no other source could be identified; however, cultures were unable to be obtained from the companion canine. Those who are immunosuppressed, such as with solid organ transplants, should take caution with exposure to companion animals due to the potential for S. pseudintermedius infection.

With the increasing number of confirmed cases and accumulating clinical data, our understanding of COVID-19 continues to evolve. Here we describe the case of a patient who was initially admitted for decompensated heart failure with reduced ejection fraction (HFrEF). Only later in his course did he develop fever that led to testing for severe acute respiratory syndrome coronavirus-2 (SARS-COV-2). Although we are aware of the common respiratory failure induced by SARS-COV-2, we have scant information that describes cardiac manifestations caused by this novel virus.

We surveyed urgent care centers (UCCs) in the state of Arizona to determine whether they offered the influenza vaccine during the 2016-2017 influenza season. Overall vaccine availability was 80.3% at these facilities. During this season, one-third of the UCCs offered influenza vaccination to children 6 months or older; approximately two-thirds offered influenza vaccination to children and young adults 16 years or older. This is the first study of influenza vaccine availability at UCCs.

Background Kissing bugs are common household pests in the Desert Southwest of the United States. These hematophagous bugs enter homes and suck blood from resident humans and pets. They are vectors of Trypanosoma cruzi, an enzootic parasite in small mammals and the cause of Chagas disease in humans. Autochthonous cases of Chagas disease are rare in the United States despite the presence of the vector and parasite. Environmental and biological factors accounting for this phenomenon need studying. Methods Homeowners in Bisbee and Tucson, Arizona captured kissing bugs inside homes during 2017-2018. Bugs were tested for presence of T. cruzi by polymerase chain reaction. Residents bitten by kissing bugs were tested for Chagas disease by serology. We evaluated invaded homes in the 2 cities. Results Three species of kissing bugs (n = 521) were collected in or near homes. Triatoma rubida was the most common triatomine in Tucson; T. recurva in Bisbee. T. protracta was uncommon. Seventeen percent of bugs captured in Bisbee and 51.1% in Tucson harbored T. cruzi. Bite victims (n = 105) recalled more than 2200 bites. Reactions to bites were common, including 32 episodes of anaphylaxis in 11 people (10.5%). Tests for Chagas disease (n = 116) were negative. Median age of houses was 91 years in Bisbee and 7 years in Tucson. Bisbee houses had pier and beam foundations. Tucson houses were built on concrete slabs. Conclusions Kissing bugs harboring T. cruzi readily entered new and old homes. Bites of humans caused severe, life-threatening reactions. There was no serological evidence of Chagas disease among those bitten.

Skin and soft-tissue infections (SSTIs) are commonly encountered by medical students, residents, and trainees. The Infectious Diseases Society of America (IDSA) has updated its recommendations regarding SSTI diagnosis and management in June 2014. We assessed knowledge, attitude, and practices toward diagnosis and management of SSTIs using an online survey. We disseminated the survey to medical students, residents, and attending physicians practicing in family and internal medicine department at a university-based hospital. A total of 103 surveys were completed out of 121 sent (85.1%) between July 2015 and March 2016. There were nine medical questions in the survey. The mean of correct answers was 4.5/9 ± 2.0. Medical knowledge correlated with the level of education (P < 0.001) but not with subspecialty (P = 0.97). Around 35% were familiar with the updated IDSA guidelines pertaining to SSTIs. The majority (85%) responded that the hospital staff would benefit from additional training and 75% agreed that more antibiotic stewardship education is needed. Our study shows that there are significant opportunities for development among students and physicians who encounter SSTIs.

Solid organ transplant recipients who contract coccidioidomycosis are at risk for complicated, protracted, disseminated, and severe disease. To date, no studies have described outcomes for patients who develop coccidioidomycosis only after the first posttransplant year. This study was a joint project of Mayo Clinic Hospital, Phoenix, Arizona, and the University of Arizona/Banner University Medical Center, Tucson, Arizona. We retrospectively reviewed electronic health records for patients with a history of solid organ transplant between January 1, 1998, and October 11, 2014, who developed coccidioidomycosis after the first transplant year. We identified 91 patients. Of those, 37/91 (40.7%) had pulmonary coccidioidomycosis (29/37 [78.4%] were symptomatic); and 5/91 (5.5%) had extrapulmonary disease (all were symptomatic). One patient (1.1%) died. Coccidioidomycosis was evident in 2/91 (2.2%) patients within 3 months of antirejection treatment. Many of the patients (51/91 [56.0%]) had asymptomatic coccidioidomycosis, 27 (27.9%) of whom were followed up closely but did not receive antifungal medication and had no sequelae. Although solid organ recipients taking low-level immunosuppression after the first posttransplant year appeared to have less symptomatic, disseminated, or fatal coccidioidal infection than historical cohorts, this remains an important infection with morbidity and mortality even after the first posttransplant year.

Leptospirosis is a bacterial zoonosis that affects many mammals, including humans and dogs; dogs can transmit the bacteria to humans, but the frequency of transmission and highest risk exposures are poorly understood. During 2016-2017, the Maricopa County Department of Public Health, Arizona Department of Health Services and Centers for Disease Control and Prevention investigated the zoonotic potential of a canine leptospirosis outbreak in the Phoenix metro area. We identified symptomatic persons exposed to canine leptospirosis cases by conducting active and passive surveillance. We tested dog owners (n = 9) and animal care providers (n = 109) for serological evidence of Leptospira spp. infection (via the microscopic agglutination test [MAT]) and interviewed these persons about their specific exposures to canine cases and general exposures to canine blood and urine. Through surveillance, seven symptomatic persons were identified; six were tested and all were negative by MAT, and of these six, four persons were negative by PCR (two did not have PCR testing). All serosurvey participants (n = 118) were also seronegative. Among animal care providers, bare skin contact with urine/blood from a canine case was reported by 23.2%; two persons reported dog urine splashing in their face. Veterinary technicians were more likely to have bare skin contact with blood from a canine case compared to veterinarians and boarding facility staff (p < 0.001). Infection control practices were inconsistent; when working with specimens from a canine leptospirosis case, 44.6% of participants reported always wearing gloves when working with urine (i.e., collecting specimens), and 54.5% always wore gloves when working with blood. Veterinary technicians were also most likely to engage in all activities involving potential urine/blood contact, such as conducting laboratory tests (p < 0.01). We therefore recommend that veterinary technicians specifically receive targeted education about infection control practices. Our results suggest that dog-to-human transmission of leptospirosis is uncommon.

The significance of bacteriuria in patients with end-stage renal disease (ESRD) on hemodialysis (HD) is unclear. It is not known whether treatment of asymptomatic bacteriuria is associated with lower rates of urinary tract infection or readmission. Adult patients with ESRD on HD were retrospectively evaluated to assess factors associated with the recurrence of bacteriuria and readmission. We included 68 patients in the analysis. There were 20 patients (29.4%) with urinary symptoms. All symptomatic patients received antibiotic therapy, whereas half of the asymptomatic patients received antibiotics. Antibiotic use was not associated with lower rates of readmission or the recurrence of bacteriuria.

Obstructive sleep apnea (OSA) is prevalent with type 2 diabetes. Conversely, nondiabetic patients with OSA are at increased risk of developing insulin resistance and diabetes. These disorders independently contribute to increased cardiovascular and cerebrovascular morbidity and mortality. The pathophysiology of OSA may help explain these associations. Evidence demonstrates that treatment of OSA with continuous positive airway pressure may lead to improvement in insulin sensitivity, hemoglobin A1c, systemic hypertension, and other components of the metabolic syndrome. Recognizing and treating OSA in patients with insulin resistance or diabetes ameliorates OSA-related symptoms and improves cardiometabolic risk.

A 56-year-old Hispanic male with solo risk factor of uncontrolled diabetes mellitus presented with recurrent haemoptysis. Initial concern was for malignancy with postobstructive pneumonia; however, invasive testing and biopsy confirmed infectious mass of fungal aetiology requiring surgical resection followed by a prolonged course of anti-fungal therapy. Discussion centred on approach to, progression of and course of action in the management of pulmonary abscess due to mucormycosis.

Background Bisbee, Arizona is a small mining community established 1880, located 11 miles from the United States–Mexico border with a total population of 5,500 residents. Homes in this town are revealing evidence of colonization by kissing bugs (triatomines), specifically Triatoma recurva, T. rubida, and T. protracta, which are known to harbor the causative agent of Chagas disease, Trypanosoma cruzi. Methods Community members who were bitten by triatomines, provided specimens from their homes, and completed a home evaluation as well as point-of-care testing for Chagas disease (Chagas Detect™ Plus (CDP) Rapid Test, InBiosInternational, Inc.). Results Twenty-two individuals from 17 households consented to participate and provided 117 triatomines collected from inside and/or outside their homes (N = 70 T. rubida; N = 36 T. recurva; N = 11 T. protracta). Trypanosoma cruzi DNA was detected by RT-PCR in 25.6% (30/117) of the total triatomines (31.4% (22/70) T. rubida; 18.2% (2/11) T. protracta; 16.6% (6/36) T. recurva). The median age of homes was 91 years. Mean persons per home was 2.2; with 1.0 dog and 0.8 cat per home. Seventy percent of homes used either a swamp cooler or central air conditioning. Only one home had used pesticides in an attempt to exterminate insects. All homeowners reported various wildlife near their home, including javelina, pack rat, rock squirrel, mule deer, and raccoon (Figure 1). Homeowners were asked to correctly identify these triatomines in a photo line-up of similar insects, and 75% of participants made a successful identification of at least one triatomine, 90.9% being able to identify T. recurva. When asked whether they had changed their sleeping patterns due to triatomine bites, 45.5% (10/22) had done so. The same surveyed group rated their frustration with triatomines in their home on scale of 1–10 (10 being the most frustrated) revealing a mean rating of 6.6; with nine individuals rating 10. CDP rapid testing of these participants (N = 22) were all-negative for serological evidence of T. cruzi infection. Conclusion Despite exposure to T. cruzi-positive triatomines among these household residents, some having sustained hundreds of bites throughout the years, we do not have evidence of transmission of Chagas disease. These are preliminary findings and further study is underway. Figure 1. Disclosures All authors: No reported disclosures.

Background Nocardiosis is a life-threatening opportunistic infection. Solid organ transplant (SOT) recipients are at higher risk (incidence 0.04%-3.5%) of developing nocardiosis. Rate of nocardiosis in the Southwestern US may be high due to environmental factors. Methods We performed a retrospective review study on 54 SOT patients diagnosed with Nocardia between 1997 and 2016 at our center. To explore the association of various risk factors with both the development of disseminated disease and mortality, a series of Fisher's exact tests was used. Findings Incidence of nocardiosis in SOT patients was 2.65%. Fisher's exact tests revealed no association between development of disseminated disease and the following variables: transplant rejection (P = 1), elevated tacrolimus levels (P = .4), and CMV viremia (P = .06). Also, we did not find any association between mortality and the variables we evaluated: type of transplant, transplant rejection, renal failure, disseminated nocardia, and patient's age. Overall mortality and 1-year mortality were 17% and 11%. Interpretation Based on our findings, daily 1 DS TMP/SMX prophylaxis did not appear to provide reliable protection against nocardiosis. However, we could not state definitely that TMP/SMX prophylaxis was or wasn't protective because of lack control group. None of the Fisher's exact tests revealed associations between the tested risk factors and either disease dissemination or mortality. This could be due to a true lack of association between the variables in each pair. However, it is also likely that our relatively small sample size limited our power to detect underlying relationships that may be present. Compared with other studies, 1-year mortality was lower at our institution (11% vs 16%).

Pituitary abscess is a rare intracranial infection that can be life-threatening if not appropriately diagnosed and treated upon presentation. The most common presenting symptoms include headache, anterior pituitary hypofunction, and visual field disturbances. Brain imaging with either computed tomography or magnetic resonance imaging usually reveals intra- or suprasellar lesion(s). Diagnosis is typically confirmed intra- or postoperatively when pathological analysis is done. Clinicians should immediately start empiric antibiotics and request a neurosurgical consult when pituitary abscess is suspected.Escherichia coli(E. coli) causing intracranial infections are not well understood and are uncommon in adults. We present an interesting case of an immunocompetent male with a history of hypogonadism presenting with worsening headache and acute right eye vision loss. He was found to have a polymicrobial pituitary abscess predominantly involvingE. coliin addition toActinomyces odontolyticusandPrevotella melaninogenicain the setting of an apoplectic pituitary prolactinoma. The definitive etiology of this infection was not determined but an odontogenic process was suspected. A chronic third molar eruption and impaction in close proximity to the pituitary gland likely led to contiguous spread of opportunistic oral microorganisms allowing for a polymicrobial pituitary abscess formation.

A 53-year-old man presented to the emergency department with symptoms of bilateral ear pain that developed over the past 8 h. The patient was a chronic cocaine user for the past 35 years and had last inhaled ‘crack cocaine’ on the day of presentation. On examination, both auricles were erythematous and painful to the touch (figure 1). Palpable, non-blanching retiform purpura were evident with a similar non-blanching erythematous patch on both cheeks (figure 2). The anterior portions of both lower extremities had developing purpura (figure 3). Skin necrosis was also found on the right hand (figure 4). Figure 1 Right auricle with haemorrhagic and necrotic lesions in levamisole-associated vasculitis. Figure 2 Characteristic retiform purpura noted on right cheek. Figure 3 Small purpuric …

No abstract available. Article truncated at 150 words. A 65 year-old man with chronic obstructive lung disease (COPD), hypertension and alcohol abuse presented to the emergency department with complaints of feeling unwell and shortness of breath. He was tachycardic but otherwise hemodynamically stable, afebrile, and requiring 3 liters/min supplemental oxygen. Pertinent initial laboratory findings revealed a neutrophilic predominant leukocytosis (WBC 37.8 x 103 micro/L) with lactic acidosis (2.7 mMol/L). Chest radiograph showed a dense opacity within the region of the lingula (Figure 1). Follow-up CT chest confirmed a consolidation likely representing lobar pneumonia in the setting of severe bullous emphysema (Figure 2). A large fluid-containing emphysematous bulla (Figure 3) was present which was not visualized one year prior. He was started on broad spectrum antibiotics after peripheral blood cultures were drawn which revealed Streptococcus pneumoniae. Broad spectrum antibiotics were discontinued and patient was started on intravenous ceftriaxone 2g every 24 hours. He improved clinically and was discharged home …

Background The BioFire FilmArray™ Gastrointestinal (GI) Panel is a 1 hour multiplex real-time PCR test that can detect the presence of 22 GI pathogens (viral, bacterial, and parasitic) known to cause infectious diarrhea. Our tertiary-care academic medical center implemented the GI Panel for all cases of suspected infectious diarrhea replacing the previous conventional testing once utilized to detect GI pathogens. Since its implementation we have not had any criteria for ordering this test to aid healthcare providers. Methods The aim of this IRB approved, retrospective investigation was to determine the appropriateness of ordering the GI panel at our academic institution. Cases were randomly selected, stratified by age group and result (specific pathogens or negative result) from May 2015 through April 2016 in the post-implementation period (n = 400 of 1117 total tests). We developed appropriateness criteria for ordering the GI panel which included: passage of at least 3 unformed stools in 24 hours plus one or more enteric symptom (nausea, vomiting, abdominal pain/cramps, tenesmus, fecal urgency, moderate to severe flatulence), and one of the following: grossly bloody diarrhea (dysenteric), persistent diarrhea (14 – 30 days), worsening or relapsing diarrhea, fever ≥ 101 F°, severe diarrhea > 10 bouts in 24hrs, immunosuppression, pregnancy, food handler, infant < 1 year and their care takers, age ≥ 65 years old, concern for disseminated GI infection, with no previous GI panel testing in the past 30 days. Results Overall appropriateness of GI panel testing based off our generated criteria was 36% (n = 144/400). This included all tests ordered in the outpatient clinics, emergency department, inpatient medical/surgical wards, and intensive care units. Conclusion Currently there is not a well-established standard criteria for ordering the GI panel for investigating suspected infectious diarrhea. After implementation at our academic tertiary-care medical center the GI panel was used inappropriately in most cases without a criteria for ordering in place to aid clinicians. Educating healthcare providers about appropriate testing indications is being performed. Further studies are needed to assess if our generated criteria will lead to decreased costs and unnecessary testing. Disclosures All authors: No reported disclosures.

No abstract available. Article truncated at 150 words. A 64-year-old woman with hypertension, hypothyroidism and prior episode of pericarditis treated with steroids presents with complaints of generalized fatigue, fevers, rigors and body aches for 5 days. The patient recently was evaluated at an outside facility and was found to have normal routine labs and negative blood cultures. She was told that her symptoms were likely related to a viral illness. Further history taking revealed that the patient had recently being staying in a cabin located in the White Mountains of Arizona about one month prior. She was exposed to the outdoors but does not recall any insect bites and did not remove any ticks. The cabin was sprayed with insecticides prior to their arrival. The patient was initially afebrile but exhibiting tachycardia, hypotension, and tachypnea. Repeat complete blood counts revealed Leukopenia (WBC 2.9 x 103/microL) and profound thrombocytopenia (PLT 32 x 103/microL). Patient was admitted to the hospital …

Background The BioFire FilmArray™ Gastrointestinal (GI) Panel is a 1 hour multiplex real-time PCR test that can detect the presence of 22 GI pathogens (viral, bacterial, and parasitic) known to cause infectious diarrhea. Our tertiary-care academic medical center implemented the GI Panel for all cases of suspected infectious diarrhea replacing the previous conventional testing once utilized to detect GI pathogens. Methods The aim of this IRB approved, retrospective investigation was to determine the utility of the GI panel testing vs. the conventional testing to guide patient management. Cases were randomly selected, stratified by age group and result (specific pathogens or negative result) in the pre-implementation period (n = 119 of 1550 samples) from May 2014 through April 2015 and in the post-implementation period (n = 333 of 1117 samples) from May 2015 through April 2016. Results The rate of a positive test for any stool pathogen per patient was 34.2% (n = 342 of 999) for the GI panel and 11.6% (n = 162 of 1391) for conventional testing, P =

A 56-year-old man with a history of injection drug use and two prior episodes of native valve infective endocarditis presented with dyspnoea on exertion. Our preliminary work-up revealed bacteraemia with reported growth of 'Mycobacterium abscessus group' on multiple blood cultures. The patient was later found to have eustachian valve and prosthetic pulmonic valve endocarditis. Initially, he responded to standard antimycobacterial therapy for rapidly growing mycobacteria (RGM) with supporting laboratory susceptibilities. However, he later developed refractory disease and persistent bacteraemia in the setting of these alleged susceptible antibiotics. Further molecular testing revealed a functional and inducible erm(41) gene which confers macrolide resistance. A subspecies analysis of the M abscessus group revealed the subspecies to be abscessus We present a challenging case of M abscessus subsp. abscessus bacteraemia and prosthetic valve endocarditis with further discussion on treatment and management of this infection along with the taxonomic complexity of this ubiquitous RGM.

A 35-year-old man with no known medical history presented to an outpatient clinic, with a warm, erythematous, tender skin lesion that was draining purulent fluid, on his left medial lower extremity (figure 1). The patient denied any similar events and was lacking other systemic symptoms. Vital signs were normal. The remainder of the physical examination was benign. Incision of the lesion yielded purulent drainage that was sent for culture. The wound was then washed with sterile saline and packed with cotton gauze; an elasticised dressing was applied over the top. The patient was given oral doxycycline with instructions to return the next day. Approximately 12 h later, the patient returned with symptoms of worsening left leg pain. The external dressing was removed from the lesion, revealing a black necrotic centre with expanding erythematous borders (figures 2 and 3). Purulent ‘fuzzy’-appearing discharge was noted …

Kissing bugs ( Triatoma spp.) frequently enter homes and bite human and pet occupants. Bites may lead to severe allergic reactions and, in some cases, death. Kissing bugs are also vectors of Trypanosoma cruzi, the cause of Chagas disease. In general, modern houses in the United States are not conducive to domiciliation of kissing bugs (bugs living out their entire life within the home with the presence of eggs, nymphs, adults, and exuviae). Construction features such as concrete foundations, solid walls and ceilings, window screens, tight thresholds for doors and windows, and other measures impede bug entry into homes, and air conditioning reduces the need for open doors and windows. Where Chagas disease is endemic in Mexico and Central and South America, homes often have thatch roofs, adobe walls, and open doors and windows. We investigated numerous instances of kissing bug intrusions into homes in Southern Arizona, California, and Louisiana and documented the reactions to kissing bug bites. Our work confirms the importance of modern home construction in limiting kissing bug intrusions. Older homes, especially those lacking modern screening, caulking, and weather stripping to reduce air leakage, may be subject to kissing bug intrusions and domiciliation. We describe a community in Southern Arizona where domiciliation of homes by Triatoma recurva is common. We also provide recent data regarding kissing bug bites and allergic reactions to the bites.

ABIES deserves to be considered one of the most important of health problems. The number of deaths is not appalling but the suffering and fear caused by it are so great that they make this the most dreaded of all diseases. The co-authors of this paper, having both served at different times as director of the Indiana Pasteur Institute and, having seen. the great increase in the disease in that state, determined to find to what extent this condition prevailed in other states and in other parts of the world. Data on the subject are fragmentary, hard to get, and not at all reliable. Questionnaires were sent to the health officer of every state in the Union, to all the provinces of Canada, and to practically all foreign countries, asking for data on rabies in man and in animals. By this and other means information was received from every state though not always was the information complete. Medical literature was exhaustively searched for references to geographical distribution of the disease and for evidences of its increase or decrease. About thirty foreign countries answered our letter-a most interesting correspondence. A voluminous letter from Japan is still untranslated. From this large mass of evidence we have endeavored to sort out the salient facts, though we are keenly aware of the fact that much of the data is conflicting, as for example the total number of human deaths as reported to us by states, and as reported by the Bureau of the Census for the U. S. Registration Area. In order to show present conditions in as graphic a manner as possible we have attempted to shade a map of the United States to represent the prevalence of rabies. This map was made as nearly as possible on the same scale as another published by Sellers' representing conditions in 1921, also presented here. Sellers's shading is made on basis