Disaster Medicine and Public Health Preparedness

Research Article

Unexplained Deaths in Connecticut, 2002–2003:Failure to Consider Category A Bioterrorism Agents in Differential Diagnoses

John P. Palumbo c1, James I. Meek, Darcy M. Fazio, Susan B. Turner, James L. Hadler and André N. Sofair


Background: Recognition of bioterrorism-related infections by hospital and emergency department clinicians may be the first line of defense in a bioterrorist attack.

Methods: We identified unexplained infectious deaths consistent with the clinical presentation of anthrax, tularemia, smallpox, and botulism using Connecticut death certificates and hospital chart information. Minimum work-up criteria were established to assess the completeness of diagnostic testing.

Results: Of 4558 unexplained infectious deaths, 133 were consistent with anthrax (2.9%) and 6 (0.13%) with tularemia. None were consistent with smallpox or botulism. No deaths had anthrax or tularemia listed in the differential diagnosis or had disease-specific serology performed. Minimum work-up criteria were met for only 53% of cases.

Conclusions: Except for anthrax, few unexplained deaths in Connecticut could possibly be the result of the bioterrorism agents studied. In 47% of deaths from illnesses that could be anthrax, the diagnosis would likely have been missed. As of 2004, Connecticut physicians were not well prepared to intentionally or incidentally diagnose initial cases of anthrax or tularemia. More effective clinician education and surveillance strategies are needed to minimize the potential to miss initial cases in a bioterrorism attack. (Disaster Med Public Health Preparedness. 2008;2:87–94)

(Received August 20 2007)

(Accepted November 05 2007)

Key Words

  • unexplained deaths;
  • Category A bioterrorism agents;
  • electronic death data;
  • infectious disease;
  • public health preparedness/response


c1 Correspondence and reprint requests to John Palumbo, MS, CT Emerging Infections Program, One Church Street, 7th Floor, New Haven, CT 06510(e-mail: john.palumbo@yale.edu).

Mr Palumbo, Mr Meek, Ms Fazio, Ms Turner, and Dr Sofair are with the Connecticut Emerging Infections Program, Yale University School of Medicine, Department of Epidemiology and Public Health. Dr Hadler is with the Connecticut Department of Public Health.