Diagnostic Methods Used to Classify Confirmed and Probable Cases of Spotted Fever Rickettsioses - United States, 2010-2015

Abstract

Spotted fever rickettsioses (SFR), including Rocky Mountain spotted fever (RMSF), are nationally notifiable diseases in the United States caused by spotted fever group Rickettsia. The annual incidence of SFR increased from 1.7 cases per 1 million persons in 2000 to 13.2 in 2016 (1,2). Although this demonstrates a substantial increase in SFR cases, the actual magnitude of the increase is questionable because the current case definition allows for nonspecific laboratory criteria to support diagnosis (3). To analyze the quality of laboratory data used to support the diagnosis of SFR cases with illness onset during 2010-2015, CDC examined supplementary case report forms. Among 16,807 reported cases, only 167 (1.0%) met the confirmed case definition, and the remaining 16,640 (99.0%) met the probable case definition. The most common supportive laboratory evidence for probable cases was elevated immunoglobulin G (IgG) antibody titer by indirect immunofluorescence assay (IFA), which was reported for 14,784 (88.8%) probable cases. Antibodies to spotted fever group Rickettsia can persist for months or years following infection, making a single antibody titer unreliable for diagnosing incident disease without a convalescent specimen. Increased use of molecular assays and use of paired and appropriately timed IFA IgG testing practices could improve understanding of SFR epidemiology and increase the accuracy of disease incidence estimates.

FIGURE

Summary of laboratory methods used to classify confirmed and probable cases of spotted fever rickettsiosis (SFR) — United States, 2010–2015 *^,†,§ Abbreviations: EIA/ELISA = enzyme immunoassay/enzyme-linked immunosorbent assay; IFA = immunofluorescence assay; IgG = immunoglobulin G; IgM = immunoglobulin M; IHC = immunohistochemistry; PCR = polymerase chain reaction. * “Confirmed SFR” and “Probable SFR” classifications are mutually exclusive; cases cannot be included in both categories. ^† Percentages for “Seroconversion demonstrated by IFA in paired IgG titers” and “PCR, IHC, or culture positive” might not sum to 100% because categories are not mutually exclusive. Percentages for “IFA IgG positive” and “Other supportive laboratory evidence” also might not sum to 100% because categories are not mutually exclusive. ^§ One case was reported confirmed by both “PCR” and “Seroconversion demonstrated by IFA in paired IgG titers.”