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705 Vol. 4, No. 4, OctoberDecember 1998 Emerging Infectious Diseases Letters Among the 54 reporting systems for which further information was obtained, clinical diagnoses (in some countries laboratory con- firmed) are reported through the hierarchical chain, normally by mail or facsimile, but in two countries by electronic links. Almost all military reporting systems are parallel to civilian systems. Thirty-four (63%) of 54 systems feed into the civilian system, with a built-in mechanism to avoid duplicate reporting; 16 (30%) systems feeding into the civilian system have no such mechanism in place; and four have no link with the civilian system. The third survey addressed vaccination policies. Among 52 countries that replied, 47 (90%) have a compulsory military vaccination schedule: 45 (87%) for tetanus, 30 (58%) for diphtheria, 23 (44%) for typhoid, 16 (31%) for bacillus Calmette-Guerin and polio, 12 (23%) for meningococcal meningitis, and 10 (19%) for measles, mumps, and rubella. These surveys show that military popula- tions are protected against many infectious diseases and that a wealth of information is obtained by military laboratories and health- care facilities on populations at high risk for infectious diseases. While most of the informa- tion collected from the health-care facilities is reported through civilian systems as well, incorporating the military network of laborato- ries into the WHO global surveillance network could ensure broader coverage. Raffaele DAmelio* and David L. Heymann *Ministero della Difesa, Direzione Generale Sanita Militare, Roma, Italy; and World Health Organization, Geneva, Switzerland Reference 1. Heymann DL, Rodier GG. Global surveillance of CommunicableDiseases.EmergInfectDis1998;4:362-5. Dual Infection with Ehrlichia chaffeensis and a Spotted Fever Group Rickettsia: A Case Report To the Editor: In their article, Daniel J. Sexton et al. state, Well- documented cases of simulta- neous human infections with more than one tick- borne pathogen are rare (1) and mention only two reports of such cases. However, another report should be mentioned because of its historical interest and the lessons it may teach.

Editor: In their article, Daniel J. Sexton et al. state, Well- documented cases of simulta- neous human infections with more than one tick- borne pathogen are rare (1) and mention only two reports of such cases. However, another report should be mentioned because of its historical interest and the lessons it may teach. In 1900 to 1905, in the Bitter Root Valley, a tick-borne disease emerged, which became known as Rocky Mountain spotted fever. Although Ricketts et al. later published a report (2), which identified the causative agent, in 1904 L.B. Chowning and W.M. Wilson published Studies on Pyroplasma hominis (3). They reported finding Pyroplasma (since changed to Babesia) in the blood of approximately 20 patients with spotted fever. They studied this organism in detail and even found the reservoir for it in the local rodent species. Wilson et al. thought that the organism was the causative agent of spotted fever. On the basis of their excellent plates and descriptions, it is clear that the organism they were describing was what we later came to know as Babesia microti. The work of Wilson and Chowning was ignored and forgotten for many years. They had incorrectly concluded that spotted fever was caused by a parasite. For many years it was well known that Babesia infections became apparent in human patients only on removal or inactivation of the spleen. That persons with functional spleens were subject to infection with B. microti was finally established by the so-called Nantucket outbreak (4) and subsequent publications. Therefore, Wilson and Chownings work reports several cases of simultaneous infections of humans by two tickborne pathogens; i.e., patients had spotted fever and B. microti in the blood. More poignant was that an emerging disease of humans was missed and not discovered again for some 70 years. Alexander J. Sulzer Fellow, American Academy of Microbiology; Fellow, emeritus, Royal Society of Tropical Medicine and Hygiene; Member, emeritus, American Society of Tropical Medicine and Hygiene References 1. SextonDJ,CoreyGR,CarpenterC,KongLQ,GandhiT, Breitschwerdt E, et al. Dual infection with Ehrlichia chaffeensis and a spotted fever group rickettsia: a case report. Emerg Infect Dis 1998;4:311-6. 2. Ricketts HT. Some aspects of Rocky Mountain spotted fever. Rev Infect Dis 1909;1227-40. 3. Wilson LB, Chowning WM. Studies on Pyroplasma hominis. Rev Infect Dis 1904;1:31-57. 4. Ruebush TK, Juranek DD, Chisholm ES, Snow PC, Healy GR, Sulzer AJ.

ed fever group rickettsia: a case report. Emerg Infect Dis 1998;4:311-6. 2. Ricketts HT. Some aspects of Rocky Mountain spotted fever. Rev Infect Dis 1909;1227-40. 3. Wilson LB, Chowning WM. Studies on Pyroplasma hominis. Rev Infect Dis 1904;1:31-57. 4. Ruebush TK, Juranek DD, Chisholm ES, Snow PC, Healy GR, Sulzer AJ. Human babesiosis on Nantucket Island. N Engl J Med 1977;297:825-87.