Supplementary Material for: An Aggregate of Four Anthrax Cases during the Dry Summer of 2011 in Epirus, Greece

Background: Human anthrax is currently a sporadic disease in Europe, without significant regional clustering. Objective: To report an unexpected aggregate of anthrax cases and correlate local climatic factors with yearly anthrax admissions. Methods: Clinical description of a geographical-temporal anthrax aggregate, correlation of disease admissions with local weather data in the period 2001-2014 and literature reports of anthrax clusters from Europe in the last 20 years. Results: We identified 5 cases, all cutaneous: an unexpected aggregate of 4 cases in mid-summer 2011 (including a probable human-to-human transmission) and a sporadic case in August 2005, all in relatively dry periods (p < 0.05). Remarkably, 3/6 reports of human anthrax aggregates from Europe were observed in Balkan Peninsula countries in the year 2011. Conclusion: In the light of the predicted climatic change, unexpected anthrax aggregates during dry periods in southern Europe underscore the risk of future anthrax re-emergence on this continent.