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West Nile virus is naturally transmitted through mosquito bites. This year, the U.S. is experiencing its worst outbreak of West Nile fever since the virus was first detected in this hemisphere, in 1999 in New York City. Over the weekend, the total number of cases has risen to 638, including 31 deaths. The theoretical possibility of transmitting West Nile Virus through blood transfusions and questions about the nation's blood supply were put to a real test in recent days because of the detection of West Nile infection in one recipient of the donor's organs. That recipient has encephalitis, or inflammation of the brain. Three other recipients, in Georgia and Florida, of the same donor's organs are suspected of developing West Nile fever. Preliminary tests of a patient who died with encephalitis after receiving a kidney from the donor show evidence of infection with a mosquito-borne virus. Further tests are needed to prove it is West Nile virus

Because blood is involved in the natural transmission of West Nile -- through mosquito bites -- doctors have theorized that West Nile could be transmitted through transfusions and organ transplants. Two weeks ago, health officials said they reminded the nation's blood banks to enforce a standard procedure -- rejecting donations from patients with fever and flulike symptoms, which could be symptoms of mild West Nile fever. Dr. [Jesse Goodman] said he would not expect people who have recovered from an infection to have West Nile virus in their blood for long because by the time symptoms develop, the virus is difficult to detect. In such cases, evidence of West Nile infection is based on detecting the specific antibodies that a patient's immune system develops in response to the infection. ''It is very important to recognize that unlike H.I.V. or hepatitis, West Nile virus is an acute infectious disease and we are unaware of any kind of chronic carrier state,'' Dr. Goodman said. He also said: ''If I were a person with severe chronic disease and I needed an organ transplant, concern about this would be right at the bottom of my list of things that I was worried about. Similarly, if I needed a transfusion this would be at the bottom of the list of my concerns. If I lived in an area where West Nile was circulating, which is much of the country at the moment, my greatest concern about West Nile would be to take precautions to minimize my risk of being bitten by mosquitoes.''

Three of the four recipients of organs from a single donor who had West Nile virus also developed West Nile encephalitis, strengthening the possibility that the virus can be transmitted through organ transplants or blood, federal health officials said last night. The new tests do not necessarily prove that the three patients acquired West Nile encephalitis from the organ transplants. Because the three recipients lived in Georgia and Florida, where infected mosquitoes have transmitted the virus to humans and birds, a remote possibility exists that all three acquired the West Nile virus through insect bites. Dr. [Jesse Goodman] said he was not aware that blood centers had conducted research to randomly test donated blood for the West Nile virus. A concern is that most people infected with West Nile virus have no symptoms but could have the virus in their blood when they donate. But unlike H.I.V. and hepatitis, West Nile virus is an acute infectious disease and chronic carriers have not been detected, Dr. Goodman said

The centers' new director, Dr. Julie L. Gerberding, said some of the problems presented by the West Nile outbreak were similar to those the agency would confront in a biological attack, in that communities were threatened by a seemingly novel microbe. She said the agency was drawing useful lessons from its experiences with West Nile, and applying lessons it had learned in the anthrax outbreak. There is wide agreement in and out of the agency that lack of openness was a major problem in the anthrax outbreak. Particularly embarrassing to C.D.C. workers, hundreds of whom were investigating the anthrax outbreak, was that the government's leading scientific spokesman on the attack was the director of a rival agency, Dr. Anthony S. Fauci of the National Institute of Allergy and Infectious Diseases. Dr. Gerberding said she had also reorganized the centers' schedule of scientific and administrative meetings to avoid the duplication that she said was ''extremely disruptive'' in the anthrax outbreak. And she said she would streamline the operation of the agency's headquarters, which was so cumbersome that members of the anthrax investigating team often learned about developments in the case from news reporters

The officials reported six such cases and said they were working to determine the frequency of the polio-like syndrome, which doctors have reported in past years. The paralysis from West Nile is painless and usually does not involve loss of sensation. Its tendency to affect only one side of the body and the preservation of sensation distinguish West Nile paralysis from Guillain-Barre, which usually affects both sides of the body and usually involves changes in sensation

Doctors were urged to perform tests to distinguish Guillain-Barre Syndrome or strokes from West Nile because treatments for those two conditions have risks and would be useless for those with West Nile fever. No specific treatment exists for West Nile fever beyond supportive care like good nursing and mechanical respirators when needed. The West Nile virus is closely related to one that causes St. Louis encephalitis. The pattern of the current West Nile epidemic resembles an epidemic of St. Louis encephalitis with nearly 2,000 cases in 1975, Dr. [Lyle Petersen] said. Additional evidence that West Nile virus can be transmitted through transplants came yesterday from scientists at the New York state health department who tested organs and tissues from a patient who died of the infection. Dr. Dale L. Morse and Dr. Guthrie S. Birkhead of the health department said that their team had detected West Nile virus throughout the patient's body, including virtually every organ that can be transplanted. The patient's organs were not transplanted

Because the vaccine is classified as ''investigational'' permission is required from any patient before receiving it. In the event mass vaccinations are offered, Dr. [Julie L. Gerberding] said, the C.D.C. has prepared a videotape in which she explains the risks and benefits of the vaccine with the hope that the tape will ease the permission process

Federal health officials issued their most comprehensive plan for containing an outbreak of smallpox in the event of a bioterrorist attack

In releasing their most comprehensive smallpox preparedness plan to date, officials at the federal Centers for Disease Control and Prevention said publicly for the first time that even one case of smallpox might result in a nationwide program of voluntary vaccinations. That is in part because even a single case could be a harbinger of a larger outbreak and in part because even one case would undoubtedly spark panic and a clamor for vaccine. The new document does not supplant the ''ring vaccination'' plan, Dr. [Julie Gerberding] said. But Dr. Bill Bicknell, a professor of international health at Boston University critical of that strategy, said the guide was undoubtedly influenced by recent studies showing that ring vaccination would not contain a large outbreak. He said studies had found that if 1,000 people were infected in a large city like New York and ring vaccination were used, within three months there would be 300,000 cases of smallpox and 100,000 deaths and the epidemic would not be contained. But mass vaccination, he said, would contain such an epidemic in 40 to 45 days, with 1,500 cases and 500 deaths. Federal officials began building a smallpox vaccine stockpile after last year's anthrax attacks. Mr. [Tommy G. Thompson], the health secretary, signed contracts with two companies to buy 209 million doses to add to the existing stockpile of vaccine, some of which dates to the 1950's. In the interim, studies have shown that the existing stockpile could be diluted

The drug, T-20 or enfuvirtide, is a member of a new class of drugs called fusion inhibitors that attack H.I.V., the virus that causes AIDS. When added to combinations of standard drugs, injections of T-20 significantly reduced high levels of H.I.V. in the blood among patients who it had been documented were infected with resistant virus compared with those who took the standard drugs. Once started, lifetime treatment of H.I.V. is needed, AIDS experts say. But because the T-20 trials lasted 24 weeks, the long-term benefits and dangers of the drug are not known. So H.I.V. resistance to T-20 could eventually become a problem, Dr. [Anthony S. Fauci] and other AIDS experts said. T-20 blocks H.I.V.'s cell machinery at a site different from any of the standard anti-H.I.V. drugs. Existing anti-H.I.V. drugs disrupt enzymes in the virus; T-20 blocks the entry of H.I.V. into body cells. That entry, a process called fusion, releases the virus's genetic material and allows it to replicate