Minnesota Department of Health (MDH) Bug Bytes
February 1, 2001
Vol. 2: No. 3
1. Typhoid Fever in a Somali Refugee
Last week we were informed of a case of Salmonella typhi in a 30-year-old male Somali refugee. His symptoms included abdominal pain, muscle aches, headache and fever. Blood cultures revealed Salmonella typhi. The Salmonella typhi isolate was resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole, but was sensitive to ciprofloxacin. The patient emigrated to the U.S. in October, and had not traveled since then. It is unclear if he is a chronic carrier of Salmonella typhi, or if he contracted the illness from a contact here in Minnesota. This patient's symptoms were fairly typical for an acute case of typhoid fever. In particular, fever, headache, and abdominal pain are common. Typically, patients have a relative bradycardia, meaning that their pulse rate is slower than one would expect given their high fever. Also, typhoid fever is commonly associated with constipation, not diarrhea. Diagnosis in acute cases is confirmed with blood culture, although patients can have prolonged fecal shedding without symptoms (such happened to Mary Mallon, better known as Typhoid Mary who infected 22 New Yorkers [one of whom died] between 1900-1907 through her work as a cook). Typhoid fever remains an important travel medicine issue; 200-400 cases are reported annually in the US and most are travel-associated. Typhoid vaccine is recommended for travelers to areas of the world with recognized risk (Latin America, Asia, Africa) who have prolonged exposure to potentially contaminated food and drink.
2. Rash Illness Outbreak In early December, we were notified of a suspect rubella case in an infant Apple Valley resident. The initial diagnosis of this child was chickenpox and was subsequently diagnosed as rubella because the rash did not develop into blisters characteristic of chickenpox. The child attended a childcare center; 8 other ill children were noted in the same infant classroom (age range of 6 to 16 months). A 4 year-old sibling of a child in the infant classroom was also ill. Upon further investigation by the Dakota County Public Health Department, various symptoms among children were identified including rash (with no consistent pattern among children), cough, coryza, diarrhea, fever (range 100.4 to 104.5° F), and conjunctivitis. Four children had laboratory specimens collected by their private providers. Serum was obtained to test for rubella antibody on all four; all were negative. One also tested negative for measles antibody. Three had throat specimens collected: 2 were positive for enterovirus (one child in the infant classroom and the 4 year-old) and 1 was positive for adenovirus (the 4 year-old's infant sibling). Because of the varied symptoms, stool and throat specimens were obtained for viral culture at MDH from all of the ill children. All throat specimens tested by MDH were negative. Six children only had enteroviruses, specifically echovirus 9, identified in stool. Three children had adenovirus 1, identified in stool. One child had both enterovirus and adenovirus identified in stool. Viral rash illness outbreaks are common among young children; however, for most outbreaks the agent is not specifically identified because a ubiquitous virus is suspected. Due to further investigation and laboratory work, MDH and Dakota County Public Health were able to identify the cause of this rash illness outbreak.
3. Nevirapine - To Treat or Not to Treat
CDC recently issued a warning on the use of nevirapine (NVP) for postexposure prophylaxis (PEP) after occupational exposure to HIV (MMWR January 5, 2001). Twenty-two cases of serious adverse events including a case of fulminant hepatitis and hepatic failure necessitating a liver transplant and a case of life threatening fulminant hepatitis were reported in persons receiving NVP for PEP. NVP has never been recommended for basic or expanded PEP regimens. The risks of the exposure need to be weighed against the risks of the drugs prescribed for PEP. PEP guidelines are at:
mmwrhtml/00052722.htm. Attention: Non-MDH link This warning does not apply to NVP use in other settings. Single dose NVP is a recommended regimen for the prevention of perinatal HIV transmission. Perinatal HIV prevention guidelines are at: http://hivatis.org/guidelines/perinatal/
Nov_00/text/PerinatalNov00.pdf. Attention: Non-MDH link PEP regimens are continually evolving. Two excellent resources are: PEPLine: 1-888-HIV-4911 (24 hours) and PEPNET http://epi-center.ucsf.edu/PEP/PEPNet.html. Attention: Non-MDH link
4. TB Guidelines
We recently developed guidelines for making decisions about tuberculosis (TB) screening of students in elementary, secondary, and post-secondary schools. These guidelines were developed in collaboration with a multi-disciplinary workgroup of school nurses, public health professionals, clinicians, and others. The guidelines emphasize several concepts, including: a) universal TB screening of all students is not recommended; screening should be targeted to students at highest risk for TB, b) decisions about instituting a school-based TB screening program should be made jointly by local public health agencies in collaboration with school nurses and administrators, and c) school-based TB screening programs should be implemented only if they include plans for providing necessary clinical follow-up and treatment indicated for students identified with latent TB infection or TB disease. For post-secondary schools, we recommend TB screening targeted to international students originating from countries where TB is common and students involved in extensive international travel to such areas. We also developed several practical tools (e.g., fact sheets and prototype letters to parents) for use by school staff following the diagnosis of a case of TB disease in the school setting. These recommendations and corresponding resources are available at http://www.health.state.mn.us/tb or by calling us at (612) 676-5414.
5. In Memory of Edward Jenner
Last Friday, January 26, marked an important date. On that date in 1823 Edward Jenner died of a stroke. Born in 1749, orphaned at age 5, Jenner was trained in medicine. In 1796, Jenner successfully "vaccinated" (this word emanates from his work; from Latin, vacca for cow) 8 year-old James Phipps, his gardener's son, against smallpox using material obtained from the pustule of a milkmaid (which contained cowpox). Interestingly, Jenner was successful in other areas as well. In 1789 he was made a Fellow of the Royal Society for his work on the nesting behavior of cuckoos. He was seeing patients, including the local coroner who curiously also had had a stroke, the day he died.
6. Legislative Proposal
You may have read that MDH is seeking funding from the Legislature to address "Emerging Health Threats." Much of the money would be directed toward environmental health issues: detecting and evaluating hazardous substances in the environment, dealing with the exposures from illicit methamphetamine labs, and responding to disasters. Some of the funding would deal with issues Bug Bytes readers are directly involved in. The MDH Clinical Laboratory is facing drastic cutbacks in federal funding that supports core lab benchtop personnel. Without these lab persons, we would simply not be able to respond to infectious disease issues. Additionally, we are seeking funds to address antibiotic resistance, information technology upgrades, and planning for public health emergencies. As the legislative session proceeds, you may hear more about this proposal and we welcome your input and support.
Bug Bytes is a combined effort of the Infectious Disease Epidemiology, Prevention and Control Division and the Public Health Laboratory Division of MDH. We provide Bug Bytes as a way to say THANK YOU to the infection control professionals, laboratorians, local public health professionals, and health care providers who assist us.
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