Minnesota Department of Health (MDH) Bug Bytes

October 15, 2001
Vol. 2: No. 19

Topics in this Issue:

1. Bioterrorism -- Heightened Surveillance and Anxiety
2. E. coli O157:H7, Apples, Diarrhea, and the Beauty of PFGE
3. Meningitis Fatality Due to Streptococcus pneumoniae
4. Rabies Alert

1. Bioterrorism -- Heightened Surveillance and Anxiety
We were at a heightened state of readiness for bioterrorism prior to October 4. The news of inhalation anthrax from Boca Raton and New York City was startling and made us ever more alert. Fearing possible simultaneous releases, we instituted quick active surveillance with intensive care units and medical examiners across the state for any critical illnesses or deaths possibly due to anthrax or other agents of bioterrorism. Thanks for your timely responses! We also have developed a temporary ongoing surveillance effort with ICPs (thank you also!).

We continue to receive many calls from the public regarding bioterrorism and have many resources available on our website (at http://www.health.state.mn.us/divs/
and updated situational reports at http://www.health.state.mn.us/divs/
). Many of the callers want to know about antibiotics and/or vaccine for anthrax and smallpox, and our fact sheets cover these issues. Our favorite caller asked whether or not anthrax was being put into her cigarettes; we assured her that MDH is confident her cigarettes are safe (at least from anthrax, but not from carcinogens).

Beginning October 12, we began receiving hundreds of calls from persons receiving envelopes, some with powder in them, wondering about their risk of anthrax. We opened an information "warmline" (hate to raise it to the level of a hotline) that stayed open late Friday night and all day Saturday. The Minnesota Division of Emergency Management also opened a hotline. We are working closely with them and law enforcement officials to develop screening procedures. We have a protocol in place, posted on our website, to assess the risk and determine the need for environmental testing. There was a credible incident at the Science Museum of Minnesota last week and we did test the contents of a satchel that was thought to have been deliberately left in the museum; all tests were negative for pathogens. Several other instances have been assessed to be credible enough to warrant environmental sample testing at MDH; results are pending.

Obviously we have a new thought about anthrax and bioterrorism - we must now consider cutaneous anthrax as well as inhalation anthrax. We have put up materials on our website regarding cutaneous anthrax including photos of cutaneous anthrax. Clinicians should be aware of the signs and symptoms of cutaneous anthrax.

If you have any questions or if you have any patients with suspicious illness, please call us at (612) 676-5414.

2. E. coli O157:H7, Apples, Diarrhea, and the Beauty of PFGE
On October 5 we became aware of a cluster of cases of E. coli O157:H7 in children attending a preschool in Hennepin County. Over the weekend we interviewed parents of children and ultimately determined that there were 10 culture confirmed cases and 7 suspect cases (i.e. bloody diarrhea). Two children were hospitalized with HUS.

Onset dates were tightly clustered in time between September 28-October 4 suggesting a point source outbreak. All of the preschoolers had visited an apple orchard on either September 25, 26, or 27. There they had eaten apples and apple donuts, and a few had drunk pasteurized cider. We had no other evidence of ill children in the preschool so we began to look more closely at the apple orchard as being the source of infection. There have been reported outbreaks of E. coli O157:H7 associated with apples and apple cider contaminated with cow or possibly deer feces. However, there were no other contemporaneous cases of E. coli O157:H7 occurring in Minnesota, making the apple hypothesis less plausible.

Once the PFGE subtype of the case isolates was known, we re-interviewed a previously reported case unrelated to this outbreak with the same PFGE subtype. This case was a child who had symptom onset in mid-September. While symptomatic, that child had had contact with a child who attended the preschool. We found out that this preschooler had a diarrheal illness prior to the orchard field trips and had attended the preschool and gone on the field trip while ill with diarrhea. We obtained a stool sample from this pre-schooler; results are pending. Case attack rates were higher in the classroom attended by this child. Thus, we conclude that this was an outbreak of E. coli O157:H7 due to person-to-person transmission. Once again, the value of routine isolate submission and PFGE subtyping by our lab has been demonstrated in determining the source of this outbreak.

3. Meningitis Fatality Due to Streptococcus pneumoniae
Two cases of pneumococcal meningitis in young children, including one fatality have been reported to us this month. Pneumococcal and meningococcal meningitis are the most common causes of meningitis in children since the introduction of Haemophilus influenzae type b conjugate vaccine in 1988. The 7-valent pneumococcal conjugate vaccine for children was licensed in 2000. In 1999, 18 cases (1 fatal) of pneumococcal meningitis in children less than 10 years old were reported to MDH. Nine of 14 (64%) of the isolates with known serotypes were among the seven serotypes included in the vaccine. In 2000, the overall incidence of invasive pneumococcal disease dropped and there were 10 cases (1 fatal) of pneumococcal meningitis in children under the age of 10. Four of six (67%) cases with a known serotype were serotypes included in the vaccine. So far in 2001, there have been 11 cases (2 fatal) of pneumococcal meningitis reported in the same age group with 5 of 9 (56%) cases with known serotype having a vaccine serotype. Current recommendations are for children under age 2 years to be given vaccine and for those 2-5 years in certain higher risk groups (at http://www.cdc.gov/mmwr/preview/

4. Rabies Alert
On October 10 a dog brain submitted to our laboratory tested positive for rabies. This dog, a 5 year-old chocolate Labrador, had attacked a young girl on October 6. Despite extensive facial wounds the girl was not put on rabies postexposure prophylaxis until October 10. Health care providers should be familiar with the recommendations and consult with us 24 hours/day at (612) 676-5414.

We interviewed the owner of the dog and found out that the dog was often allowed to run free on the farm which included a self service produce (pumpkins, gourds, and squash) stand. The owner could not say for certain that a customer might have stopped, been bitten by the dog, and then left without having been seen by the owner. Therefore, we issued a press release to alert such persons of the need for rabies postexposure evaluation. The farm is Adamek's Farm located mile southwest of Randall on Dove Road (formerly Highway 1) off of Highway 10.



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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Updated Friday, November 19, 2010 at 02:16PM