Minnesota Department of Health (MDH) Bug Bytes
January 7, 2002
Vol. 3: No. 1
1. MARC Website is Live!
The Minnesota Antibiotic Resistance Collaborative (MARC) is a broad-based collaborative whose mission is to decrease antibacterial resistance and promote the appropriate use of antibiotics in Minnesota. MARC member organizations include: MDH, BlueCross BlueShield BluePlus of Minnesota, HealthPartners, Medica, Minnesota Medical Association, Minnesota Pharmacy Association, PreferredOne, StratisHealth, and UCare of Minnesota. MDH has developed the MARC website and it is now live at http://www.minnesotaarc.org/. Visit the MARC website for educational materials, related links and information about the Minnesota Adult Cough and Cold Care Kits. The site contains resources for health care providers, adults, parents of young children, and childcare providers. We welcome your feedback.
2. Smallpox Plan
Due to concerns that smallpox virus may be used for bioterrorism, the Centers for Disease Control and Prevention (CDC) has updated its smallpox response plan and guidelines (at http://www.bt.cdc.gov/DocumentsApp/
Smallpox/RPG/index.asp). The guidelines are for state and local health departments to assist them in developing smallpox outbreak response plans; however, you may wish to read and provide comments on them to CDC. We are continuing with our bioterrorism preparedness efforts including planning for smallpox.
3. Suspect Infant Botulism
Last week we received a call regarding a case of suspect infant botulism in a six month-old who had displayed fussy behavior, poor feeding, and then progressive difficulty breathing which eventually required mechanical ventilation. We tested stool for botulinum toxin by mouse neutralization and cultured stool and gastric aspirate for Clostridium botulinum; all tests were negative.
According to Dr. Stephen Arnon, Chief of California Department of Health Services Infant Botulism Treatment and Prevention Program, of the three forms of botulism (foodborne, wound and infant), infant botulism is the most recently recognized, and the most common in the U.S. Infant botulism results when ingested C. botulinum spores germinate, colonize the colon, and in it produce botulinum neurotoxin. All cases of infant botulism reported to date have occurred in children less than 1 year of age; 95% of cases occur in the first 6 months of life. Honey is the one dietary reservoir of C. botulinum spores thus far definitively linked to infant botulism by both laboratory and epidemiologic evidence but it does not account for all cases.
The onset of infant botulism ranges from insidious to abrupt. Some patients are nursing normally 6 hours before becoming so floppy that acute meningitis is the suspect diagnosis, and at the other extreme are patients who returned to their physicians several times as the signs of illness gradually became manifest. Botulism is manifested clinically as a symmetric, descending paralysis. Early on, weakness and hypotonia characterize the illness. The first signs of illness are found in the cranial nerves; bulbar palsies are always present. The typical patient has an expressionless face, a feeble cry, ptosis (evident when the eyelids must work against gravity), poor head control and generalized weakness and hypotonia. Eye muscle paralysis varies, and the pupils are often midposition and initially briskly reactive. The gag, suck and swallow reflexes are impaired. In hospitalized patients, the case-fatality ratio is less than 1%.
The diagnosis of infant botulism is established by identification of C. botulinum organisms in the feces. If the fecal specimen is obtained early enough in illness, it will also contain botulinum toxin. A mouse neutralization test remains the most sensitive and specific assay for botulinum toxin. Laboratory diagnosis that identifies the toxin type responsible for illness is essential for the case to be registered as infant botulism and is important to prognosis; mean hospital stay is significantly longer in type A cases. MDH is the only lab in the state that conducts mouse neutralization tests for botulinum toxin.
Specific treatment for infant botulism is now available. A recently completed 5-year, randomized, double-blinded, placebo-controlled treatment trial demonstrated the safety and efficacy of human-derived botulinum antitoxin, formally known as botulism immune globulin (BIG). Use of BIG reduced mean hospital stay per case from approximately 5.5 weeks to approximately 2.5 weeks and reduced mean hospitalization cost per case by approximately $70,000. Treatment with BIG should be started as early in the illness as possible. BIG may be obtained from the California Department of Health Services under a U.S. Food and Drug Administration-approved Treatment Investigational New Drug protocol; we can assist you in this process.
Please call us at (612) 676-5414 for assistance or to report a suspect case.
4. Meningococcal Disease Death
On Christmas morning, a 15 year-old Anoka County resident was admitted to a hospital with an initial presentation of confusion and combativeness; he quickly became lethargic and unresponsive. His CSF and blood cultures grew out Neisseria meningitidis, later confirmed by us as serogroup Y. He died on 12/26/01. Household and other close contacts were notified and given antibiotics.
In 2001 there were 27 cases of meningococcal disease reported, including 4 deaths. The ages of the 4 deaths were 15, 19, 49, and 85 years. Two of the deaths were serogroup C and 2 were serogroup Y.
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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