Minnesota Department of Health (MDH) Bug Bytes
March 10, 2003
Vol. 4: No. 3
1. Resistant Gonorrhea
Three ciprofloxacin-resistant Neisseria gonorrhoeae isolates were identified in Minnesota in 2002 (minimal inhibitory concentrations > 1.0 µg/ml). All three infected persons were heterosexual males. One of the infections was linked to recent travel to Southeast Asia. The other two infections may have been acquired locally.
These cases, along with recently reported increases of fluoroquinolone-resistant
N. gonorrhoeae in Hawaii and California, highlight
the ongoing need for monitoring antimicrobial susceptibilities
of gonococcal isolates in Minnesota (see MMWR at http://www.cdc.gov/mmwr/preview/
mmwrhtml/mm5146a1.htm). Because the prevalence of resistance in Minnesota is still relatively low, fluoroquinolones can continue to be administered for treatment of uncomplicated gonococcal infections not acquired in Asia, the Pacific Islands including Hawaii, California, or other areas with increased prevalence of fluoroquinolone resistance. For persons who might have acquired gonorrhea infection in those areas, the current CDC recommended treatment is ceftriaxone 125 mg IM.
More information regarding treatment is available in the CDC 2002 Treatment Guidelines at http://www.cdc.gov/std/treatment/TOC2002TG.htm and in the CDC Notice to Readers at http://www.cdc.gov/std/treatment/Cefixime.htm.
Healthcare providers are encouraged to routinely obtain travel histories of patients suspected to have gonorrhea (and their sex partners) and to be alert for treatment failures. Clinicians and laboratories should report suspected treatment failures and resistant gonococcal isolates to us at 651-201-5414.
2. World TB Day, March 24
Monday, March 24, 2003, marks the 21st annual observance of World TB Day. This is the anniversary of the date in 1882 when Dr. Robert Koch announced the discovery of the tubercle (TB) bacillus, paving the way for the development of medications to treat a disease that had been a major cause of morbidity and mortality for centuries. Today, TB remains a leading infectious disease killer worldwide. According to the World Health Organization, more than 20,000 people develop active TB and 5,000 die from the disease every day. The TB epidemic continues to increase by 3% each year globally and by 10% annually in sub-Saharan Africa, fueled largely by the HIV/AIDS epidemic.
While the number of TB cases reported in the U.S. has decreased each year since 1993, the incidence of TB in Minnesota has increased significantly during the same time period. In 2002, 237 new cases of TB disease (4.8 cases per 100,000 population) were reported statewide - i.e., comparable to the 239 cases reported in 2001, which was the largest number of cases reported since the early 1970s.
The epidemiology of TB in Minnesota is distinct nationally, with the most significant factor being the very high percentage of TB cases that occur among foreign-born persons. In 2002, 181 (76%) cases occurred in persons born outside the U.S. These data reflect the unique and changing demographics of immigrant populations arriving in the state, particularly persons from regions of the world where TB is prevalent. Twenty-five (29%) of the state's 87 counties reported at least one case of TB disease in 2002, with the majority (78%) of TB cases occurring in the seven-county Twin Cities metropolitan area. A relatively large proportion of Minnesota TB cases involve extrapulmonary sites of disease. Of 1,016 TB cases reported from 1998-2002, 361 (36%) had only extrapulmonary involvement, 570 (56%) were exclusively pulmonary, and 85 (8%) had both pulmonary and extrapulmonary sites of disease. Of TB cases with any pulmonary involvement, only 237 (36%) had AFB-positive sputum smears (an indicator of likely infectiousness), while the remaining cases had either negative smears (52%) or smear results were not obtained (12%).
In 2002, 52 (28%) cases of drug-resistant TB were reported
in Minnesota, including 25 (13%) cases resistant to isoniazid,
and six (3%) cases of multi-drug resistant TB (MDR-TB) (i.e.,
resistant to at least isoniazid and rifampin). This is the
highest prevalence of MDR-TB statewide since such data have
been reported and considerably higher than the prevalence
of MDR-TB nationally (1.2%) in 2001. Forty-six (88%) of the
52 persons with drug-resistant TB disease reported in 2002
were born outside the U.S., including 23 (88%) of 26 INH-resistant
cases and five (83%) of six MDR-TB cases. The one U.S.-born
MDR-TB case was resistant to all five first-line TB medications
and represented the first U.S.-born MDR-TB case ever reported
in Minnesota, although this patient had resided for several
years in another country where TB is more common.
Of TB cases counted in 2001 whose disease characteristics made them "eligible" to compete therapy within 12 months, 176 (80%) did so, while another 29 (13%) completed therapy after 12 months, for a total of 205 (93%) completing a full course of therapy.
The theme of this year's World TB Day observance is "People with TB." Two well-known former "people with TB" are Nelson Mandela and Bishop Desmond Tutu of South Africa. Both men have used their high profiles to de-stigmatize the disease and influence public policy regarding TB. Less well-known "people with TB" work locally to increase awareness of the disease and to improve case-detection rates in their own communities. World TB Day 2003 events will feature stories of such people around the world. In Minneapolis, the Somali Health Project is planning a "Somali Community Awareness About Tuberculosis" event to mark World TB Day. The CDC Division of TB Elimination will observe World TB Day in El Paso, Texas, with a program featuring the Binational TB Card Pilot Project. This program is designed to improve continuity of care and treatment outcomes for TB patients crossing the U.S.-Mexico border. For additional information about World TB Day observances around the world, see the "Stop TB" web site at www.stoptb.org. Minnesota TB surveillance data, TB-related educational brochures for patients in nine languages, national and state recommendations for TB screening and treatment, and other resources are available on the MDH web site at www.health.state.mn.us/tb.
3. Group B Strep Website
CDC has developed a website specifically for the prevention of Group B Streptococcal disease at http://www.cdc.gov/groupBstrep/default.htm. Check it out for useful educational resources including print materials and slidesets for clinicians/healthcare providers, laboratory personnel, and the general public.
4. Smallpox Vaccination Update
To date, we along with our local public health partners have vaccinated approximately 1,350 patient care providers and public health response team members for smallpox. We are nearing the end of Phase 1 of the national smallpox preparedness effort. We are very grateful to those physicians who took "adverse event call". We have reports of various reactions, including some that don't appear to be related to smallpox vaccine. Of note, three individuals vaccinated through our program have been evaluated for mild to moderate non-specific rash one to nine days after vaccination. One re-vaccinee developed myocarditis two days after vaccination; however, the timing of her illness is more consistent with an antecedent influenza-like illness that had occurred two weeks prior to her myocarditis. Another vaccinee presented with a forehead ulcer one week post-vaccination and the subsequent development of eyelid vesicular lesions. The forehead and eyelid lesions turned out to be PCR positive for varicella-zoster virus (viral culture is pending), highlighting the importance of evaluating these patients carefully.
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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