Minnesota Department of Health (MDH) Bug Bytes

December 2, 2003
Vol. 4: No. 13

Topics in this Issue:
1. Three Toddlers and A King
2. Influenza Season is Here
3. Conjunctivitis Outbreak
4. Salmonella Enteriditis, a Restaurant, and Eggs
5. Cover Your Cough

1. Three Toddlers and A King
On October 30, an ICP notified us of two children hospitalized at the same time with osteomyelitis/septic arthritis due to Kingella kingae. Both children had undergone orthopedic surgery, one in the hip and one in the ankle, and both attended the same daycare center.

Kingella kingae is a relatively rare fastidious Gram-negative bacteria increasingly recognized to cause skeletal disease in young (<4 years of age) children. It is part of the normal respiratory flora and colonizes the lower respiratory and oropharyngeal tract. The organism was first described by Dr. Elizabeth King in the 1960s. To our knowledge a cluster of cases has never been reported anywhere before.

We began an investigation of the daycare and found that both cases were in the same toddler class, one of two toddler classes at that daycare (21 in the class). We found an additional possible case of ankle osteomyelitis, diagnosed clinically and by MRI, which had occurred at the same time in a child from the same toddler class. This child's blood cultures were negative, probably because he had been placed on antibiotic therapy for a suspect ear infection (synovial fluid/bone cultures were not performed). We inspected the daycare and collected throat swabs from attendees and staff. Sixteen (14%) children but no staff had positive throat cultures for Kingella. Higher Kingella carriage rates were found in the toddler class that included the cases. Pulsed-field gel electrophoresis (PFGE) subtyping of the isolates revealed that 15/16 isolates were identical; the different isolate was from an older child. Our investigation of risk factors for disease and search for additional cases continues.

2. Influenza Season is Here
Minnesota's first laboratory-confirmed case of influenza occurred in a Wright County male in his 40's. He was infected with the influenza A/New Caledonia-like (H1N1) strain. This is one of the strains included in this year's vaccine. On the national level influenza A (H3N2) strains predominate. Seventy-eight percent of the H3N2 strains characterized by the CDC have been the A/Fujian/411/2002 drift variant; A/Fujian has yet to be identified in Minnesota. This strain was not included in this year's vaccine; however, CDC has stated that while this variant is not a perfect match to the vaccine strain, it is related to the A/Panama (H3N2) strain in the vaccine and “it is expected that the current U.S. vaccine will offer some cross-protective immunity against the A/Fujian/411/2002-like viruses and reduce the severity of disease."

Influenza-like illness (ILI) activity as reported by influenza sentinel providers nationwide has indicated very early activity. During week 46, 3.3% of patient visits to U.S. sentinel providers were due to ILI. This percentage is above the national baseline of 2.5%. During last year's influenza season, ILI activity peaked at 3.2% during the first week in February.

CDC has requested that states collect information on cases of acute encephalopathy associated with influenza and influenza related deaths in persons <18 years of age. Cases should meet the following criteria: <18 years of age, altered mental status, or personality change in patient lasting >24 hours and occurring within 5 days of the onset of an acute febrile respiratory illness, laboratory or rapid diagnostic test evidence of acute influenza virus infection, and diagnosis occurring in the U.S. Please report any case of suspect influenza related acute encephalopathy to us at (612) 676-5414.

3. Conjunctivitis Outbreak
We received a call on November 12 from the medical director of a southeastern Minnesota clinic who reported several cases of Streptococcus pneumoniae conjunctivitis. This physician reported 10 culture confirmed cases with an additional 100 possible cases. Prior to this account there had not been an outbreak of conjunctivitis due to S. pneumoniae reported in Minnesota.

We reviewed medical records of patients at the clinic and its affiliated eye center that had presented to the two clinics with conjunctivitis since 9/1/03. We also asked healthcare providers in the area to perform bacterial and viral cultures on conjunctivitis cases. In addition to contacting clinics in the area, local schools and daycares were contacted and asked to report the absences due to conjunctivitis. Clinics, schools and daycares were also provided with conjunctivitis infection control information.

To date, 680 conjunctivitis cases have been reported. Fifty-seven of those are culture-confirmed S. pneumoniae cases and at least 272 of the conjunctivitis cases (most without bacterial cultures done) have epidemiological links to the culture-confirmed cases. Our initial laboratory testing showed the S. pneumoniae isolates to be untypeable and PFGE demonstrated three subtypes, two of which are closely related. The 18 isolates tested so far have varying susceptibilities to penicillin, and most reports indicate good recovery after use of topical antibiotics.

We are continuing to monitor the situation. We are requesting that healthcare providers, who have already been contacted, in the affected area continue to send reports of and submit bacterial cultures for conjunctivitis cases through December 7.

4. Salmonella Enteriditis, a Restaurant and Eggs
We have been investigating a Salmonella Enteritidis outbreak associated with a restaurant. School nurses from different schools alerted us to two salmonellosis cases on Thursday, November 13. The following day, our laboratory reported that isolates from those two cases and two additional cases were confirmed as Salmonella Enteritidis and that the isolates matched by PFGE. Since the cases were temporally and regionally clustered, we contacted the ICP in the area hospital and requested that she report by phone other Salmonella cases seen in her facility. The ICP went above and beyond the call of duty, reporting over the weekend cases of Salmonella infection and cases of compatible illness seen at her facility. Her hard work allowed us to interview potential cases and identify the source of the outbreak by late Monday morning.

To date we have identified 27 cases, including six restaurant employees. Eight persons were hospitalized. Meal dates for the case-patients ranged from 10/26 to 11/15. Many of the ill patrons ate French toast or other egg dishes. The restaurant closed on Monday, November 17, and reopened on Thursday, November 20, after thorough cleaning, assessment of illness among employees, and initiating testing of employees for Salmonella. On inspection, many egg-handling problems were identified. A traceback is being conducted on the eggs that were used. The restaurant in now using pasteurized eggs.

5. Cover Your Cough
We have collaborated with the Association of Professionals in Infection Control and Epidemiology, and the Minnesota Antibiotic Resistance Collaborative to develop a campaign designed to reduce the person-to-person spread of respiratory infections like influenza or SARS. The “new normal” approach to infection control includes possibly asking patients in waiting rooms to wear a surgical mask if they're coughing or sneezing. Alternatively patients will be asked to sneeze or cough into tissues that are provided, and to wash their hands with soap and water or alcohol-based hand rubs. We have produced a poster and brochure with these messages for use in patient care waiting areas. Posters are being sent to hospitals and long term care facilities. Call us at 651-201-5414 or 1-877-676-5414 for limited additional copies. For further information and to download posters and brochures for printing, see: http://www.health.state.mn.us/divs/idepc/


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.

For concerns or questions regarding content, please use our Bug Bytes Feedback Form.

You can also subscribe to the MDH Bug Bytes newsletter.

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