Minnesota Department of Health (MDH) Bug Bytes

March 29, 2004
Vol. 5: No. 2

Topics in this Issue:

1. Kingella kingae Outbreak Investigation Update
2. Cough and Cold Care Kits
3. Tuberculosis Highlights
4. Changes to the Communicable Disease Reporting Rule
5. April 18-24 is National Medical Laboratory Week

1. Kingella kingae Outbreak Investigation Update
As previously reported in the December 2, 2003 Bug Bytes issue, we investigated a cluster of three children, from the same toddler classroom of the same day care center, with osteomyelitis/septic arthritis who presented in the same week. Two children were hospitalized, had undergone orthopedic surgery, and were culture positive for Kingella kingae. This is the first K. kingae cluster ever reported. In last week's MMWR there was a full report of our investigation (at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5311a4.htm).

K. 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.

Our investigation did not reveal a source or risk factors for this cluster. Prophylaxis with rifampin was offered to the students and staff in the toddler classroom. We collected throat swabs from center attendees and staff (immediately prior to beginning prophylaxis for the affected toddler classroom). 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. Throat cultures were collected again 10-14 days later in the toddlers who were offered rifampin. Of the nine toddlers originally colonized, three remained positive on re-culture. An additional toddler, who was initially culture-negative, was positive on re-culture.

2. Cough and Cold Care Kits
At the recent International Conference on Emerging Infectious Diseases, we presented the results of an evaluation of the use of cough and cold care kits as a tool to promote judicious antibiotic use. The Minnesota Antibiotic Resistance Collaborative (MARC; a collaboration of six health plans, Stratis Health, the Minnesota Medical Association, the Minnesota Council of Health Plans, the Minnesota Pharmacy Association, and MDH) produced and distributed adult cough and cold care kits to selected Minnesota clinics as an alternative to prescribing antibiotics for patients with viral illness. During the 2000-2001 cold and flu season, MARC distributed 17,000 kits to MARC member clinics. The kits were very well received, and the number was expanded to 31,000 for the 2001-2002 season.

In 2003, we conducted an evaluation of the kits. Ten family practice clinics were randomly selected from each of four Twin-Cities Metro area health plans. Five intervention clinics distributed the kits and five control clinics did not distribute kits. The study population included all adult patients 18 to 65 years old diagnosed with a URI or acute bronchitis from February through April 2003. Participating health plans provided administrative (claims) data for analysis. The data collected and analyzed included: number of total adult patients; number of adult patients seen with diagnosis codes for URI or acute bronchitis and with no chronic conditions or co-morbidities (chronic bronchitis, emphysema, ear infection, streptococcal pharyngitis, pneumonia, urinary tract infection, skin infection, bacteremia); number of patients (with pharmacy insurance coverage) who filled a prescription for an oral systemic antibiotic within three days of their visit.

For the intervention clinics, 13% (524/4,083) patients diagnosed with URI filled a prescription for an antibiotic within 3 days of their visit. For the control clinics 18% (1,258/6,902) filled antibiotic prescriptions. Intervention clinic patients were less likely to fill a prescription than patients seen at control clinics (O.R.= 0.66, 95% C.I.=0.59-0.74). Penicillins were used more often in intervention clinics than in the control clinics (O.R.= 1.25, 95% C.I =1.01-1.55). Macrolides were used less often in intervention clinics (O.R.= 0.65, 95% C.I =0.51-0.81).

Although there are limitations to this study, providing cough and cold care kits does appear to be a useful tool to decrease unnecessary antibiotic use for URI and bronchitis in the family practice setting.

3. Tuberculosis Highlights
March 24 was World TB Day. Minnesota tuberculosis surveillance reports for 1999-2003 are available at www.health.state.mn.us/tb.

Highlights include:

  • In 2003, 214 new cases of TB disease were reported. Although this represents a 10% decrease from 2002, the number of cases has more than doubled in the last 15 years.
  • In 2003, TB disease was reported in 23 of Minnesota's 87 counties. Although the majority of cases occur in the Twin Cities area, 45 cases were reported in Greater Minnesota.
  • The primary risk factor for TB is birth in a country where TB is common. Much less frequent risk factors include homelessness, HIV infection, incarceration and residence in a nursing home.
  • Drug-resistant TB remains a significant problem.
    A very wide range of nationalities and languages is represented.
  • Extrapulmonary TB is common, especially among foreign-born cases.
  • In contrast to U.S.-born cases, the majority of TB disease in foreign-born persons occurs in younger individuals between 15-44 years old.

    Information regarding drug susceptibility results for TB cases by country of origin is available upon request ([612] 676-5414). These data may be empirically useful to guide the treatment of confirmed/suspected TB disease when patient-specific susceptibility results are not available. Your ongoing assistance with TB surveillance, prevention, and control activities is greatly appreciated.

4. Changes to the Communicable Disease Reporting Rule
We are proposing changes to the Communicable Disease Reporting Rule, Minnesota Rules, Parts 4605.7500 to 4605.79. The last significant rule revision occurred 20 years ago. We are making changes to address diagnostic advances and issues surrounding new and emerging communicable diseases. Some of the changes include adding new diseases to the reporting rule, changing the type of materials submitted to the MDH Laboratory, adding a requirement to report “unexplained critical illness” that may be caused by an infectious agent, and allowing the Commissioner to select certain diseases for sentinel rather than complete statewide surveillance.

A detailed draft of the rule is at: http://www.health.state.mn.us/divs/idepc/dtopics/
. You may send comments on the proposed changes to commdisrule@health.state.mn.us. Comments will be accepted until May 10, 2004.

5. April 18-24 is National Medical Laboratory Week
National Medical Laboratory Week is sponsored by 11 professional laboratory organizations. Its purpose is to honor the more than 280,000 clinical and public health laboratory professionals across the nation who aid in the diagnosis and treatment of disease and help to prevent disease by detecting unknown health and environmental problems.

Clinical laboratory science emerged in the early 1900's and was brought into being by a group of dedicated scientists who had to convince physicians of the day that testing the fluids and cells of the body was an adequate and efficacious way to diagnose disease. These founding pioneers would be both proud and amazed to view today's clinical laboratories, their menu of over 2,000 tests, and the assortment of pathologists, clinical laboratory scientists, medical laboratory technicians, histotechnologists, cytotechnologists, microbiologists, and phlebotomy technicians working to detect and treat disease.

The MDH Public Health Laboratory (PHL) was established more than 100 years ago at a time when the germ theory of infectious disease was just being established and little was known about the impact of environmental contamination on the public's health. Today, the PHL focuses on surveillance for early detection of public health threats, identification of rare chemical and biological hazards, emergency preparedness and response, and assurance of quality laboratory data through establishment of collaborative partnerships with clinical and environmental laboratories throughout the state.

The Minnesota Laboratory System (MLS) was created in 2001 as an innovative means of collaboration of both public health and clinical laboratories in Minnesota. The MLS goal is to increase the communication and collaboration of the laboratories serving Minnesota residents in order to protect and improve the health of all Minnesotans. The most recent MLS endeavor has been the creation of a listserv in order to improve communications.

For more information about the PHL and MLS see http://www.health.state.mn.us/divs/phl/index.html. For more information about the National Medical Laboratory Week, see the American Society for Clinical Pathology's website at http://www.ascp.org/general/labweek.


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