Minnesota Department of Health (MDH) Bug Bytes
Sept. 7, 2007
Vol. 8: No.1
Bug Bytes is Back by Request!
Topics in this Issue:
1. World Rabies Day
2. West Nile Cases Peaking
3. A New Campylobacter Species Human Pathogen?
4. Unusual Botulism Vehicle
5. Be Careful Making That Drum
6. Quinolone-resistant Gonorrhea
7. A Bug Bite Gone Bad?
8. 13th Annual Emerging Infections in Clinical Practice and Public Health Conference
September 8 is World Rabies Day. The mission of World Rabies Day is not to celebrate the disease but to raise awareness about the impact of human and animal rabies, prevention strategies, and how to eliminate the main global sources. More than 55,000 people, one every 10 minutes, die from rabies every year. Through the World Rabies Day initiative, partners will be “Working together to Make Rabies History!”
This is the peak time for us to receive calls from clinicians seeking consultation about animal bites and the risk of rabies. More than 90% of all animal rabies cases reported annually in the United States now occur in wildlife; before 1960 the majority was in domestic animals. The principal rabies hosts today are wild carnivores and bats; in Minnesota the reservoirs are skunks and bats. The number of rabies-related human deaths in the United States has declined from more than 100 annually at the turn of the 20th century to now one or two per year. Modern day prophylaxis has proven nearly 100% effective. Most recent cases in the United States have been due to bat bites that were not recognized or reported.
To celebrate World Rabies Day, MDH and the Minnesota Board of Animal Health sent a fax to every veterinary clinic in the state inviting them to check the rabies titers for all of their rabies-vaccinated staff members. This is in collaboration with the Kansas State University Rabies Laboratory, which is offering the rapid fluorescent focus inhibition test (RFFIT) for a reduced fee from September 8-22, 2007. The RFFIT (a virus neutralization test) is the recommended test to assess the need for a rabies vaccine booster. Veterinary personnel should have their rabies titers checked every 2 years, and when the titer drops below 1:5 by the RFFIT test, a single rabies vaccination booster is recommended.
Learn more about: Rabies >>
We are in the high-risk time for West Nile virus (WNV) activity in Minnesota and expect continued WNV transmission to people through September. We have had 66 reported human cases from 31 counties and have not had this many reports since 148 cases in 2003. Thirty-nine (59%) of the cases had fever only and the remaining 27 cases were classified as either WN meningitis or WN encephalitis. No deaths have been reported to date but at least one person remains critically ill. Six blood donors have also tested positive for WNV. Most of our cases have occurred in residents of western and central Minnesota. We maintain an updated Minnesota map of human and equine cases, and positive mosquito pools on the MDH West Nile Virus Statistics website.
Physicians should call us at 651-201-5414 or 1-877-676-5414, to report suspect cases of WNV.
Learn more about: West Nile Virus >>
3. A New Campylobacter Species Human Pathogen?
We are investigating three cases of Campylobacter helveticus infection that have been reported through routine Campylobacter surveillance. There is no documentation of this Campylobacter species having been isolated from humans in the past. The cases include a 1 year-old, a 14 year-old, and a 63 year-old, all from the same geographic area with onset dates in May, May, and July, respectively. All specimens were collected in August. The duration of illness appears to be longer than is typically seen with other Campylobacter species; the median duration of diarrhea was 3 months (range, 3 weeks to 3.5 months). All three cases reported having contact with cats. Two of the cases reported having contact with cats that came from a specific animal shelter. We intend to sample cats at the shelter for C. helveticus and interview shelter employees.
Learn more about: Campylobacter >>
We recently assisted a neighboring state providing confirmatory human and food testing for a patient with suspect botulism. The patient was an adult Amish male hospitalized with classic botulism symptoms who was successfully treated with botulism antitoxin obtained from the CDC by the state health department for the clinician’s use. The patient had consumed home-made chili and myrrh oil and home-canned chicken and cake. The patient’s serum and canned cake was positive for botulism toxin type A. These cakes are made by pouring batter into glass canning jars and baking them in the oven. The steaming jars are taken out of the oven and sealed and cooled to create a vacuum. Clostridium botulinum spores grow and produce toxin in unrefrigerated high moisture foods that are low in acid and exposed to little or no oxygen. These conditions occur in canned foods such as asparagus, green beans, beets, and corn, and also “canned” bread and cake.
This past week the Connecticut Department of Public Health announced that cutaneous anthrax has been identified in two members of a family in Danbury, Connecticut. On August 28, a 47-year-old male presented to an infectious disease physician at a local hospital with 4-5 weeks of a progressive papular lesion on his foreman, with necrotic/black eschar and some lymphagitic spread with associated axillary lymphadenopathy. A punch biopsy of the lesion was positive for Bacillus anthracis by polymerase chain reaction (PCR) on August 31. On August 29, the health department was notified that a second family member had recently developed a skin lesion that was subsequently positive by PCR for B.anthracis.
The index patient makes drums from unprocessed animal hides (cow and goat) imported from Africa. The process includes cleaning and removal of hair from hides. The most recent shipment of animal hides occurred in June 2007. These appear to be isolated cases of naturally occurring anthrax. The two ill family members were never hospitalized and are being treated with antibiotics. Goat skins from the patient’s barn have tested positive for anthrax.
Anthrax is caused by the bacterium B. anthracis, which forms spores which may survive for many years. There are three types of anthrax: skin (cutaneous), lungs (inhalational) and digestive (gastrointestinal). A person can be infected with anthrax by handling products from infected animals and by breathing in the anthrax spores from infected animal products (wool, hides). A person can get gastrointestinal anthrax by eating contaminated meat. There was a case of inhalational anthrax in 2006 in a New York City drum maker using imported animal hides. Due to its ease in production and storage, and its lethality, anthrax is a likely bioterrorism agent.
Learn more about: Anthrax >>
A record number of 16,428 cases of sexually transmitted diseases (STDs) were reported to the MDH in 2006. Reportable STDs in Minnesota include chlamydia, gonorrhea, and syphilis. Chlamydia remains the most commonly reported STD in Minnesota with incidence rates more than doubling in the last 10 years. Although there was a slight drop in gonorrhea cases in 2006 compared to 2005, this still remains the second most commonly reported STD in Minnesota with 3,303 cases reported in 2006. Of particular concern is the increasing prevalence of quinolone-resistant Neisseria gonorrhoeae (QRNG) in Minnesota, especially among men who have sex with men (MSM). The overall prevalence of QRNG increased from 1.5% in 2002 to 5.8% in 2006. Twenty-seven percent of the gonorrhea isolates tested from cases in MSM tested were resistant to ciprofloxacin compared to 0.8% from heterosexual men.
The CDC closely monitors QRNG prevalence at the national level and uses a 5% threshold to change treatment guidelines for specific groups and locations. In 2004, CDC recommended that fluoroquinolones no longer be used to treat gonococcal infections among MSM. In April 2007, this recommendation was expanded to include all persons with gonorrhea due to a national QRNG prevalence of 6.7% among heterosexuals.
MDH encourages clinicians to use CDC’s updated recommended treatment regimens for gonorrhea, which exclude fluoroquinolones. However, given the current low prevalence of QRNG among heterosexuals in Minnesota and the oral single-dose convenience and cost savings of fluoroquinolones over other available therapies, MDH further recommends that in the following limited situations, the cautious use of fluoroquinolones is appropriate:
- For males whose risk assessment findings indicate that their sex partner(s) are only female(s) who reside in Minnesota.
- For females whose risk assessment findings indicate that their sex partner(s) are male(s) who only have sex with females and the partners reside in Minnesota.
MDH will continue to monitor QRNG and encourages clinicians to report instances of suspected fluoroquinolone treatment failures at 651-201-5414.
The 2006 Antibiogram of Antimicrobial Susceptibilities of Selected Pathogens is available on-line
and also in laminated pocket-sized cards. Call 651-201-5414 if you want a copy.
Learn more about: Gonorrhea >>
In July an alert physician called us to report a possible case of tularemia in a preschool-aged child based on a high titer serology result. The child became ill with influenza-like illness symptoms, fever, sore throat, and an ear infection while out of the country and was hospitalized for 2 days and treated with antibiotics. Approximately 10 days later, the child developed progressively worsening neck swelling upon return to Minnesota and was re-hospitalized. A CT scan of child’s neck was consistent with right-sided lymphadenopathy and suggestive of some necrotic changes. The right-sided neck abscess was drained and was culture negative for Francisella tularensis, but the case was confirmed by acute and convalescent serologies.
After investigation including an on-site field examination, we concluded that a tick bite was the likely source of transmission. The child, living in a rural central Minnesota area, had received several tick bites on the head, around the ears and hairline in the spring of 2007 and may have had deer fly bites. He had no other known source of exposure to F. tularensis.
Naturally-occurring cases of tularemia are uncommon in Minnesota (less than one case per year) but appear in other parts of the United States with greater frequency. Tularemia, also known as rabbit fever, is a bacterial disease caused by F. tularensis and can occur in both humans and animals. It is typically transmitted to humans by contact with infected animal tissues or by ticks, biting flies, or mosquitoes.
Learn more about: Tularemia >>
Save the dates of November 8 and 9 (half day) for the Annual Emerging Infections in Clinical Practice and Public Health. Another great conference is planned and brochures and registration forms will be mailed out shortly. Further preliminary information is at the University of Minnesota Continuing Medical Education Course Calendar.
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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