Minnesota Department of Health (MDH) Bug Bytes

July 3, 2008
Vol. 9: No.2


Topics in this Issue:
1. Human Anaplasmosis: Minnesota’s Other Major Tick-borne Disease
2. Salmonella Montevideo and “Hot Chicks”
3. Meningococcal Disease Cluster
4. Gonorrhea Treatment Update
5. It’s Just a Name – Don’t Blame Us
6. Save the Date

1. Human Anaplasmosis: Minnesota’s Other Major Tick-borne Disease

The blacklegged tick (formerly called deer tick; Ixodes scapularis) is the primary vector for the agents of Lyme disease, human anaplasmosis (HA), and babesiosis in Minnesota. Most cases of these diseases are exposed to infected ticks from mid-May through mid-July, but there is also a smaller peak of HA transmission in the fall (late September through October). In 2007, record numbers of tick-borne disease cases were reported in Minnesota (322 HA, 1,239 Lyme disease, and 24 babesiosis cases).

HA, caused by Anaplasma phagocytophilum, is of particular concern because it severely and disproportionately affects the middle-aged and elderly. Approximately 40% of patients require hospitalization, and fatalities have been reported. Patients often present with high fever, headache, myalgia, and chills. Potential complications include renal failure, respiratory failure, pneumonia, and myocarditis. Objective signs include reduced platelet counts, reduced white blood cell counts, and elevated liver enzymes. Morulae, the intracellular bacteria, may be seen in neutrophils on blood smears (see Human granulocytic anaplasmosis and Anaplasma phagocytophilum, Dumler JS,et al [including JS Bakken from Duluth] Emerg Infect Dis 2005; 11:128-34 at http://www.cdc.gov/ncidod/EiD/vol11no12/05-0898.htm).

HA is treated with doxycycline and physicians should initiate treatment as soon as they suspect HA. We recommend that physicians confirm the diagnosis with two or more of the following tests: PCR, blood smear, or serology by IFA. HA was formerly called human granulocytic ehrlichiosis (HGE), but do not order an “ehrlichiosis” test. Instead, make sure to order tests that specify “human anaplasmosis” or “Anaplasma phagocytophilum” on suspect cases. Otherwise, you may be testing for a related illness that is not endemic to Minnesota (human monocytic ehrlichiosis), often leading to confusing cross-reactive laboratory results and misdiagnosis. Physicians should also discuss tick-borne disease prevention with patients who live in, or travel to, wooded areas within endemic Minnesota counties.

For more information about HA and other tick-borne diseases, please go to the MDH Tickborne Disease website.

2. Salmonella Montevideo and “Hot Chicks”

From late March through late May, we identified nine cases of Salmonella Montevideo infection associated with chicks or ducklings. The median case-age was 25 years (range, 5 months to 70 years); of note, three cases less than 1 year of age were allowed to look at the birds, but reported no direct contact. Two case-patients, aged 5 months and 42 years, were hospitalized for 2 and 3 days, respectively. We isolated the outbreak strain from chickens, ducks, and their environments from two case-households. Typically, several chick or duckling-associated Salmonella infections are identified in the spring and early summer in Minnesota, frequently in children.

In collaboration with the Minnesota Board of Animal Health, we have developed educational materials to be distributed with purchase of chicks and ducklings at Minnesota poultry vendors. Recommendations include restricting children less than 5 years of age from handling poultry, thorough handwashing after contact with poultry or their environment, and avoiding eating or drinking in poultry environments.

Learn more about: salmonella>>

3. Meningococcal Disease Cluster

In February, a male in his thirties and a high school student from Caledonia in Houston County were hospitalized with meningococcal disease with onsets on the same day. One of the cases had culture-confirmed serogroup B disease and the other had a polymerase chain reaction test result from blood that was positive for serogroup B Neisseria meningitidis. A few days prior to this, a teenager from Iowa was also hospitalized with serogroup B meningococcal disease. It was reported that he had been in Caledonia shortly before becoming ill. Molecular tests were indicative that all three case-patients had very similar strains but no clear connection could be found between them. Close contacts for each case-patient were advised to seek chemoprophylaxis.

A month later, in late March, a young adult male from Caledonia was admitted to the hospital with serogroup B invasive meningococcal disease. Pulsed-field gel electrophoreseis (PFGE) revealed that his isolate was very similar to that of the previous cases. His close contacts were also advised to seek prophylaxis and, again, no connection could be found between him and the previous case-patients. Local public health provided information to the community and area health care providers about meningococcal disease, the cluster of cases, and measures that could minimize risk of spread of disease.

No additional cases have occurred in Caledonia. However, in late May an infant from a nearby Houston County community was hospitalized with serogroup B meningococcal disease. The PFGE pattern for this case-patient’s isolate was indistinguishable from that of the first cases.

While there is a vaccine available for the prevention of meningococcal disease in the United States it only covers serogroups A, C, Y, and W-135 and it does not offer protection for serogroup B disease. N. meningitidis is spread from person to person via droplets. Household and child care contacts and others sharing oral secretions with case-patients are at increased risk for becoming ill. Sharing water bottles, drinks, eating utensils, and smoking materials should be discouraged. Household contacts and others having close contact with case-patients with meningococcal disease should be treated promptly with prophylactic antibiotics. Regardless of the non-coverage of serogroup B, meningococcal vaccine is now recommended for all adolescents. It should be routinely offered at the pre-adolescent well child visit, usually at age 11-12 years. Previously unvaccinated adolescents age 13-18 years should be vaccinated at their next visit, i.e., camp or sports physicals.

Health care providers should have a high index of suspicion for meningococcal disease for patients with evidence of meningitis or sepsis, especially if illness is accompanied by a rash and especially in southeast Minnesota. Suspect cases of meningococcal disease should be reported immediately by telephone to us (1-877-676-5414).

Learn more about: neisseria meningitidis>>

4. Gonorrhea Treatment Update

Fluoroquinolones are no longer recommended to treat gonorrhea in Minnesota due to increasing prevalence of quinolone-resistant Neisseria gonorrhoeae (QRNG). QRNG prevalence has been high (~30%) among men who have sex with men for the past 5 years. In the heterosexual population, QRNG prevalence remained low until 2007, when 4.5% of the gonococcal isolates tested by MDH were resistant to ciprofloxacin. Cephalosporins are the only remaining class recommended by CDC and MDH for treatment of gonorrhea.

Fortunately, cefixime (Suprax®) 400 milligram tablets are once again available for distribution in the United States. This is the only drug recommended by CDC that may be given in a single, oral dose to treat uncomplicated urogenital and rectal infections. Pharyngeal gonococcal infections should be treated with a 125 mg injection of ceftriaxone (Rocephin®). For more information on how to obtain cefixime, contact Lupin Pharmaceuticals at 1-866-587-4617.

We will continue to closely monitor antimicrobial susceptibilities of N. gonorrhoeae to agents used to treat gonorrhea, especially cefixime and ceftriaxone. If you have a suspected cephalosporin treatment failure, or any additional questions, please call us at (651) 201-5414 for consultation.

Learn more about: neisseria gonorrhoeae>>

5. It’s Just a Name – Don’t Blame Us

Since April, 887 persons infected with Salmonella Saintpaul with the same PFGE have been identified in 38 states and the District of Columbia. Among the persons with information available, illnesses began between April 10 and June 20, 2008. Patients range in age from <1 to 99 years; 48% are female. The rate of illness is highest among persons 20 to 29 years old; the rate of illness is lowest in children 10 to 19 years old and in persons greater than 80 years old. At least 107 persons were hospitalized. No deaths have been officially attributed to this outbreak. Until this week, two cases were reported in Minnesota residents; both had traveled to other states during their incubation periods for illness.

Only three persons infected with this strain of S. Saintpaul were identified in the country during the same period in 2007. The previous rarity of this strain and the distribution of illnesses in all U.S. regions suggest that a contaminated food distributed throughout much of the country is responsible for illness. Because many persons with Salmonella illness do not have a stool specimen tested, it is likely that many more illnesses have occurred than those reported. An initial epidemiologic investigation comparing foods eaten by ill and well persons identified consumption of raw tomatoes as strongly linked to illness. Recently, many clusters of illnesses have been identified in Texas and other states among persons who ate at restaurants. These clusters have led CDC and other state health departments to broaden the investigation to include food items that are commonly consumed with tomatoes.

As Bug Bytes is going to press, we have become aware of a cluster of suspect cases in Minnesota which we have begun to investigate.

Learn more about: food safety>>

6. Save the Date

We will be co-sponsoring the 14th Annual Conference on Emerging Infections in Clinical Practice and Public Health on November 14.

 

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, 19-Nov-2010 14:16:52 CST