Minnesota Department of Health (MDH) Bug Bytes
March 5, 2009
Vol. 10: No.1
Topics in this Issue:
1. Hib Update
2. Syphilis Still Increasing
3. Ciprofloxacin-resistant Neisseria meningitidis
4. Peanut Butter Wrap-up
5. Other Enteric Disease Outbreaks
6. Antiviral Distribution During Pandemic Influenza
1. Hib Update
On January 23, we issued a press release stating that in 2008, five children aged <5 years were reported with invasive Haemophilus influenzae type b (Hib) disease; one died. This is the greatest number of Hib cases in children <5 years of age that we’ve seen since 1992. Only one of the children had completed the primary Hib immunization series; three had received no doses of Hib-containing vaccine because of parental deferral or refusal. The cases resided in five different Minnesota counties and had no known relationship with each other. The cases occurred during a Hib vaccine recall and continuing nationwide shortage that began in December 2007. In response to the shortage, CDC recommended that health-care providers defer the routine 12-15 month booster dose for children not at increased risk for Hib disease. Our data indicate that primary Hib series coverage was lower during 2008 than coverage with other vaccines administered at the same ages, and lower than Hib coverage in previous years. A full report is in the January 30 MMWR (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5803a4.htm).
These cases highlight the need for children to be caught up on their primary series. The Hib vaccine shortage is expected to continue into fall 2009, and the amount of available single-antigen ActHib is insufficient to meet the three-dose primary series needs for all children. Providers are encouraged to not let a child remain unvaccinated because of inadequate doses of ActHib in their clinic. Pentacel, a combination of DTaP-IP-Hib, is available to assure that all infants complete their primary series. We have developed two quick references that may help: “Guidance on Using Pentacel” and “Catch-up Schedule for Hib Vaccine During the Vaccine Shortage.” Both are available at www.health.state.mn.us/divs/idepc/diseases/hib/hcp.html.
Because Hib is one of the bacterial pathogens collected as part of our Emerging Infections Program (EIP), we have among the most complete data in the country. However, no other EIP site, and no other state even anecdotally, has seen an increase in Hib cases.
To better understand what is happening in Minnesota, we have been conducting a survey of children aged 6 weeks to <5 years regarding vaccination, Hib risk factors, and attitudes about immunization, and at the same time also collecting a throat swab from participant children to test for Hib colonization. To date, we have surveyed and swabbed approximately 1,600 children. The survey was conducted by public health and private clinic staff and volunteers at a variety of public and private clinics. We thank all workers and participants and particularly these clinic sites: Children’s Hospitals and Clinics of Minnesota, General Pediatrics Clinics in Minneapolis and St. Paul; St. Paul-Ramsey County Department of Public Health; Olmsted County Public Health Services; Mayo Clinic; Olmsted Medical Center; ACMC – Willmar; Kandiyohi County Health Services; CentraCare Clinic, Women & Children, St. Cloud; Grand Itasca Clinic and Hospital, Grand Rapids; Itasca County Health and Human Services; MeritCare Clinic, Bemidji; Beltrami County Public Health; Allina Medical Clinic, Northfield; McCleod County Public Health; Meeker County Public Health; and Lakeview Clinic, Waconia.
Learn more about: Hib>>
2. Syphilis Still Increasing
As has been seen in other parts of the country, in 2008 in Minnesota, early syphilis cases were up 40% compared to 2007. Syphilis cases among men who have sex with men (MSM) began to increase in 2002 and that trend has continued. Preliminary data show that 159 early syphilis cases were reported in 2008 compared to 114 cases in 2007. Of the 159 early syphilis cases, 97% were male. New infections continued to be centered within the Twin Cities metropolitan area. For race/ethnicity, 73% were white, 16% were black, and 5% were among Hispanic. The largest increase was among men aged 15-24 years, from 17 in 2007 to 37 in 2008. Eighty-two percent of the cases were among MSM. The most concerning statistic is that 40% of the cases were also infected with HIV.
The most common risk factors reported were meeting partners on the Internet, anonymous sex, and no condom use. The CDC recommends that MSM patients be tested at least annually. For those at highest risk with multiple partners, especially if they are HIV-infected, testing should be as often as every 3 months. There are multiple resources available for clinicians, patients, and the public on syphilis and reducing the risk of transmission on the MDH website with links to other prevention resources.
Learn more about: Syphilis>>
In the February 26 New England Journal of Medicine we report on the emergence of ciprofloxacin-resistant Neisseria meningitidis in North America as we had reported in February 2008. Three cases of meningococcal disease caused by ciprofloxacin-resistant N. meningitidis, occurred in eastern North Dakota (1 case) and northwestern Minnesota (2 cases). The cases were of the serogroup B strain. To assess local carriage, we and CDC investigators conducted a pharyngeal-carriage survey and isolated the resistant strain from one asymptomatic carrier. Sequencing of the gene encoding the subunit A of DNA gyrase (gyrA) revealed a mutation associated with fluoroquinolone resistance and suggests that the resistance was acquired by means of horizontal gene transfer with the commensal N. lactamica. CDC also conducted susceptibility testing of invasive N. meningitidis isolates from our sister EIP sites from January 2007 to January 2008 and found 1 additional ciprofloxacin-resistant isolate from California.
We continue to recommend that physicians use rifampin, ceftriaxone, or azithromycin instead of ciprofloxacin as a preventive treatment for close contacts of cases of meningococcal disease in the Fargo-Moorhead areas.
We are also wrapping up our work on the outbreak of Salmonella Typhimurium associated with consumption of peanut butter or peanut butter containing products. As detailed in press accounts, our work helped to pinpoint the source of this national outbreak.
Currently there are 677 cases in 45 states with the most recent reported illness beginning on February 8. Among the persons with confirmed reported dates available, illnesses began September 1, 2008. Cases range in age from <1 to 98 years. The median age is 16 years; 21% are <5 years old, 17% are >59 years. Among persons with available information, 23% reported being hospitalized. Infection may have contributed to 9 deaths with 3 from Minnesota.
On November 10, 2008, CDC noted a small highly dispersed multistate cluster of 13 S. Typhimurium isolates with an unusual PFGE pattern reported from 12 states. On December 2, CDC and state and local partners began an assessment of a second cluster of 41 S. Typhimurium isolates with a very similar PFGE pattern. The clusters also appeared similar epidemiologically, so the two patterns were grouped together as a single outbreak strain, and the investigations were merged. By mid-December there was a preliminary association made nationally between illness and peanut butter consumption.
We did an investigation in conjunction with the Minnesota Department of Agriculture (MDA) and found that King Nut brand creamy peanut butter was a likely source of Salmonella infection among many ill persons in Minnesota. The MDA Laboratory isolated the outbreak strain from an open 5-pound container of King Nut peanut butter. King Nut creamy peanut butter is distributed to institutions such as long-term care facilities, hospitals, schools, restaurants, cafeterias, and bakeries. To date, 19 clusters of infections in five states have been reported in schools and other institutions, such as long-term care facilities and hospitals. King Nut brand peanut butter was present in all facilities.
King Nut is produced by the Peanut Corporation of America (PCA) in Blakely, Georgia. King Nut peanut butter was not sold directly to consumers but was distributed to institutions, food service providers, food manufacturers and distributors in many states and countries. Peanut butter and peanut paste is commonly used as an ingredient in many products, including cookies, crackers, cereal, candy, ice cream, pet treats, and other foods.
A national case-control study was conducted between January 17 and 19 which revealed an association between illness and consumption of pre-packaged peanut butter crackers, specifically with Austin and Keebler brands. Austin and Keebler brand peanut butter crackers are produced by the Kellogg Company in North Carolina, using peanut paste from PCA. S. Typhimurium of the same PFGE subtype was isolated in Canada from Austin brand peanut butter crackers purchased in the United States.
On February 6, Oregon public health officials confirmed that this Salmonella outbreak can also affect pets. One laboratory-confirmed case of Salmonella in a dog from an Oregon household was reported, and further characterization of this Salmonella isolate is pending. Salmonella resembling the outbreak strain was isolated by a private laboratory from recalled dog biscuits from this dog’s household.
More than 2,833 peanut-containing products produced by a variety of companies may have been made with the ingredients made by PCA which have all been recalled.
Learn more about: Salmonella>>
Learn more about: Recall of Peanut-Containing Products and Salmonella Typhimurium>>
We are in the midst of an increase in norovirus activity with outbreaks being reported consistently from long term care facilities and schools.
Along with several foodborne and waterborne disease outbreaks, we are investigating an outbreak of Campylobacter jejuni at (nalidixic acid sensitive) at a high volume restaurant in Dakota County. The outbreak was detected through routine surveillance. Nine laboratory confirmed cases are associated with the outbreak. The median age of cases is 52 years (range, 24 to 60 years). Five (56%) of the cases are female. Two (22%) cases have been hospitalized as a result of their illness.
Cases report eating a variety of chicken and non-chicken dishes at the restaurant between February 9-14. An environmental health inspection of the restaurant found that chicken (a well known vehicle for Campylobacter) was at times being undercooked. Multiple routes of possible cross-contamination with raw or undercooked chicken were also observed.
Learn more about: Foodborne Illness>>
We have been awarded a grant from CDC to determine the best way for distributing and dispensing antiviral medications to those who are voluntarily self-isolated or self-quarantined during an influenza pandemic. For example, what is the beat way to quickly prescribe, dispense, and distribute antivirals for prophylaxis to large numbers of people advised to confine themselves in their homes following an exposure to an individual who may be the first case of a pandemic strain of influenza in the United States (or Minnesota)? In addition, we are also examining how antivirals are to be distributed, once pandemic influenza is circulating in Minnesota, to individuals with influenza-like symptoms who do not require hospitalization and have been advised that they and their household members should not leave their homes.Infectious disease physicians will have an opportunity to share their thoughts on these questions at the March 10 7:30 a.m. Interhospital Infectious Disease Conference at the Minneapolis VA Medical Center. In the near future, local public health, primary care providers, home care providers, and volunteer agencies will also have opportunities to share their ideas in a series of online surveys and focus groups. In addition, Olmsted County Public Health will be leading a table top exercise based on responses to these surveys and groups in July.
Learn more about: Pandemic Planning>>
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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