MINNESOTA DEPARTMENT DDISEASEISEASE CCONTRONTROLOL NNEWEWSLETTERSLETTER OF HEALTH DDISEASEISEASE CCONTRONTROLOL NNEWEWSLETTERSLETTER

Volume 28, Number 4 (pages 25-44) June/July 2000 Annual Summary of Communicable Diseases Reported to the Minnesota Department of Health, 1999

Introduction veterinary medical laboratories are number of cases of selected communi- Assessment is a core public health required to report these diseases. cable diseases reported to MDH during function, and surveillance for communi- These reporting sources may designate 1999 by district of the patient’s resi- cable diseases is one type of assess- an individual within an institution to dence. Pertinent observations for ment activity that is continuous over perform routine reporting duties (e.g., some of these diseases are discussed time. Epidemiologic surveillance is the an infection control practitioner for a below. A summary of influenza systematic collection, analysis, and hospital). Data maintained by MDH are surveillance data is included; however, dissemination of health data for the private and are protected under the these data do not appear in Table 2 planning, implementation, and evalua- Minnesota Government Data Practices because the influenza surveillance tion of public health programs. The Act (Section 13.38). system is based on reported outbreaks Minnesota Department of Health (MDH) rather than on individual cases and collects disease surveillance informa- Since April 1995, MDH has been covers the 1999-2000 influenza season tion on certain communicable diseases participating as one of the Emerging rather than the 1999 calendar year. for the purposes of determining disease Infections Program (EIP) sites funded impact, assessing trends in disease by the Centers for Disease Control and Arboviral Encephalitis occurrence, characterizing affected Prevention (CDC) and through this LaCrosse encephalitis and Western populations, prioritizing disease control program has implemented active equine encephalitis (WEE) are the efforts, and evaluating disease preven- hospital and laboratory-based surveil- primary arboviral encephalitides found tion strategies. In addition, prompt lance for several conditions, including in Minnesota. Confirmed cases are surveillance reports allow outbreaks to selected invasive bacterial diseases defined as those which are clinically be recognized in a timely fashion, when and foodborne diseases. Isolates for and epidemiologically compatible with control measures are likely to be most pathogens associated with these arboviral encephalitis and meet one or effective in preventing additional cases. diseases are required to be submitted more of the following laboratory criteria: to MDH (indicated in Table 1). The a four-fold or greater rise in antibody In Minnesota, communicable disease MDH laboratory performs state-of-the- titer to the virus; isolation of virus from, reporting is a centralized system art microbiologic evaluation of isolates, or detection of viral antigen in, tissues whereby reporting sources submit such as pulsed-field gel electrophore- or body fluids; or detection of specific standardized report forms to the sis, to determine whether isolates of IgM antibody in cerebrospinal fluid. Surveillance Coordinator at the MDH selected pathogens (e.g., enteric Probable cases are defined as clinically Acute Disease Epidemiology Section. pathogens such as Salmonella and compatible cases occurring during a These reports are monitored daily by Escherichia coli O157:H7, and invasive period when arboviral transmission is individual program staff. Cases of pathogens such as Neisseria likely, with an elevated and stable (i.e., disease are reported pursuant to meningitidis) are related and therefore continued... Minnesota Rules Governing Communi- may be associated with a common cable Diseases (MN Rules 4605.7000- source. In addition, testing of submitted 4605.7800). The Commissioner of isolates allows detection and monitoring Inside: Health has determined that the dis- of antimicrobial resistance, which Emerging Infections in eases listed in Table 1 (page 26) must continues to be an increasing problem Clinical Practice: be reported to MDH. As stated in these with many pathogens. Conference Information rules, physicians, health care facilities, and Registration ...... 42 medical laboratories, veterinarians, and Table 2 (page 27) summarizes the Table 1. Diseases Reportable to the Minnesota Department of Health

Amebiasis (Entamoeba histolytica) Leptospirosis (Leptospira interrogans) Anthrax (Bacillus anthracis)* Listeriosis (Listeria monocytogenes)+ Babesiosis (Babesia species) Lyme Disease (Borrelia burgdorferi) Blastomycosis (Blastomyces dermatitidis) Malaria (Plasmodium species) Botulism (Clostridium botulinum)* Measles (Rubeola)* Brucellosis (Brucella species) Meningitis (caused by Haemophilus influenzae,+ Campylobacteriosis (Campylobacter species)+ Neisseria meningitidis,+ Streptococcus Cat Scratch disease (infection caused by pneumoniae,+ or viral agents) Bartonella species) Meningococcemia (Neisseria meningitidis)+ Chancroid (Haemophilus ducreyi)*,** Mumps* Chlamydia trachomatis infection** Pertussis (Bordetella pertussis)*,+ Cholera (Vibrio cholerae)*,+ Plague (Yersinia pestis) Cryptosporidiosis (Cryptosporidium parvum) Poliomyelitis* Dengue virus infection Psittacosis (Chlamydia psittaci) Diphtheria (Corynebacterium diphtheriae)+ Q Fever (Coxiella burnetii) Diphyllobothrium latum infection Rabies (animal and human cases and suspects)* Ehrlichiosis (Ehrlichia species) Retrovirus infections (other than HIV) Encephalitis (caused by viral agents) Reye Syndrome Enteric Escherichia coli infection (E. coli 0157:H7 Rheumatic Fever (cases meeting the Jones Criteria only) and other pathogenic E. coli from gastrointestinal Rubella and Congenital Rubella Syndrome infections)+ Rocky Mountain Spotted Fever (Rickettsia species) Giardiasis (Giardia lamblia) Salmonellosis, including typhoid (Salmonella species)+ Gonorrhea (Neisseria gonorrhoeae)** Shigellosis (Shigella species)+ Haemophilus influenzae disease (all invasive Streptococcal disease (all invasive disease caused disease)+ by groups A and B streptococci and S. pneumoniae)+ Hantavirus infection Syphilis (Treponema pallidum)*,** Hemolytic Uremic Syndrome Tetanus (Clostridium tetani) Hepatitis (all primary viral types including A, B, Toxic Shock Syndrome+ C, D, and E) Toxoplasmosis (Toxoplasma gondii) Histoplasmosis (Histoplasma capsulatum) Trichinosis (Trichinella spiralis) Human Immunodeficiency Virus (HIV) infection, Tuberculosis (Mycobacterium tuberculosis and including Acquired Immunodeficiency Syndrome Mycobacterium bovis)+ (AIDS)*** Tularemia (Francisella tularensis) Influenza (unusual case incidence or laboratory Typhus (Rickettsia species) confirmed cases) Unexplained deaths possibly due to unidentified Kawasaki Disease infectious causes Legionellosis (Legionella species) Yellow Fever Leprosy (Mycobacterium leprae) Yersiniosis (Yersinia species)+

*Report immediately by telephone at (612) 676-5414 or (877) 676-5414 **Report on separate Sexually Transmitted Disease Report Card ***Report on separate AIDS/HIV Report Card +Submit isolates to the Minnesota Department of Health Public Health Laboratory

< two-fold change) antibody titer to the confirmed case and five probable cases Western equine encephalitis occurs virus. were reported to MDH. During 1985- infrequently in Minnesota, usually as 1998, 75 cases of LaCrosse encephali- part of a regional epidemic or epizootic LaCrosse encephalitis is the most tis were reported to MDH, with a in Midwestern states and southern commonly reported arbovirus infection median of five cases (range, three to 12 Canada. However, during 1999 a in Minnesota. The disease, which cases) reported yearly. The disease single probable case of WEE was primarily affects children, is transmitted has been reported in 16 southeastern reported in a Marshall County resident; through the bite of infected Aedes Minnesota counties. The highest there were no reports from other states triseriatus (Eastern Tree Hole) mosqui- incidence rates occur in Houston or Canadian provinces. Prior to this toes. Persons are exposed to infected County (mean annual incidence of 22 case, the most recent cases of WEE in mosquitoes in wooded or shady areas cases per 100,000 persons <19 years Minnesota occurred during 1983 (one inhabited by this mosquito, especially in of age; range, 0 to 68 per 100,000). case) and 1975 (15 cases). The virus areas where water-holding containers Disease onsets have been reported is transmitted to humans and horses (e.g., waste tires, buckets, or cans) are from June through September; most through the bite of Culex tarsalis abundant and are utilized as mosquito cases have onset from mid-July mosquitoes in years when virus- breeding habitat. During 1999, one through mid-September. continued...

26 Table 2. Cases of Selected Communicable Diseases Reported to the Minnesota Department of Health by District of Residence, 1999 District* (population; 1998 estimates) l n n l a n n r r n r r r a e e t r e a ) t ) e t t t t t n e i 3 s 4 s l ) ) ) ) ) s ) ) s n e n c 5 e 6 e 2 1 3 1 0 a 3 1 o a e l n 3 C 2 w e w , 7 5 4 3 7 2 2 , p w e e a C o 4 7 1 r 9 8 h 2 h 1 h 8 2 o h h t d l , , , , , , , t t t t 4 n i 8 r t t 9 6 9 s 0 0 7 3 a r t r n u k 5 u u s 7 t , 4 4 5 e 2 8 4 3 , e o o e e o o o n o 2 1 2 6 2 2 4 2 4 Disease M ( N ( N ( C ( W ( S ( S ( S ( U R T ( Campylobacteriosis 394 13 28 106 39 54 117 35 0 786 Cryptosporidiosis 18 2 1 16 6 8 35 5 0 91 Ehrlichiosis 7 1 5 22 0 1 0 0 0 36 Encephalitis - viral LaCrosse 3 0 0 1 0 1 1 0 0 6 Western 0 1 0 0 0 0 0 0 0 1 Escherichia coli 0157:H7 infection 81 1 4 21 10 8 35 15 0 175 Hemolytic Uremic Syndrome 2 1 0 3 0 1 4 2 0 13 Giardiasis 723 12 32 118 69 20 110 42 430 1556 Haemophilus influenzae invasive disease 29 2 2 6 4 6 5 2 0 56 HIV infection other than AIDS 186 1 9 5 0 3 5 3 13 225 AIDS cases (diagnosed in 1999) 141 0 1 7 1 2 5 0 0 157 Legionnaires’ disease 11 1 1 2 0 0 2 1 0 18 Listeriosis 9 0 0 0 1 1 6 0 0 17 Lyme disease 151 1 5 106 1 4 15 0 0 283 Measles 1 0 0 0 0 0 0 0 0 1 Mumps 0 1 0 0 0 0 0 0 0 1 Neisseria meningitidis invasive disease 31 3 7 8 2 0 3 2 0 56 Pertussis 221 0 5 19 0 15 8 13 0 281 Rubella 4 0 0 0 0 0 1 0 0 5 Salmonellosis 325 12 23 81 60 25 58 42 0 626 Sexually transmitted diseases* Chlamydia trachomatis - genital infections 5609 183 288 561 128 104 465 112 0 7450 Gonorrhea 2567 15 51 93 17 17 58 12 0 2830 Syphilis total 53 0 2 8 1 1 6 1 0 72 primary/secondary 10 0 0 0 0 0 0 0 0 10 early latent** 9 0 0 0 0 0 0 0 0 9 late latent*** 33 0 2 8 1 1 6 1 0 52 congenital 1 0 0 0 0 0 0 0 0 1 Chancroid 1 0 0 0 0 0 0 0 0 1 Shigellosis 235 0 1 7 2 0 7 2 0 254 Streptococcus pneumoniae invasive disease (Twin Cities only) 584 ------584 Streptococcal invasive disease - Group A 102 4 6 23 12 9 15 9 0 180 Streptococcal invasive disease - Group B 128 4 15 24 9 21 22 9 0 232 Tetanus 1 0 0 0 0 0 0 0 0 1 Tuberculosis 158 2 1 4 1 2 31 2 0 201 Vancomycin Resistant Enterococci+ 102 3 2 21 1 4 9 3 0 145 Viral hepatitis, type A 105 0 1 3 2 7 4 6 0 128 Viral hepatitis, type B (acute infections only) 58 0 7 5 5 0 5 0 0 80 Viral hepatitis, type C (acute infections only) 14 0 3 2 2 0 3 1 0 25 Yersiniosis 14 1 1 6 3 1 8 3 0 37

*Cases for which the patient’s residence is unknown are assigned the geographic location of the reporting clinic when known. **Duration <1 year ***Duration >1 year +Totals do not include out-of-state residents. County Distribution within Districts Metropolitan = Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, Washington Northwestern = Beltrami, Clearwater, Hubbard, Kittson, Lake of the Woods, Marshall, Pennington, Polk, Red Lake, Roseau Northeastern = Carlton, Cook, Lake, St. Louis Central = Aitkin, Benton, Cass, Chisago, Crow Wing, Isanti, Itasca, Kanabec, Koochiching, Mille Lacs, Morrison, Pine, Sherburne, Stearns, Todd, Wadena, Wright West Central = Becker, Clay, Douglas, Grant, Mahnomen, Norman, Otter Tail, Pope, Stevens, Traverse, Wilkin South Central = Blue Earth, Brown, Faribault, LeSueur, McLeod, Martin, Meeker, Nicollet, Sibley, Waseca, Watonwan Southeastern = Dodge, Fillmore, Freeborn, Goodhue, Houston, Mower, Olmsted, Rice, Steele, Wabasha, Winona Southwestern = Big Stone, Chippewa, Cottonwood, Jackson, Kandiyohi, Lac Qui Parle, Lincoln, Lyon, Murray, Nobles, Pipestone, Redwood, Renville, Rock, Swift, Yellow Medicine infected vector populations are rela- for WEE virus). 100,000 population). Of tively high. The mosquitoes usually Campylobacter isolates submitted to feed on birds and maintain WEE virus Campylobacteriosis MDH, 88% were C. jejuni and 9% were in a mosquito-bird cycle. However, in Campylobacter continues to be the C. coli. Fifty percent of cases resided mid-summer when vector populations most commonly reported bacterial in the seven-county Twin Cities rise, a significant part of the mosquito enteric pathogen in Minnesota (Figure metropolitan area. Fifty-one percent of feeding may switch to mammalian 1). There were 786 cases of culture- cases were 20 to 49 years of age, and hosts such as humans and horses confirmed Campylobacter infection 12% of cases were 5 years of age or (both considered to be dead-end hosts reported to MDH in 1999 (16.4 per continued...

27 younger. Fifty-one percent of infections occurred during June through Septem- Figure 1. Reported Cases of Campylobacter, Salmonella, Shigella, ber. No outbreaks of and Escherichia coli O157:H7 Infection, Minnesota, 1990-1999 campylobacteriosis were identified in 1999. Campylobacter 1200 Salmonella The primary feature of public health Shigella importance was the continued emer- 1000 E. coli O157:H7 s

gence of C. jejuni isolates resistant to e s fluoroquinolone antibiotics (e.g., a 800 C

ciprofloxacin), which commonly are f o

used to treat campylobacteriosis. From r 600 e

1992 to 1999, the proportion of b quinolone-resistant C. jejuni isolates m 400 u increased from 1.3% to 17.3%. Peaks N in the proportion of resistant isolates 200 peaked during the winter months of each year and were associated with 0 foreign travel (particularly to Mexico). 90 91 92 93 94 95 96 97 98 99 More than 80% of C. jejuni isolates from patients with a history of foreign Year of Diagnosis travel (regardless of destination) during the week before onset of illness were Demographic characteristics of cases The epidemiology of HGE in Minnesota resistant to fluoroquinolones. Domesti- in 1999 were similar to those in 1997 was outlined in the May 2000 issue of cally acquired quinolone-resistant C. and 1998. Thirty-five cases (38%) the Disease Control Newsletter (Vol. jejuni infections also increased signifi- were from southeastern Minnesota, and 28, No. 3). That article also summa- cantly from 1996 to 1999. Quinolone- 18 (20%) were from the seven-county rized the clinical presentation of HGE resistant C. jejuni were recovered from metropolitan area. Ages ranged from 2 patients, diagnostic tests, case defini- 14% of retail chicken products acquired months to 85 years, with a median age tions, and treatment. by MDH in the seven-county metropoli- of 8 years. Children less than 10 years tan area in 1997; identical molecular of age accounted for 53% of cases, and Escherichia coli 0157:H7 Infection subtypes were found among resistant children less than 5 years of age for and Hemolytic Uremic isolates from chicken products and 39%. Sixty-three percent of cases Syndrome (HUS) resistant isolates from domestically occurred during July through October. During 1999, 175 cases of culture- acquired human infections. Thus, the Twenty-four percent of cases were confirmed E. coli O157:H7 infection increase in domestically acquired hospitalized. No cases were known to were reported to MDH (3.7 per 100,000 resistant cases among humans likely is be HIV-infected. population). The mean number of due largely to the use of cases reported annually from 1995 to fluoroquinolones in poultry in the United MDH conducted a case-control study of 1999 was 204, with a range of 175 to States, which began late in 1995. 63 sporadic cases of cryptosporidiosis 239 cases (Figure 1). Seventy-nine identified among Minnesota residents percent of the cases reported in 1999 Cryptosporidiosis from July through December 1998. The occurred during June through October. During 1999, 91 cases of laboratory- primary risk factors for cryptosporidiosis confirmed Cryptosporidium parvum identified by this study included Four outbreaks of E. coli O157:H7 infection were reported to MDH (1.9 per swimming in public pools, drinking well infection were identified in 1999. One 100,000 population). This represents a water, and exposure to calves. outbreak occurred in a childcare home 47% decrease from the 173 cases and resulted in two confirmed cases, reported in 1998 and a 62% decrease Ehrlichiosis including one case of HUS. The from the 242 cases reported in 1997. Ehrlichiosis is an emerging tick-borne second outbreak occurred at a family The large number of cases in 1997 was bacterial disease in several regions of picnic and resulted in two confirmed due in part to a waterborne outbreak of the United States. Human granulocytic cases, including one case of HUS. The cryptosporidiosis associated with a ehrlichiosis (HGE) is the primary form third outbreak was part of a multi-state water sprinkler fountain. One outbreak seen in Minnesota; HGE is transmitted outbreak that was identified through of cryptosporidiosis was identified in to humans by Ixodes scapularis (deer routine subtyping of isolates by pulsed- 1999, accounting for 10 confirmed tick or black-legged tick), the same tick field gel electrophoresis (PFGE). The cases. This outbreak was associated that transmits Lyme disease. During source of the multi-state outbreak was with a swimming pool in a mobile home 1999, 36 probable or confirmed cases ground beef produced by a plant in park. Excluding outbreak-associated of HGE were reported to MDH. The Minnesota and distributed nationally. cases, there still was a substantial risk of acquiring HGE was highest in Three confirmed cases associated with decrease in cases reported in 1999 (81 the same east-central Minnesota this outbreak occurred among Minne- cases) compared to 1997 (153 cases) counties where Lyme disease risk was sota residents; all three cases were and 1998 (158 cases). greatest. hospitalized, but none developed HUS. continued...

28 The fourth outbreak, also detected influenzae disease were reported to reported to MDH (3.3 per 100,000 through routine subtyping of isolates, MDH in 1999 (1.2 per 100,000 popula- population). This represents a 63% was caused by a specific PFGE tion). Cases ranged in age from decline in the reported annual inci- subtype of non-motile E. coli O157. newborn to 90 years, with a median dence of AIDS cases since the peak in This outbreak was associated with age of 67 years. Eighteen cases (32%) 1992 (423 cases) and the lowest ground beef purchased at grocery had pneumonia, 25 (45%) had bacter- reported annual incidence since 1987 stores belonging to a specific chain in emia without another focus of infection, (142 cases) (Figure 2). The recent the seven-county metropolitan area. and three (5%) had meningitis. Four decline is due in part to the benefits of Ten culture confirmed cases were deaths were reported. highly active antiretroviral therapy identified. Two cases became ill in late (HAART). The peak incidence in 1992 December, whereas the other eight Five cases (9%) were known to be type likely is due to a change in the AIDS cases became ill from January to March b (Hib), compared to two cases in 1998 surveillance case definition in 1993 of 2000. and seven cases in 1997. One of the which allowed for retrospective Hib cases reported in 1999 was a 6- diagnoses. This change incorporated Thirteen cases of HUS were reported in month-old child who had no significant CD4+ T-lymphocyte counts of <200/uL 1999; all were post-diarrheal. E. coli medical history. This child had in the absence of other AIDS-indicator O157:H7 was isolated from stool in 12 received one Hib immunization as per diseases. (92%) of the HUS cases. The only stool the recommended schedule. The other culture-negative case was serologically four cases of Hib reported in 1999 In addition to AIDS cases reported in positive for E. coli O157 antibodies. occurred in adults. The child had 1999, 225 newly identified cases of HIV Eleven (85%) of the HUS cases cellulitis, three adults had bacteremia infection which had not progressed to occurred during June through October. without another focus of infection, and AIDS by year end were reported in The mean number of HUS cases one adult had pneumonia; all survived. 1999 (4.7 per 100,000 population) reported annually from 1995 to 1999 (Figure 2). While newly identified HIV was 18 (range, 12 to 29 cases). During Thirty-two cases (57%) had untypeable (non-AIDS) case incidence rates have 1999, seven HUS cases (54%) were isolates, seven (13%) were type f, three plateaued over the past 5 years, the less than 10 years of age, and three (5%) were type e, one (2%) was type c, 1999 incidence reflects a 45% decline (23%) were greater than 60 years of and eight (14%) were unknown. from the 406 cases reported in 1987. age. All HUS cases were hospitalized, This peak number is not represented in with a mean duration of hospitalization The four deaths occurred in cases Figure 2 to avoid duplication of reported of 17 days (range, 6 to 80 days). Two ranging in age from 20 to 85 years. All cases which progressed from an HIV cases died; both were greater than 70 four cases presented with pneumonia; (non-AIDS) diagnosis to AIDS. The years of age. three had significant underlying medical plateau in HIV (non-AIDS) reports conditions. Isolates from three of the suggests that the epidemic may be Giardiasis deaths were untypeable, and the stabilizing in Minnesota, since no During 1999, 1,556 cases of Giardia isolate from the other death was type c. changes in surveillance methodology lamblia infection were reported to MDH have been made since 1993. (32.5 per 100,000 population). This HIV Infection and AIDS represents a 18% increase from the In 1999, 157 cases of AIDS were continued... 1,324 cases reported in 1998 and a 40% increase from the mean annual Figure 2. AIDS Cases by Year of Diagnosis, HIV Cases by Year of Report, number of cases reported from 1989 to 1998 (mean of 1,115 cases; range, 819 and AIDS Deaths by Year of Death, Minnesota, 1982-1999 to 1,467). The median age of cases 450 AIDS Cases reported in 1999 was 25 years. As in 400 previous years, cases were clustered HIV Cases* s 350 Deaths** among children less than 5 years of h t age (22%) and adults 30 to 39 years of a e 300 D

age (20%); only 12% of cases were / s over 50 years of age. This age e 250 s

distribution suggests a higher risk for a C transmission among young children 200 f o

and the adults who care for them. r 150 e

However, cases were not systemati- b cally interviewed to identify potential m 100 u

sources of exposure, such as atten- N dance at childcare facilities. No 50 outbreaks of giardiasis were identified in 1999. 0 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Haemophilus influenzae Year of AIDS Diagnosis/HIV Report/Death

Invasive Disease *Excludes cases which subsequently were diagnosed with AIDS. Fifty-six cases of invasive Haemophilus **Deaths occurring during a year are not necessarily related to cases diagnosed during that year.

29 New treatments for HIV infection also have led to a marked reduction in Figure 3. Persons Living with HIV/AIDS at Year End, Minnesota, 1982-1999 mortality. Deaths due to AIDS have declined substantially since 1994 4000

(Figure 2). The 65 deaths in persons s 3500 n

with a diagnosis of AIDS in 1999 was o

s 3000 the lowest number reported in Minne- r

e 2500 P

sota since 1986 (59 deaths). f 2000 o

r 1500 Several trends in reported AIDS/HIV e b 1000

cases continue to evolve (Table 3). m Male-to-male sex remained the most u 500 N common exposure category for AIDS 0 cases diagnosed in 1999 (69 cases, 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 44%), but the proportion has declined Year steadily over time. In contrast, the proportion of cases related to hetero- sexual contact has increased over time. cases. Heterosexual transmission during pregnancy, the number of The proportion of female AIDS cases accounts for 11% of HIV (non-AIDS) pediatric cases has decreased and has increased; females represented 8% cases and 6% of AIDS cases. Females remained constant at three cases per of cases diagnosed in 1992, 9% of comprise 18% of HIV (non-AIDS) cases year since 1995. cases diagnosed cumulatively before compared to 10% of AIDS cases. 1998, and 19% of cases diagnosed in Whites comprise 74% of AIDS cases As new treatments become available 1999. An increasing proportion of AIDS and 63% of HIV (non-AIDS) cases, and the occurrence of AIDS is being cases continues to be identified in while blacks and Hispanics comprise delayed, using AIDS diagnoses as a people of color, while the proportion of 18% and 5% of AIDS cases and 28% marker for the epidemic is becoming cases identified in whites is decreasing. and 5% of HIV (non-AIDS) cases, less useful. Assessing trends based on In 1999, 32% of AIDS cases were respectively. Injecting drug use as a recent HIV infections provides a better identified as black, 11% Hispanic, 4% risk factor accounts for 8% of AIDS mechanism to evaluate current trans- American Indian, and 3% Asian/Pacific cases and 10% of HIV (non-AIDS) mission risk and effectiveness of Islanders, compared to 16%, 5%, <1%, cases. prevention efforts. In addition, because and 2%, respectively, prior to 1998. of increased survival, a growing Conversely, in 1999, 50% of AIDS Since 1985, 54 pediatric cases (<13 number of persons are living with HIV cases were identified as white, com- years of age) have been diagnosed infection (Figure 3). These data pared to 77% of cases prior to 1998. with AIDS/HIV infection in Minnesota. emphasize the continued importance of Most of these children were diagnosed monitoring the epidemic to better direct When cumulative HIV (non-AIDS) from 1987 to 1994, with the peak policy and prevention efforts. infection data are compared to cumula- number of reported cases (n=8) in tive AIDS data, the HIV (non-AIDS) 1992. The majority (43 cases, 80%) Influenza trends are even more pronounced than were born to HIV-infected women and Influenza surveillance in Minnesota the trends in AIDS cases described acquired their infection perinatally. relies on passive reporting from clinics, above. For example, male-to-male sex With the increased identification of HIV hospitals, laboratories, schools, and is a risk factor for 55% of reported HIV infection in pregnant women and the long-term care facilities. The current (non-AIDS) cases and 69% of AIDS increased use of antiretroviral therapy continued...

Table 3. Adult/Adolescent Cases of AIDS by Exposure Category, Sex, and Year of Diagnosis, Minnesota, 1982-1999

Percentage of Cases in Exposure Category

1982-1997 1998 1999

Exposure Category Male Female Total Male Female Total Male Female Total (n=2909) (n=276) (n=3185) (n=154) (n=38) (n=192) (n=127) (n=30) (n=157) Men Who Have Sex With Men 78 0 71 67 0 54 54 0 44 Injecting Drug Use (IDU) 6 25 8 12 16 13 9 23 11 Men Who Have Sex With Men and IDU 8 0 7 5 0 4 4 0 3 Hemophilia/Coagulation Disorder 2 <1 2 0 0 0 2 0 1 Heterosexual 1 50 5 2 45 10 6 33 11 Transfusion, Blood/Components 1 5 1 0 0 0 0 0 0 Other/Undetermined 4 19 6 14 39 19 26 43 29

Total 100 100 100 100 100 100 100 100 100

30 surveillance systems used in schools from 64 schools in 31 counties through- oped complications due to prenatal and long-term care facilities have been out Minnesota. Possible outbreaks infection and subsequently died. in place since the 1995-96 influenza were reported from 70 schools in 30 season. A Sentinel Physician Influenza counties. Schools began reporting ILI Most cases were sporadic; however, Surveillance Network consisting of outbreaks in early January. Eighty- five cases were linked to an outbreak of three sentinel sites was initiated in eight percent of probable and possible listeriosis that occurred in Olmsted Minnesota for the 1998-99 season. ILI outbreaks were reported during County during September through Ten sentinel sites participated during November and December. Since December. The source of the outbreak the 1999-2000 season, and MDH plans 1988-89, the number of schools was a grocery store deli; multiple to further expand the number of sites to reporting suspected influenza out- isolates of L. monocytogenes with a 18 (representing one sentinel site per breaks has ranged from 38 schools in pulsed-field gel electrophoresis pattern 250,000 population). 20 counties in 1996-97, to a high of identical to case isolates were recov- 441 schools in 71 counties in 1991-92. ered from opened packages of sliced The 1999-2000 influenza season began meat and from the deli environment. early and had an earlier than usual In a long-term care facility, an ILI The original source of contamination peak in influenza activity. The first outbreak is suspected when three or was not determined. influenza isolate in Minnesota was more residents with a cough and fever confirmed by the MDH Public Health (>101° F) or chills present in a single Lyme Disease Laboratory (PHL) on October 13, 1999. unit during a period of 48 to 72 hours. The national surveillance case definition Since the 1990-91 season, the first An ILI outbreak is confirmed when at for a confirmed case of Lyme disease influenza isolate usually has been least one resident has a positive includes: 1) physician-diagnosed collected and identified in mid-Novem- culture or rapid-antigen test for erythema migrans (EM) (solitary lesion ber. Surveillance indicators for 1999- influenza. During 1999-2000, 65 long- must be >5 centimeters in diameter), or 2000 suggest that although influenza term care facilities reported confirmed 2) at least one late manifestation of activity was within the normal range, or suspected ILI outbreaks. In 48 Lyme disease (neurologic, cardiac, or considerably higher than usual activity (74%) long-term care facilities, influ- joint) and laboratory confirmation of occurred during late December and enza was laboratory-confirmed by infection. MDH has established the early January. direct antigen or culture; influenza type following as acceptable criteria for A was identified in all of these facilities. laboratory confirmation with regard to The MDH PHL received 640 influenza All long-term care facility outbreaks counting surveillance cases: 1) positive isolates for viral confirmation and strain were reported during October through results of serologic testing conducted identification. Of the isolates received, January, and 72% were reported by CDC, or 2) a positive Western blot 628 (98%) were identified as influenza during November or December (i.e., test from a clinical reference laboratory. type A (H3N2)/Sydney-like, six (1%) early in the influenza season). Since A probable case of Lyme disease is were influenza A but sub-type was not 1988-89, the number of long-term care defined as a person with at least one available, five (1%) were influenza type facilities reporting ILI outbreaks has late manifestation of Lyme disease and A (H1N1)/Beijing-like, and one (<1%) ranged from six facilities in 1990-91 to laboratory evidence of infection but was influenza type B/Yamanashi-like. 79 facilities in 1997-98. without a history of EM or appropriate Influenza type A Sydney-like also was laboratory confirmation. the predominate strain circulating Listeriosis nationally. Strains that circulated in Seventeen cases of listeriosis, includ- During 1999, 283 cases meeting the Minnesota during 1999-2000 were well ing two deaths, were reported to MDH national surveillance case definition for matched to the strains included in the in 1999. Since active laboratory a confirmed case of Lyme disease were 1999-2000 influenza vaccine. surveillance for listeriosis was imple- reported to MDH (6.0 per 100,000 mented in 1996, the annual number of population). This number represents an A probable outbreak of influenza-like cases has ranged from 10 in 1996 to 8% increase in cases from the prior illness (ILI) in a school was defined as 19 in 1998. During 1999, 14 cases high of 261 cases reported in 1998 and a doubled absence rate with all of the (82%) were 50 years of age or older. a 20% increase from the mean annual following primary influenza symptoms Fifteen cases (88%) were hospitalized number of cases reported from 1994 to reported among students: rapid onset, at the time of specimen collection. 1998 (mean of 236 cases; range, 205 to fever of 101° F or greater, illness Listeria was most frequently isolated 261) (Figure 4). During 1999, an lasting at least 3 days, and at least one from blood (71%). Other sources of additional 11 reports were classified as secondary influenza symptom (i.e., isolates were cerebrospinal fluid (12%), probable cases of Lyme disease. myalgia, headache, cough, coryza, central line (6%), urine (6%), and sore throat, chills). A possible ILI placenta (6%). One hundred sixty-three confirmed outbreak in a school was defined as a cases (58%) were male. The median doubled absence rate and symptoms One of 11 female cases in 1999 was age of cases was 31 years (range, 1 to reported among students that included pregnant. On the day she developed 85 years). Forty-one percent of cases two of the primary influenza symptoms fever and chills, the woman went into were 1 to 20 years of age, and 30% of and at least one secondary influenza premature labor and gave birth at 27 cases were 41 to 60 years of age. symptom. weeks. Listeria monocytogenes was Physician-diagnosed EM was present in isolated from the mother’s blood and 227 (80%) cases. Sixty-six cases Probable ILI outbreaks were reported from the placenta. The baby devel- continued...

31 who had a rash upon arrival in Minne- Figure 4. Reported Cases of Lyme Disease, Minnesota, 1983-1999 sota. The case was laboratory- confirmed with a positive serologic test 300 for measles IgM antibody. Measles serologic testing was performed on all

s 250 five family members. A 10-year-old e

s asymptomatic sibling was IgM- and a 200 C

IgG-positive, indicating recent infection f o 150 or immunization, although the father did r

e not provide a history of either a recent b 100

m rash illness or immunization for this u child. Other family members were IgG- N 50 positive and IgM-negative, indicating 0 past immunity. Because the case was 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 infectious during air travel from Kenya Year of Diagnosis to Minneapolis, the airlines and local refugee resettlement agencies working with other Somali refugees on the (23%) had at least one late manifesta- (13%) were white, three (4%) were flights were notified of the exposure. tion of Lyme disease (47 of 66 had a Asian, and one (1%) was of unknown No other cases were identified despite history of objective joint swelling) and race. Only 17 cases (24%) were U.S. heightened surveillance for rash illness. confirmation by a positive Western blot citizens, and nine (13%) were born in Ongoing measles transmission has test. Onsets of illness peaked in June the U.S. The majority of cases (89%) been identified in Kenyan refugee and July (30% and 38% of cases, resided in the seven-county metropoli- camps where many Somali refugees respectively). Onset peaks correspond tan area, including 34 cases (48%) in reside. to the peak of nymphal Ixodes Hennepin County. Most cases (80%) scapularis (deer tick, or black-legged had symptomatic infections, but 13 Maintaining a thorough measles tick) activity in Minnesota. (18%) were immigrants to the U.S. who surveillance program and high measles were asymptomatic at the time their vaccination coverage are essential Similar to data from previous years, infections were identified by screening. components of a measles elimination 151 (53%) of Lyme disease cases in strategy. Although current measles 1999 were residents of the seven- The geographical region where malaria activity is low in the U.S. and in county metropolitan area. However, likely was acquired by the cases Minnesota, importation of cases from only 34 (12%) cases likely were reported in Minnesota included Africa outside the U.S. and the presence of exposed to infected I. scapularis in (61 cases), Asia (6 cases), and Central groups with philosophical or religious metropolitan area counties, primarily America and South America (one case opposition to vaccination require that Anoka, Washington, and extreme each); one case traveled to both Africa surveillance for measles and other rash northern Ramsey counties. Most cases and Asia, and one had unknown illnesses remains heightened. In- are reported in patients who either live exposure. Twenty-four countries were creased attention to reducing missed in or travel to endemic counties in east- considered possible countries of origin opportunities for vaccination of central Minnesota or western Wiscon- of the malarial infections. The coun- preschoolers is needed. High vaccina- sin. Several east-central Minnesota tries from which the highest numbers of tion coverage levels among preschool- counties continue to have the highest cases possibly originated were in and school-aged children and improved incidence rates of Lyme disease within Africa, including Liberia (25 cases), the implementation and enforcement of the Minnesota (e.g., Aitkin, Kanabec, Crow Ivory Coast (16), Ghana (11), Nigeria recommendation for two doses of Wing, Mille Lacs, and Pine Counties (seven), and Kenya (five). measles vaccine among high school had incidence rates of 101, 93, 57, 44, and college students is necessary in all and 34 cases per 100,000 population, Measles communities to eliminate transmission respectively). Additional details on Measles is no longer an indigenous of endemic measles. The absence of Lyme Disease in Minnesota can be disease in the United States. However, transmission in the community from the found in the May 2000 issue of the international importation of measles case reported in Minnesota in 1999 is Disease Control Newsletter (Vol. 28, remains an important source of evidence that these goals are being No. 3). measles transmission in the U.S. In achieved. Minnesota, nine measles cases were Malaria reported from 1997 to 1999; four (44%) All suspected cases of measles should In 1999, 71 cases of malaria (all were imported, three (33%) were be reported immediately to MDH. The imported) were reported to MDH. associated with an imported case, and Centers for Disease Control and These cases and the 76 cases reported one (11%) had a recent history of Prevention recommends serologic in 1998 represent the highest numbers foreign travel. testing for measles and rubella for reported since the end of the Korean patients with rash illnesses compatible War. The median age of cases was 19 One case of measles was reported to with either measles or rubella. Blood years (range, 1 to 64 years). Of the 71 the MDH during 1999. The case specimens for IgM serologic testing cases, 58 (82%) were black, nine occurred in a 5-year-old Somali child continued...

32 should be drawn at least 72 hours after were not groupable. One case was also was hospitalized with similar rash onset. Blood specimens for acute hospitalized in another state and symptoms, but the diagnosis of and convalescent IgG serologic testing serogroup information was not avail- meningococcal disease was not should be drawn within 10 days able. culture-confirmed in the sibling. (preferably within 7 days) after rash onset, and again 3 to 5 weeks later. Ages of cases ranged from 10 days to Since the fall of 1998, MDH has Acute and convalescent specimens 82 years, with a mean age of 19 years. collected additional information on should be tested as paired sera. Fifty-five percent of the cases resided college-aged students with Neisseria in the Twin Cities metropolitan area. meningitidis invasive disease as part of Mumps Thirty cases (54%) had meningitis, 19 a nationwide effort to determine One case of mumps was reported to (34%) had bacteremia without another whether providing meningococcal MDH during 1999, compared to 13 focus of infection, five (9%) had vaccine to incoming college freshmen cases in 1998. The 1999 case was pneumonia, one (2%) had otitis, and would effectively prevent disease in this laboratory-confirmed by positive IgM one (2%) had septic arthritis. age group. Four cases reported in serology. The case, a 2-year-old child, Minnesota in 1999 were college had received one dose of MMR vaccine Four deaths occurred. A 26-year-old students. Each student attended a at 12 months of age and had no history female died of meningitis attributed to different school, and each resided in a of travel. There was no evidence of serogroup Y. The other deaths different area of the state. Three cases additional transmission from this case. resulted from meningococcemia and were due to serogroup C, and one was Since 1990, a mean of 11 cases of included a 7-year-old female with due to serogroup Y (serogroups A, C, mumps have been reported annually to serogroup C, a 24-year-old female with Y, and W135 are covered in the MDH, with the majority of cases serogroup B, and a 75-year-old female quadrivalent vaccine). In the fall of occurring among adults. with serogroup Z. 1999, the Centers for Disease Control and Prevention Advisory Committee on A shift in the age distribution of Most cases were sporadic, with no links Immunization Practices recommended reported mumps cases from a focus in to other cases through either epidemiol- that health care providers inform school-aged children to adults reflects ogy or molecular subtyping. An college students about meningococcal the success of the two-dose MMR outbreak of serogroup C meningococ- disease and about the availibility of immunization strategy in reducing the cal disease involved four American vaccine. incidence of mumps in populations for Indian patients (ages 5, 8, 13, 20 years) whom it is indicated and highlights the from the Duluth/Cloquet area. The first Pertussis need to assess mumps immunization case had onset of illness in 1998; the Two hundred eighty-one cases of status of adults. Current recommenda- others had onsets in January 1999. All pertussis were reported during 1999 tions for mumps vaccine include adults of the outbreak-associated isolates (5.9 per 100,000 population). Labora- born in 1957 or later. were closely related by pulsed-field gel tory confirmation was available for 142 electrophoresis (PFGE). Three isolates cases (51%); 80 were confirmed by Because of the difficulty in distinguish- were an identical subtype; the other culture and 62 by polymerase chain ing infectious parotitis (mumps) from isolate differed by one band. Direct reaction (PCR). The number of PCR- other forms of parotitis and the possibil- contact was not established between confirmed cases increased due to a ity of false-positive mumps IgM any of the cases. change in methodology at a large serology, both IgM and IgG mumps- private laboratory in May 1999. The specific serologic testing is recom- Antibiotic prophylaxis was provided for remainder of cases were epidemiologi- mended for all sporadic cases. The all outbreak-associated cases and their cally linked to culture-confirmed cases acute specimen for IgM and IgG testing close contacts. Vaccination clinics (83, 30%) or met the clinical case should be drawn at least 3 days after were conducted on the Fond du Lac definition (56, 20%). Two hundred onset of parotitis, and the convalescent Reservation and in Duluth, and twenty-one (79%) cases occurred in IgG specimen should be drawn 3 to 5 immunizations were provided for residents of the Twin Cities metropoli- weeks later. The acute and convales- American Indians 2 to 29 years of age tan area. One death due to pertussis cent IgG serology tests should be run living on or near the Fond du Lac was reported in 1999. as paired sera. Reservation or in the city of Duluth. Staff and students at the elementary Although pertussis often is referred to Neisseria meningitidis school that the 8-year-old case as “whooping cough,” very young Invasive Disease attended also were immunized. children, older individuals, and previ- Fifty-six cases of Neisseria meningitidis Approximately 2,300 people were ously immunized persons may not have invasive disease were reported in 1999 vaccinated. No additional cases were the typical “whoop” associated with (1.2 per 100,000 population), compared reported from the Duluth/Cloquet area pertussis. Paroxysmal coughing is the to 36 cases in 1998. The distribution of following the vaccination clinics. most commonly reported symptom. In serogroups was similar to 1998, with 25 However, a subsequent case with a 1999, 97% of reported pertussis cases (45%) serogroup C cases, 12 (21%) matching PFGE subtype was reported experienced paroxysmal coughing, and serogroup B cases, 14 (25%) in the Twin Cities area 4 weeks later. 31% experienced whooping. Post- serogroup Y cases, one (2%) The case was an American Indian child tussive vomiting was reported in 54% of serogroup W135 case, one (2%) who had close contact with persons cases, and apnea was reported in 32%. serogroup Z case, and two cases which from the Duluth/Cloquet area. A sibling continued...

33 Due to waning immunity following either traindicated in pregnancy. after cough onset was positive for B. natural infection or vaccination, pertussis on culture and PCR, despite 5 pertussis can affect persons of any age Although unvaccinated children are at days of erythromycin-equivalent and increasingly is recognized in older highest risk for pertussis, fully immu- macrolide therapy. A second culture children and adults. During 1999, nized children may develop disease. collected more than 6 weeks later was cases ranged in age from less than 1 Vaccine efficacy for currently licensed negative for B. pertussis. All other B. month to 83 years. The largest vaccines is estimated to be 71% to pertussis isolates tested to date have proportion of cases (30%) were 84% for preventing serious pertussis had low minimum inhibitory concentra- children between 5 and 12 years of disease. Of 165 cases from 2 months tions, falling within the reference range age. Thirty-nine cases (14%) were to 15 years of age with a known for susceptibility to the antibiotics infants less than 6 months of age, and vaccination history, 10 (67%) had evaluated. 43 (15%) were children 6 months received age-appropriate immunization through 4 years of age. Persons 13 to for pertussis (including infants 2 to 5 Rubella/Congenital Rubella 17 years of age and persons 18 years months of age for whom a primary Syndrome of age or older accounted for 14% and series is not yet indicated). Of the 149 Five cases of rubella were reported 27% of cases, respectively. cases from 7 months through 15 years during 1999. No cases were reported of age, 78% had received at least a during the previous 6 years, although The severity of pertussis increases primary series of three doses. Disease one case of congenital rubella syn- significantly with decreasing age; in previously immunized persons drome was reported in 1998. The pertussis is most severe in infants and usually is mild. Of the 54 cases from 7 rubella cases in 1999 included three young children. Pneumonia was months to 7 years of age, 18 (33%) Hispanic adults 25, 26, and 27 years of diagnosed in 17 (6%) cases, nine were considered preventable (i.e., the age living in Minneapolis, a 13-month- (53%) of whom were less than 6 patients received fewer than three old Southeast Asian child in Hennepin months of age. Thirty-two (11%) cases doses of DTP vaccine before onset of County, and an 11-month-old white, were hospitalized; twenty-five (78%) of illness). non-Hispanic child in greater Minne- these patients were younger than 6 sota. All five cases were laboratory- months of age. The pertussis-related Physicians should include pertussis in confirmed with a positive serologic test death occurred in an 11-day-old infant. the differential diagnosis of cough for rubella IgM antibody. illness in persons of all ages regardless Older children and adults with pertussis of immunization status. Until approved Rubella often is under-diagnosed due may expose unprotected infants at risk booster vaccination for pertussis is to the mild nature of illness and for the most severe consequences of available to protect older children and because 25% to 50% of cases are infection. During 1999, 43 cases of adults, prompt diagnosis and treatment asymptomatic. In 1999, surveillance pertussis were reported in infants less of cases and prophylaxis of contacts was heightened in response to reports than 1 year of age. A likely source of are the only means to limit transmis- of rubella outbreaks among Hispanic exposure (i.e., a person with an illness sion. individuals working in the meat-packing meeting the clinical case definition or industry in Nebraska and Iowa. MDH with laboratory-confirmed pertussis) For all 80 culture-confirmed cases, B. alerted clinicians and public health was identified for 20 cases (47%). pertussis isolates were subtyped by professionals statewide to the potential Fourteen of these 20 cases (70%) likely pulsed-field gel electrophoresis (PFGE) for rubella cases in Minnesota and were infected by an adult (most often and tested for antibiotic susceptibility. provided information to facilitate parents, grandparents, or another adult Twelve distinct PFGE patterns were laboratory testing. Targeted community relative), and six cases (30%) likely identified; four patterns (33%) were education efforts and immunization were infected by children (usually represented by a single case isolate. clinics were conducted in high-risk siblings). Twenty-three infant cases The two most common patterns areas of the state where meat process- (53%) had no identified source of accounted for 59 (74%) of the isolates ing plants employ significant numbers exposure. One case in a 3-week-old and occurred throughout the year. of Hispanic workers. Over 2,000 doses infant was epidemiologically linked to of vaccine were administered to the mother, who had culture-confirmed The first case of erythromycin-resistant susceptible high-risk persons. Al- pertussis. The mother’s cough onset B. pertussis in Minnesota was identified though the rubella cases reported in was 16 days prior to the infant’s onset in October 1999. Only five other Minnesota in 1999 had no identified ties and 2 days before the infant’s birth. erythromycin-resistant B. pertussis to cases in Nebraska and Iowa or the The mother’s pertussis was not cases have been identified in the U.S.; meat processing industry, the height- identified until the infant was hospital- the first was identified in Arizona in ened surveillance and outbreak control ized. No additional cases were 1994. The Minnesota case occurred in efforts may have contributed to the identified among contacts exposed a 10-year-old white female from Carver detection of these cases and prevented during the mother’s hospitalization. County. She had received one dose of transmission. These cases highlight the need for a pertussis-containing vaccine at 2 high index of suspicion for pertussis in months of age; however, three subse- All suspected cases of rubella should adolescents and adults with cough quent vaccinations included only be reported immediately to MDH. The illness (particularly pregnant women) diphtheria and tetanus toxoids (DT) due Centers for Disease Control and and the importance of antibiotic to a medical contraindication. A naso- Prevention recommends serologic treatment. Erythromycin is not con- pharyngeal specimen collected 35 days continued...

34 testing for both rubella and measles for of which were due to multi-drug The number of cases and rates (per patients with rash illnesses compatible resistant S. typhimurium phage type 100,000 population) of reportable with rubella or measles. Prevention of DT104 (resistant to ampicillin, chloram- bacterial STDs for 1995 through 1999 congenital rubella syndrome and phenicol, streptomycin, are presented in Table 4. Chlamydia, rubella in post-pubescent populations is sulfamethoxazole, and tetracycline). gonorrhea, and primary/secondary the objective of rubella immunization Two of the outbreaks occurred in syphilis case numbers and rates by programs and continues to warrant childcare homes. There were six residence, age, gender, and race/ attention in Minnesota, particularly as culture-confirmed cases among ethnicity for 1999 are shown in Table 5. importation of disease increases. children in one outbreak and two in the second outbreak. The third non- Chlamydia Infection Salmonellosis foodborne outbreak was linked to Chlamydia trachomatis infection is the During 1999, 626 culture-confirmed kittens adopted from a metropolitan most commonly reported STD in cases of Salmonella infection were area humane society. Four cases were Minnesota. In 1999, 7,450 cases of reported to MDH (13.1 per 100,000 identified among persons who lived in chlamydia infection were reported population). This represents a 4% households that had purchased kittens (155.8 per 100,000 population). This increase from the 601 cases reported from the humane society. Two addi- represents a 6% increase compared to in 1998 (Figure 1). Sixty-one percent of tional cases were childcare contacts of 1998 and continuation of a trend of cases were caused by the following five a case who had purchased a kitten. increasing chlamydia rates that began serotypes: S. typhimurium (172 cases), Human and cat isolates had an in 1996. S. heidelberg (88 cases), S. enteritidis identical PFGE subtype. (66 cases), S. muenchen (29 cases), Adolescents and young adults are most and S. montevideo (28 cases). Twenty- Sexually Transmitted Diseases at risk for acquiring chlamydia infection. two percent of cases were less than 10 Rates of laboratory-confirmed chlamy- The chlamydia rate was greatest years of age. Fifty-one percent of dia, gonorrhea, syphilis, and chancroid among 20- to 24-year-olds (865 per cases occurred during June through are monitored by the MDH through a 100,000 population), while the next September. passive, combined physician and greatest rate was among 15- to 19- laboratory-based sexually transmitted year-olds (763 per 100,000). The rate Five foodborne outbreaks of salmonel- disease (STD) surveillance system. of chlamydia among adults 25 to 29 losis were identified in 1999, four of Other common STDs caused by viral years of age was markedly lower (356 which occurred in restaurant settings. pathogens, such as herpes simplex per 100,000), and the rates among In June, three patrons of a restaurant virus and human papillomavirus, are older age groups were even lower. The became ill with S. heidelberg infection. not reportable to MDH. Factors that rate of chlamydia infection among Follow-up at the restaurant identified influence the completeness and women (228 per 100,000) was almost two employees who also were culture- accuracy of STD surveillance data three times higher than the rate among positive for S. heidelberg. No common include level of screening, accuracy of men (85 per 100,000); however, this is food source was identified. The second diagnostic tests, and compliance with due primarily to more frequent screen- outbreak involved one patron and nine disease reporting. Apparent changes ing among women. employees of a restaurant who were in STD incidence rates may be due to diagnosed with S. montevideo infection one of these factors or to actual The rate of chlamydia infection is in July. The third outbreak was due to a changes in STD occurrence. continued... rare pulsed-field gel electrophoresis (PFGE) subtype of S. typhimurium which was identified in five people; Table 4. Number of Cases and Incidence Rates (per 100,000 population) illness was associated with eating at a of Chlamydia, Gonorrhea, and Syphilis, Minnesota, 1995-1999 specific restaurant. The fourth restau- rant outbreak involved S. heidelberg 1995 1996 1997 1998 1999 infections associated with a specific Disease No. Rate No. Rate No. Rate No. Rate No. Rate restaurant during June and July. Twenty-five patrons and 10 employees Chlamydia 6,121 134.0 5,418 118.0 6,804 146.0 6,997 149.0 7,450 158.0 became ill with culture-confirmed S. heidelberg infection; another 15 Gonorrhea 2,819 62.0 2,622 57.0 2,438 53.0 2,716 58.0 2,830 60.0 employees had stool samples that were positive for S. heidelberg but reportedly Syphilis Total 181 4.0 123 2.7 118 2.5 78 1.7 72 1.5 were asymptomatic. During June, six Primary/ Minnesota residents were part of a Secondary 42 0.9 15 0.3 16 0.3 9 0.2 10 0.2 multi-state outbreak of S. muenchen Early Latent* 55 1.2 29 0.6 20 0.4 8 0.2 9 0.2 infection associated with consumption Late Latent** 81 1.8 78 1.7 82 1.8 61 1.3 52 1.1 of unpasteurized orange juice which Congenital*** 3 4.7 1 1.6 0 0.0 0 0.0 1 1.5 was produced in Arizona and widely distributed. * Duration <1 year Three non-foodborne outbreaks of ** Duration >1 year Salmonella were identified in 1999, all *** Rate per 100,000 live births

35 highest in communities of color. The rate for blacks (1,731 per 100,000 Table 5. Number of Cases and Rates (per 100,000 population) population) was 25 times higher than of Chlamydia, Gonorrhea, and Primary/Secondary Syphilis the rate for whites (69 per 100,000). by Demographic Characteristics, Minnesota, 1999 Although blacks comprise only 3% of the population in Minnesota, 33% of the Prim./Second. chlamydia cases occurred among Chlamydia Gonorrhea Syphilis blacks. The rates for American Indians Demographic Group No. Rate No. Rate No. Rate (609 per 100,000) and Hispanics (589 per 100,000) were nearly nine times Total 7450 158 2830 60 10 0.2 higher than the rate for whites. The Residence rate for Asians (259 per 100,000) was Minneapolis 2620 714 1570 428 5 1.4 approximately four times higher than St. Paul 1370 533 558 217 3 1.2 the rate for whites. Suburban* 1619 85 439 23 2 0.1 Greater Minnesota 1841 84 263 12 0 0.0 Reported chlamydia infections are Age (years) geographically distributed throughout <10 years 8 1 1 0 0 0.0 the state, although the rates were 10-14 years 186 50 40 11 0 0.0 highest in Minneapolis (714 per 15-19 years 2820 763 896 243 0 0.0 100,000 population) and St. Paul (533 20-24 years 2575 865 833 280 1 0.3 per 100,000). The rate in the suburban 25-29 years 1070 356 486 162 3 1.0 metropolitan area (85 per 100,000) was 30-34 years 434 125 241 69 1 0.3 very similar to the rate in greater 35-44 years 299 37 281 35 4 0.5 Minnesota (84 per 100,000). 45+ years 58 4 52 3 1 0.1

Gonorrhea Gender Gonorrhea, caused by Neisseria Male 1979 85 1336 57 5 0.2 gonorrhoeae, is the second most Female 5471 228 1494 62 5 0.2 commonly reported STD in Minnesota. Race In 1999, 2,830 cases were reported White 3029 69 598 14 5 0.1 (59.2 per 100,000 population). This Black 2434 1731 1686 1199 4 2.8 represents a 3% increase from 1998 American Indian 350 609 82 143 0 0.0 and is the second consecutive year in Asian 321 259 28 23 0 0.0 which the reported incidence has Other/Unknown** 1316 ------436 ------1 ------increased. Reasons for these in- Ethnicity creases are unknown. Hispanic*** 512 589 103 119 1 1.2 Adolescents and young adults also have the greatest risk for gonorrhea. * Seven-county metropolitan area (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and Washington Counties), excluding Minneapolis and St. Paul The rate for 15- to 19-year-olds was 243 per 100,000 population; the rate for ** No population data available to calculate rates 20- to 24-year-olds was 280 per *** Persons of Hispanic origin may be of any race 100,000; and the rate for 25- to 29- year-olds was 162 per 100,000. Gonorrhea rates for men (57 per rates are highest in Minneapolis and St. Primary and Secondary Syphilis 100,000) and women (62 per 100,000) Paul. The rate in Minneapolis (428 per The rate of primary and secondary were comparable. Communities of 100,000 population) was approximately syphilis in Minnesota is quite low color also are disproportionately twice as high as the rate in St. Paul compared to chlamydia and gonorrhea. affected by gonorrhea. Blacks ac- (217 per 100,000), about 18 times Only 10 cases of primary/secondary counted for 60% of gonorrhea cases. higher than the rate in the suburban syphilis were reported for 1999 (0.2 per The gonorrhea rate for blacks (1,199 metropolitan area (23 per 100,000), 100,000 population). The primary/ per 100,000) was nearly 90-fold higher and more than 35 times higher than the secondary syphilis rate did not change than the rate for whites (14 per rate in greater Minnesota (12 per from 1998 to 1999. 100,000). Likewise, the rates for 100,000). American Indians (143 per 100,000) The highest rates of primary/secondary and Hispanics (119 per 100,000) were Syphilis syphilis occur among persons in older nine to 10 times higher than the rate for Syphilis is caused by infection with the age groups. Men and women had whites. The rate for Asians (23 per spirochete Treponema pallidum. identical rates of primary/secondary 100,000) was nearly twice the rate for Primary and secondary syphilis cases syphilis. The primary/secondary whites. typically are used to monitor morbidity syphilis rate for blacks (2.8 per 100,000 trends because they represent recently population) was nearly 30 times higher Gonorrhea cases are focused in the acquired infections. than the rate for whites (0.1 per core urban populations; gonorrhea continued...

36 100,000). For primary/secondary percent of all Shigella cases resided in Streptococcus pneumoniae syphilis, four of the 10 cases (40%) the Twin Cities metropolitan area; 63% Invasive Disease were black, and five (50%) were white. lived in Hennepin County. Active surveillance for invasive pneu- mococcal disease has been conducted Syphilis is now exclusively an urban Five outbreaks of S. sonnei infection in the seven-county Twin Cities disease. No cases of primary/second- were identified in daycare centers, metropolitan area since April 1995. ary syphilis were reported from greater resulting in at least 220 illnesses and Among metropolitan area residents in Minnesota. The 10 cases of primary/ 97 culture-confirmed cases (49% of all 1999, there were 584 cases of invasive secondary syphilis were distributed S. sonnei cases reported in Minnesota Streptococcus pneumoniae infection between the city of Minneapolis (five in 1999). Pulsed-field gel electrophore- reported to MDH (23.2 cases per cases), the city of St. Paul (three sis (PFGE) testing identified a common 100,000 population). This rate was cases), and the suburban metropolitan subtype pattern among S. sonnei higher than that seen in prior years area (two cases). isolates from all five outbreaks; (18.8 per 100,000 in 1997 and 20.2 per antimicrobial susceptibility tests 100,000 in 1998). Incidence of invasive Congenital Syphilis indicated that isolates of this PFGE pneumococcal disease varies consider- One case of congenital syphilis was subtype were resistant to ampicillin but ably by age, with the highest rates of reported in 1999 (1.5 per 100,000 live susceptible to trimethoprim- disease in children younger than 2 births). sulfamethoxazole (TMP-SMX) and years of age and in adults 65 years of third-generation cephalosporins. age or older (Table 6). Chancroid Chancroid is very rare in Minnesota. In In Minnesota, every tenth isolate of The numbers of invasive pneumococcal 1999, one case of chancroid was Shigella received at MDH was tested cases were at usual levels in 1999 until reported. This was the first reported for antimicrobial resistance, but only the final quarter, when cases among case since 1993. one isolate was included from each older adults increased compared with outbreak. Of the 20 Shigella isolates prior years. In that quarter, incidence Summary tested in 1999, seventeen (85%) were was significantly higher in those at least Although overall STD rates in Minne- resistant to ampicillin, five (25%) were 35 years old (especially those 65 years sota are low compared to many other resistant to TMP-SMX, and five (25%) of age or older), compared with the areas of the United States, certain were resistant to both ampicillin and mean fourth quarter incidence rates in subpopulations in Minnesota have high TMP-SMX. these age groups from the prior 3 STD rates. Specifically, STDs dispro- years. In the first quarter of 2000, rates portionately affect adolescents and continued... young adults, women, and people of color. The Minnesota Year 2000 Table 6. Rates of Invasive Pneumococcal Infection per 100,000 Objectives have not yet been reached Residents of the Seven-County Twin Cities for the overall gonorrhea rate and for Metropolitan Area by Age Group and Time Period the chlamydia, gonorrhea, and primary and secondary syphilis rates among Annual =Quarterly Rates: high-risk subpopulations. Rates:

Shigellosis Fourth Quarter First Quarter Two hundred fifty-four culture-con- Mean for Mean for firmed cases of Shigella infection were Age 1999 1999 1996-98 2000 1997-99 reported in 1999 (5.3 per 100,000 Group Rate Rate Rate Rate Rate population). This represents a 23% (Years) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) decrease from the 331 cases reported in 1998 but the second highest total <2 205.7 69.9 78.3 50.7 50.1 reported since 1994 (Figure 1). The (170.0-240.0) (52.1-92.0) (66.2-90.3) (35.7-69.9) (40.0-59.7) large number of cases in 1998 was due 2-4 50.0 18.9 14.7 7.5 9.7 in part to a large foodborne outbreak of (37.5-65.4) (11.5-29.1) (10.8-19.6) (3.3-14.9) (6.6-13.8) shigellosis that involved two restaurants 5-34 5.9 2.0 1.6 1.3 1.7 in the metropolitan area. (4.6-7.6) (1.2-3.0) (1.2-2.1) (0.7-2.1) (1.3-2.2) In 1999, Shigella sonnei accounted for 35-64 16.8 6.0* 4.0 4.6 3.9 207 cases (81%), S. flexneri for 37 (14.2-19.4) (4.6-7.8) (3.3-4.8) (3.4-6.2) (3.2-4.6) cases (15%), S. boydii for five cases >65 59.3 27.1* 17.0 13.0 15.5 (2%), and S. dysenteriae for two cases (49.7-69.0) (21.1-34.3) (14-20.1) (8.9-18.2) (12.6-18.4) (1%). Ages ranged from 1 month to 76 Total 23.2 8.8* 6.8 5.4 5.6 years, with a median age of 7 years. (21.3-25.1) (7.6-10.0) (6.2-7.4) (4.5-6.4) (5.1-6.2) The majority of cases (56%) were less than 10 years of age. Twenty-three cases (9%) were hospitalized; no *Fourth quarter rate for 1999 significantly higher than mean fourth quarter rate deaths were reported. Ninety-three from the 3 prior years (p<0.05).

37 in these and other age groups were vaccine. For children less than 5 years cases with identical subtypes. The close to the mean first quarter rates of age, 145 of 200 isolates (73%) were deaths were distributed among 10 from the 3 prior years (Table 6). serotypes included in the newly different subtypes. Four deaths were Therefore, it appears that the “pneumo- licensed 7-valent pneumococcal attributed to one PFGE subtype; three coccal season” for 1999 was not simply conjugate vaccine. The American additional deaths were attributed to early, but rather that it was more Academy of Pediatrics (AAP) issued another PFGE subtype, and two deaths widespread for older adults in the Twin recommendations for use of this to another. The remaining seven Cities. conjugate pneumococcal vaccine on deaths for which isolates were available June 5, 2000. These can be accessed were each a different PFGE subtype. Bacteremia without a known focus of from the AAP web site (http:// infection (258 cases, 44%) was the www.aap.org). It is expected that the Streptococcal Invasive Disease - most frequent invasive infection in Advisory Committee on Immunization Group B 1999. Pneumonia with an isolate from Practices (ACIP) soon will issue Two hundred thirty-two cases (4.9 per blood or pleural fluid was almost as recommendations for use of this 100,000 population), including 24 frequent overall (253 cases, 43%) and vaccine; when released, this statement deaths, were reported in 1999. These was more common among adults. should be available at the ACIP web cases include only those in which group There were 39 cases (7%) of meningitis site (http://www.cdc.gov/nip/publica- B Streptococcus was isolated from a and 34 (6%) infections of other types, tions/ACIP-list.htm). A more detailed normally sterile site (except for eight including otitis media, cellulitis, arthritis, report on invasive pneumococcal cases in which there was a miscarriage and others (each associated with a disease in young children also was or stillbirth, in which placenta was the sterile site isolate). In 1999, there were recently published in the Disease site). Fifty-five percent of the cases 52 (9%) deaths among cases; this was Control Newsletter (March/April 2000: occurred among residents of the Twin a somewhat higher proportion than that Vol. 28, No. 2, pp. 10-13). Cities metropolitan area. Forty-six observed in the 3 prior years (104 cases (20%) were infants less than 1 deaths among 1,471 cases, 7%), but Streptococcal Invasive Disease - year of age, and 105 cases (45%) were this was not a statistically significant Group A 60 years of age or older. difference. One hundred eighty cases of invasive group A streptococcal (GAS) disease One hundred seventeen cases (50%) Isolates for 559 cases (96%) were (3.8 per 100,000 population), including presented with bacteremia without submitted to the MDH Public Health 19 deaths, were reported in 1999, another focus of infection. The other Laboratory for serotyping and antimi- compared to 173 cases and 23 deaths most common types of infection were crobial susceptibility testing. One in 1998. cellulitis (12%), pneumonia (6%), hundred thirty-five isolates (24%) were osteomyelitis (5%), arthritis (7%), and non-susceptible to penicillin, including Ages of cases ranged from 14 days to meningitis (4%). In 172 cases (74%), 43 (8%) penicillin-intermediate isolates 99 years, with a mean age of 46 years. the isolate site was blood only. [each with a minimum inhibitory Fifty-seven percent of cases were concentration (MIC) between 0.12 and residents of the seven-county metro- There were 53 cases of infant early- 1.0 µg/ml], and 92 (16%) penicillin- politan area. Fifty cases (28%) had onset, late-onset, or maternal GBS resistant isolates (MIC >2.0 µg/ml). bacteremia without another focus of disease, compared to 55 cases in This proportion was higher than that infection, 47 (26%) had cellulitis, and 1998. Ten stillbirths and spontaneous observed in 1998, when 95 of 469 21 (12%) had primary pneumonia. abortions were associated with 12 isolates (20%) were non-susceptible to Seventeen cases (9%) had necrotizing maternal invasive GBS infections. penicillin, 34 (7%) had intermediate fasciitis. Four cases had streptococcal Twenty-five infants developed invasive susceptibility, and 61 (13%) were toxic shock syndrome; one had disease within the first 6 days following resistant to penicillin. Considering pneumonia, one had cellulitis, and two birth (i.e., early-onset disease), and 16 resistance to any of the beta lactam did not have other associated foci of infants became ill at 7 to 90 days of age agents as resistance to the beta lactam infection. (i.e., late-onset disease). class, resistance to more than one antimicrobial drug class was seen in Of the 19 deaths, six (32%) had Minnesota was one of two EIP sites 125 (22%) of the cases with available necrotizing fasciitis, five (26%) had selected in September 1997 to partici- isolates; this was increased from 80 bacteremia without another focus of pate in the Centers for Disease Control (17%) multi-drug resistant cases in infection, four (21%) had pneumonia, and Prevention Perinatal Group B 1998. Further information on pneumo- three (16%) had cellulitis, and one (5%) Streptococcal Disease Prevention coccal resistance to various antimicro- had peritonitis. Project. Surveys of laboratories, bial agents is available at the MDH web prenatal care providers, and pediatric site (http://www.health.state.mn.us and Isolates were available for 163 cases providers were done to assess current also at http://www.health.state.mn.us/ (91%). Sixty-seven different molecular laboratory and medical practices divs/dpc/ades/antibiog/antibiog.pdf). subtypes were identified by pulsed-field regarding testing, prophylaxis, and gel electrophoresis (PFGE). Forty-six treatment of perinatal GBS disease. An For adults 65 years of age or older, 110 subtype patterns were represented by important finding of the January 1998 (79%) of 139 case isolates submitted only one isolate each; other subtypes laboratory survey demonstrated that were serotypes included in the 23- were represented by two to 23 isolates only 42% (42/101) of laboratories used valent polysaccharide pneumococcal each. No links were noted between continued...

38 selective broth (the recommended of tetanus immunity, the prevalence of county Twin Cities metropolitan area, method) for culturing GBS, and only immunity dropped sharply with increas- particularly among residents of Henne- 54% (55/101) received specimens from ing age, until it reached 27.8% in pin (57%) and Ramsey (12%) Counties. vaginal or rectal sites (the recom- persons 70 years of age or older. Approximately 20% of cases occurred mended specimen). A repeat labora- in greater Minnesota, with increasing tory survey conducted in August 1999 Tetanus spores are normal inhabitants incidence in specific areas. showed that 79% (72/91) of laborato- of human and animal intestines and are ries were using selective broth, and present in soil contaminated with The most notable trend in the epidemi- 74% (67/91) received appropriate animal or human feces. Fecal contami- ology of TB in Minnesota is the large specimens, representing significant nation of surgical or other wounds and increasing number of cases among increases over the previous survey. An presents a risk for hospitalized patients foreign-born persons. The percentage interesting finding of the prenatal and patients prone to falls. Outdoor of TB cases among persons born provider survey showed that only 76% activities such as gardening place non- outside the U.S. continued to increase (108/142) of prenatal providers who immune persons at risk for tetanus. in 1999, with 156 of 201 cases (78%) screened pregnant women for GBS Persons with tetanus frequently have a occurring among this population. From collected the recommended vaginal history of minor wounds which they did 1995 to 1999, the number of foreign- and rectal specimens. Results of the not consider sufficiently severe to born TB cases in Minnesota doubled, laboratory survey and the prenatal warrant a visit to a health care provider. while the number of cases among U.S.- provider survey are available at http:// Health care providers who treat adults born persons decreased 42% (Figure www.health.state.mn.us/divs/dpc/ades/ should review their patients’ vaccination 5). This trend reflects the changing invasive.html or by contacting the Acute status at every opportunity and demographics of immigrant populations Disease Epidemiology Section at (612) administer tetanus vaccine and other arriving in the state, particularly 676-5414. indicated vaccines as appropriate. increasing numbers of persons arriving from regions of the world (such as Sub- Tetanus Tuberculosis Saharan Africa) where TB is prevalent. One case of tetanus was reported to While the number of tuberculosis (TB) Other risk factors among TB cases in MDH during 1999. The case occurred cases reported nationally has been Minnesota include incarceration in a in a 46-year-old white Hispanic male declining since 1993, the incidence of correctional facility (2%), homelessness who had no history of tetanus immuni- TB in Minnesota is increasing markedly (3%), and HIV infection (3%); however, zation. He presented at a metropolitan (Figure 5). In 1999, 201 new cases of the percentage of cases with these risk hospital emergency room and received TB disease were reported statewide factors declined in 1999. tetanus toxoid within 7 hours of (4.2 per 100,000 population). This is receiving a stellate laceration wound to the largest number of cases reported In 1999, 26 cases (17%) of drug- the head as a result of falling down an since 1980 and a 25% increase from resistant TB occurred among the 157 outdoor stairway. Onset of generalized the 161 cases reported in 1998. During culture-confirmed cases for whom drug tetanus occurred 3 days after the injury. 1999, 23 of the 87 counties in the state susceptibility results were available, Within 6 hours of onset of symptoms, reported at least one case of TB including 18 cases (11%) resistant to the patient presented again at the disease. However, the majority (79%) isoniazid and four cases (3%) of multi- emergency room and received 500 of TB cases occurred in the seven- continued... units of tetanus immune globulin. Five days after onset, the patient was admitted at a second hospital. The Figure 5. Number of Tuberculosis Cases by Country wound was debrided and the case- of Origin, Minnesota, 1990-1999 patient received Unasyn (ampicillin and sulbactum) antibiotic therapy. The 220 Total patient was hospitalized for 55 days, U.S.-born during which time he was in the 200 Foreign-born intensive care unit on mechanical 180

ventilation for 38 days. The patient s 160 e

recovered. Because tetanus disease s

a 140

does not confer lifelong immunity, C

f 120

completing the vaccination series is o

r recommended for unvaccinated tetanus e 100 cases. b

m 80 u Tetanus is preventable through N 60 adequate vaccination, and cases of 40 tetanus occur almost exclusively 20 among persons who are unvaccinated 0 or inadequately vaccinated. A recent serologic survey of immunity to tetanus 90 91 92 93 94 95 96 97 98 99 in the U.S. found that although 80% of persons 6 to 39 years of age had levels Year of Diagnosis

39 drug resistant disease resistant to both for most of the cases and have been stable. The age distribution of cases isoniazid and rifampin. Of 26 persons sent to the Centers for Disease Control also has been consistent. Each year with drug-resistant TB disease reported and Prevention. Testing is not com- since 1996, approximately one-third of in 1999, 25 (96%) were born outside pleted and no definite etiologies have cases had isolates from sterile sites. the U.S. been determined for any of the cases at Because most of the cases meeting the this time. case definition represent infection A more detailed description of the rather than colonization with VRE, epidemiology of TB in Minnesota (as Vancomycin-Resistant Enterococci these surveillance findings suggest that well as other articles regarding clinical As part of EIP, surveillance in Minne- in Minnesota hospitals, VRE infections and culturally specific issues related to sota hospitals for vancomycin-resistant occur among a relatively stable TB in Minnesota) was published in the enterococci (VRE) was conducted from population of patients with special January/February 2000 issue of the July 1995 through the end of 1999. susceptibilities related to age, complex Disease Control Newsletter. This Cases included patients hospitalized in medical problems, and/or extended information is available on the MDH Minnesota with VRE isolated from a periods of hospitalization. web site (http://www.health.state.mn.us/ normally sterile site, a wound, or divs/dpc/ades/pub.htm). another source, excluding urinary, Although surveillance for VRE has stool, and rectal sources. In 1999, 186 been discontinued, health care profes- Unexplained Critical Illnesses incident cases were reported, repre- sionals with questions about control of and Deaths of Possible Infectious senting a 4% increase from the 178 VRE in acute care, long-term care, or Etiology cases reported in 1998. Sterile site other health care settings are encour- Surveillance for unexplained critical infections (blood, cerebrospinal fluid, aged to contact the MDH Institutional illnesses and deaths of possible and/or peritoneal fluid isolates) were Infection Control Unit at (612) 676- infectious etiology began in September reported in 59 cases (32%); the 5414. 1995 as part of EIP. Eligibility criteria remaining infections were due to include Minnesota residents between wounds (61, 33%) and other sources Viral Hepatitis A the ages of 1 and 49 years, previously (66, 35%), including pulmonary In 1999, 128 cases of hepatitis A virus healthy with no chronic medical secretions, bile, and indwelling devices. (HAV) infection were reported to MDH conditions (e.g., diabetes), and critical (2.7 per 100,000 population), including illness or death due to an illness Cases included 145 Minnesota one death. One hundred five cases suggestive of an infectious etiology. residents (78%) and 41 patients from (82%) were residents of the seven- Thirty-five possible cases were outside of Minnesota (41, 22%). The county metropolitan area, with 74 reported to MDH in 1999. Twenty-five majority of cases (153, 82%) were (58%) residing in Hennepin County. of these cases subsequently were reported from hospitals in the seven- Seventy-two cases (56%) were male. excluded. Thirteen were excluded county Twin Cities metropolitan area, Of the 124 cases for whom race was because etiologies subsequently were and the remaining 33 cases (18%) reported, 92 (74%) were white, 23 determined (one of which was non- were reported from hospitals in greater (19%) were black, six (5%) were infectious), eight were excluded due to Minnesota. Cases among males (106, American Indian, and three (2%) were underlying conditions, two had no 57%) were more frequent than among Asian. Although the greatest number of hallmarks of infection, one did not meet females (80, 43%). There were more cases were white, incidence rates were the age criteria, and one was excluded cases among older individuals, higher among blacks (16.4 per because the case was not a Minnesota including 129 cases (69%) among 100,000) and American Indians (10.4 resident. those 50 years of age or older, and 51 per 100,000). The incidence rate cases (27%) among those at least 70 among Asians (2.4 per 100,000) was Of the remaining 10 cases, four years of age. In 63 cases (34%), VRE only slightly higher than that among presented with cardiac syndromes was first isolated after 20 days of whites (2.1 cases per 100,000). (myocarditis), three with respiratory hospitalization; in 30 cases (16%), the Hispanic ethnicity, which can be any symptoms, two with shock/sepsis, and case-defining VRE isolate was obtained race, was reported for 11 cases (12.7 one with neurologic symptoms. The on the first day of hospitalization. Fifty- per 100,000). Cases ranged in age cardiac cases were 1, 6, 15, and 49 nine cases (32%) died; 43 (23%) died from 1 to 91 years; however, the years of age. The respiratory cases within 3 weeks of the culture date, but majority of cases (89, 70%) occurred in were 15, 25, and 26 years of age. The VRE was reported to MDH as a factor children and adults under 40 years of sepsis cases were 20 and 44 years of contributing to the death for only three age. age, respectively, and the neurologic cases. case was 22 years of age. One patient Of the 128 reported cases, five were with a cardiac syndrome and two Even though enterococcus is an unavailable for interview. A foodborne patients with respiratory syndromes important pathogen and control of VRE outbreak in another state accounted for survived. The remaining patients died. continues to be very challenging in a four of the 123 cases (3%) that were One cardiac and two respiratory cases variety of health care settings, MDH interviewed. Of the remaining sporadic resided in the seven-county metropoli- surveillance for VRE was discontinued cases questioned about risk factors, 38 tan area; the remaining cases resided in 2000. After a marked increase in the (32%) had known contact with another in greater Minnesota. incidence of VRE from July 1995 to case, 10 (8%) were men who reported 1997, the numbers of reported cases having sex with men, two (2%) had Laboratory specimens were available from 1998 to 1999 were relatively continued...

40 consumed raw shellfish, two (2%) used needles to inject drugs, and one (1%) Figure 6. Reported Cases of Hepatitis B by County of Residence, was associated with childcare but Minnesota, 1999 unrelated to any known outbreaks. Foreign travel accounted for 21 cases (18%), 12 of whom had traveled to Mexico. None of these cases had received hepatitis A vaccine or immune globulin prior to travel. No risk factor could be identified for 45 (37%) of those interviewed.

Of cases reported in 1999, 31 (24%) occurred in risk groups for whom hepatitis A vaccine is recommended, including travelers to HAV-endemic Number of Cases areas and men who have sex with men. (n=80) Health care providers are encouraged to educate their patients about the risk 0 of hepatitis A associated with foreign 71 1 travel. Patients who may travel to Hennepin developing countries in the future 2-9 should be offered hepatitis A vaccine. >10 Similarly, men who have sex with men should be educated about their risk and offered vaccine. Because the majority of cases acquired HAV infection while in the U.S., and more than a third had no identified risk factor, any person over vaccination screening; the MDH (8%) used needles to inject drugs, and 2 years of age who desires immunity to Perinatal Hepatitis B Prevention one case (1%) had received a tattoo HAV infection also should be vacci- Program received post-vaccination test within 6 months prior to onset of nated. results for 242 infants born to HBsAg- symptoms. Hemodialysis accounted for positive mothers during 1999. All seven transmission in one case (1%), one Viral Hepatitis B positive infants began hepatitis B case (1%) received a blood transfusion In 1999, 80 cases of acute hepatitis B immunoprophylaxis (hepatitis B within 6 months prior to onset of virus (HBV) infection were reported to immune globulin and HBV vaccine) at symptoms, and one case (1%) under- MDH (1.7 per 100,000 population), birth and completed the three-dose went hemodialysis and received a including one death. Fifty-eight cases vaccine series. Three of these infants blood transfusion within 6 months of (73%) were residents of the seven- were age-appropriately vaccinated with HBsAg-positive seroconversion. No county metropolitan area, with 27 cases second and third doses, and four were cases were reported as a result of (34%) residing in Hennepin County. delayed in the receipt of one or more occupational exposure. No risk factors More than half of cases (47, 59%) were doses of vaccine. for acquiring HBV infection were male. Fifty-two cases (65%) were identified for the remaining 23 cases young adults between 18 and 39 years Seventy-one (89%) of the 80 reported (32%). The median age for this group of age. Forty-five cases (56%) were cases were questioned about possible was 30 years (range, 13 to 50 years), white, 13 (16%) were black, 10 (13%) modes of transmission. For 25 cases which suggests possible sexual were Asian, and nine (11%) were (35%), the likely mode of transmission transmission. American Indian; race was unreported was sexual. Ten cases (14%) were for three cases (4%). Although the men who reported having sex with men; Most of the acute hepatitis B cases in greatest number of cases were white, eight cases (11%) reported hetero- 1999 had known risk factors for incidence rates were higher among sexual contact with a known carrier of acquiring HBV infection. MDH recom- American Indians (15.6 per 100,000), hepatitis B surface antigen (HBsAg); six mends hepatitis B vaccination for all blacks (9.2 per 100,000), and Asians cases (8%) reported heterosexual children and adolescents not previously (8.1 per 100,000) than among whites contact with multiple partners within 6 vaccinated. The 1998 Minnesota (1.0 per 100,000). Hispanic ethnicity, months prior to onset of symptoms; and Legislature amended the School which can be any race, was reported one case (1%) gave a recent history of Immunization Law to require hepatitis B for four cases (4.6 per 100,000). multiple sex partners with undocu- immunization for kindergartners mented sexual preference. In addition beginning in school year 2000-01 and Of the 80 reported cases, 17 (21%) to the seven perinatal cases (10%), six for seventh graders beginning in school were documented asymptomatic cases (8%) reported non-sexual year 2001-02. In addition, this vaccine seroconversions, including seven contact with a HBsAg-positive person; is recommended for all adults who are perinatal infections. These seven these cases included two parents of at increased risk of infection. Based on infants tested positive during post- infected adopted children. Six cases continued...

41 the occurrence of two cases in adoptive any race, was reported for three cases demonstrate that the recent apparent parents in 1999, prospective vaccina- (12%). increase in the number of reported tion of persons in households expecting hepatitis C cases represents an adoptees from HBV endemic countries Of the 25 reported cases, 12 (48%) “epidemic of detection” of cases is encouraged. reported using needles to inject drugs, resulting from transmission that and four (16%) had heterosexual occurred several decades ago rather Viral Hepatitis C contact and two (8%) non-sexual that an increase in the incidence of In 1999, 25 cases of acute hepatitis C contact with a known anti-HCV positive acute cases. Persons with medical virus (HCV) infection were reported to person within 6 months prior to onset of histories that include blood transfusion MDH. Fourteen cases (56%) were symptoms. Two cases (8%) reported or organ transplantation prior to July residents of the seven-county metro- having occupational exposure to blood 1992, receipt of clotting factor concen- politan area (Dakota, Hennepin, (including one accidental needlestick) trates before 1987, chronic hemodialy- Ramsey, and Washington Counties), and one case (4%) had received a sis, or evidence of liver disease should and 11 cases (44%) resided in greater recent blood transfusion. No risk factor be tested for HCV infection. In addition, Minnesota (Aitkin, Cass, Chippewa, could be determined for four cases persons with a history of injecting drug Clay, Olmsted, Otter Tail, Rice, and St. (16%). use; children born to HCV-positive Louis Counties). The median age of women; and health care workers and cases was 31 years (range, 20 to 50 This is the second year that MDH has others with occupational needlesticks, years). Slightly more than half of cases conducted systematic surveillance for sharps, or mucosal exposure are at risk (13, 52%) were male. Nineteen cases HCV. Over 2,700 positive anti-HCV for HCV infection and should be (76%) were white, three cases (12%) reports were received in 1999. How- screened. Persons who are infected were American Indian, one case (4%) ever, most were determined to be with HCV should be screened for was Asian, one case (4%) was black, chronic infections; acute cases of HCV evidence of immunity to hepatitis A and and race was unreported for one case infection accounted for less than 1% of B infection and immunized appropri- (4%). Hispanic ethnicity, which can be all reported infections. These data ately.

Emerging Infections in Clinical Practice Friday, October 6, 2000 Earle Brown Heritage Center, Brooklyn Center, Minnesota

The importance of emerging infectious fungal infections, and meningitis; 626-7766; or diseases continues to increase • describe the current scope and • e-mail the registration and credit worldwide and throughout the U.S. features of antibiotic resistance; card information to: Understanding trends and disease • list common and emerging [email protected] (be sure to occurrence can benefit primary care infections in immigrants; include the title of the course). providers, as well as practitioners of • discuss current approaches to the infectious diseases, infection control, prevention and treatment of REGISTRATION FEES public health, clinical microbiology, and influenza; The fees include records processing, pharmacy. In addition, treatment and • describe the latest knowledge course materials, refreshment breaks, diagnostic strategies for a variety of concerning chronic fatigue and lunch. Registration fee, less a $20 infectious conditions continue to syndrome; administration charge, is refundable if change; updated information is • discuss the use of new technology CME is notified of cancellation prior to important for all practitioners. This in infectious disease, including the course. course provides an update on major molecular techniques in the issues surrounding emerging infectious laboratory and the Internet in the ACCREDITATION diseases that have an impact on office. Physicians: The University of current clinical practice and the Minnesota designates this continuing important relationship between clinical TO REGISTER medical education activity for 6.5 credit practice and public health prevention. Choose one of the following methods to hours in Category 1 of the Physicians’ New trends in antibiotic resistance and register for this course: Recognition Award of the American new developments in antibacterial • mail your registration form along Medical Association. The University of therapy are a special focus of this with your check or credit card Minnesota is accredited by the year’s course. information (VISA, MasterCard or Accreditation Council for Continuing American Express); Medical Education to sponsor EDUCATIONAL OBJECTIVES • call the Office of Continuing continuing medical education for Following this conference, participants Medical Education (CME) directly physicians. This program has been will be able to: at (612) 626-7600 or toll-free 1- reviewed and is acceptable for 6.5 800-776-8636; prescribed hours by the American • identify new therapies for • fax your registration and credit Academy of Family Physicians. community-acquired pneumonia, card information to CME at (612) continued...

42 Nurses: This program has been Moderator: Michael T. 1:15 Influenza designed to meet Minnesota Board of Osterholm Lawrence Corey Nursing Continuing Education 8:15 Community-Acquired 1:45 Questions and Answers requirements and is acceptable for 8 Pneumonia: New Therapies contact hours of continuing education. 2:00 Use of Molecular Techniques John G. Bartlett in the Public Health Pharmacists: The University of 8:45 Questions and Answers Laboratory: Implications for Minnesota College of Pharmacy is 9:00 Treatment of Fungal Infections the Clinician approved by the American Council on William E. Dismukes John Besser Pharmaceutical Education as a 2:30 Questions and Answers provider of continuing pharmaceutical 9:30 Questions and Answers education. The Universal Program 9:45 The Antibiotic Resistance 2:45 Chronic Fatigue Syndrome: Number is #031-999-00-036-L-01. This Pandemic What Have We Learned? conference provides 7.0 hours of Dale Gerding Philip K. Peterson pharmacy continuing education credit 10:15 Questions and Answers 3:15 Questions and Answers (0.7 CEUs). 10:30 BREAK 3:30 BREAK PRELIMINARY PROGRAM 10:45 Infections in Immigrants 3:45 The Internet Revolution and David N. Williams Infectious Diseases 7:30 REGISTRATION Michael T. Osterholm 11:15 Questions and Answers 8:00 Welcome, Announcements 4:15 Questions and Answers 11:30 Meningitis: An Update and Opening Remarks 4:30 ADJOURN W. Michael Scheld Bart W. Galle, Phillip K. Peterson, Michael T. 12:00 Questions and Answers Osterholm 12:15 LUNCHEON

REGISTRATION FORM EmergingREGISTRATION Infections FORM Course 2824 OctoberEmerging 6, Infections2000 Course May 8, 1998 MAIL TO: EmergingEmerging Infections Course Continuing Continiung MedicalMedical Education PLEASE PRINT OR TYPE Suite Suite 107, 107, 615 615 Washington Washington Ave. Avenue SE SE Minneapolis, Minneapolis, MN MN 55414 55414 Name or Fax to: (612) 626-7766 Address City, State, Zip Payment Method CheckCheck (payable (payable to to University University of of Minnesota) Minnesota) Day Telephone No. ( ) VISAVISA MasterCard AMEX Day Fax No. ( ) Card Number Degree AMA Speciality Expiration Date E-mail Address______Registration Fees Signature $130$125 PhysicianRegular physician $120$115 Non-UniversityClinical Faculty, of Minnesota University medical of Minnesota resident orMedical fellow School $105$85 ClinicalMinnesota Faculty, physician University of Minnesota Medical School $105$85 Non-physicianNon-University health of Minnesotaprofessional medical resident or fellow $$85 80 RetiredNon-physician Minnesota health physician professional $$45 80 Fairview-UniversityRetired Minnesota Medical physician Center/Medical School/Academic Health Center faculty or staff $$45 40 MinnesotaUniversity Department of Minnesota of Health full-time Staff faculty and staff $$45 40 Non-PhysicianMinnesota Department staff of Fairview-University of Health Staff Medical Center $Medical 40 Non-Physicianresident/fellow (fee staff waived, of Fairview-University excludes lunch; limited Medical space Center available; pre-registration required) UniversityMedical student of Minnesota medical resident/fellow: (fee waived, excludes Please send me a brochure with details on The Inn on the Farm

43 Subject Index Listeriosis ...... 31 Streptococcal Invasive Lyme Disease ...... 31 Disease - Group A ...... 38 Arboviral Encephalitis ...... 25 Malaria ...... 32 Streptococcal Invasive Campylobacteriosis ...... 27 Measles ...... 32 Disease - Group B ...... 38 Cryptosporidiosis ...... 28 Mumps ...... 33 Tetanus ...... 39 Ehrlichiosis...... 28 Neisseria meningitidis Tuberculosis ...... 39 Escherichia coli O157:H7 Invasive Disease ...... 33 Unexplained Critical Illnesses Infection and Pertussis ...... 33 and Deaths of Possible Hemolytic Uremic Rubella/Congenital Rubella Infectious Etiology...... 40 Syndrome (HUS)...... 28 Syndrome ...... 34 Vancomycin-Resistant Giardiasis ...... 29 Salmonellosis ...... 35 Enterococci ...... 40 Haemophilus influenzae Sexually Transmitted Viral Hepatitis A...... 40 Invasive Disease ...... 29 Diseases ...... 35 Viral Hepatitis B...... 41 HIV Infection and AIDS ...... 29 Shigellosis ...... 37 Viral Hepatitis C ...... 42 Influenza ...... 30 Streptococcus pneumoniae .... 37

Jan K. Malcolm CHANGING YOUR Commissioner of Health ADDRESS? Please correct the address Division of Disease Prevention and Control below and send it to: Martin LaVenture, M.P.H...... Acting Division Director DCN MAILING LIST Kirk Smith, D.V.M., Ph.D...... Editor Minnesota Dept. of Health Sheril Arndt ...... Production Editor 717 Delaware Street SE Richard N. Danila, Ph.D., M.P.H...... Acting State Epidemiologist Minneapolis, MN 55414

The Disease Control Newsletter is available on the MDH Acute Disease Epidemiology Section web site at www.health.state.mn.us/divs/dpc/ades/pub.htm The Disease Control Newsletter toll-free telephone number is 1-800-366-2597