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MINNESOTA DEPARTMENT ISEASE ONTROL EWSLETTER OF HEALTH D C N

Volume 36, Number 1 (pages 1-28) January/August 2008 Annual Summary of Communicable Diseases Reported to the Minnesota Department of Health, 2007

Introduction Government Data Practices Act Incidence rates in this report were Assessment of the population’s (Section 13.38). Provisions of the calculated using disease-specific health is a core public health function. Health Insurance Portability and numerator data collected by MDH and Surveillance for communicable Accountability Act (HIPAA) allow for a standardized set of denominator diseases is one type of assessment. routine disease reporting without data derived from U.S. Census data. Epidemiologic surveillance is the patient authorization. Disease incidence may be categorized systematic collection, analysis, and as occurring within the seven- dissemination of health data for Since April 1995, MDH has participated county Twin Cities metropolitan area the planning, implementation, and as an Emerging Infections Program (metropolitan area) or outside of it in evaluation of health programs. The (EIP) site funded by the Centers Greater Minnesota. Minnesota Department of Health for Disease Control and Prevention (MDH) collects information on (CDC) and, through this program, certain infectious diseases for the has implemented active hospital- and Human anaplasmosis (HA) (formerly purposes of determining disease laboratory-based surveillance for known as human granulocytic impact, assessing trends in disease several conditions, including selected ) is caused by Anaplasma occurrence, characterizing affected invasive bacterial diseases and food- phagocytophilum, a rickettsial organism populations, prioritizing control efforts, borne diseases. transmitted to humans by bites from and evaluating prevention strategies. Ixodes scapularis (the blacklegged Prompt reporting allows outbreaks to Isolates for pathogens associated tick or deer tick). The same tick also be recognized in a timely fashion when with certain diseases are required to transmits the agents of control measures are most likely to be be submitted to MDH (Table 1). The and babesiosis. effective in preventing additional cases. MDH Public Health Laboratory (PHL) performs microbiologic evaluation In 2007, a record number of 322 HA In Minnesota, communicable disease of isolates, such as pulsed-field cases (6.2 per 100,000 population) reporting is centralized, whereby gel electrophoresis (PFGE), to were reported (Figure 1). This reporting sources submit standardized determine whether isolates (e.g., represents an 83% increase from the report forms to MDH. Cases of disease enteric pathogens such as Salmonella continued on page 4 are reported pursuant to Minnesota and O157:H7, and Rules Governing Communicable invasive pathogens such as Neisseria Diseases (Minnesota Rules 4605.7000 meningitidis) are related, and Inside: - 4605.7800). The diseases listed in potentially associated with a common Table 1 (page 2) must be reported to source. Testing of submitted isolates 14th Annual Emerging Infections MDH. As stated in the rules, physicians, also allows detection and monitoring in Clinical Practice and Public health care facilities, laboratories, of , which Health Conference, November veterinarians and others are required continues to be an important problem. 14, 2008, Program and Registra- to report these diseases. Reporting tion...... 24 sources may designate an individual Table 2 summarizes cases of selected within an institution to perform routine communicable diseases reported Antimicrobial Susceptibilities of reporting duties (e.g., an infection during 2007 by district of the patient’s Selected Pathogens, 2007...... 26 control professional for a hospital). residence. Pertinent observations for Data maintained by MDH are private some of these diseases are discussed and protected under the Minnesota below. Table 1. Diseases Reportable to the Minnesota Department of Health Report Immediately by Telephone Anthrax (Bacillus anthracis) a Q () a Botulism ( botulinum) Rabies (animal and human cases and suspected cases) (Brucella spp.) a Rubella and congenital rubella syndrome a () a Severe Acute Respiratory Syndrome (SARS) Diphtheria ( diphtheriae) a (1. Suspect and probable cases of SARS. 2. Cases of health Hemolytic uremic syndrome a care workers hospitalized for or acute respiratory Measles (rubeola) a distress syndrome.) a () Smallpox (variola) a (all invasive disease) a, b () a Orthopox virus a Unusual or increased case incidence of any suspect () a infectious illness a Poliomyelitis a Report Within One Working Day Amebiasis (Entamoeba histolytica/dispar) Malaria (Plasmodium spp.) Anaplasmosis (Anaplasma phagocytophilum) (caused by viral agents) Arboviral disease (including but not limited to, Mumps LaCrosse encephalitis, eastern equine encephalitis, western Neonatal , less than 7 days after birth (bacteria isolated from equine encephalitis, St. Louis encephalitis, and a sterile site, excluding coagulase-negative West Nile virus) Staphylococcus) a, b Babesiosis (Babesia spp.) Pertussis () a Blastomycosis (Blastomyces dermatitidis) Psittacosis (Chlamydophila psittaci) (Campylobacter spp.) a Retrovirus infection Cat scratch disease (infection caused by spp.) Reye syndrome ( ducreyi) c Rheumatic fever (cases meeting the Jones Criteria only) trachomatis infection c Rocky Mountain (, R. canada) Coccidioidomycosis , including typhoid (Salmonella spp.) a Cryptosporidiosis (Cryptosporidium spp.) a (Shigella spp.) a Cyclosporiasis (Cyclospora spp.) a Staphylococcus aureus (vancomycin-intermediate S. aureus [VISA], Dengue virus infection vancomycin-resistant S. aureus [VRSA], and death or critical Diphyllobothrium latum infection illness due to community-associated S. aureus in a previously Ehrlichiosis (Ehrlichia spp.) healthy individual) a Encephalitis (caused by viral agents) Streptococcal disease (all invasive disease caused by Groups A Enteric E. coli infection (E. coli O157:H7, other enterohemorrhagic and B streptococci and S. pneumoniae) a, b [Shiga -producing] E. coli, enteropathogenic E. coli, (Treponema pallidum) c enteroinvasive E. coli, enterotoxigenic E. coli) a Tetanus (Clostridium tetani) Enterobacter sakazakii (infants under 1 year of age) a a Giardiasis (Giardia lamblia) Toxoplasmosis (Toxoplasma gondii) () c Transmissible spongiform encephalopathy disease (all invasive disease) a,b Trichinosis (Trichinella spiralis) Hantavirus infection Tuberculosis (Mycobacterium tuberculosis complex) (Pulmonary or Hepatitis (all primary viral types including A, B, C, D, and E) extrapulmonary sites of disease, including laboratory Histoplasmosis (Histoplasma capsulatum) confirmed or clinically diagnosed disease, are reportable. Human immunodeficiency virus (HIV) infection, including Latent tuberculosis infection is not reportable.) a Acquired Immunodeficiency Syndrome (AIDS) a, d (Rickettsia spp.) (unusual case incidence, critical illness, or laboratory Unexplained deaths and unexplained critical illness confirmed cases) a, e (possibly due to infectious cause) a Kawasaki disease Varicella-zoster disease Kingella spp. (invasive only) a, b (1. Primary [chickenpox]: unusual case incidence, critical Legionellosis (Legionella spp.) a illness, or laboratory-confirmed cases. 2. Recurrent [shingles]: (Hansen’s disease) (Mycobacterium leprae) unusual case incidence, or critical illness.) a (Leptospira interrogans) Vibrio spp. a (Listeria monocytogenes) a Lyme disease (Borrelia burgdorferi) , enteric (Yersinia spp.) a

Sentinel Surveillance (at sites designated by the Commissioner of Health) Methicillin-resistant Staphylococcus aureus

a Submission of clinical materials required. If a rapid, non- b Isolates are considered to be from invasive disease if they are culture assay is used for diagnosis, we request that positives isolated from a normally sterile site, e.g., , CSF, joint fluid, be cultured, and isolates submitted. If this is not possible, send etc. specimens, nucleic acid, enrichment broth, or other appropriate c Report on separate Sexually Transmitted Disease Report Card. material. Call the MDH Public Health Laboratory at 651-201- d Report on separate HIV Report Card. 4953 for instructions. e For criteria for reporting laboratory confirmed cases of influenza, see www.health.state.mn.us/divs/idepc/dtopics/ reportable/index.html.

2 DCN 36;1 January/August 2008 Table 2. Cases of Selected Communicable Diseases Reported to the Minnesota Department of Health, by District of Residence, 2007 District* (population per U.S. Census 2007 estimates)

Disease Metropolitan ( 2,794,796) Northwestern (153,381) Northeastern ( 320,637) Central (709,386) Central West (228,559) South Central (286,848) Southeastern (484,905) Southwestern (219,109) Unknown Residence Total (5,197,621) Anaplasmosis 82 23 45 148 10 3 11 0 0 322 Arboviral disease LaCrosse 0 0 0 1 0 0 0 0 0 1 West Nile 19 17 4 6 32 3 2 18 0 101 Babesiosis 8 1 6 5 1 0 3 0 0 24 Campylobacteriosis 463 12 30 130 37 43 130 62 0 907 Cryptosporidiosis 67 4 20 37 29 42 68 35 0 302 Escherichia coli O157 infection 91 3 4 34 7 3 18 5 0 165 Hemolytic Uremic Syndrome 11 0 0 3 1 0 3 0 0 18 Giardiasis 561 7 46 72 23 43 62 16 74 904 Haemophilus influenzae invasive disease 41 7 6 10 2 2 12 2 0 82 HIV infection other than AIDS 200 2 5 10 3 2 7 0 0 229 AIDS (cases diagnosed in 2007) 134 1 6 7 1 4 3 3 0 159 Legionellosis 20 0 1 3 0 3 3 1 0 31 Listeriosis 3 0 0 1 0 2 0 0 0 6 Lyme disease 558 41 109 376 27 18 103 7 0 1,239 Meningococcal disease 11 1 0 4 2 0 4 0 0 22 Mumps 17 0 1 6 0 2 1 1 0 28 Pertussis 297 7 8 16 12 8 45 0 0 393 Salmonellosis 404 13 27 98 16 26 98 30 0 709 Sexually transmitted diseases 11,965 247 860 1,266 189 533 992 373 632 17,057 Chlamydia trachomatis - genital infections 9,028 221 715 1,102 171 491 845 337 502 13,412 Gonorrhea 2,772 26 145 158 16 42 143 34 123 3,459 Syphilis, total 165 0 0 6 2 0 4 2 7 186 Primary/secondary 55 0 0 1 1 0 1 0 1 59 Early latent** 53 0 0 0 0 0 0 0 2 55 Late latent*** 57 0 0 5 1 0 3 2 4 72 Congenital 0 0 0 0 0 0 0 0 0 0 Other † 0 0 0 0 0 0 0 0 0 0 Chancroid 0 0 0 0 0 0 0 0 0 0 Shigellosis 171 22 6 17 6 3 6 7 0 238 pneumoniae invasive disease 318 34 54 100 29 48 60 21 0 664 Streptococcal invasive disease - Group A 94 6 18 23 2 8 13 9 0 173 Streptococcal invasive disease - Group B 187 18 24 36 11 13 31 11 0 331 Toxic Shock Syndrome 2 1 3 1 0 0 0 2 0 9 Tuberculosis 187 0 3 13 2 4 24 5 0 238 Viral hepatitis, type A 61 1 2 8 3 2 8 9 0 94 Viral hepatitis, type B (acute infections only, not perinatal) 12 2 1 2 0 3 3 2 0 25 Viral hepatitis, type C (acute infections only) 12 0 6 3 0 2 4 1 0 28 Yersiniosis 8 1 1 4 1 2 7 0 0 24

*Cases for which the patient’s residence is unknown are assigned the geographic location of the reporting clinic **Duration <1 year ***Duration >1 year †Includes unstaged neurosyphilis, latent syphilis of unknown duration, and latent syphilis with clinical manifestations

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 - Aitkin, Carlton, Cook, Itasca, Koochiching, Lake, St. Louis Central - Benton, Cass, Chisago, Crow Wing, Isanti, Kanabec, 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

continued...

DCN 36;1 January/August 2008 3 176 cases in 2006 (3.4 per 100,000) intense in the northern Great Plains mosquito and bird species are involved and a 73% increase from the previous and adjacent areas (2,318 [98.5%] of in this cycle, and regional variation in record of 186 cases in 2005 (3.6 2,353 western Canada’s WNV cases vector and reservoir species is likely. In per 100,000). It is also is markedly in 2007 were residents of Manitoba, 2007, warm spring and early summer higher than the median number of Saskatchewan, or Alberta). weather lead to early and efficient cases reported annually from 1996 to amplification of WNV between birds 2004 (median, 76 cases; range, 14 to In Minnesota, 101 cases of WNV and mosquitoes and an unusually large 139). Two hundred four (63%) case- disease were reported in 2007 (the early season peak in vector numbers, patients reported in 2007 were male. highest total since 148 cases were likely contributing to the increased The median age of case-patients was reported in 2003). Fifty-eight (57%) incidence of human cases. Interpreting 58 years (range, 4 to 92 years), 17 case-patients had West Nile (WN) fever; the effect of weather on WNV years older than the median age of 23 (23%) had meningitis, and 20 (20%) transmission is extremely complex, Lyme disease cases. Onsets of illness had encephalitis. The median age of all leading to great difficulty in predicting peaked in June (33% of cases), earlier WN case-patients was 52 years (range, how many people will become infected in the season than Lyme disease. In 3 to 86 years); WN encephalitis patients in a given year. WNV appears to be 2007, 40% of HA case-patients were were older (median, 70 years; range, established throughout Minnesota; it hospitalized for their infection, for a 18 to 86 years). Two WN encephalitis will probably be present in the state to median duration of 4 days (range, 1 to patients (62 and 72 years old) died from some extent every year. The disease 26 days). One case-patient died from their illness. Seventy-six cases (75%) risk to humans, however, will likely complications of HA in 2007. occurred among residents of western continue to be higher in central and and central Minnesota. Statewide western Minnesota where the primary HA co-infections with Lyme disease WNV incidence was 1.9 cases per mosquito vector, Culex tarsalis, is most and/or babesiosis can occur from the 100,000, but ranged up to 148.6, abundant. Until 2007, locally acquired same tick bite. During 2007, 18 (6%) 104.7, and 66.6 cases per 100,000 cases of WNV disease were absent in HA case-patients also had objective in Big Stone, Norman, and Kittson the northeastern third of Minnesota, evidence of Lyme disease, and three counties, respectively. The 2007 WNV which corresponds to the region (1%) had evidence of babesiosis. transmission season was the longest where Cx. tarsalis is rare or absent. Because of under-detection, these in Minnesota to date; the earliest However three cases with possible local numbers may underestimate the true case-patient had onset of symptoms exposure (St. Louis County [n=2] and frequency of co-infections. on June 25; the latest on October 12. Koochiching County) were reported Similar to previous years, the peak in during 2007. The risk for HA is highest in many of illness onsets was from July 15 through the same Minnesota counties where September 15 (85 [84%] cases). During 2007, only one case of LaCrosse the risk of Lyme disease is greatest. In encephalitis was reported to MDH. 2007, 140 (59%) of 237 case-patients The field ecology of WNV is complex. The disease, which primarily affects with a single known county of exposure The virus is maintained in a mosquito- children, is transmitted through the bite in Minnesota were exposed in Aitkin, to-bird transmission cycle. Several of infected Aedes triseriatus (Eastern Cass, or Crow Wing counties. About half of anaplasmosis case-patients in Figure 1. Reported Cases of Anaplasmosis, 2007 (133 [51%] of 262 cases with Babesiosis, and Lyme Disease, Minnesota 1996-2007 a known activity) were most likely exposed to I. scapularis ticks at their home property. 1300 Lyme di sease 1200 Arboviral Disease Human anapl asmos is 1100 LaCrosse encephalitis and Western Babesi os is equine encephalitis historically 1000 have been the primary arboviral 900 encephalitides found in Minnesota. During July 2002, West Nile virus 800 (WNV) was identified in Minnesota 700 for the first time; subsequently, 441 600 human cases (including 14 fatalities) 500 were reported from 2002 to 2007. In Number of Cases 400 2007, WNV cases were reported from 43 states; nationwide, 3,623 human 300 cases of WNV disease were reported, 200 including 124 fatalities. The largest 100

WNV case counts during 2007 occurred 0 in Colorado (576 cases), California (380 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 cases), and North Dakota (369 cases). Most of the states with large case totals Year of Diagnosis were Great Plains states, and WNV transmission to humans was especially *Includes 6,175 Lyme disease cases, 996 anaplasmosis cases, and 58 babesiosis cases.

4 DCN 36;1 January/August 2008 Tree Hole) mosquitoes. Persons are and north-central Minnesota and identified in Minnesota in 2007; this was exposed to infected mosquitoes in western Wisconsin. an outbreak of C. upsaliensis infections wooded or shaded areas inhabited by associated with contact with cats from a this mosquito species, especially in Campylobacteriosis local humane society. areas where water-holding containers Campylobacter continues to be the (e.g., waste tires, buckets, or cans) that most commonly reported bacterial A primary feature of public health provide mosquito breeding habitats enteric pathogen in Minnesota (Figure importance among Campylobacter are abundant. From 1985 through 2). There were 907 cases of culture- cases was the continued presence of 2007, 123 cases were reported from 21 confirmed Campylobacter infections Campylobacter isolates resistant to southeastern Minnesota counties, with reported in 2007 (17.5 per 100,000 fluoroquinolone (e.g., cipro a median of five cases (range, 1 to 13 population). This is similar to the floxacin), which are commonly used to cases) reported annually. The median 899 cases reported in 2006 and to treat campylobacteriosis. In 2007, the case-patient age was 6 years. Disease the median annual number of cases overall proportion of quinolone resis onsets have been reported from June reported from 2001 to 2006 (median, tance among Campylobacter isolates through September, but most onsets 918 cases; range, 843 to 953). In 2007, tested was 23% (a slight increase from have occurred from mid-July through 51% of cases occurred in people who 2006). However, 64% of Campylobacter mid-September. resided in the metropolitan area. Of the isolates from patients with a history of 868 Campylobacter isolates confirmed foreign travel during the week prior to Babesiosis and identified to species by MDH, 90% illness onset, regardless of destina Babesiosis is a malaria-like illness were C. jejuni and 8% were C. coli. tion, were resistant to fluoroquinolones. caused by the protozoan Babesia Twelve percent of Campylobacter microti. This parasite is transmitted to The median age of case-patients isolates from patients who acquired the humans by bites from Ixodes scapularis was 32 years (range, 1 month to 92 infection domestically were resistant to (the blacklegged tick or deer tick), the years). Forty-six percent of cases were fluoroquinolones. same vector that transmits the agents of between 20 and 49 years of age, and Lyme disease and human anaplasmosis 14% were 5 years of age or younger. Cryptosporidiosis (HA). B. microti can also be transmitted Fifty-seven percent of cases were During 2007, 302 confirmed cases by blood transfusion. male. Eleven percent of case-patients of cryptosporidiosis (5.8 per 100,000 were hospitalized; the median length population) were reported. This is the In 2007, a record number of 24 of hospitalization was 2 days. Forty-six highest number of cases ever reported babesiosis cases (0.5 per 100,000 percent of infections occurred during in Minnesota, and is 75% higher population) were reported. This is a June through September. Of the 806 than the median number of cases 22% increase from the previous record (89%) case-patients for whom data reported annually from 1996 to 2006 of 18 cases (0.4 per 100,000) in 2006. were available, 176 (22%) reported (median, 173 cases; range, 81 to 242). The frequency of babesiosis cases travel outside of the United States The median age of case-patients in since 2006 is notably higher than the during the week prior to illness onset. 2007 was 20 years (range, 1 month median number of cases reported The most common travel destinations to 101 years). Children 10 years of annually from 1996 to 2005 (median, 2 were Central or South America or the age or younger accounted for 37% of cases; range, 0 to 10). Nineteen (79%) Caribbean (n=44), Mexico (n=41), cases. Sixty-seven percent of cases babesiosis case-patients reported in Europe (n=30), and Asia (n=22). There occurred during July through October. 2007 were male. The median age of was one outbreak of campylobacteriosis continued... case-patients was 63.5 years (range, 17 to 101 years). The peak in onsets Figure 2. Reported Cases of Campylobacter, Salmonella, Shigella, and of illness occurred in July and August Escherichia coli O157:H7 Infection, Minnesota, 1996-2007 (14 cases [61%]). In 2007, 74% of case-patients were hospitalized for their infection, for a median duration Campylobacter Shigella of 6 days (range, 2 to 15 days). One Salmonella E.coli O157 case-patient died from complications of babesiosis in 2007. 1200

1000 Babesiosis co-infections with Lyme disease or HA can occur from the 800 same tick bite, although the majority of 600 babesiosis infections are asymptomatic. 400 During 2007, four (17%) babesiosis 200 case-patients also had objective Number of Cases evidence of Lyme disease, and three 0 (13%) had objective evidence of HA. 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

The risk for babesiosis is highest in Year of Diagnosis many of the same Minnesota counties where the risk of Lyme disease and HA is greatest, especially in east-central

DCN 36;1 January/August 2008 5 The incidence of cryptosporidiosis in 24, and therefore it is unknown if reports of a lack of serving utensils at in the Southwestern, South Central, those were O157 or another serogroup. the event, and that utensils were used Southeastern, and West Central Serogroups other than O157 accounted to serve multiple items. A 5-year-old districts (16.0, 14.6, 14.0, and 10.1 for the remaining 43 STEC cases. E. child who had diarrhea prior to and cases per 100,000, respectively) was coli O111, O103 and O26 represented during the potluck dinner and who had significantly higher than the statewide 70% of all non-O157 STEC, with 10 self-served fruit and chips was the most incidence. Only 67 (22%) reported case-isolates of each. likely source of contamination. cases occurred among residents of the metropolitan area (2.4 per 100,000). Six E. coli O157 outbreaks were Six Minnesota cases and one Forty-eight (16%) case-patients identified during 2007. Four of Wisconsin case with the same or required hospitalization, for a median of the outbreaks involved foodborne closely-related PFGE subtype of E. coli 3 days (range, 1 to 20 days). Two cases transmission. One outbreak involved O157:H7, and an additional Minnesota were known to be HIV-infected. Three contact with animals, and one involved case of Shiga-toxin producing E. case-patients with cryptosporidiosis person-to-person transmission. coli that was not culture-confirmed, died; all had underlying health attended the Minnesota State Fair in conditions. From March through May, 10 cases August. All but one of the cases showed with the same pulsed-field gel cattle or visited the cattle barn. Five outbreaks of cryptosporidiosis electrophoresis (PFGE) subtype of E. were identified in 2007, accounting coli O157:H7 consumed ground beef A multi-state outbreak of E. coli for 21 laboratory-confirmed cases. purchased at grocery stores of the O157:H7 infections associated with An outbreak in a child daycare setting same chain in the Minneapolis/St. Paul the consumption of premade, frozen accounted for two laboratory-confirmed metropolitan area. Seven cases were ground beef patties purchased from the cases. Three recreational waterborne hospitalized, none developed hemolytic same retailer occurred from August to outbreaks occurred, including 20 cases uremic syndrome (HUS). The beef October. Eleven cases were identified (five laboratory-confirmed) associated trim used to make this ground beef in Minnesota, including four cases with a membership club swimming pool, originated from a processing plant in of HUS. Three of the 11 cases did 60 cases (three laboratory-confirmed) Cottonwood County. not have culture confirmation of their associated with a hotel water park, and infection. There were 36 additional 33 cases (nine laboratory-confirmed) In June and July, an outbreak of E. coli E. coli O157:H7 isolates reported associated with a membership club O157:H7 infections occurred at a home from 14 other states that had PFGE swimming pool. One foodborne daycare in Ramsey County. Eight of the patterns indistinguishable from the outbreak with two laboratory-confirmed nine children in the daycare ultimately outbreak subtype pattern, including cases was associated with an event at tested positive for E. coli O157. Two two additional HUS cases. Leftover a private home. case-patients were hospitalized and product collected from case households one had HUS. The source of infection tested positive for the outbreak PFGE Escherichia coli O157 Infection and for the index case was not identified, subtype. Packaging material obtained Hemolytic Uremic Syndrome (HUS) but person-to-person transmission from cases revealed that the products During 2007, 165 culture-confirmed resulted in all of the additional cases. were produced on the same day at cases of Escherichia coli O157 infection The index case was infectious when approximately the same time. The (3.2 per 100,000 population) were he returned to the daycare, and was investigation resulted in a recall of reported. The number of reported cases most likely the source for the additional approximately 850,000 pounds of is similar to the median number of cases. ground beef. cases reported annually from 1997 to 2006 (median, 168 cases; range, 110 Three cases of E. coli O157:H7 In 2007, 18 HUS cases were reported. to 219) but represents a 12% increase infection in two households with illness There were no fatal cases. From 1997 from the 147 cases reported in 2006 onsets in July were associated with the to 2007, the median annual number and the highest count since 2001. consumption of sirloin ball tip steaks of reported HUS cases in Minnesota During 2007, 91 (55%) cases occurred purchased from the same retailer. The was 17 (range, 9 to 25), and the overall in the metropolitan area. One hundred source of the steaks was one of two case fatality rate was 6.6%. In 2007, the twenty-six (76%) cases occurred during beef processing companies in Kansas. median age of HUS case-patients was May through October. The median age 4.5 years (range, 1 to 66 years); 13 of of case-patients was 20 years (range, An outbreak of E. coli O157:H7 the 18 cases occurred in children. All 18 5 months to 85 years). Twenty-five infections associated with a potluck case-patients were hospitalized, with a percent of case-patients were 7 years dinner at a high school in Hennepin median hospital stay of 19 days (range, of age or younger. Seventy (42%) case- County occurred in July. An 6 to 122 days). All 18 HUS cases patients were hospitalized; the median investigation was initiated when the reported in 2007 were post-diarrheal. duration of hospitalization was 3 days MDH foodborne illness hotline received E. coli O157:H7 was cultured from the (range, 1 to 28 days). None died. a report of illness among a group of stool of 10 (55%) case-patients; there people who attended the potluck. were no non-O157 STEC infections In addition to the 165 culture-confirmed Nine laboratory-confirmed cases of E. identified among the HUS cases in E. coli O157 cases, 67 cases of Shiga- coli O157:H7 and 17 probable cases 2007. toxin producing E. coli (STEC) infection were identified. Baked beans and fruit were identified in 2007. Of those, served at the event were significantly culture-confirmation was not possible associated with illness. There were

6 DCN 36;1 January/August 2008 Giardiasis isolated from blood and one from epidemic through the early 1990s, During 2007, 904 cases of Giardia pleural fluid. Seven had significant reaching a peak of 370 cases in infection (17.4 per 100,000) were underlying medical conditions. Of the 1992. Beginning in 1996, the annual reported. This represents an 18% nine case-patients who died, seven number of new AIDS diagnoses, and decrease from the 1,105 cases reported case-isolates that were untypeable had deaths among AIDS case-patients, in 2006 and an 18% decrease from one serotype f, and one case-isolate declined sharply, primarily due to new the median number of cases reported was not available from the hospital lab antiretroviral therapies, which delay the annually from 1996 through 2006 for typing. progression from HIV infection to AIDS (median, 1,105, cases; range, 851 to and improve survival. In 2007, 159 new 1,556). Of the total number of Giardia HIV Infection and AIDS AIDS cases (Figure 3) and 54 deaths cases for 2007, 40% represented Surveillance for AIDS has been among AIDS patients were reported. positive tests during routine screenings conducted in Minnesota since 1982. of recent immigrants and refugees. In 1985, Minnesota became the first The annual number of newly diagnosed state to make HIV infection a name- HIV (non-AIDS) cases reported in The median age for all case-patients based reportable condition; all states Minnesota has increased slightly reported in 2007 was 19 years (range, now require name-based HIV infection from 185 in 2003 to 229 in 2007 (a 1 month to 102 years). The median age reporting. 24% increase). This trend, coupled among non-immigrant cases was 36 with improved survival, has led to years (range, 1 month to 102 years). The incidence of HIV/AIDS in Minnesota an increasing number of persons in Twenty-two percent of cases were less is moderately low. In 2006, state- Minnesota living with HIV or AIDS. than 5 years of age, and only 16% specific AIDS rates ranged from 0.7 Approximately 6,000 persons with HIV/ of cases were over 50 years of age. per 100,000 population in Montana AIDS were residing in Minnesota at the Overall, 5% of case-patients were to 29 per 100,000 in Maryland. end of 2007. hospitalized; 10% of case-patients over Minnesota had the 11th lowest AIDS 50 years of age were hospitalized. No rate (4.1 cases per 100,000). Similar Historically, and in 2007, nearly 90% outbreaks of giardiasis were identified in comparisons for HIV (non-AIDS) (285/325) of new HIV infections (both Minnesota in 2007. incidence rates are not possible, HIV [non-AIDS] and AIDS at first because some states only began HIV diagnosis) reported in Minnesota Haemophilus influenzae Invasive (non-AIDS) reporting recently. occurred in the metropolitan area. Disease However, HIV or AIDS cases have Eighty-two cases of invasive As of December 31, 2007, a cumulative been diagnosed in residents of more Haemophilus influenzae disease (1.6 total of 8,504 cases of HIV infection, than 80% of counties statewide. HIV per 100,000 population) were reported 5,151 AIDS cases and 3,353 HIV (non- infection is most common in areas with in 2007. Case-patients ranged in age AIDS) cases had been reported among higher population densities and greater from newborn to 103 years (median, Minnesota residents. Of the HIV/AIDS poverty. 66 years). Thirty-seven (45%) case- case-patients, 2,912 (35%) are known patients had pneumonia, 36 (44%) had to have died. The majority of new HIV infections bacteremia without another focus of in Minnesota occur among males. infection, five (6%) had meningitis, and The annual number of AIDS cases Trends in the annual number of new four (5%) had other conditions. Nine reported in Minnesota increased HIV infections diagnosed among (11%) deaths were reported among steadily from the beginning of the continued... these case-patients.

Of 73 H. influenzae isolates for which Figure 3. HIV/AIDS in Minnesota: Number of New Cases, typing was performed at MDH, eight Prevalent Cases, and Deaths by Year, 1990-2007 (11%) were type f, four (5%) type e, four HIV ( non- AIDS ) AIDS^ AIDS Deaths* Living HIV / AIDS

(5%) type a, two (3%) type d, one (1%) 500 No. of Persons Living w/ HIV/AIDS type b, one (1%) type c, and 53 (73%) 5000 were untypeable. 400 4000 One case of type b (Hib) disease occurred in 2007, compared to four 300 3000 cases in 2006, one case in 2005, and two cases in 2004. The 2007 case 200 occurred in a child <5 years of age that 2000 had received two Hib vaccinations. The child had meningitis and survived. 100 1000

0 0 The nine deaths occurred in patients No. of New HIV/AIDS Cases and Deaths ranging in age from newborn to 103 1990 1993 1996 1999 2002 2005 Year of Diagnosis years. Three case-patients presented with pneumonia and six with bacteremia * Deaths among AIDS cases, regardless of cause. without another focus of infection. > Includes refugees in the HIV + Resettlement Program with AIDS subsequent to their arrival in the United States Eight case-patients had H. influenzae

DCN 36;1 January/August 2008 7 males differ by race/ethnicity. New and 48% of new HIV infections among Historically, race/ethnicity data for infections occurred primarily among men. Similarly, persons of color HIV/ AIDS in Minnesota have grouped white males in the 1980s and early comprised approximately 11% of the U.S.-born blacks and African-born 1990s. Although whites still comprise female population and 74% of new persons together as “black.” In the largest proportion of new HIV HIV infections among women. It bears 2001, MDH began analyzing these infections among males, the number noting that race is not considered a groups separately, and a marked of new infections in this population has biological cause of disparities in the trend of increasing numbers of new decreased since 1991. In contrast to occurrence of HIV, but instead race HIV infections among African-born declining numbers of new HIV infections can be used as a proxy for other risk persons was observed. In 2007, there among white males, the decline among factors, including lower socioeconomic were 48 new HIV infections reported U.S.-born black males has been more status and education. among Africans. While African-born gradual, falling from a peak of 81 new persons comprise less than 1% of the infections in 1992 to 36 new infections Since the beginning of the HIV state’s population, they accounted for in 2006. However in 2007 that number epidemic, male-to-male sex has been 15% of all HIV infections diagnosed increased slightly to 54. The number the predominant mode of exposure to in Minnesota in 2007. Until recently, of HIV infections diagnosed among HIV reported in Minnesota, although culturally specific HIV prevention Hispanic males increased substantially the number and proportion of new HIV messages have not been directed to in 2006 from the previous year (37 infections attributed to men who have African communities in Minnesota. versus 17) and that trend continued in sex with men (MSM) has declined Taboos and other cultural barriers make 2007, with 33 new infections reported since 1991. In 1991, 69% (324/470) it challenging to deliver such messages among Hispanic males. The number of new HIV infections were attributed and to connect HIV-infected individuals of new infections among African-born to MSM (or MSM who also inject with prevention and treatment males increased in 2007 to 24 from 18 drugs); in 2007, this group accounted services. However, in 2005, several in 2006. for 48% of new infections (158/325). African agencies were awarded HIV However, current attitudes, beliefs, and prevention funds to initiate and in some Females account for an increasing unsafe sexual practices documented in cases continue prevention programs percentage of new HIV infections, surveys among MSM nationwide, and in these communities. Additionally, from 10% of new infections in 1990 to a current epidemic of syphilis among collaborations between MDH, the 23% in 2007. Trends in HIV infections MSM documented in Minnesota and Minnesota Department of Human diagnosed annually among females elsewhere, warrant concern. Similar to Services, and community-based also differ by race/ethnicity. Early in syphilis increases in other U.S. cities organizations serving African-born the epidemic, whites accounted for the and abroad, over 40% of the recent persons in Minnesota are continuing to majority of newly diagnosed infections syphilis cases in Minnesota among address these complex issues. in women. Since 1991, the number of MSM were co-infected with HIV, new infections among women of color some for many years. “Burn out” from One of the few success stories in the has exceeded that of white women. The adopting safer sexual practices and history of HIV infection is the use of annual number of new HIV infections exaggerated confidence in the efficacy medication to successfully reduce diagnosed among U.S.-born black of HIV treatments may be contributors HIV perinatal transmission. Since the females had remained stable at 20 to resurging risky sexual behavior release of the U. S. Public Health or fewer cases during 2001 to 2004, among MSM. CDC recommends annual Service guidelines in 1994, HIV but increased to 28 new cases in both screening for sexually transmitted perinatal transmission in the United 2005 and 2006. In 2007 the number diseases (including HIV and syphilis) for States decreased 81% between 1995 decreased again, with 17 infections sexually active MSM and more frequent and 1999. The trend in Minnesota has reported. In contrast, the number of new screening for MSM who report sex with been similar but on a much smaller infections among African-born females anonymous partners or in conjunction scale. While the number of births to increased greatly from four cases in with drug use. HIV-infected women increased 10 1996 to 41 in 2002. However, since fold between 1990 and 2007, the rate 2002 the number of new HIV infections The number and percentage of HIV of perinatal transmission decreased in African-born females has decreased infections in Minnesota that are six-fold, from 18% in 1990–1995 to steadily, with 18 new cases diagnosed attributed to injection drug use has 3% in 1996–2006. The overall rate in 2006. In 2007, the number of new declined over the past decade for men of transmission for 2005–2007 was cases among African-born females and women, falling from 17% (80/470) 1.3%; however, it was twice that among increased again to 24.The annual of cases in 1991 to 5% (16/325) in foreign-born mothers indicating the number of new infections diagnosed 2007. Heterosexual contact with a need for additional education and among Hispanic, American Indian, and partner who has or is at increased risk prevention. Asian females is small, with 10 or fewer of HIV infection is the predominant cases annually in each group. mode of exposure to HIV for women. Influenza Ninety percent of 250 new HIV On November 2, 2007, the PHL isolated Despite relatively small numbers diagnoses among women between influenza virus from a Minnesota of cases, persons of color are 2005 and 2007 can be attributed resident for the first time during the disproportionately affected by HIV/ to heterosexual exposure after re 2007-2008 influenza season. This date AIDS in Minnesota. In 2007, non-white distributing those with unspecified risk. represented a slightly early start of men comprised approximately 12% influenza activity. Since 1990-1991, the of the male population in Minnesota first isolate typically has been between

8 DCN 36;1 January/August 2008 mid-November and mid-December. for that season. Two cases resided identified as influenza B/Malaysia- Influenza activity peaked in late in the metropolitan area and one like. Four hundred twenty isolates February/early March 2008. Nationally, resided in Greater Minnesota. During (48%) were identified as influenza B/ a similar activity pattern was seen. the 2006-2007 season, six pediatric Shanghai-like, a different lineage than influenza deaths were reported. Prior to the reference strain. For Influenza surveillance in Minnesota 2006-2007, the last reported pediatric 30% of isolates in the PHL, a vaccine relies on reporting of selective individual influenza death in Minnesota occurred match could not be determined; it is cases from clinics, hospitals, and during the 2004-2005 season. likely that many of these isolates were laboratories, as well as outbreak antigenically different from strains reporting from schools and long-term A probable outbreak of influenza-like included in the 2007-2008 vaccine. care facilities. The current system for illness (ILI) in a school is defined as reporting outbreaks has been in place a doubled absence rate with all of the The PHL detected one case of influenza since the 1995-1996 influenza season, following primary influenza symptoms A (H1N1) swine influenza in a 26 year- and a Sentinel Provider Influenza reported among students: rapid onset, old female. The case was black, non- Network was initiated in 1998-1999 to fever of >101º F, illness lasting 3 or Hispanic and lived in the metropolitan conduct active surveillance. Twenty- more days, and at least one secondary area. She had no underlying medical eight sentinel sites participated during influenza symptom (e.g., myalgia, conditions and was not vaccinated for the 2007-2008 season. While the headache, cough, coryza, sore throat, the 2007-2008 influenza season. The program has surpassed its goal of 20 or ). A possible ILI outbreak in a identification of this case demonstrates sentinel sites (i.e., one site per 250,000 school is defined as a doubled absence the capacity of the PHL to detect novel population), MDH plans to expand rate with reported symptoms among influenza viruses. the network to ensure sites represent students, including two of the primary all areas of the state. Clinics are influenza symptoms and at least one The highly pathogenic avian strain particularly needed in southern region secondary influenza symptom. During of influenza A (H5N1) continues to of the state, where coverage is sparse. the 2007-2008 season, MDH received circulate in Southeast Asia, Europe, and reports of probable ILI outbreaks from , causing illness in poultry and MDH requests reports of all suspected 135 schools in 44 counties throughout humans. The World Health Organization or confirmed cases of influenza-related Minnesota and possible outbreaks in reported on April 8, 2008 that a total of encephalopathy or encephalitis in 81 schools in 38 counties. A total of 379 human cases including 239 deaths children <18 years of age, suspected 216 schools in 54 counties reported have been confirmed since January or confirmed influenza-related deaths suspected outbreaks in 2007-2008. 2003, with an overall case-fatality rate in children <18 years of age, suspected Since 1988-1989, the number of of 63%. Fourteen countries in Asia and or confirmed cases of influenza and schools reporting suspected influenza Africa have reported human cases of staphylococcal co-infection, suspected outbreaks has ranged from a low of 38 avian influenza. MDH utilizes guidelines or confirmed influenza in hospitalized schools in 20 counties in 1996-1997 to developed by the CDC to assess pregnant women, and suspected cases 441 schools in 71 counties in 1991 ill patients returning from affected of novel influenza. Surveillance initiated 1992. countries. Currently, no cases of H5N1 in 2003 in the metropolitan area to have been identified in the United monitor influenza-related pediatric An influenza outbreak is suspected in States. Although person-to-person hospitalizations was continued through a long-term care facility when three or spread of H5N1 has likely occurred the 2007-2008 season. Surveillance for more residents in a single unit present in situations of very close contact, influenza-related adult hospitalizations with a cough and fever (>101º F) or sustained person-to-person spread has in the metropolitan area was added in chills during a 48- to 72-hour period. An not been demonstrated. 2005 and continued through the 2007 influenza outbreak is confirmed when at 2008 season. From October 1, 2007 to least one resident has a positive culture Legionellosis April 26, 2008, 525 adult and pediatric or rapid antigen test for influenza. One During 2007, 31 confirmed cases of hospitalizations with lab-confirmed hundred fifteen facilities in 48 counties legionellosis (Legionnaires’ disease influenza were reported to MDH from reported confirmed influenza outbreaks [LD]) were reported including 19 hospitals in the metropolitan area. in 2007-2008. In all facilities, influenza cases (61%) among residents of the was laboratory-confirmed by rapid tests metropolitan area and 12 cases (39%) Three pediatric influenza-related deaths or culture. Since 1988-1989, the number among Greater Minnesota residents. were identified during the 2007-2008 of long-term care facilities reporting ILI One (3%) case-patient died. Older influenza season. Two cases were outbreaks has ranged from a low of six adults and elderly persons were more female and one was male. Cases in 1990-1991 to 140 in 2004-2005. often affected, with 23 (74%) cases ranged in age from 5 to 12 years. occurring among individuals 50 years One case was white, non-Hispanic; As of May 5, 2008, 189 (22%) of 869 and older (median age, 57 years; one case was white, Hispanic; and influenza isolates in the PHL were range, 37 to 72 years). Twenty-three one case’s race and ethnicity were well-matched to one of the three strains (74%) cases had onset dates in June unknown. Onsets occurred between included in the vaccine for the 2007 through September. Travel-associated mid-February and early March 2008. 2008 influenza season, compared to legionellosis accounted for seven (23%) Deaths occurred between late February approximately 40% nationally. Of those, cases, defined as spending at least 1 and mid-March 2008. One case had an 55 (29%) were identified as influenza underlying health condition. The three A/H1, 125 (66%) were identified as cases were not vaccinated for influenza influenza A/H3, and 7 (4%) were continued...

DCN 36;1 January/August 2008 9 night away from the case’s residence bert, blue-veined, and Mexican-style western Wisconsin. As in 2006, Crow in the 10 days before onset of illness. cheeses) and unpasteurized milk; 2) Wing County continued to have the thoroughly heat/reheat deli meats, hot highest number of Lyme disease case Confirmed LD case criteria includes dogs, other meats, and leftovers; and 3) exposures (136 [21%] of 658 cases who X-ray confirmed pneumonia and wash raw vegetables. reported a single county of exposure positive results for one or more of the in Minnesota). Five hundred fifty-eight following tests: culture of Legionella Lyme Disease (45%) cases occurred among residents spp., or detection of L. pneumophila, Lyme disease is caused by Borrelia of the metropolitan area. However, serogroup 1 infection by Legionella burgdorferi, a spirochete transmitted to only a minority of these residents urinary antigen, direct fluorescent humans by bites from Ixodes scapularis (79 [22%] of 360 case-patients with antigen, or by acute and convalescent (the blacklegged tick or deer tick). The known exposure) were likely exposed antibody titers with a four-fold or same tick vector also transmits the to infected I. scapularis ticks in the greater rise to >1:128. A single agents of human anaplasmosis (HA) metropolitan area, primarily Anoka antibody titer at any level is not of and babesiosis. and Washington Counties. Over half diagnostic value for LD. For detection of Lyme disease case-patients in 2007 of LD, the Infectious Diseases Society In 2007, 1,239 confirmed Lyme disease (482 [60%] of 809 cases with a known of America treatment guidelines for cases (23.8 per 100,000 population) activity) were most likely exposed to community-acquired pneumonia were reported (Figure 1). This is a 36% I. scapularis ticks while on vacation, recommend urinary antigen assay and increase from the 913 cases (17.7 per visiting cabins, hunting, or during culture of respiratory secretions on 100,000) in 2006. It is also substantially outdoor recreation. selective media. Culture is particularly higher than the 918 cases in 2005 useful because environmental and and the previous record number of Measles clinical isolates can be compared 1,023 cases in 2004. The frequency One case of measles was reported by molecular typing in outbreaks of Lyme disease since 2004 has been during 2007. The case was confirmed and in investigations of healthcare considerably higher than the median by a positive measles IgM antibody associated LD. number of cases reported annually test. The case-patient was a 16 month- from 1996 through 2003 (median, old child residing in the metropolitan Starting in 2005, CDC recommended 374 cases; range, 252 to 866). Seven area. The child had returned from routine assessment of travel history hundred seventy-one (62%) confirmed an extended stay in Japan 2 days among LD cases so that travel- case-patients in 2007 were male. prior to onset and was therefore associated LD clusters or outbreaks The median age of case-patients considered an international importation. could be more readily and quickly was 41 years (range, <1 to 88 years). The child had a history of vaccination detected. Physician-diagnosed erythema migrans for measles at exactly 1 year of age. was present in 1,019 (82%) cases. Two The child’s mother was born in Japan Listeriosis hundred forty-four (20%) cases had one and had measles at 2 years of age Six cases of listeriosis were reported or more late manifestations of Lyme and subsequently received measles- during 2007. All case-patients were disease (including 203 with a history containing vaccine in 2002. Maternal hospitalized, and two died. The of objective joint swelling, 32 with measles antibodies have been shown to median age of case-patients was 78 cranial neuritis, four with lymphocytic persist longer in infants born to mothers years (range, 68 to 95 years). Four meningitis, six with radiculoneuropathy, with disease-induced immunity than had Listeria monocytogenes isolated and six with acute onset of 2nd or 3rd mothers with vaccine-induced immunity. from blood, one from cerebral spinal degree atrioventricular conduction It is possible that circulating maternal fluid, and one from a joint. None of defects) and confirmation by a positive antibody neutralized the vaccine virus, the cases were part of a recognized IgG antibody test or positive PCR. inhibiting a protective immune response outbreak. The six cases reported in Onsets of illness peaked in July (37% in the case-patient. 2007 is similar to the median annual of cases), corresponding to the peak number of cases reported from 1996 activity of nymphal I. scapularis ticks in No secondary cases were identified through 2006 (median, 8 cases; range, mid-May through mid-July. despite numerous exposures just 4 to 19). prior to and during the child’s measles Lyme disease co-infections with HA prodrome. Exposure notification and Elderly persons, immunocompromised and babesiosis can occur from the follow-up were conducted for the child’s individuals, pregnant women, and neo same tick bite. During 2007, 18 (1%) primary care clinic and assistance nates are at highest risk for acquiring Lyme disease case-patients also with follow-up for passengers on three listeriosis. Listeriosis generally mani had objective evidence of HA, and airplane flights was provided by the fests as and/or four (<1%) had objective evidence CDC. septicemia in neonates and adults. of babesiosis. Because of under- Pregnant women may experience a detection, these numbers likely This was the second consecutive mild febrile illness, abortion, premature underestimate the true frequency of year with a reported case of measles delivery, or stillbirth. In healthy adults co-infections. in Minnesota. In 2006, a case was and children, symptoms usually are reported in a 7-month-old infant adopted mild or absent. L. monocytogenes can Most case-patients in 2007 either from Africa. The child had arrived in multiply in refrigerated foods. Persons resided in or traveled to endemic the United States 9 days prior to rash at highest risk should: 1) avoid soft counties in north-central, east- onset and was therefore considered an cheeses (e.g., feta, Brie, Camem central, or southeast Minnesota or international importation.

10 DCN 36;1 January/August 2008 Suspect measles cases should be living in dormitories, and other groups MDH initiated active surveillance for reported to MDH immediately. Blood in the licensed age range previously CA-MRSA at 12 sentinel hospital specimens for IgM serologic testing determined to be at high risk. In 2006, laboratories in January 2000. The should be drawn at least 72 hours MDH in collaboration with the CDC laboratories (six in the metropolitan after rash onset. Testing for measles and other sites nationwide, began a area and six in Greater Minnesota) IgM antibody provides timely results; case-control study of the efficacy of were selected to represent various however, the positive predictive value MCV4. Eight cases occurred among geographic regions of the state. is suboptimal when disease incidence 11-22 year-olds, including one college Sentinel sites report all cases of MRSA is low (as it is currently). Multiple tests student with two episodes of disease identified at their facilities and for the (including acute and convalescent and three high school students. One first six years of surveillance submitted measles IgG antibody and viral culture) case had serogroup B disease and one all CA-MRSA isolates to MDH. The are therefore strongly recommended. had disease caused by an ungroupable purpose of this surveillance is to Testing for both measles and rubella is isolate that would not have been determine demographic and clinical routinely recommended for individuals prevented by the vaccine. There was characteristics of CA-MRSA infections presenting with acute generalized also a culture-negative, PCR-positive in Minnesota, to identify possible risk rash and fever. Blood specimens for suspected case of serogroup C disease factors for CA-MRSA, and to identify acute and convalescent IgG serology in a high school student. The case- the antimicrobial susceptibility patterns should be drawn within 4 days of rash patients in this age group who had and molecular subtypes of CA-MRSA onset and again 3 to 5 weeks later, serogroup C or serogroup Y disease isolates. A comparison of CA- and HA and tested as paired sera. Specimens had not received meningococcal MRSA using sentinel site surveillance for viral culture (throat swabs, urine, vaccine except for the case-patient with data from 2000 demonstrated that CA- or nasopharyngeal swabs) should be recurrent disease who had received and HA-MRSA differ demographically collected as soon as possible within 10 vaccine prior to the second episode of and clinically, and that their respective days of rash onset. illness. isolates are microbiologically distinct.

Meningococcal Disease Methicillin-Resistant In 2007, 3,495 cases of MRSA Twenty-two cases of Neisseria Staphylococcus aureus (MRSA) infection were reported by the 12 meningitidis invasive disease (0.4 per Strains of Staphylococcus aureus sentinel hospital laboratories. Fifty 100,000 population) were reported in that are resistant to methicillin and percent (1,761/3,495) of these cases 2007, compared to 15 cases in 2006. all available beta-lactam antibiotics were classified as CA-MRSA; 47% There were six (27%) serogroup B are referred to as methicillin-resistant (1,644/3,495) were classified as HA- cases, nine (41%) serogroup C, six S. aureus (MRSA). Traditional risk MRSA; and 3% (90/3,495) could not (27%) serogroup Y, and one (5%) factors for healthcare-associated (HA) be classified. CA-MRSA infections ungroupable case. In addition, there MRSA include recent hospitalization or increased from 131 cases (12% of all were five culture-negative suspect surgery, residence in a long-term care MRSA infections reported) in 2000 cases that were positive by polymerase facility, and renal dialysis. to 1,761 cases (50% of total MRSA chain reaction (PCR) in the PHL. infections reported) in 2007. In 1997, MDH began receiving reports Case-patients ranged in age from 1 to of healthy young patients with MRSA The CDC classifies MRSA isolates into 82 years, with a median of 19 years. infections. These patients had onset of pulsed-field types (PFTs) (currently Fifty percent of the cases occurred their MRSA infections in the community USA100-1200) based on genetic in the metropolitan area. Six (27%) and appeared to lack the established relatedness. CA-MRSA isolates case-patients had bacteremia without risk factors for MRSA. Although most are most often classified as PFT another focus of infection and 16 (73%) of the reported infections were not USA300 or USA400. In Minnesota, had meningitis. One individual had two severe, some resulted in serious illness the predominant CA-MRSA PFT has episodes of invasive meningococcal or death. Strains of MRSA cultured changed dramatically over time. In disease. All cases were sporadic, with from persons without HA risk factors for 2000, 63% of CA-MRSA isolates no definite epidemiologic links. One MRSA are now known as community- were USA400 and 4% were USA300. death occurred; a 5-year-old male died associated MRSA (CA-MRSA). CA In 2006, only 10% of CA-MRSA of meningitis attributed to serogroup B. MRSA is defined as: a positive culture isolates were USA400 and 78% were for MRSA from a specimen obtained USA300. Because USA400 isolates In January 2005, a meningococcal <48 hours of admission to a hospital in are much more likely than USA300 polysaccharide-protein conjugate a patient with no history of prior MRSA isolates to demonstrate inducible vaccine for serogroups A,C,Y, and infection or colonization; no presence clindamycin resistance (ICR) on disk W-135 (MCV4) was licensed for use of indwelling percutaneous devices or diffusion testing, the change in the in the United States for persons aged catheters at the time of culture; and predominant CA-MRSA PFT has also 11 to 55 years. In 2007, the license no history of hospitalization, surgery, been associated with a decrease in the was approved to include 2 to 10 year residence in a long-term care facility, proportion of erythromycin-resistant, olds. The Advisory Committee on hemodialysis, or peritoneal dialysis in clindamycin-sensitive CA-MRSA Immunization Practices and American the year prior to the positive MRSA isolates demonstrating ICR, from 93% Academy of Pediatrics recommend culture. in 2000 to 10% in 2006. immunization with the new vaccine at age 11-12 years, or at high school entry, as well as for college freshmen continued...

DCN 36;1 January/August 2008 11 In 2005, as part of the CDC Active in 2006. By comparison, a total of 29 after symptom onset. Specimens for Bacterial Core surveillance (ABCs) mumps cases had been reported in viral culture include buccal and throat system, MDH initiated population- Minnesota in 2000-2005, all of which swabs, and should be collected during based invasive MRSA surveillance were laboratory-confirmed. the first 5 days of illness. Occasionally, in Ramsey County. In 2005 the false-negative mumps IgM results occur incidence of invasive MRSA infection Thirteen (46%) case-patients had when serum specimens are collected in Ramsey County was 19.8 per a documented history of two doses within 3 days after onset of parotitis. A 100,000 population and was 19.4 and of mumps-containing vaccine. Five second serum sample (collected 5-7 18.5 in 2006 and 2007, respectively. In (18%) case-patients had a history days after onset) is recommended in 2007, most MRSA was isolated from of one dose of mumps-containing this situation. blood (82% in 2007), and 23% of the vaccine. One (4%) case-patient had cases (21/93) died. Of the invasive not received mumps-containing vaccine Neonatal Sepsis isolates that underwent molecular because they were younger than Neonatal sepsis was added to subtyping, 79% (45/57) were of a the recommended minimum age for the Minnesota Rules Governing known HA-MRSA PFT. Ramsey vaccination. The other nine (32%) case- Communicable Diseases in September County had a somewhat lower invasive patients had no documented history 2005, and surveillance and collection MRSA infection incidence rate than of vaccination for mumps; four (44%) of isolates in addition to group B other participating surveillance sites reported a history of mumps and were Streptococcus began in January 2006. (Klevens RM, et al. Invasive methicillin- born before 1957 and three (33%) self- This statewide effort includes reporting resistant Staphylococcus aureus reported a history of receiving mumps- of all bacteria other than coagulase- infections in the United States. JAMA. containing vaccine which could not be negative Staphylococcus isolated from 2007;298(15):1763-71). verified. a sterile site in infants 7 days of age. The most prevalent sterile sites have In 2007, MDH started collecting isolates Case-patients ranged in age from 7 been in blood and CSF. from CA-MRSA and HA-MRSA invasive months to 62 years. Seventeen (61%) (isolated from a normally sterile cases occurred in persons younger The 2006 summary consisted of body site) infections. Antimicrobial than 21 years of age; five (18%) cases 75 organisms, whereas the 2007 susceptibility and PFGE testing were occurred in persons 22 through 33 summary for Minnesota neonatal sepsis performed on submitted isolates. years of age; two (7%) cases occurred organisms in infants <7 days of age is Please refer to the MDH antibiogram for in persons 34 through 49 years of as follows: details. (see pp. 25-26). age; and four (14%) cases occurred in persons 50 years and older. The 23 Group B Streptococcus, Critical illnesses or deaths due to multi-state mumps resurgence in 7 Escherichia coli, community-associated S. aureus 2006 demonstrated that birth before 8 Streptococcus viridians, infection (both methicillin-susceptible 1957 does not correlate with immunity 4 Haemophilus influenzae, and-resistant) are now reportable to mumps, suggesting that natural 3 Corynebacterium spp., in Minnesota, as is vancomycin- immunity to mumps wanes in the 3 Bacillus spp., intermediate and vancomycin-resistant absence of exposure to wild virus. This 2 Staphylococcus aureus, S. aureus. observation was supported in 2007 in 2 Klebsiella spp., Minnesota, as four case-patients were 2 Streptococcus pneumoniae, Mumps born before 1957. 1 each Bacteroides spp., Enterococcus, During 2007, 28 cases of mumps Enterobacter cloacoe, Bacteroides (0.54 per 100,000 population) were Six (21%) cases occurred among family fragilis, Group A Streptococcus, Group reported in Minnesota. Seven (25%) members residing in two households. G Streptococcus, Neisseria spp., cases were laboratory confirmed, No source of infection was identified Stomatococcus spp., Acinetobacter, including one (14%) case confirmed for the index cases or for the remaining and Actinomyces spp. by both positive mumps IgM serology 22 (79%) cases, demonstrating that and a demonstrated rise in mumps asymptomatic infections occur and Isolates were received for 54 of 64 IgG between acute and convalescent suggesting that mumps is under- identified neonatal sepsis organisms. serologic specimens, five (71%) cases diagnosed. confirmed by mumps IgM serology Pertussis only, and one (14%) case confirmed Mumps surveillance is complicated During 2007, 393 cases of pertussis by mumps virus isolation from a by nonspecific clinical presentation, (7.6 per 100,000 population) were throat specimen. Four (14%) of the asymptomatic infections in an estimated reported in Minnesota, compared 28 total cases were epidemiologically 20% of cases, and suboptimal to 320 in 2006 and a peak of 1,571 linked to a laboratory confirmed case. sensitivity and specificity of laboratory cases reported in 2005. Laboratory Seventeen (61%) cases met the clinical testing. False-positive serologic assays confirmation was available for 248 case definition for mumps and were for mumps have been reported due (63%) cases, 32 (13%) of which reported as probable cases. Nineteen to parainfluenza infections (viruses 1 were confirmed by culture and 216 (68%) cases were reported between and 3). Therefore, both IgM and IgG (87%) of which were confirmed by January and April, following a multi- serologic testing as well as viral culture PCR. In addition to the laboratory- state resurgence of mumps in 2006. should be performed on all suspect confirmed cases, 58 (15%) cases were Minnesota reported 180 mumps cases mumps cases as soon as possible epidemiologically linked to laboratory-

12 DCN 36;1 January/August 2008 confirmed cases, and 87 (22%) met the immunized children may also develop possible, culture should be done in clinical case definition. Two hundred disease. Disease in those previously conjunction with PCR testing. Direct ninety-seven (76%) of the reported immunized is usually mild. Efficacy fluorescent antibody (DFA), provides cases occurred in residents of the for currently licensed is a rapid presumptive diagnosis of metropolitan area. estimated to be 71 - 84% in preventing pertussis; however, because both false- serious disease. Of the 34 case- positive and false-negative results can Paroxysmal coughing was the most patients who were 7 months to 6 years occur, DFA tests should not be relied commonly reported symptom. Three of age, 22 (65%) were known to have upon solely for laboratory confirmation. hundred seventy-one (94%) of the received at least a primary series of Serological tests are not standardized case-patients experienced paroxysmal three doses of DTP/DTaP vaccine and are not acceptable for laboratory coughing. Nearly one third (108, 27%) prior to onset of illness, 12 (35%) confirmation at this time. reported whooping. Although commonly received fewer than three doses and referred to as “,” very were considered preventable cases. Salmonellosis young children, older individuals, and During 2007, 709 culture-confirmed persons previously immunized may not MDH reporting rules require that cases of Salmonella infection (13.6 per have the typical “whoop” associated clinical isolates of Bordetella 100,000 population) were reported. with pertussis. Post-tussive vomiting pertussis be submitted to the PHL. This represents a 2% decrease from was reported in 158 (40%) of the Of the 32 culture-confirmed cases, the 725 cases reported in 2006 but cases. Infants and young children are 27 (84%) of the isolates were a 13% increase from the median at the highest risk for severe disease received and sub-typed by PFGE annual number of cases reported from and complications. Pneumonia was and tested for susceptibility 1996 to 2006 (median, 626 cases; diagnosed in four (1%) case-patients, to erythromycin, ampicillin, and range, 576 to 725) (Figure 2). Of two (50%) of whom were less than 18 trimethoprim-sulfamethoxazole. Nine the 99 serotypes identified in 2007, months of age. Seventeen (4%) case- distinct PFGE patterns were identified; five serotypes, S. Typhimurium (152 patients were hospitalized; 11 (65%) of five of these patterns occurred in cases), S. Enteritidis (138 cases), S. the hospitalized patients were younger only a single case isolate. The most Montevideo (39 cases), S. Newport than 6 months of age. common pattern identified accounted (37 cases) and S. I 4,[5],12:i:- (37 for 15 (56%) of the total isolates and cases) accounted for 57% of cases. Due to waning of immunity from either they occurred throughout the year. Salmonella was isolated from stool in natural infection or vaccine, pertussis 634 (89%), urine in 37 (5%), and blood can affect persons of any age. The No cases of erythromycin-resistant in 34 (5%) case-patients. There were disease is increasingly recognized B. pertussis have been identified in eight cases of S. Typhi infection. Five in older children and adults. During Minnesota since the first case was of the S. Typhi case-patients traveled 2007, case-patients ranged in age identified in 1999. Statewide, all internationally (India, Laos, , from 1 week to 97 years. One hundred 1,194 other isolates tested to date and Pakistan) within approximately 3 thirty-five (34%) cases occurred in have had low minimum inhibitory weeks of their illness onset. Twenty-five adolescents 13 to 17 years of age; concentrations, falling within the percent of salmonellosis case-patients 110 (28%) cases occurred in adults reference range for susceptibility to the were 12 years of age or younger. 18 years of age and older; 93 (24%) antibiotics evaluated. Only eight other Twenty-four percent of case-patients occurred in children 5-12 years of age; erythromycin-resistant B. pertussis were hospitalized for their infection. 30 (8%) occurred in children 6 months cases have been identified to date in Of the 635 case-patients who were through 4 years of age, and 25 (6%) the United States. interviewed, 107 (17%) traveled occurred in infants less than 6 months internationally during the week prior to of age. Laboratory tests should be performed their illness onset. A 58-year-old case- on all suspected cases of pertussis. patient died; the cause of death was a Infection in older children and adults Culture of B. pertussis requires pulmonary embolism, but Salmonella may result in exposure of unprotected inoculation of nasopharyngeal mucous was isolated from a blood specimen 8 infants who are at risk for the most on special media and incubation for days prior to death. severe consequences of infection. 7 to 10 days. However, B. pertussis During 2007, 30 pertussis cases were is rarely identified late in the illness; Eighty-seven cases were part of 12 reported in infants less than 1 year therefore, a negative culture does not outbreaks of salmonellosis identified in of age. A likely source of exposure rule out disease. A positive PCR result 2007. Nine of the outbreaks involved was identified for 14 (47%) cases; is considered confirmatory in patients foodborne transmission, including four nine (30%) were infected by adults 18 with a 2-week history of cough illness. outbreaks with cases in multiple states. years of age and older, two (7%) were PCR can detect non-viable organisms. Three outbreaks involved contact with infected by a child 13 years of age or Consequently, a positive PCR animals, or food for animals; all three older, and three (10%) were infected by result does not necessarily indicate had cases in multiple states. a child less than 13 years of age. For current infectiousness. Patients with the 16 cases with no identified source a 3-week or longer history of cough Ten S. Tennessee cases (seven cases of infection, the source was likely from illness, regardless of PCR result, may in 2007 and three in 2006) with isolates outside the household. not benefit from antibiotic therapy. of the same (PFGE) subtype that were Cultures are necessary for molecular part of a national outbreak associated Although unvaccinated children are and epidemiologic studies and for with peanut butter were identified in at highest risk for pertussis, fully drug susceptibility testing. Whenever continued...

DCN 36;1 January/August 2008 13 Minnesota. This outbreak resulted in 714 cases in 48 states from August Table 3. Number of Cases and Incidence Rates (per 100,000 population) 2006 to July 2007. of Chlamydia, Gonorrhea, Syphilis and Chancroid, Minnesota, 2003-2007 2003 2004 2005 2006 2007 An outbreak of S. Typhimurium Disease No. Rate No. Rate No. Rate No. Rate No. Rate infections resulted in 11 cases in March Chlamydia 10,802 220 11,647 237 12,359 251 12,977 264 13,412 273 and April. Additional cases with the same PFGE pattern were identified in Gonorrhea 3,235 66 2, 974 60 3,505 71 3,317 67 3,459 70 six other states. A case-control study found an association with eating leafy Syphilis, Total 198 4.0 148 3.0 210 4.3 188 3.8 186 3.8 greens; however, the specific type of Primary/Secondary 49 1.0 27 0.5 71 1.4 47 1.0 59 1.2 leafy green was not identified. Early Latent 45 0.9 22 0.4 48 1.0 58 1.2 55 1.1 Late Latent 103 2.1 97 2.0 88 1.8 81 1.6 72 1.5 Other* 1 0.0 1 0.0 1 0.0 0 0.0 0 0.0 From May through August, nine Congenital** 0 0.0 1 1.4 2 2.8 2 2.8 0 0.0 cases with the same PFGE subtype of S. Montevideo were associated Chancroid 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 with contact with chickens or their D* Includes unstaged neurosyphilis, latent syphilis of unknown duration, and late syphilis with clinical environment. The cases reported D manifestations. purchasing chickens to raise for meat ** Congenital syphilis rate per 100,000 live births. from a single hatchery in Iowa. Forty- Note: Data exclude cases diagnosed in federal or prIvate correctional facilities two cases of the outbreak subtype of S. Montevideo were ultimately identified in Table 4. Number of Cases and Incidence Rates (per 100,000 population) 19 other states. of Chlamydia, Gonorrhea, and Primary/Secondary Syphilis by Residence, Age, Gender, and Race/Ethnicity, Minnesota, 2007 In June, one case of S. Wandsworth infection was part of a multi-state Chlamydia Gonorrhea Syphilis outbreak that resulted in 65 cases in Demographic Group No. Rate No. Rate No. Rate 20 states. A snack of puffed rice and corn with a vegetable coating was Total 13,412 273 3,459 70 58 1.2 implicated as the vehicle. The outbreak subtype of S. Wandsworth was isolated Residence* Minneapolis 2,943 769 1,245 325 35 9.1 from sealed bags of the product and St. Paul 1,893 659 700 244 5 1.7 from one of the ingredients used in Suburban** 4,192 213 827 42 15 0.8 the seasoning mix. The investigation Greater Minnesota 3,882 170 564 25 3 0.1 resulted in a recall of the implicated product and another product made by Age the same manufacturer. <15 years 141 13 34 3 0 0.0 15-19 years 4,010 1,071 859 229 2 0.5

One case of S. Paratyphi B L(+) 20-24 years 5,134 1,592 1,073 333 5 1.6 25-29 years 2,289 716 657 205 9 2.8 tartrate+ (var Java) infection with onset 30-34 years 985 279 363 103 13 3.7 of illness in June was part of a multi- 35-44 years 649 79 320 39 19 2.3 state outbreak associated with contact >45 years 204 12 153 9 11 0.7 with pet turtles. A total of 103 cases with isolates indistinguishable from the Gender outbreak subtype were reported to CDC Male 3,570 153 1,528 63 58 2.4 from 33 states. Female 9,679 390 1,930 78 1 0.0 Transgender^^ 3 ----- 1 ----- 0 0.0

In July, three cases of S. Agona Race^/Ethnicity infections that ate at a single Chinese White 5,600 130 955 22 34 0.9 buffet restaurant in Hennepin County Black 3,797 1,871 1,728 851 7 5.4 were identified. Meal dates of the case- American Indian 409 504 81 100 1 0.0 patrons occurred from mid-May through Asian 524 311 34 20 1 0.6 mid-June. Three restaurant employees Other ^^ 567 ---- 101 ----- 1 ---- tested positive for the same PFGE Unknown^^ 2,515 ----- 560 ----- 3 ---- Hispanic^^^ 926 646 145 101 5 0.7 subtype of S. Agona. All three positive restaurant employees denied having a * Residence information missing for 502 chlamydia cases,123 gonorrhea cases, and one history of gastrointestinal symptoms. P&S syphilis case. Inadequate utensil washing and ** Suburban is defined as the seven-county metropolitan area (Anoka, Carver, Dakota, Hen disinfection, and cross-contamination nepin, Ramsey, Scott, and Washington Counties), excluding the cities of Minneapolis and St. Paul. were also identified as problems at ^ Case counts include persons by race alone. Population counts used to calculate results the restaurant. The ultimate source of include race alone or in combination. contamination was not identified. ^^ No comparable population data available to calculate rates. ^^^ Persons of Hispanic ethnicity may be of any race. Note: Data exclude cases diagnosed in federal or private correctional facilities.

14 DCN 36;1 January/August 2008 A S. Schwarzengrund case in July nine probable cases that attended the affect adolescents, young adults, and matched the outbreak PFGE subtype potluck. A specific food vehicle was not persons of color. in a multi-state outbreak associated identified. with contact with contaminated dry pet Chlamydia food made by a single manufacturer. Six S. Montevideo cases with isolates Chlamydia trachomatis infection is The outbreak resulted in 62 cases in of the same PFGE subtype that were the most commonly reported STD in 18 states. It is unclear if the Minnesota identified from September through Minnesota. In 2007, 13,412 chlamydia case had contact with the contaminated December 2007, and an additional cases (273 per 100,000 population) pet food. three cases that were identified from were reported, representing a 4% January through March 2008, were increase from 2006 (Table 3). An outbreak of S. Enteritidis infections part of an outbreak associated with a associated with eating at a Mexican grocery store deli in Wadena County. Adolescents and young adults are at restaurant in Hennepin County was The outbreak subtype was the same highest risk for acquiring chlamydial identified in August. Sixteen culture- as that from the earlier outbreak infection (Table 4). The chlamydia rate confirmed and three probable case- associated with contact with chickens is highest among 20 to 24-year-olds patrons ate at the restaurant from discussed above. The chicken contact (1,592 per 100,000), with the next August 1 through August 8. Restaurant outbreak evidently resulted in infection highest rate among 15 to 19-year-olds employees and environmental samples of deli workers; leading to foodborne (1,071 per 100,000). The incidence tested negative for Salmonella. Eating transmission to deli patrons. Two deli of chlamydia among adults 25 to 29 salsa was associated with illness, but employees tested positive for the years of age (716 per 100,000) is the source of contamination was not outbreak subtype of S. Montevideo, and considerably lower but has increased identified. one of the employees owned back in recent years. The chlamydia rate yard chickens. Infected foodworkers among females (390 per 100,000) is Seven cases of S. I 4,5,12:i:- infection were the source of contamination. This more than twice the rate among males with onset of illness from August investigation is ongoing. (153 per 100,000). This difference is through October were part of a likely due to more frequent screening multi-state outbreak associated with Sexually Transmitted Diseases among women. consumption of frozen pot pies. (STDs) Although not a ready-to-eat food, Active surveillance for gonorrhea and The incidence of chlamydia infection is most cases cooked the products in the chlamydia, initiated in 2002, involves highest in communities of color (Table microwave. The cooking instructions cross-checking laboratory-reported 4). The rate among blacks (1,871 were confusing and likely inadequate. cases against cases reported by per 100,000) is over 14 times higher The implicated pot pies were recalled. clinicians. Although both laboratories than the rate among whites (130 per Between January and December, 2007, and clinical facilities are required to 100,000). Although blacks comprise 401 isolates of S. I 4,[5],12:i:- of the report STDs independently of each approximately 4% of Minnesota’s outbreak subtype were collected from ill other, an episode of STD is not population, they account for 28% persons in 35 states. considered a case for surveillance of reported chlamydia cases. Rates purposes until a corresponding case among Asian/Pacific Islanders (311 A S. Typhimurium outbreak associated report is submitted by a clinical facility. per 100,000), American Indians (504 eating tomatoes at a sandwich Case reports contain demographic per 100,000), and Hispanics (646 per restaurant in Olmsted County occurred and clinical information that is not 100,000) are two to five times higher in October. Eighteen culture-confirmed available from laboratory reports. than the rate among whites. patron-cases and five probable cases When a laboratory report is received with meal dates at the restaurant from but no corresponding case report is Chlamydia infections occur throughout October 1 through October 8 were received within 45 days, MDH mails a the state, with the highest reported identified. Two restaurant employees reminder letter and case report form rates in Minneapolis (769 per 100,000) with onsets of illness during the same to the corresponding clinical facility. and St. Paul (659 per 100,000). In week in October as the patrons also Active surveillance for syphilis also 2007, the greatest increases for tested positive for the outbreak subtype began in 2002 and involves immediate chlamydia were seen in the suburbs of S. Typhimurium. Cross-contamination follow-up with the clinician upon receipt and Greater Minnesota with increases of the tomatoes from foods of animal of a positive laboratory report. Cases of 4% and 8%, respectively. origin at the restaurant was ruled- of chancroid are monitored through a out. The tomatoes were likely already mostly passive surveillance system. Gonorrhea contaminated when they entered the Herpes simplex virus and human Gonorrhea, caused by Neisseria restaurant. The restaurant’s practice of papillomavirus infections are not gonorrhoeae, is the second most storing tomatoes at room temperature reportable. commonly reported STD in Minnesota. for ripening before being used may In 2007, 3,459 cases (70 per 100,000 have contributed to amplification of the Although overall incidence rates for population) were reported, representing contamination. STDs in Minnesota are lower than an increase of 5% from 2006 (Table 3). those in many other areas of the United In November, two cases of S. States, certain population subgroups in Adolescents and young adults are at Newport infection associated with Minnesota have very high STD rates. greatest risk for gonorrhea (Table 4), an office potluck were identified. The Specifically, STDs disproportionately with incidence rates of 229 per 100,000 investigation identified an additional continued...

DCN 36;1 January/August 2008 15 among 15 to 19-year-olds, 333 per is the high prevalence among men were reported compared to 47 (1.0 per 100,000 among 20 to 24-year olds, who have sex with men (MSM), 100,000) cases in 2006. and 205 per 100,000 among 25 to 29- which increased sharply from 0% in year-olds. Gonorrhea rates for males 2002, to 8.9% in 2003, and to 27% Early Syphilis (63 per 100,000) and females (78 per in 2004. Since then the prevalence In 2007, the number of early syphilis 100,000) are comparable. Communities among MSM has remained stable but cases increased by 10%, with 114 of color are disproportionately affected elevated (28% in 2007). As a result, cases occurring compared to 105 by gonorrhea, with 50% of cases fluoroquinolones (e.g., ) cases in 2006. The incidence is highest reported among blacks. The incidence are no longer recommended for treating amongst MSM, where cases increased of gonorrhea among blacks (851 per gonorrhea in men with male sexual by 29% from 2006 to 2007 (80 to 103). 100,000) is approximately 40 times partners in Minnesota. In 2007, QRNG Of the early syphilis cases in 2007, 111 higher than the rate among whites (22 prevalence also reached a critical level (97%) occurred among men; 103 (93%) per 100,000). Rates among American in heterosexuals (4.5%), prompting the of these men reported having sex with Indians (100 per 100,000) and MDH to recommend non-quinolone other men; 44% of the MSM diagnosed Hispanics (101 per 100,000) are almost therapy for that population as well. with early syphilis were co-infected with five times higher than among whites. HIV. The rate among Asian/Pacific Islanders Syphilis (20 per 100,000) is slightly lower than Surveillance data for primary and Congenital Syphilis among whites. secondary syphilis are used to monitor No cases of congenital syphilis were morbidity trends because they represent reported in Minnesota in 2007 (Table 3). Gonorrhea rates are highest in the recently acquired infections. Data for cities of Minneapolis and St. Paul early syphilis (which includes primary, Chancroid (Table 4). The incidence in Minneapolis secondary, and early latent stages Chancroid continues to be very rare in (325 per 100,000) is 1.3 times the rate of disease) are used in outbreak Minnesota. No cases were reported in in St. Paul (244 per 100,000), nearly investigations because they represent 2007. eight times higher than the rate in the infections acquired within the past 12 suburban metropolitan area (42 per months and signify opportunities for Shigellosis 100,000), and 13 times higher than disease prevention. During 2007, 238 culture-confirmed the rate in Greater Minnesota (25 per cases of Shigella infection (5.0 per 100,000). However, the rate in Greater Primary and Secondary Syphilis 100,000 population) were reported Minnesota is growing rapidly, with a The incidence of primary/secondary (Figure 2). This represents an 8% 34% increase from 2006 to 2007. syphilis in Minnesota is lower than that decrease from the 259 cases reported of chlamydia or gonorrhea (Table 3), in 2006, and a 7% increase from the Quinolone-resistant N. gonorrhoeae but has remained elevated since an median number of cases reported The prevalence of quinolone-resistant outbreak was observed in 2002 among annually from 1999 to 2006 (median, N. gonorrhoeae (QRNG) has increased men who have sex with men (MSM). In 222 cases; range, 68 to 904). approximately six-fold from 1.5% in 2007, 59 cases of primary/secondary 2002 to 8.6% in 2007. Of concern syphilis (1.2 per 100,000 population) In 2007, S. sonnei accounted for 208 (88%) cases, S. flexneri for 27 (11%), and S. dysenteria for one (<1%). Case- Figure 4. Invasive Pneumococcal Disease Incidence Among patients ranged in age from 1 month to Children <5 Years and Adults >65 Years of Age, by Year and 90 years (median, 9 years). Fifty-one Serotype, Twin Cities Metropolitan Area, 1999-2007 percent of case-patients were less than

125 10 years of age; children less than 5 years of age accounted for 28% of cases. Forty-three (18%) case-patients

100 were hospitalized. Seventy-nine Other Serotypes percent of case-patients resided in the PCV-7 Serotypes metropolitan area, including 35% in

75 Hennepin County and 14% in Ramsey County.

Five outbreaks of shigellosis were 50 identified in 2007; all five were caused by S. sonnei. These outbreaks resulted in 17 culture-confirmed

Cases/100,000 25 cases (representing 7% of reported Shigella cases). Four person–to-person outbreaks occurred in child daycare 0 facilities and one community associated 1999 2000 2001 2002 2003 2004 2005 2006 2007 1999 2000 2001 2002 2003 2004 2005 2006 2007 person-to-person outbreak also occured. Children < 5 Years Adults > 65 Years

16 DCN 36;1 January/August 2008 Every tenth Shigella isolate received 4]). This small degree of replacement The 16 deaths included eight cases of at MDH is tested for antimicrobial disease due to non-PCV-7 serotypes, bacteremia without another focus of resistance. Twenty-four isolates were similar to that seen in other parts of infection and three cases of pneumonia. tested in 2007; 71% were resistant the country, has been far outweighed The five remaining fatal cases had to ampicillin, 21% were resistant to by the declines in disease caused by (2), peritonitis (1), trimethoprim-sulfamethoxazole, and PCV-7 serotypes. This trend supports and the type of infection was unknown 13% were resistant to both ampicillin the need for ongoing monitoring, for two deaths. The deaths occurred in and trimethoprim-sulfamethoxazole. however, because further increases persons ranging in age from 1 month to All isolates tested were susceptible to due to non-vaccine serotypes are 95 years. For the 15 deaths in patients . possible. In Figure 4 rates of invasive with known health histories, significant pneumococcal disease among adults underlying medical conditions were Streptococcus pneumoniae Invasive aged > 65 years are also shown by reported for 13 of the case-patients. Disease serotypes included and not included Statewide active surveillance for in PCV-7. Declines in incidence in this Isolates were available for 160 (92%) invasive Streptococcus pneumoniae age group, particularly in disease due to cases, and 159 were subtyped using (pneumococcal) disease began in PCV-7 serotypes, have been observed PFGE; 51 different molecular subtypes 2002, expanded from the metropolitan elsewhere in the United States and are were identified. Twenty-five subtypes area, where active surveillance has likely attributable to herd immunity from were represented by one isolate each; been ongoing since 1995. In 2007, 664 use of PCV-7 among children. Among other subtypes were represented by (12.9 per 100,000 population) cases cases overall, a serotype not included two to 54 isolates each. No direct of invasive pneumococcal disease in the PCV-7 vaccine, serotype 19A, is epidemiologic links were noted among were reported. By age group, annual now most commonly associated with cases with indistinguishable subtypes incidence rates per 100,000 were 30.3 invasive pneumococcal disease in except for the two pairs of nursing home cases among children aged 0-4 years; Minnesota. residents from the same facilities. 3.7 cases among children and adults aged 5-39 years, 12.9 cases among Of the 615 isolates submitted for 2007 Isolates were available for 14 of the adults 40-64 years, and 40.0 cases cases, one (<1%) isolate was resistant deaths and were distributed among six among adults aged 65 years and older. to penicillin and 40 (6%) exhibited different PFGE subtypes. Eight deaths intermediate-level resistance using were attributed to the most common In 2007, pneumonia accounted for 381 nonmeningitis breakpoints (Note: CLSI subtype, and two other deaths had (57%) cases of invasive pneumococcal penicillin breakpoints changed in 2008; indistinguishable subtypes. disease among all cases (i.e., those refer to the MDH antibiogram on pp. infections accompanied by bacteremia 25-26); 96 isolates (16%) exhibited Streptococcal Invasive Disease or isolation of pneumococci from multi-drug resistance (i.e., high-level Group B another sterile site such as pleural resistance to two or more antibiotic Three hundred thirty-one cases of fluid). Bacteremia without another classes). group B streptococcal invasive disease focus of infection accounted for 206 (6.3 per 100,000 population), including (31%) cases statewide. Pneumococcal Streptococcal Invasive Disease 12 deaths, were reported in 2007. meningitis accounted for 38 (6%) cases. Group A These cases were those in which group Sixty-one (9%) patients with invasive One hundred seventy-three cases of B Streptococcus (GBS) was isolated pneumococcal disease died. invasive group A streptococcal (GAS) from a normally sterile site; five cases disease (3.3 per 100,000 population), of miscarriage or stillbirth in which GBS In 1999, the year before the pediatric including 16 deaths, were reported in was cultured from the placenta were pneumococcal conjugate vaccine 2007, compared to 171 cases and 17 also reported. (Prevnar, Wyeth-Lederle [PCV-7]) deaths in 2006. Ages of case-patients was licensed, the rate of invasive ranged from 6 days to 99 years Overall, 156 (47%) cases presented pneumococcal disease among children (median, 50 years). Fifty-four percent with bacteremia without another focus < 5 years in the metropolitan area of case-patients were residents of the of infection. The other most common was 111.7 cases/100,000. Over the metropolitan area. Fifty-nine (34%) types of infection were (16%), years 2000-02 there was a major case-patients had bacteremia without pneumonia (8%), osteomyelitis (8%), downward trend in incidence in this age another focus of infection, and 31 arthritis (6%), and meningitis (2%). group (Figure 4). Rates in each of the (18%) case-patients had cellulitis with The majority (79%) of cases had GBS subsequent four years were somewhat bacteremia. There were 22 (13%) cases isolated from blood only. Fifty-one higher, although there has not been of primary pneumonia and 14 (8%) percent of cases occurred among a continuing upward trend (25.8 cases of necrotizing fasciitis. Eighteen residents of the metropolitan area. cases/100,000 in 2003; 29.0, 27.4, and (10%) case-patients had septic arthritis Thirty-seven (11%) case-patients were 23.3, and 30 cases/100,000 in 2004, and/or osteomyelitis, and three (2%) infants less than 1 year of age, and 165 2005, 2006, and 2007, respectively had streptococcal toxic shock syndrome (50%) were 60 years of age or older. (Figure 4). Based on the distribution (STSS) accompanied by another focus of serotypes among isolates from of infection. Thirteen (8%) case-patients Forty-six cases of infant (early-onset or these cases, this increase was limited were residents of long-term care late-onset) or maternal GBS disease to disease caused by non-vaccine facilities. Two facilities each had two were reported, compared to 59 cases in serotypes (i.e. serotypes other than case-patients. 2006. Twenty-three infants developed the seven included in PCV-7) [Figure continued...

DCN 36;1 January/August 2008 17 invasive disease within 6 days following weeks later for symptoms consistent Tuberculosis birth (0.31 cases per 1,000 live with generalized tetanus. He received While the number of cases of births), and 13 infants became ill at tetanus immune globulin (TIG) 3 days tuberculosis (TB) disease reported 7 to 89 days of age. Five stillbirths or after illness onset. The case-patient nationally has decreased each year spontaneous abortions were associated received mechanical ventilation for 18 since 1993, the incidence of TB in with 10 maternal invasive GBS days and was hospitalized for 28 days Minnesota increased throughout infections. before recovering. much of the 1990s and peaked at 239 TB cases (4.8 cases per 100,000 From 1997 to 2007, there were 278 Toxic Shock Syndrome population) in 2001. After 3 consecutive early-onset disease cases reported, and In 2007, nine cases of suspect or years (2002-2004) of decreasing 15 infants died. Sixty-one infants were probable staphylococcal toxic shock incidence followed by a plateau at born at less than 37 weeks gestation syndrome (TSS) were reported. Of 199 cases in 2005, the number of and accounted for 22% of early-onset the reported cases, most (78%) were reported TB cases in Minnesota has cases. Bacteremia without another female and the median age was 14 steadily increased. A 9% increase in focus of infection (79%) was the most years (range, 10 to 19 years). Five 2006 resulted in 217 cases, and a 10% common type of infection in these early- of the nine (56%) were menstrual- increase in 2007 resulted in 238 cases onset cases, followed by pneumonia associated, three were wound- (one case short of the 2001 peak). The (11%) and meningitis (7%). associated, and one had no source increase in cases observed in 2006 identified. primarily was due to a 62% increase The Prevention of Perinatal Group in the number of U.S.-born cases, B Streptococcal Disease, Revised Staphylococcal toxic shock syndrome whereas the number of foreign-born Guidelines published by CDC in with isolate submission (if isolated) is cases counted in 2006 was essentially August 2002 included the following reportable to MDH within one working the same as the prior year. In 2007, the key changes: the recommendation day. MDH follows the 1997 CDC increase in cases was due to a 16% for universal prenatal screening of all case definition which includes fever increase in the number of foreign-born pregnant women at 35 to 37 weeks (temperature > 102.0°F or 38.9°C), cases (from 175 to 203), while the gestation and updated prophylaxis rash (diffuse macular erythroderma), number of U.S.-born cases decreased regimens for women with penicillin desquamation (within 1-2 weeks after by 17% (from 42 to 35). The 238 allergies. In light of these revised onset of illness), hypotension (SBP < cases counted in 2007 represent an guidelines, MDH reviewed the maternal 90 mm Hg for adults or less than fifth incidence rate of 4.6 cases per 100,000 charts for all 23 early-onset cases percentile by age for children aged < population. The statewide incidence is reported during 2007. Overall, 12 (52%) 16 years; orthostatic drop in diastolic slightly above that of the national rate of 23 women who delivered GBS- blood pressure greater than or equal (4.4 cases per 100,000 population in positive infants underwent prenatal to 15 mm Hg from lying to sitting, 2007); it also exceeds the U.S. Healthy screening for GBS. Of these, two (17%) orthostatic syncope, or orthostatic People 2010 objective of 1.0 case per women were positive and 10 (83%) dizziness), multisystem involvement 100,000 population (Figure 5). were negative. Among the eight women (> 3 of the following: vomiting or who did not receive prenatal screening diarrhea at onset of illness; severe The most distinguishing characteristic for GBS, two (25%) were screened myalgia or creatine phosphokinase of the epidemiology of TB disease in upon admission to the hospital and level at least twice the upper limit Minnesota continues to be the large prior to delivery of her infant. Among of normal; vaginal, oropharyngeal, proportion of TB cases reported among the 23 women of infants with invasive or conjunctival hyperemia; blood foreign-born persons. During the past GBS disease, eight (32%) received urea nitrogen or creatinine at least decade, the percentage of foreign-born intrapartum antimicrobial prophylaxis twice the upper limit of normal for persons among TB cases reported in (IAP). Both of the women with a positive laboratory or urinary sediment with Minnesota increased from 71% in 1998, GBS screening result received IAP. pyuria (> 5 leukocytes per high- to 87% in 2005. In 2007, 85% of TB MDH continues to follow the incidence power field) in the absence of urinary cases in Minnesota were foreign-born, of GBS disease among infants, tract infection; total bilirubin, alanine which is consistent with the average screening for GBS among pregnant aminotransferase enzyme, or asparate percentage of foreign-born cases (83%) women, and the use of IAP for GBS- aminotransferase enzyme levels at reported from 2003 through 2007. In positive pregnant women during labor least twice the upper limit of normal for contrast, 59% of TB cases reported and delivery. laboratory; platelets less than 100,000/ nationwide in 2007 were foreign-born. mm3; disorientation or alterations in Tetanus consciousness without focal neurologic The 203 foreign-born 2007 TB case- One case of tetanus was reported signs when fever and hypotension are patients represent 27 different countries during 2007. The case occurred in a absent); negative results for blood, of birth. The most common region of 10-year-old white, non-Hispanic male throat, or cultures birth among foreign-born TB cases with no history of receiving tetanus (blood culture may be positive for reported in 2007 was sub-Saharan and diphtheria toxoid (Td). He had Staphylococcus aureus) or rise in Africa (66%), followed by South/ sustained a deep laceration on his right titer to Rocky Mountain spotted fever, Southeast Asia (18%) (Figure 6). The foot when running on a farm without leptospirosis, or measles. ethnic diversity among these foreign- shoes. No immediate medical attention born TB cases reflects the unique and was sought and he was hospitalized 2 constantly changing demographics of immigrant and other foreign-born

18 DCN 36;1 January/August 2008 C 61 January/August 2008 DCN 36;1 and otherforeign-bornpersons. recently arrivedrefugees,immigrants, treatment oflatent TB infection among domestic screening,evaluation,and be preventablebyfocusingonthorough TB casesreportedinMinnesotamay suggest thatatleasthalfofforeign-born in theUnitedStates. These data diagnosed 2ormoreyearsafterarriving reported inMinnesotaduring2007were (62%) offoreign-born TB case-patients performed overseas.Morethanhalf of theresultsmedicalexams arrived foreign-born persons, regardless index ofsuspicionfor TB amongnewly the needforclinicianstohaveahigh exam results. These findings highlight noted intheirpre-immigrationmedical (26%) hadany TB-related condition as immigrantsorrefugees,onlynine the UnitedStatesandwhoarrived 2007 within12monthsofarrivingin were diagnosedinMinnesotaduring patients 15yearsofageorolderwho pulmonary TB disease.Of34 TB case- overseas thatincludesscreeningfor pre-immigration medicalexamination as immigrantsorrefugeesreceivea or olderwhoarriveintheUnitedStates to immigrating.Persons15yearsofage progressing toactive TB diseaseprior outside theUnitedStatesandbegan persons whoacquired TB infection States. These caseslikelyrepresent months afterarrivingintheUnited 2007 werediagnosedwithin12 born TB case-patientsreportedin Nearly one-fourth(24%)oftheforeign- Minnesota. most affected byandatriskfor TB in and controlservicesforpopulations linguistically appropriate TB prevention challenges inprovidingculturallyand This diversityalsoposessignificant populations arrivinginMinnesota. parents. These first-generationU.S.- children bornintheU.S.toforeign-born these U.S.-borncase-patients were respectively), althoughnearly allof foreign-born cases(11% versus0%, U.S.-born TB casesthanamong of agewasconsiderablylargeramong of pediatricpatientslessthan5years years ofageorolder. The proportion U.S.-born TB case-patientswere45 this agecategory. Incontrast,54%of cases occurredamongpersonsin whereas only20%ofU.S.-born TB in 2007were15to44yearsofage, case-patients reportedinMinnesota The majority(68%)offoreign-born TB continued...

Percentage of Cases Number of Cases Figure 6.Foreign-BornTuberculosis CasesbyRegionofBirthand Year of Cases per 100,000 Figure 7.Tuberculosis CasesbySiteofDiseaseandPlaceBirth, 100 100 120 140 10 20 30 40 50 60 70 80 90 20 40 60 80 10 12 Figure 5.Tuberculosis IncidenceRatesper100,000 Population, 0 0 0 2 4 6 8

*Includes caseswith bothextrapulmonaryandpulmonary sitesofdisease Number of Cases 1992 Southeast Asia Diagnosis, Minnesota,2003-2007innesota,1992-2007 1993 South/

1994 United StatesandMinnesota,1992-2007 (47%) 1995 Foreign-Born

u-Saharan Sub- 1996 Africa Pulmonary Minnesota, 2003-2007

(53%) 1997 Year ofDiagnosis Region ofBirth

1998

1999 East Asia/East Pacific 2000

2001

2002 Extrapulmonary LatinAmerica/ Caribbean

2003 (63%) (63%)

U.S.-Born 2004 Objective Objective Objective* Minnesota United StatesUnited Healthy People 2010 Healthy People 2000 2005 (37%) Eastern EuropeEastern (37%) 2006

2007 2007 2006 2005 2004 2003 19 born children appear to experience an Twenty-seven (31%) of the state’s TB cases than it is among U.S.-born increased risk of TB disease that more 87 counties reported at least one cases in Minnesota. Of particular closely resembles that of foreign-born case of TB disease in 2007, with the concern, six (32%) of 19 MDR-TB persons. Presumably, these children majority (79%) of cases occurring in cases reported from 2003 through may be exposed to TB as a result of the metropolitan area, particularly 2007 were resistant to all four first-line travel to their parents’ country of origin in Hennepin (48%) and Ramsey drugs. These six pan-resistant MDR and/or visiting or recently arrived family (20%) Counties, both of which have TB case-patients represented six members who may be at increased risk public TB clinics. Eleven percent different countries of birth (one each for TB acquired overseas. of TB cases occurred in the five from China, , Laos, Thailand, suburban metropolitan counties Somalia, and the United States). The The majority (81%) of TB cases in 2007 (i.e., Anoka, Dakota, Carver, Scott, U.S.-born pan-resistant patient was a in Minnesota were identified as a result and Washington). Olmsted County, young child infected by a foreign-born of presenting for medical care. Other which maintains a public TB clinic family member. One of the MDR-TB methods of case identification during staffed jointly by the Olmsted County cases (2006) also met the current this time period included TB contact Health Department and Mayo Clinic, World Health Organization definition of investigations (6%), domestic refugee represented 8% of cases reported extensively drug-resistant (XDR) TB. health examinations (6%), and follow-up statewide in 2007. The remaining 13% evaluations following abnormal findings of cases occurred in primarily rural Another clinical characteristic of on pre-immigration exams performed areas of Greater Minnesota. MDH significance among TB cases in overseas (3%). The remaining 4% of TB calculates county-specific annual TB Minnesota is the preponderance cases were identified through a variety incidence rates for Hennepin, Ramsey, of extrapulmonary disease among of other means. and Olmsted counties, as well as for foreign-born TB patients. Just over the five-county suburban metropolitan half (53%) of foreign-born TB case- Aside from foreign-born persons, other area and collectively for the remaining patients counted from 2003 through high-risk population groups comprise 79 counties in Greater Minnesota. 2007 had an extrapulmonary site much smaller proportions of the TB In 2007, the highest TB incidence of disease; in contrast, only 37% cases reported in Minnesota. Among rate (14.3 cases per 100,000) was of U.S.-born TB case-patients had cases reported in 2007, persons with reported in Olmsted County, followed extrapulmonary TB (). The most certain medical conditions (excluding by Hennepin and Ramsey counties, common extrapulmonary sites of TB HIV infection) that increase the risk for respectively. The TB incidence rate disease in Minnesota are lymphatic, progression from latent TB infection in Hennepin County increased from pleural, peritoneal, bone/joint, and to active TB disease (e.g., silicosis, 8.4 cases per 100,000 in 2006 to 10.0 meningeal. The unusually high diabetes, prolonged corticosteroid cases per 100,000 in 2007, while the incidence of extrapulmonary TB therapy or other immunosuppressive TB incidence rate in Ramsey County disease in Minnesota exemplifies the therapy, end stage renal disease, increased from 8.5 cases per 100,000 need for clinicians to be aware of the etc.) were the most common of these in 2006 to 9.4 cases per 100,000 in epidemiology of TB in Minnesota and other high-risk population groups, 2007. In 2007, the incidence rates to have a high index of suspicion for representing 16% of the cases. in both the five-county suburban TB, particularly among foreign-born Substance abuse (including alcohol metropolitan area (2.2 cases per patients and even when the patient abuse and/or illicit drug use) was the 100,000) and Greater Minnesota (1.4 does not present with a cough or other second most common of these other cases per 100,000) were considerably common symptoms of pulmonary TB. risk factors, with approximately 7% of lower than that in the state overall. TB case-patients having a history of The epidemiology of TB in Minnesota substance abuse during the 12 months Drug-resistant TB is a critical concern highlights the need to support global prior to their TB diagnosis. Twelve (5%) in the prevention and control of TB in TB elimination strategies, as well of the 238 TB case-patients reported in Minnesota, as well as nationally and as local TB prevention and control Minnesota during 2007 were infected globally. The prevalence of drug- activities targeted to foreign-born with HIV; all 12 of those HIV-infected resistant TB in Minnesota, particularly persons. TB in Minnesota occurs TB case-patients were foreign-born, resistance to isoniazid (INH) and multi- primarily, although not exclusively, including four persons born in Mexico, drug resistance, exceeds comparable among foreign-born persons, with two persons each from Ethiopia, Kenya, national figures. In 2007, 22 (13%) TB case-patients representing many Liberia, and one person each from of 176 culture-confirmed TB cases countries of origin and varied cultural and Sudan. The percentage were resistant to at least one first- backgrounds. The prevalence of of TB case-patients in Minnesota with line anti-TB drug (i.e., INH, rifampin, drug-resistant TB in Minnesota is high HIV co-infection remains less than pyrazinamide, or ethambutol). In compared to that of the national rate, that among all TB cases reported particular, 17 (10%) cases were and extrapulmonary sites of disease nationwide. Other risk groups such as resistant to INH, and three (2%) cases are common, especially among homeless persons, correctional facility were multidrug-resistant (i.e., resistant foreign-born cases. The proportion of inmates, and residents of nursing to at least INH and rifampin). These TB cases occurring in persons under homes each represented only 1-3% of data reflect the prevalence of MDR-TB 5 years of age in Minnesota exceeds TB cases reported in Minnesota during in Minnesota during the past 5 years, the comparable figure nationally, with 2007. which averaged approximately 2% many of these children being born to of cases annually. Drug resistance is foreign-born parents. These trends more common among foreign-born suggest that the incidence of TB in

20 DCN 36;1 January/August 2008 Minnesota is not likely to decrease in Nineteen cases were eligible for ers seven counties, including Carver, the foreseeable future. the CDC project (five cardiac, four Chisago, Dakota, Houston, Fillmore, respiratory, three sepsis, three Goodhue, and Scott, which together Unexplained Critical Illnesses neurologic, two SUD, the GI case, and make up 14.3% of the state population. and Deaths of Possible Infectious the renal syndrome case). Specimens Lastly, the ME offices actively report Etiology were obtained for testing at MDH or cases that have infectious causes or Surveillance for unexplained critical CDC for 14 cases. Probable etiologies are suspicious for infectious causes illnesses and deaths of possible were established for nine cases. and MDH collaborates with them to infectious etiology (UNEX) began in Immunohistochemical (IHC) testing determine the cause of death. In some September 1995. Any case should be and a viral culture of the lungs were instances, these become UNEX cases reported, regardless of the patient’s positive for influenza A from a 1 year-old and may have additional testing done age or underlying medical conditions. who experienced sudden unexpected at CDC. A subset of cases (persons up to 49 death. A viral culture and PCR test years of age with no underlying medical of a nasopharyngeal swab was also In 2007, MED-X was expanded to conditions who died of an apparent positive for influenza A. A 2-year-old include the Hennepin County Medical non-nosocomial infectious process) are had influenza A cultured from the lung Examiner’s Office and the Midwest eligible for testing performed at CDC and spleen and also had a culture and Regional Forensic Pathology Office as part a special project. For cases PCR test of the lung that were positive in Anoka, in addition to the MRMEO. not eligible for the CDC project, some for group A streptococcus. A 10-month- Additional counties covered by these testing may be available at MDH or old, a 4-year-old, and a 25 year-old two offices include Anoka, Crow Wing, CDC, at the physician’s request. male who died from myocarditis all had Hennepin, Mille Lacs, Meeker, McLeod, positive PCR tests for enterovirus from Sibley, and Wright counties. The three Sixty-four cases (39 deaths and 25 heart samples. A 44 year-old male who ME offices together cover 48% of the critical illnesses) were initially reported died with a respiratory syndrome had state population. in 2007, compared to 45 cases in 2006. positive PCR tests of lung samples The cause(s) of illness subsequently for Streptococcus pneumoniae. A MDH distributes specimen collection were determined for 13 cases and were 47 year-old male who died with a kits to the ME offices to help guide no longer considered unexplained. respiratory syndrome had IHC testing of the number and type of specimens Among the remaining 51 cases, 15 a lung sample that was positive for S. collected. These specimens are then presented with neurologic symptoms; pneumoniae. A 2 year-old who died with tested at the facility laboratory or sent 11 case-patients presented with a respiratory syndrome had adenovirus to MDH for testing. There were 15 kits respiratory symptoms; 10 presented type 2 isolated from a viral culture of a distributed in 2007. Use of these kits with cardiac symptoms; seven nasopharyngeal swab. A 3 year-old who has continued to improve the quality presented with shock/sepsis; five died with shock/sepsis syndrome had a and number of specimens sent to presented with sudden unexpected positive PCR test of blood for serogroup MDH, which has increased our ability to death (SUD); one presented with C Neisseria meningitidis. determine a cause of death. gastrointestinal (GI) symptoms; one presented with a renal syndrome; and Testing was also provided at MDH and/ There were 104 MED-X cases in 2007, one had an illness that did not fit a or CDC at the physician’s request for 18 and 24 of these were also UNEX defined syndrome. Case-patients with of the 32 cases that were not eligible for cases. Based on MRMEO data, the neurological symptoms were 1 to 76 the CDC project. Positive results were population-based rate of potential years of age; those with respiratory found for four of these cases. All four infectious disease related deaths as symptoms ranged from 2 to 54 years (a 2 year-old, a 3 year-old, a 17 year- reported to medical examiners was of age; those with the cardiac case- old female, and a 40 year-old female) 5,700 per 100,000 ME cases, which patients were 8 days to 52 years of were hospitalized with culture-negative translates to 2,700 per 100,000 total age; those with sepsis were 1 to 54 meningitis and had positive PCR tests deaths and 12 per 100,000 among years of age; the case-patients with of cerebrospinal fluid for serogroup C N. the total population. The mean age of SUD were 1 to 53 years of age; the meningitidis. the case was 58 years, and 52% were case-patient with GI symptoms was female. The majority of cases were 16 years of age; the case-patient with Medical Examiner Surveillance found through death investigation report renal symptoms was 39 years old, MED-X is a population-based surveil review (78, [75%]). MEs reported 22 and the case-patient without a defined lance program aimed at identifying all cases (21%), and four (4%) were found syndrome was 15 years of age. Nine infectious disease related deaths that through death certificate review. The patients with a cardiac syndrome, six are investigated by medical examiners most common presenting symptom was patients with sepsis, five patients with (MEs). There are three mechanisms pneumonia/upper respiratory infection, respiratory symptoms, two patients with in place for case finding. First, as part which was also the most common neurologic symptoms, and the patient of the unexplained deaths surveil pathologic finding. In addition, there with a GI syndrome died, as did the lance (UNEX), MDH reviews all death were 12 cases with myocarditis. Of the patient with a renal syndrome. Twenty- certificates for deaths due to infectious 104 cases, 35 (34%) were confirmed to five patients resided in the metropolitan causes. Second, MDH reviews all death be due to an infectious cause, 58 (56%) area, 14 case-patients resided in investigation reports at the Minnesota were possibly due to infectious cause, Greater Minnesota, and 12 case- Regional Medical Examiner Office nine (9%) were determined to not patients were out-of-state residents (MRMEO) in Hastings. This office cov hospitalized in Minnesota. continued...

DCN 36;1 January/August 2008 21 be due to infectious cause, and two the only reported in one to occur during a school year among (2%) were unable to be determined. case-patient. All five case-patients the 876,353 total school-aged Pathogens that were identified as the recovered. children (in Minnesota schools with cause of death included Streptococcus more than 99 students), representing pneumoniae, Staphylococcus aureus Varicella surveillance in Minnesota 0.08% of this population, for an and methicillin-resistant S. aureus, includes reporting of outbreaks incidence rate of 77.4 per 100,000 Group A Streptococcus, influenza A, from all schools, and reporting population. Estimated grade level- enterovirus, Haemophilus influenzae, of individual cases from selected specific annual incidence rates are and prion disease. Other pathogens sentinel schools and childcare 141.1 per 100,000 (585 of 414,616) identified as possibly related to the centers. Eighty sentinel schools were for elementary school students; cause of the death included Coxsackie selected and participated throughout 52.1 per 100,000 (67 of 128,653) virus, Group F Streptococcus, and the 2006-2007 school year and 77 for middle school students; and 8.2 adenovirus. participated in the 2007-2008 school per 100,000 (26 of 315,706) for high year. One hundred nineteen sentinel school students. Varicella and Zoster childcare centers were selected and Varicella and zoster surveillance were participated throughout 2007 In 2007, MDH received two reports implemented in Minnesota pursuant of varicella cases from one (2.1%) to their addition to the Minnesota An outbreak of varicella in a school of 47 sentinel childcare centers and Rules Governing Communicable is defined as five or more cases no reports from 72 sentinel family Diseases, effective September 13, within a 2-month period in persons childcares. Based on sentinel 2005. The reporting rules require that less than 13 years of age, or three or childcare data, an estimated 75 unusual case incidence, individual more cases within a 2-month period cases of varicella would have been critical cases, and deaths due to in persons 13 years of age and older. expected to occur during the calendar varicella and zoster be reported. The An outbreak is considered ended year among the 95,110 children reporting rules also allow for the use when no new cases occur within enrolled in Minnesota childcare of a sentinel surveillance system to 2 months after the last case is no centers, representing 0.08% of this monitor varicella and zoster incidence longer contagious. During the 2007 population, for an incidence rate until that system no longer provides 2008 school year, MDH received of 79.1 per 100,000. No cases of adequate data for epidemiological reports of outbreaks from 40 schools varicella would have been expected purposes, at which time case-based in 22 counties throughout Minnesota to occur during the calendar year surveillance will be implemented. involving 487 students and no staff. among the 142,165 children enrolled This summary represents the second By comparison, MDH received in Minnesota family childcares. full year of these surveillance efforts. reports of outbreaks from 73 schools Over time, these data will be used to in 30 counties throughout Minnesota MDH currently conducts zoster monitor trends in varicella and zoster involving 1,230 students and no staff surveillance in all schools and disease in Minnesota, and will be used during the 2006-2007 school year. selected sentinel childcare centers. to extrapolate to the statewide disease The number of cases per outbreak During the 2007-2008 school year, burden. ranged from five to 37 (median, 9) MDH received 128 reports of zoster during the 2007-2008 school year from schools in at least 43 counties No varicella-related deaths were and five to 96 (median, 13) during the throughout Minnesota, representing identified in 2007. Five cases of 2006-2007 school year. 0.01% of the total school population critical varicella illness were reported. of 919,176 students for an incidence Four had underlying medical A case of varicella is defined for rate of 13.9 per 100,000. Ages conditions and were being treated sentinel school and childcare ranged from 5 to 18 years. By with immunosuppressive drugs. The facility reporting as an illness with comparison, MDH had received other case-patient had no underlying acute onset of diffuse (generalized) 144 reports of zoster in 37 counties conditions and was not known to be maculopapulovesicular rash without throughout Minnesota during the immunosuppressed. Three of the other apparent cause. During 2006-2007 school year. Ages ranged case-patients were male. Race was the 2007-2008 school year, MDH from 5 to 18 years. As opposed to reported for four case-patients, all received 67 reports of varicella from varicella, which is mainly diagnosed of whom were white. Ethnicity was 17 (22%) sentinel schools. Four by school heath personnel and reported for two, both of whom were sentinel schools reported clusters parents, most zoster cases (93%) are not Hispanic. Two case-patients of cases that met the outbreak physician-diagnosed. had a documented history of one definition. Thirty-nine (58%) of 67 dose of varicella-containing vaccine. reported cases were included in these In 2007, MDH received one report of Two case-patients had not received four outbreaks. Cases per outbreak zoster from one (2.1%) of 47 sentinel varicella-containing vaccine; one was ranged from five to 13 (median, 10.5). childcare centers and no reports born before 1980 and the other did The 28 cases not associated with an from 72 sentinel family childcares. not specify a reason for not being outbreak represent sporadic varicella Based on sentinel childcare data, an vaccinated. The other case-patient incidence in Minnesota schools. estimated 38 cases of zoster would reported receiving varicella-containing have been expected to occur during vaccine but this was not verified. Each Based on sentinel school data, an the calendar year among the children case-patient was hospitalized for a estimated 678 sporadic cases of enrolled in Minnesota childcare mean of 5.4 days. Dehydration was varicella would have been expected centers, representing 0.04% of this

22 DCN 36;1 January/August 2008 population, for an incidence rate of associated with travel. Of these 17, (0.5 per 100,000 population) were 39.5 per 100,000. No cases of zoster 13 (76%) traveled to Mexico, Central, reported, with no deaths. In addition would have been expected to occur or South America, four of whom to the 25 cases, six individuals during the calendar year among the reported consuming raw oysters. with documented asymptomatic children enrolled in Minnesota family seroconversions were reported. Prior childcares. In 2007, there were eight outbreaks of to 2006, both symptomatic cases hepatitis A. Forty-two (45%) cases of and asymptomatic seroconvertors Vaccine supply issues have caused hepatitis A were outbreak-associated. were counted as incident cases. major delays in getting the varicella The number of cases per outbreak This change in case counting vaccine to providers, resulting ranged from two to 15. Of the eight criteria should be considered when in children unable to receive the outbreaks, three were common- examining case incidence trends. second dose of varicella vaccine. It source food-borne outbreaks, three MDH also received 1,022 reports of is unclear when the vaccine supply were community outbreaks, and two newly identified cases of chronic HBV will stabilize. Until it does, the two- occurred among contacts of hepatitis infection. dose requirement for kindergarteners A positive international adoptees. and seventh graders enrolling Post-exposure prophylaxis (immune Acute cases ranged in age from in Minnesota schools has been globulin [IG] or hepatitis A vaccine) 23 to 79 years (median, 47 years). postponed. However, a single dose is recommended to prevent hepatitis Twelve (48%) of the 25 cases were of varicella vaccine is still required for A in persons exposed and to prevent residents of the metropolitan area, students enrolling in these grades, or control outbreaks. One restaurant- including five (20%) in Hennepin and providers are encouraged to associated outbreak in Hennepin County and two (8%) in Ramsey administer the second dose as County accounted for 15 (16%) County. Fourteen (56%) cases were recommended if varicella vaccine is cases. One restaurant-associated male and 10 (40%) were adolescents available. outbreak in Murray County accounted or young adults between 13 and 39 for eight (9%) cases, three (38%) of years of age. Ten (40%) were white, Viral Hepatitis A whom were restaurant employees. In two (8%) were black, and one (4%) In 2007, 94 cases of hepatitis A response to the restaurant associated was Asian; race was unknown for 12 (1.8 per 100,000 population) were outbreak in Murray County, over (48%) cases. Two (8%) case-patients reported including one (1%) death. 2,200 patrons received IG at a mass were of Hispanic ethnicity. Although Sixty-one (65%) case-patients were clinic conducted by the Lincoln, Lyon, the majority of cases were white, residents of the metropolitan area, Murray, and Pipestone Public Health incidence rates were higher among including 47 (50%) residents of Services. One foodborne outbreak blacks (0.9 per 100,000), Hispanics Hennepin or Ramsey Counties. Forty- accounted for four (4%) cases and (0.9 per 100,000), and Asians (0.5 seven (50%) of the cases were male. was associated with consuming raw per 100,000) than among non- Case-patients ranged in age from shellfish in Mexico. Seven (7%) Hispanic whites (0.2 per 100,000). 1 to 89 years (median, 40 years). cases, including three (3%) personal Seventy-two (77%) cases were care attendants, were associated with MDH attempts to ascertain risk factor white, four (4%) were black, three an outbreak in a home in Hennepin information and possible modes of (3%) were American Indian, and one County. The source case in this transmission by collecting information (1%) was Asian; race was unknown outbreak was travel-associated. Two reported by the case-patient to his/ for 14 (15%) cases. The three cases (2%) cases were associated with her health care provider, and by in American Indians were the first an outbreak among group home interviewing the case-patient directly, reported in American Indians in residents. An outbreak in a daycare if possible. A case-patient may report Minnesota since 2002. The incidence included two (2%) cases. One more than one risk factor, and may rate of hepatitis A in American outbreak associated with international report different information to his/her Indians declined steadily from 10.4 adoptee accounted for two (2%) health care provider than to MDH. per 100,000 in 1999 to 6.0, 3.7, and cases including the source of Five (20%) case-patients reported 2.5 per 100,000, in 2000, 2001, and infection in the group home outbreak. illicit drug use. Of these, two (40%) 2002 respectively, demonstrating the The other international adoptee case-patients reported injection success of targeted immunization associated outbreak accounted for drug use. Ten (40%) case-patients efforts initiated in 1999. Hispanic two (2%) cases. reported having sexual contact ethnicity was reported for nine cases with one or more partners within 6 (4.4 per 100,000). Hepatitis A vaccine is now months prior to onset of symptoms. recommended for post-exposure Of these, three (30%) case-patients A risk factor was identified for 74 prophylaxis of certain groups. reported sexual contact with two or (79%) of the 94 cases, 20 (27%) Hepatitis A vaccine used for post- more partners, three (30%) case- of whom had known exposure to a exposure prophylaxis gives longer patients were males who reported confirmed hepatitis A case. These protection than IG, is often more having at least one male sexual persons became infected following readily available, and is easier to partner, and one (10%) case-patient exposure to a close contact, administer. reported having sexual contact with representing missed opportunities a known carrier of hepatitis B surface to administer immune globulin. Of Viral Hepatitis B antigen (HBsAg). Two (8%) of the the remaining 54 (73%) cases with a In 2007, 25 cases of symptomatic risk factor identified, 17 (31%) were acute hepatitis B virus (HBV) infection continued...

DCN 36;1 January/August 2008 23 25 total case-patients reported having change in case counting criteria should consider each patient’s risk for HCV household contact with a known carrier be considered when examining case infection to determine the need for of hepatitis B (HBsAg). No risk factor incidence trends. testing. Patients for whom testing is was identified for eight (32%) cases. indicated include: persons with past or Sixteen (57%) of the 28 case-patients present injection drug use; recipients In addition to the 25 hepatitis B cases, resided in Greater Minnesota. The of transfusions or organ transplants one perinatal infection was identified median age was 40 years (range, 19 to before July 1992; recipients of clotting in an infant who tested positive 61 years). Fifteen (54%) case-patients factor concentrates produced before for HBsAg during post-vaccination were female. Seventeen (61%) were 1987; persons on chronic hemodialysis; screening performed between 9 and white, three (11%) were American persons with persistently abnormal 15 months of age. The perinatal case- Indian, and three (11%) were black; alanine aminotransferase levels; patient was born in 2006. The perinatal race was unknown for five (18%) cases. healthcare, emergency medical, and infection occurred in an infant identified public safety workers after needle through a public health program MDH attempts to ascertain risk factor sticks, sharps, or mucosal exposures that works to ensure appropriate information for the 6 months prior to HCV-positive blood; and children prophylactic treatment of infants born to onset of symptoms by collecting born to HCV-positive women. Infants to HBV-infected mothers. The infant information reported by the case- born to HCV-infected mothers should was born in the United States and had patient to his/her health care provider be tested at 12 to 18 months of age, as received hepatitis B immune globulin and by interviewing the case-patient, earlier testing tends to reflect maternal and three doses of hepatitis B vaccine if possible. A case-patient may report antibody status. Persons who test in accordance with the recommended more than one risk factor, and may positive for HCV should be screened for schedule (i.e., was a treatment failure). report different information to his/her susceptibility to hepatitis A and B virus Despite this treatment failure, the health care provider than to MDH. infections and immunized appropriately. success of the public health prevention Among the 28 case-patients, 11 (39%) program is demonstrated by the fact used injection drugs; four (14%) had that an additional 325 infants born to sexual contact with a known HCV- HBV-infected women during 2006 had infected partner; two (7%) had multiple post-serologic testing demonstrating sexual partners; two (7%) had one no infection. sexual partner; one (4%) had sexual contact with an injection drug user; Viral Hepatitis C and one (4%) had an occupational In 2007, 28 cases of symptomatic exposure. No risk factor was identified acute hepatitis C virus (HCV) for seven (25%) cases. infection were reported. In addition to the 28 cases, nine individuals with MDH received more than 2,000 reports asymptomatic, laboratory-confirmed of newly identified anti-HCV positive acute HCV infection were reported. persons in 2007, the vast majority Prior to 2006, both symptomatic of whom are chronically infected. and asymptomatic acute infections Because most cases are asymptomatic, were counted as incident cases. This medical providers are encouraged to

Emerging Infections Conference Program Program Includes: • Global Climate Change and the • The Future: Predictions for Case Presentations: Panel to Impact on Emerging Infections Emerging Infections - Michael Discuss Diagnoses - Moderator: - Jonathan D. Mayer, PhD, T. Osterholm, PhD, University of Phillip K. Peterson, MD, University of Washington Minnesota University of Minnesota

• Current Status of Vertical • Vaccine Update - Priya Panel: Transmission of HIV - Laura Sampathkumar, MD - Mayo - Richard Anderson, MD, Hoyt, MD, Children’s Hospitals Clinic Children’s Hospitals, and Clinics • Hot Topics from the Minnesota - Mark R. Schleiss, MD, U of MN, • Methicillin-reisistant Department of Health - Staphylococcus aureus (MRSA)- Richard Danila, PhD, Minnesota - James Johnson, MD, VA A View from the Centers for Department of Health Medical Center-Minneapolis, Disease Control and Prevention - Scott K. Fridkin, MD, CDC • Dermatologic Manifestations of - Douglas R. Osmon, MD, Mayo Epidemic and Endemic Diseases Clinic, • Update - - Lisa A. Drage, MD, Mayo Clinic Abinash Virk MD, Mayo Clinic - David Williams, MD, Hennepin County Medical Center

24 DCN 36;1 January/August 2008 14th Annual Emerging Infections in Clinical Practice and Public Health Conference November 14, 2008 (See Program, p. 24) 14th Annual Emerging Infections in Clinical Practice and Public Health Conference, November 14, 2008 Radisson University, Minneapolis

REGISTRATION FORM PLEASE PRINT OR TYPE: MAIL TO: Emerging Infections Conference Name Office of Continuing Medical Education University of Minnesota Affiliation University Park Plaza, Suite 601 2829 University Avenue SE Department Minneapolis, MN 55414 or Fax to: 612-626-7766 Address Phone: 612-626-7600 or 1-800-776-8636 or Online: www.cmecourses.umn.edu Mail Stop

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continued...

DCN 36;1 January/August 2008 25 Antimicrobial Susceptibilities of Selected Pathogens, 2007

On the following pages is the Anti Please note the data on inducible Limited laminated copies can be microbial Susceptibilities of Selected clindamycin resistance for Group A and ordered from: Antibiogram, Minnesota Pathogens, 2007, a compilation of B Streptococcus and community associ Department of Health, Acute Disease antimicrobial susceptibilities of selected ated methicillin-resistant Staphylococ Investigation and Control Section, PO pathogens submitted to MDH during cus aureus. Box 64975, St. Paul, MN 55164 or by 2007 in accordance with Minnesota calling (651) 201-5414. Rule 4605.7040. Because a select The MDH Antibiogram is available on group of isolates is submitted to MDH, the MDH Web site at: www.health.state. it is important to read the notes entitled mn.us/divs/idepc/dtopics/antibioticresis- “Sampling Methodology” and “Trends, tance/antibiogram.html. Comments, and Other Pathogens.”

26 DCN 36;1 January/August 2008 DCN 36;1 January/August 2008 27 Influenza season is coming - Increase immunization coverage of your patients and among health care providers.

Sanne Magnan, M.D. Ph.D., Commissioner of Health To access the Disease Control Newsletter Division of Infectious Disease Epidemiology, Prevention and Control go to this link; www.health.state. mn.us/divs/idepc/newsletters/ dcn/index.html Ruth Lynfield, M.D...... State Epidemiologist and click on “Subscribe.” Richard N. Danila, Ph.D., M.P.H...... Editor/Assistant State Epidemiologist Barbara Kizzee...... Production

The Disease Control Newsletter is available on the MDH Acute Disease Investigation and Control (ADIC) Section web site (http://www.health.state.mn.us/divs/idepc/newsletters/dcn/index.html).

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