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MINNESOTA DEPARTMENT OF HEALTH D ISEASE C ONTROL N EWSLETTER

Volume 33, Number 4 (pages 37-56) July/August 2005 Annual Summary of Communicable Diseases Reported to the Minnesota Department of Health, 2004 Introduction private and protected under the Incidence rates in this report were Assessment is a core public health Minnesota Government Data Practices calculated using disease-specific function. Surveillance for communi­ Act (Section 13.38). Provisions of the numerator data collected by MDH and a cable diseases is one type of assess­ Health Insurance Portability and standardized set of denominator data ment. Epidemiologic surveillance is the Accountability Act (HIPAA) allow for derived from U.S. Census data. systematic collection, analysis, and routine communicable disease report­ Disease incidence may be categorized dissemination of health data for the ing without patient authorization. as occurring within the seven-county planning, implementation, and evalua­ Twin Cities metropolitan area or outside tion of health programs. The Minnesota Since April 1995, MDH has participated of it (Greater Minnesota). Department of Health (MDH) collects as an Emerging Program information on certain communicable (EIP) site funded by the Centers for diseases for the purposes of determin­ Disease Control and Prevention (CDC) Human anaplasmosis (HA) is the new ing disease impact, assessing trends in and, through this program, has imple­ nomenclature for the disease formerly disease occurrence, characterizing mented active hospital- and laboratory- known as human granulocytic affected populations, prioritizing control based surveillance for several condi­ . HA (caused by the efforts, and evaluating prevention tions, including selected invasive rickettsia Anaplasma phagocytophilum) strategies. Prompt reporting allows bacterial diseases and food-borne is transmitted to humans by Ixodes outbreaks to be recognized in a timely diseases. scapularis (deer tick or black-legged fashion when control measures are tick), the same tick that transmits Lyme most likely to be effective in preventing Isolates for pathogens associated with disease. additional cases. certain diseases are required to be submitted to MDH (Table 1). The MDH Similar to , HA case In Minnesota, communicable disease Public Health Laboratory performs numbers also increased during 2004, reporting is centralized, whereby extensive microbiologic evaluation of from 78 cases in 2003 (1.6 per reporting sources submit standardized isolates, such as pulsed-field gel 100,000 population) to 139 cases (2.8 report forms to MDH. Cases of disease electrophoresis (PFGE), to determine per 100,000). The record high oc­ are reported pursuant to Minnesota whether isolates (e.g., enteric patho­ curred in 2002, with 149 cases (3.0 per Rules Governing Communicable gens such as Salmonella and Escheri 100,000 population). Eighty-one (58%) Diseases (MN Rules 4605.7000 - 4605. chia coli O157:H7 and invasive case-patients reported in 2004 were 7800) which were recently updated pathogens such as Neisseria male. The median age of case-patients (See “Revisions to the Communicable meningitidis) are related, and poten­ was 59 years (range, 1 to 89 years). Disease Reporting Rule” in the May/ tially associated with a common source. The peak in onsets of illness occurred June 2005 issue [vol 33. no. 3] of the Testing of submitted isolates also in June and July (77 cases [56%] of Disease Control Newsletter). The allows detection and monitoring of 137 cases with known onset). Co- diseases listed in Table 1 (page 38) antimicrobial resistance, which contin­ infections with Lyme disease and HA must be reported to MDH. As stated in ues to be an important problem. continued... these rules, physicians, health care facilities, laboratories, and veterinarians Table 2 summarizes cases of selected Inside: are required to report these diseases. communicable diseases reported Mark the Date: 11th Annual Reporting sources may designate an during 2004 by district of the patient’s Emerging Infections in Clinical individual within an institution to residence. Pertinent observations for Practice and Emerging Health perform routine reporting duties (e.g., some of these diseases are discussed Threats Conference, an control practitioner for a below. Minneapolis, November 10- hospital). Data maintained by MDH are 11(half-day), 2005...... 56 Table 1. Diseases Reportable to the Minnesota Department of Health

Report Immediately by Telephone

Anthrax (Bacillus anthracis) a () a Botulism ( botulinum) Rabies (Brucella spp.) a (animal and human cases and suspected cases) () a Rubella and congenital rubella syndrome a Diphtheria ( diphtheriae) a Severe Acute Respiratory Syndrome (SARS) a Hemolytic uremic syndrome a Smallpox (variola) a Measles (rubeola) a () a () Unusual or increased case incidence of any (all invasive disease) a, b suspect infectious illness a Orthopox a () a Poliomyelitis a

Report Within One Working Day

Amebiasis (Entamoeba histolytica/dispar) (Listeria monocytogenes) a Anaplasmosis (Anaplasma phagocytophilum) Lyme disease (Borrelia burgdorferi) Arboviral disease (including but not limited to, Malaria (Plasmodium spp.) LaCrosse encephalitis, eastern equine encephalitis, Meningitis (caused by viral agents) western equine encephalitis, St. Louis encephalitis, Mumps and West Nile virus) Neonatal sepsis, less than 7 days after birth ( isolated from a Babesiosis (Babesia spp.) sterile site, excluding coagulase-negative Staphylococcus) a, b Blastomycosis (Blastomyces dermatitidis) Pertussis () a (Campylobacter spp.) a Psittacosis (Chlamydophila psittaci) Cat scratch disease (infection caused by spp.) Retrovirus infection Chancroid ( ducreyi) c Reye syndrome trachomatis infection c Rheumatic fever (cases meeting the Jones Criteria only) Coccidioidomycosis Rocky Mountain (, R. canada) Cryptosporidiosis (Cryptosporidium spp.) a , including typhoid (Salmonella spp.) a Cyclosporiasis (Cyclospora spp.) a (Shigella spp.) a Dengue virus infection Staphylococcus aureus (vancomycin-intermediate S. aureus [VISA], Diphyllobothrium latum infection vancomycin-resistant S. aureus [VRSA], and death or critical illness Ehrlichiosis (Ehrlichia spp.) due to community-associated S. aureus in a previously healthy Encephalitis (caused by viral agents) individual) a Enteric E. coli infection Streptococcal disease (all invasive disease caused by Groups A and B (E. coli O157:H7, other enterohemorrhagic [Shiga toxin-producing] streptococci and S. pneumoniae) a, b E. coli, enteropathogenic E. coli, enteroinvasive E. coli, () c 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 Trichinosis (Trichinella spiralis) (all invasive disease) a Tuberculosis (Mycobacterium tuberculosis complex) Hantavirus infection (Pulmonary or extrapulmonary sites of disease, including laboratory Hepatitis (all primary viral types including A, B, C, D, and E) confirmed or clinically diagnosed disease, are reportable. Latent Histoplasmosis (Histoplasma capsulatum) tuberculosis infection is not reportable.) a Human immunodeficiency virus (HIV) infection, including (Rickettsia spp.) Acquired Immunodeficiency Syndrome (AIDS) a, d Unexplained deaths and unexplained critical illness Influenza (possibly due to infectious cause) a (unusual case incidence, critical illness, or laboratory Varicella-zoster disease (1. Primary [chickenpox]: unusual case confirmed cases) a, e incidence, critical illness, or laboratory-confirmed cases. 2. Recurrent Kawasaki disease [shingles]: unusual case incidence, or critical illness.) a Kingella spp. (invasive only) a Vibrio spp. a Legionellosis (Legionella spp.) a Yellow fever (Hansen’s disease) (Mycobacterium leprae) , enteric (Yersinia spp.) a (Leptospira interrogans) Sentinel Surveillance (at sites designated by the Commissioner of Health)

Methicillin-resistant Staphylococcus aureus

a Submission of clinical materials required. If a rapid, non-culture c Report on separate Sexually Transmitted Disease Report Card. assay is used for diagnosis, we request that positives be cultured, and isolates submitted. If this is not possible, send specimens, d Report on separate HIV Report Card. enrichment broth, or other appropriate material. Call the MDH Public Health Laboratory at 612-676-5396 for instructions. e For criteria for reporting laboratory confirmed cases of influenza, see www.health.state.mn.us/divs/idepc/dtopics/reportable/index.html. b Isolates are considered to be from invasive disease if they are isolated from a normally sterile site, e.g. blood, CSF, joint fluid, etc. continued...

38 DCN 33;4 July/August 2005 Table 2. Cases of Selected Communicable Diseases Reported to the Minnesota Department of Health, by District of Residence, 2004 District* (population per U.S. Census 2000) 2,642,056) 322,073) Disease Metropolitan ( Northwestern (152,001) Northeastern ( Central (610,139) Central West (222,691) South Central (280,332) Southeastern (460,102) Southwestern (230,085) Unknown Residence Total (4,919,479) Anaplasmosis 33 12 16 68 2 1 7 0 0 139 Campylobacteriosis 399 16 37 109 53 66 146 70 0 896 Cryptosporidiosis 21 1 18 30 11 16 29 21 0 147 Encephalitis - viral LaCrosse 0 0 0 0 0 1 1 0 0 2 West Nile 6 1 0 5 4 8 0 10 0 34 O157 infection 45 2 4 13 2 12 18 14 0 110 Hemolytic Uremic Syndrome 4 0 0 2 1 0 0 2 0 9 Giardiasis 1,045 10 45 123 21 36 88 30 0 1,398 Haemophilus influenzae invasive disease 23 4 4 6 1 1 133 0 55 HIV infection other than AIDS 164 0 2 6 0 6 7 3 4 192 AIDS (cases diagnosed in 2004) 164 1 4 14 2 3 3 4 1 196 Legionnaires’ disease 10 0 4 0 0 0 1 1 0 16 Listeriosis 2 0 0 0 0 1 1 1 0 5 Lyme disease 442 43 98 312 29 19 76 4 0 1,023 Mumps 1 0 0 0 0 1 2 0 0 4 Neisseria meningitidis invasive disease 17 1 1 2 1 0 1 1 0 24 Pertussis 859 41 58 149 53 27 130 51 0 1,368 Salmonellosis 344 9 2779 26 28 66 64 0 643 Sexually transmitted diseases* 10,323 276 734 971 173 461 934 325 506 14,703 - genital infections 7,805 248 613 866 161 395 807 299 407 11,601 Gonorrhea 2,394 28 121 102 11 64 118 23 96 2,957 Syphilis, total 124 0 0 3 1 2 9 3 3 145 primary/secondary 26 0 0 0 0 0 1 0 0 27 early latent** 19 0 0 0 0 0 1 0 1 21 late latent*** 74 0 0 3 1 2 7 3 2 92 congenital 1 0 0 0 0 0 0 0 0 1 other 4 0 0 0 0 0 0 0 0 4 Chancroid 0 0 0 0 0 0 0 0 0 0 Shigellosis 47 0 4 6 2 0 4 5 0 68 pneumoniae invasive disease 286 14 48 72 20 36 49 15 0 540 Streptococcal invasive disease - Group A 84 6 5 16 3 7 16 9 0 146 Streptococcal invasive disease - Group B 189 14 21 38 15 19 34 11 0 341 Tuberculosis 157 2 3 3 3 2 227 0 199 Viral hepatitis, type A 45 2 0 0 0 1 110 0 59 Viral hepatitis, type B (acute infections only, not perinatal) 36 0 4 9 3 7 9 1 0 69 Viral hepatitis, type C (acute infections only) 9 3 8 1 1 0 1 0 0 23 Yersiniosis 13 0 0 3 2 1 3 0 0 22

*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 neurosyphillis 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

can occur from the same tick bite; in the May/June 2005 issue (vol. 33, of Columbia; nationwide, 2,535 human during 2004, two HA case-patients no. 3) of the Disease Control Newslet- cases of WNV disease were reported, (1.4%) also had objective evidence of ter. including 98 fatalities. The largest Lyme disease. The risk for HA is WNV outbreaks during 2004 occurred highest in many of the same Minne- Arboviral Encephalitis in Arizona and California. sota counties where the risk of Lyme LaCrosse encephalitis and Western disease is greatest, including Aitkin, equine encephalitis historically have In Minnesota, 34 cases of WNV Cass, Crow Wing, Hubbard, and Pine been the primary arboviral encephaliti- disease were reported in 2004 (down Counties. des found in Minnesota. During July from 148 cases in 2003, and 48 in 2002, West Nile virus (WNV) was 2002). Twenty-one (62%) case-patients For additional information, see identified in Minnesota for the first had West Nile (WN) fever; five (15%) “Dramatic Increase in Lyme Disease time. In 2004, WNV cases were had meningitis, and eight (24%) had and Other Tick-borne Diseases, 2004” reported from 47 states and the District continued...

DCN 33;4 July/August 2005 39 encephalitis. The median age was 53 disease, which primarily affects years). Forty-four percent of cases years (range, 3 to 83 years), but WN children, is transmitted through the bite were between 20 and 49 years of age, encephalitis patients tended to be of infected Ochlerotatus triseriatus and 16% were 5 years of age or older (median, 74 years; range, 51 to (Eastern Tree Hole) mosquitoes. younger. Fifty-eight percent of cases 83 years). Two WN encephalitis Persons are exposed to infected were male. Fifteen percent of case- patients (51 and 66 years old) with pre­ mosquitoes in wooded or shaded patients were hospitalized; the median existing health problems died from areas inhabited by this mosquito length of hospitalization was 2 days. their illness. Twenty-three cases species, especially in areas where Fifty-one percent of infections occurred (68%) occurred among residents of water-holding containers (e.g., waste during June through September. Of the western and southcentral Minnesota. tires, buckets, or cans) that provide 804 (90%) case-patients for whom The earliest case-patient had onset of mosquito breeding habitats are data were available, 145 (18%) symptoms on July 12; the latest on abundant. From 1985 through 2004, reported travel outside of the United October 8. Similar to previous years, 119 cases were reported from 20 States during the week prior to illness the peak in illness onset was from southeastern Minnesota counties, with onset. The most common travel August 1, 2004 through September 19, a median of six cases (range, 2 to 13 destinations were Mexico (n=40), 2004 (24 of 34 [71%] cases). cases) reported annually. Disease Central or South America (n=41), onsets have been reported from June western Europe (n=32), and Asia The field ecology of WNV is complex. through September; most onsets have (n=25). There were no outbreaks of The virus is maintained in a mosquito- occurred from mid-July through mid- campylobacteriosis identified in 2004. to-bird transmission cycle. Several September. mosquito and bird species may be A primary feature of public health involved in this cycle, and regional Campylobacteriosis importance among Campylobacter variation in vector and reservoir Campylobacter continues to be the cases was the continued presence of species is likely. In 2004, cooler than most commonly reported bacterial Campylobacter isolates resistant to normal weather in August kept mos­ enteric pathogen in Minnesota (Figure fluoroquinolone antibiotics (e.g., quito numbers relatively low and likely 1). There were 896 cases of culture- ), which are commonly contributed to the reduced incidence. confirmed Campylobacter infection used to treat campylobacteriosis. In Interpreting the effect of weather on reported in 2004 (18.2 per 100,000 2004, the overall proportion of WNV transmission demonstrates the population). This is similar to the 937 quinolone-resistant Campylobacter difficulty of predicting how many cases reported in 2003 and to the isolates was 15%. However, 67% of C. people will become infected. WNV median annual number of cases jejuni isolates from patients with a appears to be established throughout reported from 1999 to 2003 (median, history of foreign travel (regardless of Minnesota; it will probably be present 941 cases; range, 786 to 1,079). Fifty- destination) during the week before in the state to some extent every year. five percent of cases occurred in illness onset were resistant to The disease risk to humans, however, people who resided outside the Twin fluoroquinolones. Domestically will likely continue to be higher in Cities metropolitan area. Of the 805 acquired quinolone-resistant C. jejuni central and western Minnesota where Campylobacter isolates confirmed and infections also have increased in the primary vector, Culex tarsalis, is identified to species by MDH, 92% recent years. This increase likely is most abundant. were C. jejuni and 7% were C. coli. due largely to the use of fluoroquinolones in poultry (the During 2004, two cases of LaCrosse The median age of case-patients was primary source of Campylobacter for encephalitis were reported. The 33 years (range, 3 months to 93 humans) in the United States, which began late in 1995. In 2004, 5% of C. Figure 1. Reported Cases of Campylobacter, Salmonella, Shigella, and jejuni isolates from patients who Escherichia coli O157:H7 Infection, Minnesota, 1995-2004 acquired the infection domestically were resistant to fluoroquinolones.

Campyl obacter Shigella Cryptosporidiosis Salmonella E.coli O157 During 2004, 147 confirmed cases of cryptosporidiosis (3.0 per 100,000 1200 population) were reported. This is 1000 similar to the 155 cases reported in 2003 but represents a 21% decrease 800 from the median number of cases

600 reported annually from 1996 to 2003 (median, 185 cases; range, 81 to 242). 400 The median age of case-patients in

Number of Cases 2004 was 24 years (range, 6 months to 200 87 years). Children 10 years of age or 0 younger accounted for 30% of cases. 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Forty-five percent of cases occurred Year of Di agnos is during July through October. The incidence of cryptosporidiosis in the Southwestern, Southeastern, and continued...

40 DCN 33;4 July/August 2005 South Central districts (9.1, 6.3, and O157:H7 infections occurred as a over 50 years of age were hospitalized. 5.7 cases per 100,000 population, result of this outbreak. There were no outbreaks of giardiasis respectively) was significantly higher in Minnesota in 2004. than the statewide incidence. Only 21 There were three daycare-associated (14%) reported cases occurred among outbreaks of E. coli O157:H7 in 2004, MDH began systematically interviewing residents of the Twin Cities metropoli­ resulting in a total of 14 laboratory- cases of giardiasis in January 2002 to tan area (0.8 per 100,000 population). confirmed cases (four to six cases per better characterize the illness and Thirty-six (24%) case-patients required daycare). The route of transmission for evaluate potential risk factors for hospitalization, for a median of 3 days all three outbreaks was likely person- infection. In 2004, 67% of the non­ (range, 1 to 34 days). Two case- to-person. There were no associated immigrant cases were interviewed. The patients were known to be HIV- cases of hemolytic uremic syndrome symptoms most commonly reported by infected. No outbreaks of cryptospo­ (HUS). case-patients included diarrhea (94%), ridiosis were identified in 2004. gas or bloating (74%), abdominal pain In 2004, nine HUS cases were (72%), weight loss (66%) and nausea Escherichia coli O157:H7 Infection reported. There were no fatal cases. (61%); less commonly reported and Hemolytic Uremic Syndrome From 1997 to 2004, the median annual symptoms included fatigue (41%), (HUS) number of reported HUS cases was 14 vomiting (37%), and fever (28%). The During 2004, 110 culture-confirmed (range, nine to 25), and the overall median duration of diarrhea was 17 cases of Escherichia coli O157:H7 case fatality rate was 9%. In 2004, the days (range, 1 to 660 days). infection (2.2 per 100,000 population) median age of HUS case-patients was were reported. This represents a 17% 7 years (range, 1 to 63 years). All Case-patients were interviewed about decrease from the 133 cases reported cases occurred in either children (eight potential exposures during the 14 days in 2003 and a 41% decrease from the cases) or the elderly (one case). All prior to their illness onset. Thirty-seven median number of cases reported nine case-patients were hospitalized, percent of interviewed case-patients annually from 1997 to 2003 (median, with a median hospital stay of 18 days reported traveling prior to their onset. 187 cases; range, 133 to 219). Forty- (range, 1 to 82 days). All but one of the Among travelers, 30% reported travel five (41%) cases occurred in residents HUS cases reported in 2004 were outside the United States. Eleven of the Twin Cities metropolitan area. post-diarrheal. E. coli O157:H7 was percent of case-patients reported The remaining 65 cases occurred cultured from the stool of five case- camping or hiking prior to onset, and throughout Greater Minnesota. Eighty- patients. Non-O157 Shiga toxin- 29% reported swimming or entering four (76%) cases occurred during May producing E. coli was isolated from two water. Forty-one percent of adult case- through October. The median age of case-patients; the isolate from one patients reported having children in case-patients was 17.5 years (range, 4 was identified as E. coli O145:H28, the their households; 48% of those case- months to 80 years). Thirty-nine (35%) other serotype was not identified for patients had children in diapers. case-patients were hospitalized; the the other case-isolate. E. coli O157:H7 Twenty-eight percent of adults reported median duration of hospitalization was serology was positive in one HUS changing a diaper prior to onset. 3 days (range, 1 to 82 days). patient with a negative stool culture. Among pediatric cases, 30% of There were no outbreak-associated interviewed parents reported that their Five E. coli O157:H7 outbreaks were HUS cases in 2004. child had contact with a childcare identified during 2004. Of these, two setting prior to and/or during illness. outbreaks were foodborne. The first Giardiasis foodborne outbreak was associated During 2004, 1,398 cases of Giardia Haemophilus influenzae Invasive with consumption of frozen ground infection (28.0 per 100,000 population) Disease sirloin patties purchased from a were reported. This represents a 64% Fifty-five cases of invasive membership grocery warehouse club; increase from the 851 cases reported Haemophilus influenzae disease (1.1 this outbreak resulted in four confirmed in 2003 and is greater than the median per 100,000 population) were reported E. coli O157:H7 cases in Minnesota number of cases reported annually in 2004. Case-patients ranged in age and one confirmed case in Wisconsin. from 1996 through 2003 (median, from newborn to 96 years (median, 65 The second foodborne outbreak was 1,066 cases; range, 851 to 1,556). Of years). Twenty-five (45%) case- associated with consumption of custom the total number of Giardia cases for patients had , 16 (29%) had slaughter ground beef used at a church 2004, 811 (58%) represented positive bacteremia without another focus of spaghetti dinner served during a tests during routine screenings of infection, eight (15%) had meningitis, charity bicycle tour in Minnesota. recent immigrants and refugees. and 6 (11%) had other conditions. Nine Approximately 980 people participated (16%) deaths were reported among in this event. Of 244 participants The median age for all case-patients these case-patients. interviewed, 19 cases (14 from reported in 2004 was 10 years (range, Minnesota) met the clinical case 5 months to 89 years). The median Of 49 H. influenzae isolates for which definition and seven had culture- age among non-immigrant cases was typing was performed at MDH, 10 confirmed E. coli O157:H7 infections. 33 years (range, 5 months to 89 (20%) were type f, five (10%) type e, Of the 50 bicycle tour participants years). As in previous years, cases two (4%) type b, two (4%) type a, one interviewed who reported eating the were clustered among children less (2%) type c, and 29 (59%) were spaghetti dinner, 14 (28%) met the than 5 years of age (20%); only 19% of untypeable. Isolates from six cases case definition. By extrapolation, an cases were over 50 years of age. were not available for typing. estimated 70 (28% of 250 persons Overall, 6% of case-patients were served the spaghetti dinner) E. coli hospitalized; 16% of case-patients continued...

DCN 33;4 July/August 2005 41 Two cases of type b (Hib) disease of new AIDS diagnoses, and deaths infections in this population has occurred in 2004, compared to five among AIDS case-patients, declined decreased since 1991. In contrast to cases in 2003, and one case in 2002. sharply in Minnesota, primarily due to declining numbers of new HIV infec­ The Hib cases reported in 2004 new antiretroviral therapies, which tions among white males, the decline occurred in a 5-month-old and an adult delay the progression from HIV among U.S.-born black males has older than 40. The 5-month-old had not infection to AIDS and improve survival. been more gradual, falling from a peak been vaccinated, and the other In 2004, 196 new AIDS cases and 58 of 81 new infections in 1992 to 40 new individual had underlying medical deaths among AIDS patients were infections in 2004. The number of HIV conditions. The adult had pneumonia reported (Figure 2). infections diagnosed among Hispanic and the infant had meningitis. Both and African-born males has increased patients survived. The annual number of newly diag­ annually, with 24 new infections, nosed HIV (non-AIDS) cases reported among each group, diagnosed in 2004. The nine deaths occurred in patients in Minnesota has remained fairly ranging in age from 44 to 87 years. Six constant since the mid-1990s, with 192 Females account for an increasing case-patients presented with pneumo­ reported in 2004. This trend, coupled percentage of new HIV infections, from nia, two with bacteremia without with improved survival, has led to an 10% of new infections in 1990 to 29% another focus of infection, and one increasing number of persons in in 2004. Trends in HIV infections with peritonitis. Eight case-patients had Minnesota living with HIV or AIDS. diagnosed annually among females H. influenzae isolated from blood and Approximately 5,000 persons with HIV/ also differ by race/ethnicity. Early in the one from peritoneal fluid. Six had AIDS were residing in Minnesota at the epidemic, whites accounted for the significant underlying medical condi­ end of 2004. majority of newly diagnosed infections tions. Three of the isolates from the in women. Since 1991, the number of nine deceased case-patients were type Historically, and in 2004, nearly 90% new infections among women of color c; five were untypeable isolates and (272/307) of new HIV infections (both has exceeded that of white women. one isolate was not available for HIV [non-AIDS] and AIDS at first The annual number of new HIV typing. diagnosis) reported in Minnesota occur infections diagnosed among U.S.-born in the Twin Cities metropolitan area. black females has remained near 20 HIV Infection and AIDS However, HIV or AIDS cases have cases the past 4 years. During that Surveillance for AIDS has been been diagnosed in residents of more same time the number of new infec­ conducted in Minnesota since 1982. In than 80% of counties statewide. HIV tions among African-born females 1985, when the U.S. Food and Drug infection is most common in areas with increased 25% to 35 cases in 2004, Administration (FDA) approved the first higher population densities and continuing a dramatic increase from diagnostic test for HIV, Minnesota greater poverty. just three cases in 1996. The annual became the first state to make HIV number of new infections diagnosed infection a reportable condition; 39 The majority of new HIV infections in among Hispanic, American Indian, and states now require confidential report­ Minnesota occur among males. Trends Asian females is small, with 10 or ing of HIV infection. in the annual number of new HIV fewer cases annually in each group. infections diagnosed among males Compared to other states nationwide, differ by race/ethnicity. New infections Despite relatively small numbers of the incidence of HIV/AIDS in Minnesota occurred primarily among white males cases, persons of color are dispropor­ is moderately low. In 2003, state- in the 1980s and early 1990s. Al­ tionately affected by HIV/AIDS in specific AIDS incidence rates per though whites still comprise the largest Minnesota. In 2004, non-white men 100,000 population ranged from 0.5 in proportion of new HIV infections comprised approximately 12% of the North Dakota to 34.8 in New York, with among males, the number of new continued... 3.5 cases per 100,000 population reported in Minnesota. Similar compari­ Figure 2. HIV (non-AIDS) and AIDS Cases by Year of Diagnosis, and AIDS sons for HIV (non-AIDS) incidence Deaths by Year of Death, Minnesota, 1990-2004 rates are not possible, because some states only began HIV (non-AIDS) HIV (non-AIDS) AIDS AIDS Deaths* reporting recently. 400

As of December 31, 2004, a cumula­ 300 tive total of 7,547 cases of HIV infec­ tion have been reported to MDH, including 4,334 AIDS cases and 3,213 200 HIV (non-AIDS) cases. Of these HIV/ AIDS case-patients, 2,697 (36%) are known to have died. 100

The annual number of AIDS cases Cases/Deaths of Number 0 reported in Minnesota increased steadily from the beginning of the 1990 1992 1994 1996 1998 2000 2002 epidemic through the early 1990s, Year of Diagnosis/Death reaching a peak of 370 cases in 1992. * Deaths among AI DS cases, regardl ess o f cause Beginning in 1996, the annual number

42 DCN 33;4 July/August 2005 male population in Minnesota and 43% for women without HIV risk information. and laboratories, as well as outbreak of new HIV infections among men. MMWR 2001; 50[RR-6]:29-40). reporting from schools and long-term Similarly, persons of color comprised care facilities. The current system for approximately 11% of the female Historically, race/ethnicity data for HIV/ reporting outbreaks has been in place population and 77% of new HIV AIDS in Minnesota have grouped U.S.- since the 1995-96 influenza season, infections among women. It bears born blacks and African-born persons and a Sentinel Provider Influenza noting that race is not considered a together as “black.” In 2001, MDH Network was initiated in 1998-99 to biological cause of disparities in the began analyzing these groups sepa­ conduct active surveillance. Twenty- occurrence of HIV, but instead race is rately, and a marked trend of increas­ eight sentinel sites participated during a marker for other risk factors, includ­ ing numbers of new HIV infections the 2004-5 season. While the program ing lower socioeconomic status and among African-born persons was has surpassed its goal of 20 sentinel education. observed. In 2004, there were 59 new sites (i.e., one site per 250,000 HIV infections reported among Afri­ population), MDH plans to expand the Since the beginning of the HIV cans. While African-born persons network to ensure sites represent all epidemic, male-to-male sex has been comprise less than 1% of the state’s areas of the state. Clinics are particu­ the predominant mode of exposure to population, they accounted for nearly larly needed in northern and southern HIV reported in Minnesota, although 20% of all HIV infections diagnosed in areas of the state where coverage is the number and proportion of new HIV Minnesota in 2004. Until recently, sparse. infections attributed to men who have culturally specific HIV prevention sex with men (MSM) have declined messages have not been directed to In response to increasing influenza- since 1991. In 1991, 69% (324/470) of African communities in Minnesota. related encephalitis cases in children new HIV infections were attributed to Taboos and other cultural barriers in Japan and reports of severe MSM (or MSM who also inject drugs); make it challenging to deliver such influenza in pregnant women in the by 2004, this percentage had de­ messages and to connect HIV-infected United States, enhanced influenza creased to 44% (134/307). However, individuals with prevention and surveillance was implemented during current attitudes, beliefs, and unsafe treatment services. Collaborations the 2003-4 influenza season and sexual practices documented in between MDH, the Minnesota Depart­ continued through the 2004-5 season. surveys among MSM nationwide, and ment of Human Services, and commu- MDH requested reports of suspected a current epidemic of syphilis among nity-based organizations serving or confirmed cases of influenza-related MSM, documented in Minnesota and African-born persons in Minnesota are encephalopathy or encephalitis in elsewhere, warrant concern. Similar to underway addressing these complex children < 18 years of age, suspected syphilis increases in other U.S. cities issues. or confirmed influenza-related deaths and abroad, nearly 50% of the recent in children < 18 years of age, sus­ syphilis cases in Minnesota among Influenza pected or confirmed cases of influenza MSM were co-infected with HIV, some On October 5, 2004, MDH received and staphylococcal co-infection, for many years. “Burn out” from notice that half of the influenza vaccine suspected or confirmed influenza in adopting safer sexual practices and expected for the upcoming season hospitalized pregnant women, and exaggerated confidence in the efficacy would not be available. This prompted suspected cases of novel influenza. of HIV treatments may be contributors immediate public health action to Surveillance initiated in 2003 in the to resurging risky sexual behavior determine the vaccine supply in metropolitan area to monitor influenza- among MSM. CDC recommends Minnesota and redistribute it to reach related pediatric hospitalizations was annual screening for sexually transmit­ groups most at risk for complications of also continued through the 2004-5 ted diseases (including HIV and influenza. As a result of public health season. syphilis) for sexually active MSM and efforts, as well as private providers, more frequent screening for MSM who vaccine was made available to all Two cases of influenza-related report sex with anonymous partners or Minnesota long-term care facility encephalopathy and one pediatric, in conjunction with drug use. residents by early November 2004. influenza-related death were identified in 2004-5. The encephalopathy cases The number and percentage of HIV The Public Health Laboratory isolated presented in a 14-year-old and a 4- infections in Minnesota that are influenza for the first time of the 2004­ year-old. The 14-year-old had no pre­ attributed to injection drug use have 5 influenza season from a Minnesota existing conditions, and the 4-year-old declined over the past decade for men resident on October 18, 2004, which had a history of pneumonia, diabetes, and women, falling from 17% (80/470) represented an early start of activity. and gastroesophageal reflux. Onsets of cases in 1991 to 4% (13/307) in Since 1990-91, the first isolate typically of symptoms in the two were in mid- 2004. Heterosexual contact with a has been between mid-November and December and early January; both partner who has or is at increased risk mid-December. Despite the early resulted in mild neurologic sequelae. of HIV infection is the predominant isolation, influenza activity was The pediatric death occurred in a 6- mode of exposure to HIV for women. sporadic in Minnesota until mid- year-old from Otter Tail County. The Eighty percent of 90 new HIV diag­ December and didn’t peak until the child had a co-infection of group A noses among women in 2004 can be first week in February. Nationally, a streptococcus and influenza B with no attributed to heterosexual exposure similar activity pattern was seen. history of current influenza vaccination. after re-distributing those with unspeci­ The patient presented to a hospital fied risk (Lansky A, et al. A method for Influenza surveillance in Minnesota emergency department in March in full classification of HIV exposure category relies on reporting of selective indi­ vidual cases from clinics, hospitals, continued...

DCN 33;4 July/August 2005 43 respiratory arrest; resuscitation efforts facilities in 54 counties reported enza. Vaccination of high-risk individu­ were unsuccessful. confirmed or suspected ILI outbreaks als for seasonal influenza, surveillance in 2004-5. In all 140 facilities, influenza for novel virus strains, and planning The Public Health Laboratory received was laboratory-confirmed by rapid efforts for an influenza pandemic are 820 influenza specimens for viral tests or culture. In comparison, 44 all important strategies to increase our confirmation and strain identification. long-term care facilities reported capacity to effectively deal with Of these isolates, 535 (65%) were outbreaks during the 2003-4 season. influenza. influenza type A/Wyoming like (H3); Since 1988-1989, the number of long- 273 (33%) were B/Sichuan-like; 9 (1%) term care facilities reporting ILI Listeriosis were A; two (< 1%) were B/Hong Kong outbreaks has ranged from six in 1990­ Five cases of listeriosis were reported like, and one (< 1%) was B. Influenza 91 to 79 in 1997-98. during 2004. Four case-patients were A/California/7/2004-like (H3N2), which hospitalized, but none died. None of was not included in the 2004-5 vaccine, The highly pathogenic avian strain of the cases were associated with a was the predominant strain circulating influenza A (H5N1) continues to recognized outbreak. The median age nationally, representing 72% of circulate in Southeast Asia and cause was 53 years (range, 40 to 76 years). influenza A typed at CDC. In illness in poultry and humans. The Two case-patients had Listeria Minnesota, there were no cases of World Health Organization (WHO) monocytogenes isolated from joint fluid influenza A/California/7/2004-like reported on July 27, 2005 that a total of or tissue. One of these two case- identified this past season, and all of 109 human cases including 55 deaths patients had L. monocytogenes the circulating strains were well have been confirmed since January isolated from knee tissue and fluid. matched to the vaccine components. 2004, with an overall case-fatality rate This case presented with knee pain Studies conducted during previous of 51%. These confirmed cases have and had a history of total knee replace­ seasons with imperfect vaccine been identified in Thailand, Vietnam, ment 5 years earlier. The other case matches have shown that even a and Cambodia. Collective surveillance presented with hip pain, had L. poorly matched vaccine is still moder­ efforts from WHO, the CDC, as well as monocytogenes isolated from hip fluid, ately effective in preventing influenza- health authorities from Southeast Asia and had a history of total hip replace­ related hospitalizations and deaths. and around the world are in place to ment 6 years earlier. A 46-year-old attempt to identify new cases and case-patient with a history of alcohol A probable outbreak of influenza-like prevent spread. Minnesota utilizes dependency and mental health illness (ILI) in a school is defined as a guidelines developed by the CDC to problems had L. monocytogenes doubled absence rate with all of the assess ill patients returning from isolated from blood. One case-patient following primary influenza symptoms affected countries. Currently, no cases had several underlying conditions reported among students: rapid onset, of H5N1 have been identified in (congestive heart failure, anemia, fever of >101º F, illness lasting 3 or Minnesota or the United States. H5N1 arthritis, and history of acute gas­ more days, and at least one secondary has not definitively demonstrated trointestinal bleed) and had L. influenza symptom (e.g., myalgia, person-to-person spread, but in May monocytogenes isolated from blood. headache, cough, coryza, sore throat, 2005, WHO reported that the virus One case-patient, a 53-year-old, did chills). A possible ILI outbreak in a showed evidence of becoming more not have any underlying medical school is defined as a doubled ab­ transmissible, though less virulent. It is conditions, and had L. monocytogenes sence rate with reported symptoms possible that this change could make isolated from blood and cerebrospinal among students including two of the widespread global transmission of fluid. primary influenza symptoms and at H5N1 more likely. Pandemic influenza least one secondary influenza symp­ planning has intensified at global, The five cases reported in 2004 tom. During the 2004-5 season, MDH national, and state levels in the past continue a recent trend of decreased received reports of probable ILI year as the threat of H5N1 increases. listeriosis reports in Minnesota. Since outbreaks from 155 schools in 48 2000, the number of cases reported counties throughout Minnesota and In April 2005, it was discovered that ranged from four to eight cases per possible outbreaks in 101 schools in 44 U.S. laboratories including some in year (median, 5 cases). This is a counties. Since 1988-89, the number of Minnesota had inadvertently received substantial decrease from 1997-1999, schools reporting suspected influenza proficiency samples containing the when 17 to 19 cases were reported per outbreaks has ranged from 38 schools H2N2 influenza strain, which has not year. Only one of 27 cases reported in in 20 counties in 1996-97 to 441 circulated in humans since 1969. H2N2 Minnesota since 2000 occurred in a schools in 71 counties in 1991-92. was the strain responsible for causing pregnant woman. the 1957 pandemic. The CDC and An ILI outbreak is suspected in a long- agencies that sent out the samples Elderly persons, immunocompromised term care facility when three or more provided instructions to immediately individuals, pregnant women, and residents in a single unit present with a destroy any remaining samples. MDH neonates, are at highest risk for cough and fever (>101º F) or chills followed up with all Minnesota labora­ acquiring listeriosis. Listeriosis during a 48 to 72 hour period. An ILI tories to ensure that the samples had generally manifests as meningoen­ outbreak is confirmed when at least been destroyed. cephalitis and/or septicemia in neo­ one resident has a positive culture or nates and adults. Pregnant women rapid antigen test for influenza. The The events of the 2004-5 influenza may experience a mild febrile illness, number of long-term care facilities season highlight the need for coordi­ abortion, premature delivery, or reporting outbreaks this season was nated efforts between public and stillbirth. In healthy adults and children, particularly high. One hundred forty private health care to manage influ­ continued...

44 DCN 33;4 July/August 2005 symptoms usually are mild or absent. Methicillin-Resistant resistant Staphylococcus aureus in L. monocytogenes can multiply in Staphylococcus aureus (MRSA) Minnesota. JAMA. 2003;290(22):2976- refrigerated foods. Persons at highest Strains of Staphylococcus aureus that 84). In a recent study comparing the risk should: 1) avoid soft cheeses are resistant to methicillin and all beta­ results from three different states (e.g., feta, Brie, Camembert, blue- lactam antibiotics are referred to as conducting MRSA surveillance, 12% of veined, and Mexican-style cheeses) methicillin-resistant Staphylococcus all MRSA reported in Minnesota from and unpasteurized milk; 2) thoroughly aureus (MRSA). Risk factors for 2001-2003 were CA-MRSA compared heat/reheat deli meats, hot dogs, other healthcare-associated (HA) MRSA to 20% of cases in Atlanta, Georgia meats, and leftovers; and 3) wash raw include recent hospitalization or and 8% of all cases in Baltimore, vegetables. surgery, residence in a long-term care Maryland. Additionally, this study found facility, and renal dialysis. that in Atlanta and Baltimore, children Lyme Disease less than 2 were overrepresented During 2004, reported Lyme disease In 1997, MDH began receiving reports among CA-MRSA cases (population­ cases increased to a record number of of healthy young patients with MRSA based surveillance was not conducted 1,023 (20.0 cases per 100,000 infections. These patients had onset of in Minnesota). (Fridkin, S., et al. population). An additional 24 cases their MRSA infections in the commu­ Methicillin-resistant Staphylococcus were classified as probable Lyme nity and appeared to lack the estab­ aureus disease in three communities. disease. Six hundred forty-four (63%) lished risk factors for MRSA. Although N Engl J Med. 2005;352(14):1436-44). confirmed case-patients in 2004 were most of the reported infections were male. The median age of case-patients not severe, some resulted in serious In 2004, 2,411 cases of MRSA infec­ was 39 years (range, 1 to 94 years). illness or death. Strains of MRSA tion were reported. Twenty-one Physician-diagnosed erythema cultured from persons without percent of these cases were classified migrans was present in 880 (86%) healthcare-associated risk factors for as CA-MRSA; 77% were classified as cases. Two hundred (20%) cases had MRSA are now known as community- HA-MRSA, and <2% could not be at least one late manifestation of Lyme associated MRSA (CA-MRSA). classified. Isolates were received from disease (including 132 with a history of 452 (89%) of the 508 CA-MRSA cases. objective joint swelling and 54 with CA-MRSA is defined as: a positive To date, antimicrobial susceptibility cranial neuritis) and confirmation by a culture for MRSA from a specimen testing has been completed on 155 positive Western blot test. Onsets of obtained < 48 hours of admission to a (34%) and molecular subtyping by illness peaked in July (35% of cases), hospital (if patient admitted); in a PFGE has been completed for 104 corresponding to the peak activity of patient with no history of prior MRSA (23%) of these isolates. CA-MRSA nymphal Ixodes scapularis (deer tick infection or colonization; no presence patients continue to be younger than or black-legged tick) in mid-May of indwelling percutaneous devices or patients with HA-MRSA (median age, through mid-July. catheters at the time of culture; and no 33 years vs. 61 years) and more likely history of hospitalization, surgery, to have MRSA isolated from the skin Four hundred forty-two (43%) cases residence in a long-term care facility, (80% vs. 31%). Most CA-MRSA occurred among residents of the Twin hemodialysis, or peritoneal dialysis in isolates belonged to one particular Cities metropolitan area. However, the year prior to the positive MRSA PFGE clonal group that is distinct from only 40 (5%) of 736 case-patients with culture. the most common HA-MRSA clonal known exposure likely were exposed to group. infected I. scapularis in metropolitan MDH initiated active surveillance for counties, primarily Anoka and Wash­ CA-MRSA at 12 sentinel hospital Clinicians should be aware that ington Counties. Most case-patients laboratories in January 2000. The therapy with beta-lactam antimicrobials either resided in or traveled to endemic laboratories (six in the Twin Cities can no longer be relied upon as the counties in east-central Minnesota or metropolitan area and six in Greater sole empiric therapy for severely ill western Wisconsin. As in 2003, Crow Minnesota) were selected to represent patients whose infections may be Wing County continued to have the various geographic regions of the staphylococcal in origin. However, all highest number of Lyme disease case state. Sentinel sites report all cases of 2004 CA-MRSA isolates tested to date exposures (153 [21%] of 736 cases). MRSA identified at their facilities and have been susceptible to , Lyme disease risk appears to be submit all CA-MRSA isolates to MDH. linezolid, synercid, trimethoprim- spreading north and west, indicated by The purpose of this surveillance is to sulfamethoxazole, and vancomycin. an increasing number of exposures in determine demographic and clinical Most CA-MRSA isolates (95%) were counties with a history of sporadic characteristics of CA-MRSA infections susceptible to tetracycline and rifampin Lyme disease case exposures in Minnesota, to identify possible risk (99%). Sixty-eight percent were (Becker, Hubbard and Itasca Coun­ factors for CA-MRSA, and to identify susceptible to ciprofloxacin and 84% ties). the antimicrobial susceptibility patterns were susceptible to clindamycin and molecular subtypes of CA-MRSA Conversely, only 24% of CA-MRSA For a more detailed discussion of isolates. A comparison of CA- and HA­ isolates were susceptible to erythromy­ Lyme disease and other tick-borne MRSA using sentinel site surveillance cin. Eighteen percent (17/93) of diseases in Minnesota, including a data from 2000 demonstrated that CA- -resistant, clindamycin­ map of high-risk areas, see “Dramatic and HA-MRSA differ demographically susceptible isolates demonstrated Increase in Lyme Disease and Other and clinically, and that their respective inducible clindamycin resistance using Tick-borne Diseases, 2004” in the May/ isolates are microbiologically distinct the D test. June 2005 issue (vol. 33, no. 3) of the (Naimi, T., et al. Community-onset and Disease Control Newsletter. healthcare-associated methicillin- continued...

DCN 33;4 July/August 2005 45 MDH also has received reports of spinal fluid specimens. Specimens for one confirmed serogroup C case serious illness and death due to viral culture should be collected during occurred among high school students community-associated methicillin- the first 5 days of illness. in 2004. Two culture-negative sus­ susceptible S. aureus infection. Critical pected cases of meningococcal illnesses or deaths due to community- Neisseria meningitidis Invasive disease, positive by polymerase chain associated S. aureus infection, Disease reaction (PCR) in the Public Health regardless of susceptibility to methicil­ Twenty-four cases of Neisseria Laboratory, occurred in high school lin, is now reportable in Minnesota. meningitidis invasive disease (0.5 per students also were included in the 100,000 population) were reported in study in 2004. Mumps 2004, compared to 29 cases in 2003. Four cases of mumps were reported to The distribution of serogroups among In January 2005, a meningococcal MDH during 2004; a total of 23 mumps case isolates from 2004 was similar to polysaccharide-protein conjugate cases were reported between 2000­ 2003, with 12 (50%) serogroup C vaccine for serogroups A,C,Y, and W­ 2004. Three of the case-patients were cases, six (25%) serogroup B cases, 135 was licensed for use in the United white, non-Hispanic males, ages 22, four (17%) serogroup Y cases, one States for persons aged 11 to 55 years. 44 and 50 years. The fourth case- (4%) serogroup W-135 case, and one The ACIP and American Academy of patient was a 37-year-old white, non- (4%) case whose isolate was not Pediatrics recommend immunization Hispanic female. All four cases had an groupable. with the new vaccine at age 11-12 unknown history of vaccination for years or at high school entry as well as mumps. Between 2002 and 2004, eight Case-patients ranged in age from 2 for college freshmen living in dormito­ of the 10 cases reported have oc­ months to 91 years, with a mean of 32 ries and other groups previously curred in adults, highlighting the need years. Seventy-one percent of the determined to be at high risk in the to assess the mumps immunization cases occurred in the Twin Cities licensed age range. Complete recom­ status of adults. metropolitan area. Twelve (50%) case- mendations are available in MMWR patients had meningitis, 10 (42%) had 2005; 54 (No. RR-7). No source case was identified for two bacteremia without another focus of of the cases (ages 22 and 50 years). infection, and two (8%) had bacteremia Pertussis The 44-year-old reported a history of with pneumonia. All cases were During 2004, 1,368 (27.8/100,000 domestic travel that included meeting sporadic, with no definite epidemio­ population) cases of pertussis were with persons from numerous other logic links. reported in Minnesota. This number is states and Canada. He and the female more than six times the number case-patient were epidemiologically Three deaths occurred among cases reported in 2003 (207), more than linked. Transmission of mumps had not reported in 2004. An 81-year-old twice the number reported during the previously been identified in Minnesota female and a 91-year-old female died most recent previous peak year of since 1999. of bacteremia attributed to serogroup Y 2000 (575), and higher than the (one had bacteremia with pneumonia). number reported during any year since All four cases were laboratory con­ An 83-year-old male died of bacter­ 1950 (1,377). The increase in reported firmed by positive IgM serology. emia due to serogroup C. cases occurred nationally as well, and Convalescent serum results were may be attributable to several factors unavailable; therefore, a rise in serum Since the fall of 1998, MDH has including increased awareness of IgG was not verified. Specimens for collected additional information on pertussis among health care providers viral culture were not collected from college-aged students with N. and the general public, increased any of the cases. Although IgG meningitidis invasive disease as part of availability of more sensitive diagnostic serologic tests and viral culture were a nationwide effort to determine testing using PCR, as well as a true not performed for the two epidemio­ whether providing meningococcal increase in incidence. Laboratory logically linked cases, the clinical vaccine to incoming college freshmen confirmation was available for 935 presentation (including orchitis in the effectively prevents disease in this age (68%) cases; 92 (10%) were confirmed male), negative laboratory test results group. In the fall of 1999, the Advisory by culture and 843 (90%) by PCR. for common differential diagnoses Committee on Immunization Practices Among the remaining cases, 210 were (e.g., mononucleosis and streptococcal (ACIP) recommended that health care epidemiologically linked to culture- infection), and the relative symptom providers inform college students confirmed cases, and 223 met the onset dates supported the diagnosis of about meningococcal disease and the clinical case definition. Eight hundred mumps. Neither case developed availability of vaccine. Serogroups A, sixty (63%) of the reported cases additional complications nor was C, Y, and W-135 are covered by the occurred in residents of the Twin Cities hospitalized. Close contacts were quadrivalent vaccine. No cases metropolitan area. notified of their exposure; no subse­ reported in Minnesota during 2004 quent transmission was identified. were identified as college students. One death due to pertussis-related complications was reported in 2004. Both IgM and IgG serologic testing In the spring of 2002, MDH in collabo­ The case was a 1-month-old with no should be performed on suspect ration with CDC and other EIP sites underlying medical conditions. Pertus­ mumps cases, as false-positive indirect nationwide, began a case-control study sis complications included pneumonia immunofluorescent antibody (IFA) tests of risk factors for meningococcal leading to respiratory failure. for mumps IgM have been reported. disease among high school students in Mumps can also be confirmed by viral Minnesota. One culture-confirmed, culture of throat washings, urine, or serogroup undetermined case, and continued...

46 DCN 33;4 July/August 2005 Paroxysmal coughing is the most nized children may also develop are necessary for molecular and commonly reported symptom. In 2004, disease. Disease in those previously epidemiologic studies and for drug 1,312 (96%) of the case-patients immunized is usually mild. Efficacy for susceptibility testing. Whenever experienced paroxysmal coughing. currently licensed vaccines is esti­ possible, culture should be done in Over one third (485, 35%) reported mated to be 71% to 84% in preventing conjunction with PCR testing. Direct whooping. Although commonly referred serious disease, but waning immunity fluorescent antibody (DFA), provides a to as “,” very young begins approximately 3 years after the rapid presumptive diagnosis of children, older individuals, and persons last dose of DTaP. Of the 766 case- pertussis; however, because both previously immunized may not have patients who were 7 months to 15 false-positive and false-negative the typical “whoop” associated with years of age, 568 (74%) are known to results can occur, DFA tests should not pertussis. Post-tussive vomiting was have received at least a primary series be relied upon solely for laboratory reported in 631 (46%) of the cases. of three doses. Of the 142 cases in confirmation. Serological tests are not Four hundred eighty-five (35%) case- persons 7 months through 6 years of standardized and are not acceptable patients reported apnea. Infants and age, 48 (34%) received fewer than for laboratory confirmation. young children are at the highest risk three doses of DTP/DTaP vaccine for severe disease and complications. before onset of illness, and were Pertussis booster vaccines for persons Pneumonia was diagnosed in 37 (3%) considered preventable cases. 7 years of age and older will help to case-patients, four of whom were less decrease the incidence and transmis­ than 18 months of age. Thirty-one (2%) MDH reporting rules require that sion of pertussis in the community. Two case-patients were hospitalized; 20 clinical isolates of Bordetella pertussis new Tetanus Toxoid, Reduced Diphthe­ (65%) of the hospitalized patients were be submitted to the Public Health ria Toxoid and Acellular Pertussis younger than 6 months of age. Laboratory. Of the 92 culture-con- Vaccine, Adsorbed (Tdap) products firmed cases, 75 (82%) isolates were were licensed by the FDA in 2005 as Due to waning immunity, either of received and subtyped by PFGE and single dose booster vaccines to natural infection or vaccine, pertussis tested for antibiotic susceptibility to provide protection against tetanus, ® can affect persons of any age. The erythromycin, ampicillin, and diphtheria, and pertussis. Boostrix, disease is increasingly recognized in trimethoprim-sulfamethoxazole. Fifteen developed by GlaxoSmithKline, is older children and adults; however, it is distinct PFGE patterns were identified; indicated for persons 10 to 18 years of ® not clear whether it is a true increase four of these patterns occurred in only age. Adacel, developed by Sanofi or due to changes in surveillance and a single case isolate. The two most Pasteur, is indicated for persons 11 to reporting. During 2004, case-patients common patterns identified accounted 64 years of age. On June 30, 2005 the ranged in age from 5 days to 82 years. for 38 (51%) of the total isolates and ACIP voted to recommend the routine Four hundred seventy-nine (35%) they occurred throughout the year. use of Tdap vaccines in adolescents cases occurred in persons 13 to 17 aged 11-18 years in place of tetanus years of age. Three hundred thirty- No cases of erythromycin-resistant B. and diphtheria toxoids (Td) vaccines. eight (25%) cases occurred in persons pertussis have been identified in Detailed information is published on 18 years of age and older. Persons 5­ Minnesota since the first case was the CDC website at: 12 years of age accounted for 28% identified in October 1999. Statewide, http://www.cdc.gov/nip/vaccine/tdap/ (379) of all cases. Fifty (3%) of the all 1,040 other isolates tested to date tdap_acip_recs.pdf total cases occurred in infants less have had low minimum inhibitory than 6 months of age, and 120 (9%) concentrations, falling within the Salmonellosis occurred in children 6 months through reference range for susceptibility to the During 2004, 643 culture-confirmed 4 years of age. Age was unknown for antibiotics evaluated. Only eight other cases of Salmonella infection (13.1 per one case. erythromycin-resistant B. pertussis 100,000 population) were reported. cases have been identified to date in This represents a 12% increase from Infection in older children and adults the United States. the 576 cases reported in 2003 and a may result in exposure of unprotected 4% increase from the median annual infants who are at risk for the most Laboratory tests should be performed number of cases reported from 1996 to severe consequences of infection. on all suspected cases of pertussis. 2003 (median, 619 cases; range, 576 During 2004, 71 cases of pertussis Culture of B. pertussis requires to 693) (Figure 1). Four serotypes, S. were reported in infants less than 1 inoculation of nasopharyngeal mucous Typhimurium (164 cases), S. Enteriti­ year of age. A likely source of expo­ on special media and incubation for 7 dis (111 cases), S. Newport (65 cases), sure was identified for 26 (37%) cases; to 10 days. However, B. pertussis is and S. Heidelberg (33 cases) ac­ 15 (21) were infected by adults 18 rarely identified late in the illness; counted for 58% of cases reported in years of age and older, one (4%) was therefore, a negative culture does not 2004. There were seven cases of S. infected by an adolescent, and 10 rule out disease. A positive PCR result Typhi infection. Only one of the S. (38%) were infected by a child less is considered confirmatory in patients Typhi cases traveled internationally, than 13 years of age. Forty-five (63%) with a 2-week history of cough illness. two lived in the same household, and cases had no identified source of PCR can detect non-viable organisms. one was a group-home resident where infection. For these cases, the source Consequently, a positive PCR result an asymptomatic carrier was identified. of infection was likely outside the does not necessarily indicate current Four percent of salmonellosis case- household. infectiousness. Patients with a 3-week patients were less than 1 year of age, or longer history of cough illness, and 25% were 12 years of age or Although unvaccinated children are at regardless of PCR result, may not younger. Twenty-five percent of case- highest risk for pertussis, fully immu- benefit from antibiotic therapy. Cultures continued...

DCN 33;4 July/August 2005 47 patients were hospitalized for their In November, 20 S. Newport cases 2002. This involves cross-checking infection. Of 592 case-patients that among employees of a medical clinic laboratory-reported cases against were interviewed, 96 (16%) traveled were identified. An additional 23 ill cases reported by clinicians. Although internationally during the week prior to persons were identified but not tested. both laboratories and clinical facilities their illness onset. Gravy served at a catered lunch was are required to report STDs the implicated vehicle. Undercooked independently of each other, an Three case-patients died. Isolates from turkey that was being prepared episode of STD is not considered a these case-patients included one S. concurrently likely contaminated the case for surveillance purposes until a Subspecies I isolated from blood, one gravy. In December, two cases of S. corresponding case report is submitted S. Newport isolated from stool, and Newport were identified that reported by a clinical facility. Additionally, case one Salmonella group C2 from stool. eating at the restaurant that catered reports contain critical demographic Two of the cases had serious underly­ the medical clinic lunch. Three and clinical information that is not ing medical conditions; one had lung, asymptomatic restaurant employees available from laboratory reports. stomach, and prostate cancer, and the tested positive for S. Newport. The When a laboratory report is received other had complications following cases among restaurant patrons may but no corresponding case report is surgery for a chronic gastroesophageal have resulted from environmental received within 45 days, MDH mails a condition. The third case was an 87- contamination that occurred during the reminder letter and case report form to year-old person whose Salmonella preparation of the turkey for the earlier the corresponding clinical facility. infection was listed as the primary catered lunch. It is possible that the Cases of syphilis and chancroid are cause of death. infected foodworkers played a role in monitored through a mostly passive transmission. surveillance system. Eight outbreaks of salmonellosis were virus and human papillomavirus identified in 2004. Four outbreaks A person-to-person outbreak occurred infections are not reportable. involved foodborne transmission. among residents of a nursing home. Person-to-person transmission Two nursing home residents tested Although overall incidence rates for resulted in one outbreak. The remain­ positive for S. Newport in August, and STDs in Minnesota are lower than ing three outbreaks involved infected an additional resident tested positive in those in many other areas of the pets. November. United States, certain population subgroups in Minnesota have very high Three cases of S. Enteritidis with In March, a cluster of four S. STD rates. Specifically, STDs illness onsets in May through July Typhimurium cases was identified. Two disproportionately affect adolescents, reported eating at the same restaurant of the cases lived in a group home, young adults, and persons of color. before their illness. Several deficien­ and the other two cases were family cies in food holding and preparation, members of one of the group home Chlamydia including inadequate refrigeration and residents. These family members had Chlamydia trachomatis infection is the potential for cross-contamination were adopted two puppies from the group most commonly reported STD in found at the restaurant. Two environ­ home. The two adopted puppies tested Minnesota. In 2004, 11,601 cases (236 mental samples (underneath a positive for S. Typhimurium. Some of per 100,000 population) were reported, sandwich cutting board and egg grill) these cases likely occurred due to representing a 8% increase from 2003 tested positive for S. Enteritidis. An contact with feces of the infected dogs, (Table 3). asymptomatic cook also tested positive but person-to-person transmission for S. Enteritidis. could have also played a role. Adolescents and young adults are at highest risk for acquiring chlamydial In June, six persons became ill with S. Two S. Javiana cases occurred in a 3- infection (Table 4). The chlamydia rate Agona after attending a graduation month-old and a 7-month-old infant in is highest among 20 to 24-year-olds party. Eighteen additional cases of July. The familly of one of the infants (1,372 per 100,000 population), with gastrointestinal illness were identified had a dog that was ill with diarrhea the next highest rate among 15 to 19- but were not tested for Salmonella. earlier in July. A stool specimen from year-olds (968 per 100,000). The Samples of the turkey and turkey/soup the dog tested positive for S. Javiana. incidence of chlamydia among adults mixture left over from the event tested After the dog recovered, the two 25 to 29 years of age (597 per positive for S. Agona. families and the dog spent time at a 100,000) is considerably lower but has cabin. While at the cabin, one of the increased in recent years. The chlamy­ From August through October, three infants became ill with diarrhea; 2 days dia rate among females (343 per cases of S. Typhimurium who had later the second infant became ill as 100,000) is more than twice the rate eaten ground beef purchased at a well. among males (126 per 100,000). This member-only warehouse were identi­ difference is likely due to more fied. One of the three cases reported One S. Typhimurium case in a 5-year- frequent screening among women. tasting the raw ground beef after old child was part of a multi-state purchase and before storing it in the outbreak associated with infected pet The incidence of chlamydia infection is freezer. Cases of S. Typhimurium rodents. Cases in this outbreak were highest in communities of color (Table associated with ground beef from the identified in 10 states. 4). The rate among blacks (1,456 per same warehouse chain were identified 100,000 population) is 13 times higher in at least two other states. Sexually Transmitted Diseases than the rate among whites (113 per Active surveillance for gonorrhea and 100,000). Although blacks comprise chlamydia was initiated in January continued...

48 DCN 33;4 July/August 2005 approximately 4% of Minnesota’s Table 3. Number of Cases and Incidence Rates (per 100,000 population) population, they account for 25% of of Chlamydia, Gonorrhea, and Syphilis, Minnesota, 2000-2004 reported chlamydia cases. Rates among Asian/Pacific Islanders (260 per 2000 2001 2002 2003 2004 100,000), American Indians (488 per Disease No. Rate No. Rate No. Rate No. Rate No. Rate 100,000), and Hispanics (594 per Chlamydia 8,147 166.0 8,369 170.0 10,118 206.0 10,807 220.0 11,601 236.0 100,000) are two to five times higher than the rate among whites. Gonorrhea 3,189 65.0 2,708 55.0 3,050 62.0 3,237 66.0 2,957 60.0

Chlamydia infections occur throughout Syphilis, Total 80 1.6 135 2.7 149 3.0 198 4.0 145 2.9 the state, with the highest reported Primary/ rates in Minneapolis (694 per 100,000 Secondary 16 0.3 33 0.7 59 1.2 48 1.0 27 0.5 population) and St. Paul (639 per Early Latent 18 0.4 16 0.3 23 0.5 45 0.9 21 0.4 100,000). The incidence in the subur­ Late Latent* 44 0.9 81 1.6 65 1.3 105 2.1 95 1.9 0.0 3 0.02 ban metropolitan area (168 per Neurosyphilis 0 0.1 1 0 0.0 1 0.02 Congenital** 2 3.0 2 3.0 1 1.5 0 0.0 1 1.4 100,000) is similar to that in Greater Chancroid 0 0.0 1 0.0 0 0.0 0 0.0 0 0.0 Minnesota (149 per 100,000). D *DLate latent syphilis includes neurosyphillis Gonorrhea **DCongenital syphilis rate per 100,000 live births Gonorrhea, caused by Neisseria Note: Data exclude cases diagnosed in federal or private correctional facilities gonorrhoeae, is the second most commonly reported STD in Minnesota. In 2004, 2,957 cases (60 per 100,000 Table 4. Number of Cases and Incidence Rates (per 100,000 population) population) were reported, represent­ of Chlamydia, Gonorrhea, and Primary/Secondary Syphilis ing a decrease of 7% from 2003 (Table by Residence, Age, Gender, and Race/Ethnicity, Minnesota, 2004 3). Chlamydia Gonorrhea Syphilis Adolescents and young adults are at Demographic Group No. Rate No. Rate No. Rate greatest risk for gonorrhea (Table 4), with incidence rates of 198 per Total 11,601 236 2,957 60 27 0.5 100,000 population among 15 to 19- year-olds, 288 per 100,000 among 20 Residence* Minneapolis 2,655 694 1,055 276 16 4.2 to 24-year olds, and 157 per 100,000 St. Paul 1,835 639 545 190 3 1.0 among 25 to 29-year-olds. Gonorrhea Suburban** 3,315 168 794 40 7 0.4 rates for males (51 per 100,000) and Greater Minnesota 3,389 149 467 21 1 0.0 females (69 per 100,000) are compa­ rable. Communities of color are Age disproportionately affected by gonor­ <10 years 3 0 1 0 0 0.0 rhea, with 41% of cases reported 10-14 years 119 32 34 9 0 0.0 among blacks. The incidence of 15-19 years 3,623 968 740 198 1 0.3 gonorrhea among blacks (592 per 20-24 years 4,426 1,372 929 288 3 0.9 25-29 years 1,910 597 503 157 4 1.3 100,000) is approximately 27 times 30-34 years 840 238 293 83 3 0.8 higher than the rate among whites (22 35-44 years 539 65 334 41 9 1.1 per 100,000). Rates among American >45 years 141 8 123 7 7 0.4 Indians (89 per 100,000) and Hispan­ ics (97 per 100,000) are approximately Gender five times higher than among whites. Male 3,081 126 1,244 51 24 1.0 The rate among Asian/Pacific Islanders Female 8,520 343 1,712 69 3 0.1 (36 per 100,000) is similar to that Transgender ------1 ------among whites. Race^/Ethnicity White 5,048 113 966 22 19 0.4 Gonorrhea rates are highest in the Black 2,956 1,456 1,202 592 7 3.4 cities of Minneapolis and St. Paul American Indian 396 488 72 89 1 1.2 (Table 4). The incidence in Minneapolis Asian 438 260 61 36 0 0.0 (276 per 100,000 population) is nearly Other 465 522 86 97 0 0.0 1.5 times the rate in St. Paul (190 per Unknown^^ 2,298 --- 570 --- 0 --- 100,000), seven times higher than the Hispanic^^^ 852 594 139 97 0 0.0 rate in the suburban metropolitan area (40 per 100,000), and 13 times higher *Residence information missing for 407 chlamydia cases and 96 gonorrhea cases. **Suburban is defined as the seven-county metropolitan area (Anoka, Carver, Dakota, than the rate in Greater Minnesota (21 Hennepin, Ramsey, Scott, and Washington Counties), excluding cities of Minneapolis and per 100,000). St. Paul ^Case counts include persons by race alone. Population counts used to calculate results include race alone or in combination. ^^ No comparable population data available to calculate rates ^^^ Persons of Hispanic ethnicity may be of any race continued... Note: Data exclude cases diagnosed in federal or private correctional facilities

DCN 33;4 July/August 2005 49 Quinolone-resistant Neisseria Chancroid Streptococcus pneumoniae Invasive gonorrhoeae Chancroid continues to be very rare in Disease While the overall rate of gonorrhea Minnesota. No cases were reported in Statewide active surveillance for has stayed relatively constant over the 2004. invasive Streptococcus pneumoniae past three years, the prevalence of (pneumococcal) disease began in quinolone-resistant Neisseria Shigellosis 2002, expanded from the Twin Cities gonorrhoeae (QRNG) has increased During 2004, 68 culture-confirmed metropolitan area, where active five-fold from 1.5% in 2002 to 8.4% in cases of Shigella infection (1.4 per surveillance has been ongoing since 2004. Of concern is the high preva­ 100,000 population) were reported 1995. In 2004, 540 cases of invasive lence among men who have sex with (Figure 1). This represents a 34% pneumococcal disease were reported, men (MSM), which has increased from decrease from the 103 cases reported including 286 cases among Twin Cities 0% in 2002, to 8.9% in 2003, and in 2003, and a 73% decrease from the metropolitan area residents, and 254 26.9% in 2004. As a result, median number of cases reported cases among residents of Greater fluoroquinolones (e.g. ciprofloxacin) annually from 1999 to 2003 (median, Minnesota. Incidence rates overall, are no longer recommended for 254 cases; range, 103 to 904). and by age group were similar be­ treating gonorrhea in men with male tween these two geographic regions. sexual partners in Minnesota. In 2004, S. sonnei accounted for 41 For example, there were 10.5 cases of (60%) cases, S. flexneri for 22 (32%), invasive pneumococcal disease per Syphilis S. boydii for four (6%), and S. 100,000 Twin Cities metropolitan area Surveillance data for primary and dysenteriae for one (1%). Case- residents, and 10.8 cases per 100,000 secondary syphilis are used to monitor patients ranged in age from 1 to 75 residents of Greater Minnesota. By age morbidity trends because they years (median, 24 years). Thirty-two group, annual incidence rates per represent recently acquired infections. percent of case-patients were less than 100,000 Twin Cities area residents and Data for early syphilis (which includes 10 years of age; children less than 5 Greater Minnesota residents were, primary, secondary, and early latent years of age accounted for 21% of respectively, 29.0 and 19.1 cases stages of disease) are used in cases. Seventeen (25%) case-patients among children aged 0-4 years; 2.7 outbreak investigations because they were hospitalized. Sixty-nine percent of and 2.9 cases among children and represent infections acquired within case-patients resided in the Twin Cities adults aged 5-39 years, 10.6 and 8.9 the past 12 months and signify metropolitan area, with 41% of all case- cases among adults 40-64 years, and opportunities for disease prevention. patients residing in Hennepin County. 37.7 and 37.8 cases among adults aged 65 years and older. Primary and Secondary Syphilis Two foodborne outbreaks of shigellosis The incidence of primary/secondary included Minnesota residents in 2004. In 2004, pneumonia accounted for 286 syphilis in Minnesota is lower than that One occurred among people who flew (53%) cases of invasive pneumococcal of chlamydia or gonorrhea (Table 3). on commercial airline flights out of disease among all cases (i.e., those Twenty-seven cases of primary/ Honolulu, and one occurred at a infections accompanied by bacteremia secondary syphilis (0.5 per 100,000 Minnesota restaurant. In August, 44 or isolation of pneumococci from population) were reported in 2004. confirmed S. sonnei cases were another sterile site such as pleural identified among people who traveled fluid). The 166 pneumonia cases Early Syphilis to four countries and 22 U.S. states on among Twin Cities area residents The number of cases of early syphilis 12 flights, all served by the same accounted for a higher proportion of all decreased in 2004 compared to 2003, caterer in Honolulu. Six of the 44 cases invasive disease in that group (58%), however the number of cases among were Minnesota residents. Salad than the 120 cases among residents of men who have sex with men (MSM) consumption was statistically associ­ Greater Minnesota (47%). Bacteremia remained high. Forty-eight cases of ated with illness, and raw carrot was without another focus of infection early syphilis were reported in 2004, the only salad component common to accounted for 186 (34%) cases compared to 93 cases in 2003. Of the all flights. The second outbreak took statewide, including 86 (30%) cases in 48 early syphilis cases in 2004, 42 place during September at a restau­ Twin Cities area residents and 100 (88%) occurred among men; 34 (81%) rant. Two cases of S. flexneri had (39%) cases in Greater Minnesota of these men reported having sex with eaten at the same restaurant in residents. Pneumococcal meningitis other men. Almost a third (32%) of the Ramsey County. No food vehicle could accounted for 34 (6%) cases state­ MSM diagnosed with early syphilis be identified in this outbreak; the wide, including 20 (7%) of cases in were co-infected with HIV. However, source was likely an unidentified Twin Cities area residents and 14 (6%) preliminary data for early syphilis infected food handler. cases in Greater Minnesota residents. cases in 2005 shows a return to 2003 Forty-nine patients with invasive levels. Similar patterns in syphilis Every tenth Shigella isolate received at pneumococcal disease died (9%); 9% among MSM have been observed in MDH was tested for antimicrobial (25) of case-patients who were Twin other parts of the Unites States. resistance. Twelve isolates were tested Cities area residents and 9% (24) of in 2004; 66% were resistant to ampicil­ case-patients who were Greater Congenital Syphilis lin, 50% were resistant to trimethoprim- Minnesota residents. One case of congenital syphilis was sulfamethoxazole, and 42% were reported in Minnesota in 2004 (Table resistant to both ampicillin and In 1999, the year before the pediatric 3). trimethoprim-sulfamethoxazole. pneumococcal conjugate vaccine ® (Prevnarâ, Wyeth-Lederle [PCV-7]) continued...

50 DCN 33;4 July/August 2005 was licensed, the rate of invasive penicillin and 45 (9%) exhibited streptococcal toxic shock syndrome pneumococcal disease among children intermediate-level resistance; 62 (STSS). Fifteen (10%) case-patients < 5 years in the Minneapolis-St. Paul isolates (13%) exhibited multi-drug were residents of 14 long-term care Metropolitan Area was 111.7 cases/ resistance (i.e. high-level resistance to facilities. One facility had two case- 100,000. Over the years 2000-2002 two or more drug classes). The patients with indistinguishable PFGE there was a major downward trend in proportion of isolates submitted from subtypes whose illness onsets were 4 incidence in this age group (Figure 3). Greater Minnesota residents with high- days apart. Compared with the lowest rate in 2002 or intermediate-level resistance to (22.5 cases/100,000) the incidence penicillin (29/205, 14.1%) was lower The 18 deaths included eight (44%) rate in this age group increased slightly than the proportion from Twin Cities cases of bacteremia without another in 2003 (25.8 cases/100,000) and area residents (57/275, 21%, p=.06). focus of infection, three (17%) cases of again in 2004 from 2002 (29.0 cases/ S. pneumoniae is one of several , and two (11%) 100,000) (Figure 3). Based on the pathogens included in the MDH cases of pneumonia. One case-patient distribution of serotypes among Antibiogram, which gives detailed had STSS and one case had puerperal isolates from these cases, this in­ antimicrobial susceptibility results of sepsis. The remaining fatal cases had crease was limited to disease caused isolates tested at the Public Health bacteremia with another focus of by non-vaccine serotypes (i.e. sero­ Laboratory from 2004 cases, and is infection, including two (11%) with types other than the seven included in available on the MDH website: , and one (6%) with both PCV-7) (Figure 3). This small degree of http://www.health.state.mn.us/divs/ pneumonia and cellulitis. The deaths replacement disease due to non-PCV-7 idepc/dtopics/antibioticresistance/ occurred in persons ranging in age serotypes, similar to that seen in other antibiogram.html. from three to 92 years. For the 15 parts of the country, has been far deaths in patients with known health outweighed by the declines in disease Streptococcal Invasive Disease histories, significant underlying medical caused by PCV-7 serotypes. This trend Group A conditions were reported for all but supports the need for ongoing monitor­ One hundred forty-six cases of three of the cases. ing, however, because further in­ invasive group A streptococcal (GAS) creases due to non-vaccine serotypes disease (2.9 per 100,000 population), Isolates were available for 133 (91%) are possible. In Figure 3 rates of including 18 deaths, were reported in cases, of which all were subtyped invasive pneumococcal disease among 2004, compared to 181 cases and 22 using PFGE; 56 different molecular adults aged > 65 years are also shown deaths in 2003. Ages of case-patients subtypes were identified. Thirty-nine by serotypes included and not included ranged from newborn to 100 years subtypes were represented by one in PCV-7. Declines in incidence in this (mean, 50 years). Fifty-eight percent of isolate each; other subtypes were age group, particularly in disease due case-patients were residents of the represented by two to 42 isolates each. to PCV-7 serotypes have been ob­ Twin Cities metropolitan area. Forty- No epidemiologic links were noted served elsewhere in the United States seven (32%) case-patients had among cases with indistinguishable and are likely attributable to herd bacteremia without another focus of subtypes, except for the two cases immunity from use of PCV-7 among infection. There were 14 (10%) cases from the same long-term care facility children. of primary pneumonia and 16 (11%) as described previously. cases of necrotizing fasciitis. Thirteen Of the 480 isolates submitted for 2004 (9%) case-patients had septic arthritis The deaths were distributed among 10 cases, 41 (9%) were highly resistant to and/or osteomyelitis, and two (1%) had different PFGE subtypes, with seven (41%) deaths attributed to the most Figure 3. Invasive Pneumococcal Disease Incidence Among common PFGE subtype. No other Children <5 Years and Adults >65 Years by Year and Serotype, subtype accounted for more than two Seven County Twin Cities Metropolitan Area, 1999-2004 deaths.

Streptococcal Invasive Disease – 125 Group B Three-hundred forty-one cases of group B streptococcal invasive 100 Other Serotypes disease (6.7 per 100,000 population), including 20 deaths, were reported in PCV-7 2004. These cases were those in 75 Serotypes which group B Streptococcus (GBS) was isolated from a normally sterile site; 10 cases of miscarriage or 50 stillbirth in which GBS was cultured

Cases/100,000 Cases/100,000 from the placenta were also reported.

25 Overall, 158 (46%) cases presented with bacteremia without another focus of infection. The other most common 0 types of infection were cellulitis (14%), 1999 2000 2001 2002 2003 2004 1999 2000 2001 2002 2003 2004 pneumonia (9%), osteomyelitis (8%), Children < 5 Years Adults > 65 Years continued...

DCN 33;4 July/August 2005 51 arthritis (6%), and meningitis (4%). The pregnant women during labor and years of age or older who were majority (72%) of cases had GBS delivery. diagnosed within 12 months of their isolated from blood only. Fifty-five arrival in the United States and who percent of cases occurred among Tuberculosis arrived as immigrants or refugees, only residents of the Twin Cities metropoli­ While the number of cases of tubercu­ six (17%) had any TB-related condi­ tan area. Forty-five (13%) case- losis (TB) disease reported nationally tions noted in their pre-immigration patients were infants less than 1 year has decreased each year since 1993, medical exams performed overseas. of age, and 160 (47%) were 60 years the incidence of TB in Minnesota These findings highlight the need for of age or older. increased throughout much of the clinicians to have a high index of 1990s and peaked at 239 TB cases suspicion for TB among newly arrived Fifty-seven cases of infant (early-onset (4.8 cases per 100,000 population) in foreign-born persons, regardless of the or late-onset) or maternal GBS disease 2001. In 2004, 199 new cases of TB results of medical exams performed were reported, compared to 40 cases disease (3.9 cases per 100,000 overseas. Health care providers should in 2003. Twenty-six infants developed population) were reported in Minne­ pursue thorough screening, evaluation, invasive disease within 6 days follow­ sota, representing a 7% decline from and, if indicated, treatment of active TB ing birth (i.e., early-onset disease), and 2003 and the third consecutive year of disease or latent TB infection among 18 infants became ill at 7 to 89 days of decreasing incidence since 2001 patients who originate from regions age (i.e., late-onset disease). Ten (Figure 4). The incidence of TB where TB is endemic. stillbirths or spontaneous abortions disease in Minnesota, however, were associated with thirteen maternal exceeds the U.S. Healthy People 2010 Both demographic and clinical charac­ invasive GBS infections. objective of 1.0 cases per 100,000 teristics of TB cases reported in population. Minnesota differ between foreign-born From 1997 to 2004, there were 215 and U.S.-born patients. For example, early-onset disease cases reported In several ways, the epidemiology of the majority (71%) of foreign-born TB and 10 infants died. Forty infants were TB in Minnesota is distinct from other case-patients reported in Minnesota in born at less than 37 weeks’ gestation states and has been a precursor of 2004 were 15 to 44 years of age, and accounted for 19% of early-onset trends that now are emerging nation­ whereas the majority (58%) of U.S.- cases. Bacteremia without another ally. The most significant such factor is born TB cases occurred among focus of infection (79%) was the most the very large proportion of TB cases persons 45 years of age or older. The common type of infection in these reported among foreign-born persons proportions of pediatric cases (less early-onset cases, followed by pneu­ in Minnesota, which has averaged 80% than 15 years of age) and those 65 monia (13%) and meningitis (6%). over the past 5 years. In 2004, 163 years of age or older were larger (82%) new TB cases in Minnesota among U.S.-born TB cases than In August 2002, CDC published occurred in persons born outside the among foreign-born cases (22% revised guidelines for the prevention of United States. In contrast, 54% of TB versus 9% and 25% versus 9%, perinatal GBS disease (www.cdc.gov/ cases reported nationwide in 2004 respectively). The relatively high groupbstrep/docs/RR5111.pdf). Key were foreign-born. proportion of U.S.-born pediatric cases changes include the recommendation can be attributed primarily to children for universal prenatal screening of all The 163 foreign-born TB case-patients born in the U.S. to foreign-born pregnant women at 35 to 37 weeks’ reported in 2004 represent 33 different parents. Also, extrapulmonary TB gestation and updated prophylaxis countries of birth. The most common disease is reported more frequently regimens for women with penicillin region of birth among foreign-born TB among foreign-born TB cases than allergies. In light of these revised cases reported in 2004 was sub- among U.S.-born cases in Minnesota. guidelines, MDH reviewed the mater­ Saharan Africa (59%), followed by In 2004, extrapulmonary TB was the nal charts for all 26 early-onset cases South/Southeast Asia (15%) and Latin most common (52%) form of TB reported during 2004. Overall, 18 America/Caribbean (15%) (Figure 5). disease among foreign-born TB cases, (69%) of 26 women who delivered The ethnic diversity among these whereas 44% of U.S.-born TB cases GBS-positive infants underwent foreign-born TB cases reflects the had an extrapulmonary site of disease prenatal screening for GBS. Of these, unique and constantly changing (Figure 6). six (33%) women were positive and 12 demographics of immigrant and other (67%) women were negative. Among foreign-born populations arriving in Aside from country of birth, other less the eight women who did not receive Minnesota. common risk factors among TB cases prenatal screening for GBS, three reported in Minnesota during 2004 (38%) were screened upon admission Persons 15 years of age or older who included HIV infection (7%), substance to the hospital and prior to delivery of arrive in the United States as immi­ abuse (i.e., illicit drug use and/or her infant. Among the 26 women of grants or refugees receive a medical alcohol abuse) (5%), homelessness infants with invasive GBS disease, evaluation overseas that includes (2%), and residence in a nursing home seven (27%) received intrapartum screening for pulmonary TB disease. (1%). Notably, the prevalence of HIV antimicrobial prophylaxis (IAP). Two of Among 161 foreign-born persons who infection among TB cases reported in the six women with a positive GBS were diagnosed with TB disease in 2004 was the highest since MDH screening result received IAP. MDH Minnesota during 2004 and whose began collecting this information in continues to monitor the incidence of date of arrival in the United States was 1993. Ten (77%) of the 13 TB case- GBS disease among infants, screening known, 96 (60%) were diagnosed less patients reported in 2004 with HIV co- for GBS among pregnant women, and than 5 years after arriving in this infection were foreign-born persons, the use of IAP for GBS-positive country. Of 36 TB case-patients 15 continued...

52 DCN 33;4 July/August 2005 nine (90%) of whom were born in Figure 4. Tuberculosis Cases by Country of Origin, Minnesota, 1995-2004 Africa. In 2004, no new TB cases were reported among inmates at correctional facilities in Minnesota. 240 Total 220 Foreign-Born Twenty-seven (31%) of the state’s 87 200 U.S.-Born counties reported at least one case of 180 TB disease in 2004, with the majority 160 (79%) of cases occurring in the seven- 140 county Twin Cities metropolitan area, 120 particularly in Hennepin (52%) and 100 Ramsey (14%) Counties, both of which 80

have public TB clinics. Thirteen percent Number of Cases 60 of TB cases occurred in the five 40 suburban Twin Cities metropolitan 20 counties (i.e., Anoka, Dakota, Carver, 0 Scott, and Washington). Olmsted 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 County, which maintains a public TB clinic staffed jointly by the Olmsted Year of Diagnosis County Health Department and Mayo Clinic, represented 7% of TB cases reported statewide in 2004. The remaining 15% of cases occurred in Figure 5. Foreign-Born Tuberculosis Cases by Region of Origin and primarily rural areas of Greater Year of Diagnosis, Minnesota, 2000-2004 Minnesota.

Drug-resistant TB is a critical and 120 growing concern in the prevention and 2000 control of TB in Minnesota, as well as 100 2001 2002 nationally and globally. The prevalence 80 of drug-resistant TB in Minnesota, 2003 particularly resistance to isoniazid 60 2004 (INH) and multi-drug resistance, exceeds comparable national figures. 40

In 2004, 22 (16%) of 138 culture- Number of Cases 20 confirmed TB cases with drug suscepti­ bility results available were resistant to 0 at least one first-line anti-TB drug (i.e., South/ Su b- East A sia/ Latin Eastern Sou th east Sah aran Pacific America/ Eu rope INH, rifampin, pyrazinamide, or Asia Africa C aribbean ethambutol). In particular, 17 (12%) cases were resistant to INH, and five Region of Origin (4%) cases were multidrug-resistant (i.e., resistant to at least INH and rifampin). As of 2004, MDH updated its definition of first-line TB drug resis­ Figure 6. Tuberculosis Cases by Site of Disease and Place of Birth, tance to exclude resis­ Minnesota, 2000-2004 tance, in accordance with recently revised national recommendations for 100 the treatment of TB disease, which no 90 longer include streptomycin as a first- 80 line anti-TB drug. Drug resistance is 70 significantly more common among foreign-born TB cases in Minnesota 60 than among U.S.-born cases. The 50 prevalence of drug-resistance among 40 foreign-born TB cases reported in 2004 30 was 18%, compared to 5% among

Percent of Cases 20 U.S.-born cases. Of particular concern, 10 eight (38%) of 21 multidrug-resistant 0 TB (MDR-TB) cases reported during the past 5 years (2000-2004) were Fo r eign -B orn U.S.-B orn resistant to all four first-line drugs. These eight pan-resistant MDR-TB P ulm ona ry E x tra pulm o na ry* case-patients represented seven continued... *Includes cases with both extrapulmonary and pulmonary sites of disease

DCN 33;4 July/August 2005 53 different countries of birth (i.e., one pected death (SUD), and four pre­ one (53%) of the cases were male. each from Ethiopia, Laos, Moldova, sented with gastrointestinal (GI) Although the greatest number of cases Somalia, South Korea, Thailand, and symptoms. Case-patients with respira­ (34, 58%) were white, incidence rates two from the U.S.). One of the two tory symptoms ranged from 15 to 72 were higher among Asians (11.2 per U.S.-born pan-resistant patients had years of age; those with sepsis were 100,000) than among whites (0.8 per resided in Africa for several years; the 22 to 43 years of age; the neurologic 100,000) or blacks (0.49 per 100,000). other was a young child infected by a case-patients were 10 to 76 years of No cases were reported in American foreign-born family member. age; the cardiac case-patients were 29 Indians in 2003 or 2004. The incidence and 45 years of age; the sudden rate of hepatitis A in American Indians The epidemiology of TB in Minnesota unexpected deaths were 2 months to declined steadily from 10.4 per 100,000 highlights the need to support global 44 years of age; and the case-patients population in 1999 to 6.0, 3.7, and 2.5 TB elimination strategies, as well as with GI symptoms were 30 to 83 years per 100,000, respectively, in 2000, local TB prevention and control of age. Eleven patients with respiratory 2001, and 2002 demonstrating the activities targeted to foreign-born symptoms, four patients with sepsis, success of targeted immunization persons. MDH is among 22 sites and one patient with neurologic efforts initiated in 1999. Hispanic funded by the CDC to conduct a study symptoms died as did one patient with ethnicity was reported for four cases designed to identify missed opportuni­ GI symptoms and one with a cardiac (2.8 per 100,000). Case-patients ties for preventing TB disease among syndrome. Seven respiratory case- ranged in age from one to 87 years. foreign-born populations in the United patients; two of the neurologic case- States and Canada. This study, which patients, three shock/sepsis case- Two (4%) case-patients were employ­ includes conducting more than 50 1­ patients; and both cardiac case- ees of food-serving establishments. No hour interviews with foreign-born TB patients; and two case-patients with community transmission of hepatitis A case-patients diagnosed in Minnesota, sudden unexpected death resided in was identified. began in the summer of 2004 and will the Twin Cities metropolitan area. The continue throughout 2005. remaining case-patients resided in Of the 59 cases, a risk factor was Greater Minnesota, except for two identified for 35 (59%). Twenty-one TB-related resources for patients and respiratory case-patients who were (60%) had known exposure to a health care providers (including out-of-state residents hospitalized in confirmed hepatitis A case. Four of additional TB surveillance data and Minnesota. these persons, in three separate patient education materials translated families, became infected following in 12 languages) are available on the Eighteen cases were eligible for the exposure to a family member, repre­ MDH TB Program’s web site CDC project (eight respiratory, three senting missed opportunities to (www.health.state.mn.us/tb). sepsis, one neurologic, one GI, one administer immune globulin. Sixteen cardiac case(s); and four SUDs). persons were related to an outbreak Unexplained Critical Illnesses and Specimens were obtained for testing at associated with Hmong arrivals from Deaths of Possible Infectious MDH or CDC for all cases. Plausible the Wat Tham Krabok refugee camp in Etiology etiologies were established for four Thailand; 14 of these cases acquired Surveillance for unexplained critical cases. A 28-year-old female who died their infection abroad, and two case- illnesses and deaths of possible with respiratory symptoms had positive patients acquired their infection in infectious etiology began in September PCR tests for S. pneumoniae and Minnesota through contact with these 1995. Any case should be reported, picornavirus from two lung samples. refugee cases. One other case-patient regardless of the patient’s age or The same samples had viral cultures was a household contact of a confirmed underlying medical conditions. A positive for Echovirus 5. A 44-year- hepatitis A case while visiting Turkey. subset of cases (persons 6 months to male who died with a respiratory 49 years of age with no underlying syndrome had a urine antigen and Of the remaining 14 (40%) cases with a medical conditions who died of immunohistochemical testing of lung risk factor identified, 13 (93%) were apparent non-nosocomial infectious samples that were positive for associated with travel. Of these 13, six processes) are eligible for testing serogroup 1. (46%) traveled to Mexico or South performed at CDC as part a special The 48-year-old male who died of a America, and two reported consuming project. For cases not eligible for the neurologic syndrome had a 16s PCR raw shellfish. One additional case was CDC project, some testing may be test of a brain that was a man who reported having sex with available at MDH or CDC, at the positive for nucleatum. men (MSM). Twenty-four cases did not physician’s request. Immunohistochemistry and PCR report any known exposure or risk testing demonstrated the presence of factors; however, one had contact with Fifty-two cases were investigated by Clostridium perfringens in necrotic a household member enrolled in a MDH in 2004, compared to 38 cases in bowel of a 30-year-old female who childcare center. Young children 2003. The cause(s) of illness subse­ died with GI symptoms. infected with hepatitis A are often quently were determined by the asymptomatic or have mild illness, but providers for 11 cases. Among the Viral Hepatitis A are efficient transmitters of disease. remaining 41 cases, 17 case-patients In 2004, 59 cases of hepatitis A (1.2 per presented with respiratory symptoms; 100,000 population) were reported. Hepatitis A vaccine is licensed for five presented with shock/sepsis; six Forty-five (76%) case-patients were persons 2 years of age and older. presented with neurologic symptoms; residents of the Twin Cities metropolitan Although all persons could potentially two presented with cardiac symptoms, area, including 16 (36%) residents of benefit from receiving hepatitis A seven presented with sudden unex­ Hennepin or Ramsey Counties. Thirty- continued...

54 DCN 33;4 July/August 2005 vaccine, those who travel to hepatitis A sexual. Two (5%) case-patients case-patients resided in Greater endemic countries and MSM, in reported using needles to inject drugs, Minnesota. The median age was 24 particular, should be educated about four (9%) received a tattoo within 6 years (range, 14 to 53 years). Twelve their increased risk of acquiring months prior to onset of symptoms, (52%) case-patients were female. hepatitis A, and offered vaccine. and one (2%) case-patient reported a Fourteen (61%) were white; six (26%) recent history of blood transfusion. were American Indian; two (9%) were Viral black, and one (4%) was of unknown In 2004, 69 cases of acute hepatitis B Hepatitis B vaccine has been available race. Incidence rates were higher virus (HBV) infection (1.4 per 100,000) since 1982, yet it continues to be among American Indians (10.9 per were reported, with no deaths. The age underutilized in persons at greatest risk 100,000 population) and blacks (1.2 of case-patients ranged from 1 to 75 of infection. A large proportion of per 100,000 population) than among years (median, 35 years). Forty-two hepatitis B case-patients identified risk whites (0.3 per 100,000 population). (61%) of these case-patients had factors for sexual transmission; clinical symptoms; the remaining 27 therefore, health care providers should Among the 23 case-patients, 17 (74%) had documented asymptomatic discuss the need for HBV testing and reported using needles to inject drugs. seroconversions. Thirty-seven (54%) vaccination with at-risk patients, Five (22%) case-patients had sexual were residents of the Twin Cities including all unvaccinated adolescents, contact with a known anti-HCV-positive metropolitan area, including 18 (26%) young adults, and patients seen for partner within 6 months prior to onset in Hennepin County and 13 (19%) in other sexually transmitted diseases. of symptoms; two (9%) had a recent Ramsey County. Forty-eight (70%) tattoo and one (4%) had recent cases were male, and 36 (52%) were In addition to the 69 hepatitis B cases, surgery. (A case-patient may have >1 adolescents or young adults between five perinatal infections were identified risk factor.) 13 and 39 years of age. Forty-one in infants who tested positive for (59%) were white, 16 (23%) were HBsAg during post-vaccination MDH received more than 3,200 reports black, and three (4%) were Asian; race screening performed at 9 to 15 months of newly identified anti-HCV-positive was unknown for nine (13%). Two (3%) of age. Four perinatal case-patients persons in 2004, the vast majority of case-patients were of Hispanic were born in 2003 and one was born in whom are chronically infected. ethnicity. Although the majority of 2002. All five perinatal infections Because most cases are asymptom­ cases were white, incidence rates were occurred in infants identified through a atic, medical providers are encouraged higher among blacks (9.3 per public health program that works to to consider each patient’s risk for HCV 100,000), Asians (2.1 per 100,000), ensure appropriate prophylactic infection to determine the need for and Hispanics (1.4 per 100,000) than treatment of infants born to HBV- testing. Patients for whom testing is among non-Hispanic whites (1 per infected mothers. The infants were indicated include: persons with past or 100,000). born in the United States and had present injecting drug use; recipients received hepatitis B immune globulin of transfusions or organ transplants Forty-three (62%) of the 69 case- and three doses of hepatitis B vaccine before July 1992; recipients of clotting patients were interviewed regarding in accordance with the recommended factor concentrates produced before possible modes of transmission. Thirty- schedule (i.e., were treatment failures). 1987; persons on chronic hemodialy­ five (81%) reported having sexual Despite these treatment failures, the sis; persons with persistently abnormal contact with one or more partners success of the public health prevention alanine aminotransferase levels; within 6 months prior to onset of program is demonstrated by the fact healthcare, emergency medical, and symptoms; 17 (49%) of whom reported that an additional 791 infants born to public safety workers after needle sexual contact with two or more HBV-infected women during 2002-2003 sticks, sharps, or mucosal exposures partners. Of those reporting sexual had post-serologic testing demonstrat­ to HCV-positive blood; and children activity, 27 (77%) reported their sexual ing no infection. born to HCV-positive women. Infants preference as heterosexual, five (14%) born to HCV-infected mothers should reported their sexual preference as Viral Hepatitis C be tested at 12 to 18 months of age, homosexual, and three (9%) reported In 2004, 23 cases of acute hepatitis C as earlier testing tends to reflect their sexual preference as bisexual. virus (HCV) infection were reported. maternal antibody status. Persons who Thirteen (30%) case-patients reported Sixteen (70%) of these case-patients test positive for HCV should be having contact with a known carrier of had clinical symptoms, and seven screened for susceptibility to hepatitis hepatitis B surface antigen (HbsAg); 10 (30%) were asymptomatic A and B virus infections and immu­ (77%) of whom reported the contact as seroconversions. Fourteen (61%) nized appropriately. WE ARE MOVING AT THE END OF OCTOBER TO ST. PAUL The Minneapolis building will be vacated including the Public Health Laboratory. The telephone numbers for infectious disease reporting are 612-676-5414 until 10/31/05, and 651-201-5414 beginning 10/31/05. Toll-free 1-877-676-5414 will remain the same.

DCN 33;4 July/August 2005 55 Mark the Date: 11th Annual Emerging Infections in Clinical Practice and Emerging Health Threats Conference, Minneapolis, November 10-11(half-day), 2005 Topics Include: STD’s, Diagnostics, Tuberculosis, New Vaccines, Neonatal Infections, CA-MRSA, Infection Control, Hot Topics and More..... See University of Minnesota CME Website http://www.med.umn.edu/cme/courses/home.html for more informaton

CHANGING YOUR ADDRESS? Dianne Mandernach, Commissioner of Health Please correct the address below and send it to: DCN MAILING LIST Division of Infectious Disease Epidemiology, Prevention and Control Minnesota Department of Health 717 Delaware Street SE Harry F. Hull, M.D...... Division Director & State Epidemiologist PO Box 9441 Richard N. Danila, Ph.D., M.P.H...... Assistant State Epidemiologist Minneapolis, MN 55440-9441 Valerie Solovjovs...... Production Editor or email to [email protected]

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). If you require this document in another format such as large print, Braille, or cassette tape, call 612-676-5414 or, Toll-Free, call 1-877-676-5414