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State of Illinois Pat Quinn, Governor Department of Public Health Damon T. Arnold, M.D., M.P.H., Director

The Epidemiology of Infectious Diseases in Illinois, 2007 The Epidemiology of Infectious Diseases in Illinois, 2007 TABLE OF CONTENTS

Reportable Communicable Diseases in Illinois ...... 1 2007 Summary of Selected Illinois Infectious Diseases ...... 3 Acquired Immune Deficiency /Human Immunodeficiency Virus ...... 6 Amebiasis ...... 10 Babesiosis ...... 12 Blastomycosis ...... 13 ...... 15 ...... 18 Campylobacteriosis ...... 21 Central Nervous System ...... 24 Aseptic Meningitis or Encephalitis of Unknown Etiology ...... 25 Aseptic Meningitis or Encephalitis of Known Etiology, Excluding Arboviruses ...... 27 Arboviral Infections ...... 29 Haemophilus influenzae (Invasive Disease) ...... 37 ...... 40 Neisseria meningitidis, Invasive ...... 43 ,Group B, Invasive ...... 47 Cryptosporidiosis ...... 49 Cyclosporiasis ...... 53 ...... 54 Shiga Toxin Producing E. coli, Enterotoxigenic E. coli, Enteropathogenic E. coli ...... 58 Foodborne and Waterborne outbreaks...... 63 Giardiasis ...... 92 Hansen’s Disease (Leprosy) ...... 95 Hemolytic Uremic Syndrome ...... 96 Hepatitis A ...... 98 Hepatitis B ...... 102 Hepatitis C, Acute...... 105 Hepatitis C, Chronic or Resolved ...... 108 Histoplasmosis ...... 110 , Novel ...... 113 Influenza-associated Pediatric Mortality (< 18 years) ...... 114 Legionellosis ...... 115 ...... 118 Malaria ...... 123 ...... 128 Mumps ...... 130 Pertussis ...... 133 Q ...... 136 Rabies ...... 138 Rabies, Potential Human Exposure ...... 154 Rocky Mountain Spotted Fever ...... 159 (Non-Typhoidal) ...... 162 Sexually Transmitted Diseases ...... …… ...... 172 ...... 172 ...... 174 ...... 176 ...... 179 , Intermediate or High Level Resistance ...... 185 , Group A (Invasive Disease) ...... 186 S. pneumoniae, Invasive ...... 189 ...... 192 Tick-borne Diseases Found in Illinois ...... 193 Toxic Syndrome Due to Staphylococcus aureus ...... 195 Tuberculosis ...... 197 ...... 201 Typhoid Fever ...... 203 Varicella ...... 205 Vibrio, Non-cholera...... 207 Yersiniosis ...... 209 Non-foodborne Non-Waterborne Outbreaks, 2007 ...... 212 Other Incidents Occurring in 2007 ...... 234 Reported Cases of Infectious Diseases in Illinois, 2007 ...... 236 Methods ...... 237 Reportable Communicable Diseases in Illinois The following diseases must be reported to local health authorities in Illinois (those in bold are also nationally notifiable, which means reportable by the state health department to the U.S. Centers for Disease Control and Prevention):

CLASS 1(a) - The following diseases are reportable by telephone immediately (within three hours): 1. 5. Smallpox 2. Botulism, foodborne 6. Tularemia 3. 7. Any suspected bioterrorist threat 4. Q-fever or event

CLASS 1(b) -The following diseases are reportable within 24 hours of diagnosis: 1. Botulism, infant, wound, and other 12. Measles 2. Cholera 13. Pertussis 3. of the newborn 14. Poliomyelitis 4. Diphtheria 15. Rabies, human 5. Foodborne or waterborne illness 16. Rabies, potential human exposure 6. Hemolytic uremic syndrome, post-diarrheal 17. Typhoid fever 7. Hepatitis A 18. Typhus 8. Any unusual case or cluster of cases that may 19. Enteric Escherichia coli infections indicate a public health hazard (E. coli)0157:H7 and other 9. Haemophilus influenzae, meningitis and other enterohemorrhagic E. coli, invasive disease enterotoxigenic E. coli) 10. Neisseria meningitidis. Meningitis and invasive enteropathogenic E. coli) disease 20. Staphylococcus aureus infections with 11. Streptococcal infections, Group A, invasive intermediate or high level (Including toxic shock syndrome) and sequelae resistance to to group A streptococcal infections ( and acute glomerulonephritis)

(Continued on attached page)

1 CLASS II-The following diseases shall be reported as soon as possible during normal business hours, but within seven days (exceptions to the seven-day notification requirement are marked with an asterisk; see note below.) 1. AIDS 27. Malaria 2. Amebiasis 28. Meningitis, aseptic (including arbovirus ) 3. Blastomycosis 29. Mumps 4. Brucellosis 30. Ophthalmia neonatorum (gonococcal)* 5. Campylobacteriosis 31. Psittacosis 6. Chanchroid* 32. Reye’s syndrome 7. Chickenpox 33. Rocky Mountain spotted fever 8. Chlamydia* 34. Rubella, including congenital 9. Cryptosporidiosis 35. Salmonellosis (other than typhoid) 10. Cyclosporiasis 36. Shigellosis 11. Ehrlichiosis, human 37. Staphylococcus aureus infection, toxic shock granulocytic syndrome 12. Ehrlichiosis, human 38. Staphylococcus aureus infections occurring in monocytic infants under 28 days of age (within a health care 13. Encephalitis care institution or with onset after discharge) 14. Giardiasis 39. Streptococcal infections, group B, invasive disease, 15. Gonorrhea* of the newborn 16. Hantavirus pulmonary 40. , invasive disease syndrome (including susceptibility test results) 17. Hepatitis B 41. Syphilis* 18. Hepatitis C 42. Tetanus 19. Hepatitis, viral, other 43. Trichinosis 20. Histoplasmosis 44. Tuberculosis 21. HIV infection 1 45. Yersiniosis 22. Legionnaires’ disease 23. Leprosy 24. 25. Listeriosis 26. Lyme disease *Must be reported by mail or by telephone to the local health authority within five days The occurrence of any increase in incidence of disease of unknown or unusual etiology should be reported, with major listed. When an epidemic of a disease dangerous to the public health occurs and present rules are not adequate for its control or prevention, more stringent requirements shall be issued by the Illinois Department of Public Health.

2 2007 Summary of Selected Illinois Infectious Diseases In Illinois, the communicable disease (CD) surveillance system relies on the passive reporting of cases required by state law. Diseases are made reportable because regular and timely information is necessary for prevention and control efforts. Lists of notifiable diseases are revised to include new pathogens or delete those with declining importance. The current reportable disease list mandates reporting, within specific time frames, of certain diseases and of selected positive laboratory tests. Surveillance of notifiable diseases provides public health workers the opportunity to ensure that ill persons receive appropriate treatment, provide contacts with needed vaccines or other preventive treatments, and halt outbreaks. The effectiveness of the surveillance system relies heavily on the cooperation and support of health care providers, laboratories and local health departments in submitting information on reportable disease cases. In Illinois, regulations require reporting by physicians, nurses, nurses aides, dentists, health care practitioners, laboratory personnel, school personnel, long-term care personnel, day care personnel, and university personnel. Notifiable disease data are submitted by the Illinois Department of Public Health (the Department) on a weekly basis to be included with national data in the Morbidity and Mortality Weekly Report (MMWR). CD rules also include laboratory reporting. Some isolates are required to be forwarded to the Department. For selected agents and situations, pulse field gel electrophoresis may be performed to subtype isolates. Four diseases – SARS, smallpox, human influenza caused by a new subtype and wild type polio - are considered to be a public health emergency of international concern by the World Health Organization. There are 55 diseases or conditions listed as nationally reportable to the U.S. Centers for Disease Control and Prevention (CDC). This number reflects certain combinations; for example, HIV and AIDS are combined under one category (human immunodeficiency virus/acquired immune deficiency syndrome [HIV/AIDS]) as are invasive group A streptococcus (GAS) and toxic shock syndrome due to GAS. Diseases reportable to CDC but not reportable in Illinois include animal rabies, severe acute respiratory syndrome (SARS), varicella, coccidioidomycosis, influenza associated pediatric mortality, and yellow fever. Animal rabies testing only is performed by state laboratories, so reporting is complete through state laboratory reporting. Other diseases in Illinois of public health importance can be reported as cases or clusters of unusual illness. Varicella and severe acute respiratory syndrome reporting in Illinois was mandated in 2008. In 2007, the 10 most frequently reported notifiable infectious diseases in the were chlamydia, giardiasis, gonorrhea, AIDS, salmonellosis, shigellosis, varicella, Lyme disease, tuberculosis and syphilis.. In 2007, 65 different types of infectious diseases were reportable to the Illinois Department of Public Health (see pages 1 and 2). Many of the reportable diseases are discussed in this annual report along with some non-reportable diseases of importance in 2007. Case numbers for the various infectious diseases listed in this summary should be considered minimum estimates. There are several reasons why reported numbers are lower than the actual incidence of disease: Many individuals do not seek medical care and thus are not diagnosed; some cases are diagnosed on a clinical basis without confirmatory or supportive laboratory testing; and among diagnosed cases, some are

3 not reported. These surveillance data are used to evaluate disease distribution trends over time rather than to identify precisely the total number of cases occurring in the state. The five most frequently reported nationally notifiable infectious diseases in Illinois were chlamydia, gonorrhea, HIV/AIDS, Salmonella and invasive S. pneumoniae. Diseases with increased reporting in 2007 over the previous five-year median included amebiasis, Chlamydia, human monocytic ehrlichiosis, human granulocytic anaplasmosis, other ehrlichia species, giardiasis, S. pneumoniae, Shigella, mumps, Lyme disease, N. meningitidis, ehrlichiosis, blastomycosis, , Rocky Mountain spotted fever, cryptosporidiosis, hepatitis A, histoplasmosis, Legionellosis, pertussis, staphylococcal toxic shock, and typhoid fever. The number of reported cases of California encephalitis, West Nile virus, Giardia, hepatitis A, pertussis, tuberculosis, tularemia, have been decreasing compared to the previous five-year median. Highlights of 2007 in Illinois included: • A large number of complaints about itch mite bites • A cluster of cases in slaughterhouse workers • A foodborne adult lead poisoning cluster • Reported cases of cases • Two reportable cases of novel influenza • Two reported babesiosis cases exposed outside Illinois • Two tetanus cases • A case of excema vaccinatum in a household member of a military person vaccinated for smallpox Studies mentioned in the text of this report will be referred to in the selected readings sections. The reporting of infectious diseases by physicians, laboratory and hospital personnel, and local health departments is much appreciated. Without the support of the local health departments in following up on disease reports, it would not be possible to publish this annual report. The Department hopes you find this information useful and welcomes any suggestions on additional information that would be of use to you.

Useful Contact/Surveillance Information Illinois Department of Public Health website www.idph.state.il.us

To report cases: Contact your local health department.

To refer isolates to the Department lab ship to one of these locations: Public Health Laboratory; 825 N. Rutledge St., Springfield IL 62761 Public Health Laboratory; 1155 S. Oakland Ave., P.O. Box 2797, Carbondale IL 62901 Public Health Laboratory; 2121 W. Taylor St., Chicago, IL 60612

4 Illinois Counties

5 Acquired Immune Deficiency Syndrome/Human Immunodeficiency Virus

Background Since the first cases were reported in the summer of 1981, acquired immune deficiency syndrome (AIDS) has become one of the major health problems to emerge in the past 25 years. In 1984, the human immunodeficiency virus (HIV) was identified as the causative agent of AIDS. The disease is spread by the exchange of blood, semen or vaginal secretions between individuals. The most common routes of transmission are 1) having sex (anal, oral or vaginal) with an infected person, 2) sharing drug injection equipment with an infected person (including insulin or steroid needles), and 3) from mother to infant (perinatal) before or at the time of birth or through breastfeeding. In 2007, injection drug use (IDU) was the third most frequently reported risk factor for HIV infection in the United States after male-to-male sexual contact and high-risk heterosexual contact. From 2004 through 2007, in the United States, the majority of HIV- infected IDUs (62 percent) were male. Many IDUs engage in high-risk behaviors like sharing syringes and having unprotected sex. Within weeks to months after infection with HIV, some individuals develop a flu- like illness. After this initial illness, individuals with HIV may remain free of clinical signs for months to years. Clinical indicators of HIV infection may include , chronic diarrhea, weight loss, fever and fatigue followed by opportunistic infections. HIV may progress to AIDS, which includes a variety of late-term clinical manifestations including low T-cell counts. Opportunistic infections associated with AIDS include Pneumocystis carinii , chronic cryptosporidiosis, central nervous system toxoplasmosis, candidiasis, disseminated cryptococcosis, tuberculosis, disseminated atypical mycobacteriosis and some forms of cytomegalovirus infection. Some cancers also may be associated with AIDS (e.g., Kaposi sarcoma, primary B-cell lymphoma of the brain, invasive cervical cancer and non-Hodgkin’s lymphoma). Increased knowledge of the disease and improved diagnostic and treatment methods have led to significant advances in the clinical management of HIV and resulted in a delay in the progression from HIV to AIDS and a reduction in AIDS morbidity and mortality. A number of antiretroviral agents are available for treatment of HIV/AIDS, and combination therapies have been shown to prolong and improve the quality of life for those who are infected. At the end of 2007, an estimated 455,636 persons in the United States were living with AIDS. During 2003 to 2007 the number of new AIDS cases decreased 7.5 percent.

Case definition The CDC case definition (available on the CDC website) is used for HIV and AIDS.

Descriptive epidemiology • Cumulative AIDS cases reported in Illinois (1981 through 2007) – There were 3,682 cases reported. • Number of AIDS cases reported in calendar year 2007 - The number of reported AIDS cases rose from 2006 (1,254) to 2007 (1,394). The number of reported HIV cases was 1,707, a decrease from the 1,876 reported in 2006.

6 • Mode of transmission among all AIDS cases reported in Illinois in 2007 is shown in Figure 1 and for HIV in Figure 2. • The majority of reported AIDS cases in 2007 were in males (1,083 cases or 78 percent). For all cases reported among males, men who have sex with men (MSM) accounted for the largest number of AIDS cases (596 cases or 55 percent), followed by injection drug use (IDU) with 122 cases or 11 percent (Figure 3). The majority of reported HIV cases in 2007 were in males (1,341 or 78 percent). For all cases reported among males, MSM accounted for the largest number of HIV cases (870 or 65 percent), followed by IDUs with 66 or 5 percent (Figure 4). • Reported cases of AIDS among females accounted for 311 cases or 22 percent of the total AIDS cases reported in 2007. Among females, heterosexual contact accounted for 140 cases or 45 percent of the total, with IDU accounting for 65 cases or 21 percent (Figure 5). Reported cases of HIV among females accounted for one case or 21 percent of the total reported HIV cases in 2007. Among females, heterosexual contact accounted for 129 cases or 39 percent of the total HIV cases reported, with IDU accounting for 38 cases or 11 percent (Figure 6). • Non-Hispanic African Americans accounted for 55 percent of the AIDS cases reported in 2007, followed by 27 percent or white non-Hispanic and 14 percent Hispanic. For HIV infection, non-Hispanic African Americans accounted for 48 percent of cases, white non-Hispanics accounted for 37 percent and Hispanics for 12 percent. • Heterosexual contact as the mode of transmission accounted for 16 percent, or 225 of all the reported AIDS cases in 2007. It accounted for 11 percent of HIV cases. • In 2007, Cook County and the collar counties (DuPage, Kane, Lake, McHenry and Will) comprised 87 percent of the total reported AIDS cases. Cook County and the collar counties comprised 86 percent of the total reported HIV cases.

Summary There were 1,394 AIDS cases and 1,707 HIV cases reported in Illinois between January 1 and December 31, 2007. Most reported AIDS and HIV cases involved males. The most common risk factor for transmission for HIV and AIDS in males was MSM. Heterosexual contact was the most common risk factor for females with HIV and AIDS, followed by IDU. The increased number of reported cases of AIDS is probably due to delays in reporting by healthcare providers.

Figure 1. Reported AIDS Cases in Illinois by Mode of Transmission, 2007

23% MSM Heterosexual 44% 4% IDU 13% MSM/IDU 16% Undetermined/other

7 Figure 2. Reported HIV Cases in Illinois by Mode of Transmission, 2007

MSM 30% Heterosexual 51% IDU 2% MSM/IDU 6% Undetermined/other 11%

Figure 3. Reported AIDS Cases in Illinois Males by Mode of Transmission, 2007

20% MSM Heterosexual 5% IDU 56% 11% MSM/IDU 8% Undetermined/other

Figure 4. Reported HIV Cases in Illinois Males by Mode of Transmission, 2007

24% MSM Heterosexual 2% IDU 5% 65% MSM/IDU 4% Undetermined/other

8 Figure 5. Reported AIDS Cases in Illinois Females by Mode of Transmission, 2007

34% Heterosexual 45% IDU Undetermined/other 21%

Figure 6. Reported HIV Cases in Illinois Females by Mode of Transmission, 2007

36% Heterosexual 54% IDU Undetermined/other 10%

9 Amebiasis

Background Entamoeba histolytica is a protozoan parasite that exists in two forms: the cyst and the trophozoite. It is an important health risk to travelers to the Indian subcontinent, southern and western Africa, the Far East, and areas of South and Central America. Intestinal disease can range from mild diarrhea to dysentery with fever, chills, weight loss and bloody or mucoid diarrhea. Extraintestinal amebiasis also can occur. Persons can develop amebic , which is more common in males than females. This may occur within two to four weeks of infection and include fever, cough and dull aching abdominal pain. Some persons are asymptomatic. Humans are the reservoir for Entamoeba histolytica. Infection occurs when a person ingests fecally contaminated food or water that contains the cyst or through oral-anal contact. The incubation period ranges from two to four weeks. In the United States, amebiasis is most commonly seen in immigrants and travelers to foreign countries. While examination of stool for ova and parasites often is done, these tests cannot differentiate E. histolytica from nonpathogenic species like E. dispar and E. moshkovskii. There are now polymerase chain reaction (PCR) and antigen detection tests which can be used for differentiation.

Case definition The CDC case definition used by the Department for a confirmed intestinal amebiasis case is as follows: a clinically compatible illness that is laboratory confirmed by demonstration of cysts or trophozoites of E. histolytica in stool, or demonstration of trophozoites in tissue biopsy or in ulcer scraping by culture or histopathology. The definition for a case of extraintestinal amebiasis is a parasitologically confirmed infection of extraintestinal tissue; or, among symptomatic persons with clinical and/or radiographic findings consistent with extraintestinal infection, demonstration of specific antibody against E. histolytica as measured by indirect hemagglutination or enzyme-linked immunosorbent assay (ELISA).

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – 107 (five-year median = 75). All cases were confirmed. From 2002 to 2007, the number of cases reported per year ranged from 49 to 107 (Figure 7). • Age - Cases ranged from birth to 84 years of age (mean = 30 years) (Figure 8). • Gender - Males accounted for 53 percent of cases. • Race/ethnicity – Twenty-one percent of cases were white, 57 percent were African American, with 22 percent reporting some other racial identity; 6 percent of 65 cases for whom a response is known identified themselves as Hispanic. • Seasonal variation – There was an increase in cases in April, June, August and September (Figure 9). • Geographic location – Ninety of 107 (84 percent) of cases lived in Cook County. • Clinical outcome – Two of 15 cases with information available were admitted to the hospital, and none were known to be fatal.

10 Summary The number of cases in 2007 was higher than the five-year median. Amebiasis was dropped from the required reporting in Illinois in 2008.

Figure 7 . Amebiasis Cases in Illinois, 2002-2007

150 107 86 89 100 75 75 49 50

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 8. Age Distribution of Amebiasis Cases in Illinois, 2007

30

20

10

Number of cases Numberof 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Age in years

Figure 9. Amebiasis Cases in Illinois by Month, 2007

20 15 10 5

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month

11 Babesiosis

Background Babesiosis is a protozoal illness transmitted primarily by Ixodes scapularis ticks in North America. B. microti, B. duncani and B. divergens-like organisms infect humans. B. microti is found mainly in the northeast and upper Midwestern states. The incubation period is from one to six weeks. In Minnesota, onsets of illnesses are usually in July and August. Babesiosis is usually a self-limiting disease and symptoms include fever, , and fatigue. Complications can include congestive heart failure, acute respiratory failure and renal failure. People at increased risk for complications are those who are immunocompromised, asplenic, elderly or infected with other tick-borne pathogens. Patients can harbor the parasite for months or years asymptomatically and can transmit it through blood products. There is no licensed screening test for babesiosis in donated blood. Treatment is and quinine.

Case definition A confirmed case is a person with clinically compatible illness and laboratory positive by blood smear or PCR for Babesia. Probable cases are clinically compatible with positive serology.

Descriptive epidemiology Number of cases – Two cases were reported in Illinois residents. Individual Descriptions • A woman in her eighties who had traveled to Mexico and Minnesota eight months prior to illness in September developed fever and dark urine. She was hospitalized for nine days. She also had multiple blood transfusions in late July but all donors tested negative. She was laboratory positive for B. microti infection at CDC. Cases of babesiosis have been acquired in Minnesota, however, the Minnesota exposure was well prior to the usual incubation period for this pathogen. • Another female in her seventies was diagnosed with babesiosis in August while in Massachusetts. She had a splenectomy as a result of this infection.

Suggested readings Gallagher, L.G. et. al. An 84-year-old woman with fever and dark urine. CID 2009;49: 278, 310-311. Gubernut, D.M., et. al. Babesia infection through blood transfusions: Reports received by the U.S. Food and Drug Administration, 1997-2007. CID 2009;48:25-30.

12 Blastomycosis

Background Blastomycosis is most often found in persons living in Midwestern, southeastern and south central United States and the Canadian provinces that border the Great Lakes. Occasionally, outbreaks occur in areas outside the endemic areas. The ideal area for the mycelial form of the organism is soil of warm, moist, wooded areas rich in organic debris. Recreational activities along waterways are considered to be a major risk factor for infection. Transmission is usually through inhalation of spore-laden dust. Blastomycosis most commonly presents as a subacute pulmonary disease but can range from asymptomatic to disseminated disease. For symptomatic infections, the incubation period ranges from 30 to 45 days. Blastomycosis is usually localized to the respiratory tract but can expand to other locations in the body in about 25 to 40 percent of cases. Persons with moderate to severe pneumonia, disseminated infection or persons infected who are also immunocompromised need treatment. Diagnosis is through culture, direct visualization of the organism in cytologic or histologic specimens. There are also commercial tests for Blastomyces antigen. Urine antigen assays can cross react with other fungal diseases, such as histoplasmosis. Serologic testing lacks sensitivity and specificity.

Case definition The case definition for confirmed blastomycosis in Illinois is culture confirmation of Blastomyces dermatitidis. If the diagnosis was based on a needle aspirate or other diagnostic specimen with demonstration of organism resembling Blastomyces or a presumptive Blastomycosis culture, it is considered a probable case if illness is clinically compatible.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – 137 (previous five-year median= 91). All but 12 cases were confirmed. From 2002 to 2007, the number of cases per year ranged from 87 to 137 (Figure 10). The 2007 incidence rate was 1.1. per 100,000 population in Illinois. • Age - The mean age was 43 years (range eight to 88) (Figure 11). • Gender - Seventy-one percent were male. • Race/ethnicity – Fifty-four percent of the cases were white, 32 percent were African American, and 14 percent were other races; Twenty-one percent were Hispanic. • Geographic distribution – Sixty-three percent of the cases had residential addresses in Cook, Lake or Will counties. • Seasonal – There appeared to be a slight decrease in cases from July through September. • Reporting – Fifty-eight percent of reports were from infection control professionals and 26 percent from laboratory staff. • Treatment – Seventy-two percent of cases were hospitalized and two cases were fatal.

13 Summary A higher number of blastomycosis cases were reported in 2007 (137 cases) as compared to the five-year median of 91. This is the highest number of cases reported since at least 1996. Blastomycosis cases occur predominantly in adults. Many cases had symptoms of respiratory involvement, including cough, dyspnea or hemoptysis. Among reported cases, 63 percent of cases reported living in Cook, Lake and Will counties. This is the last year with full year reporting for blastomycosis.

Suggested readings Chapman, S.W. Clinical practice guidelines for the management of blastomycosis: 2008 Update by the Infectious Diseases Society of America. Clin Inf Dis 2008;46:1801- 12.

Figure 10. Blastomycosis Cases in Illinois, 2002-2007

137 150 119 104 89 91 100 87

50

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 11 . Blastomycosis Cases by Age in Illinois, 2007

40 30 20 10

Number of cases Numberof 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39yr 40-49 yr 50-59 yr >60 yr Age in years

14 Botulism

Background There are three forms of botulism: foodborne, wound and intestinal (adult and infant). Botulism toxins cause neuromuscular blockage, which results in flaccid paralysis. All forms of botulism produce the same distinct clinical syndrome, which includes symmetrical cranial nerve palsies followed by descending flaccid symmetrical paralysis that can progress to constipation, respiratory failure, and death. Other symptoms of botulism include diplopia, blurred vision, abnormal body temperature, and ptosis. As botulism progresses, the patient retains intellectual function. The absence of cranial nerve palsies (blurry vision, diplopia, ptosis, facial paralysis, dysphagia, severe dry mouth) rules out a diagnosis of botulism. Differential diagnoses include myasthenia gravis and Guillain-Barré syndrome. These can be differentiated using electromyography (EMG), the pattern of paralysis and reaction to Tensilon. Foodborne botulism is caused by a neurotoxin produced by botulinum and results from ingestion of preformed toxin present in contaminated food. C. botulinum is found in soil and aquatic sediments. Seven toxins (A-G) can be produced by C. botulinum. C. baratii and C. butyricum also can produce some botulinum toxins. Human cases are caused mainly by toxin types A, B, E and, rarely, F. C. botulinum can form a spore that survives cooking and food processing measures. Spore germination can occur during anaerobic conditions, consisting of nonacidic pH and low salt and sugar content. Botulism toxins are inactivated by heating. Foodborne botulism can occur in home canned foods and traditional Alaska native dishes. From 1950 through 2005, 405 events of foodborne botulism were identified in the United States where an implicated food item was identified. Ninety-two percent of events were linked to home-processed foods and 8 percent to commercially processed foods. Treatment for foodborne botulism is prompt administration of polyvalent equine source antitoxin which can decrease progression of paralysis but not reverse existing paralysis. Equine botulinum antitoxin for types A, B and E can prevent progression of neurologic disease if administered early in the course of illness. The most common form of intestinal botulism and of botulism in general is infant botulism. It occurs in infants younger than one year of age. Infant botulism results when swallowed spores germinate and temporarily colonize the large intestine. It is believed to occur because competing organisms are not yet present in the digestive tract. Honey consumption has been linked to some infant botulism cases but probably only accounts for about 20 percent of infections. Botulism in infants younger than 12 months of age should be suspected when constipation, lethargy, poor feeding, weak cry, bulbar palsies, and failure to thrive are present. Diagnosis of infant botulism involves detection of botulinum toxin in stool or serum by using a mouse neutralization assay or the isolation of toxigenic C. botulinum in the feces by enrichment culture techniques. Adult intestinal botulism is rare and occurs mainly in patients with an anatomical or functional bowel abnormality or those patients using antimicrobials, which decreases the normal flora to compete with Clostridium species. Wound botulism occurs after the causative organism contaminates a wound that is anaerobic. Wound botulism has increased in recent years due to an increase in injection drug users, especially those who use heroin. Wound botulism is caused by toxin elaboration in infected tissue. The mouse bioassay may not detect all clinical cases of

15 wound botulism. Iatrogenic botulism is caused by injection of botulinum toxin for cosmetic or therapeutic purposes. The doses used for cosmetic treatment are too low to cause systemic disease. If botulism is suspected, contact your local health department immediately. This will allow for rapid investigation to identify the source. If the source was a commercial product, it can be removed promptly from the market. Laboratory confirmation is still by the mouse bioassay that is costly, requires an animal facility and takes longer than one day. Twenty-two public health laboratories in the United States can do the mouse bioassay. Infant botulism cases have low circulating toxin levels but high stool toxin levels so stool testing is preferred. Administration of botulinum antitoxin must be done based on clinical suspicion. There were 26 cases of foodborne botulism reported in 2007 to CDC. There were also 91 cases of infant botulism and 22 cases of other types of botulism reported to CDC. Eleven states reported foodborne botulism cases. Toxin type A accounted for 58 percent of cases, type B for 15 percent and type E for 27 percent. Four outbreaks were reported. Three were in Alaska and due to beaver tail, seal oil and white fish. The fourth outbreak was related to contaminated commercial hot dog chili sauce. At least four cases of botulism were linked. Botulinum toxin type A was identified in leftover chili mix. Product was recalled after improper canning was identified. Toxin also was identified in previously unopened cans from the plant and there were many cans that were swollen. There were 91 cases of infant botulism from 23 states. The toxin types involved were A (43 percent), B (56 percent) and E (1 percent). The median age of cases was 15 weeks. The wound botulism cases were reported from California and Washington states.

Case definition Botulism, infant Clinical illness may include poor feeding, constipation, failure to thrive, and respiratory failure. The case definition for infant botulism is a clinically compatible case that is laboratory confirmed, occurring in a child younger than 1 year of age. Laboratory confirmation is isolation of C. botulinum from stool or detection of botulinum toxin in stool or serum.

Botulism, foodborne Clinical illness includes diplopia, blurred vision and bulbar weakness. Symmetric paralysis may progress quickly. Laboratory confirmation consists of detection of botulinum toxin in stool, serum or patient ‘s food or isolation of C. botulinum from stool. A probable case is a clinically compatible case with an epidemiologic link (ingestion of home-canned food within the previous 48 hours). A confirmed case is a clinically compatible case that is laboratory confirmed or that occurs among persons who ate the same food as persons who have laboratory-confirmed botulism.

Botulism, wound Common symptoms include diplopia, blurred vision and bulbar weakness as well as symmetric paralysis. Laboratory confirmation is by detection of botulinum toxin in serum or isolation of C. botulinum from wound. A confirmed case is a clinically compatible illness that is laboratory confirmed in a patient who has no suspected

16 exposure to contaminated food and who has a history of a fresh, contaminated wound during the two weeks before symptom onset.

Descriptive epidemiology • There was one case of infant botulism in Illinois in 2007. • Individual description o Type E botulism was identified in specimens from a one-week-old patient from Dupage County. No food source could be identified as the cause of illness.

Suggested readings Ginsberg, M.M., et. al. Botulism associated with commercially canned chili sauce- Texas and Indiana, July 2007. Sobel, J. Diagnosis and treatment of botulism: A century later, clinical suspicion remains the cornerstone. CID 2009; 48:1674-5. Wheeler, C., et. al. Sensitivity of mouse bioassay in clinical wound botulism. CID 2009;48:1669-73.

17 Brucellosis

Background Brucellosis is a systemic bacterial infection that affects a wide variety of mammalian species and is caused by Brucella species. This infection can cause intermittent or continuous fever and headache, lower back pain, sweating and arthralgia. Chronic disease can result in in the liver, spleen, brain, bone or heart valves. The incubation period varies from two to 10 weeks (range of a few days to six months). Symptoms can last from days to years. Six major species have been characterized: B. abortus, B. melitensis, B. suis, B. canis, B. bovis and B. neotomae. Brucella species considered of importance in human disease include B. abortus (cattle are the primary reservoir), B. melitensis (sheep and goats are the primary reservoir) and B. suis (swine are the primary reservoir). Dogs are reservoirs of B. canis but are not considered to be an important public health concern in the United States. Transmission is by contact with animal tissues, such as blood, urine, vaginal discharges, aborted fetuses and placentas and by ingestion of raw milk or other dairy products. Investigation of Brucella cases could reveal foci of infection in United States livestock that should be investigated and eliminated. The disease is most common in residents or travelers to the Mediterranean, Middle East, Mexico, and Central and South America. The large majority of human Brucella cases are thought to be due to travel outside the country and consumption of contaminated products from those countries. Consumption of soft cheese from regions where Brucella is endemic in cattle, sheep and goats is a risk for illness. The risk for Brucella from dairy products produced in the United States is extremely low. Brucella is also a Class A bioterrorism agent. Biosafety level 3 is recommended for laboratory manipulation of isolates. Brucella is the most commonly recognized cause of laboratory transmitted infection; about 2 percent of all Brucella cases may be laboratory acquired. The infecting dose for humans is low; the organism can enter the body in many ways including through the respiratory tract, conjunctivae, through the gastrointestinal tract or through abraded skin. Laboratory infections have been acquired from sniffing culture plates and exposure to spills. Most cases of laboratory-acquired infection are from the more virulent B. melitensis species. Unidentified specimens are often handled on an open bench, which may result in exposures. When Brucella is suspected, the clinician or forwarding laboratory should note on the laboratory submission form, “Suspect or rule out brucellosis” so appropriate precautions can be taken. Antimicrobial treatment must continue for at least six weeks. In some developing countries the incidence of brucellosis may be as high as 200 per 100,000, but the disease is rare in the United States. Since 2003, the brucellosis incidence has increased in the United States. The majority of cases are Hispanic. Forty- nine states and three territories were classified as Brucellosis class free for cattle. B. abortus remains enzootic in elk and bison in Yellowstone Park and B. suis has been identified in feral swine in the southeastern United States. In the United States in 2007, 131 human brucellosis cases were reported to CDC. Most were in international travelers or immigrants. Illinois was fifth in the nation in the number of Brucella cases reported.

Case definition Illinois uses the CDC case definition for brucellosis. The case definition for a confirmed case of brucellosis is a clinically compatible illness with one of the following

18 laboratory findings: isolation of Brucella from a clinical specimen, a four-fold or greater rise in Brucella agglutination titer between acute and convalescent phase serum specimens obtained greater than or equal to two weeks apart and studied at the same laboratory, or demonstration of Brucella species in a clinical specimen by immunofluorescence. A probable case is defined as a clinically compatible case that is epidemiologically linked to a confirmed case or that has supportive serology (i.e., Brucella agglutination titer of at least 160 in one or more serum specimens obtained after symptom onset).

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – Six (five were confirmed, and one was probable) (See Figure 12). The five-year median was eight cases. • Age – The mean age of cases was 32 years (range two to 65 years). • Gender - Two cases were male and four were female. • Race/ethnicity – Race was known for three cases and all were white; all five cases with Hispanic status noted were Hispanic. • Seasonal – Onsets of illness occurred from January to October. • Geographic distribution by residence – There were four cases in Cook County and two cases from Kane County. • Individual Case Descriptions o Case one – B.melitensis biovar 1 was isolated from a Cook County 10-year- old female in September. The food source was unknown. Laboratory workers were exposed to the culture and had serial serologies to follow up. o Cases two and three – These two adult household members, one male and one female, developed infection from B. melitensis biovar 3. Onsets of illness were in April and June. The both consumed goat cheese from an unknown location. o Case four – A 2-year-old female from Kane County developed infection from B. abortus biovar 1. She had onset of illness in January and had eaten cheese from Mexico brought into the United States. o Case five – This case was a 41-year-old female living in Kane County with onset of illness in October. B. melitensis biovar 3 was isolated from the patient. She had eaten cheese brought into the United States from Mexico. o Case six – A 65-year-old male from Cook County had onset of illness in January. The case consumed dairy products from Guatemala while traveling. He had a titer to B. abortus making this case a probable case. • Diagnosis – Cultures were Brucella positive for five cases. Results for speciation were identified for five isolates: B. melitensis biovar 1 (one), B. melitensis biovar 3 (three) and B. abortus biovar 1 (one). One probable case had a high titer to B. abortus. • Clinical syndrome – Symptoms reported by cases included fever (six cases), weight loss (two cases) and night sweats (two cases). Four cases were hospitalized. No deaths were reported. • Epidemiology – One case with an epidemiologic history reported travel overseas. Four of these individuals remembered consuming dairy products from other countries. Two ate goat cheese from an unknown source and one case had an unknown exposure.

19 • Laboratory exposures - In November 2007, laboratorians at a clinical laboratory in Cook County were exposed to a Brucella culture. Five persons were offered prophylaxis. Four high-risk individuals accepted prophylaxis and one with a low-risk exposure declined. Twelve female employees had followup serologic testing. Four sequential serum samples were tested and none tested positive.

Summary In Illinois, brucellosis is an uncommon disease and tends to occur primarily in individuals who have recently traveled to foreign countries and consumed unpasteurized dairy products or who have consumed unpasteurized dairy products imported from foreign countries. In 2007, there were six brucellosis cases reported in Illinois residents, which was the fifth highest number among the states reporting cases.

Suggested readings Glynn, M.K. and Lynn, T.V. Brucellosis. JAVMA 2008;233(6):900-908.

Figure 12. Brucellosis Cases in Illinois, 2002-2007

15 13 9 10 8 7 6 5 0

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

20 Campylobacteriosis

Background Campylobacteriosis is a zoonotic bacterial enteric disease caused primarily by Campylobacter jejuni and occasionally by Campylobacter coli. Campylobacter organisms are motile, gram-negative with a curved shape. The infectious dose is large. The incubation period is two to five days. Symptoms may last up to 10 days and include diarrhea, abdominal pain and fever; however, many infections are asymptomatic. Sequelae may include reactive arthritis, febrile convulsions, a typhoid-like syndrome, Guillain-Barré syndrome or meningitis. C. jejuni infection is the most frequently identified infection preceding Guillain-Barre syndrome. Reactive arthritis can occur seven to 10 days after diarrheal illness. Excretion of the organism can occur for two to seven weeks. Approximately 1 percent of the population acquires Campylobacter each year in the United States. Among all 10 diseases under active surveillance in the federal FoodNet sites (Campylobacter, Cryptosporidium, Cyclospora, E. coli O157:H7, HUS, , Salmonella, Shigella, Vibrio and Yersinia enterocolitica), infection with Campylobacter comprised 35 percent of all of those reported in 2007. The overall incidence for this infection from the 10 FoodNet sites was 12.8 per 100,000 in 2007 (range: 7.2 to 28.4). The incidence did not change between 2004-2006 and 2007. The 2010 national health objective is for 12.3 cases per 100,000. The reservoir for Campylobacter is animals, most commonly poultry and cattle. The most important mode of transmission to humans is the consumption and handling of raw poultry products. Campylobacter is found in approximately 80 percent of retail chicken meat. Campylobacter is also a cause of traveler’s diarrhea. A study of enteric infections in Washington state showed that important risk factors for Campylobacter infections was exposure to aquatic recreation, suboptimal kitchen hygiene after preparation of raw meat or chicken, consumption of food from restaurants, domestic travel within the United States, consumption of raw herbs, farm animals on home property and drinking untreated water. Prevention of campylobacteriosis includes cooking meat thoroughly, not consuming unpasteurized milk, avoiding cross-contamination between foods and handwashing after animal handling.

Case definition The case definition for a confirmed case of campylobacteriosis in Illinois is a clinically compatible illness with isolation of Campylobacter from any clinical specimen. A probable case is a clinically compatible illness that is epidemiologically linked to a confirmed case.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – 1,277 (previous five-year median = 1294); incidence rate of 10 per 100,000 (Figure 13). All but three were confirmed cases. • Gender – Fifty-four percent of cases were male. • Age – The mean age of reported cases was 39; highest incidence rate occurred in those 1 to 4 years of age and those 50 to 59 years old. (Figure 14). • Race/ethnicity - The majority of cases (89 percent) were in whites, with 4 percent in

21 African Americans, 4 percent in Asians and 3 percent in other races. Those indicating Hispanic ethnicity accounted for 13 percent of the cases. There was a significantly higher proportion of whites with campylobacteriosis and a lower proportion of African Americans with the disease than in the total Illinois population. • Seasonal variation - Campylobacteriosis was reported more often in the warmer months of the year in Illinois (June through August) (Figure 15). • Geographic distribution – The five counties reporting the most cases were Cook (465), Lake (130), DuPage (120), Will (59) and Kane (53). • Clinical – Ninety-eight percent of 588 cases reported diarrhea. Thirty-two percent of 484 cases reported . Twenty-five percent of 897 reported cases with hospitalization information were hospitalized. No cases were reported to have died as a result of this illness. • Campylobacter species identified – The species of Campylobacter was available for 587 cases. The species were identified as jejuni (532 cases), coli (34), lari (16) and fetus (five). • Risk factors o Travel – Sixty-one of 371 cases (16 percent) reported travel to another country prior to onset. Thirty-four of 367 (9 percent) reported travel to another state prior to onset. o Animal contact – Information on animal contact was available for 343 cases. Of these, 190 (6 percent) reported animal contact. Twenty-six cases had contact with cattle. Contact with dogs was reported for 136 cases and contact with ill animals was reported for 15 dog owners. Five specifically reported contact with ill puppies. One individual reported contact with dogs in kennels or humane societies. Of the 343 cases with animal contact information, 78 cases reported contact with cats. Twelve of the cases reported contact with cats with diarrhea with three of these 12 cases reporting contact with kittens with diarrhea. Seventeen cases had contact with poultry. • Reporting – Seventy percent of cases were reported by personnel from hospitals and 21 percent of cases by commercial or public health laboratory staff. • Outbreaks – One confirmed and one suspect outbreak were reported (see foodborne outbreak section for details).

Summary The incidence of the disease in 2007 was 10 per 100,000. This rate was below the 2010 national objectives of 12 per 100,000. Campylobacter infections occur more commonly from June through August. The incidence was highest in 1 to 4-year-olds and 50- to 59-year-olds. Whites are more likely to be reported with campylobacteriosis than other races. This is the last year for full year reporting of campylobacteriosis.

Suggested readings U.S. Centers for Disease Control and Prevention. FoodNet 2007 Surveillance Report. Atlanta: U.S. Department of Health and Human Services, 2009. Denno, D.M., et. al. Tri-county comprehensive assessment of risk factors for sporadic reportable bacterial enteric infection in children. JID 2009;199:467-476.

22

Figure 13. Campylobacteriosis Cases in Illinois, 2002-2007

1500 1405 1376 1400 1294 1277 1300 1204 1235 1200

Number of cases 1100 2002 2003 2004 2005 2006 2007 Year

Figure 14 . Incidence of Campylobacteriosis Cases in Illinois by Age, 2007

20 15 10

100,000 5

Incidence per 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Year

Figure 15. Campylobacteriosis Cases in Illinois by Month, 2007

200 150 100 50

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year

23 Central Nervous System Infections

General Both aseptic meningitis and acute encephalitis were reportable in Illinois in 2007. The purpose of this reporting is to identify arboviral infections. Control measures for arboviruses are possible and include public education and mosquito control activities. Aseptic meningitis is usually a self-limiting illness characterized by sudden onset of fever, headache and stiff neck. A may be present along with vomiting, photophobia and nausea. In the United States, enteroviruses cause most cases with known etiology. Some arboviral infections may present as aseptic meningitis. Acute infectious and post-infectious encephalitis infections are characterized by headache, high fever, meningeal signs, stupor, disorientation, , tremors, convulsions or paralysis. Aseptic meningitis and encephalitis are combined into an unknown etiology and known etiology category. Arbovirus infections were put in a third section. Cases of each type of CNS infection are shown in Table 1 and the number of reported CNS infections by year is shown in Figure 16.

Table 1. Number of Reported CNS Infections Reported in Illinois, 2007 Type of CNS Infection 2007 Aseptic meningitis, unknown 942 etiology Aseptic meningitis, known 147 virus, not arboviral Encephalitis, acute, known 23 virus, not arboviral Encephalitis, acute, unknown 97 etiology WNV 101 California encephalitis 0 SLE 0 Chikungunya 2 Dengue 0 TOTAL 1,312

Figure 16. Reported Non-bacterial CNS Infections by Year in Illinois, 2002-2007

3000 2147 1528 1632 2000 1480 1293 1312

cases 1000

# reported 0 2002 2003 2004 2005 2006 2007 Year

24

Aseptic Meningitis or Encephalitis of Unknown Etiology

Background Both aseptic meningitis and encephalitis were reportable in Illinois in 2007. One of the purposes of this reporting was to identify arboviruses. Although virus isolation and serologic testing for arboviruses (during the appropriate season) was offered for free to health care providers for all persons in the state with aseptic meningitis or encephalitis, the etiology of many cases of aseptic meningitis and encephalitis remains unknown.

Case definition The case definition for aseptic meningitis in Illinois is a clinically compatible illness diagnosed by a physician as aseptic meningitis with elevated white blood cells in the CSF but no laboratory evidence of bacterial or fungal meningitis. For aseptic meningitis of unknown etiology, no virus could be isolated from the person and testing for arboviruses was negative or testing was not done. The case definition for primary encephalitis is a clinically compatible illness diagnosed by a physician as primary encephalitis. For encephalitis of unknown etiology, no virus could be isolated from the patient and there were no positive tests for arboviruses.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – 1,039 (942 meningitis cases and 97 encephalitis cases). • Age – The annual incidence rate was highest in those younger than 1 year of age (118 per 100,000) (Figure 17). In all other age groups, the incidence rate was below 10 per 100,000. The mean age of reported cases was 28. • Gender – Fifty percent were male. • Race/ethnicity – Seventy-four percent were white, 16 percent African American and 9 percent other races; 24 percent were Hispanic. • Seasonal variation – Cases were most common from July through September (Figure 18); Of the total cases, 676 (65 percent) had onsets between May 15 and October 31 (363 cases had onsets outside of this time frame). • Geographic distribution – The highest number of cases were reported from Cook (457), Will (109), DuPage (99), Kane (65) and Lake (53).

Summary Cases of aseptic meningitis and acute encephalitis with no known cause occur with greater frequency in the summer months and in those younger than 1 year of age. However, reporting of these infections is required from May 15 through October 31 resulting in an increase in reporting during these months of the year.

25 Figure 17. Incidence of Aseptic Meningitis and Encephalitis, Unknown Etiology in Illinois by Age, 2007

150 100 50 100,000

Incidence per 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-59 yr > 59 yr Age groups

Figure 18. Aseptic Meningitis and Encephalitis, Unknown Etiology by Month, 2007

200 150 100 50 0 Number of cases Numberof Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of Year

26 Aseptic Meningitis or Encephalitis of Known Etiology, Excluding Arboviruses

Background Both aseptic meningitis and encephalitis were reportable in Illinois in 2007. One of the purposes of this reporting was to identify arboviruses. Virus isolation is offered to all health care providers of persons in the state with aseptic meningitis or encephalitis, and this helps to identify the etiology of some cases. Encephalitis can be caused by infectious, postinfectious and postimmunization causes. Pathogens causing infectious encephalitis include herpes simplex virus, arboviruses, lymphocytic choriomeningitis, mumps, cytomegalovirus, Epstein-Barr virus, human herpesvirus 6 and enteroviruses. Herpes simplex is a common cause of acute encephalitis that occurs most frequently in children and the elderly. Many encephalitis cases in the United States and Illinois are not identified as to the etiology. Aseptic meningitis is an inflammation of the meninges that cover the brain and spinal cord. It is often caused by a virus, frequently an enterovirus. Enterovirus activity usually peaks during summer and early fall. Enterovirus illness is usually mild and only a small proportion result in aseptic meningitis. Children are at greater risk of severe manifestations with enteroviruses. Adults with enterovirus are more likely to experience upper respiratory symptoms. Enterovirus is shed in saliva and feces of infected persons. Persons should wash their hands thoroughly after using the bathroom and avoid sharing drinks and utensils during an outbreak. Enterovirus infections are not nationally notifiable. Serotypes of human enteroviruses include echoviruses, coxsackieviruses and polioviruses.

Case definition The case definition for aseptic meningitis in Illinois is a clinically compatible illness diagnosed by a physician as aseptic meningitis with elevated white blood cells (greater than four cells) in the CSF but no laboratory evidence of bacterial or fungal meningitis. For aseptic meningitis of known etiology, a virus could be isolated from the person and no arbovirus testing was positive in specimens from the person. The case definition for primary encephalitis is a clinically compatible illness diagnosed by a physician as primary encephalitis. For encephalitis of known etiology, a virus could be isolated from the patient and there was no positive test for arboviruses.

Descriptive epidemiology • Number of cases – 170 cases were reported (147 meningitis and 23 encephalitis). • Age – The mean age was 23 years. • Gender – Forty-eight percent of cases were male. • Race/ethnicity – Seventy-two percent were white, 19 percent African American and 8 percent other races; 21 percent were Hispanic. • Seasonal variation - Aseptic meningitis or encephalitis of known etiology, excluding arboviruses were most commonly reported from July through September (Figure 19). Of the 170 cases, 132 (78 percent) had onsets during arbovirus season from May 15 through October 31. • Geographic – The counties reporting the highest number of cases were Cook (75), Dupage (11) and Will (10).

27 • Diagnosis – Viruses identified as the etiologic agent were enterovirus, not further specified (90), herpes simplex (43), coxsackie B1 (two), coxsackie A4 (one), echovirus 6 (one), echovirus, not further specified (two), cytomegalovirus (one), post cytomegalovirus (one), post Epstein Barr virus (two), post varicella zoster (11), other or unknown (eight). Other types of organisms reported as etiologic agents included Cryptococcus (eight).

Summary In 273 of 1,312 (21 percent) of encephalitis and aseptic meningitis cases, an etiologic agent (including arboviruses) was identified as the cause of illness. Enteroviruses, not further specified and herpes simplex were the most common viruses identified as the causative agents for aseptic meningitis and encephalitis cases. Arbovirus cases are described in a later section.

Figure 19. Aseptic Meningitis and Encephalitis, Non-Arbovirus, Known Etiology by Month, 2007

40 30 20 10 0 Number of cases Numberof Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of Year

28 Arboviral Infections

Background Arboviruses that cause encephalitis are members of the Togaviridae, Flaviviridae or Bunyaviridae families. Humans and domestic animals, such as horses, can develop clinical disease but are usually dead-end hosts because they do not develop sufficient viremia to contribute to the transmission cycle. Arboviral infections that have ever been reported in Illinois residents due to exposure in Illinois include those due to St. Louis encephalitis (SLE), West Nile virus (WNV), California encephalitis (CE) and Western equine encephalitis (WEE) viruses. WEE has not been seen in Illinois since the 1960s. The most likely mosquito-borne diseases to occur in people in Illinois as of 2004 are WNV and CE.

WNV WNV is a flavivirus in the Japanese encephalitis antigenic complex. Birds become infected from mosquitoes. Bird-to-bird transmission also may occur. WNV is maintained in a bird-mosquito-bird cycle with passerine birds as the primary amplifiers. Mosquitoes from the Culex genus are the primary WNV vectors. The incubation period for WNV is three to 14 days in people. WNV can cause a wide variety of clinical , including fever, meningitis, encephalitis and a flaccid paralysis characteristic of a poliomyelitis-like syndrome. Febrile illness (fever, headache, fatigue, backache, myalgia) is not uncommon. Gastrointestinal symptoms and a rash also may occur. The rash is usually maculopapular and appears between days five to 12 of illness. WNV produces a viremia that tends to disappear with the onset of clinical symptoms. West Nile encephalitis occurs more often in persons with immunosuppression or persons greater than 55 years of age. IgM antibodies can persist for up to a year following infection. In recent epidemics almost 80 percent of infections were asymptomatic and 20 percent were WNV fever and less than 1 percent were neuroinvasive. Approximately 25 to 50 percent of persons will have rash. There is still a low prevalence of antibodies in persons in the United States even in locations with intense transmission. Nonavian species with WNV in the United States have included llamas, wolves, horses, dogs, cats, skunks, bats and squirrels. In the United States, almost 90 percent of cases were reported from July through September. Fifty-nine percent of cases were in males. The median age was 57 years. Eight-nine percent of patients were hospitalized. Ten percent of cases died. Sixty-two percent of neuroinvasive cases were encephalitis, 37 percent were meningitis and 5 percent were acute flaccid paralysis. In the United States, total human cases reported to CDC by year are as follows, 2000 (21), 2001 (66), 2002 (4,156), 2003 (9,862), 2004 (1,604) and 2005 (3,000) and 2006 (4,261) and 2007 (3,630). In 2007, 1,217 neuroinvasive and 2,413 non- neuroinvasive human WNV cases were reported in the United States from 43 states with 124 deaths reported. The incidence rate was 0.4 per 100,000. Thirty-three percent of cases were neuroinvasive. The peak was in the first week of August. There were 2,182 birds, 8,125 mosquito pools, and 507 horses positive for WNV in the United States in 2007. Corvids were 77 percent of the positive birds. Ninety-three percent of cases in nonhuman mammals occurred in equines.

29 California encephalitis (CE), Saint Louis encephalitis (SLE) and other U.S. acquired arboviruses CE virus is the main cause of pediatric encephalitis in the United States. Severe illness occurs most commonly in children younger than 15 years of age. The majority of CE infected persons have no symptoms or a mild febrile illness. Only about 1 percent to 4 percent of infected persons develop any symptoms. In Illinois, cases of CE virus infection are most often reported from Peoria, Tazewell and Woodford counties. The main vector is thought to be Ochlerotatus triseriatus (treehole mosquitoes). The primary vector of CE is a container-breeding mosquito only. Therefore, human activities which can increase the numbers of containers, such as tires or buckets, can increase the population of the treehole mosquito. In 2007, the Department lab tested only those persons negative for WNV and younger than 18 years of age for CE due to limitations on reagents for testing. A total of 55 cases were reported in the United States from 10 states. The three states reporting the most cases were Tennessee, West Virginia and Ohio. SLE also can be identified in persons in Illinois. In 2007, eight cases of SLE were reported from states. In the United States, there also were three cases of EEE reported, seven cases of Powassan and no cases of WEE.

Dengue and Chikungunya Several arboviruses seen in Illinois result from traveling overseas, including Dengue and Chikungunya. Chikungunya epidemics have occurred in Africa, India, and southeast Asia. The disease is transmitted by the Aedes mosquito. Chikungunya virus is a mosquito-borne disease indigenous to tropical Africa and Asia. The primary reservoirs are primates and rodents. However, the range has spread to India and Italy. The incubation period is usually three to seven days. Chikungunya virus is an illness characterized by fever, , lower back pain and arthralgias accompanied by rash and conjunctivitis. The arthritis primarily affects smaller joints such as the wrists and ankles. The polyarthralgias can be very debilitating. It is estimated that from 3 percent to 25 percent of persons with Chikungunya infections are asymptomatic. The diagnosis should be considered in travelers to endemic areas who have fever and arthritis. Serologic testing may be negative during the first week of infection. RT-PCR testing may be more sensitive early in the course of illness. Patients may be viremic for six to seven days (shortly before and during the febrile period). No autochtonous cases have occurred yet in the United States. Treatment consists of supportive care, including analgesics, and anti-inflammatory medications. Dengue is an arbovirus caused by four serotypes (DEN-1, DEN-2, DEN-3 and DEN-4). Dengue is the most common arbovirus in tropical and subtropical parts of the world. United States residents who travel to countries with endemic dengue are at risk for the disease. The incubation period ranges from three to 14 days. Dengue infection can range from asymptomatic to mild to more severe disease. A second infection with a different serotype can result in dengue hemorrhagic fever. Persons traveling to areas with dengue should wear repellents and protective clothing. Diagnosis is by acute and convalescent serum samples. Dengue was not nationally notifiable in 2007, but became notifiable in 2010. Arboviral encephalitis prevention includes limiting mosquito bites in humans and reducing mosquito habitat. Mosquito bites can be minimized by using appropriate repellents, by avoiding the outdoors during peak mosquito feeding times and by repairing

30 screens on windows and doors. The use of repellents provides the best protection against mosquitoes. Prevention involves personal protective behaviors and mosquito control activities. People can eliminate breeding areas for mosquitoes such as standing water in clogged rain gutters. During the period May 15 through October 31, physicians and laboratories in Illinois are encouraged to submit cerebrospinal fluid (CSF) from aseptic meningitis and encephalitis cases to the Department laboratory for further testing. In addition, serum samples are requested for testing for arboviral antibody from clinically compatible cases. The CSF can be examined for antibodies to LAC, SLE and EEE viruses upon request.

Case definition The case definition for a confirmed case of arboviral encephalitis in Illinois is a clinically compatible illness that is laboratory confirmed at either commercial laboratories or public health laboratories. The laboratory criteria are a fourfold or greater rise in serum antibody titer; or isolation of virus from, or demonstration of viral antigen in tissue, blood, CSF or other body fluid; or specific IgM antibody in CSF. A probable case of arboviral encephalitis is a clinically compatible illness occurring during the season when arbovirus transmission is likely to occur and with the following supportive serology: a stable (twofold or smaller change) elevated antibody titer to an arbovirus, e.g., at least 320 by hemagglutination inhibition, at least 128 by complement fixation (CF), at least 256 by IF, at least 160 by neutralization, or a positive serologic result by enzyme immunoassay (EIA).

Descriptive epidemiology California encephalitis surveillance Number of cases – One case of CE was reported in Illinois in 2007. Individual case description • A 6-year-old boy from Cook County was diagnosed with CE in 2007. He was hospitalized for four days with fever, headache, agitation, seizures, depressed consciousness and diarrhea. Laboratory testing of enzyme immunoassay and PRNT at CDC was positive. He is believed to have acquired infection in Cook County. • Past incidence - The reported cases of CE in Illinois are as follows: 1990 (one), 1991 (15), 1992 (seven), 1993 (two), 1994 (six), 1995 (five), 1996 (13), 1997 (three), 1998 (four), 1999 (three), 2000 (three), 2001 (five), 2002 (eight), 2003 (11), 2004 (eight), 2005 (one) and 2006 (none) (Figure 20).

Chikungunya surveillance • Number of cases reported in Illinois – Two Chikungunya cases were reported in Illinois residents. • Individual case descriptions o One probable case was male in his fifties and a resident of Cook County who traveled to India and had onset in July. There was a fourfold rise in his titer by PRNT and virus was isolated from serum. He was seen at an emergency department but was not hospitalized. o A confirmed case was a female in her sixties living in Chicago with travel to Nigeria. Onset of illness was in December with serum PRNT testing

31 positive at CDC. She had fever, rash, myalgias and arthralgias. She was seen in an emergency department but was not admitted.

SLE surveillance • Number of cases reported in Illinois - No cases of SLE were reported in 2007.

Dengue surveillance • Number of cases reported in Illinois – No cases of Dengue were reported in 2007.

West Nile virus surveillance

Human

• Number of cases reported in Illinois – There were 101 WNV cases reported; 40 (40 percent) were confirmed and 61 (60 percent) were classified as probable (Figure 21). The five year median was 215. The incidence in Illinois was 0.8 cases per 100,000 population. Six asymptomatic blood donors were reported. • Age – Ages ranged from 2 weeks to 87 years of age (mean = 50 years) (Figure 22). • Gender – Sixty-three (62 percent) of the cases were male. • Race/ethnicity – Cases reported the following race, white (88 percent), African- American (7 percent) and other (4 percent). Ten percent of cases reported being Hispanic. • Diagnosis – The Department laboratory performed the MAC ELISA test on all submitted specimens. Of the reported cases with known site of positive test, 100 positive results occurred as follows: both serum and CSF (20 cases), CSF only (18) and serum only (62). • Clinical presentation – Cases were classified as: West Nile fever (26), neuroinvasive disease (64) and other (11) (Figure 23). Of the neuroinvasive cases, 34 were classified as encephalitis, 23 were classified as meningitis and seven were classified as flaccid paralysis. Cases exhibited the following symptoms: fever, 82 (84 percent); stiff neck, 40 (44 percent); rash, 31 (33 percent) and change in consciousness, 28 (32 percent). • Hospitalization – Sixty-four of 98 (65 percent) cases were hospitalized. • Fatalities – Three cases were fatal. All three fatal cases had neuroinvasive disease. Fatal cases ranged in age from 69 to 81 years of age (mean = 76 years). • Seasonal distribution – Onset of cases ranged from June 2 (Dupage County) through December 11 (Hardin County). The highest number of case onsets occurred in September. Figure 24 shows the number of WNV infections by month. Table 2 shows the earliest human onset per year from 2002 through 2007. • Geographic distribution – Twenty-nine counties had evidence of WNV activity in humans (Figure 25). The largest number of cases per county (33, 33 percent) occurred in Cook County (0.61 per 100,000 population). Case numbers and incidence rates in selected other counties were DuPage (10, 1.1 per 100,000), Kane (13, 3.21 per 100,000) and Lake (five, 0.77 per 100,000).

32 • Reporting – Of the 99 cases with the reporting source listed, the most frequent reporters were hospital personnel (38 percent), the Department laboratory (33 percent) and private or hospital laboratories (24 percent). • Historical – The number of cases reported in Illinois were 2002 (884), 2003 (53), 2004 (60), 2005 (252) and 2006 (215).

Bird testing The number of counties submitting birds for WNV testing: 2004 (69), 2005 (62), 2006 (89) and 2007 (85). Twenty-three counties in 2007 reported positive birds (27 percent of counties submitting birds for testing). Bird types that could be submitted for WNV testing was expanded to include robins, grackles, starlings, house sparrows, blackbirds, cardinals and mourning doves as well as crows and blue jays. The total submitted for each species: crow (58, 43 percent positive), blue jay (34, 20 percent), house sparrow (20, 5 percent), cardinal (13, 0 percent), house finch (15, 13 percent), starling (26, 0 percent), grackle (70, 3 percent), robin (99, 0 percent). One hundred forty- three other types of birds were submitted with 1 percent testing positive. Birds were tested using immunohistochemistry testing (IHC). The first positive bird of the season was collected on July 25 from Cook County and the last positive bird of the season was collected on October 10 from Montgomery County.

Mosquito pool testing In 2007, 62 counties submitting mosquito pools for testing (39 percent) had pools that tested positive. The first positive mosquito sample was collected on January 17, 2007, from Cook County. The last positive mosquito pool was identified in October 22, 2007, in Dupage County. In 2007, 1,553 of 38,271 mosquito pools (4 percent) pools tested positive.

Horses reported with WNV Five horses were reported with WNV in 2007. Date of report ranged from August 29 (McHenry County) to October 14 (Logan County). The five horses were stabled in Logan, McHenry, Monroe, Tazewell and Whiteside counties.

Other species No other animals were positive for WNV in 2007.

Summary Because encephalitis cases are more commonly reported in the summer months in Illinois, the Department asks physicians to increase testing to establish the etiology and to report individuals with acute encephalitis from May 15 to October 31 each year. Positive dead birds were collected in Illinois between July 25 and October 10. There were no cases of CE and no cases of SLE reported in 2007. During 2007, human WNV cases were reported from 29 of the 102 counties in Illinois. In 2007, the majority of the cases were in the Chicago metropolitan area.

33 Suggested readings Gubler, D.J. The continuing spread of West Nile virus in the Western hemisphere. Clin Inf Dis 2007;45:1039-46. Staples, J.E., et. al. Chikungunya fever: An epidemiological review of a re- emerging infectious disease. Clin Inf Dis 2009;49:942-48.

Figure 20. California Encephalitis Cases in Illinois, 2002-2007

15 11 9 10 8

5 1 0 1

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 21. West Nile virus Cases in Illinois, 2002-2007

1000 884 800 600 400 252 215 200 53 60 101

Number of cases 0 2002 2003 2004 2005 2006 2007 Year

Figure 22 . Reported WNV Cases in Illinois by Age, 2007

40 30 20 10

Number of cases Numberof 0 0-14 yrs 15-29 yrs 30-44 yrs 45-59 yrs >59 years Age category

34 Figure 23. Clinical Syndrome for WNV Cases in Illinois, 2007

Other WNV fever 11% 26% WNV fever WNV meningitis WNV encephalitis 23% WNV meningitis Other WNV encephalitis 40%

Table 2. Earliest Onset of a Human Case, 2002-2007

Year Earliest human onset 2002 July 2 2003 July 15 2004 June 11 2005 June 29 2006 May 27 2007 June 2

Figure 24. Epidemic Curve for Human WNV Cases in Illinois, 2007

60

40

20

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Week of onset

35 Figure 25. Incidence Rate by County for Human WNV Cases, 2007

36 Haemophilus influenzae (Invasive Disease)

Background Haemophilus influenzae is an obligate pathogen of the human respiratory tract and can cause invasive disease such as meningitis, septic arthritis, pneumonia, epiglottitis and bacteremia. H. influenzae forms part of the normal flora of the human throat and is divided into six serotypes (a through f). The polysaccharide capsule is a known virulence factor and is the antigen used in serotyping. The organism is transmitted by droplets and discharges from the nose and throat. The incubation period is probably short, from two to four days. Children younger than 5 years of age should be vaccinated against H. influenzae. Prior to the introduction of vaccine against serotype b, most cases were due to serotype b. Reductions in asymptomatic carriage reduces Hib disease. Full vaccination with primary Hib vaccine by 7 months of age is critical to protect children from disease. In December 2007, recalls and cessation of production of two Hib-containing vaccine products left a shortage. CDC recommended that providers defer the 12-15 month booster dose. In 2007, 401 cases were reported in those younger than 5 years of age in the United States. Five percent of all cases in children younger than 5 years of age were attributable to type B. The Healthy People 2010 objectives are to decrease the incidence of invasive H. influenzae in children younger than 5 years of age to 0.

Case definition The case definition for a confirmed case of invasive H. influenzae in Illinois is a clinically compatible illness with isolation of the organism from a normally sterile site. A probable case is a clinically compatible illness and detection of H. influenzae type b antigen in CSF.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 - 124 (five-year median = 120). All cases were confirmed. From 2002 to 2007, the number of cases reported per year ranged from 109 to 135 (Figure 26). • Age – Seventy-five percent of the cases were older than 49 years of age (mean = 59 years of age) (Figure 27). Ages ranged from newborn to 99 years of age. One type b case was in a person younger than 5 years of age. • Gender - Sixty percent of cases were in females. • Race/ethnicity - Sixteen percent were African Americans, 77 percent were white, and 7 percent were other races; 12 percent were Hispanic. • Seasonal distribution – H. influenzae occurs throughout the year, with an increase in the winter months (Figure 28). • Presentation – The case presentations for 94 cases were bacteremia (46 percent), pneumonia (40 percent), meningitis (7 percent), epiglottitis (2 percent), septic arthritis (2 percent), abscess (1 percent) and peritonitis (1 percent). • Outcome – Ninety-six percent of 114 reported cases for which information was available were hospitalized. Six of 58 (10 percent) cases for which information was available died due to H. influenzae. Ages of the fatal cases ranged from 28 to 85.

37 • Diagnosis - All cases were culture confirmed. H. influenzae was isolated from blood (113 cases), CSF (six cases), synovial fluid (two), peritoneal fluid (one), amniotic fluid (one) and sterile site, unknown location (one). • Serotype results – Typing results were available for 104 of 124 (84 percent) of cases. For the 104 cases with typing available, the following serotypes were identified: f (11 cases), b (seven cases), e (six cases), d (two cases) and a (one cases. Seventy-one of the cases were non-typable. • Geographic location – Forty percent of the cases resided in Cook County. • Epidemiology – Seven cases resided in residential facilities, such as assisted living or long-term care. • Reporting – Reporters included hospital personnel (non-laboratory) (84), the Department laboratory (22), private or hospital laboratory staff (17) and other reporters (one).

Summary The number of H. influenzae cases in 2007 was similar to the five-year median. Of the isolates that were typed, 7 percent were type b. Cases occur throughout the year. One type b case occurred in a children younger than 5 years of age for whom the vaccine is indicated. The 7 percent of isolates serotyped as type b was lower than the 11 percent seen in 2006. Sixty-eight percent of cases in 2007 were untypable. Seventy-five percent of all cases occurred in people older than 49 years of age.

Suggested readings CDC. 2008. Active Bacterial Core surveillance report, Emerging infections Program Network, Haemophilus influenzae, 2007. Available on the Internet: http:www.cdc.gov/ncidod/dbmd/abcs/survreports/hib07.pdf. Rainbow, J., et. al. Invasive Haemophilus influenza type B disease in five young children-Minnesota, 2008. MMWR 2009;58(3): 58-61.

38 Figure 26. H. influenzae Cases in Illinois, 2002-2007

135 150 120 124 120 124 109 100

50

Number of cases of Number 0 2002 2003 2004 2005 2006 2007 Year

Figure 27. H. influenzae Cases by Age in Illinois, 2007

80 60 40 20

Number of cases 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-59 yr >59 yr Year

Figure 28. H. influenzae Cases in Illinois by Month, 2007

20 15 10 5

Number of cases 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year

39 Listeriosis

Background Listeriosis is a rare cause of human illness but it can lead to severe disease, with a case fatality rate of 20 percent. Listeriosis is caused by infection with Listeria monocytogenes, which is common in the environment. It is a that can cause sepsis in immunocompromised persons and meningoencephalitis and febrile gastroenteritis in immunocompetent persons. Febrile gastroenteritis is considered to be uncommon. A study in Canada identified only 17 cases of L. monocytogenes in 8,000 stool specimens submitted for diagnosis of a diarrheal illness. Patients receiving antineoplastic therapy are more susceptible to listeriosis. Bloodstream infection, sepsis and meningitis are typical clinical presentations. Listeriosis has the highest case fatality rate of any foodborne illness. Risk factors for mortality in Los Angeles for non-perinatal listeriosis were underlying disease such as nonhematologic malignancy, alcoholism, kidney disease and other factors such as steroid medication or age older than 69 years. Pregnant women whose gastrointestinal tracts become colonized with the after they eat contaminated foods can transmit the organism to the fetus or can contaminate the baby’s skin or respiratory tract during childbirth. The median incubation period is three weeks, which makes identifying a suspect food vehicle difficult. L. monocytogenes is found frequently in nature and can be cultured from foods and the environment, which makes typing of isolates from patients and suspected food items important. The majority of isolates from cases are 1/2 a, 1/2 b or 4b. Pulse field gel electrophoresis can be used to further discriminate between isolates. Contaminated food vehicles often identified in outbreaks of listeriosis in the United States include unpasteurized dairy products. However, other vehicles have been identified. One listeriosis outbreak in Massachusetts in 2007 was linked to consumption of pasteurized milk. The same strain of Listeria was identified in milk and in four patients. L. monocytogenes can resist salt, heat, nitrite and acidity better than many other organisms. It also can survive and multiply at cold temperatures. Refrigerators at 40° F or below are best for reducing the potential for listeriosis. Of the 10 diseases/syndromes under active FoodNet surveillance (those caused by Campylobacter, Cryptosporidium, Cyclospora, E. coli O157:H7, HUS, Listeria monocytogenes, Salmonella, Shigella, Vibrio and Yersinia enterocolitica), listeriosis comprised 122 of 16,801 (0.73 percent) of the reported infections in 2007. Incidence rates ranged from 0.12 to 0.37 per 100,000 at the 10 sites with an overall incidence of cases of 0.27 per 100,000 population. In 2007, 808 cases of listeriosis were reported to CDC from 52 states and territories.

Case definition Illinois uses the CDC case definition for Listeria cases: a clinically compatible history (stillbirth, listeriosis of the newborn, meningitis, bacteremia or localized infection) and isolation of L. monocytogenes from a normally sterile site. In the setting of miscarriage or stillbirth, isolation of L. monocytogenes from placental or fetal tissue is adequate as laboratory confirmation. A maternal-child pair will only be counted as one maternal case.

40 Descriptive epidemiology • Number of cases reported in Illinois in 2007 – There were 34 total cases reported (five were described as cases of meningitis). All cases were confirmed. The five- year median is 24 (Figure 29). The 2007 incidence for all reported listeriosis was 0.27 per 100,000 population. • Age - Cases ranged in age from infant to 90 years of age; 73 percent of cases were older than 59 years of age. • Seasonal distribution – Cases occurred from January to December. • Gender – Fifty percent of cases were female. • Race/ethnicity - Eighty-one percent of the cases were white, 12 percent were African American and 6 percent were other races. Eighteen percent reported Hispanic ethnicity. • Geographic location – Forty-four percent of the cases were reported from Cook County. Fourteen counties reported cases. • Diagnosis - The site of Listeria isolation was identified as follows: blood (29) and one each for cerebrospinal fluid, heart tissue, placenta, synovial fluid and brain. CDC typed 22 isolates. They were typed as 4b (eight), 1 / 2 b (five), 1 /2 a (four) and 4c (two), 3a (one) and untypable (two). PFGE was done on 21 isolates. All 21 patterns were unique to each other in 2007. • Underlying conditions – Twenty-one of 22 (95 percent) cases with information available on immunosuppressive conditions reported an immunosuppressive condition. These included pregnancy, cancer, diabetes mellitus, renal disease/dialysis or steroid therapy. • Clinical – Thirty of 32 cases with information available were hospitalized. Types of infections were septicemia (11), meningitis (four), pneumonia (two), abscess (two) and one each for endocarditis and septic arthritis. One case had a stillborn baby. Another pregnant case had a healthy infant. One fatal case was reported and that person was 61 years of age. • Epidemiology – Three cases resided in residential facilities. All three were in long- term care facilities. • Reporting – Seventy-five percent of cases were reported by hospital personnel other than laboratory personnel. • There were no outbreaks of reported listeriosis in Illinois in 2007.

Summary In 2007, Illinois recorded 34 listeriosis cases; 73 percent of the cases were older than 59 years of age. The incidence rate (0.27) was the same as described by CDC’s FoodNet sites in 2007 (0.27 per 100,000). The most common serotypes were 4b and 1 / 2 b. All PFGE patterns were unique.

Suggested Readings CDC. Foodborne Active Disease Surveillance Network. Surveillance Report 2007. Available at http://www.cdc.gov/foodnet/annual/2007/2007_annual_report_508.pdf Guevara, R.E., et. al. Risk factors for mortality among patients with non perinatal listeriosis in Los Angeles County, 1992-2004. CID 2009;48:1507-1515.

41

Figure 29. Listeriosis Cases in Illinois, 2002-2007

40 34 32 31 30 23 24 24 20 10

Number of cases of Number 0 2002 2003 2004 2005 2006 2007 Year

42 Invasive Neisseria meningitidis

Background N. meningitidis is an important cause of bacterial meningitis and septicemia in the world. The bacteria that causes , N. meningitidis, is carried in the pharynx by about 5 percent to 10 percent of the population. The organism is transmitted by direct contact with respiratory droplets from the nose and throat of an infected person. Most patients acquire infection from an asymptomatic carrier during face-to-face contact including coughing, sneezing and kissing and the sharing of drinks, foods or cigarettes. The incubation period ranges from two to 10 days and is usually three to four days. Meningococcal disease is an acute bacterial disease that may be characterized by fever, headache, stiff neck, delirium and, often, a rash and vomiting. It presents as meningitis in 80 percent to 85 percent of cases. Septicemia also can result from infection with N. meningitidis. The overall case fatality rate is between 10 percent and 14 percent. Carriage of the meningococcus organism is transient and the level of carriage does not predict the course of an outbreak. Less than 1 percent of exposed persons who become infected develop invasive disease. Rates are highest in infants with a second peak in those aged 18 years. Among those aged 11 to 19 years, 75 percent of cases are caused by A, C, Y, W-135. The majority of cases in infants are group B. Antimicrobial chemoprophylaxis is used for close contacts of cases. Only close contacts should be given chemoprophylaxis due to concerns about antimicrobial resistance. Vaccination can be used as an adjunct measure to protect against A, C, Y and W135 serogroups. A meningococcal vaccine that protects against these serogroups was licensed in the United States in 1982. It is given routinely to military recruits and to certain travelers. A second vaccine using conjugate technology was approved in early 2005 for protection against the same four serotypes among persons aged 2 to 55 years. A tetravalent (A,C,Y,W-135) conjugate meningococcal vaccine, Menactra® was licensed for persons aged two to 55 years. In 2007, ACIP recommended routine use of MCV4 to include children aged 11 to 12 years and adolescents aged 13 to 18 years. Specific vaccination campaigns are used in highly selected situations. In October 2007, FDA approved the quadrivalent meningococcal conjugate vaccine (MCV4 Menactra®, Sanofi Pasteur) for use in children aged 2 to10 years, in addition to its use in the 11-to-55 year age group. The use of their vaccine was recommended for children at increased risk for meningococcal disease (those with terminal complement deficiencies or those with anatomic or functional asplenia) and travelers to endemic areas. The recommendations also state that MCV4 is preferable to MPSV4 (Menamume, Sanofi Pasteur). Also, the recommendation to routinely vaccinate persons aged 11 to 18 remained in effect. A national immunization survey in 2007 of adolescents aged 13 to 17 identified that meningococcal vaccine had been received by 32 percent of adolescents nationally as compared to only 12 percent in 2006. In 2007, 2,154 cases were reported in the United States. The Healthy People 2010 objective is to reduce invasive N. meningitidis to one case per 100,000 population.

Case definition The case definition for a confirmed case of meningococcal disease is a clinically compatible case with N. meningitidis isolated from a normally sterile site or from skin scrapings of purpuric lesions. The case definition for a probable case is a compatible

43 illness with PCR positive from a normally sterile site or evidence of N. meningitidis from latex agglutination of CSF or positive immunohistochemistry on formalin fixed tissue. A suspect case has clinical purpura fulminans in absence of positive blood culture or clinically compatible case with gram negative diplococci from a normally sterile site. Suspect cases are not counted as official cases in the case count for Illinois.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 - 61 (incidence of 0.49 per 100,000) (five-year median = 46) (Figure 30). Fifty-eight cases were confirmed and three were probable. At least three cases were reported to be in college students. • Age - The age distribution of reported meningococcal disease is shown in Figure 31. Mean age of cases was 40 (range: one week to 86 years of age) • Gender – Forty-four percent of cases with gender information were female. • Race/ethnicity – Thirty-three percent of cases were African American, 60 percent were white and 7 percent were other; 6 percent were Hispanic. • Seasonal distribution - Meningococcal disease occurred throughout 2007 with increases in March and June (Figure 32). • Geographic location – Fifty-nine percent of reported cases were from Cook County. Other counties with more than one case (two each) were Champaign, Kane, Lake, Sangamon and Vermilion. • Presentation – For 40 cases with case reports, the presentation of illness was bacteremia (47 percent), meningitis (40 percent) and pneumonia (12 percent). • Outcome – Fifty-four of 60 (90 percent) of individuals with information available were hospitalized. The case fatality rate was 11 percent for patients where the outcome of infection was known. Ages of the seven fatal cases were from three to 63 years of age. • Diagnosis - The organism was isolated from blood only (49 cases), CSF only (seven), blood and CSF (one). One case classified as confirmed only had CSF latex agglutination positive and should have been counted as probable. For three probable cases, diagnostic testing included identification of gram negative diplococcic in brain tissue (one), CSF and blood PCR (one) and antigen testing of CSF (one). Serogrouping was performed on isolates from 53 (87 percent) of cases. In cases where typing was done, the serogroups identified were Y (36 percent), C (30 percent), B (25 percent), W-135 (6 percent) and nontypable (4 percent) (Figure 33). • Contacts given prophylaxis – For 11 cases, the number of close contacts given prophylaxis was reported. The number ranged from one to 23 contacts (median = five). • Reporting – Fifty-one cases were reported by hospital personnel excluding laboratory personnel. • Clusters – None reported. No clusters requiring a vaccination campaign occurred in 2007.

Summary The number of N. meningitidis cases reported in Illinois in 2007 (61) was higher than the five-year median (46 cases). Eighty-seven percent of isolates were serogrouped in Illinois, which is less than the 93 percent serogrouped in the United States from 1998

44 through 2007. Serogroup Y was the most common serogroup reported. The incidence of 0.49 per 100,000 in Illinois is similar to that reported from a CDC estimate incidence for the United States of 0.53 per 100,000 from 1998 through 2007. Eleven percent of cases were fatal, which is similar to that reported by CDC for the United States from 1998 through 2007.

Suggested readings ACIP. Recommendations from the Advisory Committee on Immunization Practices (ACIP) for use of quadrivalent meningococcal conjugate vaccine (MCV4) in children aged 2-10 years at increased risk for invasive meningococcal disease. MMWR 2007;56(48):1265-6. CDC. 2008. Active bacterial core surveillance report. Emerging infections program network, Neisseria meningitidis, 2007. Available on the intranet: http:www.cdc.gov / ncidod/dbmd/abcs/survreports/mening07.pdf Cohn, A.C. et al. Changes in Neisseria meningitidis disease epidemiology in the United States, 1998-2007: Implications for prevention of meningococcal disease. Clin Inf Dis 2010;50:184-91. Jain, N. et. al. Vaccination coverage among adolescents aged 13-17 years – United States, 2007. MMWR 2008; 57(40):1100-1103.

Figure 30. Meningococcal Disease in Illinois, 2002-2007

80 73 57 61 60 46 36 34 40 20

Number of cases of Number 0 2002 2003 2004 2005 2006 2007 Year

45 Figure 31. N. meningitidis Cases by Age in Illinois, 2007

20 15 10 5

Number of cases 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-59 yr >59 yr Year

Figure 32. N. meningitidis Cases in Illinois by Month, 2007

15

10

5

Number of cases 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year

Figure 33. N. meningitidis Cases in Illinois by Serogroup, 1993-2007

80 B 60 C 40 Y 20 Other

Number of cases 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year

46 Invasive Group B Streptococcus

Background Group B streptococcus and E. coli cause most cases of sepsis in infants. Around 10 percent to 35 percent of pregnant women may be colonized with group B streptococcus at the time of labor placing them at risk for transmitting the disease to their infants. Group B streptococcus infections are due to and cause disease and death in newborns and morbidity in peripartum women and nonpregnant adults with chronic medical conditions. Early-onset disease of neonates (less than seven days) may consist of sepsis, respiratory distress, apnea, shock, pneumonia and meningitis. The infection is acquired during delivery or in utero. Early-onset disease is caused by maternal group B streptococcus carriage. Risk factors for early-onset group B streptococcal sepsis (that occur within 72 hours of life) include fever in the mother during labor, preterm delivery, membrane rupture greater than 18 hours before delivery and a mother with a previous infant with group B streptococcus. Infants acquire infection through aspiration of contaminated amniotic fluid or during passage through the birth canal. Late-onset disease (seven days to several months) is characterized by sepsis and meningitis and is acquired by person-to-person contact. Only about 50 percent of late- onset disease cases have been shown to be of maternal origin. Persons at higher risk in the CDC’s Active Bacterial Core Surveillance were older persons, African Americans and adults with diabetes. Invasive group B streptococcus in adults mainly causes bacteremia without focus or pneumonia. Most isolates are from blood. The incidence of adult group B streptococcal disease has increased to seven cases per 100,000 in 2007.

Case definition A confirmed case of invasive group B streptococcus disease is defined as isolation of GBS from a normally sterile site (e.g., blood or cerebrospinal fluid). A probable case is defined as a person who is latex agglutination positive for group B streptococcus from a sterile site. Only cases younger than 3 months of age were required to be reported in Illinois in 2007.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – There were 92 cases reported; 75 cases were younger than 3 months of age. Seventeen cases were in older age groups. • Age – Seventy-five of 92 (81 percent) of cases were younger than 3 months of age. Only cases younger than 3 years of age were reportable in 2007. • Gender – Thirty-eight of 75 (51 percent) of all cases younger than 3 months were female. Fifty-three percent of those older than 3 months were female. • Race/ethnicity – Fifty-six percent of all cases younger than 3 months were white and 36 percent were African American; 21 percent were Hispanic. • Seasonal variation – There were small increases in cases in May, September and October in cases younger than 3 months of age. • Diagnosis – Eighty-four of 92 cases (all ages) were confirmed by a positive culture. The organism was isolated from blood (75 cases), CSF (six cases), blood

47 and CSF (one case) and other or unknown sites (two cases). The laboratory confirmation for other cases included latex agglutination in four cases. In two cases the type of laboratory testing was unknown at the time of this report. • Case outcome – Seventy-two of 74 cases (97 percent) younger than 3 months of age were hospitalized; two cases were known to be fatal. For those older than 3 months of age, 14 of 14 cases were hospitalized and one fatality occurred among this age group. • Reporter – Seventy-three of the 92 cases (79 percent) were reported by hospital personnel excluding hospital laboratory personnel and 13 were reported by hospital laboratory personnel

Summary Cases of invasive group B streptococcal disease in newborns can be prevented if the appropriate guidelines are followed by health care providers. Ninety-two cases of group B streptococcus disease were reported in Illinois, the majority in those younger than 3 months of age. Although only group B streptococcal disease in those younger than 3 months of age is reportable, voluntary reporting of invasive group B streptococcus disease in persons older than 3 months of age occurs.

48 Cryptosporidiosis

Background Cryptosporidiosis is primarily a gastrointestinal disease that affects humans and 45 other species. Disease results from infection with Cryptosporidium species oocysts. There are 12 species recognized. Two species, C. hominis (previously known as C. parvum genotype 1) and C. parvum (previously known as C. parvum, genotype 2) are the most important human pathogens. The organism is shed in the feces in the form of an oocyst, which has a hard shell to protect it from the environment. Oocysts are immediately infective upon excretion by an infected host and can be shed for up to two weeks or longer in immunocompetent humans. Illness can be caused by ingestion of only 10 oocysts. Infection is spread through person-to-person transmission, from direct contact with animals and by swimming in contaminated water. Approximately 1 percent to 3 percent of the general population may be excreting oocysts. The incubation period is an average of seven days (range is one to 12 days). Predominant symptoms include profuse and watery diarrhea accompanied by abdominal cramping. Infection in immunocompetent people lasts one to two weeks. Persons at risk for more severe infection include young children, pregnant women or persons with weakened immune systems. A new treatment for cryptosporidium, nitazoxanide was made available. Oocysts of cryptosporidia can be found in many types of water including untreated surface water, filtered swimming pool water and even from chlorine-treated or filtered drinking water. The minimum level of detectable oocysts that pose a public health threat in domestic water supplies is not known. Outbreaks have occurred due to person-to- person and waterborne spread. Cryptosporidium is the leading cause of reported outbreaks of gastroenteritis linked to treated swimming venues. Of the 10 diseases under active surveillance in FoodNet sites (illnesses caused by Campylobacter, Cryptosporidium, Cyclospora, E. coli O157:H7, HUS, Listeria monocytogenes, Salmonella, Shigella, Vibrio and Yersinia enterocolitica), Cryptosporidium comprised 7 percent of the reported infections. The incidence rate overall was 2.7 per 100,000 for Cryptosporidium and incidence ranged from 0.6 to 6.1 at the ten FoodNet sites in 2007. In 2007, 11,657 confirmed cryptosporidiosis cases were reported to CDC through NETSS. The number of cases was highest in those one to nine years of age. A tenfold increase occurred from summer to fall when there is increase usage of recreational water. There was a large increase in 2007 as compared to prior years due to several large outbreaks. Important features of cryptosporidiosis include: 1) waterborne outbreaks are typical, 2) oocysts are resistant to commonly used disinfectants 3) transmission can occur by direct fecal-oral contact, 4) as few as 10 to 100 oocysts can cause infection, 5) oocysts are infectious upon excretion and 6) asymptomatic infections occur. There was an outbreak of cryptosporidiosis in a splash park in Idaho in 2007. Splash parks have multiple interactive water features that spray visitors with little to no supervision. Prevention of outbreaks includes advising ill persons to wash hands with soap and water after using the toilet and before eating or preparing food, to avoid swimming in recreational water during illness and for at least two weeks after diarrhea stops and to avoid fecal exposure during sexual activity. Environmental control measures, such as hyperchlorination, may be needed when outbreaks in recreational water facilities are discovered. For splash parks, ultraviolet or ozone treatment systems can increase safety. 49

Case definition A confirmed symptomatic case of cryptosporidiosis in Illinois is laboratory confirmed (demonstration of Cryptosporidium oocysts in stool by microscopic examination, or demonstration of Cryptosporidium in intestinal fluid or small bowel biopsy specimens, or demonstration of Cryptosporidium oocyte or sporozite by a specific immunodiagnostic test such as ELISA or by PCR techniques or demonstration of reproductive stages in tissue preparations) and is associated with one of the following symptoms: diarrhea, abdominal cramps, loss of appetite, low-grade fever, nausea or vomiting. A confirmed asymptomatic case is a laboratory confirmed case associated with none of the symptoms described above.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – 205 (five-year median = 160; see Figure 34). Four cases were probable; the rest were confirmed. The incidence rate was 1.6 per 100,000. CDC only counts 201 confirmed cases for Illinois for 2007. • Age - Mean age for all 2007 cases was 35 years. Age distribution of cases is shown in Figure 35. • Gender – Forty-four percent were male. • Race/ethnicity – Seventy-seven percent were white, 16 percent were African American, and 4 percent were other races; 8 percent were Hispanic. • Seasonal variation - Cases peaked from July through October (Figure 36). • Clinical – Two cases were reported to be asymptomatic. Symptoms included diarrhea (97 percent), fever (40 percent) and vomiting (48 percent); 30 percent were hospitalized, no cases were fatal. • Geographic location – The three counties with the highest incidence of cryptosporidiosis were: JoDaviess (54 per 100,000), Carroll (24 per 100,000) and Mercer (18 per 100,000). • Reporting – The most common reporters were laboratory staff (94) and infection control professionals (92). • Risk factors – o Contact with animals – Contact with animals was reported by 177 cases, including eight who had contact with cattle. One individual worked on a dairy farm and drank unpasteurized milk and some of the cattle had diarrhea. Another child helped his grandfather on his cattle farm. o Travel - Seventeen persons reported travel outside the United States including travel to Mexico (four) and Italy (three). Thirty–eight cases traveled out-of-state but within the United States including 11 who traveled to Iowa and 10 who traveled to Wisconsin. o Swimming – Fifty-two of 182 (28 percent) of the cases reported swimming in chlorinated water. Twenty-seven of 183 (15 percent) reported swimming in non-chlorinated water. o Well water exposure – Seventeen of 188 cases (9 percent) reported drinking private well water. o Day care contact – Thirteen of 184 cases (7 percent) reported contact with a day care facility. o Residential facility – Twenty of 181 cases (11 percent) had contact with a 50 residential facility. • Outbreaks: In 2007, two recreational water outbreaks were reported. These outbreaks are discussed in further detail in the foodborne and waterborne disease outbreak section.

Summary The number of reported cases of cryptosporidiosis in 2007 was lower than the number reported in 2006. Two outbreaks were reported in 2007. Most cases in 2007 occurred in the late summer and early fall. The incidence of reported cryptosporidiosis in Illinois (1.6 per 100,000) was lower than the incidence reported in FoodNet sites (2.7).

Suggested Readings Centers for Disease Control and Prevention. FoodNet 2007 Surveillance Report. Atlanta: U.S. Department of Health and Human Services, 2009. Yoder, J.S., et. al. Cryptosporidiosis surveillance – United States, 2006-2008. MMWR 2010; 59(SS-6). 1-25.

Figure 34. Cryptosporidiosis Cases in Illinois, 2002-2007

300 257 205 200 161 160 121 102 100

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 35. Age Distribution of Cryptosporidiosis Cases in Illinois, 2007

50 40 30 20 10

Number of cases Numberof 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Year

51 Figure 36. Cryptosporidiosis Cases in Illinois by Month, 2007

60

40 Outbreak

20 Non-outbreak

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of Onset

52 Cyclosporiasis

Background Cyclosporiasis is caused by a protozoal organism, Cyclospora cayatensis. Clinical illness consists of watery diarrhea and abdominal cramping. Diarrhea is usually self-limiting but may be prolonged. The median incubation period is seven days. Transmission to persons is usually through drinking or swimming in contaminated water. Several international outbreaks have involved consumption of raspberries from Guatemala. Basil and lettuce also have been implicated in transmission. In 2007, 93 confirmed cyclosporiasis cases were reported to CDC through NETSS. Florida reported the most cases in 2007. Of the 10 diseases under active surveillance in FoodNet sites (illnesses caused by Campylobacter, Cryptosporidium, Cyclospora, E. coli O157:H7, HUS, Listeria monocytogenes, Salmonella, Shigella, Vibrio and Yersinia enterocolitica), (13 of 18,039) Cyclospora comprised 0.07 percent of the reported infections in 2007. Data from 2007 showed the incidence rate was 0.03 per 100,000 for Cyclospora and ranged from 0.0 to 0.10 at the ten FoodNet sites.

Case definition Laboratory confirmation is the finding of C. cayatensis oocysts in stool by microscopic examination or in intestinal fluid or small bowel biopsy specimens; or demonstration of sporulation or PCR positive in stool, duodenal/jejunal aspirates or small bowel biopsy specimens. CDC has two case classifications: Confirmed, symptomatic - laboratory confirmed with clinically compatible illness. Confirmed, asymptomatic - laboratory confirmed with no symptoms.

Descriptive epidemiology Number of cases reported in Illinois in 2007 – Three confirmed cases were reported. All were symptomatic. • Age – The median age for cases was 36 years. • Gender – Sixty-seven percent were female. • Race/ethnicity – Two were white and one did not report race; Hispanic status was unknown. • Seasonal variation – Case onsets were reported in June (two) and February (one). • Geographic location – All three cases resided in Cook County. • Travel – Two persons traveled overseas, one to Peru and one to Guatamala.

Summary No outbreaks of cyclosporiasis were reported in Illinois in 2007.

Suggested readings Centers for Disease Control and Prevention. FoodNet 2007 Surveillance Report. Atlanta: U.S. Department of Health and Human Services, 2009.

53 Ehrlichiosis and Anaplasmosis

Background Ehrlichia are bacteria that infect a wide variety of animals and are transmitted by tick bites. One case of HGA was transmitted by blood transfusion in Minnesota in 2007 Because HGA is a rare disease and there is not a cost effective test method for the disease, blood donor’s are not screened for HGA. Four Ehrlichia pathogens have been identified in the United States: E. chaffeensis (causing human monocytic ehrlichiosis (HME)), Anaplasma phagocytophilum (formerly Ehrlichia phagocytophila) causing human granulocytic anaplasmosis (HGA), E. canis and E. ewingii. Only one person with E. canis has been reported and the person was not clinically ill. E. chaffeensis and E. canis mainly invade the monocyte, and the disease caused by these organisms is termed HME. A. phagocytophilum and E. ewingii invade mainly the granulocytes and the disease is referred to as granulocytic ehrlichiosis. Both HGA and HME are zoonotic diseases requiring an arthropod vector and a mammalian reservoir. A specific history of a tick bite can be elicited in about 68 percent of ehrlichiosis cases. E. chaffeensis, the primary cause of HME, is transmitted to humans primarily by the lone star tick, A. americanum. The white-tailed deer is a major host for this tick and acts as a natural reservoir for E. chaffeensis. Cases of HME are most commonly reported from Missouri, Oklahoma, Tennessee, Arkansas and Maryland. The blacklegged tick (Ixodes scapularis) is the vector for A. phagocytophilum which causes HGA in New England, the North Central United States and Europe. E. ewingii can be carried by Ambylomma americanum. Cases of HGA caused by E. ewingii have been reported primarily in immunocompromised patients from Missouri, Oklahoma and Tennessee. Infection also may occur in dogs. Both HME and HGA result in similar symptoms: fever, headache and myalgia. Cases also may have low platelets, low white blood cells and increased liver enzymes. Rash occurs in approximately one third of HME patients and is rare in patients with HGA or E. ewingii. In 25 percent of HME cases, respiratory tract involvement occurs, and in 20 percent of cases central nervous system disease occurs. More than 40 percent of HME cases require hospitalization, and severe complications can include meningoencephalitis, acute respiratory distress syndrome, toxic shock like syndrome, renal failure, coagulopathy and multiorgan failure. Serious outcomes can occur with HGA in persons with impaired immune systems. These Ehrlichia organisms can form clusters of organisms called morulae, in the white blood cells. There is strong cross reactivigy to ehrlichia types when serology is used for diagnosis. The case fatality rate has been reported as 5 percent in HME and 10 percent in HGA. All symptomatic cases of HGA should be treated. Fever should be reduced within 48 hours of the initiation of antimicrobial therapy. In 2007, 834 HGA, 828 HME and 337 other or unknown types of ehrlichiosis cases were reported to CDC. There was an increase in HME and HGA in the United States over previous years. Illinois was eighth in the nation for the number of HME cases.

Case definitions HME A clinically compatible illness with demonstration of a four-fold change in antibody titer to E. chaffeensis antigen by IFA in paired serum or positive PCR and confirmation of E. chaffeensis DNA, or identification of morulae in leukocytes and a positive IFA titer to 54 E. chaffeensis antigen, or immunostaining of E. chaffeensis antigen in a biopsy or autopsy specimen or positive culture for E. chaffeensis in a clinical specimen.

HGA A clinically compatible illness with demonstration of a four-fold rise in antibody titer to A. phagocytophilum antigen by IFA in paired serum or positive PCR and confirmation of A. phagocytophilum DNA, or identification of morulae in leukocytes and a positive IFA titer to A. phagocytophilum antigen, or immunostaining of A. phagocytophilum antigen in a biopsy or autopsy specimen or positive culture for A. phagocytophilum in a clinical specimen.

Ehrlichiosis, human, other or unspecified agent A clinically compatible illness with demonstration of a four-fold change in antibody titer to more than one Ehrlichia/Anaplasma species by IFA in paired serum samples, in which a dominant reactivity cannot be established, or identification of Ehrlichia/Anaplasma species other than E. chaffeensis or A. phagocytophilum by PCR, immunostaining or culture.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 - 50; Thirty-seven were HME, six were HGA and seven were ehrlichiosis/anaplasmosis, type unknown.

HME cases • Seven HME cases were confirmed and 30 were probable. • Age – HME cases ranged in age from 6 to 77 years of age (mean = 48 years). • Gender – Twenty-four cases were male and 13 were female. • Race/ethnicity – Thirty-one HME cases were white, one reported “other” race and five did not report race; One reported Hispanic ethnicity. • Residence of cases – Cases resided in 25 Illinois counties. • Exposure Sites – Thirty-one HME cases reported in-state tick exposures. Counties in which exposures took place included Franklin (three), Jefferson (three), Perry (three), Williamson (three), Adams (two), Jackson (two) and one each in Calhoun, Cass, Dupage, Fulton, Hancock, Johnson, Logan, Marion, McHenry, Monroe, Moultrie, Pike, Sangamon, Union and Winnebago. Fifty-five percent of exposures were reported from the Marion region (southern Illinois). Two cases reported tick exposure out-of-state (one in Missouri and one in Wisconsin). Four did not report an exposure location. • Seasonal variation – Onsets of HME cases were from April to October (Figure 37 shows onsets by month for all ehrlichiosis/anaplasmosis cases). • Diagnostic testing – The cases of HME were diagnosed by a single serologic titer (30 cases), PCR (four) and four-fold rise in titer (three). • Clinical syndrome – Symptoms reported by HME cases were fever (31 of 35), rash (9 of 32), headache (26 of 34) and myalgia (26 of 31). • Outcomes – Sixty-one percent of cases were hospitalized. There was one fatality reported. • Reporting – All but 5 cases were reported by laboratories. • Past incidence – The number of reported cases of ehrlichiosis in Illinois in past years: 2004 (four) and 2005 (five) and 2006 (25). 55

HGA cases • Number of cases – Six cases of HGA were reported and all were probable cases. • Age – HGA cases ranged in age from 20 to 73 years of age (mean = 54 years). • Gender - Five cases were male and one was female. • Race/ethnicity – Four HGA cases were white and two did not report race; none were reported to be Hispanic. • Residence of cases – HGA cases resided in Adams, Cook, Kane, Mason, McHenry and Saline counties. • Exposure Sites – Three HGA cases were exposed in-state; one in Saline County, one in Adams and one in multiple counties (Cass, Mason and Fulton). Three cases reported tick exposure in Wisconsin. • Seasonal variation – Onsets of HGA cases were from May to October (Figure 37 includes all ehrlichiosis/anaplasmosis cases). • Diagnostic testing – All cases were diagnosed by serologic testing. • Clinical syndrome – Symptoms reported by HGA cases were fever (six of six), rash (two of six), headache (five of six) and myalgia (five of six). • Outcomes – Fifty percent of cases were hospitalized and no fatalities were reported. • Reporting – All cases were reported by laboratories. • Past incidence - Reported cases of ehrlichiosis in Illinois in past years have been infrequent : 2004 (one) and 2005 (two) and 2006 (six).

Unknown ehrlichiosis type • Number of cases – Seven cases were reported in 2007; four were confirmed and three were probable. • Age – The unknown ehrlichiosis type cases ranged in age from 28 to 82 years of age (mean = 55 years). • Gender - Five cases were male and two were female. • Race/ethnicity – Six was white and one did not report race; no cases reported being Hispanic. • Residence of cases – Cases resided in Jefferson (three) and one each in Adams, Calhoun, Jackson and Sangamon counties. • Exposure Sites – Five cases were exposed in-state; three in Jefferson County, one in Adams and one in Calhoun County. One case reported out-of-state tick exposure in Missouri. One case had an unknown exposure site. • Seasonal variation – Onsets occurred between May and August (Figure 37 includes all cases of ehrlichiosis/anaplasmosis). • Diagnostic testing – Four cases were diagnosed by PCR and three by serologic testing. • Outcomes – Seventy-one percent of cases were hospitalized.There were no fatalities reported. • Reporting – Four were reported by infection control personnel and three by laboratories. • Past incidence - Reported cases of ehrlichiosis in Illinois in past years have been infrequent : 2004 (seven) and 2005 (one) and 2006 (one).

56 Summary Thirty-seven ehrlichiosis cases were reported in Illinois in 2007. Sites of tick exposure for HME cases were primarily in southern Illinois. Most onsets were from May through July.

Suggested readings Kemperman, M., et. al. Anaplasma phagocytophilum transmitted through blood transfusion – Minnesota, 2007. MMWR 2008;57(42):1145-48.

Figure 37. Onsets of All Ehrlichiosis Cases Reported in Illinois by Month, 2007

20 15 10 5 0 Number of cases Numberof Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of Onset

57 Shiga-toxin Producing E. coli, Enterotoxigenic E. coli, enteropathogenic E. coli)

Background Strains of Escherichia coli that cause diarrhea are classified into pathotypes. Shiga toxin producing E. coli (STEC) may cause bloody diarrhea and hemolytic uremic syndrome because they produce Shiga toxins. Enteropathogenic E. coli (EPEC) lack Shiga toxins and cause nonspecific diarrhea in infants in less-developed countries. Enterotoxigenic E. coli outbreaks are rarely reported in the United States. E. coli O157:H7 is one type of STEC and was first recognized as a cause of human illness and associated with ground beef in 1982. E. coli O157:H7 causes primarily a diarrheal illness. The infectious dose is thought to be low due to evidence of person-to-person transmission and recreational water exposure transmission. The incubation period is from three to eight days with an average of three to four days. Occasionally, longer incubation periods have been reported. Infection with E. coli O157:H7 produces symptoms that range from mild to bloody diarrhea and that may progress to hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura (TTP); 3 percent to 5 percent of HUS cases are fatal. The term HUS is used to describe acute renal failure accompanied by non-immune hemolytic anemia and . It occurs most frequently in children younger than five years of age after infection by an agent producing shiga toxin. The illness can involve the central nervous system (CNS), pancreas, heart and other organs. HUS can be caused by Shigella dysenteriae type 1 and STEC. The most common cause of HUS in the United States is E. coli O157:H7. STEC can be transmitted within households from children who are infected. In a study in Wales, 20 of 98 (22 percent) households during an outbreak of E. coli O157:H7 had secondary cases within the household. Primary cases were mainly children. Household transmission mainly occurred from children to their younger siblings. Young age of the primary case (less than five years) was a risk factor for secondary cases in the household. Separating the primary case from siblings may present secondary infections in households. In a study of STEC in Minnesota, E. coli O157:H7 were more likely than non-O157 cases to involve bloody diarrhea, hospitalization and HUS. E. coli O157:H7 is transmitted through consumption of contaminated food or beverage, person-to-person contact or swimming in contaminated recreational water. In a study in Washington state, risk factors for E. coli O157:H7 infections were exposure to aquatic recreation, using private wells and residential septic systems and domestic travel within the United States. In a study in Australia, case patients with E. coli O157:H7 were more likely to report eating hamburgers and eating at restaurants as compared to controls. Risk factors for non-O157 STEC included occupational exposure to animals, consumption of sliced processed chicken meat, camping, eating at a catered event and eating sliced corn beef. During 2007, 4,847 STEC cases were reported from 49 states. Three serogroups (O26, O103 and O111) accounted for 67 percent of the non-O157 isolates. Of the 10 diseases under active surveillance in the FoodNet sites (illnesses caused by Campylobacter, Cryptosporidium, Cyclospora, E. coli O157:H7, HUS, Listeria monocytogenes, Salmonella, Shigella, Vibrio and Yersinia enterocolitica), E. coli O157:H7 was responsible for 546 of 18,039 (3 percent) of the reported infections in 2007 data. STEC non-O157 were responsible for 272 of 18,039 (1.5 percent) of the reported infections. The incidence rate for E. coli O157:H7 was 1.2 per 100,000 and ranged from 0.4 to 3.2 per 100,000 at the ten FoodNet sites. The incidence rate for STEC non-O157 58 was 0.6. On STEC non-O157, the following were the most common O antigens identified: O103 (21 percent), O26 (20 percent), O121 (17 percent) and O111 (15 percent). CDC recommends that all bloody diarrheal stools be routinely cultured for E. coli O157:H7. Rapid tests also are available to directly detect shiga toxin in stool specimens. Specimens testing positive should be cultured to identify which organism (E. coli or Shigella) produced the shiga toxin. Broth culture media or specimens in which shiga toxin has been detected should be cultured for E. coli or submitted to the state public health laboratory for E. coli isolation. Pulsed-field gel electrophoresis (PFGE) is done routinely in Illinois on E. coli O157:H7 isolates that are submitted to the state laboratory. Epidemiologic investigation into a cluster of cases should occur after finding a match by two enzyme PFGE. Single enzyme analysis is insufficient to determine whether isolates and cases are truly related. Enterotoxigenic E. coli is believed to be a common cause of traveler’s diarrhea. United States residents who travel overseas may return to the United States with ETEC. Enterotoxigenic E. coli is not identified by routine stool culture methods. Prevention measures for enteric E. coli infections include cooking food thoroughly, prompt refrigeration of foods and separation of cooked and raw foods. are contraindicated for treatment of E. coli O157:H7 infections; this treatment leads to release of toxin as bacteria die and increased risk for development of hemolytic uremic syndrome (HUS). Food safety practices that can decrease risk of E. coli O157:H7 from ground beef include thawing frozen ground beef in the refrigerator, not at room temperature, and cooking to a temperature of 160° F. Kitchen items in contact with raw ground beef should be washed thoroughly before reusing.

Case definition The case definition for a confirmed case of E. coli O157:H7 used in Illinois is a clinically compatible illness with isolation of E. coli O157:H7 from a stool specimen or E. coli O157 organisms that are laboratory confirmed as producing shiga toxin. E. coli isolated in stool from a person with clinically compatible illness that produce shiga toxin but are not identified as O157 also is reportable as shiga toxin producing E. coli, non- O157. A confirmed case of ETEC is a clinically compatible illness with laboratory confirmation of enterotoxigenic E. coli from stool. A confirmed case of enteropathogenic E. coli is a clinically compatible illness with laboratory confirmation of enteropathogenic E. coli from stool. A probable case of ETEC or enteropathogenic E. coli, or STEC is a clinically compatible case which is epidemiologically linked to cases but has not been laboratory confirmed.

Descriptive epidemiology Shiga-toxin producing E. coli, including E. coli O157:H7 • Number of cases reported in Illinois in 2007 – 131 (five-year median = 124) (see Figure 38). An additional four cases of STEC, shiga toxin positive but not cultured or serotyped were not counted in CDC numbers. The incidence for the 131 STEC cases in Illinois was 1.05 cases per 100,000 population. Of these 131 cases, 112 were identified as E. coli O157:H7, 13 were identified as E. coli O157, H antigen unknown. Six were identified as STEC, non-O157. Nine cases were probable and the rest were confirmed.

59 • Age - Cases ranged in age from 8 months to 77 years of age (mean = 24 years of age) (Figure 39). • Gender – Fifty percent were female. • Race/ethnicity – Ninety-two percent were white, 6 percent were African American, and 2 percent were other races; 5 percent of cases were Hispanic. • Seasonal variation - The largest number of cases occurred in the months from June to October (77 percent of cases) (Figure 40). • Geographic location – The county with the most cases was Cook (27 cases), followed by Effingham (12 cases). Ten of the Effingham cases were linked to one outbreak in the county. • Clinical syndrome – Of the 125 cases with symptom information, 100 percent reported diarrhea, 83 percent reported bloody diarrhea, 51 percent reported vomiting and 30 percent reported fever; five cases (8 percent of patients for whom information was available) had HUS and no cases had thrombotic thrombocytopenic purpura (TTP). Four cases reportedly were put on dialysis. Seventy-nine of 125 cases (63 percent) were hospitalized. No cases were reported to be fatal. • Reporter – The most common reporters included infection control professionals (57 percent) and laboratories (37 percent). • Sensitive occupations - There were two cases involving health care workers, two involving workers at food service facilities and one involving a worker at a daycare. • Outbreaks – Two foodborne outbreaks were reported in 2007. (see detailed description in the “Food and Waterborne Outbreaks” section).

Risk factors • Eight of 119 (7 percent) of the cases reported contact with a day care. There were four of 113 (3 percent) of cases reporting contact with a residential facility. • Three cases attended pre-school. • Travel – o Twenty-two of 120 cases (18 percent) reported traveling to another state. o Missouri and Indiana were the most common destinations (six each). o Two of 116 cases (2 percent) reported traveling to another country during their incubation period. One traveled to the Ukraine and one to the Dominican Republic. • Animal contact o Sixty-one of 109 cases (56 percent) reported contact with animals. Five cases had contact with cattle. Two of the persons reporting cattle contact had recently attended cattle sales in different locations. • Well water exposure - Fifteen of 121 (12 percent) reported drinking well water. • Recreational water exposure o Sixteen cases of 117 (14 percent) reported swimming in non-chlorinated water. o Nineteen of 114 cases (17 percent) reported swimming in chlorinated water. • Ground beef consumption – o Sixty-six of 102 cases (65 percent) reported consuming ground beef. o Eleven of these cases reported consuming the ground beef undercooked. 60

ETEC • Number of cases reported in Illinois in 2007 - None.

Other types of reportable enteric E. coli There were no other types of E. coli infections reported in 2007.

Summary The incidence of infection with E. coli O157:H7 in 2007 was 0.9 cases per 100,000 population, which is lower than what was found in CDC’s FoodNet sites (1.2 per 100,000). Most cases (77 percent) of shiga toxin producing E. coli occurred in the months of June through October. Bloody diarrhea was reported by 83 percent of case individuals; 8 percent of patients reportedly had HUS diagnosed by a physician. Sixty-three percent of cases were hospitalized. Sixty-five percent of cases reported consuming ground beef.

Suggested readings Ahn, C.K., et. al. Isolation of patients acutely infected with Escherichia coli O157:H7: Low-tech, highly effective prevention of hemolytic uremic syndrome. CID 2008;46:1197-99. Centers for Disease Control and Prevention. FoodNet 2007 Surveillance Report. Atlanta: U.S. Department of Health and Human Services, 2009. Denno, D.M., et. al. Tri-county comprehensive assessment of risk factors for sporadic reportable bacterial enteric infection in children. JID 2009;199:467-476. Hedican, E.B., et. al. Characteristics of O157 versus non-O157 shiga toxin- producing Escherichia coli infections in Minnesota, 2000-2006. CID 2009; 49: 558-364. McPherson, M., et. al. Serogroup-specific risk factors for shiga toxin-producing Escherichia coli infections in Australia. CID 2009; 49: 249-56. Werber, D., et. al. Preventing household transmission of shiga toxin-producing Escherichia coli O157 infection: Promptly separating siblings might be the key. CID 2008;46:1189-96.

Figure 38 Shiga-toxin producing E. coli Cases in Illinois, 2002-2007

250 200 150 E. coli O157:H7 100 197 STEC, not further specified 102 112 50 124 122 96 40 19 Number of cases Numberof 0 8 2002 2003 2004 2005 2006 2007 Year

61 Figure 39. Age Distribution of shiga toxin producing E.coli Cases in Illinois, 2007

40 30 20 10 0 Number of cases Numberof <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Year

Figure 40. Shiga toxin producing E. coli cases in Illinois by Month, 2007

30

20

10

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year

62 Foodborne and Waterborne Outbreaks

Background The surveillance on food-related disease outbreaks (foodborne outbreaks) is significant in that food can act as a vehicle for transmission of pathogens or their byproducts. Although many foodborne illnesses result in a few days of diarrhea, with additional symptoms such as fever, vomiting or muscle aches, others can have serious health effects such as hemolytic uremic syndrome, reactive arthritis, sepsis or Guillain Barré syndrome. Foodborne illness can be caused by microorganisms and their toxins, marine organisms and their toxins, fungi and chemical contaminants. There are three categories of organisms to consider in discussing the causes of foodborne illness: viruses, bacteria and parasites. For some viruses, such as hepatitis A or Noroviruses, humans are the only reservoir. Prevention of foodborne illness depends heavily on food handlers and proper food handling practices. Rotaviruses can occasionally cause foodborne outbreaks. Shellfish have been associated with hepatitis A virus, calicivirus and Vibrio spp. outbreaks. The use of gloves for food handlers is often recommended to decrease transmission of enteric pathogens. A study of glove use did not verify that glove wearers had less coliform bacteria on the food as compared to food handlers who did not wear gloves. It has been observed that food handlers wear the same pair of gloves for extended periods of time. Proper hygiene, such as keeping the environment clean, avoiding cross contamination, and proper hand washing can help prevent a large number of food and waterborne outbreaks. CDC estimates that in the 1990s approximately 12 percent of foodborne outbreaks were linked to produce items. Bacteria comprise the largest category of foodborne agents. These include E. coli O157:H7, Salmonella and Listeria monocytogenes. Parasites like Trichinella in pork, Anasakis in raw fish or Cyclospora in raspberries also can cause foodborne illness. Some enteric pathogens, such as Campylobacter, Giardia and Shigella, rarely cause foodborne outbreaks. One common cause of waterborne outbreaks in water parks is cryptosporidiosis. High flow sand filtration and chlorination disinfection may not be enough to protect swimmers. Prevention of outbreaks can include signs asking patrons to wash young children’s bottoms before entering the water, diaper changing only in designated areas, discouraging of drinking any water and not entering water with diarrhea. CDC’s Foodborne Disease Active Surveillance Network (FoodNet) is a system to collect information from seven states and selected counties in three states in the United States. The network provides stable and accurate national estimates of foodborne disease occurrences in the country. According to the 2007 FoodNet Surveillance Report, there were a total of 18,039 laboratory-confirmed cases of infection in their surveillance system. The incidence of laboratory-confirmed causes was estimated as follows: Salmonella (14.9 per 100,000), Campylobacter (12.8 per 100,000), Shigella (6 per 100,000), Cryptosporidium (2.7 per 100,000), shiga-toxin producing E. coli (STEC) O157 (1.2 per 100,000), Yersinia (0.4 per 100,000), Vibrio (0.2 per 100,000), Listeria

63 (0.3 per 100,000), STEC non-O157 (0.6 per 100,000), and Cyclospora (0.03 per 100,000). In 2007, 1,097 foodborne outbreaks involving 21,244 cases and 18 deaths, were reported to CDC. For confirmed outbreaks, viruses caused 40 percent of outbreaks and bacteria caused 52 percent. Chemical agents and parasites caused 1 percent each. Norovirus was the most common cause, followed by Salmonella. Illinois’s ranking for the number of confirmed outbreaks reported was bacterial (seventh highest number), chemical (sixth highest) and viral (third highest). A food vehicle was identified in 43 percent of outbreaks. Poultry, beef and leafy vegetables were the most common food commodities implicated.

Case definition A foodborne outbreak is an incident in which two or more persons (usually residing in separate households) experience the onset of a similar, acute illness (usually gastrointestinal) following ingestion of common food or drink. With multi-state outbreaks, there may be one Illinois resident affected and multiple cases from other states. CDC has established case definitions for confirmed outbreaks and these are listed under the specific organisms in this outbreak section. For foodborne outbreaks, the number ill reflects those who meet a clinical case definition. For outbreaks where the etiologic agent was suspected and not confirmed, and the clinical syndrome matched the suspect etiologic agent but no laboratory confirmation was obtained, the suspect cause is ascribed to this etiologic agent. IDPH receives reports of potential foodborne outbreaks from many sources. Outbreak investigations, which are conducted by local health departments, may not result in a confirmed foodborne outbreak designation and will not be counted in the state totals. There are a number of reasons for this: lack of information, classification as person-to-person transmission or because the symptoms and incubation period do not clearly indicate a known foodborne pathogen.

Descriptive epidemiology The number of possible foodborne or waterborne outbreaks reported to the Department by local health departments (LHDs) was 91 during 2007. The total for the year was 79 foodborne outbreaks that met the definition of an outbreak and were submitted to the Centers for Disease Control and Prevention (CDC). Two recreational waterborne outbreaks were reported to CDC. Of the 81 foodborne and waterborne outbreaks, the etiology was confirmed in 34 foodborne and two waterborne outbreaks, suspected in 28 outbreaks and unknown in 17 outbreaks. Two of the 81 outbreaks were due to recreational water exposure. (Note: Drinking water outbreaks were not counted under recreational water outbreaks). In the year 2007, a total of 2,525 people were reported to have become ill as the result of the 79 foodborne outbreaks and 10 as a result of the two recreational water outbreaks. The mean number of ill persons was 32 per foodborne outbreak and five for waterborne outbreaks; the median number of cases ill was 10 per foodborne outbreak and five for waterborne outbreaks; the number of ill persons per outbreak ranged from

64 one to 526 for foodborne and waterborne outbreaks combined. The outbreaks with one Illinois resident affected were due to multi-state outbreaks. There were 105 persons hospitalized as a result of the foodborne outbreaks and one hospitalized due to waterborne outbreaks. There were no fatalities reported due to foodborne or waterborne illness during the year 2007. Foodborne outbreaks reported during 2007 were from the following counties: Cook (38), Kane (nine) and DuPage (four); three each for the counties of McHenry and Rock Island; two each for the counties of Mclean, Tazewell and Winnebago; and one each for the counties of Effingham, JoDaviess, Madison, McDonough, Peoria, Stephenson, Vermilion, Warren, Wayne, Will, Williamson and Woodford; and there were four multi-county or multi-state foodborne outbreaks recorded. The waterborne outbreaks were reported from the counties of Jo Daviess and Winnebago. The 79 reported foodborne outbreaks occurred in the following months: January, seven (9 percent); February, five (6 percent); March, four (5 percent); April, seven (9 percent); May, seven (9 percent); June, seven (9 percent); July, 12 (15 percent); August, seven (9 percent); September, five (6 percent); October, seven (9 percent); November, five (6 percent); and December, six (7 percent) (Figure 41). Both recreational water outbreaks were in August. In the 79 foodborne and recreational water outbreaks reported, the etiologic agent was determined to be due to bacterial agents (infection or intoxication), either suspect or confirmed, in 27 (34 percent) (Tables 3 and 4). The bacterial pathogens were as follows: Salmonella spp. (12 outbreaks), shiga toxin producing E. coli (four), toxin (four), cereus/ S. aureus toxin (one), B. cereus/C perfringens toxin (two), S. aureus (two) and Campylobacter (two). The etiologic agent in 33 (42 percent) of the 79 foodborne outbreaks was suspected or confirmed to be caused by viruses. One was confirmed to be hepatitis A. Thirty-two of the 33 were attributed to norovirus infection. Nine (28 percent) of these were confirmed. The remaining 23 (70 percent) of norovirus outbreaks were classed as suspect norovirus outbreaks, largely based on symptoms, incubation and duration in the people who were affected. One foodborne outbreak was due to tetrodotoxin and one due to lead. Both of the recreational water outbreaks were caused by parasitic agents. Although thorough investigations were conducted, there was inconclusive evidence to classify either suspect or confirm etiologic agents in 17 (21 percent) of the foodborne or recreational water outbreaks and they were thus classified as etiology unknown. Food handlers were laboratory tested in 15 of the foodborne outbreaks (19 percent). In 13 (87 percent) of the outbreaks food handlers were found to be positive for the etiologic agent implicated in the outbreak. Food handlers tested positive for norovirus in six outbreaks and Salmonella in seven outbreaks. In one outbreak involving E. coli O157:H7 and one outbreak due to unknown cause, food handlers were negative. Environmental samples were taken in two foodborne outbreaks and neither of the waterborne outbreaks. Through either epidemiology, supportive information or food testing, 25 food or water items were implicated in outbreaks. In seven outbreaks, meat products were implicated (poultry for three outbreaks, ground beef for two outbreaks and pork for two

65 outbreaks). The poultry products involved were roasted turkey, shredded chicken and turkey. The pork products implicated were roasted pork and pork barbeque. Vegetables were implicated in one outbreak (lettuce). Fish was implicated in one outbreak (puffer fish) and dairy products in one outbreak (unpasteurized cheese). Complex foods were implicated in 11 outbreaks. Complex food items implicated were chili, dill dip and raspberry dressing, pasta, pancit palabok, pighead meat and salsa, enchiladas, beef burritos, pot pie, taco salad, beef stew and chocolate strawberries and deli sandwiches. Other food items involved included Veggie Booty snack food, hummus and Sindoor. The food causing illness in 54 foodborne outbreaks (70 percent) was unknown. Food was tested for pathogens in 23 (30 percent) of the outbreaks. Positive foods were found in 12 (52 percent) of the 23 outbreaks where samples were tested. The responsible pathogens found were Salmonella (four), C. perfringens (three), S. aureus (two), fecal coliforms (one), tetrodotoxin (one) and lead (one). In one of the 12 outbreaks the food tested positive in states other than Illinois. The site of food preparation in 78 foodborne or drinking water outbreaks with available information were: restaurant, 44 (56 percent); private home, seven (9 percent); caterer, three (4 percent); banquet facility, three (4 percent); grocery, three (4 percent), commercial product, four (5 percent) and one each for one percent each for school, hotel and sailing club. Eleven (14 percent) had food preparation done at multiple sites. The two recreational waterborne outbreaks were from entering pools. The site where the food was consumed was: restaurant, 30 (38 percent); private home, 16 (20 percent); work, 11 (14 percent); banquet facility, four (5 percent); fair, three (4 percent); park, two (2 percent) and one each in hotel, sailing club, tavern, church, picnic, grocery and school (1 percent each). In six outbreaks (8 percent) food was consumed in multiple areas. In 29 (35 percent) of the foodborne and drinking water outbreaks, contributing factors were known. Food handlers were identified as a contributing factor in 68 percent of the outbreaks. Other contributing factors included improper holding temperatures (21 percent), contaminated raw products (14 percent) and preparing food ahead of time (14 percent). Other contributing factors included unlicensed product, cross contamination, commercial product not cooked properly, contaminated product, insufficient reheating and contaminated storage site. A line listing of outbreaks is provided in Table 5.

Figure 41. Number of Foodborne Outbreaks by Month of First Onset, Illinois, 2007

15

Number of 10 outbreaks reported 5 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month

66 Summary

In 2007, Illinois recorded 79 foodborne and two waterborne outbreaks compared to a five-year median of 69. The most common site of food preparation in the reported outbreaks was restaurants. Issues with food handlers were the most commonly reported contributing factor to outbreaks. For confirmed outbreaks, viruses caused a lower percent (29 percent) of Illinois outbreaks as compared to 40 percent on the national level. For confirmed outbreaks, bacteria caused a higher percent (65 percent) of Illinois outbreaks as compared to national data (52 percent). Nationally, food items were implicated in 43 percent of outbreaks as compared to 32 percent in Illinois. In 2007, the month of July had an increased number of outbreaks.

Suggested readings Boone, A., et. al. Surveillance for foodborne disease outbreaks – United States, 2007. MMWR 2010; 59(31): 973-979. Centers for Disease Control and Prevention. FoodNet 2007 Surveillance Report. Atlanta: U.S. Department of Health and Human Services, 2009. Jue, R., et. al. Outbreak of cryptosporidiosis associated with a splash park, Idaho, 2007. MMWR 2009;615-618.

Table 3. Foodborne Outbreaks, Cases and Deaths by Etiology in Illinois, 2007 Outbreaks Cases Deaths Etiology# Count % Count % Count % Bacterial B. cereus/S. aureus ** 1 1 3 0.1 0 --- B. cereus/C. perfringens** 2 2 24 0.9 0 Campylobacter 2 2 21 0.8 0 --- Clostridium perfringens 4 5 56 2 0 --- Shiga-toxin producing Escherichia coli (O157:H7) 4 5 15 0.6 0 --- Salmonella 12 15 974 38 0 --- Staphylococcus aureus 2 2 87 3 0 --- Total Bacterial* 27 34 1,180 47 0 --- Chemicals/Fish Toxin Tetrodotoxin 1 1 2 0.08 0 --- Total Chemical/Fish Toxin 1 1 2 0.08 0 --- Heavy metal Lead 1 1 3 0.1 0 --- Total Heavy Metal 1 1 3 0.1 0 --- Viral Hepatitis A 1 1 2 0.08 0 --- Norovirus 32 40 1,192 47 0 Total Viral 33 42 1,194 47 0 --- Unknown etiology 17 21 146 6 0 Total 2007 79 - 2,525 - #Confirmed and suspected etiologies ** Suspected intoxication * Some outbreaks are suspected to be due to bacterial intoxication with more than one suspected pathogen.

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Table 4. Foodborne Outbreak Pathogens by Testing Status in Illinois, 2007 Confirmed Suspected Unknown Etiology Count % Count % Count % Bacterial B. cereus/S. aureus ** 0 --- 1 3 B. cereus/C. perfringens** 0 --- 2 7 Campylobacter 1 3 1 3 Clostridium perfringens 4 12 0 --- Shiga-toxin producing Escherichia coli (O157:H7) 3 9 1 3 Salmonella 12 35 0 --- Staphylococcus aureus 2 6 0 --- Total Bacterial 22 65 5 18 Chemicals/Fish toxin Tetrodotoxin 1 3 0 --- Total Chemical/Fish toxin 1 3 0 --- Heavy metal Lead 1 3 0 --- Total Heavy Metal 1 3 0 --- Viral Norovirus 9 26 23 82 Hepatitis A 1 3 0 --- Total Viral 10 29 23 82 Total 2007 34 --- 28 --- .

68 Specific Types of Foodborne Outbreaks B. cereus causes foodborne illness through intoxication. There are two types of illness caused by B. cereus, depending on the enterotoxin elaborated by the organism. In one type, the incubation period is from one to six hours and symptoms last 12 hours or less. Almost all individuals experience vomiting and about one-third experience diarrhea. The illness is caused by a preformed enterotoxin. Rice has been associated with this type of B. cereus in past outbreaks. In the other type, the incubation period ranges from eight to 16 hours and symptoms last less than 24 hours. Diarrhea is a prominent feature but vomiting is absent. Foods associated with previous outbreaks include custards, cereals, and meat or vegetable dishes. The organism multiplies rapidly at room temperature and the spores can survive boiling.

Case definition Laboratory confirmation for B. cereus includes isolation of greater than 105 organisms per gram in properly handled food or isolation of the organism from two or more ill people and not from controls.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 - None confirmed. There was one outbreak that may have been caused by either B. cereus or S. aureus intoxication as suggested by the clinical presentation and two outbreaks in which the clinical picture suggested either B. cereus or C. perfringens intoxication, both were not confirmed. • Bacillus cereus had been identified as the cause of one foodborne outbreak in 2002, five outbreaks in 2003, and two in 2006; there were no outbreaks caused by B. cereus in 2004, 2005 or 2006.

Campylobacter species Campylobacter infection usually presents as bloody diarrhea, abdominal pain, nausea, vomiting and fever within two to five days of exposure. However, there are asymptomatic cases of campylobacteriosis. Cases are often associated with improper handling of raw poultry or eating raw or undercooked poultry.

Case definition Campylobacteriosis is diagnosed through isolation of the organism from any clinical specimen. Two or more cases with a common epidemiologic link constitute an outbreak.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 - One outbreak of Campylobacter was confirmed and one was suspected. A total of 21 persons became ill and none were hospitalized. • Individual Descriptions of Confirmed Outbreaks o An outbreak of Campylobacter jejuni occurred in September in Wayne County. Eighteen persons became ill after a rehearsal dinner meal. Food

69 was prepared in several places for the event including a private home, a church and a caterer. Unlicensed individuals were used for some of the food preparation. No foods were tested. Three persons were laboratory confirmed for Campylobacter. No persons were hospitalized. No specific food was linked to illness by epidemiologic analysis. • There were only two outbreaks caused by Campylobacter in the previous 5 year period and these outbreaks occurred in 2005 and 2006.

Campylobacter Confirmed Suspected* Outbreaks 1 1 Total number of ills 18 3 Average number of ills/outbreak 18 3 Number of cases hospitalized 0 0 Number of fatalities 0 0 Outbreak months July 0 1 September 1 0 Counties of outbreaks Cook 0 1 Wayne 1 0

Clostridium perfringens Another foodborne intoxication is caused by C. perfringens enterotoxin. Diarrhea is common but symptoms of vomiting and fever are usually absent. The incubation period is eight to 16 hours (usually 12 hours). The illness lasts one day or less. Almost all outbreaks are associated with the inadequate heating or reheating of meats or gravies, which allows the organism to multiply. The enterotoxin is heat-resistant.

Case definition There are three ways to establish laboratory confirmation of a C. perfringens outbreak: 1) isolation of greater than 105 organisms per gram of food that has been properly handled for testing, 2) demonstration of enterotoxin in the stool of two or more ills, or 3) isolation of greater than 106 organisms per gram in the stool of two or more ill persons.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 – Four outbreaks were confirmed; two outbreaks were suspected to be due to either C. perfringens or B. cereus without laboratory confirmation. For the four confirmed outbreaks, foods that tested positive in three outbreaks were roasted pork, turkey and chili. In one outbreak, shredded chicken was epidemiologically linked to illness. In four of these outbreaks improper holding temperature was believed to be contributing factor. The site at which food was prepared for the four confirmed outbreaks was restaurant (two outbreaks), caterer (one) and private home (one). • Individual Descriptions of Confirmed Outbreaks o An outbreak of confirmed C. perfringens Type A occurred in Kane County

70 in January. Twenty-three of 40 persons developed symptoms after a median of nine hours following a party at a home. One person had illness resulting in hospitalization, colectomy and hepatorenal failure. Tissue samples from her colon tested positive for C. perfringens by PCR testing. No fatalities were reported. Testing of chili from the meal revealed 1,500,000 organisms per gram of C. perfringens Type A. Contributing factors to this outbreak were preparing foods ahead and improper hot holding temperatures and improper temperature and time for reheating. o An outbreak of C. perfringens occurred in July in Kane County in individuals eating a lunch brought in from a restaurant. A total of seven persons reported illness. Five individuals were positive for C. perfringens. Shredded chicken was linked by epidemiologic analysis. Foods were kept at incorrect holding temperatures. o Foods were catered to an airline work place. Fourteen persons became ill following the meal. Turkey was served that was reported to have a foul smell and service of the food was stopped. Turkey tested positive for C. perfringens at 250,000 per gram. Food was prepared in advance and may have been held at improper temperatures. o Twelve persons became ill after a party held in a private home in December in Chicago. Roast pork was purchased at a restaurant and brought home. Roast pork tested positive for C. perfringens at 2,100,000 per gram. Two ill persons tested negative for C. perfringens. Restaurant inspection revealed improper holding temperatures for foods. No one was hospitalized. • C. perfringens caused four foodborne outbreaks in 2002, three in 2003, one in 2004, and two in 2006 and there were none in 2005 and 2006.

Confirmed Outbreaks 4 Total number of ills 56 Average number of ills/outbreak 14 Number of cases hospitalized 1 Number of fatalities 0 Outbreak months January 1 July 1 November 1 December 1 Counties of outbreaks Cook 2 Kane 2 Food testing Chili, positive Turkey, positive Roasted pork, positive

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Shiga toxin producing E. coli (E. coli O157:H7 and others) Foodborne outbreaks of E. coli O157:H7 have been linked to undercooked ground beef, apple cider, sprouts and lettuce. Other types of E. coli also can be pathogenic in humans and cause outbreaks. A total of 4,847 shiga toxin producing E. coli cases reported to CDC in 2007. Ground beef is the most common vehicle in foodborne outbreaks. Produce-associated outbreaks are also common. Person-to-person outbreaks occur most commonly in day care centers.

Case definition Laboratory confirmation of an outbreak occurs when E. coli O157:H7 or other Shiga toxin-producing E. coli is isolated from stool of two or more ill persons or from the implicated food or water.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 – Four STEC outbreaks were reported and all were due to E. coli O157:H7. Three confirmed and one suspect E. coli O157:H7 outbreak were reported. Outbreaks occurred in DuPage, Effingham, St Clair and Warren. A total of 15 people became ill and 12 were hospitalized. There were no fatal cases. A specific food item was implicated in two of the four outbreaks. The food item was ground beef and it was implicated as a result of investigations in other states. For the three confirmed outbreaks two different Xba1 PFGE patterns were identified. The contributory causes for two outbreaks was contamination of raw product (ground beef). For two outbreaks the contributing factors were unknown. • Individual Descriptions for Confirmed Outbreaks o A confirmed E. coli O157:H7 outbreak occurred in September in Effingham County. Ten cases were reported from patrons of a restaurant. One person developed HUS and seven persons were hospitalized. The CDC PFGE pattern was EXHX01.0047/EXHA26.0015. All food handlers tested negative and no specific food could be linked to illness. All environmental specimens taken of surfaces at the restaurant tested negative. All food samples tested from the restaurant tested negative. Onsets of illness were September 13 to September 17. o One Illinois resident from St. Clair County with onset in April was linked to a multi-state outbreak of E. coli O157:H7 (EXHX01.0047) associated with ground beef. The case was hospitalized. o One Illinois resident from Dupage County with onset in April was linked to a multi-state outbreak of E. coli O157:H7 (EXHX01.0200) associated with ground beef. The case was hospitalized. • There were two STEC outbreaks in each of the following years: 2002, 2003, 2004 and 2006 each; one outbreak was reported in 2005.

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E. coli O157:H7 Confirmed Suspected* Outbreaks 3 1 Total number of ills 12 3 Average number of ills/outbreak 4 3 Number of cases hospitalized 9 3 Number of fatalities 0 0 Outbreak months April 2 0 July 0 1 September 1 0 Counties of outbreaks Dupage, multi-state 1 0 Effingham 1 0 St. Clair, multi-state 1 0 Warren 0 1 Check up samples Food tested negative Food handlers tested All negative Not tested Environmental specimen tested None ---

Enterotoxigenic E. coli Enterotoxigenic E. coli is the most common cause of traveler’s diarrhea. People are the reservoir for this organism. Transmission is usually from consumption of food or water contaminated with feces from infected persons. The incubation period is 10 to 12 hours if one toxin is present and 24 to 72 hours if both toxins are present. Symptoms are acute watery diarrhea. Three outbreaks were reported in Illinois from 1998 to 2006.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 – None.

Salmonella Salmonella is the most common causative agent associated with bacterial foodborne outbreaks. The incubation period for Salmonella is six to 72 hours. Symptoms may include diarrhea, vomiting, fever and headache. Several large multi- state outbreaks were reported in 2007. One outbreak of Salmonella serotype I 4,5,12:i- was linked to consumption of frozen, not-ready-to-eat pot pies in 41 states. Testing of pot pies yielded the outbreak strain. Illinois residents were affected by this outbreak. A concern during this outbreak was the recommended microwave cooking times may vary by microwave wattage and many persons may not know the wattage of their microwave. A second multi-state outbreak was linked to a commercial vegetable-coated snack food. Illnesses were caused by S. ser. Wandsworth and were primarily in infants and toddlers. The product tested positive for four Salmonella serotypes including Wandsworth. Illinois residents were affected by this outbreak. This outbreak may have been caused by

73 adding seasoning after the heating step. This seasoning did not undergo a lethal processing step.

Case definition A laboratory-confirmed outbreak of Salmonella occurs when bacteria are either cultured from implicated food or Salmonella of the same serotype is cultured from clinical specimens from two or more ill individuals.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 - 12 confirmed outbreaks were reported with 974 people ill (mean = 81 persons ill per outbreak). Outbreaks occurred in five counties. In addition, two outbreaks were multi-state outbreaks. Serotypes causing outbreaks included Enteritidis (three outbreaks), Montevideo (two) and one each for Heidelberg, Infantis, Litchfield, Newport and Typhimurium. Two outbreaks had two serotypes (Typhimurium and Wandsworth for one outbreak and Typhimurium and I 4,5,12,i:-). Food handlers were tested in seven of the eight outbreaks occurring in a facility with food handlers and in all seven outbreaks food handlers tested positive for Salmonella. In five of the eight outbreaks where food handlers were present, information was available on food handler illnesses. In two outbreaks a food handler reported gastrointestinal illness. In three outbreaks they did not report illnesses. In four of the five outbreaks, food handlers tested positive for Salmonella. Contributing factors were unknown for two of the 12 outbreaks. For 10 outbreaks contributing factors were identified including food handlers ill or laboratory positive for a pathogen (six), contaminated raw product (one), contaminated commercial product (one), contaminated commercial product cooked improperly by consumer (one), unlicensed product (one) and food not cooked sufficiently (one). One outbreak had two contributing factors. Food testing was performed in six outbreaks. In five outbreaks a food tested positive. Foods testing positive were hummus, unpasteurized milk, spices used in a snack food, pot pies and in one outbreak both salsa and pigs head meat. In one outbreak, only check up samples were tested and were negative. • Individual Descriptions of Confirmed Outbreaks o An outbreak of S. ser. Newport occurred in the Hispanic community primarily in Kane County. Ninety-six cases. Isolates from 47 cases tested by PFGE matched (PFGE pattern: SneO2X8/SneO6B1). Illnesses were linked to consumption of unpasteurized cheese sold at a local Hispanic grocery store. Unpasteurized milk from a local dairy farm tested positive for the same PFGE pattern of Salmonella. The weight slips from this farm were variable over time possibly indicating diversion of milk from pasteurization. Once the sale of this unpasteurized cheese was stopped cases also stopped. o An outbreak of Salmonella ser. Enteritidis in 18 persons occurred in Madison County in February and was linked to eating at a restaurant. Isolates from three cases were tested by PFGE and all three matched (Sen07X11/ JEGX01.0034). Twelve persons were laboratory confirmed. One food handler reported working with diarrhea. Two food handlers (including the one who reported diarrheal illness) tested positive for Salmonella ser. Enteritidis. No

74 specific food item was linked to illness. o A multi-state outbreak of S. ser. Typhimurium occurred related to consumption of lettuce. Seven Illinois residents were affected. Twenty-five residents matched the outbreak pattern but only seven had a consistent food history. This lettuce was sold in grocery stores and eaten in private homes. o Two persons tested positive for S. ser. Enteritidis in March in Cook County after eating at a restaurant. No PFGE testing was done on isolates. o An outbreak of S. ser. Litchfield occurred in Rock Island in May of 2007. Six confirmed cases reported eating at a restaurant. Food handlers were tested. The number positive is not known at this time. Isolates from six persons had two PFGE patterns (CDC pattern: JGXX01.0054 and JGXX01.0053).The contributing factors were unknown. The restaurant was closed until employees tested negative. o An outbreak of S. ser. Montevideo (CDC PFGE pattern Xba1: JIXX01.0011) occurred in Dupage County in April in persons who purchased food at a grocery store. Nine cases had PFGE performed and all matched. No food handlers reported illness but one tested positive for S. ser. Montevideo of the same PFGE pattern as the cases. Pancit Palabok was implicated by epidemiologic analysis and was prepared by the laboratory confirmed food handler. Two persons were hospitalized. o Nine individuals who purchased foods from a grocery store in Kane County became ill with S. ser. Montevideo (CDC PFGE Xba1: JIXX01.0140). Isolates from three persons were PFGE’d and all three matched. One was a food handler tested positive for the same PFGE pattern of S. ser. Montevideo. Samples of green salsa, red salsa and pig head meat from one household tested positive for S. ser. Montevideo and the isolates matched the case isolates. o A large outbreak of S. ser. Heidelberg (PFGE pattern Xba: JF6X01.0032, Bln: JF6A26.0076) occurred in persons after a large outdoor festival in Chicago in June. The number of persons laboratory confirmed was 191. There were 146 isolates tested by PFGE that had a two enzyme match and five isolates that had one PFGE enzyme run and matched by one enzyme. An estimated 802 people became ill as a result of this outbreak. Hummus tested positive for S. ser. Heidelberg. Three food handlers tested positive for the same strain and reported gastrointestinal illness while working. Illnesses occurred in persons from multiple states. o A multi-state S. ser. Typhimurium and ser. I 4,5,12:i:- occurred in late 2007. Pot pie consumption was linked with illnesses. Salmonella was present in pot pies that were then not sufficiently cooked by consumers resulting in illnesses. Seven Illinois residents were PFGE matches to this outbreak and reported consumption of the implicated pot pies. All seven Illinois residents matched by PFGE (JJPX01.0206/JPXA26.0180). o At least 60 cases of S. ser. Wandsworth and Typhimurium from 19 states occurred and were PFGE matched. The isolate from one case in Illinois was PFGE’d and the CDC pattern was WWSX01.0013. Cases were linked to consumption of Veggie Booty snack food. Two Chicago residents became ill

75 with the same strain and reported eating the implicated food. Neither were hospitalized and both survived. o Five persons became ill with a diarrheal illness after a group of 20 ate at a restaurant in DuPage County in July. Two persons tested positive for S. ser. Enteritidis. Cooperation could not be obtained to get a list of attendees. Five persons called in with illness relating to the restaurant. One food handler tested positive for S. ser. Enteritidis. In addition, foods were found improperly held at room temperature. o Seven persons reported diarrheal illness after eating foods from a Hispanic grocery in Chicago. Six cases were confirmed as S. ser. Infantis, PFGE pattern JFXX01.0069. One food handler tested positive for the same organism. Check up samples from carnitas were negative for Salmonella. • In 2002, there were six Salmonella outbreaks, five in 2003, seven in 2004, six in 2005 and four in 2006.

Confirmed Outbreaks 12 Total number of ills 974 Average number of ills/outbreak 80 Number of cases hospitalized 79 Number of fatalities 0 Outbreak months February 2 March 2 April 1 May 1 June 3 July 2 September 1 Counties of outbreaks Cook 4 Dupage 2 Kane 2 Madison 1 Rock Island 1 Multi-county 2 Yes, spices in Veggie Booty Yes, hummus Yes, unpasteurized milk used for cheese Yes, pot pies Yes, salsa and pig Food testing positive head meat Food handlers positive 7 outbreaks Environmental specimen tested None

Suggested readings Meyers, S., et. al. Multistate outbreak of Salmonella infections associated with

76 frozen pot pies – United States, 2007. MMWR 2008; 51(47_:1277-80.

Shigella The Shigella organism is not a common cause of foodborne outbreaks. Instead, it causes a gastrointestinal illness often transmitted from person-to-person. However, outbreaks have been associated with consumption of bean dip, lettuce, parsley and contaminated water. Outbreaks of shigellosis have also been associated with swimming in contaminated water.

Case definition The case definition for an outbreak of Shigella is identification of the same serotype of the bacteria in two or more ill persons.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 - None.

Staphylococcal food poisoning One type of foodborne illness, classified as intoxication, is caused by enterotoxin- producing strains of S. aureus. Within 30 minutes to eight hours (usually two to four hours) after eating contaminated food, a person may experience explosive vomiting and diarrhea. The duration of illness is usually short - less than 24 hours. Humans are considered to be the primary source of the organism in foodborne outbreaks. S. aureus can be found in nasal passages, throat and hair and on the skin of healthy people; bacteria are present in high numbers in cuts, pustules and abscesses. The enterotoxins produced by S. aureus are heat stable. The organism may produce toxin in foods and then die so cultures of foods may be negative and yet the foods contained the staphylococcal enterotoxin that made people ill. Foodborne outbreaks caused by S. aureus and those caused by the B. cereus type where vomiting predominates have similar incubation periods and clinical syndromes.

Case definition Laboratory confirmation of an outbreak attributable to S. aureus requires detection of enterotoxin in food or organisms with the same phage type in stools or vomitus of two or more cases or isolation of greater than 105 organisms per gram in properly handled food.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 – Two confirmed outbreaks were reported. There was one suspected outbreak that was either S. aureus or B. cereus but the agent was not confirmed. In two outbreaks, food tested positive. Foods testing positive were pulled pork and enchiladas. • Individual Descriptions of Confirmed Outbreaks o An outbreak of confirmed S. aureus enterotoxin B occurred in 75 persons in Cook County in June after a catered picnic. Pulled pork was epidemiologically

77 linked to illness and tested positive for S. aureus at 314,000 organisms/gram. The incubation period was three hours. Food was not kept at proper temperatures. Three persons tested positive for toxin. o In June 2007 in Rock Island, enchiladas were served at a work place after preparation in a private home. Twelve of 22 persons became ill with diarrhea and vomiting an average of three hours after eating the enchiladas. Five persons tested positive for S. aureus. Leftover enchiladas also tested positive with 230,000,000 per gram of S. aureus. Both preparing food ahead and improper heating may have contributed to the outbreak. Three persons were hospitalized.

• Outbreaks of S. aureus: one in 2002, six in 2003, two in 2004, none in 2005 and two in 2006.

Confirmed Outbreaks 2 Total number of ills 87 Average number of ills/outbreak 43 Number of cases hospitalized 3 Number of fatalities 0 Outbreak months June 2 Counties of outbreaks Cook 1 Rock Island 1 Environmental specimen tested 0 Food testing positive Yes, pulled pork Yes, enchiladas

Chemical agents/Fish toxins This category includes toxins such as ciguatera and scombrotoxin, associated with fish consumption. Ciguatera toxin poisoning is caused by the ingestion of the toxin in predatory reef fish, such as barracuda, amberjack and grouper. The toxin is initially produced by dinoflagellates that are eaten by herbivorous fish, which are then consumed by the predatory fish. There is a test to detect the toxin in fish. However, the toxic fish have a normal taste and appearance. The toxin cannot be destroyed by cooking or freezing. Symptoms of diarrhea and vomiting develop within three to six hours after consuming contaminated fish. Neurologic symptoms may follow and persist for weeks or months. These neurologic symptoms include numbness, tingling of the mouth and extremities, muscle pain and weakness, and reversal of temperature sensation. There is no diagnostic test or treatment available for humans. A cluster of nine cases of ciguatera fish poisoning occurred in North Carolina in 2007. Patients became ill four to 48 hours (median = 12 hours) after consuming amberjack. The toxin was identified in the fish.

78 Scombroid fish poisoning occurs after persons have consumed fish that contain high levels of histamine or other biogenic amines. Histamines accumulate when bacterial enzymes metabolize histidine in fish. Histamines are not destroyed when fish are frozen or cooked. This occurs when fish is held at high temperatures. Symptoms include facial flushing, sweating, rash, a burning or peppery taste in the mouth and diarrhea. More severe symptoms can occur and result in the need for medical treatment. Prevention is consistent temperature control of fish at less than 41 F at all times. Rapid cooling of fish after catch is the best method for prevention of scombroid fish poisoning. Scombridae include tuna and mackerel which have high levels of free histidine and are the main fish type linked to scombroid poisoning. Other fish implicated include mahi mahi, amberjack, bluefish, abalone and sardines. Tetrodotoxin is a heat-stable neurotoxin found in puffer fish. Tetrodotoxin poisoning occurs after someone consumes puffer fish that is improperly prepared. The skin and certain internal organs may contain this toxin that is highly toxic to humans. Importation of puffer fish meat is generally not permitted into the United States. Mislabeling of fish imported into the United States has led to cases. Symptoms include numbness of the lips and tongue, paresthesias, a floating sensation and progression of an ascending paralysis.

Case definition The case definition for ciguatera toxin outbreaks is the demonstration of ciguatoxin in epidemiologically implicated fish or a clinical syndrome among persons who have eaten a type of fish previously associated with ciguatera fish poisoning. The case definition for scombroid toxin outbreaks is demonstration of histamine in epidemiologically implicated fish or a clinical syndrome among persons who have eaten a type of fish previously associated with histamine fish poisoning.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 - One outbreak of tetrodotoxin poisoning was reported. • Individual Description of Confirmed Outbreak o Two of three family members became ill after eating puffer fish in Chicago in May. Fish tested positive for tetrodotoxin (300-600 ug tetrodotoxin per 100 grams). One family member prepared the fish in a soup. A recall of imported monk fish, believed to have been improperly labeled puffer fish occurred. One family member was hospitalized for three weeks with numbness, tingling of the periorial region and extremities and extreme weakness. The other family member had minor illness. One family member who only tasted the soup had no symptoms. Both cases survived. Although this outbreak occurred only within one family because of the unusual nature of this outbreak and the known consumption of puffer fish this was counted as an outbreak.

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Confirmed Outbreaks 1 Total number of ills 2 Average number of ills/outbreak Number of cases hospitalized 1 Number of fatalities 0 Outbreak months May 1 Counties of outbreaks Cook 1 Environmental specimen tested --- Food tested Yes, fish tested positive

Suggested readings Cohen, N.J., et. al. Public health response to puffer fish (tetrodotoxin) poisoning from mislabeled product. J Food Protection 2009: 72(4): 810-817. Langley, R., et. al., Cluster of ciguatera fish poisoning – North Carolina, 2007. MMWR 2009; 58 (11): 283-5.

Heavy metals Occasionally heavy metals can contaminate foods. One source of heavy metals in foods is leaching of metallic containers into the food.

Case definition Elevated heavy metal levels in blood in multiple persons linked to a common food item.

Descriptive Epidemiology • Number of outbreaks reported in Illinois in 2007 - One outbreak of lead poisoning was reported. • Individual Description of Confirmed Outbreaks In December 2007 a person contacted a physician for severe abdominal pain and was hospitalized with suspected lead toxicity. The initial case had symptoms of severe abdominal pain for one month despite multiple medical visits and hospitalizations. A physician contacted for a second opinion suspected lead poisoning and hospitalized the patient who had an elevated blood lead level of 88 ug/dL (normal < 20 ug/dl). A suspect product in the household was a colored powder used as a spice on food. It was improperly labeled as “Do not eat” on the back and “best food in town” on the front. The food product tested as 87 percent lead. A second person in the household also consumed the mixture and had an

80 elevated blood lead level. A third person had similar symptoms after sharing food with the two cases and returned home to Morocco without a diagnosis. Confirmed Outbreaks 1 Total number of ills 3 Average number of ills/outbreak - Number of cases hospitalized 1 Number of fatalities 0 Outbreak months December 1 Counties of outbreaks Rock Island 1 Environmental specimen tested --- Sindoor used as food Food Tested coloring, positive for lead

Parasitic agents There are a variety of parasitic agents that can cause foodborne or waterborne outbreaks, for example, Cryptosporidia, Cyclospora and Giardia. The incubation periods for parasitic agents can be up to 25 days.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 – None reported.

Viral gastroenteritis Noroviruses are a common cause of gastroenteritis in the United States. Estimates are that 23 million people are affected by noroviruses in the United States each year. There are five genogroups (1-5). Genogroup G1 (Norwalk virus, Southampton virus and Desert shield virus), G2 (Toronota virus, Mexico virus, Hawaii virus, Bristol virus, Lordsdale virus, camberwall virus, Snow Mountain agent and Melksham virus) and genogroup G4 infect humans, genogroup G3 has been found in cattle and genogroup G5 has been identified in mice. Sapoviruses have only been identified in humans, especially children. In Canada, 11 percent of norovirus negative outbreaks were positive for sapovirus. Noroviruses are transmitted through consumption of contaminated food or water, directly from person to person and from airborne droplets produced during vomiting. The most common method of spread is via the fecal-oral route. The virus is excreted in stool and vomitus for up to 10 days. The median infectious dose is 18 viruses. The incubation period and duration of illness ranges from 24 to 48 hours. Duration of illness ranges from 12 to 60 hours. Virus shedding peaks 25 to 72 hours after exposure to the virus. Within 48 to 72 hours after symptom onset, virus concentration in the stool declines below levels detectable by electron microscopy. Short-term immunity occurs after infection. Vomiting, diarrhea, headache and body aches are commonly reported. A common feature of norovirus outbreaks is secondary transmission to household members not exposed to the implicated food or water. Humans are the only known reservoir for these viruses. These viruses cannot replicate outside the human body and therefore will not multiply in food items.

81 Characteristics of the virus that facilitate spread include low infectious dose, high concentration of virus in stool, strain diversity, environmental stability and prolonged shedding. Approximately 25 percent of infected persons shed for at least three weeks. CDC estimates that approximately 50 percent of all norovirus outbreaks are linked to ill food handlers. Approximately 20 percent of norovirus infected persons are asymptomatic. Failure of an ill food handler to perform proper handwashing may result in fecal contamination of food. Illness caused by norovirus can be suspected based on incubation period, duration of illness, symptoms or by identification of the organism in stool. Noroviruses can survive freezing and temperatures of up to 60 C and can survive chlorine levels up to 10 ppm (that exceeds what is normally present in public water systems). Outbreaks are not uncommon in closed settings, such as detention facilities, cruise ships, long-term care facilities and hospitals. An outbreak of norovirus affected six consecutive cruises on a single ship. Multiple strains of norovirus were identified. The virus cannot be grown in cell culture; a polymerase chain reaction (PCR) test is used to diagnose norovirus. Testing for viral gastroenteritis in humans is not useful for screening individual samples but is useful when multiple samples are available in an outbreak. Approximately 25 state health department laboratories, including Illinois, can do the RT-PCR to detect norovirus. Norovirus can be present in stools for up to a week after illness onset. Immunity is short-lived and appears to be strain specific. Since there are so many strains, individuals can be repeatedly infected by noroviruses during their lifetime.

Case definition Several laboratory tests may help to confirm an outbreak related to norovirus. These include positive results on RT-PCR, visualization of small round structured virus (SRSV) in electron microscopy of stool from ill individuals, or a fourfold rise in antibody titer to norovirus seen in acute and convalescent sera in most serum pairs. Multiple samples are needed from each outbreak to provide sufficient specimens to verify the causative agent as norovirus. An outbreak is considered confirmed when at least two ill persons have positive laboratory results.

Descriptive epidemiology • Number of outbreaks reported in Illinois in 2007 – Twenty-three suspected outbreaks of norovirus gastroenteritis, based on clinical syndrome, incubation period and duration of illness and nine laboratory confirmed outbreaks were reported. Norovirus outbreaks affected 1,192 people who experienced compatible illness (median = 17 ill persons per outbreak). The number of ills per outbreak ranged from three to 526 ill persons. The median incubation period for the confirmed outbreaks was 34 hours. The norovirus outbreaks occurred in the counties of Cook, (14), Kane (five), McLean (two) and Tazewell (two), and one each for DuPage, JoDaviess, McDonough, McHenry, Peoria, Stephenson, Vermilion, Will and Winnebago. Genotyping information was available on 16 suspect or confirmed outbreaks. Three were G1 (two confirmed and one suspect outbreak) and 13 were G2 (seven confirmed and six suspect outbreaks). Fifty-six of the cases sought health care consultation, eight were hospitalized, and there

82 were no fatalities. Food handlers were tested for norovirus in six outbreaks and positive food handlers were identified in all six outbreaks. In 10 of 11 outbreaks with information available, food handlers reported gastrointestinal illnesses. In four of the outbreaks, specific food vehicles were implicated. In two of the outbreaks foods were linked to illness by epidemiologic analysis (taco salad in one outbreak and raspberry dressing and dill dip in the second outbreak). In the third outbreak, water had high coliforms and in the fourth outbreak chocolate strawberries and sandwiches were implicated. Contributory causes were unknown for 24 outbreaks. Contributing factors in eight outbreaks were food handler related. • Individual Descriptions of Confirmed Outbreaks o Three persons became ill after eating at a restaurant in January in Mclean County. o Twenty-three persons became ill in March in Chicago after eating at a restaurant. One person was hospitalized. Three persons tested positive for norovirus G2. The status of food handler illness was not stated. o Forty-one persons became ill with norovirus G2 after eating food from the same restaurant in May in McLean County. Three persons tested positive for norovirus G2. Three food handlers were ill with gastrointestinal illness but were not tested. The food vehicle was unknown. o Forty-four persons became ill in Chicago in May after eating at a restaurant. Seventeen ill persons tested positive for norovirus G2 and one ill food handler also tested positive. No specific food item was implicated. o In July 2007 a large outbreak of norovirus G1 occurred at a conference in a hotel in Chicago. At least 526 persons attending the conference became ill. Eight persons tested positive for norovirus G1 type 4. Persons attended the conference from multiple states and countries. An e-mail survey was conducted of participants. No specific food item could be linked to illness. No persons were hospitalized. The status of food handler illness was not reported. o In July, an outbreak of norovirus G1 occurred in individuals after attending a wedding party at a restaurant in McHenry County. Twenty-eight persons reported illness. One attendee tested positive for norovirus G1 and two food handlers tested positive. Food handlers did report illness. Water from the restaurant had high coliforms. o In October 2007 in Kane County an outbreak of norovirus G2 occurred in 16 persons. Six persons were laboratory confirmed. Taco salad prepared in a private home and brought to work was implicated by epidemiologic analysis. Gastrointestinal illness status of taco salad makers prior to the meal was unknown. o In October 2007 in Winnebago County an outbreak of norovirus G2 occurred in 17 of 20 coworkers sharing a take out meal. Six persons tested positive. The median incubation period was 28 hours. Six persons tested positive including two food handlers. It is unknown if any of these food handlers were ill before the outbreak. One person was hospitalized and there were no fatalities. Contributing factors leading to the outbreak

83 included handling of food by infected employees. o In November, 40 persons became ill with norovirus in DuPage County after eating at a banquet. Norovirus G2 was identified in stool specimens. Suggested readings Moe, C.L. Preventing norovirus transmission: How should we handle food handlers? CID 2009;48:38-40. Pang, X.L. Epidemiology and genotype analysis of sapovirus associated with gastroenteritis outbreaks in Alberta, Canada: 2004-2007. JID 2009:199:547- 551. Norovirus Confirmed Suspected* Outbreaks 9 23 Total number of ills 738 454 Average number of ills/outbreak 82 20 Number of cases hospitalized 2 6 Number of fatalities 0 0 Outbreak months January 1 4 February 0 2 March 1 1 April 0 3 May 2 1 June 0 0 July 2 2 August 0 3 October 2 3 November 1 1 December 0 3 Counties of outbreaks Cook 3 11 DuPage 1 0 Jo Daviess 0 1 Kane 1 4 Lake 0 0 Macomb 0 1 McHenry 1 1 McLean 2 0 Peoria 0 1 Tazewell 0 2 Vermilion 0 1 Will 0 1 Winnebago 1 0 Food handler positive for pathogen Yes, 3 outbreaks Yes, 2 outbreaks Yes, 3 outbreaks 1 outbreak had Yes, 3 outbreaks; water positive for sandwiches with Food testing coliforms in one outbreak fecal coliforms Environmental specimen tested None None

84 Hepatitis A Foodborne outbreaks of hepatitis A are uncommon. When they do occur they are often associated with foods contaminated by infected food handlers. Also, contaminated produce, such as lettuce or strawberries, also may be a source of illness. The incubation for hepatitis A is 28 to 30 days. The agent can be found in feces before the onset of illness.

Descriptive epidemiology • Number of hepatitis A outbreaks in 2007 – One outbreak was reported. • Individual Description of Confirmed Outbreak o Two hepatitis A cases occurred, one with onset on May 24 and one on May 27 in Woodford County after a family celebration held from May 4 through May 6 in a private home.

Confirmed Outbreaks 1 Total number of ills 2 Average number of ills/outbreak 2 Number of cases hospitalized 0 Number of fatalities 0 Outbreak months May 1 Counties of outbreak/s Woodford 1 Food handler positive for pathogen No testing Environmental specimen tested None Food tested None

Recreational Water Outbreaks Swimming is a very popular recreational exercise. Pool chemicals and filtration are used as barriers to waterborne pathogen transmission. However, pool chemicals can also cause injury to persons when levels are not adequately maintained or when ventilation around pools is not adequate. Recreational water outbreaks can be due not only to infectious agents but also to chemical agents. An example is a large outbreak at an indoor hotel waterpark in Ohio that was believed to be linked to trichloramine in the air. Persons experienced respiratory and eye irritation. Ventilation at the waterpark was modified and no further cases were identified.

Descriptive epidemiology • Number of recreational waterborne outbreaks in 2007 –Two outbreaks were reported. The outbreaks occurred in JoDaviess and Winnebago County. A total of 10 persons became ill due to recreational water exposure. Both outbreaks were confirmed to be caused by Cryptosporidium. There was one person hospitalized and no fatalities for waterborne outbreaks in Illinois in 2007.

85 • In the first outbreak in JoDaviess county, four persons became ill with three testing positive for Cryptosporidium after swimming in a water park pool in August. Pool water could not be tested as the pool was closed for the season at the time of identification of the outbreak. The cause of the outbreak was unknown. • Another outbreak occurred in August in Winnebago County. Six persons became ill and one was hospitalized following swimming in a swimming pool. The source of water was a well. Six persons were laboratory confirmed. Hyperchlorination of the pool was done before water samples could be taken.

Suggested readings Sacke, H., et. al. Pool chemical associated health events in public and residential settings – United States, 1983-2007. MMWR 2009; 58(18):489-93. Stansburg, D., et. al. Respiratory and ocular symptoms among employees of a hotel indoor waterpark resort – Ohio, 2007. MMWR 2009; 58 (4): 81-85.

86 Table 5. Foodborne and Waterborne Outbreaks in Illinois in 2007

Exposure IDPH Log Onset Incubation Place of Number Date City County ExpIl/lExp Symptoms* Hours Food Implicated Agent Implicated Status Preparation Place Eaten

IL2007-006 1/6 Fithian Vermilion 7/U AC,D,V 30 Unknown Norovirus S Restaurant Restaurant C. perfringens IL2007-007 1/6 Sugar Grove Kane 23/40 AC,D 9 Chili Type A C Private home Private home

IL2007-008 1/6 Chicago Cook 6/23 AC,D,V 34 Unknown Norovirus S Restaurant Restaurant Restaurant & Commercial IL2007-012 1/14 Chicago Cook 10/40 D,V 36 Unknown Norovirus G2 S product Restaurant

IL2007-024 1/18 Marion Williamson 3/ 4 AC,D,V 12 Unknown Unknown U Restaurant Restaurant

IL2007-015 1/21 Bloomington Mclean 3/3 AC,D,V 35 Unknown Norovirus G2 C Restaurant Restaurant IL2007-054 1/25 Westchester Cook 19/22 AC,D,V 36 Unknown Norovirus S Restaurant Restaurant IL2007-051 2/1 Edwardsville Madison 18/ U AC,D 38 Unknown S. ser. Enteritidis C Restaurant Restaurant IL2007-059 2/12 Orland Park Cook 12/20 AC,D,V 32 Unknown Norovirus S Banquet Banquet

IL2007-044 2/16 Orland Park Cook 17/29 D,V 33 Unknown Unknown U Restaurant Work place Restaurant & Private home IL2007-048 2/25 Chicago Cook 19/25 AC,D,F,V 36 Unknown Norovirus G2 S & Bakery Private home

S. ser. IL2007-087 2/26 Multi-state 7/U D,V U Lettuce Typhimurium C Grocery Home Grocery store Unpasteurized & private IL2007-047 3/2 multiple Kane 96/U D U cheese S. ser. Newport C Unknown home Dill dip& raspberry Restaurant& IL2007-064 3/11 Orland Park Cook 19/43 AC,D,V,HA U dressing Norovirus S Restaurant private home

IL2007-072 3/16 Oak Lawn Cook 2/U AC,D,F U Unknown S. ser. Enteritidis C Restaurant Restaurant

IL2007-070 3/24 Chicago Cook 23/52 AC,D,V 35 Unknown Norovirus G2 C Restaurant Restaurant

IL2007-077 4/9 South Elgin Kane 8/21 AC,D U Unknown Norovirus S Restaurant Restaurant

87

Exposure IDPH Log Onset Incubation Place of Number Date City County ExpIl/lExp Symptoms* Hours Food Implicated Agent Implicated Status Preparation Place Eaten

IL2007-075 4/9 Woodstock McHenry 6/31 D,V 37 Unknown Unknown U

IL2007-073 4/10 East Peoria Tazewell 91/U AC,D,V U Pasta Norovirus S

IL2007-078 4/22 Orangeville Stephenson 31/95 D,V 30 Unknown Norovirus G1 S Private home Private home Dupage, multi- IL2007-089 4/25 state 1/U D,V U Ground beef E. coli O157:H7 C Restaurant Restaurant Restaurant & private home S. ser. & grocery IL2007-092 4/26 Dupage 13/U AC,D 20 Pancit Palabok Montevideo C Restaurant store

St Clair, multi- Commercial IL2007-088 4/27 state 1/U D U Ground beef E. coli O157:H7 C product Private home

Restaurant& IL2007-083 5/1 Downs Mclean 41/138 AC,D,V,F 28 Unknown Norovirus G2 C Restaurant work place

IL2007-084 5/5 Chicago Cook 44/73 AC,D,V,F 40 Unknown Norovirus G2 C Restaurant Restaurant

Severe IL2007-101 5/9 Chicago Cook 2/3 weakness 1/ 2 Puffer fish soup Tetrodotoxin C Private home Private home

IL2007-102 5/24 Eureka Woodford 2/U Jaundice U Unknown Hepatitis A C Private home Private home

IL2007-104 5/26 Moline Rock Island 6/U AC,D,V 48 Unknown S. ser. Litchfield C Restaurant Restaurant Private home IL2007-095 5/26 Woodstock McHenry 7/17 AC,D,V 9 Unknown Unknown U & grocery Fairgrounds

IL2007-097 5/27 Geneva Kane 11/34 AC,D,V 38 Unknown Norovirus G2 S Restaurant Restaurant Pig head meat; red and green S. ser. IL2007-100 6/10 Elgin Kane 9/U AC,D,F,V 15 salsa Montevideo C Grocery store Grocery store Cook, multi- Veggie Booty S. ser. Commercial IL2007-112 6/15 Chicago state 2/U AC,D,F,V U snack food Wandsworth and C product Private home 88 Typhimurium

IL2007-103 6/17 Oak Park Cook 75/112 AC,D,V 3 Pork, Barbeque S. aureus C Caterer Picnic Caterer & Banquet IL2007-107 6/23 Rockford Winnebago 34/50 AC,D 12 Turkey, roasted Unknown U private home facility

IL2007-109 6/29 Crestwood Cook 3/3 D,V 8 Unknown Unknown U Restaurant Restaurant

IL2007-110 6/29 Milan Rock Island 12/22 AC,D,V 3 Enchiladas S. aureus C Private home Work place S. ser. Fair & IL2007-115 6/30 Chicago Cook 802/U AC,D,F 48 Hummus Heidelberg C Restaurant Fair

Il2007-111 7/1 Galena JoDaviess 5/U D,V 33 Unknown Norovirus S Restaurant Restaurant

IL2007-119 7/3 Chicago Cook 3/5 AC,D,F 70 Unknown Campylobacter S Restaurant Restaurant

IL2007-130 7/16 Chicago Cook 7/U AC,D,F,V 48 Unknown S. ser. Infantis C Grocery Store Private home Norovirus G1, IL2007-123 7/16 Chicago Cook 526/1322 AC,D,F,V U Unknown Type 4 C Hotel Hotel S. aureus/B. IL2007-122 7/20 Chicago Cook 3/3 AC,D 2 Unknown cereus S Restaurant Work place Chicken, IL2007-121 7/23 Aurora Kane 7/18 AC,D 14 shredded C. perfringens C Restaurant Work place

IL2007-126 7/25 Bloomingdale Dupage 5/20 AC,D,F 60 Unknown S. ser. Enteritidis C Restaurant Restaurant B. cereus/C. IL2007-124 7/26 Chicago Cook 12/14 AC,D 7 Beef Burrito perfringens S Restaurant Work place Restaurant & Restaurant & IL2007-127 7/28 Villa Park DuPage 38/52 AC,D,V,HA 53 Unknown Unknown U Banquet Banquet

IL2007-129 7/28 Woodstock McHenry 28/98 AC,D,V 36 Ice water Norovirus G1 C Restaurant Restaurant

IL2007-128 7/29 Macomb McDonough 4/15 AC,D,V 28 Unknown Norovirus S Restaurant Work place

IL2007-141 7/30 Cameron Warren 3/3 AC,D,F,V 84 Unknown E. coli O157:H7 S Private home Private home Sindoor Abdominal cosmetic Commercial IL2007-203 8/1 Rock Island 3/3 pain U powder Lead C product Private home Banquet Banquet IL2007-131 8/4 Shorewood Will 23/49 AC,D,F,V 48 Unknown Norovirus S facility facility

IL2007-132 8/4 Des Plaines Cook 9/U AC,D,HA,V 36 Unknown Norovirus S Restaurant Restaurant

IL2007-187 8/5 Chicago Cook 2/2 D,V 3 Unknown Unknown U Restaurant Restaurant

IL2007-133 8/5 Hodgkins Cook 4/4 D 5 Unknown Unknown U Restaurant Restaurant

89 IL2007-138 8/16 Chicago Cook 42/U AC,D,F,V U Unknown Norovirus G2 S Sailing Club Sailing Club

IL2007-143 8/23 Melrose Park Cook 3/5 AC,D,V 3 Unknown Unknown U Restaurant Restaurant S. ser. Typhimurium & I Commercial IL2007-163 9/5 Multi-county 7/U AC,D,V U Pot pie 4,5,12:i:- C product Private home

IL2007-156 9/9 Chicago Cook 3/ 4 D,V 48 Unknown Unknown U Restaurant Fair

IL2007-153 9/11 Effingham Effingham 10/U AC,D,V 72 Unknown E. coli O157:H7 C Restaurant Restaurant Private home &Caterer& IL2007-155 9/16 Fairfield Wayne 18/U AC,D,F 72 Unknown C. jejuni C Church Church

IL2007-160 9/27 Evanston Cook 3/U AC,D,V 14 Unknown Unknown U Restaurant Restaurant Grocery store & Private IL2007-162 10/7 St. Charles Kane 16/19 AC,D,V 22 Unknown Norovirus G2 S home Private home

IL2007-166 10/9 Streamwood Cook 3/3 D,V 6 Unknown Unknown U Restaurant Private home

IL2007-188 10/13 Orland Park Cook 7/20 D,V 10 Unknown Unknown U Restaurant Park Banquet Banquet IL2007-164 10/14 Peoria Peoria 39/87 AC,D,V 36 Unknown Norovirus S Facility facility

IL2007-167 10/20 Aurora Kane 16/26 AC,D,V 34 Taco salad Norovirus G2 C Private home Work place

IL2007-184 10/26 Rockford Winnebago 17/20 AC,D,V 28 Unknown Norovirus G2 C Restaurant Work place Restaurant & IL2007-173 10/31 Morton Tazewell 17/24 AC,D,V 34 Unknown Norovirus S private home Work place Grocery store IL2007-180 11/5 Chicago Cook 14/16 D,V 31 Unknown Norovirus S & Caterer Tavern Banquet & Banquet & IL2007-177 11/11 Winfield DuPage 40/56 AC,D,F,HA,V 35 Unknown Norovirus G2 C restaurant Restaurant

IL2007-179 11/11 Wheeling Cook 2/11 AC,D 5 Unknown Unknown U Restaurant Restaurant B. cereus/C. IL2007-210 11/17 Chicago Cook 12/12 AC,D 12 Beef stew perfringens S Restaurant Private home

IL2007-185 11/22 Chicago Cook 14/15 AC,D,V 1 Turkey C. perfringens C Caterer Work place

IL2007-191 12/2 Rolling Meadows Cook 28/50 AC,D,V 34 Unknown Norovirus S Restaurant Park

IL2007-193 12/7 Geneva Kane 11/13 AC,D,V 33 Unknown Norovirus G2 S Restaurant Restaurant Chocolate Elk Grove strawberries & IL2007-194 12/8 Village Cook 13/26 AC,D,V 40 deli sandwich Norovirus S Caterer Work place 90 IL2007-206 12/16 Chicago Cook 6/11 AC,D 4 Unknown Unknown U Restaurant Restaurant

IL2007-207 12/21 Chicago Cook 5/6 AC,D,V 25 Unknown Unknown U Restaurant Restaurant

Il2007-205 12/24 Chicago Cook 12/18 AC,D 14 Roasted pork C. perfringens C Restaurant Private home * BA=body ache, BD=bloody diarrhea, D=diarrhea, F=fever, H=headache, V=vomiting, AC=cramps

91 Giardiasis

Background Giardia is the most commonly diagnosed intestinal parasite in public health laboratories. A common intestinal parasite of children, especially those attending day care, it is spread from person to person through fecal-oral transmission and has a median incubation period of seven to 10 days. Many infections are asymptomatic and repeated infections can occur in the same person. There are three species of giardia: G. lamblia, G. agilis and G. muris. The main human pathogen is G. lamblia. Cysts are infective immediately upon excretion and can remain viable for months. The infectious dose is low; as few as 10 cysts can cause infection and excretion can continue for months. Giardiasis also affects domestic and wild mammals including cats, dogs, cattle, deer, and beavers. Persons at greatest risk are children in day care facilities, close contacts of these children, men who have sex with men, backpackers, persons in contact with infected animals, campers, and persons drinking from shallow wells contaminated by run-off with the organism. The most commonly identified intestinal parasite in international travelers is G. lamblia. Giardiasis peaks in late summer and early fall. Metronidazole is the most frequent treatment in the United States. Approximately 85 percent of infections can be diagnosed with a single stool specimen. Diagnosis is made by identification of the parasite in wet mount staining with trichrome or iron hematoxylin, by direct fluorescent antibody detection, or by enzyme immunosorbent assay. Because of its long period of communicability, low infectious dose and environmental resistance, giardiasis is easily transmitted. Preventive measures should include practicing good hygiene, avoiding water or food that might be contaminated and avoiding fecal exposure during sex with infected persons. In 2007, the CDC received reports on 19,794 cases. Illinois was fourth in the nation in the number of cases reported. The incidence of giardiasis was highest for the northern states from 2006 through 2008. The peak onset of illness occurred annually during early summer through early fall. During this time period giardiasis was reportable in 45 states. The number of reported cases was highest in children aged one to nine years of age and adults aged 35 to 44 years.

Case definition The case definition for giardiasis in Illinois is the presence of diarrhea and the identification of Giardia trophozoites or cysts in stool, or detection of antigen by the ELISA antigen test. Probable cases are those without laboratory confirmation but who are clinically compatible and epidemiologically linked to a confirmed case.

Descriptive epidemiology • Number of cases (confirmed and probable) reported in Illinois in 2007 – 866 (five- year median = 807); the incidence rate was seven per 100,000 population. All but two of the cases were confirmed. Reported cases increased from 2006 (See Figure

92 42). • Age - Mean age of cases was 27 years. The age group with the highest incidence was 1 to 4 years of age, which included 167 cases (24 per 100,000), followed by 5 to 9 years of age (12 per 100,000) (Figure 43). • Gender – Fifty-four percent were male. • Race/ethnicity – Sixty-five percent were white, 17 percent were African American, 12 percent were Asian and 5 percent were other races; 9 percent were Hispanic. There were a significantly lower proportion of whites with giardiasis compared to the Illinois population and a higher proportion of Asians with giardiasis compared to the Illinois population. • Seasonal variation - More cases occurred in the summer months (Figure 44). • Geographic variation - For 2007, the counties with the highest incidence rates per 100,000 included Cass (22), McDonough (18), Logan (16) and Woodford (14). • Clinical - Symptoms reported by cases were diarrhea (84 percent), vomiting (25 percent), and fever (15 percent). Thirteen percent were hospitalized. No fatalities were reported. At least 147 cases were asymptomatic. • Reporters – Cases were most frequently reported by laboratory staff (54 percent) and infection control professionals (31 percent). • Employment – Cases reported working in the following occupations: day care center (one case), food service (six cases), health care worker (10 cases), residential facility (two cases) and other sensitive occupation (11 cases). • Risk Factors – Seventy-nine of 422 (19 percent) reported travel to another country. The three countries most frequently visited were India (11 cases), Mexico (nine cases) and Russia (eight). Fifty-six of 432 (13 percent) of cases traveled to another state. Wisconsin (nine cases) was the most common state visited. Thirty-seven of 442 cases (8 percent) reported drinking well water. Thirty-two of 425 cases (7 percent) of cases reported swimming in non-chlorinated water, while 50 of 417 cases (12 percent) reported swimming in chlorinated water. Forty-eight of 440 (11 percent) had contact with a residential facility and three cases reported attending or residing in a residential facility. Thirty-four of 438 (8 percent) had contact with a day care facility and 11 cases attended or resided in a day care center. • Outbreaks – No giardiasis outbreaks were reported in 2007.

Summary Giardiasis cases increased in 2007 compared to the previous five-year median (807). Whites were underrepresented in the case population for giardiasis (65 percent) compared to their representation in the Illinois population (73 percent). Asians were overrepresented in the case population for giardiasis (12 percent) as compared to the Illinois population (3 percent). The mean age of cases was 27 years, and more cases occurred in the warmest months of the year.

Suggested readings Yoder, J.S., et. al. Cryptosporidiosis surveillance – United States, 2006-2008 and Giardiasis surveillance – United States, 2006-2008. MMWR 2010; 59 (SS-6).15-25.

93

Figure 42. Giardiasis Cases in Illinois, 2002-2007

1000 871 861 866 807 772 800 695 600 400 200

Number Number of cases 0 2002 2003 2004 2005 2006 2007 Year

Figure 43. Giardiasis Cases in Illinois by Month, 2007

150

100

50

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of onset

Figure 44. Incidence by Age of Giardiasis Cases in Illinois, 2007

30

20

10

0

Incidence per 100,000 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Age in years

94 Hansen’s Disease

Background Hansen’s disease or leprosy is caused by Mycobacterium leprae. This organism causes a chronic bacterial disease of the skin. Most of the cases diagnosed in 2006 were identified in India. The disease is endemic in some parts of the United States including California, Louisiana, Hawaii, Texas and Puerto Rico.

Case definition A clinically compatible case that is laboratory confirmed. Only new cases, not recrudescent cases should be counted.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – One case of leprosy was reported in Illinois in 2007. • Individual case description – This case was a 41-year-old Cook County resident. The specimen was examined at the National Hansen’s Disease Laboratory in Baton Rouge, Louisiana. This patient was born in the Philippines and had traveled to Manila. He believes his onset began when he was 12 years of age. If that is the situation, then this case should not have been counted in the annual totals.

Summary One case of Hansen’s disease was reported in Illinois in 2007. Due to a previous history of Hansen’s disease this case should not have been counted as an acute case.

95 Hemolytic Uremic Syndrome (HUS)

Background Hemolytic uremic syndrome (HUS) is characterized by acute hemolytic anemia, thrombocytopenia and renal insufficiency. Many microbes including Shigella dysenteriae, Salmonella ser. Typhi, Campylobacter jejuni and E. coli O157:H7 have been linked to HUS. Bacteria, such as E. coli O157:H7 produce a toxin that can cause vascular cell damage. The most serious sequelae from infection with Shiga toxin- producing E. coli in people is HUS. In a study using CDC FoodNet sites from 2000 to 2006, 6 percent of persons with E. coli O157:H7 developed HUS. The highest proportion of HUS cases occurred amongst children less than five years of age. In a study of HUS in Italy, consumption of raw milk was linked to HUS. HUS occurs primarily in children younger than 5 years of age after infection by an organism producing shiga toxin and causing diarrhea. HUS usually occurs within two to 14 days after onset of diarrhea. Almost half of children with HUS require dialysis. The illness can involve the central nervous system (CNS), pancreas, heart and other organs. During 2007, 292 cases of HUS were reported to CDC from 37 states. Antibiotic therapy has been identified as a risk factor for HUS development; therefore, if antibiotic therapy is being considered, it should be withheld for treatment of patients with diarrhea until (at least) a culture confirms that E. coli O157:H7 is not present in a stool specimen.

Case definition Laboratory criteria are both acute anemia with microangiopathic changes (i.e. schistocytes, burr cells or helmet cells) on peripheral blood smear and acute renal injury evidenced by either hematuria, proteinuria, or elevated creatinine level (i.e. greater than or equal to 1.0 mg/dL in a child aged less than 13 years or greater than or equal to 1.5 mg/dL in a person aged greater than or equal to 13 years, or greater than or equal to 50 percent increase over baseline). A probable case is an acute illness diagnosed as HUS or TTP that meets the laboratory criteria in a patient who does not have a clear history of acute or bloody diarrhea in the preceding three weeks, or an acute illness diagnosed as HUS or TTP that a) has onset within three weeks after onset of an acute or bloody diarrhea and b) meets the laboratory criteria except that microangiopathic changes are not confirmed. A confirmed case is an acute illness diagnosed as HUS or TTP that both meets the laboratory criteria and began within three weeks after onset of an episode of acute or bloody diarrhea.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – Five cases were reported to CDC (median = 5) (Figure 45). • Of the five cases, three also were listed as an E. coli O157:H7 case. Four cases were probable and one was confirmed. • Age - The five HUS cases reported to CDC ranged from 3 to 57 years of age. Four

96 cases were younger than 6 years of age. • Sex – Three cases were female and two were male. • Race/ethnicity – All cases were white; one was reported as Hispanic. • Seasonal - Onsets occurred in June to November. • Geographic location – Counties in which cases occurred were Cook, Kane, Macon, Whiteside and Will counties. • Clinical – Four cases reported diarrhea, and all four reported having bloody diarrhea. One case reported fever. All cases were admitted to the hospital. All cases required dialysis. No cases were fatal.

Summary Five cases of HUS were reported by Illinois to CDC in 2007. Three of the five cases were known to have had E. coli O157:H7.

Suggested readings Centers for Disease Control and Prevention. FoodNet 2007 Surveillance Report. Atlanta: U.S. Department of Health and Human Services, 2009. Gould, L.H., et. al., Hemolytic uremic syndrome and death in persons with Escherichia coli O157:H7 infection, foodborne diseases active surveillance network sites, 2000-2006. CID 2009; 49: 1480-85. Scavia, G., et. al., Consumption of unpasteurized milk as a risk factor for hemolytic uremic syndrome in Italian children. CID 2009;48:1637-8.

Figure 45. Hemolytic Uremic Syndrome Cases in Illinois, 2002- 2007

10 8

4 5 4 5 5 3

0 Number Number of cases 2002 2003 2004 2005 2006 2007 Year

97

Hepatitis A Background Hepatitis A virus is transmitted though the fecal-oral route by person-to-person contact and by contaminated food, water or fomites. HAV infection can spread in household members, through day care centers, among persons who consume contaminated or uncooked food handled by infected workers and among men who have sex with men (MSM). It is one of the most frequently reported vaccine preventable diseases. There is only one serotype, and immunity after infection is lifelong. Young children who are frequently asymptomatic when infected may play an important role in HAV transmission in communities. The incubation period is 15 to 50 days. Onset of illness with HAV can be abrupt with fever, anorexia, nausea and abdominal discomfort, followed by jaundice. The disease can vary from one to two weeks of mild symptoms to a severe illness lasting months. Severity generally increases with age, and many infections are asymptomatic, especially in young children. Peak levels of the virus appear in the feces one to two weeks before symptom onset and diminish rapidly after symptoms appear. Serologic testing for IgM anti-HAV is required for laboratory confirmation of hepatitis A infection. IgM anti-HAV becomes detectable five to 10 days after exposure and can persist for up to six months. Hepatitis A virus infection can be prevented by good personal hygiene, particularly handwashing, pre-exposure or post-exposure immunization with immune globulin (IG), and pre-exposure immunization with HAV vaccine. The administration of IG for persons exposed to HAV is 85 percent effective in preventing symptomatic HAV infection if given within two weeks of exposure and may prevent infection entirely if given soon after exposure. The effect of IG starts within hours of administration and provides from three to six months of protection. Without post-exposure prophylaxis (PEP), the secondary attack rate ranges from 15 percent to 30 percent in households with an HAV case. For PEP for non-immune persons who have been exposed to HAV through sexual or household contact, a single dose of hepatitis A vaccine or IG should be given. The second dose should be administered to complete the series. For persons 12 months to 40 years of age, vaccine is recommended within two weeks of exposure. For persons aged 41 and older IG is perferred. For children younger than 12 months, immuncompromised persons, persons who have chronic liver disease and persons contraindicated for vaccine should be given IG. In child care centers, vaccine or IG should be given to all non-immune staff members and attendees if a case of hepatitis A is identified in children or employees or if cases are recognized in two or more households of center attendees. If children with diapers are not present, only classroom contacts of the hepatitis A case need PEP. If cases occur in three or more households, PEP should be considered for household members of center attendees. Other food handlers at the same establishment as a food handler with hepatitis A should receive PEP. IG or vaccine to patrons could be considered if during the time when the food handler was likely to be infectious, the food handler both directly handled uncooked or cooked food and had diarrhea or poor hygiene and patrons can be treated within two weeks. International travelers to countries with high or intermediate levels of hepatitis A should receive protection through vaccination or IG depending on how long before their

98 travel they seek medical advice. In 1995, a hepatitis A vaccine was licensed for individuals older than two years of age. The vaccine was recommended for individuals traveling to areas where there is a higher endemnicity rate. In 2006, ACIP recommended routine vaccination of all children aged 12 to 23 months after a vaccine was licensed for children aged 12 to 23 months. Recommendations are for vaccine use in children at 12-23 months. Catch-up vaccination of older children in selected areas and vaccination for high-risk persons (travelers to endemic areas, men who have sex with men and illicit drug users). Travelers to developing countries are at higher risk for hepatitis A. About three-quarters of travel-related cases in the United States, are due to travel to Central or South America. Outbreaks can occur in men who have sex with men communities. Outbreaks have also occurred in methamphetamine users. In Alaska there was a drop in the incidence rates for acute hepatitis A from 60 per 100,000 in 1972-1995 to 0.9 in 2002- 2007. The National Immunization survey provides annual estimates of vaccine coverage in states. In Illinois, 37 percent of children aged 24 to 35 months were vaccinated with at least one dose of hepatitis A vaccine as compared to 26 percent in 2006. In Chicago the percent vaccinated was 47 percent. Nationally, the percent in 2007 was 47 percent. Hepatitis A is typically transmitted from person to person through the fecal-oral route. Occasionally, foodborne transmission occurs when an HAV-infected food handler contaminates food that is not later cooked. Food handler associated outbreak characteristics include the presence of an HAV infected food handler who worked while infectious and had contact with uncooked food or food after it had been cooked, secondary cases among other food handlers who ate food contaminated by the index case and low attack rates in patrons. There were 2,979 acute hepatitis A cases reported in the United States in 2007. The hepatitis A rate in the United States in 2007 was one case per 100,000. The highest rate was in those 20 to 39 years of age. The incidence rate was 1.4 per 100,000 for Hispanics and 0.6 for non-Hispanics. Hepatitis A cases have declined probably due to the recommendation for routine childhood vaccination. In the pre- vaccine era hepatitis A was highest in children five to 14 years of age, hepatitis A rates have declined more sharply in age groups covered by vaccine. The mortality rates in the United States due to hepatitis A were 32 percent lower in the post-vaccination era than in the pre-vaccine era.

Case definition The CDC case definition for a case of hepatitis A is used in Illinois: an illness with a discrete onset of symptoms and jaundice or elevated serum aminotransferase levels, and IgM anti-HAV positive serology.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – 118 (five-year median = 176) (see Figure 46). The overall incidence rate for hepatitis A was 0.95 per 100,000. • Age – Ages ranged from two months to 94 years of age (mean = 41 years). The

99 highest number of cases was reported in the 20 to 29 year age group (see Figure 47). • Gender – Forty-one percent of cases were female. • Race/ethnicity - Seventy-seven percent were white, 10 percent were Asian, 5 percent African American, and 8 percent other races; 24 percent were Hispanic. Hispanics were overrepresented in the case population as compared to the Illinois population. • Employment - Three hepatitis A cases were food handlers and two were in health care workers. • Seasonal variation - Cases occurred throughout the year (see Figure 48). • Geographic variation – Cases were reported from 25 counties. Cook County reported the highest number (41 cases), followed by Dupage (16) and Kane (15). • Hospitalizations and deaths - Forty-eight percent of cases were hospitalized. No deaths were linked to acute hepatitis A. • Reporters – Forty-six percent of cases were reported by non laboratory hospital personnel and 41 percent were reported by laboratories.

Summary Hepatitis A cases have begun declining in the state. The incidence rate (0.95 per 100,000) was similar to the national incidence (1 per 100,000). The number of cases reported in 2007 was lower than the five-year median. Hispanics were overrepresented in hepatitis A cases.

Suggested readings Chaves, S.S., et. al. Hepatitis A vaccination coverage among children aged 24- 35 months – United States, 2006 and 2007. MMWR 2009; 58(25): 689-694. Daniels, D., et. al. Surveillance for acute viral hepatitis – United States, 2007. MMWR 2009; 58 (SS-3): 1-27. Novak, R., et.al. Update: Prevention of hepatitis A after exposure to a hepatitis A virus and in international travelers. Updated recommendations of the Advisory Committee on Immunization Practices. MMWR 2007; 56(41):1080-84. Singleton, R.J., et. al. Impact of a statewide childhood vaccine program in controlling hepatitis A virus infections in Alaska. Vaccine 2010; Jul 14.Epub. Vogt, T.M., et. al. Declining hepatitis A mortality in the United states during the era of hepatitis A vaccination. JID 2008;197:1282-8.

100 Figure 46 . Hepatitis A Cases in Illinois, 2002-2007

300 262 186 176 200 130 109 118 100

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 47. Number of Hepatitis A Cases in Illinois by Age, 2007

30

20

10

Number of cases Numberof 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Year

Figure 48. Hepatitis A Cases in Illinois by Month, 2007

15

10

5

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year

101 Hepatitis B

Background Hepatitis B virus is a vaccine-preventable bloodborne and sexually transmitted virus. It is acquired by percutaneous and mucosal exposure to blood or body fluids from an infected person. Men who have sex with men (MSM) are at increased risk for hepatitis B. Approximately 35 percent of cases of acute hepatitis B occur in people who report no recognized risk factor. The most commonly reported risk factors for transmission in the United States are high-risk sexual activity and injection drug use. The incubation period is 45 to 180 days (average 60 to 90 days). Positivity for HBeAg is linked to an increased risk of hepatocellular carcinoma. Fewer than half of acute hepatitis B cases will have jaundice (less than 10 percent of children, and 30 percent to 50 percent of adults). The onset is usually insidious with anorexia, nausea, vomiting, abdominal discomfort, jaundice, occasional arthralgias and rash. Chronic HBV infection is found in about 0.5 percent of adults in North America. An estimated 15 percent to 25 percent of persons with chronic hepatitis B will progress to cirrhosis or hepatocellular carcinoma. A vaccine became available in 1982. In Illinois, hepatitis B vaccination in children was mandated in 1997. CDC also recommends vaccination for MSMs, certain travelers, injection drug users, heterosexuals with multiple sex partners or with sexually transmitted diseases, clients or staff in developmentally disabled institutions, health care workers with blood contact, some immigrants, hemodialysis patients, household contacts and sexual partners of hepatitis B virus carriers and male prisoners. During 2007, 4,519 acute hepatitis B cases were reported to CDC from across the United States. There were 2,323 chronic hepatitis B cases reported to CDC. In the United States there has been an 80 percent decrease in hepatitis B since 1990, the year before the national strategy for vaccination was started. In 2007, the overall rate of acute hepatitis B was 1.5 per 100,000. Thirty-eight percent had greater than one sexual partner and 12 percent reported surgery prior to onset. Ten percent reported homosexual activity. Most of the cases were in homosexual or bisexual men (72 percent). Injection drug use was reported by 15 percent of persons. Seventy-six percent were jaundiced, 40 percent were hospitalized and 1.5 percent died. Universal vaccination of children against hepatitis B has reduced hepatitis B incidence rates in younger age groups.

Case definition The CDC case definition is used as the surveillance case definition for hepatitis B in Illinois: a clinical illness with a discrete onset of symptoms and jaundice or elevated serum aminotransferase levels, and laboratory confirmation. Laboratory confirmation consists of IgM anti-HBc-positive (if done), or HbsAg-positive, and IgM anti-HAV- negative (if done).

Descriptive epidemiology • Number of cases reported in Illinois in 2007 - 130 confirmed acute cases (five-

102 year median =130) (see Figure 49). The overall one-year incidence rate of reported acute hepatitis B in Illinois was 1 case per 100,000 population. Note: CDC had 129 recorded for 2007. For the purposes of this report we will use 130. • Age – Most cases of acute hepatitis B occurred in those greater than 20 years of age (Figure 50). Ages ranged from 15 to 86 (mean = 45 years). • Gender - Fifty-eight percent were male. • Race/ethnicity – Forty-one percent of cases were African American, 53 percent were white and 2 percent were Asian; 9 percent were Hispanic. • Geographic location – Counties reporting the most cases included Cook County (53 cases) followed by Will County (12) and Dupage (10). • Symptoms/outcomes – Forty-nine percent were hospitalized. One fatality was reported.

Summary There were 130 confirmed acute hepatitis B cases reported in Illinois in 2007. Almost 50 percent of cases were hospitalized.

Suggested readings Daniels, D., et. al. Surveillance for acute viral hepatitis – United States, 2007. MMWR 2009; 58 (SS-3): 1-27. Wasley, A., et. al., The prevalence of hepatitis B virus infection in the United States in the era of vaccination. JID 2010; 202 (2): 192-201.

Figure 49. Hepatitis B Cases in Illinois, 2002-2007

185 200 166 130 130 130 150 111 100 50

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

103 Figure 50 . Age Distribution of Hepatitis B Cases in Illinois, 2007

40 30 20 10

Number of cases 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Year

104 Hepatitis C, Acute

Background Hepatitis C virus (HCV), an RNA virus, is the most common chronic bloodborne infection in the United States. There are at least six distinct genotypes of HCV; types 1a and 1b are most common in the United States. It is estimated that 1.8 percent of United States residents have been infected with HCV. The incubation period for HCV ranges from two weeks to six months, most commonly six to nine weeks. Many individuals are asymptomatic and only a small proportion become jaundiced. Forty percent of infected adults are symptomatic, and 85 percent of adults with acute hepatitis C develop persistent infection. Acute hepatitis C is uncommon. WHO estimates that 170 million people worldwide are infected with HCV. The most efficient route of transmission is by direct percutaneous exposure (e.g., blood or blood product transfusion, organ or tissue transplants, and sharing of contaminated needles between injection drug users [IDUs]). Low efficiencies of transmission occur from sexual and household exposure to an infected contact. Transmission of HCV has been reported from patient to health care worker. The majority of HCV cases are in IDUs. The virus has been shown to be transmitted by the use of shared drug preparation equipment such as drug cookers and filtration cotton. In the United States, injection drug use accounts for 60 percent of HCV infection, sexual contact (20 percent) and other exposures (household, perinatal and occupational) for 10 percent. Ten percent of cases have no identified risk factor. The rate of transmission after needle-stick injury from a known infected person is less than 10 percent. The prevalence of HCV in non-injection drug users in a study in Italy was 20 percent. Hepatitis C is the most common indication for liver transplantation in adults and accounts for about 40 percent of all transplants in the United States. About 50 percent to 80 percent of patients with pretransplantation viremia develop hepatitis in the liver graft. The hepatitis C virus can cause chronic hepatitis, cirrhosis and hepatocellular carcinoma. Among adults who had acute hepatitis C, 26 percent to 50 percent developed chronic active hepatitis and 3 percent to 26 percent developed cirrhosis. In a study of transfusion related hepatitis C in the United States from 1968 through 1980, the risk for developing cirrhosis was 17 percent. Heavy alcohol use increased the risk for developing cirrhosis. Anti-HCV positive persons had a 5- to 50-fold higher risk of primary hepatocellular carcinoma compared to anti-HCV negative patients. These sequelae typically take 20 or more years to develop. In a multi-site study of acute HCV infection in the United States, with seroconversion to positive for hepatitis C, 64 percent of persons were asymptomatic. Sixty-six percent were injection drug users. At least six cases of acute hepatitis C in Nevada in 2007 had recently been to the same endoscopy clinic and transmission was suspected of having occurred after the re-use of syringes on individual patients and use of single-use medication vials on multiple patients. Routine screening for HCV infection is recommended only for persons who have a history of ever injecting drugs, recipients of clotting factor concentrates prior to 1987, recipients of blood transfusions or solid-organ transplants prior to July 1992, and

105 chronic hemodialysis patients. Screening is also recommended for sex partners of HCV-infected persons, infants 12 months or older who were born to HCV-infected women, and health care workers after accidental needle-sticks or mucosal exposure to anti-HCV-positive blood. There is no vaccine or effective post-exposure prophylaxis to prevent HCV infection. Diagnostic tests for HCV infection include serologic assays for antibodies and molecular tests for viral particles. Screening tests for HCV include enzyme immunoassays (EIAs) to measure anti-HCV antibody. While these tests are highly sensitive, they do not distinguish between acute, chronic or resolved infections. False- positive results are common, resulting in the need for supplementary testing. Diagnostic testing for HCV should include use of both an enzyme immunoassay (EIA) and supplemental or confirmatory testing with a more specific assay such as the recombinant immunoblot (RIBA, Chiron Corporation). RIBA results are reported as positive, indeterminate or negative. It is not as sensitive as the EIA and should not be used for screening. Persons with chronic hepatitis C should not drink alcohol and should be vaccinated for hepatitis A and hepatitis B. HCV-positive persons should not donate blood, organs, tissues or semen. There is insufficient data to recommend that infected persons change sexual practices with steady partners. HCV-positive household members should not share toothbrushes or razors. Treatment for hepatitis C may be recommended for persons with elevated serum alanine aminotransferase (ALT) and tests that indicate the presence of circulating HCV RNA. HCV RNA levels do not correlate with grade or stage of disease. HCV is divided into six genotypes. Genotype is a predictor of response to therapy. Genotype 1a and 1b HCV infection, the most common types in the United States, have a poorer response to therapy than other types. Response to therapy is higher in those with genotypes 2 and 3. In the United States, 845 acute hepatitis C cases were reported to CDC (0.5 per 100,000). The most common risk factor reported was intravenous drug use reported by 48 percent followed by greater than one sexual partner (42 percent) and surgery (20 percent). In 2007, 71 percent of persons reported jaundice, 49 percent were hospitalized and 0.5 percent died.

Case definition The CDC case definition, which is used in Illinois, is a discrete onset of symptoms with either jaundice or liver enzymes (ALT or AST) greater than 2.5 x upper limit of normal and negative serology for acute hepatitis A and hepatitis B and positive for HCV antibody confirmed by a supplemental test (or simply positive for HCV by the supplemental test).

Descriptive epidemiology • Number of cases in Illinois in 2007 – Sixteen cases of acute hepatitis C were reported. • Age – Acute hepatitis C cases ranged from 18 to 73 years of age (mean age = 42).

106 • Gender – Forty-four percent of acute hepatitis C cases were male. • Race/ethnicity - For acute hepatitis C cases, 80 percent of cases were white and 20 percent were African American; No cases reported Hispanic ethnicity. • Seasonal variation – Cases were reported from January to November. • Geographic variation – Cases were reported from 10 counties. • Reporter – Sixty-two percent of cases were reported by hospitals and 38 percent by private laboratories. • Risk factors - For acute hepatitis C, nine cases reported a history of injection drug use. • Symptoms/outcomes – Fifty percent of 14 acute hepatitis C cases with histories were hospitalized, and no cases were fatal.

Suggested readings Daniels, D., et. al. Surveillance for acute viral hepatitis – United States, 2007. MMWR 2009; 58 (SS-3): 1-27. Labus, B., et.al. Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic-Nevada, 2007. MMWR 2008;57(19):514-521. Wang, C.C., et. al. Acute hepatitis C in a contemporary US cohort: Modes of acquisition and factors influencing viral clearance. JID 2007;196:1474-82.

107 Hepatitis C, chronic or resolved Background The World Health Organization estimates that 170 million people worldwide are infected with HCV. The hepatitis C virus can cause chronic hepatitis, cirrhosis and hepatocellular carcinoma. Among adults who had acute hepatitis C, 26 percent to 50 percent developed chronic active hepatitis and 3 percent to 26 percent developed cirrhosis. In a study of transfusion related hepatitis C in the United States from 1968 through 1980, the risk for developing cirrhosis was 17 percent. Heavy alcohol use increased the risk for developing cirrhosis. Anti-HCV positive persons had a 5- to 50- fold higher risk of primary hepatocellular carcinoma compared to anti-HCV negative patients. These sequelae typically take 20 or more years to develop. Hepatitis C is the most common indication for liver transplantation in adults and accounts for about 40 percent of all transplants in the United States. About 50 percent to 80 percent of patients with pretransplantation viremia develop hepatitis in the liver graft. Persons with chronic hepatitis C should not drink alcohol and should be vaccinated for hepatitis A and hepatitis B. HCV-positive persons should not donate blood, organs, tissues or semen. There is insufficient data to recommend that infected persons change sexual practices with steady partners. HCV-positive household members should not share toothbrushes or razors. Treatment for hepatitis C may be recommended for persons with elevated serum alanine aminotransferase (ALT) and tests that indicate the presence of circulating HCV RNA. HCV RNA levels do not correlate with grade or stage of disease. HCV is divided into six genotypes. Genotype is a predictor of response to therapy. Genotype 1a and 1b HCV infection, the most common types in the United States, have a poorer response to therapy than other types. Response to therapy is higher in those with genotypes 2 and 3.

Descriptive epidemiology • Number of cases in Illinois in 2007 – There were 7,840 cases of chronic or resolved hepatitis C reported. Because this is a chronic disease, these cases may have acquired infection years ago and the number of cases is just the number of cases reported in 2007, not necessarily the year of exposure or onset of any illness. • Age – Chronic or resolved hepatitis C cases ranged from less than one year to 99 years of age (mean age = 50 years). • Gender – Sixty-one percent of chronic or resolved hepatitis C cases were male. • Race/ethnicity - For chronic or resolved hepatitis C cases, 70 percent of cases were white, 25 percent were African American and 4 percent were other races; 6 percent were Hispanic. • Geographic variation – Reported cases resided in 100 of the 102 counties in Illinois. The counties reported the highest incidence per 100,000 included Brown (388) Pope (181), Massac (171), Johnson (163), Jefferson (157), Randolph (147) and Saline (142). These are small population counties where small populations and prison populations may elevate the incidence rates. Fourteen of the 27 Brown

108 County cases were reported by correctional facilities.The counties reporting the most cases were Cook (3,777), Winnebago (307), Lake (303), Dupage (296), Will (264) and St Clair (253). • Genotype – Genotype was only available for 172 cases. The most common genotypes reported were 1a (86 cases), 1b (44), 2b (17) and 3a (nine). Genotypes reported in five or less persons included 1a/1b, 2, 2a, 2a/2c, 2d, 1, 3, 3b, 3 and 4a. • Symptoms/outcomes – Of the 2,946 cases with information about hospitalization status, 26 percent of cases were hospitalized. Five cases were fatal. • Reporter – Seventy-six percent of cases were reported by laboratories and 18 percent by hospital personnel other than laboratory.

109 Histoplasmosis Background Histoplasmosis is a systemic fungal disease caused by Histoplasma capsulatum. Transmission occurs through inhalation of the organism. The incubation period ranges from three to 17 days. Signs and symptoms of histoplasmosis include fever, headache, muscle aches, cough and chest pain. Patients who have underlying lung disease may develop chronic lung disease after H. capsulatum infection. Bird and bat droppings are beneficial to the growth of the organism. Diagnosis of infection can be through culture or serology. The M precipitin alone indicates active or past infection. The H precipitin indicates active disease or recent infection. Histoplasmosis can be a severe infection in persons with HIV or other immunocompromising conditions. Approximately 5 percent of persons with AIDS who live in endemic areas may develop histoplasmosis, which frequently disseminates.

Case definition Histoplasmosis is not a nationally notifiable disease. The case definition for histoplasmosis in Illinois is either: 1) Isolation of the organism from a clinical specimen in patients with acute onset of flu-like symptoms, or 2) In patients with flu-like symptoms, hilar adenopathy and/or patchy infiltrates found on chest radiograph, if done, and at least one of the following a. M or H precipitin bands positive by immunodiffusion b. A four-fold rise between acute and convalescent complement fixation (CF) titers c. A single CF titer of >1:32 d. Demonstration of histoplasma polysaccharide antigen by radioimmunoassay (RIA) in blood or urine, or demonstration of organisms by silver staining blood specimens or biopsy material A confirmed must be culture confirmed. A probable case is a clinically compatible illness not culture confirmed but with one of the other laboratory tests listed above positive.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 - 123 (five-year median = 96) (see Figure 51). At least 22 (18 percent) of these cases were in immunocompromised persons; therefore, it is not possible to determine whether they represent new infections or reactivation of previous infections. • Sex – Sixty-three percent of cases were male. • Age – Ages ranged from two to 87 years (mean age was 42 years) (Figure 52). • Race/ethnicity – Seventy-nine percent were white, 16 percent were African Americans, and 5 percent were other races; 11 percent were Hispanic. • Diagnosis - Thirty-two cases (26 percent) were confirmed by culture. Cultures were positive from blood (nine), bone or bone marrow (three), sputum (one), bronchial

110 wash (six), lung tissue (six), other site (four) and unknown site (three). For those not culture positive, the following test types were positive: serum (81), urine (eight) and both urine and antigen (two). • Seasonal variation - No seasonal trend was identified (See Figure 53). • Geographic variation - The three counties reporting the most cases were Cook (20 cases), Champaign (11 cases) and Will (10 cases). • Outcomes – Sixty-eight (61 percent) of cases were hospitalized; three cases were believe to have died due to histoplasmosis. • Outbreaks - One outbreak was reported in 2007. Four residents of Grundy county traveled to Union county to hunt and became ill with histoplasmosis. A specific source could not be identified. • Reporting- The most common reporters were laboratories (49 percent) and hospital personnel (47 percent).

Summary In 2007, 123 cases were reported as compared to 112 in 2006. One outbreak was reported.

Figure 51. Histoplasmosis Cases in Illinois, 2002-2007

150 123 98 96 112 100 72 57 50 Number of of Number cases 0 2002 2003 2004 2005 2006 2007 Year

Figure 52 . Age Distribution of Histoplasmosis Cases in Illinois, 2007

30

20

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Number of cases Numberof 0 0-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 Age groups

111 Figure 53. Histoplasmosis Cases in Illinois by Month, 2007

25 20 15 10 5

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of onset

112 Influenza, novel Background Novel influenza is reportable to monitor trends in influenza. Novel subtypes of influenza include, but are not limited to, H2, H5, H7 or H9 or influenza H1 or H3 subtypes from a non human species or from genetic reassortment between animal and human viruses. Novel infections were reported from three states in 2007 (Ohio, Illinois and Michigan). Ill patients were infected with swine influenza viruses (swine H1N1 and H1N2). The virus was a triple reassortment containing genes from swine, avian and human viruses.

Descriptive Epidemiology Number of cases reported in Illinois – One case was reported in 2007.

Individual case description • A 48-year-old woman in Illinois was diagnosed with swine influenza (H1N1). The patient had underlying disease-COPD. She had fever, chills and cyanosis on August 22 and was hospitalized and intubated for respiratory distress on August 24. Viral culture was positive on August 31 and oseltamivir therapy was initiated. She had traveled to a fair where swine were present but had not been near the swine and the swine had shown no signs of illness.

113 Influenza-associated pediatric mortality (< 18 years) Background This category of influenza reporting is to monitor the effect of influenza on young persons. Seventy-seven cases were reported in the United States from 27 states in 2007 (0.10 deaths per 100,000). The median age at death was seven years. Forty- three percent had one or more underlying conditions. Only 6 percent were fully vaccinated. The ACIP recommends annual vaccination of all children aged 6 months to 18 years.

Descriptive epidemiology Cases reported in Illinois – One death from influenza in those less than 18 years were reported in Illinois. Individual Case Description • A 12-year-old Cook County resident developed fever, pneumonia, pulmonary hemorrhage and acute respiratory distress syndrome in March. She had not received an influenza vaccine that season. She tested positive for influenza type B and CDC identified B/Victoria/2/87 lineage. She was put on mechanical ventilation and started on Tamiflu. She also was culture positive for MRSA in sputum. The case was fatal.

114 Legionellosis

Background Legionella spp are a group of intracellular pathogens that often inhabit aquatic environments where they can survive well. There are 48 species of Legionella and several serotypes. L. pneumophila serotype 1 is responsible for most lower respiratory tract infections. However, 19 other Legionella species have been documented as human pathogens based on isolation from clinical material. The two major clinical manifestations of infection with Legionella bacteria are Legionnaires’ disease (legionellosis) and Pontiac fever. Legionellosis may be epidemic or sporadic, nosocomial or community acquired. The incubation period is two to 10 days (average five to six days). For Pontiac fever, it is five to 66 hours (average 24-48 hours). Initial symptoms of both are anorexia, myalgia and headache often followed by a nonproductive cough and diarrhea. Patients with legionellosis clinically have pneumonia and abnormal chest radiographs. Legionellosis most often occurs in those who are immunocompromised due to disease or aging. Risk factors are underlying medical conditions such as human immunodeficiency virus, organ transplantation, renal dialysis, diabetes, chronic obstructive pulmonary disease, cancer, immunosuppressive medication or smoking. Pontiac fever is an acute, febrile illness with a high attack rate, short incubation period and rapid recovery. Most cases are sporadic (not associated with a known outbreak). Outbreaks have been associated with aerosol producing devices such as whirlpool spas, showers, humidifiers, respiratory care equipment, evaporative condensers, air conditioners, grocery store mist machines and cooling towers and have occurred in industrial settings. Approximately 20 percent of all Legionnaires’ disease cases are associated with recent travel. Many are thought to be associated with potable water systems in hotels or whirlpool spas in hotels or on board cruise ships. Legionella urine antigen testing and culture of respiratory secretions are useful for diagnostic testing. The urine antigen test provides rapid diagnosis for L. pneumophila serogroup 1 but will not provide an isolate to compare to clinical and environmental isolates gathered during outbreak investigations. Testing for Legionella species is not performed by the Department laboratory. Most test results among reported cases are from hospital or commercial laboratories. In a study of legionellosis in Canada, male gender and advanced age were associated with Legionella infection. Cases increased in summer and autumn months. In 2007, 2,716 cases of legionellosis were reported to CDC from state health departments. CDC has a travel-associated Legionella surveillance e-mail address used by state health departments to report cases of Legionella that have traveled outside their state.

Case definition A confirmed case in Illinois is one that meets the CDC case definition, i.e., a clinically compatible illness with laboratory confirmation of disease by 1) isolation of Legionella from lung tissue, respiratory secretions, pleural fluid, blood or other normally

115 sterile sites; or 2) demonstration of a fourfold or greater rise in the reciprocal indirect fluorescence (IF) antibody titer to greater than or equal to 128 against L. pneumophila serogroup 1 between paired acute and convalescent phase serum specimens; or 3) demonstration of L. pneumophila serogroup 1 in lung tissue, respiratory secretions, or pleural fluid by direct fluorescent antibody (FA); or 4) demonstration of L. pneumophila serogroup 1 antigens in urine by radioimmunoassay (RIA) or enzyme-linked immunoassay (ELISA).

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – There were 111 cases reported (five- year median = 55). All cases were confirmed (Figure 54). • Age - Ages ranged from 25 to 88 (mean age=61). Seventy-eight percent were greater than 49 years of age (see Figure 55). • Gender - Seventy-four (67 percent) cases were male. • Race/ethnicity – Seventy-one percent of cases were white and 26 percent were African American; 4 percent reported Hispanic ethnicity. • Seasonal - An increase in cases occurred from June to September (Figure 56). • Geographic distribution – Twenty-six counties reported cases. The two counties with the most cases were Cook County (43 percent) and DuPage County (12 percent). • Risk factors - Four cases were reported as residing in a residential facility. • Diagnosis - Cases were diagnosed through urine antigen alone (93), serology alone (one), culture alone (two), direct fluorescent antibody of lung biopsy alone (four) or multiple tests (11). • Outcomes - Hospitalization was required for 106 of 109 (97 percent) cases with information available; Seven fatalities were attributed to reported legionellosis infection. • Reporting – Seventy-seven of 119 (70 percent) cases with information available were reported by infection control professionals. • Outbreaks – No outbreaks were reported in 2007.

Summary In 2007, there was an increase in cases of legionellosis, as compared to the five- year median. There were no outbreaks of legionellosis reported in 2007.

Suggested readings Ng, Victoria, et. al. Laboratory-based evaluation of legionellosis epidemiology in Ontario, Canada, 1978 to 2006. BMC Infectious Diseases 2009; 9:68.

116 Figure 54. Legionellosis Cases in Illinois, 2002-2007

150 133 111 100 66 50 55 50 28

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 55. Age Distribution of Legionellosis Cases in Illinois, 2007

80 60 40 20

Number of cases Numberof 0 <30 30-39 40-49 50-59 >59 Age groups

Figure 56. Legionellosis Cases in Illinois by Month, 2007

40 30 20 10

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of onset

117 Lyme Disease

Background Lyme disease is a tickborne zoonotic disease caused by the bacterium Borrelia burgdorferi sensu lato. The reservoir is the black-legged tick (Ixodes scapularis), commonly called the deer tick. Human disease is thought to be primarily caused by nymphal tick bites, usually in late spring or summer. Babesiosis and ehrlichiosis also are transmitted by the same tick. In the Midwest, wild rodents and other animals maintain the transmission cycle. Deer are the preferred host of the adult tick. Laboratory studies indicate ticks must be attached for at least 24 hours for transmission to humans to occur. Experiments in animals have shown that most often the tick must feed at least 48 hours before the risk of transmission becomes substantial. Lyme disease is characterized by a rash-like skin lesion called erythema migrans (EM) that may be followed by cardiac, neurologic and/or rheumatologic involvement. The incubation period for EM ranges from three to 32 days (mean: seven to 10 days) after tick exposure; it is present in 80 percent to 90 percent of case patients. Erythema migrans may be characterized by a homogenous rash rather than a target appearance because of early presentation for treatment. EM is the most common clinical manifestation of Lyme disease and resolves within about 28 days. Early manifestations include fever, headache, fatigue, migratory arthralgias and possibly lymphadenopathy. It can take approximately two to four weeks or longer for antibodies to be detected by blood tests, so these tests are not required for patients diagnosed with EM in the public health surveillance case definition. There were 27,444 cases of Lyme disease (9.2 per 100,000) reported in 2007 in the United States, mainly from the Northeast, mid-Atlantic and north-central regions of the country. All but three states reported cases during 2007. Ten states - Connecticut, Delaware, Maryland, Massachusetts, Minnesota, New Jersey, New York, Pennsylvania, Rhode Island and Wisconsin - accounted for 87 percent of all cases reported. Effective prevention measures include personal protective measures (tick checks, repellents) and decreasing tick exposure. The Infectious Disease Society of America has advanced the recommendation that antimicrobial prophylaxis can be offered after a recognized tick bite if the following conditions are true: 1) the attached tick is identified as Ixodes and was attached for greater than 36 hours, 2) Prophylaxis can be started within two hours of when the tick was removed, 3) the tick infection rate in the area is 20 percent or greater and 4) doxycycline is not contraindicated.

Case definition The surveillance case definition for Lyme disease in Illinois is the CDC definition for 2007: 1) erythema migrans, or 2) at least one late manifestation (musculoskeletal system, nervous system or cardiovascular system) and supportive laboratory evidence of infection or laboratory confirmation, i.e., isolation of B. burgdorferi from a clinical specimen, or demonstration of diagnostic immunoglobulin M or immunoglobulin G antibodies to B. burgdorferi in serum or cerebrospinal fluid (CSF). A two-test approach

118 using a sensitive enzyme immunoassay or immunofluorescence antibody followed by Western blot is required by the Department for confirmation of non-EM cases.

Descriptive epidemiology

• Number of cases reported in Illinois in 2007 – There were 149 (five-year median = 87) cases reported (See Figure 57). All cases were confirmed. The incidence was 1.2 per 100,000. • Age - Cases ranged in age from one to 83 years of age (mean= 36) (Figure 58). • Gender – Sixty percent were male. • Race/ethnicity – Of the 118 cases (98 percent) for which race is known, cases were white; one case identified themselves as Hispanic. • Seasonal distribution – Lyme disease case onsets were most common from June through July. (Figure 59). • Geographic distribution - Seventy-three cases reported a tick exposure within Illinois, these are mapped in Figure 60. The regions where cases reported exposures included the Rockford region (30 cases), West Chicago (13), Peoria region (11), Bellwood region (six), Edwardsville region (five), Champaign region (two) and Marion region (one). The counties most likely to be implicated as exposure sites included Jo Daviess (10 cases) and Ogle (seven). Cases reported 23 Illinois counties as exposure sites. Five cases reported multiple Illinois regions as exposure sites. Twelve cases reported exposures both in-state and out-of-state. Fifty-seven cases reported non-Illinois exposure locations including Wisconsin (46), New York (three), Massachusetts (two), Michigan (two), Indiana (one), Missouri (one), Connecticut (one), Arkansas (one). Four persons reported exposures outside of the country including Canada (two) and Poland (two). For three cases no exposure location could be identified. There were thirty counties with residents diagnosed with Lyme disease. The top six counties reporting residents with Lyme disease included Cook County (30 cases), Dupage (16), Winnebago (11 cases), JoDaviess (nine), Will (eight) and Lake (eight). • Tick distribution – A map of Illinois with the distribution of known Ixodes scapularis (the vector for Lyme disease) is provided (Figure 61). • Symptoms - Qualifying manifestations were EM (129, 86 percent), rheumatologic signs (11, 7 percent) and neurologic signs such as Bell’s palsy (eight, 5 percent). Six percent of cases were hospitalized; no deaths were reported in cases. • Reporting – The three top reporters of Lyme disease cases were laboratory staff (63 percent), infection control professionals (17 percent) and clinics (16 percent). • Tick exposure – Forty-eight of 108 (44 percent) of cases reported a tick bite before illness onset. One hundred thirty two of 139 (95 percent) of cases reported being in a tick habitat. The three most common sites of tick exposure habitat were own property (32 cases), parks and nature preserves (32 cases) and a campground (26 cases). • Past incidence - In Illinois, reported Lyme cases for previous years are as follows: 1991 (51), 1992 (41), 1993 (19), 1994 (24), 1995 (18), 1996 (10), 1997 (13), 1998

119 (14), 1999 (17), 2000 (35), 2001(32) and 2002 (47), 2003 (71) and 2004 (87), 2005 (127) and 2006 (110).

Summary For the cases reported in Illinois residents during 2007, EM was the most common qualifying manifestation for Lyme disease. The number of cases peaked in the summer months. The out-of-state exposures occurred most commonly in Wisconsin. The incidence in Illinois (1.2 per 100,000) is much lower than the national average (9.2 per 100,000) for 2007. The number of reported cases of Lyme disease increased over 2006.

Figure 57. Lyme Disease Cases in Illinois, 2002-2007

200 149 127 150 110 87 100 71 47 50

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 58. Age Distribution of Lyme Cases in Illinois, 2007

40 30 20 10

Number of cases Numberof 0 <10 yr 10-19 yr 20-29 yr 30-39 40-49 50-59 >59 yr Age groups

Figure 59. Lyme Disease Cases in Illinois by Month, 2007

60

40

20

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of onset

120

Figure 60. Illinois Map of Reported Exposure Location of Lyme disease Cases by County, 2007

121 Figure 61. Tick distribution map

122 Malaria

Background Malaria is a very important global parasitic disease. It is endemic in more than 100 countries. The incubation period may range from seven days to 10 months. Symptoms of malaria include fever, headache, muscle aches, fatigue, diarrhea and vomiting. Four species of Plasmodium (P. vivax, P. falciparum, P. malariae and P. ovale) cause disease in people. P. vivax malaria is the most common form. P. falciparum is the most common species in tropical areas and causes the most malaria deaths. The majority of malaria-endemic countries are in sub-Saharan Africa, Southeast Asia and Latin America. More than 90 percent of the incidence of malaria in the world occurs in sub-Saharan Africa and two-thirds of the remaining cases occur in India, Myanmar, Afghanistan, Vietnam and Colombia. The highest risk of malaria is for travelers to sub-Saharan Africa, Papua New Guinea and the Solomon Islands. About 90 percent of P. falciparum infections are acquired in Africa. More than 70 percent of P. vivax infections are due to exposures in Asia or Latin America. Immunity lasts less than two years once a person leaves an endemic area. Many persons who travel back to their home country assume they are immune. Identification of the species is important because treatment can differ. For example, disease caused by P. falciparum has a more serious and must be treated differently. Untreated P. falciparum can progress to coma, renal failure, pulmonary edema and death. In a large study in Asia, mortality increased from 6 percent in children less than 10 years of age to 36 percent in persons older than 50 years of age. The majority of fatal cases in the United States are due to not using correct chemoprophylaxis, incorrect initial chemotherapy and delays in malarial diagnosis. One of the most important diagnoses to consider in recent travelers with fever is malaria. Imported malaria cases occur in Illinois when someone with the disease immigrates to the United States or when someone who travels overseas uses inadequate chemoprophylaxis. Persons traveling to malarious areas should take recommended chemoprophylaxis regimens and use appropriate personal protective measures against mosquito bites (using mosquito nets at night when accommodations do not protect against mosquitos and using repellents). The risk of malaria depends on geographic location of travel, urban versus rural stay, type of accommodations, duration of stay, time of the year, activities, elevation and compliance with preventive measures. In the United States, malaria is transmitted predominantly by the bite of an infective female anopheline mosquito in travelers while overseas. Other less common methods include infected blood products, congenital transmission or local mosquito borne transmission. Malarial infection or relapse during pregnancy results in risk to the mother and fetus, including maternal anemia, spontaneous abortion, perinatal mortality, low birth weight, and prematurity. Symptoms in newborns include fever, poor appetite, irritability, and lethargy and can mimic sepsis. Malaria should be considered in the of illness in persons with 1) fever and a history of travel to areas where malaria is endemic, including immigrants, 2) fever of unknown origin, regardless of travel history, or in 3) ill neonates

123 and young infants with fever and mothers who have immigrated or traveled to areas where malaria is endemic. A new rapid diagnostic test for malaria was approved by FDA in June 2007. All rapid tests should be followed by microscopy to confirm. The majority of malaria infections in Illinois are caused by travel to areas with ongoing transmission. In 2007, 1,505 malaria cases were reported in the United States including one fatal case. The species of malaria identified in these cases was falciparum (43 percent), vivax (20 percent), malariae (2 percent) and ovale (3.5 percent). In 30 percent of cases the species was unknown. Malaria is transmitted in parts of Africa, Asia, the Middle East, Central and South America, the island of Hispaniola and Oceania. The majority of infections in the United States were acquired in Africa (64 percent), followed by Asia (22 percent), the Americas (11 percent) and Oceania (2 percent). Twenty-six percent of the cases who took an antimalarial drug did not take a CDC recommended drug for the region they were visiting. Of the 143 patients who contracted malaria after taking a recommended antimalarial drug for chemoprophylaxis, 30 percent reported compliance with the regimen, 59 percent reported noncompliance and 10 percent had missing compliance information. For P. vivax or P. ovale, if onset develops 45 days after arriving in the United States, this is consistent with relapsing infections and does not indicate primary prophylaxis failure. Of the United States civilians with malaria, 63 percent of persons had visited friends or relatives in malarious areas. The second leading reason for travel was tourism (10 percent), followed by missionary work (8 percent).

Case definition Illinois uses the CDC case definition. A confirmed case is a person (symptomatic or asymptomatic) with an episode of microscopically confirmed malaria parasitemia diagnosed in the United States, regardless of whether the person experienced previous episodes of malaria while outside the country.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – There were 63 cases reported (five-year median = 61) (see Figure 62). All were confirmed cases. • Age – Forty-eight percent of cases occurred in persons from 10 to 39 years of age. The mean age was 30. (Figure 63) • Sex – Sixty-five percent were male. • Race/ethnicity – Fifty-six percent were African American, 14 percent were white, 19 percent were Asian and 10 percent were other races; no cases were reported to be of Hispanic ethnicity. There were significantly higher proportions of African Americans and Asians with malaria compared to their presence in the Illinois population and significantly lower proportions of whites and Hispanics with malaria compared to the Illinois population. • Geographic location – Malaria cases were reported from 14 counties. The majority were reported from Cook County (49 percent). • Seasonal variation - Cases of malaria were reported in greater numbers in

124 January (Figure 64). • Speciation - The malaria species identified in the reported cases were P. falciparum (38 cases, 61 percent of cases with known species), P. vivax (18 cases, 45 percent), P. malariae (two cases, 3 percent), P. ovale (four cases, 6 percent) and unknown (one case). • Treatment/outcomes – Thirty-six of 58 cases (62 percent) were hospitalized. One person died with malaria but it is unknown if malaria was the cause of death. No cases of cerebral malaria were reported.

o The P. falciparum cases were treated with the following medications: malarone (eight cases); quinine (one); doxycycline or tetracycline (one); tetracycline or doxycycline and quinine (three), mefloquin, chloroquin and tetracycline or doxycycline (one); chloroquin and tetracycline or doxycycline (one), quinine, malarone and doxycycline or tetracycline (one); quinine and tetracycline or doxycycline (one) and unknown (21).

o The P. vivax cases were treated with the following medications: mefloquin (three), malarone (one); primaquin and mefloquin (two); primaquine and chloroquin (three); primaquin and doxycycline or tetracycline (one); mefloquin and tetracycline or doxycycline (one) and malarone and hydroxychloroquin (one). Treatment type for six cases was unknown.

o The P. ovale cases were treated with the following medications: malarone (one); primaquin and tetracycline or doxycycline (one); and tetracycline or doxycycline (one). One case had unknown treatment medications.

o The P. malariae were treated with the following medications: mefloquin (one case) and unknown (one).

• Risk factors - The major risk factor for infection is travel outside the United States. Specific information was available for 55 of the 2007 cases. The Asian countries reported by 17 cases as travel destinations were India (12 cases), Papua New Guinea (two cases), Thailand (two cases) and Burma (one case). In Africa, the following travel destinations were reported for 35 cases: Nigeria (19 cases), Tanzania (five cases), Ghana (three cases), Uganda (two cases), Liberia (one case), Ivory Coast (one case), Africa, not further specified (two) and multiple African countries (two cases). No cases reported a travel destination of South America. One case reported travel to the Middle East (Afghanistan). Two cases reported travel destinations in multiple continents. For eight persons, travel history was unknown. • Of the 19 cases reporting travel to Nigeria, all were infected with P. falciparum. Of the five cases reporting travel to Tanzania, four were falciparum and one had an unknown species. Of the three cases who visited Ghana, two had P.

125 falciparum and one case had P. ovale. Of the 12 cases reporting travel to India, 11 were infected with P. vivax and one with P. falciparum. • Cases provided the following reasons for travel overseas: visiting friends or relatives (17), immigrant (10), business (five), tourism (four), missionary work (three), adoption (two), student/teacher (two), military (one) and unknown (19). • Malaria prophylaxis was reported by only 19 of 39 cases providing information (49 percent). Nine persons reporting taking prophylaxis correctly, eight said they missed doses and for two this information was unknown. Cases indicated taking the following medications for the prevention of malaria: malarone (four), mefloquin (three), sulfadoxine/ pyrimethamine (three), doxycycline (two), chloroquin (two), primaquin (two) and unknown medication (three). • Reporting – Forty-five of 63 cases (71 percent) were reported by hospitals and 16 of 63 (25 percent) were reported by laboratories. Other reporters reported 4 percent of malaria cases. • Past infection – Twenty-nine cases reported no previous history of malaria and seven cases reported a previous history of malaria. Information on past history of malaria was not completed for 27 cases.

Summary There were 63 reported cases of imported malaria identified in Illinois in 2007, the 7th highest number of cases among the states. This was similar to the median (61 cases) for the previous five years. African Americans and Asians made up a higher proportion of persons with malaria than in the Illinois population. Laboratories should forward blood smears to the Department’s laboratory for verification of species. Laboratories should be thorough in identifying the species of this parasite because treatment differs by species (e.g., P. vivax and P. ovale require additional treatment with primaquine to prevent relapses) and simultaneous infection with more than one species does occur.

Suggested readings Dondrop, A.M., et. al. The relationship between age and the manifestations of and mortality associated with severe malaria. CID 2008;47:151-7. Mali, S., et. al., Malaria Surveillance – United States, 2007. MMWR 2009; 58(S S02); 1-16.

126 Figure 62. Malaria Cases in Illinois, 2002-2007

100 83 74 80 61 63 60 46 47 40 20

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 63. Age Distribution of Malaria Cases in Illinois, 2007

25 20 15 10 5

Number of cases 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Age Group

Figure 64. Malaria Cases in Illinois by Month, 2007

15

10

5

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of Onset

127 Measles

Background Measles is a highly communicable viral disease with humans as the only natural host for the infection. Transmission most commonly occurs through airborne spread or through direct contact with nasal or throat secretions of infected people. The incubation period is about 10 days, but varies from seven to 18 days. Infected individuals show fever, conjunctivitis, coryza, cough and Koplik’s spots on the buccal mucosa, along with a rash that appears on the third to seventh day. The disease can be prevented by proper immunizations. A two-dose vaccination schedule is recommended in the United States, one at 12 to 15 months and one at school entry (four to six years) or by 11 to 12 years. Sustaining high levels of vaccination is important to limit indigenous spread of measles from cases imported into the United States. Nationally, there were 43 cases reported to CDC; Twenty-nine were internationally imported and 12 additional cases occurred from these imported cases. For two cases, the source was classified as unknown because no link to importation could be identified. Four outbreaks occurred, all from imported sources.

Case definition A confirmed case in Illinois is one that meets the CDC definition, i.e., a case that is laboratory confirmed, or that meets the clinical case definition and is epidemiologically linked to a confirmed case. Laboratory confirmation consists of 1) isolation of measles virus from a clinical specimen, or 2) significant rise in measles antibody level by any standard serologic assay, or 3) positive serologic test for measles IgM antibody. The clinical case definition is an illness characterized by a generalized rash lasting at least three days, and a temperature of at least 101° F, and a cough or coryza or conjunctivitis. A probable case meets the clinical case definition, has noncontributory or no serologic or virologic testing, and is not epidemiologically linked to a confirmed case.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – One case of measles was reported in 2007 (five-year median=one case) (Figure 65). • Case description – A 53-year-old health care worker who had traveled to Ghana on a medical mission developed onset of illness in late September. Symptoms included fever, rash, cough and Koplik’s spots. Diagnosis was by serology at CDC. The vaccination history was unknown.

Summary One case of measles was reported.

128 Figure 65. Measles Cases in Illinois, 2002-2007

2.5 2 2 1.5 1 1 1 1 1 0.5 0

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

129 Mumps

Background Mumps is transmitted by droplet spread and by direct contact with the saliva of an infected person. The incubation period is 12 to 25 days. This viral disease is characterized by fever, headache, lethargy and swelling and tenderness of salivary glands lasting two or more days and without other apparent cause. Orchitis may occur in males and oophoritis in females. Before vaccination was available mumps was the leading cause of viral meningitis and unilateral acquired deafness in children. Winter and spring are the times of increased occurrence. Vaccination can prevent mumps. To prevent mumps a two-dose MMR vaccination series for all children (first dose at 12-15 months, second dose at 4-6 years of age) is recommended. Two doses are recommended for school and college entry unless there is other evidence of immunity. In the five-day period after onset of parotitis, isolation is recommended in both the community setting or the health care setting and standard droplet precautions are recommended. In 2007, 800 mumps cases were reported to CDC. Outbreaks can occur in highly vaccinated populations.

Case definition A confirmed case in Illinois is one that meets the CDC case definition: a clinically compatible illness that is laboratory confirmed, or that meets the clinical case definition and is epidemiologically linked to a confirmed or probable case. A laboratory-confirmed case does not need to meet the clinical case definition. The laboratory confirmation may consist of 1) isolation of mumps virus from a clinical specimen, or 2) a significant rise in mumps antibody level by a standard serologic assay, or 3) a positive serologic test for mumps IgM antibody. The clinical case definition is an illness with acute onset of unilateral or bilateral tender, self-limiting swelling of the parotid or other salivary gland, lasting more than two days, and without other apparent cause.

Descriptive epidemiology

• Number of cases reported in Illinois in 2007 – There were 170 cases reported (five- year median = 10) (Figure 66). Of the 170 cases, 74 were confirmed and 96 were probable. • Age - Mean age was 23 years (range was two years to 79 years) (Figure 67). • Gender - Fifty-one percent were female. • Race/ethnicity - Eighty percent were white, 9 percent were African American, 3 percent were Asian and 8 percent were other. Twenty-two percent reported Hispanic ethnicity. • Geographic distribution - Cases resided in 26 counties. Counties with the most cases included Cook (53), Kane (35), Dupage (13) and Dekalb (12). • Seasonal variation - Cases increased from January through March (Figure 68). • Clinical syndrome – The mean duration of parotitis was seven days. • Outcome – Complications included orchitis (seven cases). Five cases were

130 admitted to the hospital. No fatalities were reported. • Immunization status – Of the 170 cases reported in Illinois, 52 percent reported a history of two doses of mumps-containing vaccine, 10 percent had one dose and an additional 10 percent had an unsubstantiated number of mumps-containing doses. Twenty-six percent had unknown vaccination status or had not been vaccinated.

Summary Of the states in the United States, Illinois reported the highest number of mumps cases in 2007. The mean age of the 170 reported mumps cases in 2007 was 23 years. There was a decrease in mumps cases over the number of cases reported in 2006.

Suggested readings Anon. Updated recommendations for isolation of persons with mumps. MMWR 2008; 57(40): 1103-5. Dayan, G.H. and Rubin, S. Mumps outbreaks in vaccinated populations: Are available mumps vaccines effective enough to prevent outbreaks? CID 2008;47:1458- 67.

Figure 66 . Mumps Cases in Illinois, 2002-2007

1000 798 800 600 400 170 200 18 8 10 10

Number Number of cases 0 2002 2003 2004 2005 2006 2007 Year

131 Figure 67. Age Distribution of Mumps Cases in Illinois, 2007

80 60 40 20

Number of cases 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Age Group

Figure 68. Mumps Cases in Illinois by Month, 2007

40 30 20 10

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of Onset

132 Pertussis

Background Pertussis is a highly infectious respiratory disease and is caused by Bordatella pertussis and is characterized by a paroxysmal cough that can last several weeks. Pertussis should be considered in adolescents and adults especially if the cough is associated with vomiting or gagging or persists more than two weeks. Pertussis in adults may be missed because symptoms may be atypical, and nasopharyngeal cultures are rarely positive if taken during the first seven days of illness. Pertussis is transmitted from person to person via aerosolized droplets from cough or sneeze or by direct contact with secretions from the respiratory tract of infectious persons. Pertussis can be highly infectious during the three weeks after onset of illness. The incubation period is usually seven to 10 days although it can range from six to 20 days. A resurgence of cases has been reported in the last decade in the United States. A total of 10,454 pertussis cases (3.6 per 100,000) were reported to CDC from states in 2007. The likely explanation for the high numbers of cases reported include increased circulation of B. pertussis, waning vaccine-induced immunity among adolescents and adults, increased reporting and increased use of PCR testing. Of these cases, the incidence was highest (70 per 100,000 population) in infants younger than 6 months of age (too young to have received three doses of vaccine). Vaccine- induced immunity wanes about five to 10 years after pertussis vaccination. For the first week, mild fever, coryza and cough are common. From week one through six, a paroxysmal cough, inspiratory whoop, and post-tussive vomiting may occur. From six to 12 weeks, the intensity of cough decreases. Outbreaks are managed through prompt treatment of patients and antimicrobial prophylaxis of close contacts. Acellular pertussis vaccines are used in children from 6 weeks to 6 years of age. Pertussis has increased in adults. Active immunization with five doses of vaccine at 2, 4, and 6 months of age, at 12 to15 months and at school entry can prevent this disease. However, immunity from childhood vaccination decreases beginning five to 15 years after the last pertussis vaccine dose. Vaccination with Tdap vaccine of persons aged 11 to 64 is recommended. To confirm the diagnosis of pertussis in symptomatic adults, physicians should obtain a nasopharyngeal aspirate or swab for B. pertussis culture within two weeks of cough onset. The lack of fast, sensitive and specific tests makes laboratory diagnosis difficult. In outbreak settings, positive PCR should be interpreted in conjunction with epidemiologic investigation, clinical course and confirmed by culture. A subset of cases should be cultured. Culture is the gold standard and 100 percent specific. Its sensitivity can be up to 56 percent early in the course of illness but decreases with delays in specimen collection, in vaccinated patients or patients treated with antimicrobials. Isolation of the organism can take seven to 14 days.

Case definition The case definition for pertussis in Illinois is a clinically compatible illness that is

133 laboratory confirmed or epidemiologically linked to a laboratory-confirmed case. Laboratory confirmation is through culture of B. pertussis from a clinical specimen. A clinically compatible illness is a cough lasting at least two weeks with one of the following: paroxysms of coughing, inspiratory whoop or post-tussive vomiting (without other apparent causes) or greater than two weeks of cough in a person in an outbreak setting. A confirmed case is defined as a cough illness of any duration in any person with isolation of B. pertussis or a case that meets the clinical case definition and is confirmed by polymerase chain reaction or by epidemiologic linkage to a laboratory- confirmed case. A probable case meets the clinical case definition but is not laboratory confirmed or epidemiologically linked to a laboratory-confirmed case.

Descriptive epidemiology

• Number of cases reported in Illinois in 2007 – There were 199 cases reported (five- year median = 588) (Figure 69). Of the 199 cases, 140 were confirmed and 59 were probable. The one-year incidence rate for pertussis was 1.6 per 100,000. • Age – Twenty-eight percent occurred in those younger than 5 years of age (Figure 70). In 2007, 67 of 198 reported cases (34 percent) occurred in those over 19 years of age. • Gender - Females comprised 57 percent of cases. • Race/ethnicity – Eighty-seven percent were white, 6 percent were African American, 7 percent were in other races and 26 cases were of unknown race; 11 percent reported Hispanic ethnicity. • Geographic location – Cases were identified from 38 counties. Counties reporting the most cases included Cook (81), Lake (19) and Will (12). • Seasonal variation - Cases were highest in January (Figure 71). • Clinical syndrome – All cases reported cough and 158 cases reported paroxysmal cough. Sixty-two cases reported a whoop. Fifty-seven cases reported apnea and 83 cases reported post-tussive vomiting. • Previous Vaccination – Ninety-five cases reported receiving at least one pertussis vaccination. Thirty-six cases reported never having received a pertussis vaccination. • Outcome – Forty-four cases were hospitalized. No cases were fatal.

Summary The number of yearly reported pertussis cases decreased since 2006 in Illinois. The incidence in Illinois was lower (1.6 per 100,000) as compared to 3.6 per 100,000 nationally. There were 199 pertussis cases reported in Illinois in 2007. Adolescent and adult pertussis cases have increased in Illinois, and this follows a national trend in 2007.

134 Figure 69. Pertussis Cases in Illinois, 2002-2007

2000 1554 1500 922 1000 588 321 500 231 199

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 70. Age Distribution of Pertussis Cases in Illinois, 2007

30

20

10

0 Incidence of cases <1 yr 1-4 yr 5-9 yr 10-19 yr >19 years Year

Figure 71. Pertussis Cases in Illinois by Month, 2007

50 40 30 20 10

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year

135 Q fever Background Q fever is an acute rickettsial disease found worldwide. Coxiella burnetti is the causative agent. Phase I is found in nature and phase II after multiple laboratory passages in the laboratory. The infective dose can be very low, as low as one organism. The diagnosis of Q fever relies on serologic testing. In 60 percent of cases, acute Q fever can be asymptomatic. In patients with acute Q fever, it is usually mild and sometimes complicated by febrile illness, pneumonia or hepatitis infection. Chronic Q fever develops in patients predisposed to the disease and includes those who are immunosuppressed or who have valvulopathies. In a study in France, the median time to diagnosis of chronic Q fever was three months after experiencing acute Q fever. Persons at higher risk of Q fever infection include animal workers. The animal reservoirs include sheep, cattle, goats, cats, dogs, and some wild animals. The organism can be shed in high quantities in placental fluids at parturition. Ticks can be a rare source of infection in the United States. Q fever is most commonly transmitted through airborne dissemination of the organism in dust from premises contaminated with placental tissues and excreta of infected animals, in necropsy rooms or in animal processing establishments. Rarely, it can be transmitted from consumption of unpasteurized milk or cheese. The incubation period is from two to three weeks. Q fever is also a Category B bioterrorism agent. Outbreaks have been linked to aerosol transmission in heavy winds. In 2007, 171 cases of Q fever were reported to CDC. Illinois was third in the nation in the number of reported cases.

Case definition

A confirmed case of Q fever is a clinically compatible illness with either isolation of C. burnetti from a clinical specimen, demonstration of C. burnetti in a clinical specimen by detection of antigen or nucleic acid, or a fourfold or greater change in serum antibody titer to C. burnetti antigen. A probable case is defined as a clinically compatible or epidemiologically linked case with an elevated serum antibody titer to C. burnetti.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – There were 14 cases reported. All were probable cases. • Age - Cases ranged in age from 26 to 86 (mean = 46 years of age). • Gender - Females comprised 36 percent of cases. • Race/ethnicity – Ninety-two percent were white and 8 percent were African American. Two cases had unknown race; None reported Hispanic ethnicity. • Seasonal variation - Cases reported onsets from February through December. • Hospitalization – Four of 14 cases (28 percent) were hospitalized. No fatalities were reported.

136 • Reporting - Seventy-one percent of cases were reported by laboratories. • Geographic location – Eleven counties reported cases. Counties reporting multiple cases included Adams (two), Cook (two) and Stephenson (two). • Risk factors – Six cases reported exposure to cattle, sheep and/or goats. One case reported consuming unpasteurized dairy products. • Outbreaks – One outbreak of Q fever was reported in 2007. Further information is available in the nonfoodborne and nonwaterborne outbreak section.

Summary Fourteen cases of Q fever were reported in Illinois. One outbreak was reported in Illinois. States reporting the highest number of cases were California (20), Colorado (19), Illinois (14), New Mexico (12), Missouri (12) and Texas (11).

Suggested readings Landais, C., et.al. From acute Q fever to endocarditis: Serological follow-up strategy. CID 2007’44:1337-40.

137 Rabies

Background In the United States, rabies is a disease that affects primarily wildlife populations. It is a neurologic illness that follows infection with a rhabdovirus. It produces encephalitis and typically progresses to death. Transmission of rabies to humans results from the bite of a rabid animal or from contact between the saliva of a rabid animal and a mucous membrane or wound. The rabies virus is inactivated by sunlight, heat and desiccation. The incubation period is usually three to eight weeks. Symptoms may include fever, anxiety, malaise, and tingling and pruritus at the bite site. Neurologic signs, beginning two to 10 days later, may include hyperactivity, paralysis, agitation, , hypersalivation and convulsions.The paralytic form of rabies must be differentiated from Guillain Barré syndrome. After two to 12 days, the patient may go into a coma and experience respiratory failure. Rabies should be considered in the differential diagnosis of any acute rapidly progressive encephalitis, regardless of documentation of an animal bite. In 2007, the United States and Puerto Rico reported one case of human rabies and 7,258 cases of animal rabies. Wild animals accounted for 93 percent of the animal cases reported in the United States; the top three species with rabies were the raccoon, bat and skunk. The top six rabies-positive bats after speciation (not done in all states) were the big brown bat (68 percent), Mexican free-tailed bat (9 percent), Western pipistrelle (6 percent), little brown bat (4 percent), the hoary bat (2 percent) and red bat (3 percent). The most commonly identified rabid bat in the United States was the big brown bat. The peak of bat rabies in the United States occurred in August. In a study in Texas, skunk rabies had a 20-year cycle. The highest number of skunks were from identified from March to April. Most of the domestic animals exposed to rabid skunks were dogs and cats. Oral rabies vaccines have not been as effective in skunks as other species because of low acceptance rates. One 46-year-old developed rabies in the United States in 2007. In October 2007, a Minnesota resident died of rabies after an incubation period of approximately one month. This patient had handled a bat with his bare hands and felt a needle prick sensation before releasing the bat. The patient assumed he had not been bitten and did not seek medical attention. Rabies antibodies were detected in CSF and serum but the rabies virus variant could not be identified. Three family contacts and 51 health care providers received rabies PEP. From 2000-2007, 25 human rabies cases were reported in the United States. Eighteen (28 percent) were associated with suspected exposure to rabid bats or infection with bat rabies virus variants. Most case occurred in late summer or early autumn. In Asia and Africa, it is estimated that over 55,000 people die of rabies each year. Over the past 40 years in Illinois, skunks and bats have been the main wildlife reservoirs of rabies virus. The last human case of rabies in Illinois was reported in 1954.

137 Case definition The case definition for human rabies is a clinically compatible illness that is laboratory confirmed. Laboratory confirmation is through detection by direct fluorescent antibody (DFA) of viral antigens in a clinical specimen (preferably brain tissue or punch biopsy of the nape of neck, including at least 10 hair follicles where associated nerves are likely to show evidence of infection), or isolation of rabies virus from saliva or cerebrospinal fluid (CSF), or identification of a rabies-neutralizing titer of greater than 1:5 in the serum or CSF of an unvaccinated person. A case of animal rabies is confirmed by DFA of brain tissue. If samples are sent to CDC, as is normally done only for confirmation of a positive result in a domestic species, the CDC results are used as the final results for the purposes of this report.

Descriptive epidemiology Number of animals submitted for rabies testing in Illinois in 2007 – 5,248; sixty-five additional heads did not meet criteria established by the testing laboratories (Illinois departments of Agriculture and Public Health). Examples of unsatisfactory specimens are those determined to be too decomposed or too damaged to test. Of those specimens submitted, 113 specimens were DFA positive; all were bats (Table 6). Trends in animal rabies testing in Illinois are shown in Figure 72. • Exposures to rabid bats - There were 113 rabid bat situations. o In 69 of the 113 rabid bat situations, no human exposures sufficient to require rabies PEP (per ACIP guidelines) occurred (for eight situations, the human exposure information was unknown at the time of this report). In 61 situations, bats were found inside homes. In 39 situations the bat was found alive outside in yards, pools or near barns, and in 13 situations the location of where the bat was found was unknown. o Domestic animals (all dogs or cats) were either exposed or possibly exposed in 22 situations (Table 7). • Testing of bats - Bats accounted for all of the confirmed rabid animals in 2007. The total number of bats tested for rabies was 2,102 (positivity rate = 5.38 percent). o Geographic distribution - Rabid bats were dispersed in 76 counties across the state. The following counties had rabid bats: Champaign (two), Clinton (one), Cook (27), DuPage (two), Effingham (one), Franklin (one), Grundy (one), Jackson (one), Kane (five), Lake (nine), LaSalle (two), Lee (four), Logan (one), Madison (five), Marion (one), Massac (one), McHenry (13), McLean (two), Mercer (one), Moultrie (one), Peoria (one), Sangamon (five), Tazewell (two), Warren (two), Whiteside (three), Will (11), Williamson (two), Winnebago (six) (Figure 73). . Speciation - The Illinois Natural History Survey speciates bats tested for rabies in Illinois. In 2007, 2,098 bats tested for rabies were speciated (Table 8). There were 110 positive bats speciated including the big brown bat (87), eastern red bat (14), hoary bat (three), silver-haired bat (three), eastern pipistrelle (one), northern long-eared bat (one) and little brown bat (one). Of the negative bats

138 speciated, the following results were found: big brown bat (1,436), silver-haired bat (270), eastern red bat (154), little brown bat (45), northern long-eared bat (39), hoary bat (20), eastern pipistrelle (nine), evening bat (10) and not further identified/unknown (five). o Seasonal variation - Figure 74 shows bats submitted for testing by month in 2007. Bats submitted for rabies testing increase in August and September.

• Testing of skunks - Rabies testing was performed on 134 skunks in 2007 as compared to 125 in 2006. At least one skunk from each of 27 Illinois counties was tested; no skunks were tested in 75 counties. The following counties submitted more than five skunks for rabies testing: Cook (13 skunks tested), Dupage (26), Lake (19), McHenry (12), McLean (12), Will (14) and Jackson (six). For rabies surveillance to be optimal in Illinois an adequate number of skunks, the main terrestrial animal reservoir, must be tested. Test results from wild terrestrial mammals is one factor used to determine whether rabies PEP is recommended in cases of stray dog and cat bites. If enough skunks from throughout the state are not tested, recommendations against rabies PEP following such a bite cannot be made with confidence.

Figure 75 shows the number of rabid skunks found in Illinois and the road kill index from 1975 through 2007. The road kill index is calculated by the Illinois Department of Natural Resources as a measure of changes in the skunk population size. When the road kill index increases, the skunk population is increasing, and conditions are likely to be suitable for a rabies epizootic in skunks. This last occurred in the late 1970s and early 1980s, when the road kill index and the rate of skunks testing positive both increased.

• Rabies positivity rate - Table 9 shows the rabies positivity rate in different species of animals in Illinois from 1971 to 2007. This information can be useful in explaining why rabies PEP is not recommended for the large majority of mouse, rat and squirrel bites. No rats, mice or squirrels have been identified with rabies in Illinois in more than 30 years. Because bats with rabies are identified almost every year in Illinois, rabies PEP is recommended for exposures to these animals and many other wild mammals unless they can be tested and are negative for rabies. When comparing the positivity rates for cumulative 1971-2007 data vs. 1991-2007 data, the percentage of skunks positive for rabies declined dramatically, and the percentage of positive bats stayed very constant. • Other rabies issues - The McLean CHD assisted in arranging for doses needed for rabies PEP of several softball teams participating in a tournament in McLean County. The teams had been exposed to a rabid kitten in South Carolina during a softball tournament there.

Summary Bats were the main species identified with rabies in Illinois in 2007. Illinois was

139 one of six states reporting rabies in bats but not in terrestrial animals. Testing of skunks for rabies has declined in Illinois, thereby decreasing the reliability of surveillance of the terrestrial animal reservoir in the state. Local animal control jurisdictions are encouraged to increase submission of skunks for rabies testing to maintain surveillance in this species.

Suggested readings Bretous, L.M. et. al. Public health response to a rabid kitten-Four states, 2007. MMWR 2008;56(51-52):1337-1340. NASPHV. Compendium of Animal Rabies Prevention and Control. MMWR 2007;56(RR-3): 1-8. Oertli, E.H., et. al. Epidemiology of rabies in skunks in Texas. JAVMA 2009;234(5):616-620. Yee AH et al. Human rabies-Minnesota, 2007. MMWR 2008;57(17):460-2.

Figure 72. Trends in Animal Rabies Testing in Illinois, 1990-2007

2500 2000 1500 # skunks tested 1000 # bats tested 500 Number of of Number 0 animals tested

1990 1992 1994 1996 1998 2000 2002 2004 2006 Year

140 Table 6. Animal Rabies Testing in Illinois in 2007

Species Total number suitable for testing Total % positive positive

Bat 2,102 113 5.4

Cat 990 0 0

Cattle/buffalo 56 0 0

Dog 1,500 0 0

Coyote/fox/wolf 10 0 0

Ferret 6 0 0

Horse/donkey 29 0 0 Opossum 23 0 0

Raccoon 124 0 0

Rodents/lagomorphs 154 0 0

Sheep/goats 13 0 0

Skunk 134 0 0

Other* 42 0 0

TOTAL 5,183 113 2.2 *”Other” species tested in 2007 included alpaca, coatimundi, deer, elk, mink, kangaroo, shrew and zebra.

141 Table 7. Type of Exposure to Rabid Bats by Month, Illinois, 2007

Lab Date County Location where bat Human exposure? Animal exposure? number (2007) found 218643 2/8 Cook (Tinley Park) In house; caught with None None towel 218644 4/2 Whiteside (Fulton) Bat in church Yes, 1 person bitten Unknown while collecting bat 218645 4/16 Sangamon Bat in house None None (Springfield) 218655 5/10 Moultrie (Sullivan) Bat in house Yes, 1 person bitten Unknown 218656 5/10 Lake (Lake Villa) Found in/near garage; None None fell onto ground as door raised 218657 5/10 Logan (Lincoln) Unknown None Unknown 218655 5/14 Sangamon Found in house on wall None None (Springfield) 218659 5/16 Warren (Monmouth) Found dead on stairs None Yes, 1 cat locked in attic for a week 218660 5/20 Marion (Salem) Tried to pick up bat with Yes, 1 None bare hand 218661 5/20 Winnebago Bat found with dog None Yes, 1 dog (Rockford) outside 218662 5/22 Champaign (Urbana) Woke to find bat in room Yes, 1; completed None series 218663 5/22 Franklin (Benton) Found in park None None 218646 5/24 Cook (Arlington Found in bedroom Yes, 1 None Heights) 218647 5/30 LaSalle (Earlville) Bat in house in cat’s None Yes, 3 cats (2 mouth vaccinated, 1

142 unvaccinated) 218649 6/6 Whiteside (Morrison) Bat in tree None None 218650 6/6 McHenry Bat in basement None None (Woodstock) 218648 6/6 Cook (Winnetka) Bat in bedroom shortly Yes, 2 Unknown after she woke up 218652 6/14 McHenry (Crystal Bat flying in house None None Lake) 218653 6/14 McHenry Bat outside in bushes; None Yes, 1 cat (Woodstock) cat caught it 218651 6/14 Tazewell (Morton) Found dead in yard None None 218654 6/17 Peoria (Peoria) Found in bedroom Yes, 3 None 3230 6/19 Cook (Elgin) Unknown None Yes, 1 dog 218664 6/26 Lake (Antioch) Found outside in tree None Yes, 1 vaccinated dog 218665 6/27 McHenry Found in child’s Yes, 2 None (Woodstock) bedroom 218667 6/29 Lake (Antioch) Found under stairs in None Yes, 3 unvaccinated basement cats 218666 6/29 McHenry Found in bedroom Yes, 1 Yes, 1 dog sniffing bat (Woodstock) 218668 7/2 Lake (Ingleside) Found in backyard; died None None 218673 7/3 Kane (Elgin) Bat found in bedroom; Yes, 1 person with None flew at boy and physical physical contact contact 218669 7/4 Lake (Zion) Outside; hit with broom, None None boiling water then bleach 218671 7/9 Massac (Belknap) Outside Yes, 1 bitten while None painting house 218670 7/9 Mchenry Bat in home; while None Yes, 1 dog caught bat (Woodstock) remodeling

143 218672 7/12 Madison (Collinsville) Backyard None None 218674 7/16 Clinton (Trenton) Backyard Bat flew out of leaf None bag and physical contact 218675 7/17 Cook (Orland Park) Alive in bathtub None None 218676 7/18 Whiteside (Morrison) Found on porch None Yes, 1 vaccinated dog had bat in mouth 218678 7/24 Lake (Waukegan) On driveway None None 218677 7/24 Dupage (Oakbrook) Found outside Yes, 1 landscaper None bitten when he picked it up 218679 7/30 DuPage (Naperville) In home None None 218680 7/31 McHenry (Marengo) In home Yes, 1 had mark on Unknown wrist; not sleeping in room where bat was 218683 8/1 Will (Beecher) Bat flying in house near 4 received PEP None sleeping area 218682 8/2 Cook (Chicago) In building Yes, 1 218681 8/2 Mercer (Aledo) In room where sleeping 3 sleeping persons in people room with bat 218684 8/3 Lee (Amboy) In home None 2 cats; both euthanized and tested negative for rabies 218686 8/6 Will (New Lenox) Found outside None None 218685 8/6 Williamson (Stiritz) Found outside None Yes, vaccinated dog picked up bat 218687 8/6 Winnebago Bat found in bedroom 3 children (Rockford) 218696 8/7 Cook (Chicago) Unknown 2 persons given PEP None 218691 8/8 Winnebago Found in home None None

144 (Rockford) 218690 8/8 McHenry (Crystal On deck None None Lake) 218688 8/8 McHenry Bat in basement where 1 person None (Woodstock) sleeping 218703 8/9 Kane (Aurora) 1, bite to hand None 218694 8/9 Cook (Glencoe) In home None None 218689 8/10 Will (Naperville) Outside house None None 218697 8/11 Cook (Chicago) Bat found in bathroom 1 None 218698 8/12 Cook (Chicago) In house Yes, 4 None 218692 8/12 Warren (Monmouth) Dead bat in home None 2 cats in home 218693 8/12 Cook (Orland Park) Dead in pool None None 218707 8/13 Will (Bolingbrook) Found in pool None None 218708 8/13 Will (Joliet) Found in school hall None None 218700 8/15 Sangamon Outside office building 1, picked up bat with None (Springfield) bare hands; received PEP; only 2 doses needed 218699 8/13 Cook (Chicago) Found in room 6 persons sleeping in None room 218704 8/17 Cook (Glencoe) In house Unknown Unknown 218701 8/17 Cook (Chicago) In bedroom with mother 3 Unknown 218702 8/17 Cook (Chicago) Found in apartment None Unknown complex hall 218705 8/17 Cook (Winnetka) Found in home Unknown Possible cat exposure 218706 8/17 Cook (Des Plaines) Found in home Unknown None 218709 8/21 Madison In bathroom Yes, 1 physical None (Edwardsville) contact with bat 218710 8/20 Winnebago In bedroom of mother Yes, 2; one sleeping None (Rockford) in room; one physical 145 contact 8/20 Grundy (Morris) Found in church None None 218711 8/21 Lee (Dixon) Bat in home 3 persons receiving Dogs in crates PEP; no known exposure 218713 8/21 Kane (Aurora) Bat flying around Yes, 1 bedroom 218715 8/23 Kane (Aurora) Bat flying in bedroom Yes, 4 received PEP; Dog smelled bat all in bedroom sleeping 218716 8/23 Cook (Chicago) Unknown None None 218714 8/23 McHenry (Harvard) In yard; owner killed bat None None 8/23 Cook (Midlothian) Bat found in basement No, 1 received PEP, Unknown no one in room sleeping 218716 8/25 Cook (Chicago) None; put box over None bat 218717 8/26 Cook (Chicago) Bat in living room Yes, 2 None 218710 8/28 Winnebago Unknown None None (Caledonia)

218729 8/28 Will (New Lenox) Found in office None None 281723 8/30 Lake (Libertyville) Unknown Unknown Unknown 218724 8/30 Cook (Mt Prospect) Bat in home Unknown Unknown 218726 8/30 Cook (Mt Prospect) Bat in home Unknown Unknown 218725 8/30 Cook (Schaumburg) Bat in home Unknown Unknown 218729 8/30 Will (New Lenox) Bat in park None None 218728 8/31 McHenry Bat flew in house thru None None (Woodstock) window 218727 9/1 Cook (Chicago) In apartment None None 146 218730 9/4 Champaign (Tolono) Found outside None Unvaccinated barn cat with bat in mouth 218731 9/4 Lee (Franklin Grove) Bat in bedroom 1 person bitten None 218733 9/4 Kane (Aurora) In bedroom 2, in room with bat None when sleeping; received PEP 218745 9/4 McHenry Unknown None Dog had bat found in (Woodstock) mouth 218734 9/5 Madison (Alton) Bat in home None None 218735 9/5 Sangamon Living room None None (Springfield) 218740 9/6 Effingham (Watson) Bat found on chicken None Chicken 218732 9/6 LaSalle (Mendota) Bat killed with pillow 1 person received Unknown PEP, only touched the pillow

218739 9/11 Will (Homer Glen) Hot tub None None 218742 9/11 Winnebago Outside residence None None (Rockford) 218741 9/12 Madison (Highland) Unknown None Unvaccinated cat caught and killed bat 218744 9/13 Will (Joliet) Swimming pool None Unknown 218743 9/17 Lake (Highland Park) Outside None None 218749 9/22 Mclean (Normal) Found outside on screen None None door 218751 9/22 Wiliamson Brought to person by None 2 vaccinated dogs; one (Thompsonville) dog had bat in mouth 218746 9/24 Lake (Antioch) Kitchen None None 218747 9/25 Will (Godley) Found in yard None None 218748 9/25 Sangamon Bat in house None None

147 (Springfield) 218750 9/25 McHenry (Algonquin) Unknown None None 218752 9/26 Madison Unknown None Unknown (Edwardsville) 218753 10/1 Will (Homer Glen) Found outside building None None 218755 10/9 Cook (Arlington House None Unvaccinated dog Heights) 218756 10/20 Mclean Found in basement None None (Bloomington) 218757 10/26 Cook (Chicago) Found outside None Vaccinated dog sniffed or picked up bat; did not receive booster 218758 10/30 Cook (Palos Heights) Found in forest preserve None None 218759 10/30 Jackson Outside None None (Carbondale) 218760 11/13 Lee (Amboy) Found in basement None None

148 Figure 73. Animal rabies cases in Illinois by County, 2007

149 Table 8. Bat Speciation Results from Bats Submitted for Rabies Testing in 2007

Species Common Name # testing neg. # testing pos. # unsatisfactory Eptesicus Big brown bat 1436 87 29 fuscus Lasiurus Eastern Red bat 154 14 7 borealis Lasiurus Hoary bat 20 3 0 cinereus Lasionycteris Silver-haired bat 270 3 2 noctivagans Pipistrellus Eastern 9 1 1 subflavus pipistrelle Myotis Little brown bat 45 1 3 lucifugus Myotis Northern long- 39 1 1 septentrionalis eared bat Nycticeius Evening bat 10 0 0 humeralis Myotis sodalis Indiana bat 0 0 0 Myotis Gray bat 0 0 0 grisescens Corynorhinus Rafinesque’s 0 0 0 rafinesquii big-eared bat Myotis Southeastern 0 0 0 austroriparius bat Unknown 5 0 4 TOTAL 1988 110 47 Source: Illinois Natural History Survey

Figure 74. Bats Tested by Month in Illinois, 2007

800 50 700 40 600 500 30 Number of bats tested 400 Positive bats 300 20 200 10 100 0 0 Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

150 Table 9. Rabies Positivity Rate by Animal Species in Illinois, Selected Time Spans.

1971-2007 1991-2007

Species # tested # positive % positive # tested # positive % positive

Bat 16,997 805 4.74 11,824 503 4.25 Cat 46,574 141 0.30 19,576 4 0.02 Cattle 3,975 215 5.41 1,543 4 0.26 Dog 49,464 110 0.22 25,919 5 0.02 Fox 1,454 73 5.02 269 1 0.37 Horse 790 23 2.91 333 1 0.30 Mouse 4,770 0 0.00 725 0 0.00 Raccoon 10,027 17 0.17 3,745 0 0.00 Rat 1,896 0 0.00 386 0 0.00 Skunk 7,963 2,532 31.80 1,795 50 2.79 Squirrel 7,192 0 0.00 2,030 0 0.00

Source: Illinois Department of Public Health

Figure 75 . Skunk Rabies and Skunk Road Kill Index in Illinois, 1975-2007

600 6 400 4 index rabid 200 2 skunks Road kill kill Road

Number ofNumber 0 0

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 Year

Rabid skunk Road kill index

151 Rabies, potential human exposure

Background Exposures to animals, especially those involving bites or bat exposures, often result in the need for public health consultation on whether rabies post-exposure prophylaxis (PEP) is needed for the exposed individual. All animal bites in Illinois are reportable to local animal control for the purposes of following up with the owner of the biting animal. Animal control authorities are responsible for ensuring that dangerous animals are maintained so that they cannot injure the public. Potential human rabies exposures are reportable to human health including all instances when rabies post-exposure prophylaxis is initiated and all exposures to bats.

Case definition The definition of exposed person to be reported is: 1) Any contact (bite or non-bite) with a bat, or 2) Any contact (bite or non-bite) with an animal that subsequently tests positive for rabies virus infection, or 3) Anyone who was started on rabies post-exposure prophylaxis, or 4) Exposure to saliva from a bite, or contact of any abrasion or mucus membrane with brain tissue or cerebrospinal fluid of any suspect rabid animal. Exposure to healthy rabbits, small rodents, indoor-only pets or rabies-vaccinated dogs, cats or ferrets is excluded, unless the exposure complies with subsections (a)(1) through (a)(3) above, or the animal displays signs consistent with rabies.

Descriptive epidemiology The following information was obtained from Illinois National Electronic Disease Surveillance System and investigation forms obtained during the surveillance of rabies, potential human exposures (RPHE) in Illinois during 2007. The investigation forms had questions on demographics, exposure characteristics and rabies post-exposure treatment information. Not all local health jurisdictions have submitted investigation forms so this is a minimum estimate of the number of potential human rabies exposures in Illinois.

• Number of cases reported in Illinois in 2007 - There were 440 potential human rabies exposures reported. • Age – Ages ranged from less than one year of age to 93 years of age. The mean age of those exposed was 32 years. • Gender – Forty-nine percent of RPHE reports were in males. 152 • Seasonal peak – Higher numbers of exposures occurred in the summer months of May through August (Figure 76). • Geographic location – Forty-seven counties reported at least one RPHE. Sixty- six percent of exposures took place in urban settings. Counties reporting the most cases included McHenry (58), DuPage (53), Cook (35) and Kane (31).

Type of exposure Three types of exposures can be summarized from the reports: bite, non-bite (scratch or abrasion or contamination of open cuts with saliva or nervous tissue, bat present in room with sleeping person or physical contact with a bat where a bite cannot be ruled out) or non-exposure (petting, handling, blood contact, bat in room but no physical contact and no one asleep). Of the 433 exposures with information reported about type of exposure, 127 (29 percent) were due to animal bites, 238 (55 percent) from non-bite exposures and 68 (16 percent) no human exposure meeting ACIP guidelines for rabies PEP. Of the 100 bite exposures with the site of bite reported, most bites were to the arm or hand, 71 (71 percent), followed by leg or foot, 17 (17 percent), head or neck, 10 (10 percent) and torso, two (2 percent). The bite site was not indicated for 27 bite exposures. Of the 233 non-bite exposures due to bats, bats were found in the room with a sleeping person in 198 (85 percent) of exposures, physical contact with a bat took place in 26 (11 percent) of exposures, a young child or an adult with dementia was unobserved with a bat in two (0.8 percent) and bat was in a house but not in sleeping area (2 percent). Other non-bite exposures included bat hissing at person and someone with marks on the body after sleeping. Bats were tested in 63 (27 percent) of the non- bite bat situations. Thirty-three bats tested negative, 26 tested positive and four specimens were unsuitable for testing. The other non-bite exposures included exposure to saliva from raccoons (three).

Animals causing exposure The following information is by each individual person’s exposure history. Multiple individuals may have been exposed to a single animal. Of 429 known type of animals causing exposures, 380 (88 percent) were wild, not domesticated animals. The types of animals causing exposures included bat, 349 (81 percent); cat, 22 (5 percent); dog, 25 (6 percent); raccoon, 21 (5 percent) and other, 11 (2.5 percent). The type of animal was unknown for two exposure situations. Of the 49 domestic animals exposing persons, 25 (67 percent) were described as stray and 26 (32 percent) were owned. For 12 animals, the ownership was not described. Of the 25 dogs that exposed an individual, 20 (80 percent) of these animals had an unknown vaccination history, four (16 percent) were up-to-date on rabies vaccination and one (4 percent) was previously vaccinated but not up-to-date on rabies vaccinations. Rabies vaccination of dogs is required in Illinois. Of the 22 cats that exposed an individual, 18 (82 percent) of these animals had an unknown vaccination history and four (18 percent) were not rabies vaccinated. Twenty-six of 37 (70 percent) of bites from dogs and cats were provoked where the type of exposure was described.

153 For 49 domestic animal exposures, 35 of 42 (83 percent) were unavailable for either confinement or testing, two (5 percent) were tested for rabies and five (12 percent) were confined for observation. The outcome for seven domestic animals was not known. One (8 percent) of the 12 owned domestic animals were owned by the family of the person bitten and 11 (92 percent) were owned by another individual. There were 262 (70 percent) of 376 wild animals that were not available for confinement or testing. One hundred fourteen (30 percent) of animals potentially exposing someone to rabies were submitted for rabies testing. Four wild animals had an unknown disposition. Of the 114 wild animals submitted for rabies testing, 64 (56 percent) were negative, 44 (39 percent) were rabies positive and six (5 percent) were unsuitable for testing. Forty-four people were exposed to known rabid bats. The specimens that were unsuitable for testing were from five bats and one coyote. In 20 exposures, the exposing animal was reported to exhibit signs of rabies. Signs of rabies included aggression, three (15 percent); no fear of humans, six (30 percent); impaired locomotion, five (25 percent); other, four (20 percent) and multiple, two (10 percent).

Rabies post-exposure prophylaxis (PEP) During 2007, 377 persons were reported to have started rabies PEP. The first recommendation about whether rabies PEP was needed for a person starting rabies PEP came from the following sources: public health personnel, 188 (51 percent), health care provider, 179 (49 percent) and other, one (0.3 percent). For nine cases the source of the recommendation was not known. The final recommendation on rabies PEP for those starting rabies PEP came from public health personnel, 192 (52 percent); health care provider, 175 (48 percent) and other, one (0.3 percent). For nine exposed persons receiving PEP, the source of the final recommendation was not known. For 229 (76 percent) of 303 persons with information available, rabies PEP was completed in an emergency department followed by completion in a physician’s office, 54 (18 percent) and completion at a local health department, 20 (7 percent). Most rabies PEP was paid for by private insurance, 144 (77 percent), followed by Medicare or Medicaid, 24 (13 percent), no payment source, 10 (5 percent), worker’s compensation, three (2 percent) and out-of-pocket expense, seven (4 percent). Payment source was unknown for 189 persons. Sixteen of 381 (4 percent) of persons recommended for rabies PEP refused to be treated. None developed rabies. Rabies PEP was completed in 305 (82 percent) of 374 persons for whom information was available. In 44 persons (12 percent), rabies PEP was not completed. In 25 persons rabies PEP was not completed because the animal was tested negative. Of these 25 situations, 22 were bat exposures, two were raccoon exposures, and one was a cat exposure. The rabies PEP recommendation for 40 of these persons was made mainly by health care providers (24 situations), followed by public health departments (16). In three (7 percent) of situations, the animal was a low-risk species, in eight (19 percent) of situations the patient refused to complete treatment, in four situations the person was lost to follow-up, in two situations the animal survived the confinement period, in one situation the person had a reaction to the vaccine and the

154 reason was unknown for one person. Decisions on rabies PEP should be based on the Advisory Committee on Immunization Practices (ACIP) guidelines. For 420 exposed persons, it was possible to determine if the PEP recommendation followed ACIP guidelines. For 287 (68 percent) of these persons, rabies PEP was recommended and the recommendation followed ACIP guidelines. For 94 (22 percent) of persons, rabies PEP was recommended but this was not correct according to ACIP guidelines. For 39 persons (9 percent), rabies PEP was not recommended and that was correct according to ACIP. There were no persons for whom PEP was not recommended and that was an incorrect recommendation. In 94 situations, PEP was recommended incorrectly. In 48 situations, PEP was recommended when a bat was found in a building, even though no one was sleeping in the room and no one was exposed who was unable to accurately report an exposure. The ACIP recommends rabies PEP if the bat is found in a room with a sleeping person or person who is unable to say whether they were bitten. In 23 situations an animal that exposed someone tested negative for rabies but PEP was started. Because the turnaround time is rapid for rabies testing, PEP can be delayed until the testing of the animal takes place. Because of the lack of terrestrial animal rabies in the last few years in Illinois, no rabies PEP would be recommended if the dog or cat bite was provoked and the animal showed no signs of rabies. In 18 situations, persons were recommended for PEP even though a domestic animal exposed the person with a provoked bite and was not acting abnormally. In three situations a low risk animal, rodent or opossum, bit someone and PEP was recommended. In two situations persons who were not exposed to saliva or neurologic tissue were incorrectly recommended for rabies PEP. Of the 377 persons who started rabies PEP, 305 of 349 (87 percent) completed rabies PEP. For 70 of 188 (37 percent) persons completing rabies PEP and with information available, the ACIP rabies protocol was followed exactly. There were 118 people who had incorrect administration of rabies PEP. Types of incorrect administration were incorrect timing of injections (89, 75 percent), multiple problems (17, 14 percent), no RIG given (two, 2 percent), incorrect site of administration of injections (seven, 6 percent) and other (three, 2 percent). Eight persons started on rabies PEP had been pre-exposure immunized for rabies. There were seven persons exposed outside the United States and 13 exposed outside Illinois but within the United States.

Summary There is vast underreporting of potential human rabies exposures in Illinois with some jurisdictions not reporting any exposures. Therefore, the summary information is not a complete picture of human rabies exposures in Illinois. Twenty-nine percent of reported exposures were due to bites. Most bites were to the hand or arm which is typical as persons reach to pick up or handle an unfamiliar animal. Of the non-bite exposures, 85 percent of reported exposures were from bats found in a room with a sleeping person. Education of the public and animal control personnel could result in increased submission of bats that have exposed person in homes being tested for rabies. If the bat tests negative, the person would not need rabies PEP.

155 The main animal causing potential human rabies exposures was the bat, followed by the cat, dog and raccoon. This is primarily due to the definition of possible rabies exposure to a bat. The bat is the only wild mammal where rabies PEP is recommended if a person is in a room sleeping where a bat is found and it cannot be tested, or tests positive. Forty-eight percent of final rabies PEP recommendations were made by emergency department health care providers or other health care providers. This indicates the importance of providing health care providers with up-to-date information on rabies incidence in their area and on rabies PEP recommendations. Twenty-two percent of the rabies PEP given in 2007 would not have been indicated according to public health guidelines. In some situations persons were started on rabies PEP even though the animal was available for testing. Health care providers, especially in emergency departments, should be advised that rabies testing of animals can be completed rapidly at the state laboratories, and, if necessary, emergency testing can be requested for high priority specimens on holidays or weekends. For emergency testing, health care providers can contact local health department personnel or use the state emergency phone number if it is after hours. Rabies PEP can be delayed until testing is completed if testing is prompt. The rabies PEP protocol is provided in, “Human Rabies Prevention-United States, 1999. Recommendations of the Advisory Committee on Immunization Practices (ACIP): MMWR 1999;48(RR-1)”. In 37 percent of cases where rabies PEP was completed, PEP was administered correctly. Common errors in administration included incorrect timing of injections and forgetting to administer RIG. The ACIP recommendation for rabies PEP should be adhered to when administering rabies PEP. It can be difficult to get exposed individuals to adhere to a complicated vaccination schedule but the person should be informed about the universally fatal nature of rabies and the importance of adhering to the ACIP schedule.

Figure 76. Rabies, Potential Human Exposure Cases in Illinois by Month, 2007

200 150 100 50 0 Number of cases Numberof Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month

156 Rocky Mountain spotted fever

Background Rocky Mountain spotted fever (RMSF) is the most frequently reported fatal tick- borne disease in the United States. RMSF has been reported throughout the continental United States. The causative agent is rickettsii. Both dogs and humans may experience clinical illness due to RMSF. In 2007, 2,221 human cases were reported nationally to the CDC. Most cases are reported from April through September when the greatest number of Dermacentor ticks are present in the environment. The ticks that are most likely to transmit RMSF include the American dog tick (Dermacentor variabilis) in the central United States. Only about 1 percent to 5 percent of ticks are usually infected with R. rickettsii in an area where transmission to humans occurs. In order for one of these ticks to transmit the bacteria, it must be attached for at least four to six hours. A history of a tick bite can be elicited in approximately 60 percent of RMSF cases. The incubation period for RMSF is three to 14 days after a tick bite. Common presenting symptoms include high fever, severe headache, deep myalgias, fatigue, chills and . A rash typically appears within two to four days after onset of fever. The rash typically begins on the ankles, wrists or forearms. A rash can be atypical or absent in up to 20 percent of RMSF cases. Starting most often on the ankles and wrists, the rash then appears on the trunk, palms and soles. Patients also may have gastrointestinal signs such as abdominal pain and nausea which may be serious enough to lead to an erroneous diagnosis such as appendicitis. RMSF can have a case fatality rate of 20 percent in untreated persons, while the case fatality rate is 5 percent in treated persons.

Case definition The case definition for a confirmed case of RMSF in Illinois is a clinically compatible illness that is laboratory-confirmed. The laboratory confirmation is a four-fold or greater rise in antibody titer by immunofluorescent antibody (IFA), complement fixation (CF), latex agglutination (LA), microagglutination (MA) or indirect hemagglutination antibody (IHA) test in acute and convalescent specimens ideally taken more than three weeks apart; or demonstration of positive immunofluorescence of a skin lesion or organ tissue, positive polymerase chain reaction or isolation of R. rickettsii from a clinical specimen. A clinically compatible illness is one characterized by acute onset and fever, usually followed by myalgia, headache and petechial rash. A probable case is defined as a clinically compatible case with a single IFA serologic titer of at least 64 or a single CF titer of at least 16 or other supportive serology (four-fold rise in titer or a single titer at least 320 by Proteus OX-19 or OX-2, or a single titer at least 128 by an LA, IHA or MA test).

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – There were 39 cases; all were probable cases. (five-year median = 12)

157 • Age - Cases ranged in age from two to 78 years of age (mean = 38 years). • Gender – Twenty-one cases were male (54 percent). • Race/ethnicity – Thirty-five cases were white, two reported other race; and three cases had unknown race; No cases were Hispanic. • Geographic distribution – Fifty-four percent of the cases resided in the southern Illinois region. • Seasonal variation - Onsets of the cases ranged from February to November (Figure 77). An increase in cases occurred from April to October (35 cases). • Symptoms/outcomes – Symptoms reported by cases included fever in 28 cases (78 percent), rash in 24 cases (73 percent), headache in 24 cases (65 percent) thrombocytopenia in four cases (15 percent) and neurologic in one case (3 percent). Sixteen of 38 cases (42 percent) were hospitalized. No cases were fatal. • Tick exposure – Twenty-five of 32 (78 percent) of cases with a tick habitat history reported being in a tick habitat. Of the persons who reported the type of tick habitat, the following location types were reported: own property (11), farm (five), park or nature preserve (three) and campground (two). Ten cases did not report the type of location. Eighteen of 35 cases (51 percent) reported a history of a tick bite. Twenty-nine cases reported exposures within Illinois. Tick exposures took place primarily in the Marion region of southern Illinois (65 percent) followed by the Edwardsville region (24 percent). One case each reported exposure in the following regions, Rockford, Champaign and Peoria. Five cases reported out of state exposures, Kentucky (two) and one each in Arkansas, Kentucky, Missouri and multiple states. Five cases had unknown exposure histories. • Reporting – The majority of cases were reported by laboratories (67 percent). • Past incidence - Rocky Mountain spotted fever cases reported per year in the state were: 1991 (five), 1992 (two), 1993 (four), 1994 (11), 1995 (10), 1996 (four), 1997 (three), 1998 (one), 1999 (seven), 2000 (five), 2001 (12), 2002 (12), 2003 (five), 2004 (14), 2005 (11) and 2006 (26).

Summary Most cases of RMSF occurred in summer months primarily in southern Illinois. The number of cases was more than three times higher than the five-year median.

Figure 77. Rocky Mountain spotted fever Cases in Illinois by Month, 2007

8 6 4 2 0 Number of cases Numberof Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month

158 Rubella Background Rubella or German measles usually causes a mild febrile illness. Adults may experience fever, coryza and conjunctivitis. The incubation period ranges from 14 to 21 days. Rubella can also cause anomalies in a developing fetus. Twelve cases were reported to CDC from eight states or territories in 2007.

Case definition A confirmed is a case that is laboratory confirmed (isolation of rubella virus or significant rise in titer between acute and convalescent titers or a positive IgM serologic test or that is clinically compatible with all the following characteristics:

• Acute onset of generalized maculopapular rash • Temperature greater than 99.0 F (greater than 37.2 C), if measured • Arthralgia/arthritis, lymphadenopathy, or conjunctivitis

and is epidemiologically linked to a confirmed case.

A probable case is one that meets the clinical case definition, had no or noncontributory serologic or virologic testing, and is not epidemiologically linked to a laboratory- confirmed case.

Descriptive Epidemiology Number of cases in Illinois in 2007 – One case was reported. Individual case description • The case was a 34-year-old visiting Chicago from Russia. He had onset of rash illness in March. He also had cough, coryza and conjunctivitis.The infection was acquired overseas. He was a confirmed case and serologically positive.

Summary A single imported case of rubella was reported in a traveler to Illinois.

159 Salmonellosis (Non-typhoidal)

Background There are more than 2,400 serovars of Salmonella. However, approximately 50 percent of human cases are caused by three serovars: Salmonella enterica ser Enteritidis, S. ser Typhimurium and S. ser Newport. Transmission to humans is usually after consumption of contaminated food products. Raw or undercooked meat, eggs, raw milk, and poultry have been identified as vehicles for Salmonella infection. Fresh produce, such as lettuce, unpasteurized apple or orange juice or sprouts also have caused outbreaks. Hospital and commercial laboratories are required to submit isolates of Salmonella to the Department’s laboratory for serotyping. This is necessary to detect increases in specific serotypes. Identification of serotypes is useful in determining which patients are likely linked to a common source of infection. Another way to link Salmonella isolates to a common source is pulse field gel electrophoresis (PFGE). A new laboratory technique for subtyping isolates is multiple-locus variable-number tandem repeats analysis (MLVA), may prove to be useful in surveillance and outbreak investigation. This technique is currently available at CDC. In the United States national surveillance data, 47,995 cases were reported to CDC in 2007. The majority of cases occurred in persons younger than five years of age. Seven serotypes comprised 62 percent of infections: Enteritidis (17 percent), Typhimurium (16 percent), Newport (10 percent), I 4,5,12:i:- (6 percent), Javiana (5 percent), Heidelberg (4 percent) and Montevideo (3 percent). The 2010 National Health objective is 6.8 per 100,000. Overall the incidence did not change from the 2004 to 2006 incidence. The incidence of Typhimurium and Heidelberg decreased and I 4,5,12:i- and Newport increased. Of the 10 diseases/syndromes (those caused by Campylobacter, Cryptosporidium, Cyclospora, shiga toxin producing E. coli O157:H7, HUS, Listeria monocytogenes, Salmonella, Shigella, Vibrio and Yersinia enterocolitica) under active surveillance in the federal FoodNet sites, Salmonella comprised 41 percent of the reported infections in 2007. The incidence rate was 14.9 per 100,000 and ranged from 8.5 to 21.4 at the 10 FoodNet sites in 2007. In data from 2007, 94 percent of isolates were serotyped. The top seven serotypes were: Enteritidis (16 percent), Typhimurium (15 percent), Newport (10 percent) and I 4,[5],12:i:- (5 percent). Multi-state otbreaks from contaminated peanut butter, frozen pot pies and a puffed vegetable snack occurred in 2007. In the United States national surveillance data, 47, 995 cases of Salmonella were reported to CDC in 2007. Serotypes Typhimurium and Enteritidis are the most common. Multi-state outbreaks of Salmonella occurred in 2007. Sixty-nine patients from 23 states with S. ser. Wandsworth had illness strongly associated with consumption of a ready-to-eat puffed snack food. The organism was isolated from product and ill patients and matched by PFGE. An outbreak of S. ser. Schwarzengrund occurred in persons and was linked to exposure to contaminated dry dog food. A case-control study linked illness to buying the dry dog food. The organism was found in dog stool from one household where human cases resided and with the suspect dog food. The outbreak strain was identified in environmental samples from the plant producing the dog food and from previously

160 unopened dry dog food. The product was recalled. A multi-state outbreak of S. ser. Paratyphi B var. Java occurred following exposure to small turtles in 2007 and 2008. Water samples from turtle habitat were also positive for the same strain. Eighty-six percent of turtles in households involved in a case-control study were less than four inches. One third of the turtles were purchased at pet stores and one-quarter were received as gifts. An outbreak of Salmonella was linked to consumption of raw milk and cheese in Pennsylvania. The bulk milk tank was also positive for the same strain of Salmonella. In a study in Washington state, risk factors associated with sporadic Salmonella infection included exposure to aquatic recreation, using private wells and residential septic systems and raw sprout consumption.

Case definition The case definition for a confirmed case is isolation of Salmonella from a clinical specimen. The case definition for a probable case is a person who has a clinically compatible illness that is epidemiologically linked to a confirmed case, but is not laboratory-confirmed. A case that is cultured at a commercial or hospital laboratory is counted as a probable case if the isolate is not forwarded to the state laboratory for confirmation.

Descriptive epidemiology

• Number of cases reported in Ilinois in 2007- There were 1,966 cases reported (five- year median = 1,770) (see Figure 78). Fifty-three cases were probable, the rest were confirmed. The annual incidence rate for salmonellosis in Illinois in 2007 was 16 per 100,000 population. • Age – Salmonellosis occurred in all age groups (mean age = 33) (see Figure 79). However, the incidence rate was highest in those younger than 1 year of age (70 cases per 100,000 population), followed by those in the 1 to 4 year age group (33 per 100,000). • Gender – Fifty-four percent were female. • Race/ethnicity – Eighty-two percent of cases were white, 13 percent African American and 15 percent other races; Twenty percent were Hispanic. • Seasonal variation - A peak in salmonellosis cases occurred in the summer months, especially July (Figure 80). • Geographic distribution – For 2007, the counties with the highest incidence per 100,000 population were Jasper (49), Kendall (46), Hardin (42), Kankakee (37), Scott (36) and Kane (33). • Serotypes - Ninety-six percent of Illinois’ Salmonella isolates were serotyped. The most common serotypes in 2007 are found in Table 10. The three most common serotypes were S. ser.Typhimurium (377, 20 per cent), S. ser. Enteritidis (331, 17 percent) and S. ser. Heidelberg (224, 12 percent). Serotypes of Salmonella found in Illinois from 1999-2007 are shown in Table 11. • Clinical syndrome – Cases reported diarrhea (93 percent), fever (68 percent) and vomiting (39 percent). Thirty-three percent were admitted to the hospital. Two deaths 161 were attributed to Salmonella and an additional eight persons died with Salmonella. • Site of isolation – The sites of isolation for cases include stool or rectal swab (1,279 cases), urine (70), blood (67), wound or abscess (six), other (11), multiple sites (24) and unknown (456). The other sites included peritoneal fluid (two), synovial (two), bronchial wash (one), gall bladder (one), vagina or uterus (three), tissue, unspecified (one) and skull plate (one). There are many unknown sites because many Salmonella laboratory results with electronic transmission have isolate as the site where the isolate was obtained. • Risk factors – Animal contact • Contact with animals was reported from 630 of 1,448 (43 percent) of cases. A history of reptile or amphibian contact was reported by 85 Salmonella cases in 2007, but a link between the reptiles and transmission of the infection was not confirmed by culture of reptiles or amphibians. • Cases reported contact with the following types of reptiles or amphibians: turtles (25), lizards (17), snakes (11), frog/toad (two), alligator (one), not specified (16) and multiple types (12). Two of the turtles were known to be less than four inches. • For those with reported reptile or amphibian contact, the mean age was 18 years; 24 cases were younger than five years of age. • Males accounted for 52 percent of the cases. • The two most common species in these cases were Enteritidis (15) and Typhimurium (12).

Travel exposure o Of the 1,494 cases with information available, 160 cases (11 percent) reported travel to another country. The most common destination was Mexico (78 cases), followed by India (14) and Dominican Republic (seven). Traveling to another state was reported by 125 (8 percent) of the cases. Wisconsin (22 cases), Florida (13) and Michigan (10) were the most common states visited. Most S. ser. Paratyphi A cases were acquired overseas (Table 12). Almost a quarter of S. ser. Enteritidis cases were acquired outside the United States.

Swimming exposure o Eighty-nine of 1,533 cases (6 percent) reported swimming in non-chlorinated water and 161 of 1505 cases (11 percent) reported swimming in chlorinated water. Seventy-five cases reported drinking well water.

Residential or day care exposure o One-hundred and sixty-nine of 1,562 cases (11 percent) reported contact with a residential facility and 108 of cases (7 percent) reported contact with a day care. o Thirty-one cases attended a day care and six cases lived in a residential facility.

162 Sensitive occupations o Sensitive occupations reported by cases included health care worker (37), food service facility worker (33), residential facility (three), day care center (two) and other sensitive occupations (34). • Reporters – Cases were reported primarily by laboratory staff (48 percent) followed by infection control professionals (45 percent) and health clinic staff (3 percent). • Outbreaks - There were 12 confirmed foodborne outbreaks of Salmonella reported in 2007. (See the section of this report detailing foodborne outbreaks for more details.). There were two multi-state outbreaks due to animal contact and one Salmonella outbreak with an unknown mode of transmission (See the section of this report detailing non foodborne non waterborne outbreaks). No person-to-person outbreaks were reported due to Salmonella.

Summary In 2007, 1,966 cases of Salmonella were reported in Illinois. The one-year incidence rate of Salmonella for 2007 was 16 per 100,000 population, which is higher than the average incidence reported at CDC’s FoodNet sites (15 per 100,000). The mean age for Salmonella cases was 33 years, although the incidence was highest in those younger than one year of age. Salmonella cases increased in Illinois during the summer. The percentage of isolates that were serotyped in Illinois was 96 percent as compared to 94 percent in the FoodNet sites. The percentages of the three most common serotypes were Typhimurium (20 percent) and Enteritidis (17 percent), and Heidelberg (12 percent). A higher proportion of Illinois isolates serotyped in Illinois were S. ser. Heidelberg (12 percent) as compared to 2007 FoodNet data (4 percent). This was due to a large S. ser. Heidelberg outbreak that occurred in Illinois, with 191 laboratory confirmed cases. The proportions of S. ser. Typhimurium (20 percent) was higher and S. ser. Enteritidis was the same percent as reported by the 2007 FoodNet data for those serotypes. Reptile or amphibian contact was reported in 24 cases younger than 5 years of age. CDC recommends that households with children younger than 5 years of age not have reptiles as pets.

Suggested readings Austin, C. et al. Outbreak of multidrug-resistant Salmonella enterica serotype Newport Infections associated with consumption of unpasteurized Mexican-style aged cheese – Illinois, March 2006-April 2007. MMWR 2008; 57(16):432-35. Bergmire-Sweat, D., et. al. Multistate outbreak of human Salmonella infections associated with exposure to turtles-United States, 2007-1008. Centers for Disease Control and Prevention. FoodNet 2007 Surveillance Report. Atlanta, GA. U.S. Department of Health and Human Services, 2009. Denno, D.M., et. al. Tri-county comprehensive assessment of risk factors for sporadic reportable bacterial enteric infection in children. JID 2009;199:467-476. Ferraro, A., et. al. Multistate outbreak of human Salmonella infections caused by contaminated dry dog food-United States, 2006-2007. MMWR 2008;57(19):521-24. Vugia, D., et. al. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food-10 states, 2007. MMWR 2008; 57(140:

163 366-69. Salmonella Typhimurium infection associated with raw milk and cheese consumption-Pennsylvania, 2007. MMWR 2007;56(44):1161-64.

Figure 78. Salmonella Cases in Illinois, 2002-2007

2500 1966 1770 1955 1837 2000 1612 1603 1500 1000 500

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 79 . Salmonella Cases in Illinois by Age Group, 2007

80 60 Male 40 Female 20 0 Incidence per 100,000 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Age Group

Figure 80. Salmonella Cases in Illinois by Month, 2007

500 400 300 200 100

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month

164 Table 10. Top 10 Salmonella Serotypes in Illinois, 2007.

Serotype Frequency Serotype Frequency

Typhimurium 377 I 4,5,12:i- 46

Enteritidis 331 Infantis 45

Heidelberg 224 Montevideo 42

Newport 131 Oranienberg 39

Muenchen 95 Agona 34

Source: Illinois Department of Public Health Table 11. Frequency of Salmonella Serotypes in Illinois, 1999-2007 Serotype 1999 2000 2001 2002 2003 2004 2005 2006 2007 45:G-Z51:- 0 0 0 0 0 0 0 0 2 Aberdeen 0 1 0 0 0 0 1 0 2 Abony 0 0 0 0 0 0 0 1 0 Adelaide 3 1 4 0 6 5 9 5 15 Agbeny 0 0 0 0 0 0 0 1 6 Agona 48 27 14 20 16 22 33 29 34 Agoueve 0 0 0 0 0 0 0 1 0 Alachua 1 2 0 1 1 0 0 1 0 Albany 2 0 1 0 0 1 2 1 0 Altona 0 0 0 0 0 0 0 0 1 Amager 0 0 0 0 0 0 0 0 1 Amsterdam 0 0 0 0 0 0 2 1 0 Anatum 7 9 10 9 15 18 13 15 18 Antsalova 0 0 0 0 0 1 0 0 0 Apapa 0 0 0 0 0 1 0 0 0 Arizonae 1 4 2 3 1 2 2 4 1 Austin 0 1 0 0 0 0 0 0 0 Baildon 0 0 0 1 2 0 1 0 0 Bareilly 6 5 7 5 1 1 6 5 2 Barranquilla 0 0 0 0 0 0 0 2 0 Berta 9 25 41 19 23 19 17 17 13 Bledgam 0 0 0 0 0 0 0 1 0 Blockley 4 5 1 3 2 0 2 2 1 Bonariensi 1 0 1 1 0 0 0 0 1 Bovis-morb 5 7 3 2 7 3 2 5 8 Braenderup 28 18 16 21 32 79 36 25 19 Brandenburg 5 5 9 2 12 2 14 8 7 165 Bredeney 0 0 2 1 4 2 2 1 0 Carmel 0 0 0 0 0 2 0 0 1 Carrau 0 0 0 0 0 0 1 1 0 Cerro 0 1 0 0 0 2 2 0 1 Chailey 0 2 0 0 0 1 0 0 0 Chameleon 1 1 0 1 0 0 0 0 0 Chester 3 3 6 1 2 0 0 1 2 Cholerae-suis 7 4 2 1 2 2 1 1 3 Serotype 1999 2000 2001 2002 2003 2004 2005 2006 2007 Coeln 0 0 0 0 0 0 0 1 0 Colindale 0 0 2 0 0 1 0 0 1 Concord 0 0 0 0 0 0 0 1 0 Corvallis 0 0 0 0 0 0 0 1 1 Cotham 0 0 0 0 1 0 1 1 1 Cubana 0 1 2 1 0 1 0 0 0 Dahra 0 0 0 0 0 0 0 0 1 Derby 14 14 9 14 5 10 16 16 18 Dublin 0 0 0 1 0 2 4 2 0 Durban 0 0 0 0 0 3 0 0 0 Durham 0 0 1 1 0 0 0 0 0 Ealing 1 0 0 0 0 0 0 2 0 Eastbourne 1 1 0 0 0 0 2 1 2 Edinburg 0 0 0 0 3 2 4 0 0 Emek 1 0 0 0 2 0 0 2 0 Enteritidis 264 262 246 376 207 236 325 309 331 Finkenwerd 1 0 0 0 0 0 0 0 0 Flint 2 0 1 0 0 0 0 0 0 Fluntern 0 0 0 0 0 1 0 1 2 Freetown 0 0 0 0 1 3 1 0 0 Gaminara 1 0 2 1 2 0 0 2 1 Give 4 1 1 7 2 3 5 2 5 Goverdhan 0 0 0 0 0 0 0 0 1 Grumpensis 0 0 0 0 0 0 5 0 0 Guinea 0 0 0 0 1 0 0 0 0 Haardt 0 0 1 0 0 1 1 0 0 Hadar 15 26 8 16 18 16 8 19 14 Haifa 0 1 0 0 0 0 0 2 0 Hartford 16 18 15 22 9 9 9 20 10 Hato 0 0 0 0 0 0 0 0 2 Havana 2 2 1 2 1 4 2 1 2 Heidelberg 101 101 66 171 113 79 93 80 224 Herston 0 0 0 1 0 0 0 0 0 Hull 0 1 0 0 0 0 0 1 0 Hvittingfoss 1 3 1 4 0 2 0 1 2 I rough:b:1,2 0 0 0 0 0 0 0 0 1 I rough:d:l,w 0 0 0 0 0 0 0 1 0 I rough:e,h: 0 0 0 0 0 0 0 1 0 e,n,z,15 I rough:r:1,5 0 0 0 0 0 0 0 1 0 I 1,4,12,i:- 0 0 0 0 0 0 0 0 12 I 1,4,5,12:b:- 0 0 0 0 0 0 0 0 5 I 4,5: nonmotile 0 0 0 0 0 0 0 1 0

166 Monophasic, 0 0 0 0 0 0 42 13 0 4,5,12:b I 4,5,12:b:- 0 0 0 0 0 0 0 3 14 I 4,5,12:i:- 0 0 0 0 0 0 0 0 46 I 4,12:i:- 0 0 0 0 0 0 0 0 2 Monophasic, I 0 0 0 0 0 0 0 1 0 4,12,i I 4,12,:H to 0 0 0 0 0 0 0 1 0 rough to type Serotype 1999 2000 2001 2002 2003 2004 2005 2006 2007 I 6,7:r:- 0 0 0 0 0 0 0 0 1 I 6,8:d:- 0 0 0 0 0 0 0 0 1 I 9,12:-:1,5 0 0 0 0 0 0 0 0 1 I 9,12:lv:- 0 0 0 0 0 0 0 0 1 I 47:Z4Z23 0 0 0 0 0 0 0 1 0 II rough:b:e,n, 0 0 0 0 0 0 0 1 0 x,z15 II 21:z10:{z6} 0 0 0 0 0 0 0 0 1 II 50:b:z6 0 0 0 0 0 0 0 0 1 IIIa 0 0 0 0 0 0 0 1 0 13,22:z4z23:- IIIa 53:z4,z23:- 0 0 0 0 0 0 0 0 1 IIIb 53:z52:z53 0 0 0 0 0 0 0 0 1 IIIb 61:-:1,5 0 0 0 0 0 0 0 0 1 IIIb 0 0 0 0 0 0 0 0 1 rough:z10:z35 IV 16:z4,z32:- 0 0 0 0 0 0 0 0 2 IV 44:z36,(z38):- 0 0 0 0 0 0 0 0 1 IV 48:g,z51:- 2 3 3 2 3 2 2 0 5 (formerly marina) Ibadan 0 0 0 0 0 0 0 2 0 Indiana 2 0 0 2 0 0 1 0 0 Infantis 51 38 35 30 130 96 35 30 45 Inverness 1 0 0 2 0 1 0 1 0 Irumu 0 0 0 0 1 0 0 0 0 Istanbul 0 0 0 0 0 0 0 0 1 Jangwani 0 0 0 1 0 0 0 0 1 Java 41 35 24 7 1 0 9 8 3 Javiana 27 24 17 19 263 24 16 11 20 Johannesburg 6 3 3 1 0 0 2 3 2 Kentucky 4 1 3 1 2 1 2 0 3 Kiambu 1 2 2 5 1 1 2 3 0 Kingabwa 0 0 1 0 0 0 0 0 0 Kintambo 0 0 1 0 0 0 0 1 0 Kottbus 0 0 2 0 0 1 1 0 0 Kua 0 0 1 1 0 0 0 0 0 Limete 0 0 0 0 0 0 0 1 0 Lindern 0 0 0 0 0 0 1 0 0 Litchfield 10 9 9 7 13 8 5 5 16 Livingstone 0 0 1 1 1 0 0 0 0 Lome 0 0 0 0 0 0 0 0 0 Lomalinda 0 2 0 9 0 0 1 0 0 Lomita 0 0 0 0 0 1 0 0 0 167 London 3 4 0 1 3 4 1 4 1 Manhattan 4 8 4 3 1 4 2 2 11 Marina 2 3 3 2 3 2 0 0 0 Matadi 0 0 0 0 2 0 0 0 0 Mbandaka 10 7 7 5 6 6 9 24 16 Meleagridis 0 0 0 0 2 0 1 3 1 Miami 4 2 4 2 4 1 2 1 0 Serotype 1999 2000 2001 2002 2003 2004 2005 2006 2007 Mikawasim 0 0 1 0 0 1 0 0 0 Minnesota 0 3 3 0 0 2 7 3 2 Mississippi 3 3 0 0 1 5 3 4 4 Molade 0 0 0 0 1 0 0 0 0 Monschaui 0 1 0 2 1 0 1 2 1 Montevideo 56 35 16 21 27 48 41 27 42 Morotai 0 0 0 0 0 0 0 0 0 Muenchen 36 32 42 32 45 34 32 30 95 Muenster 1 3 2 1 1 1 5 3 3 Nagoya 0 0 0 0 1 0 1 0 0 Napoli 0 0 1 0 0 1 0 0 0 New-brunswick 1 1 0 0 0 0 0 0 0 Newington 3 0 0 0 1 0 0 0 0 Newport 59 85 121 121 151 94 68 131 131 Nima 0 1 2 1 0 0 0 0 0 Norwich 4 6 2 2 3 5 0 2 3 Oakland 0 0 0 0 1 0 0 0 0 Offa 0 0 0 0 0 0 0 Ohio 3 0 6 2 1 23 0 5 4 Onderstepoort 0 0 0 0 1 0 0 0 0 Oranienberg 21 24 28 37 30 26 27 33 38 Oranienberg var 0 0 0 0 0 0 0 2 1 14+ Orientalis 0 0 0 0 0 1 0 0 0 Orion 0 0 0 1 0 0 0 0 0 Oslo 5 1 1 2 2 0 1 1 0 Panama 3 2 9 11 3 5 8 11 9 Paratyphi a 1 11 2 9 18 4 7 14 11 Paratyphi b 1 1 0 1 5 18 8 11 18 Paratyphi c 0 0 1 0 0 0 2 0 0 Parera 0 0 0 0 0 1 0 0 0 Pensacola 0 0 0 0 0 1 1 0 0 Poano 1 0 0 0 1 0 0 0 0 Pomona 0 0 0 0 3 3 6 1 0 Poona 19 16 12 6 7 12 7 9 13 Putten 1 0 0 0 0 0 1 0 0 Reading 2 6 4 5 5 7 4 0 8 Richmond 0 0 0 1 0 0 1 1 1 Rissen 0 1 2 1 2 0 1 1 0 Rubislaw 0 1 1 1 1 3 1 0 1 San-diego 0 3 1 5 4 11 4 9 14 Saint-paul 21 28 22 37 27 50 28 15 31 Saphra 0 0 0 1 0 0 1 0 0 Schwarzengrund 7 3 1 5 9 6 11 10 6

168 Senftenberg 13 9 12 8 2 1 10 4 6 Shubra 0 0 0 0 0 0 1 0 1 Simi 0 0 1 0 0 0 0 0 0 Singapore 0 2 0 0 0 1 0 1 0 Soahamina 0 0 0 0 0 0 2 0 0 Stanley 12 5 4 9 12 10 15 11 11 Stanleyville 1 0 0 0 0 0 2 0 1 Serotype 1999 2000 2001 2002 2003 2004 2005 2006 2007 Sundsvall 0 0 0 1 0 0 0 0 0 Takoradi 0 0 1 0 1 0 0 0 1 Tallahassee 0 0 0 0 0 0 0 1 0 Telelkebir 1 2 0 0 2 2 1 1 1 Tennessee 2 0 2 4 8 5 6 18 26 Thompson 30 36 24 24 30 35 33 24 20 Tilene 0 0 0 0 0 1 0 0 0 Tucson 0 0 0 0 0 0 0 0 1 Typhimurium 354 350 285 314 373 274 376 303 367 Typhimurium 0 0 0 0 0 0 2 0 3 var. Copenhagen Typhimurium 0 0 0 0 0 0 0 0 7 var. O:5 Uganda 5 8 15 5 3 2 2 4 2 Urbana 7 2 2 2 0 4 2 1 2 Utah 0 0 0 0 1 0 0 0 0 Virchow 8 2 4 3 11 8 4 4 2 Wandsworth 0 0 1 0 0 0 0 0 2 Wangata 0 2 1 0 0 0 0 0 0 Wassenaar 0 1 0 2 0 0 0 0 0 Waycross 0 0 0 0 2 0 0 0 0 Weltevreden 3 0 2 1 3 4 3 3 2 Weston 0 0 0 0 0 0 0 0 0 Worthington 1 1 0 0 1 5 0 4 1 Monophasic, 0 0 0 0 0 2 51 60 4 other Non-motile 0 0 0 0 0 0 13 3 2 Other 0 0 0 3 24 4 7 16 16 Too rough to 0 0 0 0 0 0 6 1 1 type Untyped 152 123 156 271 228 117 272 101 77 TOTAL 1600 1502 1383 1770 1995 1612 1837 1622 1966

Table 12. Twelve Serotypes and exposure location, 2007

Serotype TOTAL Exposed in Illinois Exposed in another state Exposed outside of the U.S. # % # % # % Agona 34 20 83 0 0 4 17

169 Braenderup 19 15 94 0 0 1 6 Enteritidis 331 191 75 8 3 54 21 Heidelberg 224 218 97 6 3 1 0.4 Infantis 45 26 90 1 3 2 7 Montevideo 42 40 93 1 2 2 5 Muenchen 95 73 94 4 5 1 1 Newport 131 101 94 5 5 1 1 Oranienberg 38 22 85 0 0 4 15 Paratyphi A 11 0 0 0 0 10 100 Paratyphi B 18 11 92 1 8 0 0 Typhimurium 367 243 93 8 3 9 3

170 Sexually Transmitted Diseases Included in this section are three diseases - chlamydia, gonorrhea and syphilis - transmitted primarily or exclusively through sexual contact and reportable under Illinois statutes and administrative rules. Other diseases not included in this section (such as herpes and human papillomavirus) may be transmitted sexually. HIV/AIDS is discussed in a separate section. The control of sexually transmitted diseases (STDs) is an important strategy for the prevention of HIV. The inflammation and lesions associated with STDs increase an individual’s risk for acquisition of HIV, as well as the ability to transmit HIV to others.

Chlamydia

Background Chlamydia trachomatis infection is a significant cause of genitourinary complications, especially in women. Early symptoms of cervicitis or urethritis are mild; asymptomatic infection is common in both women and men. If left untreated, chlamydia infection can lead to pelvic inflammatory disease in women. It may cause severe fallopian tube inflammation and damage, even though symptoms may be mild. Due to the insidious nature of the infection, C. trachomatis is a major cause of long-term sequelae such as tubal infertility and ectopic pregnancy and can cause premature rupture of membranes in pregnant women. Chlamydia also can cause ophthalmia and pneumonia in newborns exposed to it during birth. Chlamydia is reportable in all but one state. During 2007, 1,108,374 chlamydia infections were reported to the CDC, making chlamydia the most commonly reported notifiable disease in the United States. However, national data are incomplete because the majority of testing currently is conducted in females. Federal and state funding for chlamydia is targeted at providing screening programs in STD clinics, women’s health programs (such as family planning and prenatal clinics), and in adult and juvenile correctional centers.

Case definition The case definition is isolation of C. trachomatis by culture, or demonstration of C. trachomatis in a clinical specimen by detection of antigen or nucleic acid.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – 55,470; the overall incidence rate was 447 per 100,000 population. The number of cases increased by 69 percent from 1998 to 2007 (Figure 81). • Age - Adolescents and young adults (ages 15 to 24) represented the majority of cases. Adolescents aged 15 to 19 years accounted for 34 percent of reported chlamydia cases in 2007 (Figure 82). The average age of persons reported with chlamydia was 23 years. • Gender - Most reported cases were in women (75 percent) due to screening efforts that target this group. The female-to-male ratio of reported cases was 3.0: 1.0.

171 • Race/ethnicity - The racial distribution of cases was 55 percent non-hispanic African American, 20 percent non-hispanic white, 2 percent non-hispanic Asian/Pacific Islander and Native American and 13 percent other or unknown race. Eleven percent were Hispanic. • Geographic distribution - Chlamydia is geographically distributed throughout the state. Cases were reported from all 102 counties. The five counties with the highest incidence rates per 100,000 were Pope (997), St. Clair (904), Peoria (878), Alexander (876) and Jackson (835).

Summary Chlamydia is the most commonly reported sexually transmitted disease in Illinois. Cases were reported from all counties in Illinois during 2007. Adolescents and young adults had the highest incidence rates. Reasons for the increase in cases from 1993 to 2007 include increased testing, improved surveillance, and the use of more sensitive diagnostic tests.

Figure 81. Chlamydia Cases in Illinois, 2002-2007

60000 55470 53586 55000 50559 50000 48101 48294 47185 45000

Number of cases Numberof 40000 2002 2003 2004 2005 2006 2007 Year

Figure 82. Age Distribution of Chlamydia Cases in Illinois, 2007

2500 2000 1500 1000 100,000 500

Incidencepepr 0 0-4 5-9 yr 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-54 55-64 65 + yr yr yr yr yr yr yr yr yr Year

172 Gonorrhea

Background Gonorrhea is a bacterial infection caused by Neisseria gonorrhoeae. Uncomplicated urogenital infection may progress, without treatment, to complications such as infertility, pelvic inflammatory disease (PID) and disseminated infection. Resultant scarring of fallopian tubes may result in ectopic pregnancy. Women are more likely than men to suffer complications from gonorrhea infection because early symptoms are often not present or not recognized in females. Infants born to infected mothers may develop gonococcal ophthalmia, which is potentially blinding, or sepsis, arthritis or meningitis. The United States recorded 355,991 cases of gonorrhea in 2007. Currently recommended therapies for gonorrhea are highly effective, although antimicrobial drug resistance has been a problem. Gonococcal susceptibility to some currently recommended drugs is gradually declining, and active surveillance is required to monitor resistance and to ensure the effectiveness of therapy.

Case definition Isolation of typical gram-negative, oxidase positive diplococci (presumptive Neisseria gonorrhoeae) from a clinical specimen; demonstration of N. gonorrhoeae in a clinical specimen by detection of antigen or nucleic acid; or observation of gram- negative intracellular diplococci in a urethral smear obtained from a male urethral or female endocervical smear.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – 20,813; case rate was 168 per 100,000 population. Reported cases in 2007 were slightly higher than the number reported in 2006 (Figure 83). Gonorrhea is the second most commonly reported STD in Illinois. • Age - Adolescents and young adults are at greatest risk for gonorrhea infection. Persons aged 15 to 24 accounted for 63 percent of reported cases in 2007 (Figure 84). • Race/ethnicity - Illinois minorities are disproportionately affected by gonorrhea. The reported cases were 76 percent non-hispanic African American, 12 percent non- hispanic white, less than less than 1 percent non-hispanic Asian/Pacific Islander and 9 percent other or unknown race. Three percent were Hispanic. • Geographic distribution - At least one case of gonorrhea was reported in each of 90 Illinois counties. The five counties with the highest incidence rate in 2007 were Peoria (493), St. Clair (413), Alexander (386), Vermilion (357) and Macon (353).

Summary Gonorrhea is the second most commonly reported sexually transmitted disease after chlamydia in Illinois. In 2007, 63 percent of gonorrhea cases in Illinois were in those 15 to 24 years of age.

173 Figure 83. Gonorrhea Cases in Illinois, 2002-2007

30000 24026 21817 20597 20019 20186 20813 20000

10000

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 84. Age Distribution of Gonorrhea Cases in Illinois, 2007

8000 6000 4000 2000 Incidence 0 0-4 5-9 yr 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-54 55-64 65 + yr yr yr yr yr yr yr yr yr yr Year

174 Syphilis

Background Syphilis is a systemic disease caused by the spirochete Treponema pallidum. The infection is definitively diagnosed through microscopic examination of lesion exudates and presumptively through serologic testing. Without treatment, syphilis infection progresses through four stages: primary, characterized by a painless ulcer at the point at which the organism entered the body (genitals, mouth, anus); secondary, characterized by lesions, rashes, hair loss, lymphadenopathy and/or flu-like symptoms; latent with no signs or symptoms; and late symptomatic, in the form of neurosyphilis (with neurologic damage) and tertiary (cardiovascular or gummatous disease). The open lesions of syphilis are infectious to sex partners. Syphilis during pregnancy can lead to a congenital form of the disease that may result in stillbirth or severe illness and lifelong debilitating consequences for the infant. Increases in syphilis often are associated with poverty, limited availability of health services and the exchange of sex for drugs or money. Syphilis outbreaks are often a precursor of HIV increases in affected populations because the lesions caused by syphilis increase the likelihood of both acquisition and transmission of HIV. Without treatment, approximately 10 percent of persons with syphilis will develop neurosyphilis, but in persons co-infected with HIV, 25 percent may develop neurosyphilis. “Early syphilis” refers to syphilis infection of less than one year duration and progresses through primary, secondary and early latent. Public health disease intervention efforts emphasize control of early syphilis because persons with this stage of the disease are most likely to have been infectious within the past year. Many individuals do not notice or recognize the symptoms of syphilis, so screening for latent disease and partner notification and referral are important components of control efforts. Congenital syphilis occurs when the syphilis organism is transmitted from a pregnant woman to her fetus. Untreated syphilis during pregnancy can result in stillbirth, neonatal death or infant disorders such as deafness, bone deformities, and neurologic impairment. In 2007, the congenital syphilis rate increased from 2006. Significant public health resources must be devoted to the control of syphilis. Untreated syphilis can result in neurological or cardiovascular complications. It also can be transmitted to a fetus from an infected woman during pregnancy, which results in congenital syphilis. The CDC recorded 11,466 primary and secondary syphilis cases in the United States in 2007. The rate of infection was 3.8 per 100,000 population. In 2007, a total of 430 cases of congenital syphilis were reported.

Case definition Syphilis is a complex disease with a highly variable clinical course. The following case definitions are used for surveillance purposes for syphilis that has not progressed to late symptomatic stages.

• Primary. A clinically compatible case with one or more ulcers consistent with primary syphilis and a reactive serologic test; or demonstration of T. pallidum in clinical specimens by dark field microscopy, fluorescent antibody or equivalent methods.

175

• Secondary. A clinically compatible case with a reactive nontreponemal test titer of > 1:4 (probable case), or demonstration of T. pallidum in clinical specimens by dark field microscopy, fluorescent antibody or equivalent methods (confirmed case). • Latent. No clinical signs or symptoms of syphilis and the presence of one of the following: o No past diagnosis of syphilis, a reactive nontreponemal test and a reactive treponemal test. o A past history of syphilis therapy and a current nontreponemal test titer demonstrating fourfold or greater increase from the last nontreponemal test titer.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 - Eleven congenital cases and 464 primary or secondary cases (Figure 85). Primary and secondary cases increased 24 percent between 2003 and 2007. The incidence rate for 2007 was 3.7 per 100,000 population for primary and secondary syphilis and 6.1 per 100,000 live births for congenital syphilis. Note: CDC summaries show 10 congenital syphilis cases reported from Illinois in 2007. We will use 11 cases in this report. • Age - The average age of persons diagnosed with primary and secondary syphilis is 36 years. Adults aged 30 years and older accounted for 69 percent of primary and secondary syphilis cases (Figure 86). • Gender - Ninety-one percent of cases were male. • Race/ethnicity - Minorities in Illinois are disproportionately affected by syphilis, especially African Americans, who accounted for 64 percent of the congenital syphilis cases. The proportion of primary and secondary syphilis cases by race were non-hispanic white (36 percent), non-hispanic African American (42 percent) and other or unknown races (7 percent). Fifteen percent were Hispanic. • Geographic distribution - Syphilis is more prevalent in urban populations. The disease has become progressively concentrated geographically. Cases of primary and secondary syphilis were reported from 22 counties. The five highest incidence rates per 100,000 population in counties with at least three cases were St. Clair (7.4), Cook (7.3), Mclean (2.7), Peoria (2.2) and Dupage (1.3). • Clinical presentation – During 2007, there were 25 cases of reported neurosyphilis; (88 percent) of the 2007 cases were in men. Of the 22 males, 32 percent were MSM.

Summary Primary and secondary syphilis cases increased by 24 percent in 2007 compared to 2003. During 2007, African American females were disproportionately affected by syphilis.

176 Figure 85. Syphilis Cases in Illinois, 2002-2007

525 600 479 431 464 374 386 400 Primary and Secondary

200 Congenital 41 21 25 25 16 11

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 86 . Age Distribution of Syphilis Cases in Illinois, 2007

200 150 100 50

Number of cases Numberof 0 0-4 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-54 yr 55-64 yr 65+ yr Year

177 Shigellosis

Background Shigellosis is an acute bacterial disease of humans and non-human primates caused by four species or serogroups of Shigella: S. dysenteriae (group A), S. flexneri (group B), S. boydii (group C) and S. sonnei (group D). The infectious dose is low; as few as 10 to 100 bacteria can cause infection. Transmission is via direct or indirect fecal-oral routes. Outbreaks in day care centers are not uncommon and Shigella can be transmitted through unchlorinated wading pools, interactive water fountains, food items such as parsley and bean dip and between men who have sex with men. The incubation period is usually one to three days. Symptoms of the disease are watery or bloody diarrhea with fever and sometimes vomiting or tenesmus. Mild and asymptomatic infections can occur. Duration of illness is usually from four to seven days. Shigella can be shed in stool for four weeks. Disease caused by Shigella dysenteriae type 1 is the most severe and can cause hemolytic uremic syndrome (HUS) due to a toxin similar to that produced by E. coli O157:H7. Antimotility drugs are contraindicated. Antimicrobial therapy can limit the clinical course and duration of fecal excretion of Shigella. Shigella can develop antimicrobial resistance quickly. The subgroups, serotypes and subtypes of Shigella are: Group A: Shigella dysenteriae 15 serotypes (type 1 produces Shiga toxin) Group B: Shigella flexneri 8 serotypes and 9 subtypes Group C: Shigella boydii 19 serotypes Group D: Shigella sonnei 1 serotype In a study in Washington staste, risk factors for sporadic Shigella infections included exposure to aquatic recreation and consumption of raw herbs. Of the 10 diseases/syndromes (caused by Campylobacter, Cryptosporidium, Cyclospora, HUS, E. coli O157:H7, Listeria monocytogenes, Salmonella, Shigella, Vibrio and Yersinia enterocolitica) under active surveillance in the federal FoodNet sites, Shigella comprised 17 percent of the reported infections in 2007. The incidence rate overall was 6.2 per 100,000 for shigellosis and ranged from 0.9 to 17 at the 10 FoodNet sites. Ninety-five percent were serotyped. Eighty-one percent of these cases were due to S. sonnei and 13 percent were S. flexneri. In 2007, 19,758 Shigella cases were reported to CDC. S. sonnei accounts for greater than 75 percent of shigellosis cases in the United States. Multi-community outbreaks of shigellosis require extensive time and effort on the part of public health. Because of the low infectious dose, shigellosis spreads quickly between people when breaches in hand washing or sanitation occur. Propagation of shigellosis is increased because of the difficulty in maintaining handwashing and sanitation in day care centers, high proportion of mild or asymptomatic Shigella infections and frequent contact between children who attend multiple day care centers. Interventions include alerting the media to the outbreak, direct communication with day care centers and the medical community, and promoting control strategies such as supervised handwashing and exclusion of symptomatic children from day care. However, strict exclusion policies of infected but asymptomatic children can lead to spread of an outbreak if excluded day care attendees are then placed in alternative child care settings.

178

Case definition The case definition for a confirmed case of shigellosis in Illinois is a case from which Shigella is isolated from a clinical specimen. The case definition for a probable case is a person who has a clinically compatible illness that is epidemiologically linked to a confirmed case, but is not laboratory confirmed.

Descriptive epidemiology • Number of reported cases in Illinois in 2007 - 781 (five-year median = 720; see Figure 87). Overall annual incidence rate was 6 per 100,000. Of the cases, 761 were confirmed and 20 were probable. The number of shigellosis cases increased slightly in 2007 as compared to 2006. • Age - Mean age = 20 (Figure 88). By age group, annual incidence rates per 100,000 were: younger than one year old (nine); 1 to 4 years of age (27); 5 to 9 years of age (19); 10 to 19 years of age (five); 20 to 29 years of age, (six); 30 to 59 years of age (three); and 60 and older (two). • Gender – Fifty-four percent were female. • Race/ethnicity – Forty-eight percent were white, 40 percent were African American, and 12 percent were other races; Twenty percent were Hispanic. There were significantly higher proportions of Hispanics with shigellosis compared to their representation in the Illinois population (12 percent). • Geographic distribution – For 2007, counties with the highest incidence per 100,000 were Union (153), Rock Island (88), Pulaski (54), Peoria (35) and Morgan (25). • Clinical syndrome – Symptoms reported included diarrhea (98 percent), fever (72 percent) and vomiting (46 percent). • Outcome – Twenty-six percent of cases were hospitalized. No fatalities were reported. • Seasonal variation - Shigellosis cases occurred in all months of the year with a peak in the fall (Figure 89). • Serotypes - Ninety-seven percent of isolates were serotyped in 2007. The most common species was S. sonnei (89 percent of typed isolates), followed by S. flexneri (11 percent). S. boydii made up less than one percent of typed isolates. The boydii serotypes found in Illinois were 2, 4 and 19 (Table 13). No S. dysenteriae were identified (Table 14). The three most common S. flexneri serotypes were 2a (19 cases), 1b (15 cases), and two (11 cases) (Table 15). S. sonnei does not have subtypes, but there were 675 S. sonnei cases reported. • Reporter – Thirty-eight percent were reported by infection control professionals and 55 percent by laboratories. • Risk factors o Twenty-five cases acquired their infection in another country. o Seven cases acquired infection in another state. o Eighteen of 617 (3 percent) reported swimming in non-chlorinated water, and 34 of 612 (5 percent) swam in chlorinated water. o Fifty-seven cases attended day care and 32 attended a residential facility.

179 o Seventeen percent (105 of 629 cases) reported contact with someone attending a residential facility. Twenty-one percent (131 of 628 cases) reported contact with someone in a day care facility. o Twenty-eight cases reported drinking water from a well. • Sensitive occupations – Cases were employed in the following sensitive occupations: food service (four), day care (five), health care (nine), residential facility (six), and other sensitive occupations (13). • Foodborne outbreaks – There were no foodborne outbreaks of shigellosis in 2007. • Person-to-person outbreaks – Ten person-to-person outbreaks were reported (See non-foodborne non-waterborne outbreak section).

Summary There was an increase in Shigella cases from 2006 to 2007. The incidence rate for 2007 of 6 per 100,000 was the same as that reported by the CDC’s FoodNet sites. The proportion who were Hispanic was higher than their representation in the Illinois population. The mean age of cases was 20 years. Ninety-seven percent of isolates were serotyped in Illinois as compared to 95 percent in the CDC FoodNet sites. S. sonnei was the most common serotype found in Illinois, which is the same as the most common serotype identified in CDC’s FoodNet sites. Isolates of Shigella are required to be submitted to the Departments laboratories for speciation and/or serotyping (if this cannot be done by the clinical laboratory).

Suggested readings Denno, D.M., et. al. Tri-county comprehensive assessment of risk factors for sporadic reportable bacterial enteric infection in children. JID 2009;199:467-476. Centers for Disease Control and Prevention. FoodNet 2007 Surveillance Report. Atlanta: U.S. Department of Health and Human Services, 2009.

Figure 87. Shigella Cases in Illinois, 2002-2007

1500 1105 1006 1000 720 781 402 409 500

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

180 Figure 88. Age Distribution of Shigella Cases in Illinois, 2007

30 25 20 Male 15 10 Female Incidence 5 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Age category

Figure 89. Shigella Cases in Illinois by Month, 2007

150

100

50

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month

181 Table 13. Frequency of Shigella boydii in Illinois, 2000-2007 Type 2000 2001 2002 2003 2004 2005 2006 2007 boydii, unknown 0 0 0 0 0 0 0 0 boydii 1 0 2 0 0 0 0 1 0 boydii 2 4 3 1 5 1 1 1 2 boydii 3 0 0 1 0 0 0 0 0 boydii 4 2 0 2 2 1 1 0 2 boydii 5 1 0 0 0 0 0 0 0 boydii 8 0 0 0 0 2 0 0 0 boydii 10 0 0 0 0 0 0 0 0 boydii 11 1 0 0 0 0 0 0 0 boydii 12 0 0 0 0 0 0 1 0 boydii 13 1 0 0 0 0 0 0 0 boydii 14 2 1 2 1 0 0 0 0 boydii 18 1 0 0 0 1 0 0 0 boydii 19 0 0 0 0 0 0 0 1 boydii 20 0 0 0 0 1 0 0 0 TOTAL boydii 12 6 3 8 2 3 5 Source: Illinois Department of Public Health

Table 14. Frequency of Shigella dysenteriae in Illinois, 2000-2007 Type 2000 2001 2002 2003 2004 2005 2006 2007 dysenteriae, 2 0 0 1 1 0 1 0 unknown dysenteriae 1 0 0 0 0 1 0 0 0 dysenteriae 2 0 0 0 2 0 0 1 0 dysenteriae 3 0 0 1 0 1 0 1 0 dysenteriae 4 0 0 1 0 0 3 0 0 dysenteriae 9 0 0 0 0 0 0 0 0 dysenteriae 12 0 0 0 0 0 0 0 0 TOTAL 2 0 2 3 3 3 3 0 dysenteriae

182 Source: Illinois Department of Public Health

Table 15. Frequency of Shigella flexneri subtypes in Illinois, 2000-2007 Type 2000 2001 2002 2003 2004 2005 2006 2007 flexneri, unknown 31 24 14 15 18 11 21 6 flexneri 1 3 5 8 9 15 11 13 2 flexneri 1A 0 0 0 0 0 0 0 0 flexneri 1B 0 0 0 0 0 0 1 15 flexneri 2 49 23 36 33 21 29 23 11 flexneri 2A 0 0 0 1 2 0 0 19 flexneri 2A 0 0 0 0 0 0 0 4 (11:3,4) flexneri 2B 0 0 1 0 0 0 0 1 flexneri 3 27 14 7 29 27 14 14 6 flexneri 3A 0 0 0 0 1 0 3 6 flexneri 3B 0 0 0 0 0 0 1 0 flexneri 4 10 11 23 11 13 7 11 2 flexneri 4A 1 0 0 1 0 0 0 8 flexneri 4B 0 0 0 0 0 0 0 0 flexneri 5 0 0 0 0 0 0 0 0 flexneri 5A 0 0 0 0 0 0 0 0 flexneri 6 8 9 8 7 6 0 3 1 flexneri X variant 0 0 1 1 1 2 0 0 flexneri Y variant 1 3 1 0 3 5 2 0 TOTAL flexneri 130 89 99 107 107 79 92 81

Source: Illinois Department of Public Health

183 Staphylococcus aureus, Intermediate or High Level Vancomycin Resistance

Background Staphylococcus aureus causes both community and health care associated infections in persons. The National Committee for Clinical Laboratory Standards (NCCLS) defines staphylococci requiring concentrations of vancomycin of < 4 ug/mL for growth inhibition as susceptible to vancomycin. Those requiring concentrations of eight to 16 ug/mL as intermediate and those requiring concentrations of at least 32 ug/mL as resistant. S. aureus with reduced vancomycin susceptibility (SA-RVS) includes all S. aureus isolates with MICS of vancomycin of at least four ug/mL. Three cases of SA-RVS have been identified in Illinois, two in 1999 and one in 2000.

Case definition A case of S. aureus, intermediate or high level vancomycin resistance is defined as S. aureus isolated from infected humans with an MIC of vancomycin of at least four ug/mL.

Descriptive epidemiology No cases were reported in 2007.

Summary No cases were reported in 2007 in Illinois.

184 Streptococcus pyogenes, Group A (Invasive Disease) Background The spectrum of disease caused by group A streptococci (GAS) is diverse and includes pharyngitis and , severe invasive infections, post-streptococcal acute rheumatic fever and acute glomerulonephritis. Invasive GAS may present as any of several clinical syndromes including pneumonia, bacteremia in association with cutaneous infection (, or infection of a surgical or nonsurgical wound), deep soft tissue infection (myositis or ), meningitis, peritonitis, , septic arthritis, postpartum sepsis (puerperal fever), neonatal sepsis and non-focal bacteremia. Two types of invasive GAS are streptococcal toxic shock syndrome (STSS) and necrotizing fasciitis. The symptoms of STSS include fever, myalgia, vomiting, diarrhea, confusion, soft tissue swelling, renal dysfunction, respiratory distress and shock. Necrotizing fasciitis is a deep infection of subcutaneous tissue that results in destruction of fat and fascia and often leads to systemic illness. Risk factors for necrotizing fasciitis include injection drug use, obesity and diabetes mellitus. Transmission of GAS occurs by direct contact with patients or carriers, or by inhalation of large respiratory droplets. Approximately 5 percent of the population may be asymptomatic carriers, but these individuals are less likely to transmit the organism than symptomatic persons. Predisposing risk factors for invasive GAS include older age, injection drug use, human immunodeficiency infection, diabetes, cancer, alcohol abuse, varicella, penetrating injuries, surgical procedures, childbirth, blunt trauma, and muscle strain. Household members should monitor themselves for signs and symptoms for 30 days after exposure. During 2007, 1,166 cases of invasive GAS were reported from the Active Bacterial Core Surveillance site projects in 10 states. Incidence was highest in adults older than 65 years of age (9.9 cases per 100,000) and children younger than one year of age (6.4 cases per 100,000). STSS accounted for 5 percent, and necrotizing fasciitis accounted for 6 percent of cases. The overall case fatality rate was 0.44 per 100,000. In routine surveillance, 5, 294 cases of invasive GAS were reported to CDC and 132 cases of streptococcal TSS.

Case definition The case definition of invasive GAS disease in Illinois is the isolation of group A Streptococcus pyogenes by culture from a normally sterile site.

Descriptive epidemiology • Number of reported cases in Illinois in 2007 – There were 326 invasive GAS cases (five-year median = 326) reported. Of these 326, seven were necrotizing fasciitis and 33 streptococcal toxic-shock syndrome cases (see Figure 90). All but one case was confirmed. The incidence rate for 2007 was 2.6 per 100,000 population. • Age - Mean age was 50 years (Figure 91). By age group, the highest incidence per 100,000 occurred in those older than 79 years of age (15 per 100,000 in that age group), followed by those 70 to 79 years of age (six per 100,000) and 60 to 69 years of age (six per 100,000). Twenty-two cases were residents of residential institutions.

185 • Gender – Fifty percent were male. • Race/ethnicity - Cases were 68 percent white, 26 percent African American and 6 percent other races; 14 percent occurred among Hispanics. • Geographic distribution – Forty-five percent were residents of Cook County. Cases resided in 47 counties. • Seasonal variation - An increase in cases occurred from January to April (Figure 92). • Outcome – Ninety-four percent were hospitalized. The overall case fatality rate was 7 percent. • Reporting – Eighy-two percent were reported by health care providers and 17 percent were reported by laboratories.

Summary The number of reported invasive GAS cases in 2007 was the same as in 2006. The highest incidence was in those older than 79 years of age, followed by those 60 to 79 years of age. Illinois had the second highest number of streptococcal toxic shock cases reported in the United States.

Figure 90. Invasive GAS and Streptococcal TSS Cases in Illinois, 2002-2007

500 417 326 342 326 326 400 284 300 200 100

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 91. Invasive GAS and Streptococcal TSS Cases by Age in Illinois, 2007

20 15 10 5 Incidence 0 0-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr 60-69 yr 70-79 yr 80+ Age Group

186 Figure 92. Invasive GAS and Streptococcal TSS Cases in Illinois by Month, 2007

60 40 20 0 Number of cases Numberof Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of Onset

187 S. pneumoniae

Background S. pneumoniae is the most common cause of meningitis, community-acquired pneumonia and bacteremia and acute otitis media. Pneumococci colonize the nasopharynx of 15 percent to 60 percent of individuals; most remain asymptomatic. Carriage is higher in children attending child care centers outside the home. The onset of S. pneumoniae meningitis is usually sudden with high fever, lethargy and signs of meningeal irritation. It is a sporadic disease in the elderly and in young infants. In the ten states which are part of the Active Bacterial Core Surveillance, 4,012 cases were reported in 2007, 15 percent exhibited intermediate resistance to and 10 percent were fully resistant. The pneumococcal conjugate 7-valent vaccine (6B, 14, 18C, 19F, 23F, 9V, 4) was licensed in the United States in February 2000 and can be used in children younger than 2 years of age. The vaccine protects against the seven strains of pneumococcus that cause 80 percent of the invasive disease among children in the United States. Individuals at the extremes of age and in certain ethnic groups (African American, American Indians and Alaskan natives) are disproportionately affected. Males are at higher risk for S. pneumoniae. Other risk factors for invasive disease include renal dysfunction, sickle cell disease, alcoholism, smoking, HIV, organ transplantation and diabetes mellitus. The Advisory Committee on Immunization Practices (ACIP) recommends that vaccine be given to infants in a series of four injections (at 2, 4, 6 and 12-15 months of age). The recommendation applies to all children younger than 24 months of age and to children 24 to 59 months of age who are at higher risk of infection, including those with certain illnesses (e.g., sickle cell anemia, cochlear implant, immunocompromising condition, chronic heart or lung disease) and those who are Alaska natives, American Indian or African American. The vaccine also can be considered for other children ages 24 to 59 months who are at increased risk, such as children in group day care, those with frequent otitis media or those who are economically or socially disadvantaged. In data for 2007 from the National Behavioral Risk Factor Surveillance system, the percent of persons older than the age of 64 who had received at least one pneumococcal vaccination was 60 percent. The Healthy People 2010 objectives are to reduce invasive pneumococcal disease to 46 per 100,000 in children younger than five years and to 42 per 100,000 in adults aged 65 years or older. Since vaccine has been available incidence has declined.

Case definition A case is defined as a person with clinically compatible symptoms and from whom isolation of the organism from a normally sterile site has occurred. The case numbers for this section were obtained using date of onset between January 1 and December 31, 2007, not by year counted = 2007.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – 1,235 (five-year median = 1,012) (See Figure 93). The incidence rate for 2007 was 9.9 per 100,000.

188 • Age - Mean age of cases was 52 years (see Figure 94 for age distribution). Incidence per 100,000 of reported S. pneumoniae in those less than four years of age was 16.8 and for those aged 60 years and older was 29. • Gender - Forty-eight percent were female. • Race/ethnicity - Twenty-two percent were African American, 74 percent were white and 4 percent were other races; 9 percent were Hispanic. • Seasonal peak – An increase in cases occurred in the winter and spring months (Figure 95). • Outcome – Ninety percent of cases were hospitalized. Forty-eight cases were fatal. • Reporting - The majority of cases were reported by health care providers (84 percent).

Summary Cases of S. pneumoniae were lower in the summer months. The mean age of cases was 52 years.

Figure 93. S. pneumoniae Cases in Illinois, 2002-2007

1500 1226 1196 1235 1012 936 1000 823

500

Number Number of cases 0 2002 2003 2004 2005 2006 2007 Year

Figure 94 . S. pneumoniae Cases by Age in Illinois, 2007

40 30 20 10 0

Incidence per 100,000 < 4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Age group

189 Figure 95 . S. pneumoniae Cases in Illinois by Month, 2007

200 150 100 50

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year

190 Tetanus Background Tetanus is non-communicable. spores can be present in the environment and enter the body through nonintact skin. Generalized tetanus presents with trismus (lockjaw) followed by generalized rigidity caued by contractions of the skeletal muscles. Forty-one cases were reported in the United States in 2007.

Case definition A clinically compatible case as diagnosed by a health care professional.

Descriptive epidemiology • Two cases were reported in Illinois in 2007. • Description of cases o The first case was a 31-year-old male from Chicago who had a laceration when fixing a car antenna in July. He was treated for the laceration but did not receive tetanus vaccination or TIG. It had been 19 years since his last tetanus vaccination. In August he presented with difficulty in opening his jaw and was treated with TIG. o The second case was a female 72-year-old suburban Cook County resident. She had fallen in November and had a closed fracture and was hospitalized for greater than 40 days. She had difficulty opening her jaw in December and ended up on a ventilator.

191 Tickborne Diseases Found in Illinois Ticks are the most common vector of vectorborne diseases in the United States. Ticks are responsible for the following diseases in the United States: babesiosis, Colorado tick fever, human granulocytic ehrlichiosis, human monocytic ehrlichiosis, Lyme disease, Powassan encephalitis, relapsing fever, Rocky Mountain spotted fever (RMSF), tick paralysis and tularemia. Ticks usually attach around the head, neck and groin of the human host. The rates of human infection with tick borne diseases are influenced by the prevalence of vector tick species, the tick infection rate, the readiness of ticks to feed on humans, and the prevalence of their usual animal hosts. Five tickborne diseases are listed in Table 16 and in individual sections of this document. In addition, at least one case of babesiosis was reported each year from 2003 thru 2007. According to CDC guidelines, any Illinois resident diagnosed with a tick borne disease is counted in the state’s case count, even though he/she may have reported tick exposures in another state. Case counts by year for 2002 through 2007 for four of these infections that occur regularly in Illinois are shown in Figure 96. Ehrlichiosis and RMSF cases numbers are increasing each year.

Figure 96. Tickborne Disease Cases in Illinois, 2002-2007 200 149 127 110 71 87 100 47 32 39 50

cases 26 12 5 6 5 1 9 14 5 12 11 1 7 1 1 Number of of Number 0 2002 2003 2004 2005 2006 2007 Year

Lyme RMSF Tularem ia Ehrlichiosis

192 Table 16. Tickborne Diseases Reported in Illinois Residents and which can be acquired in Illinois

Add babesiosis

Disease Organism Tick vectors Symptoms Where found

Rocky Mountain Rickettsia Dermacentor fever, headache, throughout the spotted fever rickettsii variabilis rash United States but (American dog most common in tick), Southeast; entire D. andersoni state of Illinois (Rocky Mountain wood tick)

Tularemia Francisella Amblyomma ulcer at entry site, throughout North tularensis americanum enlarged lymph America; primarily (lone star tick), node central and southern Illinois D. variabilis, D. andersoni

Lyme disease Borrelia Ixodes scapularis fatigue, chills, primarily on the burgdorferi (deer tick) fever, erythema West Coast, in migrans, enlarged northeastern and lymph nodes north central United States; primarily northern Illinois

Human monocytic Ehrlichia A. americanum fever, headache, most common in ehrlichiosis chaffeensis myalgia, vomiting the southern states; more common in southern Illinois

Human Anaplasma I. scapularis fever, headache, most common in granulocytic phagocytophilum myalgia, vomiting upper Midwest ehrlichiosis and Northeast; in Illinois, unknown distribution

193 Toxic Shock Syndrome (TSS) Due to Staphylococcus aureus Background Toxic shock syndrome is classified by clinical and laboratory evidence of fever, rash, , and multiple organ failure caused by toxins produced by Staphylococcus aureus. MRSA strains have caused TSS in other countries. Most cases have been associated with strains of Staphylococcus aureus that produce a special toxin. In 2007, 92 cases were reported to CDC.

Case definition The five clinical findings used to establish whether a case meets the case definition for staphylococcal TSS are - 1) Fever - temperature greater than 102 F 2) Rash 3) Desquamation 4) Hypotension 5) Multisystem involvement (three or more of the following) a. Gastrointestinal - vomiting or diarrhea b. Muscular - myalgia or creatine phosphokinase (at least twice upper limit of normal) c. Mucous membrane - vaginal, oropharyngeal or conjunctival hyperemia d. Renal - blood urea nitrogen or creatinine at least twice the upper limit of normal or urinary sediment with pyuria in the absence of e. Hepatic - total bilirubin, alanine aminotransferase (ALT) or aspartate aminotransferase (AST) at least twice the upper limit of normal for the lab f. Hematologic - platelets less than 100,000/mm3 g. CNS - disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent. In addition, there should be negative results on the following tests (if done) a. Blood, throat or CSF cultures (blood cultures can be positive for S. aureus) b. Rise in titer to Rocky Mountain spotted fever, leptospirosis or measles

The CDC case definition for a probable case is one with any four of the five clinical findings above. A confirmed case is one with all five of the clinical findings, including desquamation, unless the patient dies before desquamation can occur.

Descriptive epidemiology

• Number of cases reported in Illinois in 2007 - Nine cases were reported (five-year median = five cases). Six were confirmed, and three were probable. • Age - Ages ranged from 12 to 46. • Gender - All cases were female. • Seasonality – Cases had onsets ranging from January to December.

194 • Race/ethnicity – All cases were white. None reported Hispanic ethnicity. • Geographic distribution - Cases were reported from five counties: Cook, Dupage, Sangamon, Will and Winnebago. • Symptoms – Diarrhea (six of eight), fever (all eight), hypotension (seven of eight cases), myalgia (seven of eight) and orthostatic dizziness (three of five cases), vaginal discharge (one of five cases), desquamation (three of four cases) and abdominal pain (two of five cases). • Laboratory findings - S. aureus was isolated from the vagina in seven cases, from urine in two cases and from the trachea in one case. Seven cases were classified as menstruation-associated and two did not have a source identified. • Treatment - All patients were hospitalized. • Outcome – One case was fatal. • Reporting – Seven cases were reported by infection control professionals, one from a private physician and one from a laboratory at a hospital. • Past cases – Toxic shock syndrome cases due to S. aureus reported per year in the state previously were 1998 (seven), 1999 (five), 2000 (three), 2001 (four), 2002 (five), 2003 (six), 2004 (six), 2005 (five) and 2006 (two).

Summary Nine cases of staphylococcal toxic shock were reported in 2007 and seven were considered to be associated with menstruation. Illinois and Minnesota each reported nine cases, the most of any states.

195 Tuberculosis

Background The Mycobacterium tuberculosis complex includes M. tuberculosis, M. africanum, M. bovis and M. microti. Tubercle bacilli are transmitted by inhalation of airborne droplet nuclei produced by persons with tuberculosis (TB) disease. Prolonged close contact with cases may lead to latent TB infection (LTBI). Tuberculin skin sensitivity often indicates LTBI (as noted by a positive skin test), which usually appears four to 12 weeks after infection. LTBI is different from TB disease and is defined as a condition in which TB bacteria are alive but inactive in the body. People with latent TB infection have no symptoms and cannot spread TB to others. They usually have a positive skin test reaction and may develop TB disease later in life if they do not receive treatment for latent TB infection. Approximately 90 to 95 percent of newly infected individuals have LTBI where early lung lesions heal and leave no residual changes except small calcifications in the pulmonary or tracheobronchial lymph nodes. In those patients whose infection progresses to disease, early symptoms may include fatigue, fever, night sweats and weight loss. In advanced disease, symptoms such as cough, chest pain, coughing up of blood, and hoarseness may occur. Several issues, such as patients’ immune status and immigration from areas where TB is common, impact the incidence of TB in Illinois. The AIDS epidemic had a profound effect on the number of TB cases in Illinois in the past. TB is a major opportunistic infection in HIV-infected persons. HIV contributes to TB because immune suppression increases the likelihood of rapid progression from TB infection to TB disease. In Illinois, the percentage of TB cases diagnosed in foreign-born individuals is increasing. CDC recommends that all immigrants, refugees, foreign-born students and their families, and others accompanying them into the country be tuberculin-test screened and medically treated when appropriate. Both suspected and confirmed cases of TB are reportable in Illinois. The sooner cases are reported to the local TB control authority, the sooner their personnel can begin investigations which may interrupt transmission of TB in the community. Extensively drug resistant (XDR) TB is TB which is resistant to isoniazid and rifampin and resistance to any fluoroquinolone, and resistance to at least one second-line injectable drug (amikacin, capromycin or kanamycin). From 1993 to 2006, 49 TB cases in the United States were classified as XDR-TB including one case from Illinois. The recommended length of drug therapy for most types of TB is six to nine months. Treatment of multi-drug resistant TB requires administration of four to six drugs for 18 to 24 months. Patients with both TB and HIV are more likely to die during anti-TB treatment than patients not infected with HIV. During 2007, a total of 13, 299 cases (4.4 per 100,000) were reported to CDC.

196 Case definition A confirmed case of tuberculosis in Illinois is a case that is either laboratory confirmed or is a case that meets the clinical case definition criteria: 1) A positive tuberculin skin test 2) Other signs and symptoms compatible with tuberculosis, such as an abnormal, unstable chest radiograph, or clinical evidence of current disease 3) Treatment with two or more anti-tuberculosis medications 4) Completed diagnostic evaluation

Laboratory criteria for diagnosis are isolation of M. tuberculosis from a clinical specimen, demonstration of M. tuberculosis from a clinical specimen by DNA probe or mycolic acid pattern on high-pressure liquid chromatography, or demonstration of acid-fast bacilli in a clinical specimen when a culture has not been or cannot be obtained.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – There were 521 cases reported (4.1 per 100,000 population). This is the second year that a decrease in reported TB cases occurred. A decrease of 12.6 percent occurred from 2006 to 2007. • Age - The highest incidence of TB occurred in older age groups (Table 17). • Gender – Sixty-three percent were male. • Race/ethnicity - Thirty-four percent were African American (non-Hispanic), 15 percent white (non-Hispanic), 25 percent Hispanic and 25 percent were Asian or Pacific Islander. ► The number and percent of foreign-born TB cases increased in 2007 (N = 304, or 59 percent) as compared to 2006 (N = 305, or 45 percent) (Figures 97 and 98). Cases were born in 43 different countries. The largest number of cases were born in Mexico (93, 31 percent), followed by India (54, 18 percent) and the Philippines (46, 15 percent). • Risk factors - Homeless in past 12 months (6.5 percent), being an inmate in a correctional facility (3 percent), residing in a long-term care facility (1.5 percent) and injection drug use (0.5 percent). • Drug resistance – Four cases were multi-drug resistant. No cases were extensively drug resistant. • Diagnosis – Seventy-eight percent were culture confirmed, 1 percent were smear positive, 8 percent met a clinical case definition and 13 percent were provider diagnosed. • Clinical syndrome – Sixty-eight percent of cases were pulmonary only, and 26 percent were extrapulmonary. • Underlying conditions – Ten percent of 521 cases were HIV positive.

Summary In 2007, 521 cases of TB were reported in Illinois with an incidence rate of

197 4.1 per 100,000, which is very similar to the national incidence rate. Fifty-nine percent of these cases were among persons born outside of the United States. An increasing percentage of foreign-born cases are being seen in Illinois, with India, Mexico and the Philippines being the most common countries of origin. Public health attention must continue to focus on high-risk groups, especially those born outside of this country. Illinois is one of seven states reporting more than 500 cases and is fifth in the nation in the number of cases reported.

Table 17. Age Distribution of Tuberculosis Cases in Illinois, 2007

Age Incidence *

< 5 years 1.1

5 – 14 0.4

15 – 24 2.4

25-44 4.4

45-64 5.9

65+ 8.0

All 4.1

U.S. 4.4 * Incidence per 100,000 based on 2000 population. Source: Illinois Department of Public Health

Figure 97. Tuberculosis Cases in Illinois, 2002-2007

500 415 407 400 339 328 305 304 265 273 268 264 300 230 217 Foreign born 200 US born 100

Number Number of cases 0 2002 2003 2004 2005 2006 2007 Year

198 Figure 98 . Country of Origin for Foreign-born TB Cases, Illinois, 2007

18% India 29% Mexico China Philippines 3% Rep. of Korea 30% Other 15% 5%

199 Tularemia

Background Tularemia is caused by Francisella tularensis and is a zoonotic disease that infects vertebrates especially rabbits and rodents. Tularemia can be classified into six primary syndromes: ulceroglandular (the most common form), glandular, typhoidal, oculoglandular, oropharyngeal, and pneumonic. The case fatality rate can be 30 percent to 60 percent if untreated and typhoidal. Tularemia can be divided into four subspecies. Human disease is mainly associated with F. tularensis subsp tularensis, found only in North America, and the moderately virulent F. tularensis subsp. Holartica, which is endemic throughout the northern hemisphere. F. tularensis subspecies tularensis can be separated into two subpopulations in the United States, A.I. and A.II. A.1. occurs primarily in the central United States and A.II. occurs primarily in the western United States. Tularemia can affect many wildlife species, including prairie dogs, squirrels and cats in addition to humans. Both ticks and biting flies can serve as vectors in the United States. The most common modes of transmission are tick bites and handling infected animals. The disease also can spread through ingestion of contaminated water or food, inhalation, and insect bites. Tularemia has two peaks in occurrence; a peak in the summer reflects transmission from ticks and a peak in winter reflects transmission from animal contacts, especially rabbits, often during hunting or trapping seasons. The most important epizootic hosts for tularemia in the United States include rodents and lagomorphs. Tularemia has been associated with die-offs in exotic animals, such as prairie dogs. The most common tick vectors in the United States are the American dog tick (Dermacentor variabilis), the Lone Star tick (Amblyomma americanum) and the Rocky Mountain wood tick (D. andersoni). The incubation period is three to five days. It can take 10 to 20 days for seroconversion. Clinical signs in people include fever, chills, malaise, cough, myalgias, vomiting and fatigue followed by the development of one of six clinical syndromes. Isolation of F. tularensis requires biosafety level 3 facilities. Tularemia is considered a possible bioterrorism agent. Vaccination is recommended only for limited numbers of persons in high-risk occupations. In a study of tularemia in Missouri from 2000 to 2007, 72 percent of the 190 cases were associated with a tick bite prior to illness onset. The ulceroglandular form was the most common manifestation. Eight percent of tick bite exposures occurred from May to September. Approximately 40 percent of all tularemia cases each year in the United States occur in Arkansas, Oklahoma and Missouri. In 2007, 137 cases were reported to CDC from 28 states. Prevention methods include wearing gloves when handling dead animals, especially rabbits and rodents; avoiding bites of ticks, flies and mosquitoes by using insect repellents, cooking game meat thoroughly, and avoiding drinking of untreated water.

200

Case definition The CDC case definition for a confirmed case of tularemia is a clinically compatible case with either isolation of F. tularensis from a clinical specimen or a four-fold or greater rise in serum antibody titer to F. tularensis antigen. A probable case is a clinically compatible case with either detection of F. tularensis in a clinical specimen by fluorescent antibody or an elevated serum antibody titer to F. tularensis antigen in a patient with no history of vaccination.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – One case was reported. This case was confirmed. The median number of cases per year for the last five years is one case. • Age - The case’s age was 47. • Gender – This case was female. • Seasonal variation – Onset of illness was in May. • Geographic distribution – The exposure site for the case was Missouri. • Symptoms/diagnosis/treatment – She had fever, lymph node enlargement, vomiting and a skin ulcer from which the organism was cultured. The case was hospitalized. The organism was cultured from the site of the tick bite. • Past incidence - The numbers of cases in Illinois by year are as follows: 1991 (five), 1992 (two), 1993 (three), 1994 (three), 1995 (four), 1996 (four), 1997 (five), 1998 (five), 1999 (two), 2000 (four), 2001 (14), 2002 (five), 2003 (one), 2004 (five), 2005 (one) and 2006 (one).

Summary One case of tularemia was reported in 2007. The case probably acquired infection through a tick bite in Missouri.

Suggested readings Turabelidze, G. et. al. Tularemia – Missouri, 2000-2007. MMWR 2009; 58(27): 744-48.

201 Typhoid Fever

Background Typhoid fever is a systemic infection caused by infection with Salmonella enterica serotype Typhi. The incubation period is from three days to three months with a usual range of one to three weeks. Transmission of typhoid fever is usually by ingestion of food or water contaminated by fecal or urinary carriers of S. enterica serotype Typhi. Types of products implicated in some countries include shellfish, raw fruits, vegetables and contaminated milk or milk products. Unlike other types of Salmonella, S. enterica ser. Typhi is not found in animal reservoirs; humans are the only reservoirs. In developed countries like the United States, most cases are sporadic after travel to endemic areas. The infectious dose ranges from 1,000 to 1 million organisms. Constipation is more common than diarrhea in adults. The onset of bacteremia with typhoid fever results in fever, headache, abdominal discomfort, dry cough and myalgia. Other findings may include bradycardia, rash and splenomegaly. Complications may include gastrointestinal , intestinal perforation and typhoid encephalopathy. Relapse may occur in 5 percent to 10 percent of patients, usually two to three weeks after resolution of fever. As many as 10 percent of untreated patients will shed organisms in the feces for up to three months. One percent to four percent may develop long-term carriage of the organism for as long as one year. Most carriers are asymptomatic. Chronic carriage is more common in women, the elderly and in patients with cholelithiasis. Typhoid fever is typically diagnosed with blood cultures. Bone marrow cultures also can be used. For travelers to developing countries, water should be boiled or bottled and food should be thoroughly cooked to avoid acquiring typhoid fever. Vaccination is recommended for persons traveling to areas where typhoid is endemic. In 2007, 434 typhoid fever cases were reported in the United States. Approximately three fourths of all cases occur among persons who report international travel during the prior month.

Case definition A confirmed case is a clinically compatible illness with isolation of S. enterica ser. Typhi from blood, stool or other clinical specimen. A probable case is defined as a clinically compatible illness that is epidemiologically linked to a confirmed case in an outbreak.

Descriptive epidemiology • Number of cases reported in Illinois in 2007 – 24 (five-year median = 18) (see Figure 99). All were confirmed cases. • Sex – Thirteen (54 percent) were male. • Age - Cases ranged in age from four to 61 years of age (median = 26 years). • Race/ethnicity – Thirteen of 21 (62 percent) were Asian; one (5 percent) was white, two (9 percent) were African American and five (24 percent)

202 were other races. Two of 17 reporting ethnicity (12 percent) were Hispanic. • Seasonal variation – Cases were reported from January through December with no seasonal increase. • Geographic distribution – Fifty percent of the cases were Cook County residents and 29 percent were Dupage residents. • Reporting – Fifty-eight percent were reported by laboratories and 42 percent were reported by infection control professionals. • Diagnosis – The specimen testing positive was blood (16), stool and blood (two), stool (four) and unknown (two). Ten different PFGE patterns were reported in isolates from the 11 persons tested by PFGE. Two isolates were Xba1 pattern StyO7X4 and one was StyO6X3. The two with the same pattern were not from the same household but both had been in Pakistan. • Employment - No cases were reported to be in sensitive occupations. • Treatment/outcomes - Eighteen of 23 cases (78 percent) were hospitalized. No deaths were reported. • Risk factors - Travel destinations for imported cases included India (10), Pakistan (four), Mexico (two), Bangladesh (one), Thailand (one) and Indonesia (one). Three persons reported no travel and no source of infection could be identified. One person had an unknown travel history and one had travel to an unknown location. Two Dupage County residents had not traveled outside the country but isolates were not PFGE’d. In 1999 a cluster of non- travel associated typhoid fever cases occurred in the same city of Glen Ellyn.

Summary There were 24 typhoid fever cases reported in Illinois in 2007. Illinois had the third highest number of cases in the United States. Most cases were acquired outside the United States. India and Pakistan were the most common travel destinations for those cases who reported travel outside the United States.

Figure 99. Typhoid Fever Cases in Illinois, 2002-2007

30 23 24 25 18 18 20 17 16 15 10 5

Number Number of cases 0 2002 2003 2004 2005 2006 2007 Year

203 Varicella (chickenpox)

Background Chickenpox (varicella), a highly infectious disease caused by varicella- zoster virus (VZV), is characterized by sudden onset of slight fever and a rash. Lesions present with successive crops and several stages of maturity present at the same time. Serious complications of varicella may occur and can include pneumonia, secondary bacterial infections, hemorrhagic complications and encephalitis. Herpes zoster (HZ) or shingles is a local manifestation of reactivation of latent varicella in dorsal root ganglia. Severe pain and paresthesia may accompany this manifestation. Fifteen percent to 30 percent of the population experience HZ during their lifetime. Postherpetic neuralgia can occur with debilitating pain weeks to months after resolution of HZ. Risk factors for HZ include initial infection with varicella in utero or when younger than 18 months of age. Intrauterine VZV infection can result in congenital varicella syndrome, neonatal varicella or HZ during infancy or early childhood. The incubation period is 14 to 16 days after exposure to rash (range 10 to 21 days). A person is communicable for one to two days before rash onset and remains infectious until the rash is crusted over (usually four to seven days after rash onset). The disease is transmitted through direct contact between persons, droplet or airborne spread of vesicle fluid or respiratory tract secretions or indirectly through fomites. Secondary attack rates in households can be 90 percent. Varicella related deaths became nationally notifiable in 1999 to allow for evaluation of the vaccine program. In the United States, six varicella deaths were reported to CDC in 2007. There were 40,146 individual varicella cases reported. Two live attenuated vaccines are available for varicella zoster virus in the United States. One was licensed in 1995 and the other in 2005. Recommendations for varicella preventive are to: 1) Implement two-dose varicella vaccination program for children (the first dose at 12-15 months and the second at 4 to 6 years) 2) Provide a second catch-up varicella vaccination for children adolescents and adults who had previously received one dose’ 3) Encourage routine vaccination of all healthy persons aged greater than 13 years without evidence of immunity 4) Conduct prenatal assessment and postpartum vaccination 5) Expand use of varicella vaccination for HIV-infected children with age-specific CD4 and T lymphocyte percentages of 15 percent to 24 percent and adolescentsand adults with CD4 and T lymphocyte counts greater than 200 cells/ul 6) Establish middle school, high school and college entry vaccination requirements

In 2003, IDPH required reporting of adult chickenpox (in those over 20 years of age) within 24 hours under the Medical Studies Practice Act. The

204 Department requests voluntary reporting of varicella deaths. Permanent rules and regulations were passed in March 2008. This reporting was implemented because a case of smallpox in an adult might be misidentified as a case of chickenpox.

Case definition The clinical case definition is an illness with acute onset of generazlied macula- papulovesicular rash without other apparent cause. The laboratory criteria for diagnosis is: isolation of varicella virus from a clinical specimen, OR DFA positive, or PCR positive or significant rise in varicella IgG antibody. A confirmed case is one that is laboratory confirmed or that meets the clinical case definition and is epidemiologically linked to another probable or confirmed case. A probable case is a case that meets the clinical case definition, is not laboratory confirmed and is not epidemiologically linked to another probable or confirmed case.

Descriptive epidemiology • Number of cases – The total number of cases reported was 1,091. In adults (21 years of age or older) 105 cases were reported. Fifty-six of the adult cases were confirmed; the rest were probable. The summary below only includes adult varicella cases. • Sex – Forty-eight percent of cases were female. • Age – Cases ranged in age from 21 to 87 years of age (mean = 34). • Race/ethnicity – Cases were African American (24 percent), white (47 percent), Asian (22 percent) and other (6 percent). Twenty-five percent were Hispanic. • Geographic distribution – Cases were reported from 21 counties. • Outcomes – Seventeen percent of adult chickenpox cases were hospitalized. • Fatalities – No varicella deaths were reported in adults in 2007. • Reporters – The most common reporter was infection control professionals (41 percent),

Summary Varicella (chickenpox) is reportable in aggregate in Illinois, and over 1,000 cases were reported in 2007. The number of reported chickenpox cases has been declining since 1997. There were 105 adult cases. No fatal adult cases were reported in 2007. The goal for vaccination levels is 90 percent by 2010.

205 Vibrio Non-cholera

Background Vibrio parahaemolyticus infection causes acute diarrhea, vomiting and fever for 1 to 3 days. The incubation period usually occurs within 24 hours after eating contaminated food. Foods most often associated with this illness include raw or undercooked shellfish or other cooked foods that have been cross contaminated with raw shellfish. Vibrio spp multiply rapidly and can increase quickly if sea food is not rapidly refrigerated after harvest and kept at proper temperatures. Diagnosis is by culturing stool specimens in persons with shellfish consumption history and symptoms. The selective media, thiosulfate-citrate-bile salts-sucrose (TCBS), can be used to isolate the organism. It is estimated that 20 cases actually occur for every laboratory confirmed case reported to CDC. In CDC FoodNet data the incidence was 0.2 per 100,000 (range at FoodNet sites: 0.0 to 0.46). The incidence did not change between 2004-2006 and 2007. The Vibrio species identified were V. parahaemolyticus (56 percent), V. alginolyticus (16 percent) and V. vulnificus (12 percent). In January 2007, vibriosis became a nationally notifiable disease. Nationally 549 cases were reported in 2007. Shellfish should be thoroughly cooked to kill pathogens, like V. parahaemolyticus.

Case definition A confirmed case is a clinically compatible case from which Vibrio spp. has been isolated from a clinical specimen. A probable case is a clinically compatible case that is epidemiologically linked to a confirmed case; or a clinically compatible case who consumed epidemiologically incriminated food (usually seafood) from which 1 million or more organisms per gram have been identified.

Descriptive epidemiology - V. parahaemolyticus • Cases – Four cases were reported in 2007. All were confirmed. • Seasonal – Cases were reported from May to November. • Race – One case was white, one was Asian, one reported being an “other” race and one did not report race; one person reported being Hispanic. • Sex – Seventy-five percent were male. • Age – Cases ranged from one to 61 years of age (mean = 34). • Geographic location – Three cases resided in Cook County and one in Dupage County. • Risk factors – Two cases reported eating raw oysters, one had no known risk factor and one could not be interviewed. • Outcome – One case was hospitalized. No cases were reported to be fatal. • Reporter – One was reported by a laboratory, two were reported by hospitals and one had an unknown reporter.

206

Descriptive epidemiology - other Vibrio species • Cases - Four cases were reported in 2007. All were confirmed. • Seasonal – Cases were reported from July to September. • Race – Three of three cases with race listed were white; two were Hispanic. • Sex – Fifty percent of the cases were male. • Outcome – All three cases with a hospitalization history were hospitalized. One case of V. cholerae non-01 was fatal. • Reporter – One case was reported by a laboratory, two by hospitals and one by a university health care center. • Age – Cases ranged in age from 7 years to 55 years of age (mean = 31). • Geographic – Three counties reported cases including Cook (two cases), McHenry (one) and Vermilion (one). • Species – Vibrio species identified in cases included Vibrio alginolyticus (one), Vibrio cholerae non 01 (one), (one) and Vibrio hollisae (one). • Site of isolation – All but the V. alginolyticus case had isolates from stool. The V. alginolyticus isolate was from a wound. • Risk factors – The V. vulnificus case reported seafood consumption. The V. alginolyticus had cellulites after cutting herself on an oyster in South Carolina waters. No history could be obtained from the V. cholerae non-01 or the V. hollisae case.

Summary A total of eight Vibrio cases were reported in Illinois in 2007. This was the first year Vibrio became a nationally notifiable disease.

Suggested readings Centers for Disease Control and Prevention. FoodNet 2007 Surveillance Report. Atlanta: U.S. Department of Health and Human Services, 2009.

207 Yersiniosis

Background Yersiniosis, an infrequently reported cause of diarrhea in the United States, is caused by Yersinia enterocolitica or Y. pseudotuberculosis. Transmission is by the fecal-oral route, through consumption of contaminated food or water or by contact with infected people or animals. The incubation period is three to seven days. Fecal shedding occurs for as long as symptoms are present, usually two to three weeks. Manifestations of the disease include an acute febrile diarrhea and abdominal pain. Symptoms can mimic appendicitis. Bloody diarrhea is seen in 10 percent to 30 percent of children with Y. enterocolitica. Animals are the principal reservoir for Yersinia, with the pig the primary reservoir of Y. enterocolitica and rodents as the main reservoirs for Y. pseudotuberculosis. Most pathogenic strains of Y. enterocolitica have been isolated from raw pork or pork products. Chitterling consumption or contact with someone preparing chitterlings is a common exposure history for those with yersiniosis. Yersinia is cold-tolerant and can replicate under refrigeration. Of the 10 diseases (those caused by Campylobacter, Cryptosporidium, Cyclospora, E. coli O157:H7, HUS, Listeria monocytogenes, Salmonella, Shigella, Vibrio and Yersinia enterocolitica) under active surveillance in the federal FoodNet sites, Yersinia comprised 0.98 percent of the reported infections in data from 2007. The incidence rate per 100,000 for yersiniosis in 2007 data was 0.36 (range from 0.15 to 0.51) at the 10 FoodNet sites. The incidence of Yersinia infections did not change between 2004-2006 and 2007.

Case definition The case definition in Illinois includes only a positive culture for Yersinia. A probable case is an case epidemiologically linked to a confirmed case.

Descriptive epidemiology • Number of reported cases in Illinois in 2007 - 24 (five-year median = 25) (see Figure 100). The incidence rate per 100,000 was 0.19. All were confirmed. • Age – Six cases (25 percent) occurred in those younger than 1 year of age. (Figure 101). • Gender – Sixty-seven percent of cases were female. • Race/ethnicity – Forty-three percent were African American and 48 percent were white. None were Hispanic. • Seasonality – Figure 102 shows the case onsets by month. • Geographic location – Forty-four percent of cases were residents of Cook County. • Clinical history – Seventeen of 20 (85 percent) had diarrhea; six of 20 (30 percent) had vomiting, and nine of 20 (47 percent) had fever. • Outcome – For 22 cases with complete case information, 10 cases were hospitalized and no cases were reported to be fatal. • Risk factors – History of chitterling consumption was obtained for 14 cases, and two had exposure to chitterlings. Both cases with chitterling consumption

208 were less than one years of age. • Reporting – The most important source of reporting was laboratories (13 cases) followed by infection control professionals (10 cases).

Summary The yersiniosis incidence rate of 0.14 per 100,000 for 2007 in Illinois was lower than that found in the CDC’s FoodNet sites. One-quarter of Illinois cases in 2007 occurred in children younger than a year old.

Suggested readings Centers for Disease Control and Prevention. FoodNet 2007 Surveillance Report. Atlanta: U.S. Department of Health and Human Services, 2009. Vugia, D., et. al. Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food-10 states, 2007. MMWR 2008; 57(140: 366-69.

Figure 100. Yersiniosis Cases in Illinois, 2002-2007

40 31 28 25 25 30 22 24 20 10

Number of cases Numberof 0 2002 2003 2004 2005 2006 2007 Year

Figure 101. Age Distribution of Yersiniosis Cases in Illinois, 2007

8 6 4 2

Number of cases 0 <1 yr 1-4 yr 5-9 yr 10-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr >59 yr Age Group

209 Figure 102. Yersinia Cases in Illinois by Month, 2007

6

4

2

Number of cases Numberof 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year

210 Non-foodborne, Non-waterborne Outbreaks, 2007

Case definition A non-foodborne, non-waterborne (NFNW) outbreak is an incident in which two or more persons (usually residing in separate households) experience the onset of a similar, acute illness following a common exposure (other than ingestion of common food or drink or exposure to recreational water). For NFNW outbreaks, the number ill reflects those who meet a clinical case definition. For outbreaks where the etiologic agent was suspected and not confirmed, and the clinical syndrome matched the suspect etiologic agent but no laboratory confirmation was obtained, the suspect cause is ascribed to this etiologic agent. The Department receives reports of potential NFNW outbreaks from many sources. Outbreak investigations, which are conducted by local health departments, may not result in an Illinois NFNW outbreak designation and will not be counted in the state totals.

Descriptive epidemiology • Number of outbreaks – There were 103 NFNW outbreaks reported and counted as an outbreak in 2007. The number of outbreaks by month is shown in Figure 103. • Pathogens – Pathogens causing these outbreaks included bacterial causes (26 outbreaks), viral (65 outbreaks), fungal (two outbreaks) and unknown (10 outbreaks) (Tables 18 and 19). The viral outbreaks included norovirus (63) and enteroviruses (two). The bacterial outbreaks included Shigella sonnei (10), methicillin resistant S. aureus (MRSA) (seven), Salmonella (three), group A Streptococcus (one), S. aureus (one), C. difficile (one), Campylobacter (one), Q fever (one) and Serratia marcescens (one). The two fungal outbreaks were due to histoplasmosis. A listing of individual outbreaks is provided in Table 20.

Figure 103. Number of Non-foodborne Non-waterborne Outbreaks by Month of First Onset, Illinois, 2007

30

Number of 20 outbreaks reported 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month

211

Table 18. Non-foodborne Non-waterborne Outbreaks, Cases, and Deaths by Etiology in Illinois, 2007 Outbreaks Cases Deaths Etiology# Count % Count % Count % Bacterial S. marcescens 1 22 0 C. difficile 1 6 0 S. aureus, sensitive 1 6 0 MRSA 7 29 0 Campylobacter 1 3 0 Salmonella 3 64 0 Shigella 10 61 0 Streptococcus, Group A 1 2 1 Q fever 1 4 0 Total Bacterial* 26 197 1 Viral Norovirus 63 97 2519 99 0 -- Enterovirus 2 3 12 1 0 Total Viral 65 2531 0 Fungi Histoplasmosis 2 5 0 Total Fungal 2 5 0 UNKNOWN 10 394 0

Table 19. Non-foodborne Non-waterborne Outbreak Pathogens by Testing Status in Illinois, 2007 Confirmed Suspected Unknown Etiology Count % Count % Count % Bacterial S. marcescens 1 0 C. difficile 1 0 S. aureus 1 0 MRSA 7 0 Campylobacter 1 0 Salmonella 3 0 Shigella 10 0 Invasive Streptococcus, Group A 1 0 Q fever 1 0 Total Bacterial Viral Norovirus 36 27 Enterovirus 1 1 Total Viral 37 28 Fungi Histoplasmosis 2 0 Total Fungal 2 0 Unknown 10

212

Specific Types of NFNW Outbreaks

BACTERIAL OUTBREAKS There were 26 bacterial NFNW outbreaks reported in 2007. These included the following pathogens: Shigella (10), MRSA (seven), Salmonella (three), invasive Group A Streptococcus (one), Campylobacter (one), C. difficile (one), Q fever (one), Serratia (one) and S. aureus non methicillin resistant (one).

Campylobacter Background Non-foodborne non-waterborne Campylobacter outbreaks can be caused by contact with animals or animal feces.

Descriptive epidemiology There was one NFNW outbreak of Campylobacter reported in 2007.

Individual description • Three cases of Campylobacter occurred in persons who reported handling poultry at a friend’s house in Winnebago County.

C. difficile

Background C. difficile is a spore forming bacteria. This organism can produce two toxins (A and B). The organism can cause diarrhea and pseudomembranous . Many cases have been on antimicrobials prior to onset of illness. Asymptomatic carriers are possible. The symptoms can recur after treatment. The mortality ranges from 1 percent to 2.5 percent. The incidence and severity has been increasing in the United States. Community-associated C. difficile also is being observed. Approximately one-third of cases had no prior antimicrobial use.

Descriptive epidemiology Number of outbreaks – One outbreak of C. difficile was reported in Illinois in 2007. Individual description • A cluster of six cases of C. difficile occurred in a long-term care facility associated with a hospital in McHenry County.

MRSA Background Methicillin resistant S. aureus (MRSA) can cause skin and soft tissue infections. These infections can cluster in various situations including sports

213 teams, prisons and other locations where crowding and close contact between persons occurs.

Case definition Two or more laboratory confirmed MRSA cases with a common non health-care associated epidemiologic link would be needed to be considered a confirmed outbreak.

Descriptive epidemiology The seven MRSA outbreaks took place in Dupage, Randolph, St Clair, Coles, Cook, Madison and LaSalle Counties. Outbreaks took place in a hospital (two), work site (one), university (one), developmentally delayed facility (one), assisted living (one) and school (one). Twenty-nine individuals with MRSA were involved in the seven outbreaks. The outbreaks took place in April (one), May (one), June (one), July (one), August (two) and November (one).

Individual Outbreak Descriptions . A cluster of three cases of MRSA infection occurred in a high school in Dupage County in April. Skin lesions occurred in one student, one teacher and a boyfriend of another teacher. . A cluster of three cases of MRSA skin infections occurred in three residents at a mental health hospital in Randolph County in May. An additional three persons were identified as nasally colonized with MRSA. . A cluster of two cases of MRSA occurred at a work site in St Clair County. One onset was in January and another in June. Both were soft tissue skin infections and neither case required hospitalization. . A cluster of six cases of MRSA occurred in a university in Coles County in August. . A cluster of four skin and soft tissue infections due to MRSA were identified in a facility for the developmentally disabled in Cook County in July. . A cluster of eight confirmed MRSA skin and soft tissue infections occurred in an assisted living facility in Madison County in August. . A cluster of three MRSA cases occurred in neonates born at a hospital in LaSalle County in November. Onsets occurred at 14 to 21 days of age.

Q fever Background Q fever, caused by Coxiella burnetti can cluster in persons in contact with infected animals, especially sheep and goats.

Case definition A cluster of two or more cases of Q fever identified with a common epidemiologic link.

Descriptive epidemiology Number of outbreaks reported – One outbreak of Q fever was reported in Illinois

214 in 2007.

Individual Outbreak Description • Four cases of Q fever (1 confirmed, 3 probable) occurred in workers at a slaughter plant in Carroll County from May to June 2007. Symptoms included fever, retrobulbar headache, myalgia and cough. On person had a four-fold rise in titer on acute and convalescent serum samples and three persons had a single serum sample positive. One person was hospitalized. At this facility pregnant goats were slaughtered.

Salmonella Background Non foodborne, non waterborne Salmonella outbreaks can occur due to contact with animals or from person to person exposure.

Case definition A NFNW outbreak is defined as multiple cases of the same Salmonella serotype with a common epidemiologic link that is not transmitted by foodborne or waterborne means.

Descriptive epidemiology Number of outbreaks reported – There were three NFNW Salmonella outbreaks reported in Illinois in 2007. Sixty-four persons were affected in the three outbreaks. Two of the outbreaks were associated with animal contact. In one outbreak the source was turtle contact and in the other poultry contact was suspected as the cause of infection. In the third outbreak a source could not be identified. Two outbreaks were multi-state and one was in Madison County residents.

Individual Descriptions • A multi-state outbreak of Salmonella infection occurred in persons with turtle contact in 2007. Both paratyphi B and I 4,5,12:b:- serotypes were involved. Five Illinois residents matched the national pattern and reported turtle exposure. Cases occurred from June through September and both Lake and Cook County residents were affected. • Two cases of Salmonella ser. Montevideo from separate households in Madison County with onsets in May reported exposure to poultry. Both PFGE matched a multi-state outbreak linked to baby chick exposure. The PFGE pattern was J1XX01.0049. Both cases reported purchasing baby chicks from the same local chain feed store. One case had direct contact with the baby poultry and the second case had another household member who had contact with the baby poultry. A letter was sent to the feed store headquarters reminding them that it is not legal to sell baby poultry in Illinois as pets. • A cluster of 57 S. ser. Muenchen cases with matching PFGE patterns occurred in Illinois in 2007. Onsets of cases ranged from April 5 through

215 June 13. Cases were residents of 14 counties. Twenty-six were female and 30 were male, one did not have sex listed. The PFGE pattern was CDC JJ6X01.0641 or Illinois Smu07X8. It was not possible to identify a source of infection for these cases.

Serratia marcescens Background S. marcescens is the species of Serratia most commonly seen in human infections. This organism is common in the environment. S. marcescens can cause a wide variety of nosocomial infections. The most common site of infection is the urinary tract but it is also frequently isolated from wounds and the respiratory tract.

Case definition A confirmed outbreak would be a report of multiple cases of S. marcescens in a single facility within a short period of time.

Descriptive epidemiology Number of outbreaks reported - A single outbreak of S. marcescens was reported in Illinois in 2007.

Individual outbreak description • Twenty-two cases of Serratia marcescens from exposure to contaminated prefilled syringes were reported in Chicago. This was a multi-state outbreak.

Shigella Background The Shigella organism can cause person-to-person outbreaks. Symptoms include fever and diarrhea.

Case definition The case definition for an outbreak of Shigella is identification of the same serotype of the bacteria in two or more ill persons with a common epidemiologic link.

Descriptive epidemiology The counties where outbreaks took place included Rock Island (five), Champaign (three) and Winnebago (two). Sixty-one persons became ill with Shigella as part of the 10 outbreaks. The settings for the 10 outbreaks included day care (four), school (two), and one each for day camp, developmentally delayed facility, shelter and a head start program at a school. The outbreaks took place in January (one), March (two), April (one), June (one), July (one), August (one) and September (three). Individual Descriptions • A cluster of seven Shigella sonnei cases occurred in a school Head start

216 program in Winnebago County in January. Six were laboratory confirmed. No hospitalizations resulted from the cluster. • A Shigella outbreak was reported in a facility for the developmentally disabled in Winnebago in March. Ten residents, three staff and one family member of a resident became ill with S. sonnei. No ill persons were hospitalized. • In March a cluster of two cases of Shigella sonnei were identified in a day care center in Champaign County. Neither case required hospitalization. • A cluster of S. sonnei occurred in a shelter in Champaign County in April. Two were adults and two were children. Onsets of illnesses occurred from April 1 to April 20. • A cluster of three Shigella sonnei cases were associated with a day camp in Champaign County in June. Two cases attended the camp and one was a household member of someone who attended the camp. No cases required hospitalization. Seventy five persons attended the camp. • Six cases of S. sonnei occurred between July 11 and July 28 in attendees of a day care in Rock Island. • A cluster of six cases of S. sonnei occurred in an elementary school in Rock Island between August 24 and September 28. One case was an adult and five were in school children. Ages of children ranged from two to 12 years. • A cluster of four S. sonnei cases occurred in a Rock Island elementary school between September 15 and September 23. Three were children between the ages of 5 and 9 years and one was an adult. • A cluster of eight cases of S. sonnei occurred in a day care in Rock Island. Illness onset dates ranged from September 17 to November 15. Seven were children and one was an adult. • A cluster of seven cases of S. sonnei occurred in a day care in Rock Island. Illness onset dates ranged from September 30 through October 18. One was an adult and the rest were children between two and three years of age.

Confirmed Outbreaks 10 Total number of ills 61 Average number of ills/outbreak - Number of cases hospitalized 1 Number of fatalities 0 Outbreak months January 1 March 2 April 1 June 1 July 1 August 1 September 3 Counties of outbreaks

217 Champaign 3 Rock Island 5 Winnebago 2

Staphylococcus aureus, not resistant Background Sensitive isolates of non-invasive S. aureus can cause clusters of infection in neonatal units.

Case Definition Multiple isolations of S. aureus in babies in newborn nurseries are reportable in Illinois.

Descriptive epidemiology Number of clusters reported – A single cluster of S. aureus in a newborn nursery was reported in Illinois.

Individual outbreak description • A cluster of six cases of S. aureus occurred in a hospital newborn unit in Dupage County. Cases were non-invasive and isolates were not antimicrobial resistant. Four affected babies were born on September 5 and two on September 9.

Streptococcus, Group A

Background Invasive Group A Streptococcus infection involves persons with clinically compatible illness and cultures confirmed from a sterile site. Clusters of invasive Group A Streptococcus infection can be identified in group settings, especially long-term care facilities.

Case definition For invasive Group A Streptococcus outbreaks, a confirmed outbreak requires culture confirmation of two or more cases of sterile site group A Streptococcus in persons with a common epidemiologic link. For an outbreak of non-invasive Group A Streptococcus at least 10 persons with a common epidemiologic link must be clinically compatible and five test positive for Group A Streptococcus.

Descriptive Epidemiology Number of outbreaks – There was one outbreak of invasive group A Streptococcus affecting two persons reported in Illinois in 2007.

Individual outbreak description • Two invasive group A streptococcus cases occurred in a long-term care unit. Both persons were hospitalized. One case was fatal. Onsets of

218 illness were May 11 and May 16.

VIRAL OUTBREAKS There were 65 NFNW viral outbreaks reported. The majority were suspect or confirmed norovirus outbreaks (N = 63). Two outbreaks were caused by enteroviruses.

Norovirus outbreaks Background Noroviruses are the most common cause of sporadic cases of acute gastroenteritis. Noroviruses have a low infectious dose, environmental persistence and prolonged shedding. In long-term care facilities, incontinent residents can predispose a facility to outbreaks of norovirus. Norovirus outbreaks often occur in settings where cluster of vulnerable susceptible people live in close quarters (long term care, hospitals or day cares) or where turnover of susceptible people is high (hotels, cruise ships). A study showed that hygiene measures decreased virus reproduction number for norovirus but the chain of transmission could not be reduced to below one. In an outbreak of norovirus in a long-term residential facility in Oregon, facility employees who cleaned up vomitus were at higher risk for illness.

Descriptive epidemiology Number of outbreaks – Sixty-three person-to-person norovirus outbreaks were reported in 2007. Thirty-six outbreaks were confirmed and 27 were suspect. Of the 36 confirmed outbreaks, 30 were the G2 type, two were G1 and four had an unknown type. Of the 27 suspect outbreaks, eight were G2 and 19 were unknown types. The sites of the confirmed outbreaks were long-term care facilities (22), hospitals (four), assisted care facilities (three), day care (two) and one each for school, retirement community, developmentally delayed facility, drug treatment facility and private home. The confirmed norovirus outbreaks occurred in the following counties: Cook (nine), Winnebago (four), Madison (four), Kane (three), Morgan (three), Richland (two), Lake (two), Will (two), Sangamon (two) and one each in Hamilton, JoDaviess, Fulton, Dupage and Calhoun. There were 1,457 persons who became ill as a result of the confirmed norovirus outbreaks and 45 persons were hospitalized. There were 1,062 persons affected by the suspect norovirus outbreaks and 10 were hospitalized. An increase in norovirus outbreaks occurred in January and February (Figure 104).

Individual descriptions of confirmed outbreaks • An outbreak of norovirus occurred in an assisted living facility in Cook County in January. Twenty four persons became ill (20 residents and four staff members). Five ill persons of seven tested were laboratory confirmed with norovirus G2. Three persons were hospitalized. This was an assisted living facility regulated by DHFS.

219 • An outbreak of norovirus G2 occurred in a Hamilton County long-term care facility in January. Fifteen residents were ill with vomiting and diarrhea and five were laboratory confirmed. No staff members were ill. No persons were hospitalized. • An outbreak of norovirus G2 occurred in Winnebago County in January in a long-term care facility. Two persons tested positive for norovirus. Thirty- five persons became ill including 21 staff and 14 residents. No persons required hospitalization. • An outbreak of norovirus G2 occurred in Cook County in January. Thirty three persons (11 staff and 22 residents) of a long-term care facility became ill with vomiting and diarrhea. Two of three persons tested positive for norovirus. • The Chicago DPH reported a long-term care facility with gastrointestinal illnesses in residents and staff in January. Twenty residents and three staff were ill. Three were laboratory confirmed with norovirus G2. None were hospitalized. • In January, a norovirus outbreak occurred in a hospital-associated long- term care facility in Richland County. Seventeen persons (three staff and 14 residents) were ill and two of five tested positive for norovirus, type not provided. • A norovirus G2 outbreak occurred in a long-term care facility in Richland in January 2007. Eighty eight (47 staff and 41 residents) were ill with vomiting and diarrhea. Two were seen in an emergency department but no one was admitted. Two of three tested positive for norovirus G2. • In January a norovirus outbreak occurred in Cook County at a long-term care facility. Twenty persons became ill (1 staff and 19 residents). Three of three tested were positive for norovirus G2. • The Kane County Health Department reported a cluster of gastrointestinal illnesses in a hospital in January. Thirteen patients, six staff and one visitor became ill. Three of five stools tested positive for norovirus G2. • An outbreak of norovirus G2 was reported in a Chicago hospital in January. Thirty-six persons (28 staff and eight residents) became ill. • There were 37 persons (26 staff and 11 residents) who became ill at a skilled nursing unit at a hospital in Madison County in February. Four of six tested were positive for norovirus G2. No hospitalizations occurred. • There were 152 persons who became ill at a long-term care facility with norovirus in February in Lake County. Eight persons were hospitalized. Five of five persons tested were positive for norovirus G2. • An outbreak of norovirus G2 occurred in JoDaviess County in February. This outbreak took place in a long-term care facility associated with a hospital and involved 14 staff and 41 residents. Two were hospitalized. Five of five persons tested positive for norovirus G2. • In February, an outbreak of norovirus G2 occurred in a long-term care facility in Will County. Seventy eight persons (45 staff and 33 residents) became ill. Three of three stools tested were positive for norovirus. One person was hospitalized.

220 • In February, 21 persons (14 staff and seven residents) became ill at a hospital in Sangamon County. Six of 10 persons tested positive for norovirus G2. • In Madison County, an outbreak of norovirus occurred in a long-term care facility in February. Sixty-three persons (18 staff and 45 residents) became ill and four of six tested positive for norovirus G2. • Another outbreak in Madison County in February involved 24 ill persons at a long-term care facility associated with a hospital. Two of seven persons tested positive for norovirus G2. • Persons at a long-term care facility in Madison County experienced a norovirus G2 outbreak in late February. Eighty-nine persons (33 staff and 56 residents) became ill. Three of five persons tested positive for norovirus G2. No persons were hospitalized. • A norovirus outbreak was reported from a long-term care facility in Morgan County in February. Three of six persons tested positive for norovirus G2. The number ill was 49 persons (26 residents and 23 staff). No persons were hospitalized. • The Kane County Health Department reported a norovirus G2 outbreak in an assisted living facility in February. Thirty-three persons (24 patients and nine staff members) were ill. Two of two persons tested were positive for norovirus G2. • A Fulton County long-term care facility reported a cluster of norovirus G2 in February. Twenty-four persons (six staff and 18 residents) became ill. Two of five tested positive for norovirus G2. • A Skokie LTC facility reported a norovirus outbreak involving 15 persons (all ill persons were residents) in February. Two of three persons tested positive for norovirus G2. Three persons were hospitalized. • The Winnebago County Health Department reported a norovirus outbreak associated with an elementary school in late February. Ninety-five persons became ill. Four of eight tested positive for norovirus G1. • A Will County long-term care facility reported a norovirus G2 outbreak in March. Forty-eight (41 residents and seven employees) experienced gastrointestinal illness. Eighteen were hospitalized. • A retirement community experienced an outbreak of norovirus G2 in March in Morgan County. Seventy-six persons (23 staff and 53 residents) became ill. Three of four persons tested positive for norovirus G2. • A hospital LTC facility in Dupage County reported a cluster of gastrointestinal illnesses in March. Four residents and no staff became ill. Four of four persons tested were positive for norovirus at a commercial laboratory. • Fifty-seven persons (11 staff and 46 residents) became ill with norovirus at a long-term care facility in Calhoun County in April. Two of five persons tested positive for norovirus G2. No one required hospitalization. • A day care center in Kane County reported a cluster of norovirus infections in six staff members and 25 children in May. Two of two persons tested positive for norovirus G2.

221 • Persons at a facility for the developmentally disabled developed norovirus G2 infection in May in Cook County. Thirty-four persons became ill. Three of three persons tested positive for norovirus G2. None required hospitalization. • A cluster of illnesses occurred in a drug treatment center in Chicago in August. Three persons became ill with vomiting and diarrhea and two tested positive for norovirus G1. • Fourteen persons reported illness after a group met at a private home in August in Winnebago County. Two persons tested positive for norovirus G2. • A group of children at a daycare in Winnebago County developed diarrhea and vomiting in August. Two tested positive for norovirus G2. Twenty- seven (7 staff and 20 children) were affected. None were hospitalized. • Seventeen (15 staff and two residents) of a hospital experienced gastrointestinal illness associated with norovirus G2. This outbreak occurred in Sangamon County in November. • Thirty-six (7 staff and 29 residents) became ill in December in a Morgan County assisted living facility. Two persons were hospitalized. • A long-term care facility in Cook County had 46 persons ill (four staff and 42 residents) with norovirus in December. Sixteen of 20 tested positive for norovirus at a commercial laboratory. Thirteen individuals were hospitalized. • Eighteen persons became ill with norovirus in December at a long-term care facility in Lake County. The type of norovirus was unknown.

Suggested readings Hedberg, K., et. al. Recurring norovirus outbreaks in a long-term residential treatment facility – Oregon, 2007. MMWR 2009; 58(25):694-698. Heijne, J.C.M., et. al. Enhanced hygiene measures and norovirus transmission during an outbreak. Emer Inf Dis 2009;15(1):24-30.

Figure 104. Norovirus Outbreaks by Month in Illinois, 2007

25 20 15 Suspect 10 Confirmed 5

Number of cases 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year

222 Norovirus Confirmed Suspected Outbreaks 36 27 Total number of ills 1,457 1,062 Average number of ills/outbreak Number of cases hospitalized 45 10 Number of fatalities Outbreak months January 10 10 February 13 5 March 3 4 April 1 0 May 2 0 June 0 0 July 0 0 August 3 0 September 0 0 October 0 0 November 1 4 December 3 4 Counties of outbreaks Bond 0 1 Brown 0 1 Calhoun 1 0 Clinton 0 1 Cook 9 3 DuPage 1 3 Fulton 1 0 Hamilton 1 0 Jo Daviess 1 1 Kane 3 0 Lake 2 0 Macon 0 1 Madison 4 2 Massac 0 1 McLean 0 2 Morgan 3 0 Richland 2 0 St Clair 0 2 Sangamon 2 4 Stephenson 0 1 Tazewell 0 1 Wabash 0 1 Will 2 0 Winnebago 4 2

Enterovirus Background Enteroviruses can cause serious disease in neonates. Neonatal systemic

223 enteroviral disease is characterized by multiorgan involvement and can be a fatal condition. Typical presentations include encephalomyocarditis and hemorrhage- hepatitis syndrome. Enterovirus infections are common, especially during the summer and fall months and typically are spread person-to-person via the fecal- oral or oral-oral routes and through respiratory droplets and fomites. Perinatal transmission can occur around the delivery time.

Case Definition Multiple cases of enterovirus in a common facility can be considered an outbreak.

Descriptive epidemiology Number of outbreaks reported – One confirmed and one suspect outbreak were reported in 2007. Both occurred in hospitals. Twelve individuals were affected.

Individual Descriptions of Confirmed Outbreaks • A cluster of Coxsackie B1 infections in neonates were reported in Chicago, Illinois. One case was fatal and one required a heart transplant. The cluster was identified in September 2007 after two cases of severe neonatal disease at a hospital in Chicago.

Suggested readings Mascola, L., et. al. Increased detections and severe neonatal disease associated with Coxsackievirus B1 infection-United States, 2007. MMWR 2008; 57(20):553-556.

Fungal Outbreaks Histoplasmosis Background Outbreaks of histoplasmosis have been identified previously in Illinois and are most commonly associated with occupational exposures, such as bridge repair or earth moving activities.

Individual descriptions • One cluster of histoplasmosis occurred in three of six Grundy County residents. They traveled to southern Illinois for a hunting trip in January and developed symptoms later that month. All three developed histoplasmosis. No specific exposure site could be identified that might have posed a risk. • Another cluster of at least two probable histoplasmosis cases occurred in workers at a bridge construction site in Peoria County. One Peoria resident and one Chicago resident were documented histoplasmosis cases. Onsets of illness were in September and November.

224 Confirmed Outbreaks 2 Total number of ills 5 Average number of ills/outbreak - Number of cases hospitalized Number of fatalities 0 Outbreak months January 1 September 1 Counties of outbreaks Grundy 1 Peoria 1

225 Table 20. Non-foodborne and non-waterborne outbreaks in Illinois in 2007.

Exposure IDPH Log Onset Ill/ Exposure Location of Number Date City County Exposure Symptoms* source Agent Implicated Status exposure

IL2007-001 1 / 1 Melrose Park Cook 24/24 D,V Person-person Norovirus G2 C Assisted living

IL2007-004 1 / 2 Rockford Winnebago 35/U D,V Person-person Norovirus G2 C LTC

IL2007-002 1 / 4 Mt. Sterling Brown 62/104 D,V Person-person Norovirus S LTC

IL2007-005 1 / 4 Woodstock McHenry 6/U D Unknown C. difficile C LTC-hospital

IL2007-009 1 / 5 Metropolis Massac 40/160 D,V Person-person Norovirus S LTC

IL2007-003 1 / 7 Mcleansboro Hamilton 15/U D,V Person-person Norovirus G2 C LTC

IL2007-021 1/8 Scales Mound Jo Daviess 72/296 D,V Person-person Norovirus S school

School-Head IL2007-030 1/8 Rockford Winnebago 7/13 D,V Person-person Shigella sonnei C Start

IL2007-010 1/9 Wheeling Cook 33/U D,V Person-person Norovirus G2 C LTC

IL2007-020 1/11 Bethalto Madison 73/186 D,V Person-person Norovirus S LTC

IL2007-016 1/13 Olney Richland 88/326 D,V Person-person Norovirus G2 C LTC

IL2007-022 1/15 Rockford Winnebago 28/U D,V Person-person Norovirus S LTC

226 IL2007-019 1/15 Northbrook Cook 20/U D,V Person-person Norovirus G2 C LTC

IL2007-018 1/15 Granite City Madison 39/185 D,V Person-person Norovirus G2 S LTC

IL2007-011 1/15 Chicago Cook 23/55 D,V Person-person Norovirus G2 C LTC

IL2007-013 1/15 Des Plaines Cook 20/U D,V Person-person Norovirus S Assisted living

IL2007-017 1/16 Trenton Clinton 31/38 D,V Person-person Norovirus G2 S Assisted living

IL2007-105 1/17 E. St Louis St Clair 2/10 SSTI MRSA C Worksite

IL2007-014 1/20 Olney Richland 17/28 D,V Person-person Norovirus C LTC-hospital

Cough, chest Multiple IL2007-069 1/22 Grundy 3/6 pain,fever Inhalation Histoplasmosis C households

IL2007-026 1/24 Oak Park Cook 59/64 D,V Person-person Norovirus S school

IL2007-023 1/27 Elgin Kane 20/25 D,V Person-person Norovirus G2 C Hospital

IL2007-025 1/30 Greenville Bond 8/16 D,V Person-person Norovirus G2 S Assisted living

IL2007-035 1/31 Chicago Cook 36/U D,V Person-person Norovirus G2 C Hospital

IL2007-033 2/1 Galena Jo Daviess 55/121 D,V Person-person Norovirus G2 C LTC-hospital

IL2007-032 2/1 Libertyville Lake 152/610 D,V Person-person Norovirus G2 C LTC

227 IL2007-027 2/3 Rockford Winnebago 7/U D,V Person-person Norovirus S LTC

IL2007-028 2/3 Alton Madison 37/60 D,V Person-person Norovirus G2 C LTC-hospital

IL2007-031 2/6 Decatur Macon 14/65 D,V Person-person Norovirus G2 S LTC-hospital

IL2007-034 2/9 Beecher Will 78/146 D,V Person-person Norovirus G2 C LTC

IL2007-036 2/10 Springfield Sangamon 21/90 D,V Person-person Norovirus G2 C hospital

IL2007-037 2/12 Wood River Madison 63/U D,V Person-person Norovirus G2 C LTC

IL2007-041 2/16 Alton Madison 24/62 D,V Person-person Norovirus G2 C LTC-Hospital

IL2007-040 2/17 Springfield Sangamon 13/178 D,V Person-person Norovirus S LTC

IL2007-045 2/18 Aurora Kane 33/60 D,V Person-person Norovirus G2 C Assisted living

IL2007-042 2/20 Alton Madison 89/213 D,V Person-person Norovirus G2 C LTC

IL2007-049 2/23 Springfield Sangamon 72/136 D,V Person-person Norovirus S LTC

IL2007-050 2/24 Skokie Cook 15/128 D,V Person-person Norovirus G2 C LTC

IL2007-046 2/26 Astoria Fulton 24/65 D,V Person-person Norovirus G2 C LTC

Elementary IL2007-052 2/26 Rockford Winnebago 95/507 D,V Person-person Norovirus G1 C school

228 IL2007-053 2/27 Elmhurst DuPage 6/U D,V Person-person Norovirus S LTC-hospital

IL2007-055 2/28 Maryville Madison 65/190 D,V Person-person Unknown U LTC

IL2007-043 2/29 Jacksonville Morgan 49/136 D,V Person-person Norovirus G2 C LTC

IL2007-062 3/3 Pekin Tazewell 32/146 D,V Person-person Norovirus S LTC

Retirement IL2007-068 3/6 Jacksonville Morgan 76/135 D,V Person-person Norovirus G2 C community

IL2007-066 3/6 Rockford Winnebago 14/30 D Person-person S. sonnei C DD facility

IL2007-060 3/7 Joliet Will 48/140 D,V Person-person Norovirus G2 C LTC

IL2007-063 3/8 Rockford Winnebago 9/U D,V Person-person Unknown U Day care

IL2007-058 3/8 Freeport Stephenson 21/60 D,V Person-person Norovirus G2 S LTC

Retirement IL2007-061 3/9 Springfield Sangamon 22/149 D,V Person-person Norovirus S community

IL2007-067 3/16 Belleville St Clair 20/U D,V Person-person Unknown U LTC-Hospital

IL2007-065 3/16 Mt Carmel Wabash 66/186 D,V Person-person Norovirus G2 S LTC

IL2007-071 3/20 Elmhurst DuPage 4/U D,V Person-person Norovirus C LTC-hospital

IL2007-074 3/28 Champaign Champaign 2/15 D Person-person S. sonnei C Day care

229 IL2007-192 4/1 Urbana Champaign 4/27 D Person-person S. sonnei C Shelter

IL2007-082 4/2 Wheaton DuPage 3/U SSTI MRSA C High school

IL2007-076 4/2 Rockford Winnebago 27/U D,V Person-person Unknown U LTC

IL2007-079 4/8 Hardin Calhoun 57/U D Person-person Norovirus G2 C LTC

IL2007-057 4/15 Alton Madison 12/U D,V Person-person Unknown U Office S. ser. Muenchen IL2007-090 4/15 Multi-county 57/U D Unknown JJ6X01.0641 C Private homes

Slaughter IL2007-125 5/1 Shannon Carroll 4/12 F, cough Inhalation Q fever C plant

IL2007-086 5/2 West Dundee Kane 31/126 D,V Person-person Norovirus G2 C Day care

Animal contact- S. ser. IL2007-099 5/4 Highland Madison 2/U D poultry Montevideo C Private home Invasive Streptococcus, IL2007-093 5/11 Springfield Sangamon 2/290 Unknown Group A C LTC Developmenta lly disabled IL2007-091 5/11 Skokie Cook 34/52 D,V Person-person Norovirus G2 C facility

IL2007-098 5/13 Chester Randolph 3/U SSTI MRSA C Hospital

IL2007-094 5/20 Jacksonville Morgan 20/36 D,V Unknown Unknown U University

IL2007-116 6/11 Champaign Champaign 3/75 D Person-person S. sonnei C Day camp

230 S. I 4,5,12:b:- IL2007-197 6/18 Cook, Lake 5/U D Turtles and paratyphi B C Private homes

IL2007-120 7/11 Moline Rock Island 6/U D Person-person S. sonnei C Day care

Girl Scout IL2007-118 7/16 Stillman Valley Ogle 10/120 V Unknown Unknown U camp

IL2007-142 7/24 Palatine Cook 4/7 SSTI Person-person MRSA C DD facility

IL2007-152 8/1 Glen Carbon Madison 8/245 SSTI Person-person MRSA C Assisted living

IL2007-136 8/5 Great Lakes Lake 200/1000 D,V Person-person Unknown U Naval base

IL2007-134 8/6 Springfield Sangamon 10/U D,F Unknown Enterovirus S Hospital Drug treatment IL2007-137 8/6 Chicago Cook 3/U D,V Person-person Norovirus G1 C center

IL2007-145 8/17 Rockford Winnebago 27/204 D,V Person-person Norovirus G2 C Day care

IL2007-151 8/18 Rockford Winnebago 3/15 D Poultry contact Campylobacter C Private home

IL2007-139 8/18 Winnebago 14/14 D,V Person-person Norovirus G2 C Private home

IL2007-140 8/6 Charleston Coles 6/U SSTI Person-person MRSA C University

IL2007-168 8/24 Rock Island 6/U D Person-person S. sonnei C School Enterovirus IL2007-new Sept Chicago Cook 2/U Multi-organ Unknown (Coxsackie B1) C Hospital Clamp, IL2007-154 9/7 Downers Grove DuPage 6/U Non-invasive suspected S. aureus C Hospital

IL2007-169 9/15 Rock Island Rock Island 4/U D Person-person S. sonnei C School IL2007-170 9/17 Rock Island Rock Island 8/U D Person-person S. sonnei C Day care IL2007-171 9/30 Rock Island 7/U D Person-person S. sonnei C Day care Bridge construction IL2008-028 9/30 Peoria/Cook 2/U SOB, cough Inhalation Histoplasmosis C site IL2007-174 11/7 Normal Mclean 87/304 D,V Person-person Norovirus G2 S School

231 Day care- autistic IL2007-176 11/7 Evanston Cook 7/52 D,V Person-person Norovirus S students

IL2007-178 11/8 Elgin Kane 5/10 D,V Unknown Unknown U School

IL2007-189 11/9 Peru Lasalle 3/U SSTI Unknown MRSA C Hospital

IL2007-182 11/14 West Chicago Dupage 50/U F,V Person-person Norovirus S School

IL2007-211 11/24 Springfield Sangamon 17/U D,V Person-person Norovirus G2 C Hospital

IL2007-186 11/25 Danforth Iroquois 26/47 D,V Person-person Unknown U LTC

IL2007-190 11/29 Normal Mclean 47/151 D,V Person-person Norovirus S School

IL2007-196 12/2 Morgan 36/135 D,V Person-person Norovirus G2 C Assisted living

IL2007-195 12/6 Elmhurst DuPage 43/103 D,V Person-person Norovirus S Day care

IL2007-199 12/6 Cook 46/U D,V Person-person Norovirus C LTC Injection from contaminated Serratia IL2007-201 12/15 Chicago Cook 22/U product marcescens C Hospital

IL2007-204 12/12 Freeburg St Clair 40/165 V Person-person Norovirus S LTC Norovirus, IL2007-208 12/14 Lincolnshire Lake 18/150 D Person-person unknown type C LTC

IL2007-202 12/19 Lebanon St Clair 42/229 D,V Person-person Norovirus G2 S LTC

IL2007-209 12/31 Sherman Sangamon 61/207 D,V Person-person Norovirus S LTC

Note: 1 U=Unknown; 2 D=Diarrhea, V=Vomiting, SSTI=skin and soft tissue infection; 3 S=suspect, C=confirmed; 4 LTC=long-term care.

232 Other incidents of interest, 2007

African tick bite fever African tick-bite fever is caused by Rickettsia africae and is spread from tick bites. It is endemic in rural areas of sub-Saharan Africa and in the French West Indies. Eight French patients developed African tick bite fever in France after travel to South Africa. Two probable cases of African tick bite fever were reported in an Illinois couple traveling to South Africa in June 2007. The husband had fever, headache, rash and red nodule with a necrotic center on the leg. The wife had myalgias, red nodule and headache.

Suggested Readings Roch, N. African tick bite fever in elderly patients:8 cases in French tourists returning from South Africa. CID 2008;47:e28-e35.

Cosmetic soft-tissue filler illnesses Soft-tissue fillers are used to augment or enhance the appearance of lips, breasts, buttocks or other soft tissue. Injections of fillers, especially liquid silicone by unlicensed practitioners can cause severe adverse reactions. In December 2007, an Illinois resident received an injection from an unlicensed practitioner in North Carolina. Within an hour of the injection she had headache and nausea and her urine turned burgundy. She was found to be in acute renal failure and hemodialysis was initiated. A renal biopsy revealed severe acute tubular necrosis. She was hospitalized for 13 days in Illinois. Two additional persons visiting the same facility and receiving injections also developed renal failure.

Suggested readings Branton, M. Acute renal failure associated with cosmetic soft-tissue filler injections-North Carolina, 2007. MMWR 2008;57(17):453-456.

Oak leaf gall mites In 2007, there were numerous reports of bites from oak leaf itch mites. Outbreaks of Pyemotes herfsi bites occurred in Kansas and Nebraska in 2004. In 2004 pin oaks had midge larvae which resulted in an increase in mites which consume the larvae. Bites from these mites result in red welts on neck, face, arms and upper torso. The bites are not usually on legs which distinguishes the bites from bites from chiggers. In Illinois complaints began in mid-August. Emergency departments in Cook and Dupage Counties reported many complaints from patients about these mites. The mite is called Pyemotes and requires an entomologist experienced with these mites to identify them. People reported bites on the back, arms and shoulders several hours after being outdoors. These mites do not carry disease but may bite people incidentally and inject a neurotoxic venom which results in itching. The University of Nebraska identified the mite. These mites are most active when it is greater than 80 F, especially after rains from August to October.

233 It is believed in Illinois that the increase in mites was associated with the emergence of the 17-year cicada. The mites parasitized the cicada. Prevention message for 2007 were to remain indoors during time periods when mite bites are occurring and to keep windows shut from August through October when mite showers can occur. When working outdoors citizens were advised to wear long sleeves, long pants and a hat. Persons could choose to use DEET or picaridin. Persons were advised to avoid direct handling of leaves and lawn clippings. When persons came inside from the outdoors in areas where the mites were active, they were to remove clothing and wash the clothes promptly. In addition, they were advised to take a warm shower when they came inside.

Suggested readings Zaborski, E.R. 2007 Outbreak of human pruritic dermatitis in Chicago, Illinois caused by an itch mite, Pyemotes herfsi (Oudemans, 1936) (Acarina: Heterostigmatai Pyemotid). Illinois Natural History Survey. Technical Report. May 20, 2008.

Eczema vaccinatum in child linked to military father given smallpox vaccination A child with eczema vaccinatum, a life-threatening of vaccinia virus infection was reported in March 2007 in a Chicago resident. This was the first reported case in the United States since 1988. An active duty military member who had received a first-time smallpox vaccination visited his home in mid-February, prior to deployment. He had a history of childhood excema and had household contact with two children, both had contraindications to vaccination. He spent time with his son who had severe eczema and reported that his scab had separated prior to the visit and that he had kept it bandaged. The child developed a generalized papular vesicular rash on the face, neck and upper extremities and was hospitalized in March. The diagnosis of orthopox DNA was made at the IDPH laboratory and confirmed at CDC. He was hospitalized for 48 days. The mother also developed vesicular lesions containing orthopox virus. No other contacts became ill. Environmental swabs from the home were positive.

Suggested readings Marcinak, J., et. al. Household transmission of vaccinia virus from contact with a military smallpox vaccinee-Illinois and Indiana, 2007. MMWR 2007;56(19): 478-80.

234 Table 21. Reported Cases of Infectious Disease in Illinois, 2007 Disease Number Disease Number AIDS/HIV 1,394/1,707 Influenza, novel/influenza, pediatric 1/1 mortality Amebiasis cases, symptomatic 107 Legionnaires disease 111

Anthrax 0 Leprosy 1

Arbovirus infection (WNV, Dengue, SLE, 101 WNV, 0 Leptospirosis 2 CE, Chikungunya) SLE, 0 CE, 0 Dengue, 2 Chikungunya Aseptic meningitis or encephalitis of 1,039 Listeriosis 34 unknown etiology Aseptic meningitis or encephalitis of 170 Lyme disease 149 known etiology, not arbovirus Blastomycosis 137 Malaria 63

Botulism 1 infant botulism Measles 1

Brucellosis 6 Meningococcal, invasive 61

Campylobacteriosis 1,277 2

Chickenpox, total 1,091 Mumps 170

Chlamydia trachomatis 55,470 Pertussis 199

Cholera 0 Psittacosis 0

Cryptosporidiosis 205 Q fever 14

Cyclospora 3 Rabies, animal/rabies, PHE 113/440

Cysticercosis 0 Reye syndrome 0

Diphtheria 0 Rocky Mountain spotted fever 39

Ehrlichiosis, human granulocytic 6 Rubella 1

Ehrlichiosis, human monocytic 37 Salmonellosis 1,966

Ehrlichiosis, unknown type 7 Shigellosis 781

E. coli, shiga toxin producing 131 S. aureus, vancomycin resistant 0

Foodborne/water/NFNW outbreaks 79/2/103 Streptococcus, group A, invasive 326

Giardiasis 866 Streptococcus, group B, invasive (< 3 75 months) Gonorrhea 20,813 Streptococcus pneumoniae, invasive 1,235

Guillain Barre syndrome Syphilis, primary or secondary 464

H. influenzae, invasive disease 124 Tetanus 2

Hantavirus 0 Toxic shock syndrome 9

Hemolytic uremic syndrome 5 Trichinosis 0

Hepatitis A, acute 118 Tuberculosis 521

Hepatitis B, acute 130 Tularemia 1

Hepatitis C, acute/Hepatitic C, chronic 16/7,840 Typhoid fever cases 24

Histoplasmosis 123 Yersiniosis 24

235 Methods Health care professionals - including infection control nurses, physicians and school nurses - are required by Illinois law to report specific infectious diseases to their local health department. There are 95 local health departments in Illinois. Some serve a city or district, some serve the entire county and some serve residents of several counties. The local health department reports cases to the Illinois Department of Public Health, which, in turn, reports all nationally notifiable diseases to the United States Centers for Disease Control and Prevention (CDC). All information about patients is confidential; case reports to the CDC do not identify patients. This annual report includes only cases reported to the Department. Therefore, these annual numbers will underestimate the total number of cases of each disease in the state. Some patients with disease do not seek medical attention, some may not have the necessary testing done for a diagnosis, or the medical provider may not report the case to public health authorities. Also, to standardize reporting in the state, only cases that are reported and meet the case definition for that disease are included in case counts. For some diseases, a case definition is listed for both confirmed and probable cases. For all diseases except HIV/AIDS, the number of cases reported in a year is closed out in mid-May of the following year. If cases from the preceding year are reported after the closing date, they are not included in the preceding year’s numbers. For HIV/AIDS, there are two categories: number of cases reported in a given year versus number of cases diagnosed in a given year. The number of cases diagnosed in a given year is continually updated even if there is an extremely long delay in reporting a case. Therefore, the numbers for diagnosed AIDS cases in 2007 may be updated. Reportable diseases diagnosed in college students living away from home and in residents of prisons, long-term care or other residential facilities are reported in the jurisdiction where the patient resides at the time of diagnosis. This results in attributing to rural counties that have a college or prison high incidence rates of certain diseases. Persons who are residents of Illinois but are not citizens of the United States may be counted. Persons who are visiting the U.S. and become clinically ill with malaria are counted in malaria statistics. Residents of other states who become ill in Illinois are not counted in this state’s statistics but are transferred to the state of residence. However, temporary workers in Illinois are counted in Illinois statistics. The Illinois population used to calculate incidence rates and race and ethnicity proportions in past editions of this document was from the 1990 Modified Age-Race-Sex (MARS) data. According to the United States Census Bureau, Illinois’ population grew from 11,430,602 in 1990 to 12,419,293 in 2000. The percentage of the population in the various age groups changed very little between the 1990 MARS data and the 2000 census. However, the racial and ethnic distribution did change substantially between 1990 and 2000. In 1990, the state’s population was 82 percent white, 15 percent African American, 2 percent Asian and 1 percent other or mixed races. In 2000, the census found the following percentages: 73 percent white, 15 percent African American, 3 percent

236 Asian and 8 percent other or mixed races. Those indicating Hispanic ethnicity accounted for 8 percent of the state’s population in 1990; in 2000, this proportion had increased to 12 percent. In 2000, 49 percent of the population was male and 51 percent was female. The following table shows the age distribution of the Illinois population as determined by the 2000 census.

Age category Census % of population numbers used for 2000 annual report

<1 year 173,373 1

1-4 years 703,176 6

5-9 years 929,858 7

10-19 years 1,799,099 14

20-29 years 1,742,602 14

30-59 years 5,108,274 41

>59 years 1,962,911 15

TOTAL 12,419,293

Where it was deemed useful, graphs were produced showing the number of cases by month, the number of cases by year since 2002 and the age distribution. Incidence rates were calculated for some diseases. Incidence rate was calculated by taking the number of cases in a category, dividing by population size from 2000 census data and multiplying by 100,000. If an annual incidence rate was calculated for the period 2003 to 2007, it was reached by taking the number of cases reported from 2003 through 2007, dividing by the population and multiplying by 100,000; it was then annualized by dividing by five. The reports for each disease were generated from the INEDSS database. The criteria used were year reported = 2007. For diseases where asymptomatic cases do not meet the case definition (hepatitis A and amebiasis) these laboratory confirmed cases were not included in the detailed information in the disease information. The epidemiologic information presented for each disease is for 2007 only, unless otherwise specified. For some diseases, where the number of cases by year was low, information may have been combined for multiple years to allow demonstration of trends by month and age. When the case population differed from the Illinois population in the racial distribution, a chi- square test for a significant difference in proportions was done using the Epi-Info software package. Suggested reading lists are provided for some diseases.

237