A Publication of the Maryland Department of Health and Mental Hygiene

The Laboratories Administration—Maryland’s State Public Health Laboratory Success Story Nancy Reilman from the Receives Public Health Recognition for Microbiology Safekeeping of Gonorrhea Drinking Water

Laboratory On August 11, 2009, on behalf of the staff of the Division of Environmental Chemistry, a unit in the Laboratories “Unsatisfactory” Administration, DHMH had the distinct result reports pleasure to present an appreciation plaque to Ms. Nancy Reilman, Chief of reduced from the Safe Drinking Water Act Implementation Division, Maryland 7% to less than 1% Department of the Environment Water Ms. Nancy Reilman, Chief, Safe Drinking Supply Program. This plaque was Water Act Implementation Division, MDE Up until the beginning of the summer of awarded to Ms. Reilman for her many Water Supply Program. Photo: Taiyin Wei 2009, local health departments and years of support and contributions to the health care providers were frustrated State’s public health drinking water with the high number of reports of the laboratories. Inside this issue: result “unsatisfactory” due to Ms. Reilman has worked tirelessly in overgrowth of patient normal flora. obtaining funds to help the Division Discovery of a upgrade instrumentation and equipment New Variant On his first day as the Laboratories used for the analysis of drinking water Administration’s Chief of the Public samples. It’s a pleasure working with of the HIV-1 Virus Health Microbiology Division, Dr. Jafar Ms. Reilman, as she is both a visionary Razeq was asked by Director Dr. Jack and a person with a practical outlook and ON PAGE 3 DeBoy to pay special attention to this novel ideas for ensuring the effective problem. implementation of the State’s Safe Drinking Water Program. After a thorough inspection of hundreds September 2009 of GC culture plates over a period of This article written by Dr. Prince Kassim. (Continued on page 2) Volume 13, Number 9 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • December 2008 • Vol. 12, No. 12 Page 1 PRODUCTION MANAGER Georgia Corso

EDITORIAL BOARD Jack DeBoy, Dr. P. H. Prince Kassim, Ph.D. The staff of the Gonorrhea Laboratory of the Public Health Microbiology Division, from left Fizza Majid, Ph.D. to right: Yaaqobah Evans, Damini Jain, Kim Shoutz, Carla Rollins, and Mara Johnson. Robert Myers, Ph.D. Jafar Razeq, Ph.D. Jim Svrjcek, B.A. (Continued from page 1) reported out as “unsatisfactory.” This Michael Wajda, M.S., J.D. Success Story from the Public Health certainly is a significant improvement Microbiology Gonorrhea Laboratory that reflects well on patient test Chengru Zhu, Ph.D. management. several months, and after spending many LABORATORIES ADMINISTRATION hours investigating what might have The Public Health Microbiology gone wrong, the Division made the Division’s staff in the GC Laboratory Director following recommendations: (see photo) and their partners in the Jack DeBoy, Dr.P.H. LHDs, especially in Howard and • Handle media properly, during Frederick counties where pilot studies Deputy Director storage and transport, both before were conducted, can be proud about this for Scientific Programs and after being inoculated; success and their commitment to

Robert Myers, Ph.D. providing quality laboratory services. • Modify the laboratory’s reporting This problem could not have been

and interpretation guidelines; solved without the hard work and Deputy Director for Administrative and • Switch to a culture medium support of all involved. Regulatory Programs (GC-Lect™) that the literature1,2 Michael Wajda, M.S., J.D. has shown to improve suppression To ensure that this problem does not of normal patient flora; recur, the “unsatisfactory” rate will remain under continuous monitoring TECHNICAL QUESTIONS • Work closely with local health departments (LHDs) to ensure proper This article written by Dr. Jafar Razeq.

Questions concerning collection, inoculation, and transport technical content of this newsletter of GC specimens. References may be referred to Implementating these recommendations 1 Evans, G.L et al. 1989. New selective medium Dr. Jack DeBoy at 410-767-6100 for the isolation of Neisseria gonorrhoeae. J. Clin. has resulted in a ten-fold decrease in Microbiol. 27: 2471-2474 reporting the result “unsatisfactory.” Between May 5 and July 5 of this year, 2 The Critical Link is published monthly Reichart, C.A. et al. 1989. Comparison of GC- by the staff of the 0.7% (34) were reported out with the Lect and Modified Thayer-Martin media for the result of “unsatisfactory.” During the isolation of Neisseria gonorrhoeae. J. Clin. Laboratories Administration Microbiol. 27: 808-811. Department of Health & Mental Hygiene same three month period last year (May 201 W. Preston Street 5 through July 5, 2008), 7% (467) were Baltimore, Maryland 21201 (Phone 410-767-6909)

Page 2 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 Patient RBF168 was born in Cameroon Her husband died in 1984 (HIV status Discovery of a in the southeast portion of the country unknown) and she reported having other and lived in towns around the capital, sexual partners (HIV status unknown) New Variant of Yaoundé. She did not live in rural areas after his death. Her positive HIV status of the country and reported no contact was discovered after her move to France the HIV-1 Virus with apes or bushmeat (meat of 4 1 in 2004. terrestrial wild animals.) Though HIV is transmitted primarily through sexual contact, exposure to bushmeat from the Classification Strain more closely butchering process and exposure to the related to a Simian hunted animals themselves is thought to A brief review of HIV classification is be a mechanism for the transfer of presented to help in understanding the 2,3 Immunodeficiency virus simian viruses to humans. need for further test results. HIV is (SIV) found in gorillas classified as a retrovirus (Family Retroviridae, genus Lentivirus) which has RNA as the major genetic

French scientists at the University of component instead of DNA. The enzyme, reverse transcriptase, contained Rouen have announced the discovery of a new variant of the HIV-1 virus, more in the retrovirus, enables it to convert this RNA to DNA which is then closely related to a simian immunodefi- ciency virus (SIV) found incorporated into the in gorillas. Genetic host cells’ genetic testing showed this strain material. This enables was more closely related the virus to replicate to a Simian Immuno- along with the host deficiency virus (SIV) cells’ DNA. found in gorillas than the Human Immuno- HIV is divided into two deficiency virus (HIV). types, HIV-1 and The scientists proposed HIV-2. Both cause this new strain should be disease though it is designated as HIV-1 believed that the group P.1 transmission of HIV-2 is more difficult and the One characteristic that period from infection to 5,6 determines further study illness is longer. is inconsistent or HIV-1 is the negative viral loads in a predominant virus and patient that is confirmed is found throughout the HIV positive with no world. HIV-2 is antiviral therapy. centered in West Africa Discrepancies in and is rarely found in 5 molecular and viral load other areas. testing of a 62-year-old woman (patient RBF168) HIV-1 is further from Cameroon resulted subdivided into three in further analysis of her groups, M (major), N HIV strain because she (non-M, non-O), and O met these criteria. Her (outlier). With the background and virus discovery of the novel strain were studied HIV-1 variant, a forth (Continued on page 4) further.

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 Page 3 (Continued from page 3) Laboratory has demonstrated that approximately 30% of specimens Discovery of a New Variant considerable HIV diversity in Maryland. from patients attending HIV treatment of the HIV-1 Virus Conducting HIV-2 specific testing is clinics in Maryland contained non- standard procedure on all HIV subtype B HIV-1 Group M viruses (see group may be added, group P. Group M serological screening test reactive figure 1). is the predominant group and is specimens that were not confirmed as subdivided into 12 subtypes or clades HIV-1 antibody positive by Western RBF 168 Test Results (A1, A2, B, C, D, F1, F2, G, H, J, and Blot testing. Since the early 1990’s, the K). The twelfth subtype consists of retrovirology laboratory has identified After reviewing patient RBF 168’s circulating recombinant forms (CRFs) 30 cases of HIV-2 in Montgomery and background (see above), her medical which are composed of viruses with Prince George’s Counties. history and test results were reviewed. mixed genetic material derived from HIV screening tests were reactive and recombination with other subtypes. In 1996, working in conjunction with a western blot showed weak reactivity to HIV-2 is divided into 7 groups, A CDC study, a rare HIV-1 Group “O” HIV-1 group M proteins. Her CD4+ 5,7 through G. virus infection was identified by count was stable. Viral load was high genotyping viruses from West African using nonspecific group M and O PCR Since HIV was first recognized as the expatriates attending HIV treatment commercial assays. Virus isolation and etiological agent of AIDS in the early- clinics in the Maryland suburbs of growth procedures proved that the virus 1980’s, HIV-1 Group M subtype B Washington DC. In more recent years, would replicate in human cells. She viruses have predominated North genotyping portions of polymerase (pol) shows no sign of AIDS, and has not America. However, through enhanced genes initially sequenced at the received any treatment.4 surveillance testing, the Laboratories retrovirology laboratory for anti-viral Administration Retrovirology drug resistance testing has demonstrated Viral load quantification was not successful when using group M specific assays. Amplification did not occur Figure 1: Pie chart showing genetic diversity of 354 HIV-1 specimens analyzed for genotype when using complementary group M at the Laboratories Administration in Baltimore from July 2008 through June 2009. Group M, Subtype B (CRF_B) predominates with 70%, followed by group M, non-subtype B (all specific PCRs or when using Group O others listed) with 30%. Source: Jonathan Johnston and Mark Massey, HIV-1 Sequencing Labo- (endemic in west central Africa- ratory, Laboratories Administration. Cameroon) primers. Amplification was successful after utilizing a nonspecific extra-long real time PCR test.4 This HIV-1 Genetic Diversity 2008-2009 analysis enabled the genetic makeup of the virus to be fully sequenced. This data pointed to the possibility that it was 1% a novel strain of HIV. 8% 1% 4% 1%

1% CRF_A (A1) HIV Origins

8% CRF_B Based on nucleotide sequencing of the CRF_C viral genome, the origin and divergence CRF02_AG of a virus can be determined. Viral 6% CRF11_CPX genomes are compared to determine CRF_F(F1) how close they are to one another, CRF_G suggesting the possible origin and CRF_Unassigned evolution of the viral strain under study.

Other Research has shown that the origins of HIV relate to SIVs found in primates. Cross species transmission, along with 70% viral mutation, resulted in the formation of HIV genomes. The origin of HIV-1, Footnote 1: CRF - circulating recombinant forms. groups M and N, is believed to be from

Page 4 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 cross-species transmission from humans. This is similar to the postulated clinical picture with the molecular chimpanzees (Pan troglodytes origins of HIV-1 group O. Direct testing results. If discrepancies are troglodytes) to humans.4 Group O is transmissions, from chimpanzees to observed, further nucleotide sequencing thought to have occurred from the humans and from chimpanzees to should be performed to detect the infection of humans existence of any new or from wild gorillas divergent strains. For (Gorilla gorilla gorilla) example, two discrepancies who were infected by include: contact with chimpanzees. 7 HIV-2 1. HIV-1- infected patients is thought to have who continue to progress originated from sooty toward AIDS (i.e., continuing mangabey (Cercocebus erosion of CD4 (+) T- atys) viruses, with each lymphocyte count) without the HIV-2 group demonstration of high viral representing a separate loads; or human transmission 2. If drug treatment failure is event.7 suspected due to consistently

high viral loads but the An SIV stain (SIVgor) infecting HIV-1 virus cannot was isolated from be sequenced from the patient gorillas that had many for drug resistance characteristics genotyping. necessary to enable it to Figure 2: This thin-section transmission electron micrograph (TEM) depicts 8 the ultrastructural details of a number of HIV particles, or virions. A member infect humans. This If these and other suggests the possibility of the genus Lentivirus, HIV is separated into two serotypes, HIV-1 and HIV- 2, and is the cause for the disease known as acquired immunodeficiency discrepancies between that HIV or similar syndrome, or AIDS. Source: Centers for Disease Control and Prevention, molecular based testing and http://phil.cdc.gov/phil/home.asp. viruses may be passed the clinical presentation are on to human observed, contact the DHMH populations gorillas, could have occurred also. The Retrovirology Laboratory at (410)767- through contact with gorillas. isolation of strains similar to RBF 168 in 6157 for consultation. It has been well- chimpanzees would provide evidence of 4 documented that substantial HIV RBF 168 Evolutionary Studies this possibility. diversity exists within some of our local testing populations, and continued English scientists (University of Conclusions vigilance may identify new variant HIV Manchester) carried out the evolutionary strains that would lead to improved 1 analysis of the RBF 168 HIV strain. The French scientists’ conclusions, patient care and a better understanding They found that this strain was most based on molecular testing and of the dynamics of HIV transmission closely related to SIVgor and that this evolutionary analysis, showed that strain within Maryland. relationship is maintained in all genome RBF 168 represents a new HIV-1 regions. Phylogenic data demonstrates variant. It was proposed that it be The detection of this new strain puts that the RBF 168 strain clusters placed in its own group, group P. further emphasis on the study of HIV extensively with SIVgor strains. This Another conclusion was that gorillas, genetic diversity. Since retroviruses provides evidence of gorilla to human along with chimpanzees, can be have the ability to mutate and/or transmission of SIVgor.4 considered as sources of HIV-1.4 undergo recombination, it is imperative that strains be monitored to detect Though evidence of gorilla to human The increased sensitivity of HIV changes in their genotype. These transmission is apparent, caution must screening tests and the improvement of changes could have a great effect on be exercised in determining the origins molecular testing methods should viral pathogenicity and treatment of the virus. It is possible that the RBF determine if HIV is present. However, modalities in the future. 168 strain developed from chimpanzees these tests, in most cases, will not signal (SIVcpz) infecting gorillas, then the presence of a new or divergent HIV This article was written by Mark Massey. strain. It is important to consider the (Continued on page 6)

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 Page 5 (Continued from page 5) F 0 2 BALTIMORE M 45 1 BALTIMORE CITY Discovery of a New Variant F 61 1 BALTIMORE M 12 1 BALTIMORE CITY of the HIV-1 Virus F 22 2 BALTIMORE M 1 1 BALTIMORE CITY F 21 1 BALTIMORE M 66 1 CECIL F 14 1 BALTIMORE M 44 1 CECIL M 0 1 BALTIMORE F 45 1 FREDERICK References M 60 1 BALTIMORE F 59 1 OUT OF STATE 1 HIV, Human, Gorilla - Cameroon: New Lineage M 50 1 BALTIMORE F 52 1 OUT OF STATE http://promedmail.org/pls/otn/f? M 31 1 BALTIMORE F 5 1 OUT OF STATE p=2400:1202:749568216072602::NO::F2400_P12 M 19 2 BALTIMORE F 1 1 OUT OF STATE 02_CHECK_DISPLAY,F2400_P1202_PUB_MAI M 16 1 BALTIMORE M 32 1 OUT OF STATE L_ID:X,78608 F 61 1 BALTIMORE CITY M 6 1 OUT OF STATE F 28 1 BALTIMORE CITY M 0 1 OUT OF STATE 2 Bush-meat Trade and Risk of Disease F 20 1 BALTIMORE CITY SALMONELLA HEIDELBERG Transmission http://promedmail.org/pls/otn/f? M 1 1 BALTIMORE CITY M 8 1 BALTIMORE p=2400:1202:749568216072602::NO::F2400_P12 M 1 1 BALTIMORE CITY M 0 1 BALTIMORE CITY 02_CHECK_DISPLAY,F2400_P1202_PUB_MAI F 70 1 MONTGOMERY F 11 2 OUT OF STATE L_ID:X,26324 F 8 2 MONTGOMERY SALMONELLA INFANTIS F 17 2 OUT OF STATE M 55 1 HARFORD 3 http://www.cdc.gov/hiv/resources.htm F 25 1 PRINCE GEORGE'S SALMONELLA JAVIANA 4 Plantier, J.C., et al. 2009 “A new human M 59 1 TALBOT M 60 1 BALTIMORE immunodeficiency virus derived from gorillas.” M 12 1 TALBOT SALMONELLA NEWPORT Nat. Med. Aug;15(8):871-2. F 0 1 UNKNOWN M 15 1 OUT OF STATE M 39 1 UNKNOWN M 0 1 WASHINGTON 5 http://www.avert.org/hiv-types.htm CAMPYLOBACTER JEJUNI SS DOYLEI SALMONELLA NORWICH M 17 1 BALTIMORE F 48 1 ANNE ARUNDEL 6 Kanki, P.J., et al. 1999 “Human immunodeficiency M 0 1 BALTIMORE CITY SALMONELLA ORANIENBURG virus type 1 subtypes differ in disease progression.” F 12 1 PRINCE GEORGE'S M 3 1 OUT OF STATE J. Inf. Disease 179, No. 1:68–73. ESCHERICHIA COLI, SEROTYPE O157:H7 SALMONELLA PARATYPHI A F 30 1 BALTIMORE U 0 1 ANNE ARUNDEL 7 http://www.hiv.lanl.gov/content/sequence/.html F 32 1 FREDERICK F 32 1 BALTIMORE 8 Takehisa, J. et al. 2009 “Origin and biology of F 50 1 OUT OF STATE F 11 1 BALTIMORE simian immunodeficiency virus in wild-living SALMONELLA M 47 3 MONTGOMERY western gorillas.” J. Virol, 83; 1635-48. F 0 1 BALTIMORE M 33 1 MONTGOMERY M 9 1 BALTIMORE SALMONELLA RUBISLAW F 5 1 FREDERICK F 1 1 BALTIMORE CITY M 30 1 FREDERICK SALMONELLA SAINTPAUL M 0 1 MONTGOMERY F 4 1 CARROLL F 67 1 OUT OF STATE M 2 1 FREDERICK M 0 1 OUT OF STATE F 28 1 OUT OF STATE M 0 1 OUT OF STATE M 2 1 OUT OF STATE M 0 2 PRINCE GEORGE'S M 1 1 OUT OF STATE F 0 2 WICOMICO SALMONELLA SCHWARZENGRUND SALMONELLA 6,7:-:1,5 F 67 1 ALLEGANY M 22 1 MONTGOMERY M 0 1 BALTIMORE CITY SALMONELLA AGONA SALMONELLA SER 4,12:I:- M 3 1 BALTIMORE CITY M 2 1 MONTGOMERY Reported from the SALMONELLA BARDO SALMONELLA SER 4,5,12:I:- M 80 1 WASHINGTON F 37 1 BALTIMORE CITY Laboratories Administration SALMONELLA BRAENDERUP M 23 1 BALTIMORE CITY during the month of M 4 1 ANNE ARUNDEL SALMONELLA SER ENTERITIDIS U 6 1 CHARLES F 75 1 BALTIMORE SALMONELLA ENTERITIDIS F 4 1 BALTIMORE F 75 1 BALTIMORE U 57 1 BALTIMORE JuneJune 20092009 F 53 1 BALTIMORE F 27 1 BALTIMORE CITY ENTERIC BACTERIOLOGY M 10 1 BALTIMORE M 0 1 BALTIMORE CITY U 0 2 BALTIMORE CITY M 47 1 BALTIMORE CITY GENUS SEROVAR F 0 1 BALTIMORE CITY M 12 1 BALTIMORE CITY SEX AGE # JURISDICTION F 30 1 BALTIMORE CITY M 64 1 OUT OF STATE F 11 1 BALTIMORE CITY SALMONELLA SER TYPHIMURIUM CAMPYLOBACTER JEJUNI F 2 1 BALTIMORE CITY M 73 1 ALLEGANY F 0 1 ALLEGANY F 0 1 BALTIMORE CITY F 27 1 BALTIMORE M 58 1 ANNE ARUNDEL M 93 1 BALTIMORE CITY F 13 1 BALTIMORE U 10 1 BALTIMORE M 87 1 BALTIMORE CITY F 4 1 BALTIMORE U 1 1 BALTIMORE M 63 1 BALTIMORE CITY M 43 1 BALTIMORE

Page 6 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 U 0 1 BALTIMORE CITY ISOLATES - REFERENCE PANTOEA AGGLOMERANS M 54 1 BALTIMORE CITY WOUND 1 FREDERICK M 50 1 BALTIMORE CITY GENUS SPECIES PASTEURELLA MULTOCIDA M 0 1 BALTIMORE CITY SOURCE # JURISDICTION ULCER 1 FREDERICK F 5 1 CALVERT PEPTOSTREPTOCOCCUS M 20 1 FREDERICK HAEMOLYTICUM ASACCHAROLYTICUS M 2 1 FREDERICK BLOOD 1 ANNE ARUNDEL UNKNOWN 1 CARROLL M 19 1 KENT ENTEROBACTER CLOACAE PROTEUS MIRABILIS F 28 1 MONTGOMERY URINE 1 ALLEGANY WOUND 2 CARROLL U 25 1 OUT OF STATE HAEMOPHILUS INFLUENZAE G-TUBE 1 WASHINGTON F 0 1 OUT OF STATE URINE 2 BALTIMORE CITY WOUND 1 WASHINGTON F 8 1 OUT OF STATE KLEBSIELLA PNEUMONIAE PSEUDOMONAS AERUGINOSA F 7 2 OUT OF STATE UNKNOWN 2 CARROLL BLOOD 1 BALTIMORE CITY M 22 1 OUT OF STATE URINE 1 CARROLL TOE 1 FREDERICK M 6 1 OUT OF STATE BLOOD 1 PRINCE GEORGE'S STAPHYLOCOCCUS AUREUS M 4 1 OUT OF STATE MORAXELLA (MORAXELLA) OSLOENSIS WOUND 1 BALTIMORE F 8 1 TALBOT OTHER 1 PRINCE GEORGE'S BONE 1 BALTIMORE CITY SALMONELLA THOMPSON MORGANELLA MORGANII WOUND 2 CARROLL M 15 1 BALTIMORE UNKNOWN 1 CARROLL WOUND 1 CARROLL F 77 1 UNKNOWN PROTEUS MIRABILIS WOUND 6 FREDERICK SALMONELLA TYPHIMURIUM VAR COPEN- HODGE 1 CARROLL CERVIX 1 PRINCE GEORGE'S HAGEN URINE 2 CARROLL VAGINAL 1 PRINCE GEORGE'S F 35 1 MONTGOMERY PROTEUS PENNERI WOUND 1 PRINCE GEORGE'S F 13 1 TALBOT UNKNOWN 1 CARROLL STAPHYLOCOCCUS, SHIGELLA FLEXNERI II:3,4 PROVIDENCIA STUARTII COAGULASE NEGATIVE M 49 1 OUT OF STATE UNKNOWN 1 CARROLL CSF 1 BALTIMORE CITY M 3 1 OUT OF STATE WOUND 1 CARROLL U 25 1 PRINCE GEORGE'S TOTAL 15 TOE 1 FREDERICK SHIGELLA SONNEI TOE 1 FREDERICK U 0 1 BALTIMORE ISOLATES - MISCELLANEOUS WOUND 3 FREDERICK F 0 1 BALTIMORE SKIN 2 MONTGOMERY GENUS SPECIES F 31 1 BALTIMORE STREPTOCOCCUS SOURCE # JURISDICTION F 18 1 BALTIMORE BETA HEMOLYTIC GROUP A

F 3 1 BALTIMORE THROAT 1 MONTGOMERY ACINETOBACTER LWOFFI M 0 1 BALTIMORE WOUND 2 FREDERICK THROAT 1 MONTGOMERY M 5 1 BALTIMORE BACILLUS SPECIES STREPTOCOCCUS U 0 3 BALTIMORE CITY WOUND 1 CARROLL BETA HEMOLYTIC NON-GROUP A F 0 1 BALTIMORE CITY CITROBACTER KOSERI THROAT 1 ALLEGANY F 40 1 BALTIMORE CITY HEEL 1 FREDERICK STREPTOCOCCUS F 29 1 BALTIMORE CITY SPECIES BETA HEMOLYTIC GROUP B F 19 1 BALTIMORE CITY CYST 1 CARROLL VAGINAL 5 ANNE ARUNDEL F 5 1 BALTIMORE CITY WOUND 1 CARROLL FOOT 1 FREDERICK F 5 1 BALTIMORE CITY DIPHTHEROIDS VAGINAL 1 HOWARD F 3 1 BALTIMORE CITY SCALP 1 MONTGOMERY VAGINAL 1 MONTGOMERY F 2 1 BALTIMORE CITY ENTEROBACTER AEROGENES CERVIX 2 PRINCE GEORGE'S F 1 1 BALTIMORE CITY PENIS 1 MONTGOMERY VAGINAL 3 PRINCE GEORGE'S M 0 1 BALTIMORE CITY ENTEROBACTER CLOACAE VAGINAL 1 PRINCE GEORGE'S M 57 1 BALTIMORE CITY SINUS 1 BALTIMORE CITY VAGINAL 11 PRINCE GEORGE'S M 2 1 BALTIMORE CITY ESCHERICHIA COLI M 2 1 BALTIMORE CITY BLOOD 1 BALTIMORE CITY TOTAL 78 M 1 1 BALTIMORE CITY CSF 1 BALTIMORE CITY SEXUALLY TRANSMITTED DISEASES U 8 1 BALTIMORE CITY FOOT 1 FREDERICK F 28 1 CECIL WOUND 1 FREDERICK GENUS SPECIES F 44 1 HARFORD VAGINAL 1 MONTGOMERY F 26 1 OUT OF STATE SEX # JURISDICTION GARDNERELLA VAGINALIS F 6 1 OUT OF STATE VAGINAL 1 PRINCE GEORGE'S SYPHILIS SEROLOGY VIBRIO MIMICUS KLEBSIELLA PNEUMONIAE F 1 ANNE ARUNDEL M 24 1 BALTIMORE CITY VAGINAL 1 PRINCE GEORGE'S M 3 ANNE ARUNDEL VIBRIO PARAHAEMOLYTICUS WOUND 1 WASHINGTON F 4 BALTIMORE M 43 1 BALTIMORE LACTOBACILLUS RHAMNOSUS M 4 BALTIMORE BLOOD 1 BALTIMORE CITY F 12 BALTIMORE CITY M 32 BALTIMORE CITY TOTAL 179 MOLD M 1 CALVERT WOUND 1 FREDERICK M 1 CAROLINE F 1 CARROLL

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 Page 7 M 1 CECIL M 3 CHARLES CHELONAE F 1 CHARLES F 1 HARFORD U 28 1 MONTGOMERY M 2 CHARLES F 1 HOWARD F 2 FREDERICK M 1 HOWARD F 78 1 BALTIMORE F 1 HARFORD F 3 MONTGOMERY M 26 1 BALTIMORE CITY U 1 HARFORD M 5 MONTGOMERY M 51 1 MONTGOMERY F 1 MONTGOMERY F 9 PRINCE GEORGE'S M 77 1 MONTGOMERY M 6 MONTGOMERY M 18 PRINCE GEORGE'S F 46 1 OUT OF STATE F 1 OUT OF STATE F 1 SAINT MARY'S F 80 1 OUT OF STATE F 6 PRINCE GEORGE'S M 1 SAINT MARY'S M 87 2 OUT OF STATE M 20 PRINCE GEORGE'S F 1 SOMERSET F 51 1 PRINCE GEORGE'S M 1 SOMERSET F 5 WICOMICO MYCOBACTERIUM FORTUITUM COMPLEX F 1 WICOMICO M 3 WICOMICO M 39 1 BALTIMORE CITY M 2 WICOMICO M 45 1 MONTGOMERY U 1 WICOMICO TOTAL 64 MYCOBACTERIUM GORDONAE F 45 1 BALTIMORE TOTAL 106 M 56 1 BALTIMORE PENICILLIN RESISTANT M 66 1 BALTIMORE CHLAMYDIA TRACHOMATIS GONORRHEA F 64 1 BALTIMORE CITY F 3 ALLEGANY M 22 1 BALTIMORE CITY M 3 ALLEGANY REPORTED QUARTERLY 4-01-09 TO 6-30-09 M 58 1 FREDERICK F 23 ANNE ARUNDEL F 50 1 HARFORD M 4 ANNE ARUNDEL SEX AGE # JURISDICTION M 55 1 OUT OF STATE F 20 BALTIMORE MYCOBACTERIUM KANSASII M 16 BALTIMORE M 42 1 PRINCE GEORGE'S M 53 2 BALTIMORE F 16 BALTIMORE CITY M 18 1 PRINCE GEORGE'S M 48 1 OUT OF STATE M 40 BALTIMORE CITY M 32 1 MONTGOMERY U 5 BALTIMORE CITY F 79 1 FREDERICK F 7 CALVERT TOTAL 3 MYCOBACTERIUM MUCOGENICUM M 4 CALVERT F 53 1 BALTIMORE CITY F 2 CAROLINE MYCOBACTERIUM SCROFULACEUM F 3 CARROLL MYCOBACTERIOLOGY F 82 1 BALTIMORE M 2 CARROLL MYCOBACTERIUM F 9 CECIL ISOLATE F 60 1 ANNE ARUNDEL F 16 CHARLES SEX AGE # JURISDICTION F 62 1 BALTIMORE M 2 CHARLES F 30 1 BALTIMORE CITY F 11 FREDERICK MYCOBACTERIA F 34 1 BALTIMORE CITY M 3 FREDERICK NON-PHOTOCHROMOGENIC M 33 1 BALTIMORE CITY F 2 GARRETT M 58 1 ANNE ARUNDEL M 54 1 BALTIMORE CITY M 2 GARRETT M 75 1 BALTIMORE M 72 1 BALTIMORE CITY F 6 HARFORD M 92 1 BALTIMORE CITY F 3 HOWARD F 48 1 BALTIMORE F 30 1 MONTGOMERY M 2 HOWARD M 69 2 BALTIMORE CITY F 87 1 MONTGOMERY F 2 KENT MYCOBACTERIUM AVIUM M 22 1 MONTGOMERY F 16 MONTGOMERY F 88 1 BALTIMORE CITY M 26 1 MONTGOMERY M 3 MONTGOMERY MYCOBACTERIUM AVIUM COMPLEX M 47 1 MONTGOMERY F 52 PRINCE GEORGE'S F 61 1 ALLEGANY M 76 1 MONTGOMERY M 50 PRINCE GEORGE'S F 62 1 ALLEGANY M 84 1 MONTGOMERY U 1 PRINCE GEORGE'S F 59 2 ANNE ARUNDEL M 28 1 OUT OF STATE F 4 SAINT MARY'S F 50 1 BALTIMORE M 31 1 OUT OF STATE F 2 SOMERSET F 54 1 BALTIMORE M 52 1 OUT OF STATE M 4 SOMERSET F 84 1 BALTIMORE M 70 1 OUT OF STATE F 3 TALBOT M 47 1 BALTIMORE F 24 2 PRINCE GEORGE'S M 2 TALBOT M 78 1 BALTIMORE F 32 1 PRINCE GEORGE'S F 9 WASHINGTON M 26 1 BALTIMORE CITY F 53 1 PRINCE GEORGE'S M 2 WASHINGTON M 40 1 BALTIMORE CITY M 25 1 PRINCE GEORGE'S F 20 WICOMICO M 58 1 BALTIMORE CITY MYCOBACTERIUM M 5 WICOMICO M 67 1 BALTIMORE CITY TUBERCULOSIS COMPLEX F 5 WORCESTER F 46 1 CARROLL M 80 1 BALTIMORE F 75 1 CARROLL M 39 5 BALTIMORE CITY TOTAL 384 F 69 1 OUT OF STATE M 54 1 BALTIMORE CITY F 84 1 PRINCE GEORGE'S M 92 1 BALTIMORE CITY NEISSERIA GONORRHOEAE M 83 1 PRINCE GEORGE'S F 34 5 HOWARD F 1 ANNE ARUNDEL F 44 1 SAINT MARY'S F 30 1 MONTGOMERY F 2 BALTIMORE F 74 1 WICOMICO F 87 3 MONTGOMERY M 3 BALTIMORE M 46 1 WICOMICO M 26 1 MONTGOMERY M 1 BALTIMORE CITY M 76 1 WICOMICO M 28 1 MONTGOMERY F 3 CALVERT M 33 2 MONTGOMERY M 1 CAROLINE U 5 1 OUT OF STATE M 35 2 MONTGOMERY F 1 CHARLES M 44 1 MONTGOMERY

Page 8 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 M 51 1 MONTGOMERY F 85 1 PRINCE GEORGE'S FONSECAEA PEDROSOI M 84 1 MONTGOMERY M 57 1 PRINCE GEORGE'S F 56 1 CARROLL F 24 1 OUT OF STATE M 69 1 PRINCE GEORGE'S FUSARIUM SPECIES F 47 1 OUT OF STATE ASPERGILLUS NIGER M 74 1 BALTIMORE CITY F 60 1 OUT OF STATE M 45 2 ALLEGANY F 21 1 TALBOT M 31 1 OUT OF STATE F 72 1 ANNE ARUNDEL GEOTRICHUM PENICILLATUM M 52 1 OUT OF STATE F 21 2 MONTGOMERY F 62 1 ANNE ARUNDEL F 24 1 PRINCE GEORGE'S M 78 1 TALBOT GORDONIA-RHODOCOCCUS COMPLEX F 32 5 PRINCE GEORGE'S ASPERGILLUS TERREUS F 48 1 ANNE ARUNDEL F 60 3 PRINCE GEORGE'S F 83 1 BALTIMORE MYCELIA STERILIA M 25 4 PRINCE GEORGE'S CANDIDA ALBICANS M 79 1 ANNE ARUNDEL M 58 3 PRINCE GEORGE'S M 40 2 BALTIMORE CITY M 45 1 BALTIMORE CITY U 23 1 UNKNOWN M 54 1 BALTIMORE CITY M 41 1 CALVERT M 90 4 WASHINGTON M 66 1 BALTIMORE CITY U 65 1 CHARLES SCOTOCHROMOGENIC MYCOBACTERIA M 68 2 BALTIMORE CITY F 65 1 TALBOT F 82 1 BALTIMORE CITY F 36 1 CALVERT M 3 1 TALBOT M 41 1 CALVERT FARCINICA TOTAL 132 F 22 1 MONTGOMERY F 81 1 TALBOT F 23 1 MONTGOMERY PENICILLIUM SPECIES F 47 1 MONTGOMERY F 77 1 ANNE ARUNDEL MYCOBACTERIUM F 57 1 MONTGOMERY M 56 2 ANNE ARUNDEL SUSCEPTIBILITY RESULTS F 69 2 MONTGOMERY M 45 1 BALTIMORE CITY F 72 1 MONTGOMERY M 72 1 MONTGOMERY 17 ISOLATES IDENTIFIED F 76 1 MONTGOMERY F 78 1 PRINCE GEORGE'S F 78 1 MONTGOMERY M 69 1 TALBOT 7 DRUG RESISTANT STRAINS FOUND F 85 2 MONTGOMERY STREPTOMYCES SPECIES # JURISDICTION DRUG(S) M 36 1 MONTGOMERY U 13 1 CARROLL M 37 1 MONTGOMERY TRICHODERMA A 1 ANNE ARUNDEL PYRAZINAMIDE M 40 1 MONTGOMERY F 62 1 ANNE ARUNDEL M 72 1 MONTGOMERY TRICHOPHYTON MENTAGROPHYTES 1 MONTGOMERY PYRAZINAMIDE, M 73 2 MONTGOMERY F 62 1 TALBOT ISONIAZID M 80 1 MONTGOMERY TRICHOPHYTON RUBRUM 1 PRINCE GEORGE'S STREPTOMYCIN U 39 1 MONTGOMERY M 17 1 TALBOT 0 4 PRINCE GEORGE'S M 33 1 WICOMICO B 2 PRINCE GEORGE'S STREPTOMYCIN F 0 1 PRINCE GEORGE'S TRICHOPHYTON TONSURANS F 21 1 PRINCE GEORGE'S M 7 1 BALTIMORE 1 WASHINGTON ISONIAZID, F 23 1 PRINCE GEORGE'S TSUKAMURELLA SPECIES STREPTOMYCIN F 44 1 PRINCE GEORGE'S F 41 1 TALBOT

1 WASHINGTON DC ISONIAZID F 47 1 PRINCE GEORGE'S F 48 1 PRINCE GEORGE'S TOTAL 110 A TWO ISOLATES FROM THE SAME PATIENT F 59 1 PRINCE GEORGE'S B PROBABLE FOR M. BOVIS C F 61 1 PRINCE GEORGE'S MEETS CASE DEFINITION OF PARASITOLOGY MULTI-DRUG TUBERCULOSIS (MDRTB) F 66 1 PRINCE GEORGE'S F 78 1 PRINCE GEORGE'S Mycobacterium tuberculosis complex consists of: GENUS/SPECIES M. tuberculosis F 93 1 PRINCE GEORGE'S M. bovis F 97 1 PRINCE GEORGE'S # JURISDICTION M. bovis, BCG M 57 1 PRINCE GEORGE'S M. africanum M 59 1 PRINCE GEORGE'S BLASTOCYSTIS HOMINIS M. microti 3 BALTIMORE CITY M. canettii M 68 1 PRINCE GEORGE'S 1 MONTGOMERY F 29 1 SOMERSET

CANDIDA GLABRATA BLASTOCYSTIS HOMINIS MYCOLOGY M 68 1 BALTIMORE CITY 3 FREDERICK F 54 1 MONTGOMERY 1 ANNE ARUNDEL ISOLATE 0 1 PRINCE GEORGE'S 1 PRINCE GEORGE'S SEX AGE # JURISDICTION F 23 1 PRINCE GEORGE'S 1 MONTGOMERY F 47 1 PRINCE GEORGE'S 1 PRINCE GEORGE'S ALTERNARIA SPECIES CANDIDA KRUSEI DIENTAMOEBA FRAGILIS U 61 1 CARROLL M 47 1 BALTIMORE CITY 1 PRINCE GEORGE'S F 25 1 TALBOT F 47 1 MONTGOMERY ENDOLIMAX NANA ASPERGILLUS FLAVUS CANDIDA PARAPSILOSIS 1 FREDERICK F 39 1 MONTGOMERY M 69 1 FREDERICK 2 PRINCE GEORGE'S ASPERGILLUS FUMIGATUS M 73 1 MONTGOMERY 3 MONTGOMERY M 57 3 ALLEGANY F 49 1 PRINCE GEORGE'S 5 PRINCE GEORGE'S M 52 1 BALTIMORE CITY M 68 1 PRINCE GEORGE'S 2 MONTGOMERY M 66 1 BALTIMORE CITY CANDIDA TROPICALIS 1 PRINCE GEORGE'S F 70 1 CALVERT F 66 1 PRINCE GEORGE'S ENTAMOEBA COLI 2 MONTGOMERY F 49 1 CHARLES CRYPTOCOCCUS NEOFORMANS 1 PRINCE GEORGE'S F 45 1 MONTGOMERY F 75 1 MONTGOMERY 1 ANNE ARUNDEL EPICOCCUM SPECIES F 78 2 MONTGOMERY 2 PRINCE GEORGE'S M 82 1 TALBOT

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 Page 9 ENTAMOEBA HARTMANNI VIRAL POLYMERASE 3 MONTGOMERY The services and facilities of the 1 SAINT MARY'S CHAIN REACTION (PCR) Maryland Department of Health and ENTEROBIUS VERMICULARIS Mental Hygiene (DHMH) are operated 1 CARROLL ISOLATE on a non-discriminatory basis. This policy SEX AGE # JURISDICTION 1 BALTIMORE prohibits discrimination on the basis of 1 SAINT MARY'S 3 FREDERICK age; ancestry; color; creed; marital HERPES SIMPLEX VIRUS TYPE 1 GIARDIA LAMBLIA status; mental or physical disability; U 20 1 BALTIMORE 2 HOWARD national origin; race; religious affiliation, F 21 1 BALTIMORE 3 HOWARD belief, or opinion; sex; or sexual F 25 1 BALTIMORE HOOKWORM orientation and plies to the provisions of F 0 2 BALTIMORE CITY 1 HOWARD employment and granting of F 19 3 BALTIMORE CITY HYMENOLEPIS NANA advantages, privileges and F 24 1 BALTIMORE CITY 3 BALTIMORE CITY accommodations. F 27 1 BALTIMORE CITY PLASMODIUM FALCIPARUM M 20 1 BALTIMORE CITY 1 BALTIMORE CITY The Department, in compliance with the F 18 1 CALVERT Americans with Disabilities Act, ensures M 22 1 CECIL TOTAL 48 that qualified individuals with M 25 2 CHARLES disabilities are given an opportunity to F 28 1 WICOMICO participate in and benefit from DHMH M 25 1 WICOMICO FOOD PROTECTION services, programs, benefits, and HERPES SIMPLEX VIRUS TYPE 2 F 20 1 ALLEGANY TOTALS employment opportunities. F 22 1 ANNE ARUNDEL FOOD F 22 1 BALTIMORE SAMPLES 55 F 27 1 BALTIMORE NOTABLE PATHOGENS: F 35 1 BALTIMORE SALMONELLA SP. 4 VIRUS ISOLATION M 34 1 BALTIMORE

CAMPYLOBACTER SP. 7 U 0 1 BALTIMORE CITY ISOLATE U 21 1 BALTIMORE CITY LISTERIA SP. 0 SEX AGE # JURISDICTION U 23 1 BALTIMORE CITY U 24 1 BALTIMORE CITY CRABMEAT ADENOVIRUS F 0 1 BALTIMORE CITY F 55 1 ALLEGANY SAMPLES 0 F 19 1 BALTIMORE CITY 1 M 65 1 ANNE ARUNDEL EXCEEDING STANDARDS 0 F 20 1 BALTIMORE CITY M 1 1 BALTIMORE CITY F 21 1 BALTIMORE CITY M 0 1 BALTIMORE CITY SHELLFISH F 22 2 BALTIMORE CITY

F 23 1 BALTIMORE CITY SAMPLES 3 SUBTOTAL 4 2 F 26 1 BALTIMORE CITY EXCEEDING STANDARDS 0 HERPES SIMPLEX VIRUS TYPE 1 F 28 1 BALTIMORE CITY F 33 1 BALTIMORE CITY SHELLFISH GROWING WATERS F 27 1 BALTIMORE CITY M 68 1 BALTIMORE CITY F 37 1 BALTIMORE CITY SAMPLES 288 F 38 1 BALTIMORE CITY F 19 1 BALTIMORE CITY F 41 1 BALTIMORE CITY INFANT STOOL SUBTOTAL 3 F 46 1 BALTIMORE CITY CLOSTRIDIUM BOTULINUM 1 M 22 1 BALTIMORE CITY TOXIN TYPE B INFLUENZA A VIRUS M 23 1 BALTIMORE CITY F 4 1 MONTGOMERY M 24 2 BALTIMORE CITY M 25 2 BALTIMORE CITY TOTAL SAMPLES 336 M 26 1 BALTIMORE CITY TOTAL STANDARDS EXCEEDED 11 SUBTOTAL 1 M 27 3 BALTIMORE CITY

PARAINFLUENZA VIRUS 1 M 31 1 BALTIMORE CITY STANDARDS M 0 1 BALTIMORE CITY M 35 1 BALTIMORE CITY M 41 1 BALTIMORE CITY 1 CRABMEAT FRESH SUBTOTAL 1 M 45 1 BALTIMORE CITY ESCHERICHIA COLI AT < 36 MPN/100 GRAMS M 51 1 BALTIMORE CITY STANDARD PLATE COUNT AT < 100 PARAINFLUENZA VIRUS 2 M 77 1 BALTIMORE CITY M 50 1 BALTIMORE CITY M 83 1 BALTIMORE CITY 2SHELLFISH F 19 1 CHARLES F 24 1 DORCHESTER FECAL COLIFORMS AT < 230 MPN/100 GRAMS SUBTOTAL 1 F 38 1 FREDERICK STANDARD PLATE COUNT AT < 500,000 PER GRAM PARAINFLUENZA VIRUS 3 F 26 1 HARFORD F 57 1 ANNE ARUNDEL M 23 2 KENT WATER MICROBIOLOGY F 5 1 HARFORD F 64 1 MONTGOMERY M 43 1 MONTGOMERY M 19 1 MONTGOMERY # TESTED # NON-COMPLIANT M 0 1 BALTIMORE CITY F 27 1 PRINCE GEORGE'S COMMUNITY 8 0 U 0 1 BALTIMORE CITY F 29 1 PRINCE GEORGE'S F 86 1 BALTIMORE CITY F 34 1 PRINCE GEORGE'S NON-COMMUNITY 254 58 M 26 1 PRINCE GEORGE'S SUBTOTAL 6 F 35 1 WASHINGTON

TOTAL 262 58 F 20 1 WICOMICO TOTAL 16

Page 10 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 F 21 2 WICOMICO F 46 1 BALTIMORE CITY M 7 1 HARFORD F 30 1 WICOMICO F 47 1 BALTIMORE CITY F 49 1 HOWARD INFLUENZA A(H1) F 5 1 BALTIMORE CITY F 60 1 HOWARD M 3 1 OUT OF STATE F 51 2 BALTIMORE CITY M 50 1 HOWARD M 44 1 QUEEN ANNE'S F 53 1 BALTIMORE CITY U 5 1 MONTGOMERY INFLUENZA A(H1/N1) NOVEL A F 58 1 BALTIMORE CITY F 0 2 MONTGOMERY F 4 1 ALLEGANY F 7 3 BALTIMORE CITY F 1 1 MONTGOMERY F 40 1 ALLEGANY F 9 1 BALTIMORE CITY F 12 2 MONTGOMERY F 47 1 ALLEGANY M 0 4 BALTIMORE CITY F 13 1 MONTGOMERY M 14 1 ALLEGANY M 1 3 BALTIMORE CITY F 15 2 MONTGOMERY M 18 1 ALLEGANY M 10 5 BALTIMORE CITY F 17 1 MONTGOMERY M 5 1 ALLEGANY M 11 2 BALTIMORE CITY F 22 1 MONTGOMERY F 25 1 ANNE ARUNDEL M 12 2 BALTIMORE CITY F 23 1 MONTGOMERY F 3 1 ANNE ARUNDEL M 14 3 BALTIMORE CITY F 3 1 MONTGOMERY M 0 1 ANNE ARUNDEL M 15 3 BALTIMORE CITY F 33 1 MONTGOMERY U 40 1 BALTIMORE M 16 3 BALTIMORE CITY F 38 1 MONTGOMERY F 21 1 BALTIMORE M 17 2 BALTIMORE CITY F 4 1 MONTGOMERY F 27 1 BALTIMORE M 18 4 BALTIMORE CITY F 41 1 MONTGOMERY F 32 1 BALTIMORE M 19 3 BALTIMORE CITY F 5 2 MONTGOMERY F 33 1 BALTIMORE M 2 4 BALTIMORE CITY M 0 2 MONTGOMERY F 36 1 BALTIMORE M 20 1 BALTIMORE CITY M 1 1 MONTGOMERY F 40 1 BALTIMORE M 21 3 BALTIMORE CITY M 10 2 MONTGOMERY F 41 1 BALTIMORE M 22 1 BALTIMORE CITY M 11 1 MONTGOMERY F 45 1 BALTIMORE M 26 1 BALTIMORE CITY M 13 2 MONTGOMERY F 46 1 BALTIMORE M 28 3 BALTIMORE CITY M 16 1 MONTGOMERY F 50 1 BALTIMORE M 3 3 BALTIMORE CITY M 17 1 MONTGOMERY F 60 1 BALTIMORE M 33 1 BALTIMORE CITY M 2 2 MONTGOMERY F 68 1 BALTIMORE M 4 1 BALTIMORE CITY M 26 1 MONTGOMERY F 69 1 BALTIMORE M 43 2 BALTIMORE CITY M 28 1 MONTGOMERY M 0 5 BALTIMORE M 44 1 BALTIMORE CITY M 3 1 MONTGOMERY M 15 1 BALTIMORE M 46 2 BALTIMORE CITY M 30 1 MONTGOMERY M 19 1 BALTIMORE M 47 1 BALTIMORE CITY M 37 1 MONTGOMERY M 23 1 BALTIMORE M 49 1 BALTIMORE CITY M 4 3 MONTGOMERY M 39 1 BALTIMORE M 5 2 BALTIMORE CITY M 5 2 MONTGOMERY M 68 1 BALTIMORE M 56 1 BALTIMORE CITY M 54 2 MONTGOMERY U 0 2 BALTIMORE CITY M 6 1 BALTIMORE CITY M 7 1 MONTGOMERY U 14 2 BALTIMORE CITY M 60 1 BALTIMORE CITY M 8 1 MONTGOMERY U 15 1 BALTIMORE CITY M 62 1 BALTIMORE CITY U 0 5 OUT OF STATE U 17 1 BALTIMORE CITY M 8 5 BALTIMORE CITY U 1 1 OUT OF STATE U 30 1 BALTIMORE CITY M 9 4 BALTIMORE CITY U 10 5 OUT OF STATE U 40 1 BALTIMORE CITY U 48 1 CARROLL U 11 3 OUT OF STATE U 45 1 BALTIMORE CITY F 23 1 CARROLL U 12 2 OUT OF STATE U 46 1 BALTIMORE CITY M 48 1 CARROLL U 13 5 OUT OF STATE U 61 1 BALTIMORE CITY U 42 1 CECIL U 14 5 OUT OF STATE U 7 1 BALTIMORE CITY F 37 1 CECIL U 15 4 OUT OF STATE F 0 7 BALTIMORE CITY M 3 1 CECIL U 16 3 OUT OF STATE F 10 4 BALTIMORE CITY M 56 1 CECIL U 17 3 OUT OF STATE F 11 1 BALTIMORE CITY F 10 1 CHARLES U 18 1 OUT OF STATE F 12 2 BALTIMORE CITY F 13 1 CHARLES U 19 1 OUT OF STATE F 13 3 BALTIMORE CITY F 16 1 CHARLES U 2 2 OUT OF STATE F 14 2 BALTIMORE CITY F 23 1 CHARLES U 20 1 OUT OF STATE F 16 1 BALTIMORE CITY F 27 1 CHARLES U 21 3 OUT OF STATE F 17 4 BALTIMORE CITY F 34 1 CHARLES U 24 1 OUT OF STATE F 19 3 BALTIMORE CITY F 37 1 CHARLES U 25 1 OUT OF STATE F 2 2 BALTIMORE CITY F 38 1 CHARLES U 27 2 OUT OF STATE F 20 1 BALTIMORE CITY F 4 1 CHARLES U 28 1 OUT OF STATE F 22 2 BALTIMORE CITY F 40 1 CHARLES U 3 1 OUT OF STATE F 23 1 BALTIMORE CITY F 45 1 CHARLES U 35 1 OUT OF STATE F 25 6 BALTIMORE CITY M 1 1 CHARLES U 36 1 OUT OF STATE F 26 1 BALTIMORE CITY M 13 1 CHARLES U 38 1 OUT OF STATE F 27 3 BALTIMORE CITY M 14 1 CHARLES U 39 1 OUT OF STATE F 28 1 BALTIMORE CITY M 23 1 CHARLES U 4 1 OUT OF STATE F 3 5 BALTIMORE CITY M 49 1 CHARLES U 5 3 OUT OF STATE F 30 2 BALTIMORE CITY M 6 1 CHARLES U 55 1 OUT OF STATE F 31 3 BALTIMORE CITY M 8 1 CHARLES U 6 3 OUT OF STATE F 34 1 BALTIMORE CITY F 51 1 FREDERICK U 7 4 OUT OF STATE F 35 1 BALTIMORE CITY M 63 1 FREDERICK U 8 2 OUT OF STATE F 4 2 BALTIMORE CITY F 17 1 HARFORD U 9 3 OUT OF STATE F 41 1 BALTIMORE CITY F 32 1 HARFORD F 0 1 OUT OF STATE F 45 2 BALTIMORE CITY M 18 1 HARFORD F 1 1 OUT OF STATE M 43 1 HARFORD F 12 1 OUT OF STATE

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 Page 11 F 13 3 OUT OF STATE F 41 1 PRINCE GEORGE'S VIRAL HEPATITIS F 14 1 OUT OF STATE F 45 1 PRINCE GEORGE'S F 15 2 OUT OF STATE F 49 2 PRINCE GEORGE'S ORGANISM F 17 1 OUT OF STATE F 5 3 PRINCE GEORGE'S # SPECIMENS F 18 1 OUT OF STATE F 53 1 PRINCE GEORGE'S # POSITIVES F 19 1 OUT OF STATE F 57 1 PRINCE GEORGE'S JURISDICTION F 2 1 OUT OF STATE F 6 4 PRINCE GEORGE'S HEPATITIS A F 20 2 OUT OF STATE F 60 1 PRINCE GEORGE'S 1 0 ALLEGANY F 22 3 OUT OF STATE F 8 1 PRINCE GEORGE'S 1 0 CALVERT F 23 1 OUT OF STATE F 9 2 PRINCE GEORGE'S 1 0 CARROLL F 25 1 OUT OF STATE M 0 3 PRINCE GEORGE'S 1 0 GARRETT F 27 1 OUT OF STATE M 1 1 PRINCE GEORGE'S 2 0 PRINCE GEORGE'S F 28 2 OUT OF STATE M 10 6 PRINCE GEORGE'S

F 3 1 OUT OF STATE M 11 1 PRINCE GEORGE'S F 33 1 OUT OF STATE M 12 3 PRINCE GEORGE'S SUBTOTAL 6 0 F 37 1 OUT OF STATE M 13 2 PRINCE GEORGE'S F 59 1 OUT OF STATE M 15 4 PRINCE GEORGE'S HEPATITIS B F 7 1 OUT OF STATE M 16 3 PRINCE GEORGE'S 58 1 ALLEGANY F 8 3 OUT OF STATE M 17 1 PRINCE GEORGE'S 208 1 ANNE ARUNDEL F 9 1 OUT OF STATE M 19 1 PRINCE GEORGE'S 38 1 BALTIMORE M 10 1 OUT OF STATE M 2 2 PRINCE GEORGE'S 513 6 BALTIMORE CITY M 11 3 OUT OF STATE M 21 2 PRINCE GEORGE'S 5 0 CALVERT M 12 2 OUT OF STATE M 23 2 PRINCE GEORGE'S 1 0 CAROLINE M 14 3 OUT OF STATE M 24 1 PRINCE GEORGE'S 20 0 CARROLL M 16 1 OUT OF STATE M 26 1 PRINCE GEORGE'S 155 1 CECIL M 17 1 OUT OF STATE M 28 1 PRINCE GEORGE'S 5 0 CHARLES M 18 2 OUT OF STATE M 29 1 PRINCE GEORGE'S 69 2 FREDERICK M 19 1 OUT OF STATE M 33 1 PRINCE GEORGE'S 24 0 GARRETT M 2 2 OUT OF STATE M 34 1 PRINCE GEORGE'S 43 0 HARFORD M 20 3 OUT OF STATE M 39 1 PRINCE GEORGE'S 33 0 HOWARD M 22 1 OUT OF STATE M 4 1 PRINCE GEORGE'S 329 4 MONTGOMERY M 23 1 OUT OF STATE M 43 2 PRINCE GEORGE'S 349 7 PRINCE GEORGE'S M 24 1 OUT OF STATE M 46 1 PRINCE GEORGE'S 3 0 QUEEN ANNE'S M 25 3 OUT OF STATE M 5 2 PRINCE GEORGE'S 2 0 SAINT MARY'S M 26 1 OUT OF STATE M 52 1 PRINCE GEORGE'S 1 0 SOMERSET M 27 1 OUT OF STATE M 54 1 PRINCE GEORGE'S 10 0 TALBOT M 28 1 OUT OF STATE M 6 3 PRINCE GEORGE'S 38 0 WASHINGTON M 29 1 OUT OF STATE M 7 2 PRINCE GEORGE'S 103 1 WICOMICO M 3 2 OUT OF STATE M 8 3 PRINCE GEORGE'S 1 0 WORCESTER M 32 1 OUT OF STATE M 9 2 PRINCE GEORGE'S M 48 1 OUT OF STATE F 6 1 TALBOT SUBTOTAL M 6 1 OUT OF STATE M 3 1 TALBOT 2,008 24 M 7 1 OUT OF STATE M 44 1 TALBOT M 8 2 OUT OF STATE M 7 1 TALBOT HEPATITIS C U 12 2 PRINCE GEORGE'S F 22 1 WICOMICO 65 6 ALLEGANY U 18 1 PRINCE GEORGE'S M 4 1 WICOMICO 235 80 ANNE ARUNDEL U 47 1 PRINCE GEORGE'S U 24 1 WORCESTER 43 2 BALTIMORE F 0 2 PRINCE GEORGE'S F 0 1 WORCESTER 230 58 BALTIMORE CITY F 1 1 PRINCE GEORGE'S F 10 1 WORCESTER F 10 3 PRINCE GEORGE'S F 14 1 WORCESTER 5 0 CALVERT F 11 2 PRINCE GEORGE'S F 18 1 WORCESTER 1 0 CAROLINE F 12 5 PRINCE GEORGE'S F 19 2 WORCESTER 25 2 CARROLL F 13 3 PRINCE GEORGE'S F 2 1 WORCESTER 106 13 CECIL F 14 1 PRINCE GEORGE'S F 21 3 WORCESTER 10 0 CHARLES F 15 2 PRINCE GEORGE'S F 22 1 WORCESTER 65 3 FREDERICK F 17 2 PRINCE GEORGE'S F 23 1 WORCESTER 30 0 GARRETT F 18 2 PRINCE GEORGE'S F 25 1 WORCESTER 25 0 HARFORD F 2 3 PRINCE GEORGE'S F 28 1 WORCESTER 3 0 HOWARD F 20 2 PRINCE GEORGE'S F 5 1 WORCESTER 40 2 MONTGOMERY F 22 4 PRINCE GEORGE'S F 58 1 WORCESTER 180 8 PRINCE GEORGE'S F 23 2 PRINCE GEORGE'S F 6 1 WORCESTER 16 0 QUEEN ANNE'S F 27 2 PRINCE GEORGE'S F 9 1 WORCESTER 5 0 SAINT MARY'S F 3 2 PRINCE GEORGE'S M 10 1 WORCESTER 10 0 TALBOT F 30 1 PRINCE GEORGE'S M 11 1 WORCESTER 15 2 WASHINGTON F 31 2 PRINCE GEORGE'S M 15 1 WORCESTER 17 2 WICOMICO F 33 1 PRINCE GEORGE'S M 3 1 WORCESTER 1 0 WORCESTER F 34 1 PRINCE GEORGE'S M 9 1 WORCESTER F 36 1 PRINCE GEORGE'S INFLUENZA A(H3) SUBTOTAL F 37 2 PRINCE GEORGE'S M 33 1 BALTIMORE CITY 1,127 178 F 4 1 PRINCE GEORGE'S F 40 2 PRINCE GEORGE'S TOTAL 645 TOTALS 3,141 202

Page 12 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 RABIES NEWBORN & CHILDHOOD SCREENING ENVIRONMENTAL CHEMISTRY STATISTICS FOR JUNE 2009 SOURCE # JURISDICTION

PRESUMPTIVE POSITIVES SAMPLES COMPLIANT # NON- # TESTED BAT 3 ANNE ARUNDEL DISORDERS # 1 BALTIMORE CAT 1 DORCHESTER PHENYLKETONURIA 4

1 HOWARD MAPLE SYRUP URINE DISEASE 1 1 MONTGOMERY HOMOCYSTINURIA 9 1 SAINT MARY'S TYROSINEMIA 2 FOX 1 BALTIMORE ARGININEMIA 0 ASBESTOS 1 DORCHESTER 1 MONTGOMERY CITRULLINEMIA 1 AIR 0 0 1 WICOMICO GALACTOSEMIA 1 BULK 3 5 3 WORCESTER BIOTINIDASE DEFICIENCY 3 RACCOON 1 BALTIMORE CITY HYPOTHYROIDISM 63 AIR QUALITY 1 BALTIMORE HEMOGLOBIN -DISEASE 18 2 CARROLL PM 2.5 0 591 HEMOGLOBIN -BENIGN 422 1 FREDERICK PM 10 0 0 CONGENITAL ADRENAL 2 HOWARD 46 1 MONTGOMERY HYPERPLASIA (CAH) RADIATION 1 PRINCE GEORGE’S CYSTIC FIBROSIS 3 AIR/CHARCOAL FILTERS 0 56 1 TALBOT FATTY ACID OXIDATIONS 0 8 WORCESTER ORGANIC ACIDEMIAS 6 MILK 0 2 SKUNK 1 WICOMICO ACYLCARNITINE - BORDERLINE 3 WIPES 0 40 TOTAL ACYLCARNITINE - OTHERS 11 RAW WATER 0 5 POSITIVES 34

TOTAL MONTHLY TOTALS VEGETATION 0 0 SPECIMENS 527 # OF SPECIMENS SCREENED 13,224 OTHER 0 1 NUMBER OF TESTS 1,003,901 DRINKING WATER CHLAMYDIOPHILIA PSITTACI % UNSATISFACTORY SPECIMENS 2.7 METALS (CHLAMYDIA) REPORTED QUARTERLY APRIL 2009 THROUGH JUNE 2009 YEAR-TO-DATE CONFIRMED CASES COMMUNITY 4 11 SEX AGE JURISDICTION CONDITIONS # CONFIRMED NON-COMMUNITY 5 9 MCAD 3 M 42 PRINCE GEORGE'S PRIVATE WELLS 52 167 M 18 PRINCE GEORGE'S 3MCC 1 PESTICIDES & PCBs M 32 MONTGOMERY SCAD 0 VLCAD 0 COMMUNITY 0 117 CD4 FLOW CYTOMETRY WORKLOAD GA-I 0 NON-COMMUNITY 0 44 IVA 1 COMPARING CURRENT QUARTER TO PRIVATE WELLS 0 1 SAME QUARTER LAST YEAR PA 0 MAPLE SYRUP URINE DISEASE 0 VOLATILE ORGANIC COMPOUNDS Level Level Level PKU- CLINICALLY SIGNIFICANT 1 2 3 0 COMMUNITY 3 265 DATES TOTAL VARIANT <14% 14%- ≥29% CLINICALLY SIGNIFICANT VARIANT NON-COMMUNITY 0 70 28% HYPERPHENYLALANINEMIA 0 PRIVATE WELLS 1 162 (NOT CLASSICAL PKU) 4/01/09 - 6/30/09 150 435 280 865 VARIANT RADIATION 4/01/08 - 6/30/08 229 490 301 1020 HYPERPHENYLALANINEMIA 0 (NOT CLINICALLY SIGNIFICANT) COMMUNITY 1 59 CITRULINEMIA I (CIT-I) 1 NON-COMMUNITY 0 0 BLOOD LEAD GALACTOSEMIA- 1 PRIVATE WELLS 0 5 MARYLAND CLASSICAL GALT DEFICIENCY I <10 153 GALACTOSEMIA - VARIANT 0 INORGANICS IIA 10-14 9 BIOTINIDASE DEFICIENCY 0 COMMUNITY 0 17 IIB 15-19 1 GALACTOSE EPIMERASE DEFICIENCY 0 NON-COMMUNITY 9 112 III 20-44 3 PARTIAL BIOTINIDASE DEFICIENCY 0 PRIVATE WELLS 16 189 IV 45-69 1 CAH- CLASSICAL SALT WASTING 0 V >69 0 CAH-NON-CLASSICAL 0 FOOD CHEMISTRY TOTAL 167 HYPOTHYROIDISM - PRIMARY 11 SUSPECTED OTHER HYPOTHYROIDISM 8 TAMPERING 0 0 WASHINGTON DC SECONFARY HYPOTHYROIDISM 1 MICROSCOPIC I <10 0 SICKLE CELL DISEASE -SS 37 FILTH 0 0 IIA 10-14 0 SICKLE CELL DISEASE -SC 24 LABELING 0 0 IIB 15-19 0 SICKLE CELL DISEASE -SE 0 SURVEILLANCE 0 0 III 20-44 0 SICKLE CELL DISEASE -S BETA 0 CHEMICAL IV 45-69 0 THALASSEMIA CONTAMINATION 0 5 CYSTIC FIBROSIS 2 V >69 0 TOTAL 94 1,933 TOTAL 0 Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • September 2009 • Vol. 13, No. 9 Page 13 VIRAL LOAD SPECIMENS HIV ANTIBODY SCREENING SPECIMENS SPECIMENS POSITIVE POSITIVE POSITIVE POSITIVE TOTAL % EIA % WB # EIA # EIA # WB TOTALS TOTALS 10 10

<10 >10 SUBMITTER 3 4 —10 —10 HIV-1 RNA COPIES/ML 3 5

4 5

CORRECTIONAL INSTITUTIONS 131 3 2.29% 3 100.00%

FAMILY PLANNING (NON-GOVT) 90 0 0.00% 0 0.00%

ALLEGANY 15 1 0 0 16 HEALTH CENTERS (NON-GOVT) 667 44 6.60% 42 95.45%

HEALTH DEPT, NON-STD, 556 3 0.54% 0 0.00% MONTGOMERY 97 11 16 2 126 FAMILY PLANNING HEALTH DEPT, NON-STD, OB/GYN 15 0 0.00% 0 0.00%

PRINCE GEORGE'S 63 21 13 10 107 HEALTH DEPT, NON-STD, OTHER 797 34 4.27% 33 97.06%

HEALTH DEPT, STD CLINICS 986 23 2.33% 21 91.30% WASHINGTON 5 0 0 0 5 HOSPITAL, OTHER 159 22 13.84% 21 95.45%

HOSPITAL, PUBLIC 24 2 8.33% 2 100.00% WICOMICO 1 0 1 0 2 LABORATORIES (NON-HOSPITAL) 394 19 4.82% 10 52.63%

SUBTOTALS 181 33 30 12 256 PEDIATRIC - CHILD HEALTH 2 0 0.00% 0 0.00%

PRIVATE PHYSICIANS 3 0 0.00% 0 0.00% DEPT. OF 36 7 9 1 53 CORRECTIONS PRIVATE STUDENT HEALTH CTRS 18 0 0.00% 0 0.00%

PUBLIC STUDENT HEALTH CTRS 73 3 4.11% 1 33.33% TOTALS 217 40 39 13 309

TOTALS 3,915 153 3.91% 133 86.93%

MAILING LABEL LABEL MAILING

Baltimore, Maryland 21201 21201 Maryland Baltimore,

201 West Preston Street Street Preston West 201

Department of Health & Mental Hygiene Hygiene Mental & Health of Department

J. Mehsen Joseph Public Health Laboratory Laboratory Health Public Joseph Mehsen J.

c/o Georgia Corso, Room L-15 L-15 Room Corso, Georgia c/o Critical Link Link Critical

Critical Link • www.dhmh.state.md.us/labs/html/critical-link.html • December 2008 • Vol. 12, No. 12 Page 14