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isease ontrol ewsletter DVolume 46, Number 1 (pages 1-30)C N 2019 Annual Summary of Communicable Diseases Reported to the Minnesota Department of Health, 2018 Introduction Assessment of the population’s health is a core public health function. Anaplasmosis, caused by Anaplasma Surveillance for communicable diseases is one type of assessment. Epidemiologic phagocytophilum, is transmitted surveillance is the systematic collection, analysis, and dissemination of health by bites from Ixodes scapularis, data for the planning, implementation, and evaluation of health programs. the blacklegged tick. Although the The Minnesota Department of Health (MDH) collects information on infectious organism that causes anaplasmosis diseases for the purposes of determining disease impact, assessing trends in was previously known by other disease occurrence, characterizing affected populations, prioritizing control names and thought to be a part of efforts, and evaluating prevention strategies. Prompt reporting allows outbreaks the genus Ehrlichia, anaplasmosis and to be recognized in a timely fashion when control measures are most likely to be (due to E. chaffeensis) are effective in preventing additional cases. distinct diseases caused by different rickettsial species. The same tick vector In Minnesota, communicable disease reporting is centralized, whereby reporting also transmits the etiologic agents of sources submit standardized reports to MDH. Cases of disease are reported , babesiosis, ehrlichiosis pursuant to Minnesota Rules Governing Communicable Diseases (Minnesota (due to E. muris), and Powassan Rules 4605.7000 -4605.7800). The diseases listed in Table 1 must be reported virus. In rare circumstances, A. to MDH. As stated in the rules, physicians, health care facilities, laboratories, phagocytophilum may be transmitted veterinarians, and others are required to report these diseases. Reporting by blood transfusion. sources may designate an individual within an institution to perform routine reporting duties (e.g., an preventionist for a hospital). Data maintained In 2018, 496 confirmed or probable by MDH are private and protected under the Minnesota Government Data cases (8.9 cases per 100,000 Practices Act (Section 13.3805). population) were reported, down from the 638 cases reported in 2017 (Figure Since April 1995, MDH has participated as an Emerging Program 1). Despite some annual fluctuations in (EIP) site funded by the U.S. Centers for Disease Control and Prevention (CDC) reported cases, the overall trend is an and, through this program, has implemented active hospital- and laboratory- increase in yearly case totals over time, based surveillance for several conditions, including selected bacterial diseases, with a median of 627 cases reported foodborne diseases, tickborne diseases, and hospitalized influenza cases. per year since 2010. Sixty-two percent (307) of cases reported were male. Isolates of from certain diseases are required to be submitted to The median age of cases was 61 years MDH (Table 1: Minnesota Rules Governing Communicable Diseases (Minnesota (range, 2 to 92), 17 years older than Rules 4605.7000-4605.7800). The MDH Public Health Laboratory (PHL) performs the median age of confirmed Lyme microbiologic and molecular evaluation of isolates, such as pulsed-field gel disease cases. As is typical, most cases electrophoresis (PFGE) and (WGS), to determine had illness onsets during the summer whether isolates (e.g., enteric pathogens such as Salmonella and months, with 72% of cases reporting O157:H7, and invasive pathogens such as Group A ) are related and illness onsets in June and July. In 2018, potentially associated with a common source. Testing of submitted isolates also 132 (27%) cases were hospitalized for allows detection and monitoring of antimicrobial resistance. their infection, with a median duration of 4 days (range, 2 to 33 days). Table 2 summarizes cases of selected communicable diseases reported during 2018 by district of the patient’s residence. Pertinent observations for some continued on page 4 of these diseases are presented below. Incidence rates in this report were calculated using disease-specific numerator data collected by MDH and a standardized set of denominator data derived from U.S. Census data. Disease Inside: incidence is categorized as occurring within the seven-county Twin Cities metropolitan area (metropolitan area) or outside of it in Greater Minnesota Emerging Infections in Clinical Practice and (unless otherwise indicated). Public Health Announcement and Registration...... 28 Table 1. Diseases Reportable to the Minnesota Department of Health

Reportable Diseases, MN Rules 4605.7000 to 4605.7900 Diseases Reportable to the Minnesota Department of Health 651-201-5414 or 1-877-676-5414 24 hours a day, 7 days a week

REPORT IMMEDIATELY BY TELEPHONE Anthrax ( anthracis) M Hemolytic uremic syndrome M Rabies (animal and human cases and suspected Botulism ( botulinum) Measles (rubeola) M cases) (Brucella spp.) M ( pseudomallei) M * Rubella and congenital rubella syndrome M () M ( meningitidis) Severe Acute Respiratory Syndrome (SARS) M R Diphtheria ( diphtheriae) M (invasive) M S Smallpox (variola) M Free-living amebic infection M Middle East Respiratory Syndrome (MERS) M () M (including at least: Acanthamoeba spp., Orthopox virus M Unusual or increased case incidence of any Naegleria fowleri, Balamuthia spp., Sappinia () M suspect infectious illness M spp.) Poliomyelitis M Viral hemorrhagic M () M * (including but not limited to Ebola virus disease ( ) M and Lassa fever)

REPORT WITHIN ONE WORKING DAY Amebiasis (Entamoeba histolytica/dispar) influenzae disease (all invasive Staphylococcus aureus M Anaplasmosis (Anaplasma phagocytophilum) disease) M S (only -intermediate Staphylococcus Hantavirus infection aureus [VISA], vancomycin-resistant Arboviral disease Staphylococcus aureus [VRSA], and death or (including, but not limited to, La Crosse (all primary viral types including A, B, critical illness due to community-associated encephalitis, eastern equine encephalitis, C, D, and E) B Staphylococcus aureus in a previously healthy western equine encephalitis, St. Louis (Histoplasma capsulatum) encephalitis, West Nile virus disease, Powassan individual) virus disease, and Jamestown Canyon virus Human immunodeficiency virus (HIV) infection, Streptococcal disease - invasive disease caused disease) including Acquired Immunodeficiency by Groups A and B streptococci and Syndrome (AIDS) B S. pneumoniae M S Babesiosis (Babesia spp.) Influenza M Blastomyces dermatitidis Streptococcal disease - non-invasive Blastomycosis ( ) (unusual case incidence, critical illness, or S. pneumoniae Candida auris M ** laboratory-confirmed cases) (urine laboratory-confirmed (Campylobacter spp.) M Kawasaki disease ) Carbapenem-resistant (CRE) M Kingella spp. (invasive only) M S (Treponema pallidum) B Cat scratch disease (infection caused by Legionellosis (Legionella spp.) M Tetanus (Clostridium tetani) species) (Hansen’s disease) (Mycobacterium M () leprae) Toxoplasmosis (Toxoplasma gondii) Chikungunya virus disease (Leptospira interrogans) Transmissible spongiform encephalopathy trachomatis infections (Listeria monocytogenes) M Trichinosis (Trichinella spiralis) Lyme disease (Borrelia burgdorferi, and other (Mycobacterium tuberculosis Cronobacter sakazakii in infants under one year Borrelia spp.) complex) M of age M Malaria (Plasmodium spp.) (pulmonary or extrapulmonary sites of disease, Cryptosporidiosis (Cryptosporidium spp.) M (caused by viral agents) including clinically diagnosed disease). Latent Cyclosporiasis (Cyclospora spp.) M Mumps M tuberculosis infection is not reportable. Dengue virus infection Neonatal M S (Rickettsia spp.) Diphyllobothrium latum infection ( isolated from a sterile site, Unexplained deaths and unexplained critical Ehrlichia excluding coagulase-negative Staphylococcus) illness Ehrlichiosis ( spp.) less than seven days after birth (possibly due to infectious cause) M Encephalitis (caused by viral agents) Pertussis ( pertussis) M Varicella () M Enteric Escherichia coli infection M Vibrio spp. M (E. coli O157:H7, other Shiga toxin-producing Psittacosis (Chlamydophila psittaci) E. coli, enterohemorrhagic Retrovirus infections Yellow fever E. coli, enteropathogenic E. coli, enteroinvasive , including typhoid (Salmonella (enteric Yersinia spp. regardless of E. coli, enteroaggregative spp.) M specimen source) M E. coli, enterotoxigenic E. coli, or other (Shigella spp.) M Zika virus disease B pathogenic E. coli) Zoster () M Giardiasis (Giardia intestinalis) (Rickettsia spp. infections, including Rocky (all cases <18 years old; unusual case incidence/ Gonorrhea ( infections) Mountain spotted fever) complications regardless of age)

SENTINEL SURVEILLANCE FOOTNOTES Diseases reportable through sentinel surveillance are reportable based on the M Submission of clinical materials required. Submit isolates or, if an residence of the patient or the specific health care facility. Sentinel surveillance isolate is not available, submit material containing the infectious is not statewide reporting. agent in the following order of preference: a patient specimen; nucleic acid; or other laboratory material. Call the MDH Public Staphylococcus aureus M S Health Laboratory at 651-201-4953 for instructions. Candidemia (Candida spp.) (blood isolates only) M S S Invasive disease only: isolated from a normally sterile site, e.g.: Carbapenem-resistant Acinetobacter spp. (CRA), and blood, CSF, joint fluid, etc. aeruginosa (CR-PA) M R In the event of SARS or another severe respiratory outbreak, also Clostridium difficile M report cases of health care workers hospitalized for pneumonia or Severe Acute Respiratory Illness M acute respiratory distress syndrome. Respiratory syncytial virus (RSV) B Also report a pregnancy in a person with Zika; or a person chronically infected with , HIV, or syphilis. TO REPORT * Beginning July 13, 2018 pursuant to 4605.7080. ** Beginning August 1, 2018 pursuant to 4605.7080. • For immediate reporting call: *** Nontuberculous Mycobacteria (extrapulmonary) expected reportable fall 651-201-5414 or 1-877-676-5414. 2019 pursuant to 4605.7080. • Report forms and more information: www.health.state.mn.us/diseasereport

2 DCN 46;1 2019 Table 2. Cases of Selected Communicable Diseases Reported to the Minnesota Department of Health by District of Residence, 2018 District (population per U.S. Census 2017 estimates)

3,077,416) Disease Metropolitan ( Northwestern (158,973) Northeastern (324,914) Central (757,631) Central West (241,968) South Central (291,389) Southeastern (507,073) Southwestern (217,242) Unknown Residence Total (5,576,606) Anaplasmosis 104 105 99 110 43 4 29 2 0 496 Babesiosis 7 10 6 17 1 0 8 0 0 49 Blastomycosis 21 6 12 10 2 0 6 1 0 58 Botulism (Infant) 1 0 0 0 0 0 0 0 0 1 Campylobacteriosis 593 13 48 175 57 78 152 122 0 1,238 Cryptosporidiosis 142 14 29 54 35 56 133 69 0 532 Escherichia coli O157 infection 52 4 3 22 8 4 12 10 0 115 Hemolytic uremic syndrome 10 0 0 0 0 0 1 0 0 11 Giardiasis 270 7 46 35 26 26 46 52 0 508 disease 48 5 7 16 5 6 8 7 0 102 HIV (non-AIDS) 175 2 6 13 8 8 12 4 0 228 AIDS (diagnosed in 2018) 95 3 2 5 1 2 5 3 0 116 Legionnaires’ disease 94 2 8 8 5 17 16 2 0 152 Listeriosis 4 0 0 2 0 2 1 0 0 9 Lyme disease 399 61 134 218 45 16 67 10 0 950 Measles (rubeola) 2 0 0 0 0 0 0 0 0 2 Mumps 10 0 0 1 0 0 2 0 0 13 Pertussis 199 13 41 60 6 10 58 10 0 397 Q Fever (acute) 1 0 0 0 0 0 1 0 0 2 Q Fever (chronic) 0 0 0 1 0 0 0 1 0 2 Salmonellosis 565 23 41 103 48 65 86 78 0 1,009 Sexually transmitted diseases 21,757 648 1,561 2,543 791 1,178 2,363 671 512 32,024 - genital infections 15,411 468 1,213 2,023 634 1,036 1,809 634 403 23,564 5,648 142 324 438 146 124 516 97 107 7,542 Syphilis, total 698 38 24 82 11 18 38 7 2 918 Primary/secondary 232 13 6 23 5 4 7 2 0 292 Early latent* 205 20 9 29 4 4 12 1 2 286 Late latent** 255 4 8 30 2 10 18 3 0 330 Congenital 6 1 1 0 0 0 1 1 0 10 Other*** 0 0 0 0 0 0 0 0 0 0 Shigellosis 121 0 0 9 3 4 6 3 0 146 Streptococcal invasive disease - Group A 201 16 31 31 13 16 47 12 0 367 Streptococcal invasive disease - Group B 294 10 44 82 31 39 53 26 0 579 Streptococcus pneumoniae disease 231 21 44 61 26 31 42 22 0 478 Tuberculosis 121 0 2 9 5 11 16 8 0 172 Tularemia 2 0 0 0 0 0 0 0 0 2 Varicella 197 7 10 43 19 14 20 15 0 325 Viral hepatitis, type A 9 0 2 2 2 0 1 0 0 16 Viral hepatitis, type B (acute infections only, not perinatal) 11 1 0 1 0 2 1 0 0 16 Viral hepatitis, type C (acute infections only) 27 9 9 4 7 0 3 1 0 60 West Nile virus 19 5 0 5 13 4 3 14 0 63 Zika virus 1 0 0 0 0 0 0 0 0 1

* Duration ≤1 year ** Duration >1 year *** Includes unstaged neurosyphilis, latent syphilis of unknown duration, and latent syphilis with clinical manifestations

County Distribution within Districts Metropolitan - Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, Washington Northwestern- Beltrami, Clearwater, Hubbard, Kittson, Lake of the Woods, Marshall, Pennington, Polk, Red Lake, Roseau Northeastern - Aitkin, Carlton, Cook, Itasca, Koochiching, Lake, St. Louis Central - Benton, Cass, Chisago, Crow Wing, Isanti, Kanabec, Mille Lacs, Morrison, Pine, Sherburne, Stearns, Todd, Wadena, Wright West Central - Becker, Clay, Douglas, Grant, Mahnomen, Norman, Otter Tail, Pope, Stevens, Traverse, Wilkin South Central - Blue Earth, Brown, Faribault, LeSueur, McLeod, Martin, Meeker, Nicollet, Sibley, Waseca, Watonwan Southeastern - Dodge, Fillmore, Freeborn, Goodhue, Houston, Mower, Olmsted, Rice, Steele, Wabasha, Winona Southwestern- Big Stone, Chippewa, Cottonwood, Jackson, Kandiyohi, Lac Qui Parle, Lincoln, Lyon, Murray, Nobles, Pipestone, Redwood, Renville, Rock, Swift, Yellow Medicine

DCN 46;1 2019 3 Arboviral Diseases tires, buckets, or cans) that provide Twelve resided in the metropolitan breeding habitats are abundant. area, and all infections were acquired Mosquito-borne Since 1985, 144 cases have been abroad. Cases reported travel to many Arboviral Diseases reported from 22 Minnesota counties, areas of the world, including to Haiti primarily in the southeastern part (7), (3), Africa (2), and Historically, the primary arboviral of the state. Many people who are Central America (1). encephalitides found in Minnesota infected have no apparent symptoms, have been La Crosse encephalitis, but severe disease is more common in Chikungunya Western equine encephalitis children. Most people report an illness (WEE), and West Nile virus (WNV) onset during the typical arboviral Chikungunya virus is a mosquito-borne encephalitis, but in recent years season from mid-July through mid- alphavirus found in Africa, Asia, and other viruses, like Jamestown Canyon September. Europe. In late 2013, locally acquired have emerged as significant causes cases appeared for the first time in the of disease. While WNV and WEE In 2018, 11 cases of Jamestown Canyon Americas on the Caribbean island of St. are maintained in mosquito-to-bird virus disease, a California group virus Martin, and the virus subsequently has transmission cycles involving several related to La Crosse, were reported. spread throughout Central and South different species of each, La Crosse The virus is transmitted by Aedes America. The virus is transmitted by and Jamestown Canyon viruses use mosquitoes, and the maintenance the same Aedes spp. mosquitoes (Ae. mammals instead of birds as part cycle in nature is thought to include aegypti and Ae. albopictus) that also of their transmission cycles. WNV is deer and other large mammals. Much transmit dengue and Zika viruses. established throughout Minnesota, remains unknown about the clinical and will probably be present in the spectrum of Jamestown Canyon virus, Unlike many other mosquito-borne state to some extent every year, but the typical presentation includes viruses, most people who are infected whereas human cases of other fever, and in more severe cases, with chikungunya develop symptoms. diseases may occur more sporadically. meningitis or encephalitis. The virus The most common symptoms are fever Interpreting the effect of weather on is likely widespread in Minnesota. and joint pain, but patients may also arboviral transmission is complex, Cases were aged 21 to 82 years, with experience headache, muscle aches, or making it difficult to predict the a median of 58 years, and 91% were . Symptoms usually begin 3-7 days number of people who will become male. Seven (64%) presented with after a person is bitten by an infected infected in any given year. neuroinvasive disease, including mosquito, and most recover within a meningitis or encephalitis, and most week. Joint pain may persist for weeks In Minnesota, 63 WNV disease cases were residents of counties in north to years after the initial illness. were reported in 2018, slightly more central and northeastern Minnesota. than the median number of cases Due to the mosquito vectors involved In 2018, 7 cases were reported in per year (49) from 2012 to 2017, in the transmission cycle for this virus, Minnesota residents. The median case but considerably fewer than in disease onsets can occur from late age was 38 (range, 30 to 76 years). record years. Thirty-five (56%) had spring through the early part of the Five resided in the metropolitan area neuroinvasive presentations including fall. and symptom onsets occurred all year, encephalitis or meningitis, and there from February through November. were 2 deaths in older adults. The Imported Mosquito-borne All represented imported infections other 28 cases had West Nile fever. Arboviral Diseases acquired abroad, and travel occurred Seventy percent of the cases were to many areas of the world. Four male, and the median age was 62 Dengue traveled to Asia, two went to Africa, years (range, 21 to 91). Thirty-nine and one visited the Caribbean. (62%) cases were hospitalized. The Dengue fever is one of the most majority of cases (95%) reported frequently occurring mosquito-borne Zika Virus symptom onset in July, August, or diseases worldwide, with an estimated September. Twenty-one asymptomatic 390 million infections, with nearly Zika virus is a mosquito-borne WNV-positive blood donors were also 100 million people experiencing flavivirus that was initially discovered identified in 2018. Risks for human symptomatic disease each year. in 1947 in Uganda, and the first WNV infection continue to be higher in Four serotypes of dengue virus are human cases were identified in 1952. central and western Minnesota where transmitted to humans through Historically this virus occurred only the primary mosquito vector, Culex the bite of Aedes aegypti and Ae. sporadically in Africa and Asia, but it tarsalis, is most abundant. albopictus mosquitoes. Dengue is gained attention after it resulted in considered endemic in more than 100 outbreaks in Micronesia in 2007 and For the first time since 2009, there countries in tropical or subtropical French Polynesia in 2013-2014. In were no cases of La Crosse encephalitis regions around the world, and risk is spring 2015, cases were reported from reported. The disease, which primarily widespread, especially where water- Brazil, representing the first time the affects children, is transmitted holding containers (e.g., waste tires, virus had been found in the Americas. through the bite of infected Aedes buckets, or cans) provide abundant Since then, the virus has spread to triseriatus (Eastern Tree Hole) mosquito breeding habitat. most countries and territories in the mosquitoes, and is maintained in a Western Hemisphere, and infections cycle that includes mosquitoes and In 2018, 13 cases were reported in during pregnancy have been associated small mammals. Exposure to infected Minnesota residents. The median case with adverse fetal outcomes, including mosquitoes typically occurs in wooded age was 38 years (range, 8 months microcephaly. Zika has been shown or shaded areas inhabited by this to 69 years) and onset of symptoms to be transmitted perinatally as well species, especially in areas where occurred primarily in the latter half of as through sexual contact, a route of water-holding containers (e.g., waste the year from July through November. transmission that has never before 4 DCN 46;1 2019 In 2018, 49 confirmed and probable Figure 1. Reported I. scapularis-borne Disease Cases, babesiosis cases (1.1 per 100,000 2000-2018 population) were reported, down slightly from the 59 cases in 2017. 1600 Lyme disease Despite slight annual fluctuations, case Human anaplasmosis totals since 2009 (range, 31 to 72) have 1400 been consistently higher than reported Babesiosis totals from 2000 to 2008 (range, 1200 1 to 29) (Figure 1), and the overall trend is toward increasing numbers. 1000 Demographic and case characteristics are similar in recent years. In 2018, 33 800 (67%) of the cases occurred in males. The median case age was 64 years 600 (range, 5 to 84), identical to 2017, Number of of Cases Number and older than the median ages for 400 both anaplasmosis (61 years) and for confirmed cases of Lyme disease (44 200 years). Onsets of illness peaked in the summer months; 36 (86%) of 42 patients with known onset reported 0 first experiencing symptoms in June, 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 July, or August. Fifteen (31%) cases Year of Report were hospitalized for their infection in 2018 for a median duration of 4 days been associated with a mosquito- year except for 2014 and 2015, with a (range, 2 to 10 days). A single case borne virus. The mosquito vectors peak of 11 cases in 2011 (range, 1 to had severe complications (e.g., organ for humans are the same Aedes spp. 11). Three cases of POW were reported failure), but there were no deaths mosquitoes (Ae. aegypti and Ae. in 2018. Two of the three were female, attributable to babesiosis. albopictus) that transmit dengue virus and ages ranged from 48 to 61 years. and Chikungunya virus. Although cases of non-neuroinvasive Blastomycosis disease have been reported in Although the outbreak in the Americas previous years, all of the patients in In 2018, 58 blastomycosis cases were peaked in 2016, cases are still reported 2018 presented with meningitis or reported, the highest number since from around the region. The risk for encephalitis. Similar to other tick-borne enhanced surveillance began in 1999. infection persists throughout many diseases, the majority of patients The 2 previous years (2017, 2016) had areas of the world, but the ability report being exposed to ticks in north the third and fourth highest counts, to detect a new outbreak varies central Minnesota, and illness onsets 44 and 39 cases. The median age was by country, and reporting of new follow a similar pattern as is seen for 45.5 years (range, 5 to 90); 45 (78%) outbreaks may be delayed several other tickborne diseases, with cases were male. Thirty-eight (75%) cases weeks to months. Since most people first experiencing symptoms between were white, 8 (16%) were black, 2 (up to 80%) that are infected with Zika May and July. Based on findings from (4%) were American Indian/Alaska do not develop symptoms, it is possible routine tick surveillance activities, the Native, 2 (4%) were Asian/Pacific that many infections, and even small virus appears to be widely distributed Islander, 1 (2%) was mixed race, and outbreaks, may go undetected. in the same wooded parts of the state 7 were unknown race. Thirty-five that are endemic to other pathogens (60%) cases were hospitalized for a In 2018, only 1 case of Zika virus transmitted by I. scapularis. median of 7 days (range, 1 to 197). disease was reported, and 1 Eight (14%) cases died, which is a asymptomatic blood donor was Babesiosis higher fatality rate than the normally also identified. The case was a observed 9-10%, and the second year symptomatic, non-pregnant female Babesiosis is a malaria-like illness in a row with an increased case fatality who traveled to Asia, and the donor caused by a protozoan parasite, rate. Blastomycosis was the cause was a male with a recent history of typically Babesia microti, which of death for all 8. Twenty-one cases travel to Mexico. infects red blood cells. B. microti is (40%) had immunocompromising transmitted to humans by bites health conditions or medications, Endemic Tick-borne Arboviral from I. scapularis (the blacklegged including 12 (28%) with , 3 Disease tick), the same vector that transmits (9%) taking corticosteroids, and 2 the agents of Lyme disease, human (5%) on medications for rheumatoid Powassan virus (POW) is a tickborne anaplasmosis, one form of human arthritis. Forty-two (72%) cases had flavivirus that includes a strain ehrlichiosis, and a strain of Powassan pulmonary infection, 3 (5%) had extra- (lineage II or “deer tick virus”) that virus. Babesia parasites can also be pulmonary infection, and 13 (22%) had is transmitted by Ixodes scapularis. transmitted by blood transfusion. disseminated infection. The virus can cause encephalitis or Although most people infected with meningitis, and long-term sequelae Babesia have asymptomatic infections, From 1999 to 2018, 671 blastomycosis occur in approximately half of those people with weak immune systems, cases were reported; the annual patients. Approximately 10-15% of other co-morbidities, and the elderly median is 33.5 cases (range, 22 to cases are fatal. Since the first case in can become seriously ill. 58). The median annual incidence 2008, there have been cases every statewide is 0.63 cases/100,000 DCN 46;1 2019 5 continued... From 2001-2018, 14 cases of infant Figure 2. Human Blastomycosis Cases by Probable botulism and 2 cases of foodborne County of Exposure*, 1999-2018 botulism were reported. The median age of infants was 19 weeks (range 5 to 41 weeks), and 8 (57%) were male. (n=559) Eleven (79%) cases were caused by Kittson Roseau Lake botulinum toxin type B and 3 (21%) 10 of the 1 Woods by toxin type A; since 2006 all infant cases in Minnesota have been caused Marshall 9 2 Koochiching by toxin type B. Eleven infants were Beltrami St. Louis known to be hospitalized, for a median Polk Pennington 7 Cook of 15 days (range 8 to 30 days); one Clear Red Lake 16 2 Water Lake 5 infant did not require hospitalization. 1 Itasca The 2 foodborne cases were of toxin 8 type A, and occurred in 2009 in 70 131 Norman Mahnomen two men consuming home-canned Hubbard 1 Cass asparagus. Both were hospitalized for 11 6 and 16 days. No deaths occurred Clay Becker 43 Aitkin among the infant or foodborne 1 botulism cases. Wadena Crow Wing 5 Carlton Wilkin Otter Tail 1 3 Brucellosis 11 1 Pine Todd Mille Brucellosis is an acute or chronic illness Lacs 12 1 Kanabec Brucella Grant Douglas 1 caused by bacteria of the Morrison 1-5 2 3 1 genus. There are 5 important species Benton 6-15 of Brucella: B. abortus, B. melitensis, Traverse Stevens Pope Stearns Isanti B. suis, B. canis, and B. ovis, of which Big Stone 1 1 5 Sherburne 1 Chisago 16-40 2 cattle, goats, pigs, dogs, and sheep Swift 1 17 Kandiyohi Anoka >40 are the respective reservoir animals. Meeker Wright 5 Wash- ing- Ram- 13 Transmission can occur through Chippewa Hennepin ton 2 sey 15 Lac Qui Parle 19 ingestion of unpasteurized dairy McLeod Carver Renville products, contact with infected animal Yellow Medicine 2 Scott 1 1 Dakota tissue, or inhalation of aerosolized Sibley Lincoln Lyon 1 6 Redwood bacteria in a laboratory setting. Le Rice Goodhue Nicollet Sueur 1 1 Wabasha Minnesota’s livestock have been 1 1 1 Brown 2 brucellosis free since 1985; most Murray Pipestone Olmsted Cottonwood Watonwan Blue Earth Waseca Steele Dodge Winona infections are acquired in Brucella- 2 1 2 1 10 4 endemic countries. Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston 5 3 2 In 2018, 2 confirmed cases were * 52 cases were exposed in Wisconsin, 8 in other states, 10 in Canada, and 1 in South America. Exposure location is unknown for 112 cases. reported; both were infected with B. melitensis. Case ages were 34 and 49 years; both were male; both population, but was 1.03 and cause three main forms of were hospitalized and survived. The cases/100,000 in 2018. Exposure intoxication: foodborne, wound, and exposure for both cases was likely information is available for 559 cases. intestinal-toxemia, which includes ingesting unpasteurized camel milk The largest number, 131 (23%), were infant botulism and adult intestinal in Africa. One case’s clinical isolate likely exposed in St. Louis County. toxemia. Infant botulism, which is resulted in exposure of seven clinical Seventy (13%) cases were likely the most common form in the United laboratory staff. exposed in Itasca County, 43 (8%) States, results from the ingestion of C. in Cass County, 19 (3%) in Hennepin botulinum spores that germinate into From 2007 to 2018, 22 cases were County, 17 (3%) in Chisago County, and vegetative bacteria that colonize the reported. Fifteen likely acquired their 16 (3%) in Beltrami County (Figure 2). intestinal tract, producing toxin that is infection outside the United States absorbed into the circulation. and 7 were domestically acquired. Botulism The median number of cases reported In 2018, 1 infant botulism case was annually was 2 (range, 0 to 4). Fifteen Botulinum toxin, a neurotoxin, is reported. No foodborne or wound were infected with B. melitensis, 5 with produced by the spore-forming cases were reported. The infant was B. suis, 1 with B. abortus, and 1 with an bacteria Clostridium botulinum and a 26 week-old who presented to the unidentifiedBrucella species diagnosed other related species. There are 8 hospital with symptoms including by only. The median age of distinct toxin types: A, B, C, D, E, F, G, weakened cry, inability to feed, cases was 48 years (range, 3 to 86). and H. Toxin types A, B, E, F, and H can progressive weakness, and ptosis. She Thirteen of the 22 cases for which race cause human intoxication. Botulism was hospitalized for 11 days, received was known were black, 7 were white is characterized by a descending, human botulism immune globulin and (of which 1 identified as Hispanic), and bilateral paralysis that can be fatal made a full recovery. The infant tested 2 were Asian/Pacific Islander. without treatment. Botulism spores positive for C. botulinum toxin type B. are ubiquitous in the environment 6 DCN 46;1 2019 Figure 3. Incidence of Selected Enteric Pathogens, 2000-2018

25 Campylobacter Salmonella Shigella E. coli O157 X Cryptosporidium X STEC* 20

15

Rate per 100,000 perPopulation Rate 10

5

0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Year of Report *STEC (Shiga toxin producing E. coli) includes O157 and non-O157 STEC case counts.

Campylobacteriosis Mexico (n=52), Asia (n=47), Central ), which are commonly or South America or the Caribbean used to treat campylobacteriosis. There were 1,238 culture- (n=36), Africa (n=17), and the Middle In 2018, the overall proportion confirmed Campylobacter cases East (n=12). of quinolone resistance reported in 2018 (22.2 per 100,000 among Campylobacter isolates population). This is an 18% increase Seven outbreaks of Campylobacter tested (n=129) was 40%. However, over the 1,049 cases reported in infections were identified. Three 89% of Campylobacter isolates from 2017, and a 32% increase from outbreaks were due to foodborne patients with a history of foreign the annual median of 939.5 cases transmission. One outbreak was travel during the week prior to illness reported from 2008 to 2017 (range, associated with chicken liver pâté onset, regardless of destination, were 834 to 1,049) (Figure 3). In 2018, served at a restaurant, one outbreak resistant to fluoroquinolones. Twenty- 48% of cases occurred in people who was associated with a restaurant with one percent of Campylobacter isolates resided in the metropolitan area. Of an unknown vehicle of transmission, from patients who acquired the the 1,178 Campylobacter isolates and one multistate outbreak was infection domestically were resistant confirmed and identified to species associated with consumption of to fluoroquinolones. by MDH, 83% were C. jejuni and 12% chicken livers. An additional probable were C. coli. foodborne outbreak was likely In 2009, a culture-independent caused by chicken wings served at test (CIDT) became commercially The median age of cases was 36 a restaurant. Two animal contact available for the qualitative detection years (range, 3 months to 95 years). outbreaks were identified; the vehicle of Campylobacter in stool. Forty-two percent were between 20 of transmission was contact with In 2018, 74 patients were positive and 49 years of age, and 9% were puppies for both outbreaks. One for Campylobacter by an antigen ≤5 years of age. Fifty-five percent outbreak of Campylobacter infections detection CIDT conducted in a clinical were male. Fifteen percent were was associated with a child care laboratory. However, only 17 (23%) hospitalized; the median length of facility, but the route of transmission of the specimens were subsequently hospitalization was 4 days. Forty-five was not confirmed. culture-confirmed. Beginning In 2015, percent of infections occurred during some clinical laboratories in Minnesota June through September. Of the 1,126 A primary feature of began testing stool specimens cases for whom data were available, public health importance with PCR-based gastrointestinal 233 (21%) reported travel outside the among Campylobacter cases panels, another type of United States during the week prior to was the continued presence CIDT. In 2018, 1,235 patients were illness onset. The most common travel of Campylobacter isolates resistant positive for Campylobacter by a PCR destinations were Europe (n=67), to fluoroquinolone (e.g., gastrointestinal panel; 955 (77%) DCN 46;1 2019 7 continued... of these specimens were culture- lipolytica, C. kefyr, and C. lusitaniae. Other carbapenemases (e.g., New confirmed. Only culture-confirmed Three cases (2%) were co-infected Delhi metallo-β-lactamase [NDM], cases met the surveillance case with both C. albicans and C. glabrata, Verona integron-encoded metallo-β- definition for inclusion in MDH case and 1 case (0.7%) was infected lactamase [VIM oxacillinase-48 [OXA- count totals. with C. albicans, C. glabrata, and C. 48]) are more frequently identified in dubliniensis at the time of incident other countries. Resistance can also Candidemia specimen collection. be acquired through the production of a β-lactamase effective against third In 2017, surveillance began for As primarily a healthcare-associated generation (e.g., AmpC candidemia among residents of the infection, injection drug use (IDU) has β-lactamases or extended-spectrum metropolitan area. Candidemia is a not been considered a common risk β-lactamases [ESBLs]) when combined bloodstream infection with Candida factor for candidemia. However, with with mutations that prevent fungal species, and is one of the the increasing opioid epidemic, IDU carbapenem antibiotics from entering most common types of healthcare- has been reported as an increasingly the cell. associated common condition associated with in the United States. Risk factors candidemia. In 2017, only 2/143 (1.4%) MDH first identified a KPC- include prolonged hospitalization in cases had IDU documented in their producing CRE in February 2009, an , having a central medical chart. However, in 2018, 15 and began voluntary reporting, venous catheter, a weakened immune (10.8%) cases had IDU documented in including isolate submission for all system, recent surgery (especially their medical chart. MDH has started Enterobacteriaceae and A. baumannii abdominal surgery), recently receipt of collecting additional information resistant to , , antibiotics, total parenteral nutrition, regarding IDU in 2019 to monitor the doripenem, or ertapenem using kidney failure, hemodialysis, and changing trends in IDU and candidemia Clinical and Laboratory Standards diabetes. epidemiology. Institute (CLSI) breakpoints (ertapenem excluded for Acinetobacter isolates). In In 2018, 139 cases of candidemia Carbapenem-resistant 2012, MDH used standardized EIP CRE were reported among residents of Enterobacteriaceae (CRE), and CRA definitions and initiated active the metropolitan area. The overall (CRA), and laboratory- and population-based incidence rate was 4.5 per 100,000, (CRPA) surveillance in Hennepin and Ramsey and the highest county-level incidence Counties. As a subset of statewide was in Ramsey County (6.0 per Carbapenem- reporting, this surveillance includes all 100,000). The median age was 57 years resistant Enterobacteriaceae (CRE), isolates from normally sterile sites or (range, newborn to 94 years). Seventy- Acinetobacter baumannii (CRA), urine of the three most common types five cases (54%) were male; 105 (76%) and Pseudomonas aeruginosa of CRE (Escherichia coli, Enterobacter were white, 16 (12%) were black, 5 (CRPA) are Gram-negative bacilli spp., or Klebsiella spp.) and A. (4%) were Asian/Pacific Islander, 3 that most commonly occur among baumannii that are resistant to (2%) were American Indian/Alaska patients with significant healthcare imipenem, meropenem, or doripenem. Native, and race was unknown for 10 exposures, co-morbid conditions, An incident case is defined as the cases. invasive devices, and those who first eligible isolate of each species have received extended courses of collected from a Hennepin or Of the 139 cases, 97% were antibiotics. Invasive infections caused Ramsey County resident in 30 days. hospitalized at time of diagnosis, and by CRE, such as carbapenem-resistant In 2016, MDH initiated statewide 56 (41%) died while hospitalized. , are associated CRE surveillance. MDH also tracks Underlying conditions included with higher morbidity and mortality other Enterobacteriaceae including, malignancy (37%), chronic than those caused by carbapenem- but not limited to Morganella spp., condition (29%), diabetes (27%), renal susceptible Enterobacteriaceae. Proteus spp., and Providencia spp. disease (26%), neurologic condition Carbapenem-resistant A. The PHL tests all CRE isolates for (22%), (16%), and baumannii (CRA) is recognized carbapenemase production using chronic liver disease (13%). Healthcare as one of the leading causes of a phenotypic assay (modified risk factors included receiving systemic healthcare-associated infections carbapenem inactivation method antibiotics in the 14 days prior to worldwide, and is associated with [mCIM] or CarbaNP), and conducts PCR diagnosis (94%); presence of a central high mortality rates and unfavorable on isolates with a positive phenotypic venous catheter in the 2 days prior to clinical outcomes. Invasive infections test for KPC, NDM, OXA-48-like, VIM, diagnosis (75%); being admitted to the caused by CRPA are associated with and IMP genes. All CRA isolates are ICU in 14 days prior to, or 14 days after higher morbidity and mortality tested by PCR for KPC, NDM, OXA- diagnosis (41%); and having surgery in than those caused by carbapenem- 48, VIM, and IMP genes, along with the 90 days before diagnosis (37%). susceptible P. aeruginosa. Carbapenem Acinetobacter-specific OXA genes resistance can be acquired through (OXA-23, OXA-24, and OXA-58). More than 17 different Candida a variety of mechanisms including species are known to be agents of transmissible genetic elements. In 2018, 517 CRE incident cases human infection; however, the two Some CRE, CRA, and CRPA carry representing 486 patients were most common species comprised over resistance genes that produce identified from Minnesota residents; 50% of candidemia infections. Of the enzymes called carbapenemases. the most common cases were 139 cases, 44% were C. albicans, 28% Certain carbapenemase genes (e.g., K. Enterobacter spp. (239) and Klebsiella C. glabrata, 16% C. parapsilosis, 4% pneumoniae carbapenemase [KPC]) spp. (124), followed by E. coli (70), C. tropicalis, 4% C. dubliniensis, 3% can easily spread between bacteria of Citrobacter spp. (32), Serratia spp. C. guilliermondii, 2% C. krusei, and similar species. KPC is the predominant (23), Proteus spp. (11), Providencia 3% with other species including C. carbapenemase in the United States. spp. (7), Morganella spp. (5), and 8 DCN 46;1 2019 other Enterobacteriaceae (6). Among United States is a critical component MuGSI and ended July 31, 2018. This 517 incident cases, there were 122 of early detection of CRE isolates with surveillance included all CRPA isolates CRE incident cases (representing carbapenemases that are less common collected from normally sterile sites, 118 patients) reported among in the United States. In April 2019, wounds, urine, sputum, throat cultures residents of Hennepin and Ramsey MDH released recommendations for from cystic fibrosis (CF) patients, or Counties. Among these 122, 62 admission colonization screening to other lower respiratory sites that are (51%) were Enterobacter spp., 35 detect carbapenemase-producing resistant to imipenem, meropenem, (29%) Klebsiella spp., and 25 (20%) organisms (CPO). In line with CDC or doripenem using current CLSI were E. coli. KPC was identified in 4 recommendations, MDH strongly breakpoints. An incident case was (3%); all were E. cloacae. CRE was recommends that Minnesota hospitals defined as the first report of CRPA, most frequently isolated from urine screen on admission patients who or a subsequent report of CRPA ≥ 30 (116), followed by blood (2) and other received healthcare abroad in the last days after the last incident report. The sites (4). We identified 10 additional 12 months; healthcare abroad includes PHL tested all isolates submitted in surveillance cases (from 9 patients) ambulatory surgery, hemodialysis, or the 2018 surveillance year (August 1, through colonization screening. Among an overnight stay. Furthermore, MDH 2017-July 31, 2018) for carbapenemase surveillance cases, there were 4 K. recommends Minnesota hospitals production. Only 7 CRPA isolates (from pneumoniae, 2 E. cloacae, and 2 E. coli consider screening patients on 4 patients) were carbapenemase- isolates harboring carbapenemases admission who received healthcare producers (IMP [1], VIM [1]); 2 (NDM [5], KPC [3], and OXA-48 [1]). in the U.S. regions of Chicago, New isolates were found, by whole Jersey, and New York City where CPO genome sequencing, to be carrying Among the 517 incident cases, 44 are more common. potentially inducible genes (OXA-50 (9%) were carbapenemase-producing and OXA-2/OXA-50/PDC-7) capable organisms. Twenty-seven (61%) cases In 2018, CDC released the Containment of hydrolyzing carbapenems. Since (from 23 patients) were KPC positive Strategy which provides guidance there is an extremely low percentage (E. cloacae [13], K. pneumoniae [7], K. when responding to cases of novel or (<1%) of CRPA isolates found to be oxytoca [1], C. freundii [5], and E. rare multidrug-resistant organisms carbapenemase-producers, the PHL coli [1]). Of note, 1 case was positive (MDROs) including CPOs. Novel or has discontinued surveillance testing for 2 different organisms producing rare MDROs are epidemiologically of CRPA isolates for carbapenemase KPC in the same calendar year. Five important because these organisms production, but will perform testing incident cases (from 5 patients) cause severe, difficult-to-treat on submitted isolates upon request were NDM positive E.( coli [3], K. infections, and have the potential to of the submitting facility or clinical pneumoniae [1], and K. aerogenes spread within healthcare settings. laboratory. [1]). Two NDM-positive cases had MDH utilizes the Containment Strategy healthcare exposure outside of the in response to all single cases of In the 2018 surveillance year, 801 United States (India). Seven cases carbapenemase-producing CRE, CRA, CRPA incident cases representing (from 7 patients) were OXA-48 positive and CRPA. This rapid and aggressive 568 patients were identified from (E. coli [5] and K. pneumoniae [2]) and action includes prompt identification clinical cultures among Minnesota 5 cases (from 5 patients) were IMP of the organism, notification and residents. Of 801 incident cases, 440 positive (P. rettgeri [3], P. vulgaris investigation with healthcare facilities, cases from 279 unique patients were [1], and M. morgannii [1]). For and response or “containing the reported in Hennepin and Ramsey colonization screening, 7 cases (78%) spread” in an effort to slow the spread County residents. Urine (268) was had healthcare exposure outside of the of novel or rare MDROs in Minnesota. the most common source, followed United States or from an area in the by sputum (52), wounds (18), and United States where carbapenemases In 2018, 20 CRA incident cases lower respiratory sites (14). Among are more common. representing 15 patients were the 279 patients, median age was 58 identified from clinical cultures among years (range, <1 to 98); 210 (75%) Among 40 Minnesota residents with Minnesota residents. Urine (7) was were white, 31 (11%) were black, carbapenemase-producing isolates, the most common isolate source 8 (3%) were Asian/Pacific Islander, the median age was 61 years (range, followed by wound (5), sputum (4), and 30 (11%) were of unknown race. 3 to 94); 21 (53%) were female; 16 other sites (3), and blood (1). Eleven Ninety-six (34%) were inpatient at the (40%) were residents of Hennepin or (55%) were hospitalized at the time of time of specimen collection including Ramsey County, 4 were residents of culture collection. Other CRA isolates 36 patients who had their culture Anoka County, and 2 residents each were collected from patients in long- collected in the intensive care unit, were of Dakota, Scott, and Washington term care facilities (4), outpatient 105 (38%) were outpatient, 34 (12%) Counties. Seventeen (43%) were settings (3), and long-term acute were in the emergency department, inpatients at the time of specimen care hospitals (2). Three CRA isolates 25 (9%) were in a long-term acute care collection, 13 (33%) were in outpatient possessed genes for carbapenemase hospital, and 19 (7%) were in a long- settings, 7 (18%) were in long-term production (2 OXA-23, 1 OXA-24). Of term care facility. More than half (144) acute care hospitals, and 3 (8%) were 20 CRA incident cases, 7 incident cases were hospitalized within 30 days of in long-term care facilities. Urine (27) were reported for MuGSI and isolated their specimen collection date. was the most common isolate source from urine (5), wound (1), and blood followed by sputum (4), wound (3), (1). None were found to harbor a Clostridioides difficile blood (3), and other sites (3). carbapenemase. Clostridioides difficile is an anaerobic, Detection of NDM and OXA-48 serve Active laboratory- and population- spore-forming, Gram-positive bacillus as a reminder to clinicians that based surveillance for CRPA was that produces two pathogenic toxins, assessing travel history to identify initiated August 1, 2016 in Hennepin A and B. C. difficile infections (CDI) receipt of healthcare outside the and Ramsey Counties as part of range in severity from mild diarrhea DCN 46;1 2019 9 continued... to fulminant colitis and death. result are classified as CA. A more (Carver County), and one occurred at Transmission of C. difficile occurs detailed set of case definitions is a municipal pool (Nicollet County). primarily in healthcare facilities, available upon request. Two outbreaks associated with where environmental contamination animal contact accounted for 8 cases by C. difficile spores and exposure to In 2018, 868 incident cases of CDI (5 laboratory-confirmed); these antimicrobial drugs are common. The were reported in the five sentinel outbreaks occurred in Rock and primary risk factor for development counties (210 per 100,000 population), Stevens Counties. Seven outbreaks of CDI in healthcare settings is recent a decrease from 215 per 100,000 due to person-to-person transmission use of antimicrobials, particularly population in 2017. Sixty-one percent at child care centers accounted for 30 clindamycin, cephalosporins, and of these cases were classified as CA, cases (14 laboratory-confirmed); the fluoroquinolones. Other risk factors 21% as CO-HCFA, and 18% as HCFO. outbreaks occurred in Blue Earth (n=2), for CDI acquisition in these settings The median ages for CA, CO-HCFA, and Kandiyohi (n=2), Carver, Fillmore, and are age >65 years, severe underlying HCFO cases were 55, 64, and 73 years, Stearns Counties. illness, intensive care unit admission, respectively. Fifty-four percent of CA nasogastric intubation, and longer cases were prescribed antibiotics in Cyclosporiasis duration of hospital stay. the 12 weeks prior to stool specimen collection compared to 86% of HCFO There were 156 cyclosporiasis cases In the early 2000s, a marked increase cases and 85% of CO-HCFA cases. Of reported in 2018 (2.80 per 100,000 in the number of CDI cases and the 526 putative CA cases eligible population). This is markedly higher mortality due to CDI was noted for interview, 366 were interviewed than the number of cases reported across the United States, Canada, and and confirmed as CA cases. Fifty-two from 2008 to 2017 (range, 0 to 23 England. Most notable was a series of percent of CA cases reported per year). In 2018, 44% of cases large-scale outbreaks in Quebec first use in the 12 weeks prior to illness occurred in people who resided in the reported in March 2003. During this onset date. Most common uses of metropolitan area. period, Quebec hospitals reported a antibiotics included treatment of ear, 5-fold increase in healthcare-acquired sinus, or upper respiratory infections The median age of cases was 41 years CDI. These and other healthcare (38%); dental procedures (16%); (range, 13 to 88 years). Fifty-three facility (e.g., long-term care facilities) urinary tract infections (10%); and skin percent were female. Three percent outbreaks have been associated with infections (7%). Prevention efforts were hospitalized; the median length the emergence of a more virulent should focus on appropriate antibiotic of hospitalization was 3 days (range, strain of C. difficile, designated use. 2 to 8 days). Ninety percent of cases North American PFGE type 1 (NAP1), occurred during May through July. toxinotype III. Cryptosporidiosis Of the 53 non-outbreak cases for whom data were available, 11 (20.1%) In 2009, in an effort to better In 2018, 532 cases of cryptosporidiosis reported travel outside the United understand the burden of CDI in (9.54 per 100,000 population) were States during the 2 weeks prior to Minnesota, as part of EIP, MDH reported. This is markedly higher than illness onset. initiated population-based, sentinel the median number of cases reported surveillance for CDI at clinical annually from 2008 to 2017 (median, Four confirmed foodborne outbreaks laboratories serving Stearns, Benton, 342 cases; range, 235 to 481). The of cyclosporiasis were identified in Morrison, and Todd Counties; in 2012, median age of cases in 2018 was 23.5 2018, accounting for 100 laboratory- Olmsted County was added. years (range, 3 months to 92 years). confirmed cases. A multi-state Children 10 years of age or younger outbreak associated with vegetable CDIs that occur outside the traditional accounted for 22% of cases. Sixty trays purchased at convenience stores healthcare settings (i.e., community- percent of cases occurred during July resulted in 62 Minnesota cases (all associated) have also been receiving through October. The incidence of laboratory-confirmed). An outbreak increased attention. Community- cryptosporidiosis in the Southwestern, associated with cilantro consumption associated (CA) CDI data from 2009- Southeastern, South Central, and West at two independent restaurants 2011 across 10 EIP sites showed Central districts (31.8, 26.2, 19.2, and in Hennepin County resulted in 73 that 64% of CA CDI patients received 14.5 cases per 100,000, respectively) cases (19 laboratory-confirmed). prior antibiotics, and 82% had some was significantly higher than the An outbreak associated with basil outpatient healthcare exposure. statewide incidence. Only 142 (27%) consumption at a restaurant in cases occurred among residents of the Ramsey County resulted in 16 cases A CDI case is defined as a positive C. metropolitan area (4.6 per 100,000). (8 laboratory-confirmed). A multi- difficile toxin assay on an incident stool Fifty-six (11%) cases were hospitalized, state outbreak associated with salads specimen from a resident (≥ 1 year of for a median of 4 days (range, 2 to 31 at a fast food restaurant resulted in age) of one of the five counties. A CDI days). Three deaths were reported. 11 Minnesota cases (all laboratory- case is classified as healthcare facility- confirmed). onset (HCFO) if the initial specimen Fourteen confirmed outbreaks of was collected >3 days after admission cryptosporidiosis were identified, Escherichia coli O157 and Other to a healthcare facility. Community- accounting for 34 laboratory- Shiga Toxin-producing E. coli, and onset (CO) cases who had an overnight confirmed cases. Five recreational Hemolytic Uremic Syndrome stay at a healthcare facility in the 12 water outbreaks of cryptosporidiosis weeks prior to the initial specimen are occurred, accounting for 108 cases During 2018, 115 culture-confirmed classified as CO-HCFA, whereas CO (15 laboratory-confirmed). Three cases of Escherichia coli O157 infection cases without documented overnight occurred at campgrounds (Goodhue, (2.06 per 100,000 population) were stay in a healthcare facility in the 12 Le Sueur, and Waseca Counties), one reported. The number of reported weeks prior to the initial specimen was associated with a splash pad cases represents a 10% decrease from 10 DCN 46;1 2019 the median number of cases reported outbreak was due to person-to- median age of cases was 35 years annually from 2008 to 2017 (median, person transmission, one was due to (range, 7 months to 98 years). Eighteen 126.5 cases; range, 96 to 146). During waterborne transmission, and one was percent were <10 years of age, and 2018, 52 (45%) cases occurred in the due to animal contact. An outbreak of 30% were >50 years of age. Fifty-seven metropolitan area. Eighty-five (74%) E. coli O111 infections was associated percent of non-immigrant and refugee cases occurred during May through with a petting zoo at a campground. cases were male. Giardia infections October. The median age of the Five laboratory-confirmed cases were had a summer/fall seasonality; 48% cases was 27 years (range, 7 months identified. Two cases developed HUS of non-immigrant and refugee cases to 88 years). Twelve percent of the but none died. An outbreak of both occurred during July through October. cases were 4 years of age or younger. E. coli O121 and Cryptosporidium Thirty-eight (7%) cases required Thirty (26%) cases were hospitalized; infections was associated with a hospitalization, for a median of 4 days the median hospital stay was 3 days campground. Seventy-nine cases were (range, 2 to 27 days). Seven outbreaks (range, 1 to 47 days). Two cases, a identified, including 2 laboratory- were identified in Minnesota that 73-year-old female and a 46-year-old confirmed cases of E. coli O121 accounted for 16 laboratory-confirmed female, died. infections and 5 laboratory-confirmed cases. Five outbreaks were associated cases of Cryptosporidium infections. with person-to-person transmission In addition to the 115 culture- No cases developed HUS or died. An in child care settings. One outbreak confirmed E. coli O157 cases, 270 cases outbreak of E. coli O103 infections was associated with consumption of of Shiga toxin-producing E. coli (STEC) associated with person-to-person surface water along a Lake Superior infection were identified. Of those, transmission occurred at a childcare hiking trail, and one outbreak was culture-confirmation was not possible facility in Martin County. Five cases, associated with swimming at a beach. in 1, and therefore it is unknown if including 1 laboratory-confirmed, were Additionally, six Minnesota residents this was O157 or another serogroup. identified. No cases developed HUS or were involved in two outbreaks Among the remaining 269 cases, E. died. associated with backcountry camping coli O103 was the serogroup for 68 trips in states outside Minnesota. (25%) cases, E. coli O111 for 45 (17%), Hemolytic Uremic Syndrome (HUS) E. coli O26 for 28 (10%), E. coli O145 Haemophilus influenzae for 15 (6%), E. coli O121 for 10 (4%), In 2018, 11 HUS cases were reported. and E. coli O45 for 5 (2%). The median The number of reported cases is One hundred two age of the non-O157 STEC cases was similar to the median number of invasive Haemophilus 28.5 years (range, 4 months to 90 cases reported annually from 2008 to influenzae disease cases (1.8 per years). Forty-one (15%) cases were 2017 (median, 12.5 cases; range, 9 to 100,000 population) were reported hospitalized; the median hospital stay 17). In 2018, the median age of HUS in 2018. Cases ranged in age from was 2 days (range, 1 to 28 days). One cases was 46 years (range, 1 year to newborn to 97 years (median 62 case, a 63-year-old female, died. 81 years); 4 of the 11 cases occurred years). Allowing for more than one in children less than 7 years of age. syndrome per case, 42 (33%) cases had Culture-independent tests (CIDTs) All 11 cases were hospitalized, with a pneumonia, 33 (26%) bacteremia, 13 have become increasingly adopted by median hospital stay of 9 days (range, (10%) meningitis, 9 (7%) , 3 clinical laboratories for the detection 3 to 48 days). From 1997 through (2%) epiglottitis, 3 (2%) , of Shiga toxin in stool. Two hundred 2018, the overall case fatality rate 2 (2%) , 2 (2%) , twenty-two patient specimens that among HUS cases was 5.5%. Nine of 2 (2%) , and the following were positive by a CIDT conducted the 11 HUS cases reported in 2018 each had 1 (1%): cholangitis, at a clinical laboratory were not were post-diarrheal. E. coli O157:H7 chorioamnionitis, endometritis, kidney subsequently culture-confirmed, and was cultured from the stool of 8 (73%) infection, liver , otitis media, therefore did not meet the surveillance cases, E. coli O111 was cultured from pericarditis, and . Twelve case definition for inclusion in MDH the stool of 2 (18%) cases, and E. coli (12%) cases died. case count totals. O777 was isolated from the stool of 1 (9%) case. In 2018, there were 5 Of 99 H. influenzae isolates for which Two E. coli O157 outbreaks were outbreak-associated HUS cases. All typing was performed at PHL, 13 identified during 2018. Both outbreak-associated HUS cases were were type a, 1 type b (Hib), 6 type e, outbreaks were due to foodborne hospitalized; the median hospital stay 12 type f, and 66 were untypeable. transmission, and were part of national was 11 days (range, 3 to 47 days), and The 1 Hib disease case compared to investigations. These outbreaks 1 died. 2 cases in 2017, 5 in 2016, 2 in 2015, resulted in 14 laboratory-confirmed and 1 in 2014. The case was a child <1 Minnesota cases, with 2 and 12 Giardiasis year of age, who had meningitis and cases, respectively. In May, a national survived. The child had received one outbreak was associated with romaine During 2018, 508 cases Hib vaccination. lettuce. Twelve cases were identified of Giardia infection (9.1 per 100,000) in Minnesota. Three cases developed were reported. This represents a 22% The 12 deaths occurred in patients hemolytic uremic syndrome (HUS), and decrease from the median number ranging in age from newborn to 97 2 cases died. In October, a national of cases reported annually from 2008 years. Seven cases had bacteremia outbreak was associated with chicken through 2017 (median, 654 cases; without another focus of infection, salad. Two laboratory-confirmed cases range, 620 to 846). Recent immigrants (of these, 1 also had septic shock), were identified in Minnesota. Neither and refugees accounted for 8% of and 5 had pneumonia. All 12 had H. case developed HUS or died. cases. An additional 15% of cases influenzae isolated from blood. Co- reported international travel in the 3 morbidities were reported in 9 of Three non-O157 STEC outbreaks weeks prior to illness onset. Excluding them. Of the 12 that died, all case- were identified during 2018. One recent immigrants and refugees, the isolates were untypeable. DCN 46;1 2019 11 continued... Figure 4. HIV/AIDS: Number of New Cases, Prevalent Cases, and Deaths by Year, 1996-2018 500 10,000 HIV Diagnosis* AIDS^ All Deaths** Living with HIV/AIDS

9,000 PersonsNo. of LivingHIV/AIDS w/

400 8,000

7,000

300 6,000

5,000

200 4,000

3,000 No. of New HIV/AIDS Cases Deaths and Cases HIV/AIDS New of No.

100 2,000

1,000

0 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Year

* Includes all new cases of HIV infection (both HIV [non-AIDS] and AIDS at first diagnosis) diagnosed within a given calendar year. ** Deaths among HIV cases, regardless of cause. ^ Includes all new cases of AIDS diagnosed within a given calendar year, including AIDS at first diagnosis. This includes refugees in the HIV+ Resettlement Program, as well as other refugee/immigrants diagnosed with AIDS subsequent to their arrival in the United States.

Histoplasmosis cases in 2017. The median age New Hampshire to 12.5 per 100,000 of cases was 46.5 years (range, 4 population in Georgia. Minnesota had Histoplasmosis is caused by the months to 84 years); 118 (64%) were the 16th lowest rate (2.6 cases per soil-dwelling dimorphic fungus male. Of the 157 cases with race 100,000 population). Histoplasma capsulatum. Infection reported, 137 (87%) were white, 7 typically results from inhalation (5%) were black, 6 (4%) were Asian/ As of December 31, 2018, a of aerosolized spores, and Pacific Islander, 4 (3%) were American cumulative total of 11,852 cases symptomatic infections usually Indian/Alaska Native, and 3 (2%) of HIV infection (2,267 AIDS at involve pulmonary disease, though reported more than one race. Of the first diagnosis, and 9,585 HIV disseminated or non-pulmonary 138 with ethnicity reported, 7 (5%) [non-AIDS] cases) were reported infections are possible. The were Hispanic. among Minnesota residents. By the Mississippi River Valley is known to end of 2018, an estimated 8,981 be an endemic area. Additionally, Seventy-two cases (39%) were persons with HIV/AIDS were living in geographic micro-foci exist inside hospitalized, and of the 152 whose Minnesota. and outside endemic areas, and status was known, 37 (39%) were are usually associated with soil immunocompromised. Three (2%) The annual number of AIDS cases containing bird or bat guano. cases died, and histoplasmosis was reported in Minnesota increased Common activities associated with the primary cause of death in 1 of steadily from 1982 through the early exposure include farming, exposure those cases. 1990s, reaching a peak of 361 cases in to soil enriched with bird or bat 1992. Beginning in 1996, the annual guano, remodeling or demolition of HIV Infection and AIDS number of new AIDS diagnoses and old buildings, and clearing trees or deaths declined sharply, primarily due brush in which birds have roosted. HIV/AIDS incidence in Minnesota to better antiretroviral therapies. In remains moderately low. In 2017, 2018, 116 new AIDS cases (Figure 4) A new case definition was state-specific HIV infection rates and 82 deaths among persons living implemented in 2017; thus, the ranged from 2.1 per 100,000 with HIV infection in Minnesota were current case count can only be population in Wyoming to 30.0 per reported. compared with that year. In 100,000 in Georgia. Minnesota had 2018, there were 57 confirmed the 16th lowest rate (6.0 cases per The number of HIV (non-AIDS) cases and 127 probable cases of 100,000 population). In 2017, state- diagnoses has varied over the past histoplasmosis compared to 36 specific AIDS diagnosis rates ranged decade. There was a peak of 278 confirmed cases and 147 probable from 0.9 per 100,000 persons in newly diagnosed HIV (non-AIDS) 12 DCN 46;1 2019 cases in 2009, and a low of 215 new Similarly, persons of color comprised Historically, race/ethnicity data for HIV (non-AIDS) cases reported in 2017, approximately 13% of the female HIV/AIDS in Minnesota have grouped which is lower than 228 cases reported population in Minnesota and 69% of non-African born blacks and black in 2018. new HIV infections among women. It African-born persons together bears noting the use of race can be a as “black.” In 2001, MDH began In 2018, 77% (221/286) of new HIV proxy for other risk factors, including analyzing these groups separately, diagnoses (both HIV [non-AIDS] and lower socioeconomic status and and a marked trend of increasing AIDS at first diagnosis) occurred in education, and race is not considered numbers of new HIV infections among the metropolitan area. In Greater a biological cause of disparities in the black African-born persons was Minnesota there were 65 cases in 35 occurrence of HIV. observed. In 2018, there were 48 new counties. HIV infection is most common HIV infections reported among black in areas with higher population In 2018, there were 103 diagnosed Africans. While black African-born densities and greater poverty. with HIV <30 years of age, accounting persons comprise less than 1% of the for 36% of all cases. Most of these state’s population, they accounted for The majority of new HIV infections cases were among young males; 83% 17% of all HIV infections diagnosed in in Minnesota occur among males. of cases <30 years were male. The Minnesota in 2018. Trends in the annual number of new average age at diagnosis in 2018 was HIV infections diagnosed among males 34 years for males and 38 years for HIV perinatal transmission in the differ by race/ethnicity. New infections females. A population of concern United States decreased 90% occurred primarily among white males for HIV infection is adolescents and since the early 1990s. The trend in in the 1980s and early 1990s. Whites young adults (13-24 years). The Minnesota has been similar. While still comprise the largest number of number of new HIV infections among the number of births to HIV-infected HIV infections among males, but the males in this age group has remained women increased nearly 7-fold proportion of cases that white males higher than new diagnoses among between 1990 and 2018, with 65 account for is decreasing. In 2018, females since 1999, with 33 cases births to pregnant persons in 2018, there were 93 new infections among reported in 2018, which is lower the rate of perinatal transmission white males, which is slightly less than 47 cases reported in 2017. The decreased, from 15% in 1994-1996 than half of new HIV infections among number of new HIV infections among to 0.6% over the last 3 years (2016- males (43%). Among black African adolescent females has remained 2018), with 1 HIV-positive birth in American males, there were 49 new relatively consistent over time; in 2017. HIV diagnoses in 2018, which is about 2018 there were 5 cases. From 2016 a quarter of new HIV infections among to 2018, the majority (66%) of new Influenza males (23%). Among Hispanic males infections among male adolescents of any race and black African-born and young adults were among youth Several influenza surveillance males, there were 34 and 23 new HIV of color, with young black African methods are employed. Data are infections in 2018 respectively. American males accounting for 34% summarized by influenza season of cases among young males of (generally October-April) rather than Females account for an increasing color. During the same period, young calendar year. percentage of new HIV infections, women of color accounted for 75% of from 11% of new infections in 1990 to the cases diagnosed, with young black Hospitalized Cases 24% in 2018. Trends in HIV infections African American women accounting diagnosed annually among females for 43% of cases among young Surveillance for pediatric (<18 also differ by race/ethnicity. Early in women of color. years of age) laboratory-confirmed the epidemic, whites accounted for the hospitalized cases of influenza in the majority of newly diagnosed infections. Since the beginning of the epidemic, metropolitan area was established Since 1991, the number of new male-to-male sex (men who have during the 2003-2004 influenza infections among women of color has sex with men; MSM) has been the season and expanded to include exceeded that of white women. predominant mode of exposure to adults for the 2005-2006 influenza HIV reported in Minnesota. In 2018, season. For the 2008-2009 season In 2018, women of color accounted MSM (including MSM who also inject surveillance was expanded statewide. for 69% of new HIV infections among drugs) accounted for 71% of new Since the 2013-2014 season, clinicians females in Minnesota. The number diagnoses among men. Heterosexual have been encouraged to collect a of diagnoses among African-born contact with a partner who has or is throat or nasopharyngeal swab, or women has been increasing over the at increased risk of HIV infection is other specimen from all patients past decade. In 2018, the number of the predominant mode of exposure admitted to a hospital with suspect new cases among African-born women to HIV for women. influenza, and submit the specimen was 25, accounting for 37% of all new to the PHL for influenza testing. For diagnoses among women. In 2018, In 2018, 31% of 69 new HIV diagnoses the 2014-2015 season, influenza B there were 13 cases (19%) diagnosed among women was attributed to subtyping was added. among African American women. heterosexual exposure. The number of cases among people who inject During the 2018-2019 influenza Despite relatively small numbers of drugs (IDU and MSM/IDU mode of season (October 1, 2018 – April 30, cases, HIV/AIDS affects persons of exposure) has increased slightly over 2019), there were 2,490 laboratory- color disproportionately in Minnesota. the past 3 years with 32 cases in 2018 confirmed hospitalized cases (45.5 In 2018, men of color comprised compared to 26 cases in 2017, which cases per 100,000 persons compared approximately 17% of the male indicates a continued pattern of to 116.6 cases per 100,000 in 2017- population in Minnesota and 57% increased HIV infection among people 2018 and 70.9 cases per 100,000 in of new HIV diagnoses among men. who inject drugs in the state. 2016-2017) reported. Cases included DCN 46;1 2019 13 continued... 2,377 influenza A (670 A[H1N1] Of these, 121 (2%) were positive Three hundred eighty-three schools pdm09, 287 H3, and 1,420 unknown for influenza A (H3), 333 (6%) were in 74 counties reported ILI outbreaks A type), 101 influenza B (12 of positive for influenza A (H1N1)pdm09, during the 2018-2019 school year. Yamagata lineage and 4 of Victoria 5,430 (90%) were positive for influenza The number of schools reporting ILI lineage), 4 positive for both influenza A-not subtyped, and 148 (2%) were outbreaks since the 2009-2010 school A and B, and 8 of unknown influenza positive for influenza B. year ranged from a low of 92 in 2013- types. Among the cases, 13% were 2014 to a high of 1,302 in 2009-2010. 0-18, 18% were 19-49, 25% were Sentinel Surveillance 50-64, and 45% were 65 years of age An influenza outbreak is suspected in and older. Median age was 62 years. We conduct sentinel surveillance for a long-term care facility (LTCF) when Residents of the metropolitan area ILI (fever >100° F, and cough, and/or two or more residents in a facility made up 53% of cases. sore throat in the absence of known develop symptoms consistent with cause other than influenza) through influenza during a 48- to 72-hour Case report forms have been outpatient medical providers including period. An influenza outbreak is completed on 66% of the 1,326 those in private practice, public health confirmed when at least one resident metropolitan area cases. Of clinics, urgent care centers, emergency has a positive culture, PCR, or rapid these, 29% were diagnosed with rooms, and university student health antigen test for influenza and there pneumonia, 21% required admission centers. There were 29 sites in 17 are other cases of respiratory illness into an intensive care unit, and counties. Participating providers report in the same unit. Sixty facilities in 8% were placed on mechanical the total number of patient visits each 37 counties reported confirmed ventilation. An invasive bacterial week and number of patient visits for outbreaks during the 2018-2019 co-infection was present in 12% ILI by age group (0-4 years, 5-24 years, influenza season. The number of of hospitalized cases. Antiviral 25-64 years, ≥65 years). Percentage LTCFs reporting outbreaks ranged treatment was prescribed for 93% of of ILI peaked during the week January from a low of three in 2008- 2009 to a cases. Overall, 93% of adult and 47% 6-12, 2019 at 4.7%. high of 212 in 2017-2018. of pediatric cases had at least one chronic medical condition that would Influenza Incidence Surveillance Legionnaires’ Disease have put them at increased risk for influenza disease. MDH was one of 12 nationwide sites In 2018, 152 confirmed cases of to participate in Optional Influenza Legionnaires’ disease (2.7 per 100,000 Pediatric Deaths Surveillance Enhancements. Four population) were reported. This is clinic sites reported the number of ILI the highest number of cases ever There were 2 pediatric influenza- patients divided by the total patients reported, and a 55% increase over associated deaths, 1 positive for seen by the following age groups: the 98 cases reported in 2017. Prior influenza A (H3), and 1 positive for <1 year, 1-4 years, 5-17 years, 18-24 to 2016, there were never more than influenza B/Victoria lineage. years, 25-64 years, and ≥65 years, 60 cases reported annually. The CDC each week. Clinical specimens were criteria for confirmation of a case are Laboratory Data collected on the first 10 patients a clinically compatible illness and at with ILI for PCR testing at the PHL for least one of the following: 1) isolation The Minnesota Laboratory System influenza and 13 other respiratory of any Legionella organism from (MLS) Laboratory Influenza pathogens. respiratory , lung tissue, Surveillance Program is made pleural fluid, or other normally sterile up of more than 110 clinic- and Minimal demographic information fluid by culture, or 2) detection of L. hospital-based laboratories which and clinical data were provided with pneumophila serogroup 1 antigen in voluntarily submit testing data on each specimen. From September 30, urine using validated reagents, or 3) a weekly basis. These laboratories 2018–May 18, 2019, these clinics saw of fourfold or greater perform rapid testing for influenza 1,448 ILI patients. They submitted rise in specific serum antibody titer and respiratory syncytial virus. 236 specimens for influenza testing; to L. pneumophila serogroup 1 using Significantly fewer laboratories 33 (14%) were positive for influenza. validated reagents. A single antibody perform viral culture testing. Nine Of those, 10 (30%) were positive for titer of any level is not considered laboratories perform PCR testing for influenza A (H3), 14 (42%) was positive diagnostic. Patients positive by influenza, and three also perform for influenza A (H1N1)pdm09, 1 (3%) PCR only are currently classified as PCR testing for other respiratory were positive for influenza A-type suspect cases; in 2018, there were 10 viruses. The PHL provides further unspecified, 1 (3%) were positive for suspect cases. characterization of submitted influenza B/Yamagata lineage, 3 (9%) influenza isolates to determine the were positive for influenza B/ Victoria All 152 had pneumonia, and 148 hemagglutinin serotype. Tracking lineage, and 3 (9%) were positive for (97%) were hospitalized, with a laboratory results assists healthcare influenza C. median duration of hospitalization providers with patient diagnosis of 5 days (range, 1 to 49 days). Of of influenza-like illness (ILI), ILI Outbreaks in Schools and Long- those hospitalized, 57 (38%) were and provides an indicator of the term Care Facilities admitted to an intensive care unit, progression of the influenza season and 31 (21%) required mechanical as well as prevalence of disease in Since 2009, schools reported ventilation. Eight (5%) cases died. the community. Between September outbreaks when the number of One hundred five (69%) were male. 30, 2018–May 18, 2019, laboratories students absent with ILI reached 5% Older adults were more often reported data on 44,297 influenza of total enrollment, or when three or affected, with 125 (82%) occurring molecular tests, 6,032 (14%) of more students with ILI were absent among individuals ≥50 years (overall which were positive for influenza. from the same elementary classroom. median age, 64 years; range, 32 to 14 DCN 46;1 2019 96). Ninety-six (63%) cases had onset monocytogenes isolated from a EM cases experiencing symptom dates in June through September. stool specimen was reported. The onset in June or July. This timing Ninety-four (62%) were residents case was tested as part of a stool corresponds with peak activity of of the metropolitan area and 58 donation program, reported no nymphal I. scapularis ticks in mid- (38%) were residents of Greater symptoms, and was not included May through mid-July. The majority Minnesota. in official case counts; however, of cases either resided in or traveled the isolate was closely related to to endemic counties in north-central, Five cases were associated with a national case isolate by whole east-central, or southeast Minnesota, an outbreak at a senior living genome sequencing. or Wisconsin. community, 1 case was associated with an outbreak linked to a hospital Lyme Disease Malaria that was detected in early 2019, and 6 cases were associated with Lyme disease is caused by Borrelia Malaria is caused by several protozoan outbreaks in other states. The burgdorferi, a spirochete species in the genus Plasmodium. The remaining 140 cases (92%) were transmitted to humans by bites parasite is transmitted to humans by epidemiologically classified as from Ixodes scapularis, the bites from infected Anopheles genus sporadic. Of the 131 sporadic cases blacklegged tick. Recently, a new mosquitoes. The risk of malaria is for whom information was available, species, B. mayonii, has also been highest in the tropical and sub-tropical 16 (12%) had traveled out of state, identified as a cause of human regions of the world. Although local and 1 (<1%) had traveled out of the disease, and 9 cases have been transmission of malaria frequently country during the 10 days prior to reported in Minnesota residents occurred in Minnesota over 100 illness onset. since 2013, 1 in 2018. In Minnesota, years ago, all of the cases reported the same tick vector also transmits in Minnesota residents in recent The Infectious Diseases Society of the agents of babesiosis, human years have been imported infections America and the American Thoracic anaplasmosis, one form of human acquired abroad. Society, in consensus guidelines on ehrlichiosis, and a strain of the management of community- Powassan virus. In 2018, 59 cases (1 per 100,000 acquired pneumonia in adults, population) were reported. Fifty recommend urinary antigen assay In 2018, 950 confirmed Lyme (85%) cases were identified with P. and culture of respiratory secretions disease cases (17 cases per 100,000 falciparum, 3 (5%) with P. vivax, 2 on selective media for detection population) were reported. In (3%) with P. ovale, 1 (2%) with mixed of Legionella infection. Culture addition, 591 probable cases Plasmodium species, and in 1 the is particularly useful for public (physician-diagnosed cases that did species was unable to be determined. health because environmental and not meet clinical evidence criteria The median age of cases was 37 years clinical isolates can be compared for a confirmed case but that had (range, 2 to 72). Of the 55 cases with by molecular typing in outbreak laboratory evidence of infection) known race, 45 (82%) were black, 7 investigations. MDH requests that were reported. Despite some (13%) were white, 1 (2%) was Asian/ clinical laboratories submit isolates yearly fluctuations, the number of Pacific Islander, and 1 (2%) identified or available lower respiratory tract reported cases of Lyme disease has as their race as "Other." Fifty-five (sputum, BAL) specimens from been increasing, as evidenced by the cases were Minnesota residents at the confirmed and suspect cases for median number of cases from 2009 time of their illness, 49 (89%) of which culture and molecular typing. through 2017 (median, 1,203; range, resided in the metropolitan area. Of 896 to 1,431) compared to the the 50 cases with known country of Listeriosis median from 2000 to 2008 (median, birth, only 15 (30%) were born in the 913; range, 463 to 1,239) (Figure 1). United States. Fifty-six (95%) cases Nine listeriosis cases were reported likely acquired malaria in Africa, 2 (3%) in 2018. All were hospitalized, and Five hundred eighty-eight (62%) cases were likely acquired in Asia, and 2 died. The median age of cases confirmed cases were male, and 1 patient reported travel to Central was 75 years (range, newborn the median case age was 44 years America. Exposure information was to 92 years). Five had Listeria (range, 1 to 91). Physician-diagnosed not available for 1 case. Eighteen monocytogenes isolated from migrans (EM) was countries were considered possible blood, 2 from pleural fluid, 1 from present in 601 (63%) cases. Three exposure locations for malaria (CSF), and 1 from hundred eighty-nine (41%) cases infections, including Liberia (20), bile. Two cases were pregnancy- had one or more late manifestations Nigeria (8), Kenya (6), Sierra Leone (6), associated; both were neonates of Lyme disease (including 282 and Ghana (5) as well as several other who had a positive culture from with a history of objective joint countries in sub-Saharan Africa. blood and who survived. Eight cases swelling, 84 with cranial neuritis were white, and 1 was Asian/Pacific including Bell’s Palsy, 4 with Measles Islander; none were of Hispanic lymphocytic meningitis, 20 with ethnicity. The 9 cases was similar acute onset of 2nd or 3rd degree Three measles cases were reported to the median number of cases atrioventricular conduction defects, in 2018, 2 of which occurred in reported from 1996 through 2017 and 9 with radiculoneuropathy) Minnesota residents. One was a 5 (median, 7.5 cases; range, 3 to and confirmation by Western year-old black, non-Hispanic resident 19). In 2018, 1 case was part of a immunoblot (positive IgM ≤30 days of Hennepin County. The second multistate outbreak of 10 cases in 7 post-onset or positive IgG). Of the was a 2 year-old black, non-Hispanic states associated with avocadoes. 876 cases with known onset dates, non-U.S. resident. Both children onset of symptoms peaked from were unvaccinated and presented In 2018, 1 case with L. June through August, with 69% of with fever, rash, cough, coryza, and DCN 46;1 2019 15 continued... upon returning from Two (15%) cases reported a history Pertussis Kenya in August. Both required of receiving at least 1 dose of hospitalization and recovered without mumps-containing vaccine but had In 2018, 397 pertussis cases (7 per complications. The third case was a 2 no documentation of those doses. 100,000 population) were reported. year-old white, non-Hispanic resident Four (31%) cases had a documented Laboratory confirmation was available of Ramsey County. The child had a history of receiving 1 or 2 doses of for 280 (71%) cases, 19 (7%) of which history of 1 age-appropriate dose of mumps-containing vaccine. Two (15%) were confirmed by culture and 262 MMR, and became ill after returning cases were unvaccinated, and 5 (38%) (94%) by PCR. In addition, 60 (15%) from Israel in early September. This reported unknown vaccination status. cases met the clinical case definition case was not hospitalized; his illness No case reported a previous history of and were epidemiologically linked to was mild and did not resemble classic mumps disease. laboratory confirmed cases, and 56 measles infection. (15%) met the clinical case definition Eight (62%) cases were acquired only. One hundred ninety-two (48%) All 3 cases were laboratory confirmed in Minnesota and were not linked cases occurred in residents of the by PCR at the PHL. The first 2 cases to outbreaks occurring elsewhere, metropolitan area. with travel to Kenya were genotyped and 5 (38%) acquired mumps from as B3, and the third case with travel international travel. The median age Paroxysmal coughing was the most to Israel could not be genotyped. The of cases was 32 years (range 20 to 85). commonly reported symptom, third case was lab-confirmed with Nine cases (69%) occurred in persons which 369 (93%) cases experienced. other viral etiologies in addition to 18-49 years, and 4 (31%) occurred Approximately one third (118) reported measles. All 3 cases were considered in persons ≥50 years of age. Twelve whooping. Although commonly international importations (exposed to cases (92%) experienced parotitis, referred to as “,” very measles outside of the United States) and 5 (38%) reported . One young children, older individuals, and and were not epidemiologically linked unvaccinated adult was hospitalized persons previously immunized may not to each other or to any other known for 1 day with fever, arthralgia, and have the typical “whoop”. Post-tussive cases or outbreaks. bilateral orchitis and recovered without vomiting was reported in 185 (47%) complications. cases. Infants and young children are Meningococcal Disease at the highest risk for severe disease Mumps surveillance is complicated and complications. Pneumonia was For the first time ever, there were by nonspecific clinical presentation diagnosed in 8 (2%) cases, only 2 of no (NM) in nearly half of cases, asymptomatic which were in infants; 3 were 2 to 16 invasive disease cases in 2018. infections in an estimated 30% of years old, 2 were 20 to 70 years old. There were 5 cases in 2017, and 5 cases, and suboptimal sensitivity Five (1%) cases were hospitalized; 2 cases in 2016. Incidence of invasive and specificity of serologic testing. A (33%) hospitalized patients were <6 NM was stable at about 0.30 cases number of viruses can cause sporadic months of age. No deaths occurred. per 100,000 persons since 2005 parotitis including parainfluenza virus (with the exception of 2008 when types 1 and 3, influenza A virus, human Pertussis is increasingly recognized in incidence increased to 0.57 cases per herpes virus 6, enterovirus, Epstein- older children and adults. During 2018, 100,000 persons); however, invasive Barr, lymphocytic choriomeningitis cases ranged in age from <1 month NM incidence has decreased since virus, bocavirus, and human to 86 years. One hundred (25%) cases 2011. The quadrivalent conjugate immunodeficiency virus. Acute bacterial occurred in adolescents 13-17 years, vaccine, MenACWY is recommended parotitis may present with unilateral 105 (26%) in children 5-12 years, 92 at 11- 12 years with a booster at swelling. Noninfectious causes include (23%) in adults ≥18 years, 74 (19%) in age 16. Vaccination rates for at drugs, tumors, and immunologic children 6 months through 4 years, and least 1 dose among 13-17 year old diseases. 14 (4%) in infants <6 months of age. Minnesota adolescents is 78.5%; The median age of cases was 13 years. rates for the booster are lagging at Neonatal Sepsis Infection in older children and adults 26.9% (Minnesota Immunization may result in exposure of unprotected Information Connection, 2018 Statewide surveillance for neonatal infants. During 2018, 24 cases were in data). Meningococcal B vaccine sepsis includes reporting of any infants <1 year of age. A likely source of is recommended for persons 10 bacteria (other than coagulase- exposure was identified for 11 of those years of age and older with specific negative Staphylococcus) isolated from cases; 3 were infected by adults ≥18 risk factors. It should especially be a sterile site in an infant <7 days of age, years (one mother and two fathers), considered for those 16-23 years of and mandatory submission of isolates. 1 by an adolescent 13-17 years, 6 by age, especially in outbreak situations. In 2018, 38 cases (0.55 cases per 1,000 a child <13 years of age, and for 1 the live births) were reported compared to age was unknown. Eleven infant cases Mumps 53 cases in 2017. There were 6 deaths. had no identified source of infection. All were identified via blood. There was ACIP recommends vaccination of In 2018, 13 mumps cases were 1 meningitis case. Most cases (87%) women at ≥20 weeks gestation during reported. Eleven (85%) were classified were culture-positive within the first 2 each pregnancy in an effort to protect as confirmed (tested positive by days of life. Group B Streptococcus was young infants. Ensuring up-to-date PCR), and 2 (15%) as probable most common (12) followed vaccination of children, adolescents, (tested positive by IgM serology by Escherichia coli (11), Haemophilus and adults, especially those in contact or were linked to another case or influenzae (6), Streptococcus with young children is also important. outbreak). All of the confirmed cases viridians (2), Enterococcus spp. were genotyped as G, which is the (2), Klebsiella pneumoniae (2), and 1 Although unvaccinated children are dominant genotype circulating in the each of Group A Streptococcus, other at highest risk for pertussis, fully United States since 2006. Streptococcus spp., and Citrobacter spp. immunized children may also develop 16 DCN 46;1 2019 disease, particularly as the number of years since vaccination increase. Figure 5. Rabid Animals by County, 2018 (n=32)* Disease in those previously immunized is usually mild. Efficacy for currently licensed DTaP vaccines is estimated to Kittson Roseau Lake be 71-84% in preventing typical disease of the within the first 3 years of completing Woods Marshall the series. Waning immunity sharply Koochiching increases at 7 years of age, and most are Beltrami St. Louis susceptible by 11-12 years of age when Polk Pennington Cook

Tdap booster is recommended. Recent Red Lake Clear Water Lake studies suggest that immunity wanes Itasca sharply 2 years from receipt of Tdap. Of the 97 (24%) cases who were 7 months Norman Mahnomen to 6 years of age, 40 (41%) were known Hubbard Cass to have received at least a primary series of 3 doses of DTP/DTaP vaccine prior Clay Becker to onset of illness; 54 (56%) received Aitkin fewer than 3 doses and were considered Wadena Crow Wing Carlton preventable cases. Wilkin Otter Tail

Pine Isolates of must be Todd Mille submitted to the PHL in order to track Lacs Kanabec Grant Douglas changes in circulating strains. Isolates Morrison for 17 (90%) culture-confirmed cases Benton Species No. were received and sub-typed, with Traverse Stevens Pope Stearns Isanti Bat 27 two distinct PFGE patterns identified. Big Stone Sherburne Chisago Skunk 3

Nationally, isolates have had low Swift Kandiyohi Anoka Cat 1 minimum inhibitory concentrations Meeker Wright Wash- Dog 1 ing- (falling within the reference range for Chippewa Hennepin ton Lac Qui Parle Ramsey susceptibility) to and McLeod Carver Renville . Only 11 erythromycin- Yellow Medicine Scott Dakota resistant B. pertussis cases have been Sibley Lincoln Lyon identified in the United States. Redwood Le Rice Goodhue Nicollet Sueur Wabasha Brown Laboratory tests should be performed Murray Pipestone Olmsted on all suspected cases. However, B. Cottonwood Watonwan Blue Earth Waseca Steele Dodge Winona pertussis is rarely identified late in the illness; therefore, a negative culture Rock Nobles Jackson Martin Faribault Freeborn Mower Fillmore Houston does not rule out disease. A positive PCR result is considered confirmatory * Placement of symbol in county does not represent exact geographical location of the case. in patients with a 2-week history of and 77 year-old, 1 of whom was likely animals, 3 (13%) were likely exposed cough illness. PCR can detect non-viable exposed through cattle contact, the through ingestion of unpasteurized organisms. Consequently, a positive other had an undetermined exposure. dairy products, and 2 (8%) through a tick PCR result does not necessarily indicate The chronic cases were a 5 year-old bite. Eight (53%) of the 15 cases with current infectiousness. Patients with and a 71 year-old who both likely known occupations were employed in an a 3-week or longer history of cough had sheep exposures. All 4 cases agriculture-related occupation. illness, regardless of PCR result, may were hospitalized; the acute cases not benefit from antibiotic therapy. were hospitalized for 2 and 31 days Rabies Whenever possible, culture should be respectively, and the chronic cases done in conjunction with PCR testing. were hospitalized for 8 and 13 days In Minnesota, the animal reservoirs Serological tests may be useful for those respectively. All cases survived. for rabies are skunks and multiple bat with coughs >2 weeks. species. Dogs, cats, and livestock are From 1997 to 2018, 23 confirmed generally exposed to rabies through Q Fever acute cases, and 8 chronic cases were encounters with skunks. Vaccinating these reported. The median age of acute domestic animals for rabies provides a Q fever is an acute or chronic illness cases was 59 years (range, 11 to 77 buffer between wildlife and people. caused by Coxiella burnetii. Cattle, years); the median age of chronic sheep, and goats are the primary sources cases was 53 years (range, 5 to 75 In 2018, 32 (1.5%) of 2,175 animals tested of infection. Transmission can occur years). Thirteen (81%) cases for which were positive for rabies. This is similar through contact with infected animal both race and ethnicity were known to 2017 (35 [1.8%]) and consistent with tissue, inhalation of aerosolized bacteria, were white, non-Hispanic; 2 (13%) the number of positives seen in 2014 and ingestion of unpasteurized dairy were black, non-Hispanic; and 1 (6%) 2015. The majority of positive animals in products, and tick bites. was mixed race, non-Hispanic. During 2017 were bats (27/32 [84.4%]), followed this time, 19 (79%) of the 24 cases by skunks (3/32 [9.4%]), and there was 1 In 2018, 4 confirmed cases were for whom exposure information was positive cat (1/32 [3.1%]) and dog (1/32 reported, 2 acute and 2 chronic. The available were likely exposed through [3.1%]) (Figure 5). There were no human acute Q fever cases were a 70 year-old direct or indirect contact with infected cases of rabies. DCN 46;1 2019 17 continued... From 2003 to 2018, 865 (2.5%) of RSV subtype A, 21% (30) were positive able to be interviewed, and 3 had no 37,369 animals tested were positive for with RSV B, and 1 was positive with known travel history. rabies. The median number of rabies both RSV A and B. positive animals identified annually was In 2015, culture-independent 55 (range 28 to 94). From 2003 to 2018, Eighteen RSV-associated deaths tests (CIDTs) for the detection 323/714 (45.2%) skunks, 56/881 (6.4%) were reported for the 2018–2019 of Salmonella nucleic acid in stool cattle, 391/10,755 (3.6%) bats, 9/335 respiratory season. The median age became commercially available. In (2.7%) horses, 47/11,221 (0.4%) cats, of fatal RSV cases was 81 years (range 2018, 73 patient specimens that 29/10,475 (0.3%) dogs, 1/1,162 (0.1%) 4 months–98 years), and 14 cases were positive by a CIDT conducted raccoons, and 10/1,821 (0.5%) other who died had underlying medical at a clinical laboratory were not animals (fox [5], goat [2], woodchuck, conditions. Identification of additional subsequently culture-confirmed, and bison, deer) tested positive for rabies. RSV-associated deaths is ongoing. therefore did not meet the surveillance In contrast to the Eastern United States, case definition for inclusion in MDH where raccoons are the most common Salmonellosis case count totals. source of terrestrial rabies, rabies in raccoons is rare in Minnesota. In 2018, 1,009 Salmonella cases One hundred sixty cases were part (18.1 per 100,000 population) were of 20 Salmonella outbreaks in 2018, Respiratory Syncytial Virus reported. This is a 31% increase from including 18 cases that were part of the median annual number of cases outbreaks that began in 2015 or 2017. Beginning September 2016, laboratory- reported from 2008 to 2017 (median, Fifteen of the 20 outbreaks involved confirmed respiratory syncytial virus 768 cases; range, 578 to 975), and the foodborne transmission, 2 involved disease (RSV) became reportable highest number of Salmonella cases animal contact, and 3 were due to for all hospitalized residents of the reported since at least 1988. person-to-person transmission. Ten metropolitan area. Any death occurring of the outbreaks involved cases in statewide within 60 days of a positive Of the 99 serotypes identified in multiple states. The 20 outbreaks RSV test is also reportable. 2018, 5 serotypes, S. Enteritidis resulted in a median of 4 culture- (264), S. Typhimurium (104), S. I confirmed cases per outbreak (range, From October 1, 2018–April 30, 2019, 4,[5],12:i:- (88), S. Infantis (42), 1 to 32). 721 cases were reported (12.9 cases and S. Saintpaul (40) accounted for per 100,000 persons) compared to 53% of cases. Salmonella was isolated Eleven culture-confirmed and 5 1,090 cases (18.8 cases per 100,000) from stool in 860 (85%), urine in 87 probable cases of S. Enteritidis from October 2017-April 2018. The (9%), and blood in 54 (5%) cases. infection were associated with a median age was 9 months (range: 8 Other specimen sources included restaurant outbreak. The vehicle of days–98 years). Forty percent (285) abscess (3), wound (2), cerebrospinal transmission was smoked chicken. were <6 months, 15% (109) were 6-11 fluid, peritoneal fluid, and synovial The most plausible explanation for months, 16% (117) were 1 year to <2 fluid. the outbreak was undercooking of the years, 9% (68) were 2-4 years, 3% (24) smoked chicken that was served on were 5–17 years, 2% (12) were 18–49 Two hundred forty (24%) cases were the implicated meal date. Six culture- years, 4% (27) were 50–64 years, hospitalized; the median length of confirmed cases of S. Infantis (n=3), S. and 11% (79) were >65 years of age. hospital stay was 4 days (range, 2 Enteritidis (n=2), and S. Typhimurium Overall, 53% of RSV cases were male to 60 days). Five culture-confirmed (n=1) infection were associated with and 48% were white. cases died: a 75 year-old died of septic a second restaurant outbreak. Three shock and Salmonella bacteremia; of the infections were from two food Forty-one percent of cases had a an 86 year-old died of chronic workers. A single outbreak vehicle co-morbid condition at the time of obstructive pulmonary disease and was not identified. Thirty-two culture- their illness, and the presence of community-acquired pneumonia, with confirmed cases and 1 probable a co-morbid condition increased contributing Gram-negative sepsis case of S. Enteritidis infection were significantly as age increased. The secondary to S. Enteritidis and E. coli part of an extended outbreak at a most common comorbid conditions for ; a 72 year-old third restaurant. The investigation cases <2 years of age were prematurity died of acute respiratory distress included four rounds of environmental (13%), neurologic conditions (4%), syndrome and Salmonella bacteremia; health interventions, including three asthma/reactive airways disease a 99 year-old died of “natural” causes rounds of employee stool specimen (3%), and cardiovascular disease 6 days afterS. Enteritidis was isolated submissions. A single outbreak vehicle (3%). For cases 2-18 years of age, from urine; and, an 80 year-old who was not identified. The outbreak was neurologic conditions (24%), history of multiple causes including sepsis and ongoing for 5 months, indicating there of prematurity (14%), and asthma Salmonella colitis. was a reservoir for the bacteria in the (21%) were most common. The most restaurant; this reservoir could have common underlying conditions for Of the 912 cases with known travel been food workers, the environment, adults 18-64 years of age and older history, 141 (15%) had travelled or both. Two culture-confirmed cases adults (≥65 years) were chronic internationally during the week prior of S. Enteritidis infection were part of metabolic diseases (46% and 43% to their illness onset. There were an outbreak at a fourth restaurant. The respectively), cardiovascular disease 4 S. Typhi cases associated with travel vehicle and source of contamination (33% and 72% respectively), and to or immigration from India, Liberia, were not identified. Two culture- chronic lung diseases (26% and 34% Guatemala, and Nepal. There were 3 confirmed cases of S. I 4,[5],12:i:- respectively). S. Paratyphi A cases; 2 travelled infection were associated with an to India and 1 had no known outbreak at a fifth restaurant. The Of 159 RSV cases with a known international travel. There were vehicle and source of contamination subtype, 78% (124) tested positive for 4 S. Paratyphi B cases; 1 was not were not identified. 18 DCN 46;1 2019 Six culture-confirmed cases of S. Twenty culture-confirmed cases of Two culture-confirmed and 2 probable Thompson infection were part of a Salmonella infection (S. Enteritidis, cases of S. I 4,[5],12:i:- infection were sixth restaurant outbreak. One of the n = 17; S. Indiana, n = 2; and S. associated with a pig roast event. A cases was a food worker; however, the Montevideo, n = 1) were part of a single vehicle was not identified. outbreak vehicle was not identified. multi-state outbreak linked to live poultry contact. Nationally, 334 cases Among the 18 Salmonella cases in Two culture-confirmed cases of S. from 47 states in this outbreak were 2018 who were part of outbreaks that Enteritidis infection were reported infected with 6 Salmonella serotypes. began before 2018, 2 (S. Heidelberg) from a child care center; the outbreak Four culture-confirmed cases of S. were part of a 2015 outbreak was suspected to be caused by person- Infantis infection were part of a multi- associated with dairy calves, 2 (S. to-person transmission. Two culture- state outbreak of 129 cases in 32 Infantis) were part of a 2017 child care confirmed cases of S. I 4,[5],12:i:- states. Laboratory and epidemiological outbreak, 2 (S. Montevideo) were part infection were associated with an evidence suggests that the outbreak of a 2017 casino outbreak in Iowa, and outbreak at a second child care center. strain occurs widely in live chickens 12 (S. Paratyphi B var. L(+) tartrate(+), Two culture-confirmed cases of S. and a variety of raw chicken products. n=7; S. Thompson, n=3; S. Okatie, n=1; Typhimurium infection were identified and S. Weltevreden, n=1) were part of who attended the same in-home child Four culture-confirmed cases of a multi-state outbreak associated with care facility. Salmonella infection (S. Montevideo, kratom. Kratom is a product derived n=2; S. Cubana, n=2) were part of a from a tree endemic to Southeast Asia Four culture-confirmed and 1 probable multi-state outbreak associated with having opioid or stimulant properties. case of S. Typhimurium infection alfalfa sprouts. One culture-confirmed were part of a multi-state outbreak of case of S. Mbandaka infection was Sexually Transmitted Diseases 265 cases in 8 states associated with linked to a multi-state outbreak of commercially produced chicken salad 135 cases in 36 states. The implicated Gonorrhea and chlamydia in sold at grocery stores. Seven culture- product was a dry breakfast cereal; Minnesota are monitored through a confirmed cases of S. Enteritidis infection multiple food samples also tested mostly passive surveillance system were associated with raw breaded positive, and the company issued involving review of submitted case chicken products that were distributed a recall. Five culture-confirmed reports and laboratory reports. primarily through a pop-up pantry cases of S. Typhimurium infection Syphilis is monitored through active program in unlabeled bags. The outbreak were included in a multi-state CDC- surveillance, which involves immediate included 6 cases in Wisconsin, and defined outbreak that may have follow-up with the clinician upon chicken from case households in both been associated with spices. Two receipt of a positive laboratory report. states tested positive for the outbreak culture-confirmed cases of S. Newport Although overall incidence rates for strain. Twenty-five culture-confirmed infection were linked to a multi- STDs in Minnesota are lower than and 11 probable cases of S. Sandiego state outbreak of 403 cases from 30 those in many other areas of the (n=23) and S. IIIb 61:l,v:1,5,7 infection states. The implicated vehicle was raw United States, certain population (2 cases) were linked to a multi-state ground beef from a single supplier; subgroups in Minnesota have very outbreak of 101 cases in 10 states that the supplier subsequently recalled high STD rates. Specifically, STDs was associated with commercially approximately 12 million pounds of disproportionately affect adolescents, distributed pasta salad. These numbers beef products. Two culture-confirmed young adults, and persons of color. include 1 case who was positive for both cases of S. Typhimurium infection serotypes and was therefore counted were associated with hedgehog Chlamydia as 2 cases. A subset of the Minnesota contact; these cases were part of a cases attended a wedding where the multi-state outbreak that included 17 Chlamydia trachomatis infection is the pasta salad was served. The pasta salad cases in 11 states. Hedgehogs were most commonly reported infectious was produced at a central commissary purchased from a variety of sources, disease in Minnesota. In 2018, 23,564 kitchen in Nebraska; the source of including hedgehogs bred in-house in chlamydia cases (444 per 100,000 contamination was not identified. Minnesota, and some were positive for population) were reported. This is the the outbreak strain of Salmonella. same rate as in 2017 (Table 3). Table 3. Number of Cases and Rates (per 100,000 Persons) of Chlamydia, Gonorrhea, and Syphilis, 2014-2018 2014 2015 2016 2017 2018 Disease No. Rate No. Rate No. Rate No. Rate No. Rate Chlamydia 19,897 375 21,238 400 22,675 428 23,528 444 23,564 444 Gonorrhea 4,073 77 4,097 77 5,104 96 6,519 123 7,542 142 Syphilis, Total 629 11.9 654 12.3 852 16.1 934 17.6 918 17.3 Primary/Secondary 257 4.8 246 4.6 306 5.8 292 5.5 292 5.5 Early latent 159 3.0 185 3.5 251 4.7 313 5.9 286 5.4 Late latent 213 4.0 220 4.1 289 5.4 327 6.2 330 6.2 Congenital* 0 0.0 2 2.9 7 10.2 2 3.0 10 15.1

*Congenital syphilis rate per 100,000 live births. Note: Data exclude cases diagnosed in federal or private correctional facilities. DCN 46;1 2019 19 continued... Adolescents and young adults are at highest risk for acquiring a chlamydia Table 4. Number of Cases and Incidence Rates (per infection (Table 4). The chlamydia rate is highest among 20 to 24-year-olds 100,000 Persons) of Chlamydia, Gonorrhea, and (2,385 per 100,000), followed by the Primary/Secondary Syphilis by Residence, Age, 15 to 19-year-old age group (1,624 per Race/Ethnicity, and Gender, 2018 100,000). The incidence of chlamydia among adults 25 to 29 years of age Primary/ (1,155 per 100,000) is considerably Disease Chlamydia Gonorrhea Secondary Syphilis lower but has increased in recent years. The chlamydia rate among No. Rate No. Rate No. Rate females (562 per 100,000) is nearly Total 23,564 444 7,542 142 292 5.5 twice the rate among males (324 per 100,000), most likely due to more Residence frequent screening among females. Minneapolis 4,801 1,255 2,361 617 111 29.0

Chlamydia infection incidence is St. Paul 2,798 982 1,121 393 30 10.5 highest in communities of color (Table 4). The rate among black Suburban 7,812 358 2,166 99 91 4.2 non-Hispanics (2,025 per 100,000) is 9.7 times higher than the rate Greater Minnesota 7,750 316 1,787 73 60 2.4 among white non-Hispanics (209 Age per 100,000). Although black, non-Hispanic persons comprise <15 years 108 10 31 3 0 0.0 approximately 5% of Minnesota’s population, they account for 24% 15-19 years 5,972 1,624 1,248 339 15 4.1 of reported chlamydia cases. Rates 20-24 years 8,482 2,385 1,930 543 39 11.0 among Asian/Pacific Islanders (419 per 100,000), Hispanic, any race (751 25-29 years 4,304 1,155 1,619 434 61 16.4 per 100,000), and American Indian/ Alaska Natives (1,148 per 100,000) are 30-34 years 2,206 643 1,168 134 54 15.7 over 2 to 6 times higher than the rate 35-39 years 1,191 363 611 186 43 13.1 among white, non-Hispanic persons. 40-44 years 582 165 357 101 24 6.8 Chlamydia infections occur throughout the state, with the highest 45-49 years 306 75 238 59 21 5.2 reported rates in Minneapolis (1,255 50-54 years 239 59 185 46 16 4.0 per 100,000) and St. Paul (982 per 100,000). Greater Minnesota had the 55+ years 174 13 153 12 19 1.4 greatest increase in rates between 2017 and 2018 at 5%. Every county Gender in Minnesota had at least 4 cases in Male 8,528 324 4,186 159 248 9.4 2018. Female 15,017 562 3,346 125 44 5.7 Gonorrhea Transgender^^ 19 x 10 x 0 x

Gonorrhea is the second most Race^/Ethnicity commonly reported STD in Minnesota. In 2018, 7,542 cases White 9,640 209 2,640 57 138 3.0 (142 per 100,000 population) were reported. This is the highest reported Black 5,690 2,025 2,601 926 70 24.9 rate of gonorrhea in the last decade American Indian/ Alaska 773 1,148 443 658 35 52.0 with a 15% rate increase compared to Native 2017 (Table 3). Asian/PI 924 419 188 85 12 5.4 Adolescents and young adults are at greatest risk for gonorrhea (Table 4), Other^^ 365 x 68 x 1 x with rates of 339 per 100,000 among Unknown^^ 4,293 x 1,142 x 8 x 15 to 19- year-olds, 543 per 100,000 among 20 to 24-year olds, and 434 Hispanic^^ 1,879 751 460 184 28 11.2 per 100,000 among 25 to 29-year- * Residence information missing for 403 cases of chlamydia and 107 cases of gonorrhea. olds. Gonorrhea rates for males ** Suburban is defined as the metropolitan area (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and (159 per 100,000) were higher than Washington Counties), excluding the cities of Minneapolis and St. Paul. females (125 per 100,000). ^ Case counts include persons by race alone. Population counts used to calculate results include race alone or in combination. ^^ No comparable population data available to calculate rates. Communities of color are ^^^ Persons of Hispanic ethnicity may be of any race. disproportionately affected by Note: Data exclude cases diagnosed in federal or private correctional facilities. gonorrhea. The incidence of 20 DCN 46;1 2019 gonorrhea among black, non- over the past 10 years from 5 early In 2018, 224 patients were positive Hispanics (926 per 100,000) is 16 syphilis cases in 2008 to the highest for Shigella by a culture-independent times higher than the rate among number of cases reported in 2018 diagnostic test conducted in a clinical white, non-Hispanics (57 per at 94. laboratory. Of the 215 specimens that 100,000). Rates among Asian/Pacific were received at MDH, 116 (54%) Islanders (85 per 100,000), Hispanic, Congenital Syphilis were subsequently culture-confirmed any race (184 per 100,000), and and therefore met the surveillance American Indian/Alaska Natives Ten congenital syphilis cases were case definition for inclusion in case (658 per 100,000) are up to 12 times reported in 2018, which is the count totals. higher than among white, non- highest number of cases reported Hispanic persons. for Minnesota in more than 50 In 2018, 57 of the 140 Shigella isolates years. Syphilis may be passed from received at MDH were tested Gonorrhea rates are highest in a pregnant person to the unborn for antimicrobial resistance. Of the cities of Minneapolis and St. baby through the placenta.The the 57 isolates, 86% (49 isolates) Paul (Table 4). The incidence in infection can cause miscarriages were resistant to - Minneapolis (617 per 100,000) is and stillbirths, and infants born sulfamethoxazole, 77% (44 isolates) over 1.5 times higher than the rate with congenital syphilis can suffer a were resistant to ampicillin, and 63% in St. Paul (393 per 100,000), 6 times variety of serious health problems, (36) had decreased susceptibility higher than the rate in the suburban including deformities, seizures, to azithromycin (DSA). Thirty-four metropolitan area (99 per 100,000), anemia, and jaundice. The CDC (94%) of 36 of the DSA isolates were and 8 times higher than the rate in reported that the number of infants collected from adult males. Among the Greater Minnesota (73 per 100,000). born with syphilis has more than 27 adult male cases with DSA infection In 2018, the city of Minneapolis saw doubled in the past 4 years and and available information, 17 (63%) the largest increase in cases at 35%. last year reached a 20-year high. In reported sexual contact with a male Minnesota, the number and rate during the week before illness onset. Syphilis of congenital syphilis cases among infants has increased over the past Staphylococcus aureus Surveillance data for primary and 5 years from 0 in 2014 to 15.1 per secondary syphilis are used to 100,000 live births in 2018. Invasive Staphylococcus aureus (SA) monitor morbidity trends because infections are classified into one these represent recently acquired Shigellosis of three categories: hospital-onset infections. Data for early syphilis (HO-SA), healthcare-associated, (which includes primary, secondary, In 2018, 146 culture-confirmed community-onset (HACO-SA), and and early latent stages of disease) cases of shigellosis (2.6 per 100,000 community-associated (CA-SA). SA are used in outbreak investigations population) were reported. This must be isolated from a normally because these represent infections represents a 70% increase from the sterile body site >3 days after the acquired within the past 12 months 86 cases reported in 2017, and is date of initial hospital admission and signify opportunities for disease 29% more than the median annual for a case to be considered HO-SA. prevention. number of cases reported during HACO-SA cases have at least one HA 2008-2017 (median, 113.5; range, 66 risk factor identified in the year prior Primary and Secondary Syphilis to 556). S. sonnei accounted for 82 to infection; examples of risk factors (56%) cases, S. flexneri for 55 (38%) include residence in a long term care The incidence of primary/secondary cases, and S. boydii for 1 (1%) case. facility, recent hospitalization(s), syphilis in Minnesota is lower than Species was not identified for 8 (5%) dialysis, presence of an indwelling that of chlamydia or gonorrhea cases. Cases ranged in age from 1 to central venous catheter, and (Table 3), but has remained elevated 87 years (median, 38 years). Eight surgery. CA-SA cases do not have any since an outbreak began in 2002 percent of cases were ≤5 years of identifiable HA risk factors present in among men who have sex with men age; 85% were 18 years of age or the year prior to infection. (MSM). In 2018, there were 292 older. Sixty-nine percent of cases cases of primary/secondary syphilis were male. Forty-five (31%) cases In 2005, as part of EIP, population- in Minnesota (5.5 cases per 100,000 were hospitalized. No cases died. based surveillance of invasive persons), which is the same number methicillin-resistant SA (MRSA) of cases and rate as in 2017. Thirty-three percent of case were was initiated in Ramsey County; either non-white race (33 of 134 surveillance was expanded to include Early Syphilis cases) or Hispanic ethnicity (17 Hennepin County in 2008. The of 134 cases). Of the 126 cases incidence rate was 12.9 per 100,000 In 2018, the number of early syphilis for which travel information was in 2018 (Ramsey: 11.8/100,000 and cases decreased by 4%, with 578 available, 39 (31%) travelled Hennepin: 13.5/100,000) compared cases, compared to 605 cases in internationally (26 of 75 [35%] S. to 14.9 per 100,000 population 2017. The incidence remains highly sonnei, and 10 of 44 [23%] S. in 2017. In 2018, MRSA was most concentrated among MSM. Of the flexneri) prior to onset. Eighty-three frequently isolated from blood (83%, early syphilis cases in 2018, 484 percent of cases resided in the 183/221), and 10% (23/221) of the (84%) occurred among men; 363 metropolitan area, including 49% in cases died in the hospital. HACO- (62%) of these were MSM; with 39% Hennepin County and 15% in Ramsey MRSA cases comprised the majority of the MSM diagnosed with early County. (62%, 137/221) of invasive MRSA syphilis that were co-infected with infections in 2018; CA-MRSA cases HIV. However, the number of women No outbreaks of shigellosis were accounted for 24% (53/221), and reported has continued to increase reported in 2018. 14% (31/221) cases were HO-MRSA.

DCN 46;1 2019 21 continued... The median age for all cases was Streptococcal Invasive Disease (3), peripheral vascular disease 58 years (range, <1 to 94); the - Group A (3), cirrhosis (2), and chronic skin median age was 53 (range, 8 to breakdown (2). Twenty-one fatal 91), 62 (range, <1 to 89), and 49 Invasive Group A streptococcal cases had two or more underlying years (range, 2 to 94) for HO-, disease (GAS) is defined as GAS conditions, and 5 had none HACO-, and CA-MRSA cases, isolated from a usually sterile site reported. respectively. such as blood, cerebrospinal fluid, or a wound when accompanied Streptococcal Invasive Disease – In August 2014, invasive with or Group B methicillin-sensitive SA (MSSA) streptococcal toxic shock syndrome was initiated in Hennepin and (STSS). Three hundred sixty-seven Five hundred seventy-nine cases Ramsey Counties. The incidence cases (6.6 cases per 100,000 of invasive group B streptococcal rate was 32.7 per 100,000 in population), including 37 deaths, (GBS) disease (10.4 per 100,000 2018 (Ramsey: 33.4/100,000 were reported in 2018, compared population), including 28 deaths, and Hennepin: 32.3/100,000) to 359 cases and 34 deaths in were reported in 2018. By age compared to 29.6 per 100,000 2017. The median age of cases group, annual incidence was highest population in 2017. In 2018, was 60 years (range, newborn among infants <1 year of age (44.7 MSSA was most frequently to 99 years). Fifty-five percent per 100,000 population) and cases isolated from blood (79%, of cases were residents of the aged ≥70 years (39.9 per 100,000). 439/556), and 10% (58/556) of metropolitan area. Allowing for Fifteen (54%) of the 28 deaths were the cases died in the hospital. multiple presentations per patient, among cases ≥65 years. Fifty-one HACO-MSSA cases comprised 140 (38%) had cellulitis, 71 (19%) percent of cases were residents of the majority (58%, 324/556) bacteremia without another focus the metropolitan area. Bacteremia of invasive MSSA infections in of infection, 83 (23%) septic shock, without a focus of infection occurred 2018; CA-MSSA cases accounted 51 (14%) pneumonia, 25 (7%) most frequently (31%), followed by for 31% (171/556), and 11% abscess, 33 (9%) septic arthritis cellulitis (24%), septic arthritis (9%), (61/556) cases were HO-MSSA. and/or , 25 (7%) septic shock (8%), abscess (5%), The median age for all cases was necrotizing fasciitis, and 11 (3%) pneumonia (5%), osteomyelitis (4%), 60 years (range, <1 to 97); the had STSS. Twenty-three cases and meningitis (3%). The majority median age was 61 (range, <1 to (6%) were injection drug users (83%) of cases had GBS isolated from 94), 61 (range, 1 to 97), and 57 in 2018, compared to 10 (3%) blood; other isolate sites included years (range, 2 to 95) for HO-, in 2017. Forty-four (12%) cases joint fluid (10%), peritoneal fluid HACO-, and CA- MSSA cases, were residents of long-term care (3%), cerebrospinal fluid (1%), and respectively. facilities. Eighteen facilities had bone (1%). a single case, nine facilities had Vancomycin-intermediate 2 or more cases including one Twenty-nine cases were infants and (VISA) and vancomycin- facility that had 5 cases. A cluster 4 were maternal cases, compared resistant S. aureus (VRSA) are of isolates from 53 cases from to 42 cases in 2017. Twelve infants reportable, as detected and the west metropolitan area were developed early-onset disease defined according to Clinical determined to be indistinguishable (occurred within 6 days of birth [0.2 and Laboratory Standards from one another using whole cases per 1,000 live births]), and 17 Institute approved standards and genome sequencing. A review of infants developed late-onset disease recommendations: a minimum the cases revealed that these cases (occurred at 7 to 89 days [0.2 cases inhibitory concentration (MIC)=4- were primarily residents of 19 per 1,000 live births]). Four stillbirth/ 8 μg/ml for VISA and MIC≥16 μg/ different long term care facilities spontaneous abortions were ml for VRSA. Patients at risk for and had underlying wounds. An associated with the 4 maternal GBS VISA and VRSA generally have investigation of shared services infections. underlying health conditions between these facilities revealed such as diabetes and end stage that this cluster was associated Since 2002, there has been a renal disease requiring dialysis, with a single wound care provider recommendation for universal previous MRSA infection, recent who was contracted by these prenatal screening of all pregnant hospitalization, and recent facilities. women at 35 to 37 weeks gestation. exposure to vancomycin. There In light of this, we reviewed the have been no VRSA cases in The 37 deaths included 25 that maternal charts for all early-onset Minnesota. Prior to 2008, the presented with just septic shock, 7 cases reported in 2018. Overall, 6 PHL had confirmed 1 VISA case. bacteremia without another focus of 12 women who delivered GBS- Between 2008 and 2016, the PHL of infection, 8 cellulitis, and 12 positive infants underwent prenatal confirmed 18 VISA cases: 2008 pneumonia (individuals could have screening for GBS. Of these, 1 was (3), 2009 (3), 2010 (2), 2011 (5), more than one infection type). Of positive and 5 were negative. One 2013 (3), and 2016 (2). Among all the 34 deaths, the most frequently of the 6 women who did not receive cases of VISA in Minnesota, 10 reported underlying conditions prenatal screening was screened (53%) were male and the median were obesity (10), current tobacco upon admission to the hospital age was 64 years (range, 27 to smoker (8), diabetes (7), chronic and prior to delivery, and was 86). Of those cases with known kidney disease (7), heart failure positive. Among the 12 women who history (17), 89% reported recent (7), atherosclerotic cardiovascular delivered GBS-positive infants, 7 exposure to vancomycin. No disease (7), chronic obstructive received intrapartum antimicrobial cases of VISA were confirmed in pulmonary disease (4), asthma (4), prophylaxis. An update of GBS 2017 or 2018. current alcohol abuse (3), dementia perinatal prevention guidance was 22 DCN 46;1 2019 published by the American College In 1999, the year before the pediatric included in PCV-13. In 2018, 18% of Obstetricians and Gynecologists, pneumococcal conjugate vaccine of cases with isolates available for and by the American Academy of (Prevnar [PCV-7]) was licensed; the testing were caused by 6 of the PCV- Pediatrics in July 2019. rate of IPD among children <5 years 13-included serotypes: 3 (13%), 19A of age in the metropolitan area was (2%), 19F (2%), 7F (<1%), 6A (<1%), Streptococcus pneumoniae 111.7 cases/100,000. Over the years and 4 (<1%). Invasive Disease 2000-2002 there was a major downward trend in incidence in this In August 2014, the Advisory In 2018, 478 (8.6 per 100,000) cases age group (Figure 6). Rates in each of Committee on Immunization Practices of invasive pneumococcal disease the subsequent 8 years were level or (ACIP) recommended that all adults (IPD) were reported. By age group, somewhat higher. Based on the ≥65 years receive 1 dose of PCV- annual incidence rates per 100,000 distribution of serotypes among 13 followed by 1 dose of 23-valent were 7.9 cases among children aged isolates from these cases, this pneumococcal vaccine ≤5 years, 2.7 cases among children increase was limited to disease 6 to 12 months later. Among adults and adults aged 5-39 years, 9.0 cases caused by non- vaccine serotypes (i.e. ≥65 years, 14% of cases in 2018 had among adults 40-64 years, and 25.6 serotypes other than the 7 included PCV-13 serotypes. cases among adults aged ≥65 years. in PCV-7) (Figure 6). Of the 452 isolates submitted for Pneumonia occurred most frequently In March 2010, the U.S. Food and 2018 cases, 72 (16%) isolates were (55% of infections), followed by Drug Administration approved a resistant to using meningitis bacteremia without another focus of 13-valent pediatric pneumococcal breakpoints. Using non-meningitis infection (15%), septic shock (12%), conjugate vaccine (PCV-13 [Prevnar breakpoints, 4 (<1%) of 452 isolates and meningitis (6%). Forty-six (10%) 13]) which replaced PCV-7. This were resistant to penicillin. (Note: cases died. Health histories were vaccine provides protection against CLSI penicillin breakpoints changed in available for all 46 deaths; of these, the same serotypes in PCV-7, plus 6 2008). 43 had an underlying health condition additional serotypes (serotypes 1, reported. The conditions most 3, 5, 6A, 7F, and 19A). From 2007 Tetanus frequently reported were current to 2010, the majority of IPD cases tobacco smoker (12), emphysema/ among children <5 years of age One case of tetanus was reported chronic obstructive pulmonary was caused by the 6 new serotypes in 2018. A 17 year-old unvaccinated disease (11), cardiac failure (10), included in PCV-13 (Figure 6). Since male stepped on a at a (10), diabetes 2011, the majority of IPD cases construction site 12 days before he (8), current alcohol abuse (8), and among children <5 years of age presented to a clinic. He developed obesity (8). has been caused by serotypes not spasms in his jaw, a stiff neck, fever, and general muscle spasms. He received tetanus immune globulin at Figure 6. Invasive Pneumococcal Disease Incidence a clinic and was then admitted to a Among Children <5 Years of Age, by Year and Serotype hospital. After 3 days hospitalization, Group, Metropolitan Area, 1999-2001; Minnesota, his fever and neck pain resolved but 125 he still had peripheral muscle spasms. 2002-2018 Unknown Serotype The case’s mother refused to have him receive a tetanus-containing Other Serotypes vaccine prior to discharge.

Additional Serotypes in PCV-13 100 Toxoplasmosis Serotypes in PCV-7 Toxoplasmosis is an illness caused by the coccidian protozoan Toxoplasma gondii and cats are the primary 75 reservoir. T. gondii transmission in the United States is primarily foodborne, through handling or consumption of undercooked 50 pork, lamb, or venison containing bradyzoites, the microscopic tissue cyst form of the parasite. People

Cases per 100,000 Population also can be infected through direct contact with cat feces that contains 25 Toxoplasma oocysts or though consumption of food or water that has been contaminated with oocysts. In 2018, 15 cases were reported 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 (14 confirmed and 1 probable), an increase over the 9 reported in Year of Diagnosis 2017, and 7 reported in 2016. Eight PCV-13 contains the 7 serotypes in PCV-7 (4,6B,9V,14,18C,19F, and 23F) plus 6 additional cases had immunocompromising serotypes (1,3,5,6A,7F, and 19A). conditions. Seven cases DCN 46;1 2019 23 continued... were diagnosed with ocular Twenty-seven (31%) counties had ruled out (3%). An additional 9% toxoplasmosis, 3 with generalized at least 1 TB case in 2018. The were identified through other toxoplasmosis, 4 with cerebral majority (70%) of cases occurred screening (e.g., other immigration toxoplasmosis, and 1 unknown type. in the metropolitan area, primarily medical exams, employment There were no pregnant cases. The in Hennepin (31%) and Ramsey screening, other targeted testing median age of cases was 53 years (20%) Counties. Thirty-three (19%) for TB). Six (3%) cases were (range, 20 to 83 years). Eleven cases were from the other 5 metropolitan diagnosed with active TB disease (73%) were male. Nine cases were counties. The remaining 30% incidentally while being evaluated white, 1 was black, and 5 were of of cases were reported from for another medical condition. unknown race; 9 cases were non- Greater Minnesota, representing Hispanic, while 1 was Hispanic, a 3% increase from 2017. Among TB incidence is disproportionately and 5 were of unknown ethnicity. metropolitan area counties, the high among racial and ethnic Three of the confirmed cases and highest TB incidence rate in 2018 minorities in Minnesota, as it is the probable case were associated was reported in Ramsey County among cases reported nationally. with an outbreak, in which a large (6.2 per 100,000), followed In 2018, 12 cases occurred family group were infected after by Hennepin County (4.3 per among non-Hispanic whites, a consuming undercooked venison on 100,000). The TB incidence rate case rate of 0.3 per 100,000. In their annual hunting trip. A sample for all Greater Minnesota counties contrast, among non-Hispanic of their venison tested positive for combined was 2.0 per 100,000. persons of other races, 97 cases Toxoplasma. occurred among blacks/African- The largest group of new TB cases born persons (24.9 cases per Tuberculosis was the 25-44 year age group at 100,000), and 52 among Asian/ time of diagnosis (42%), followed Pacific Islanders (17.5 cases In 2018, 172 tuberculosis (TB) cases by cases 65 years and older (18%). per 100,000). Ten cases were (3.1 per 100,000 population) were Two percent of new cases were Hispanic persons of any race (3.3 reported. This represents a 3% <5 years of age when they were cases per 100,000). One case decrease in the number of cases diagnosed. was reported as multi-racial. The compared to 2017, when there were majority of Hispanic (60%), Asian 178 cases. The TB incidence rate in Most (78%) TB cases were (90%), and black cases (91%) Minnesota has typically been lower identified only after seeking were non-U.S. born. than the overall rate in the United medical care for symptoms of States, but Minnesota’s rate in the disease. Various targeted public In 2018, the percentage of TB last few years has been higher than health interventions identified the cases in Minnesota occurring in the national rate (2.8 per 100,000 majority of the remaining 22% persons born outside the United in 2018). Despite the higher TB of cases. Such case identification States was 83%, compared to case counts and rates in Minnesota methods are high priority core 70% of TB cases reported recently, the TB case count has prevention and control activities, nationally. The 142 non U.S.-born decreased 28% since 2007, when and include contact investigations TB cases represented 30 different 238 cases were reported, and has (6%) and follow-up evaluations of countries of birth; the most remained under 200 since 2009. individuals with abnormal findings common region of birth among Four (2%) cases from 2018 died, 1 of on pre-immigration exams where these cases was Sub-Saharan whom died due to TB disease. infectious TB disease had been Africa (61% of non-U.S. born cases), followed by South/ Figure 7. Non U.S.-Born Tuberculosis Cases by Region of Southeast Asia (26%), East Asia/ Birth and Year of Report, 2014 – 2018 Pacific (7%), and Latin America 100 (including the Caribbean) (4%). Patients from other regions 90 (North Africa/Middle East, and 80 Eastern Europe) accounted for 70 the remaining 1% of cases (Figure 7). 60 50 Individuals in other high risk 40 groups comprised smaller proportions of the cases. Note Number of Cases of Number 30 that patients may fall under 20 more than one risk category. Twenty-seven percent occurred 10 in persons with certain medical 0 conditions that increase the 2014 2015 2016 2017 2018 risk for progression from Year of Report latent TB infection to active TB disease (e.g., diabetes, Sub- Saharan Africa South/ Southeast Asia East Asia/ Pacific prolonged corticosteroid or Latin America/ Caribbean Other* other immunosuppressive therapy, end stage renal disease). The next most common risk * “Other” includes: Eastern Europe, North Africa/Middle East, and Western Europe factor was substance abuse 24 DCN 46;1 2019 (including alcohol abuse and/ had glandular and the other and post-mortem specimens is or injection and non-injection had pneumonic tularemia. One conducted at the MDH PHL and the drug use) during the 12 months case had type A tularemia, CDC Infectious Diseases Pathology prior to their TB diagnosis (6%). and the other was diagnosed Branch (IDPB). Three percent of cases were co- by serology only and had an infected with HIV. Two percent unidentified subtype. Case ages In 2018, 111 cases met UNEX reported being homeless during were 25 and 69 years old; 1 criteria (80 deaths, 31 critical the 12 months prior to diagnosis, was male, 1 was female. One illnesses), compared to 80 cases 2% were residents of long-term case was hospitalized, and in 2017. Of the 111, 96 (86%) care facilities, and 1% were in both survived. One case likely were reported by providers and a correctional facility at time of acquired tularemia by inhaling 15 (14%) were found by death diagnosis. the bacteria, the other case’s certificate review. Forty-one (37%) exposure route was unknown. cases presented with respiratory By site of disease, 47% of symptoms; 27 (24%) with sudden cases had pulmonary disease From 2007 to 2018, 18 tularemia unexpected death; 24 (22%) with exclusively. Another 14% had both cases were reported, with a neurologic symptoms; 7 (6%) pulmonary and extrapulmonary range of 0 to 6 cases annually. with shock/sepsis; 6 (5%) with sites of disease, and 38% had Ten cases had ulceroglandular, 4 cardiac symptoms; 2 (2%) with extrapulmonary disease exclusively. had glandular, 2 had pneumonic, gastrointestinal illness, 1 (1%) with Among the 90 patients with an and 2 had typhoidal tularemia. hepatic symptoms, and 3 (3%) with extrapulmonary site of disease, the Eight of 13 cases with a known multiple symptoms. The age of most common sites were lymphatic tularemia subtype had type B, cases ranged from newborn to 72 (51%), followed by musculoskeletal and 5 had type A. The median age years. The median age was 6 years (18%). Extrapulmonary disease is of cases was 42.5 years (range, among 96 reported cases, and generally more common among 2 to 87). Ten cases were most 39 years among 15 non-reported persons born outside the United likely exposed through a tick or cases found through active States, as seen in cases reported biting fly bite, 2 cases through surveillance. Sixty-two percent nationally as well as in Minnesota. water exposures, 2 cases through resided in the metropolitan area, Fifty-six percent of non U.S.-born a cat scratch or bite, 2 cases were 50% were female, and 8% were cases in Minnesota had at least one exposed by inhaling the bacteria, non-Minnesota residents who were extrapulmonary site of disease, and 2 cases’ exposures could not either hospitalized in Minnesota or compared to only 33% of U.S.-born be determined. Thirteen of 16 investigated by a Minnesota ME. cases. cases for which race was known were white, 1 was black, and There were 257 MED-X cases in Of 130 culture-confirmed TB cases 1 was American Indian/ Alaska 2018; 80 of these also met UNEX with drug susceptibility results Native, and 1 was Asian/Pacific criteria. The median age of the available, 25 (19%) were resistant Islander. cases was 44 years, and 57% were to at least one first-line anti-TB male. There were 155 (60%) cases drug (i.e., isoniazid [INH], rifampin, Unexplained Critical Illnesses found through death certificate pyrazinamide, or ethambutol), and Deaths of Possible review; MEs reported 97 (38%) including 16 (12%) cases resistant Infectious Etiology and cases. The most common syndrome to at least INH. There were 7 new Medical Examiner Deaths was pneumonia/upper respiratory cases of multidrug-resistant TB Surveillance infection (n=94 [37%]). (MDR-TB, or resistance to at least INH and rifampin) reported in 2018, MDH conducts surveillance There were 193 potential UNEX or making up 5% of culture-confirmed for unexplained deaths and MED-X cases that had specimens cases. critical illnesses in an effort to tested at the PHL and/or the IDPB. identify those that may have Fifty-four cases had pathogens Tularemia an infectious etiology. This identified as confirmed, probable, surveillance is performed through or possible cause of illness, Tularemia is an acute illness two complementary surveillance including 43 UNEX deaths (Table caused by Francisella tularensis systems, Unexplained Critical 5). Fifty-five were determined subspecies tularensis (type A) Illnesses and Deaths of Possible to be non-infectious. Among 52 or holarctica (type B). Routes of Infectious Etiology (known as unexplained deaths occurring in transmission include arthropod UNEX), and Medical Examiner those <50 years of age without bites (particularly ticks and deer (ME) Infectious Deaths any immunocompromising flies), contact with infected Surveillance (known as MED-X) conditions, UNEX helped to identify animals, and exposure to which is not limited to deaths the pathogen(s) involved in 29 contaminated water or soil. with infectious hallmarks. Focus (56%) cases. MED-X surveillance There are six main clinical forms is given to cases <50 years of age detected an additional 47 cases of disease and all include fever: with no significant underlying with pathogens identified by MEs ulceroglandular, glandular, conditions; however, any case as the cause of death (Table 5). pneumonic, oropharyngeal, should be reported regardless of Cases with pathogens of public oculoglandular, and typhoidal. the patient’s age or underlying health importance detected medical conditions to determine included a 57 year-old male who In 2018, 2 cases were reported; if further testing conducted was found deceased in his home. 1 was culture-confirmed, and 1 or facilitated by MDH may be He had recently traveled to was a probable case. One case indicated. Testing of pre-mortem Louisiana, and at the time of his DCN 46;1 2019 25 death, his travel companion had Table 5. UNEX/MED-X Pathogens Identified as been admitted with Legionella Confirmed, Probable, or Possible Cause of Illness, 2018* pneumonia. Although the ME had initially declined autopsy, Pathogen Identified UNEX (n=54) MED-X (n=47)** the PHL was able to culture L. Adenovirus type 1 1 0 pneumonphila serogroup 1 from a blood sample collected for Aspergillus fumigatus 0 1 toxicology screening confirming Bifidobacterium spp. 0 1 the outbreak and leading to a Blastomyces dermatitidis 0 1 public health investigation. UNEX testing detected Candida albicans 0 1 B5 in multiple specimens from Candida krusei 0 1 a neonate and a 7 year-old who presented with Candida spp. 1 0 within days of each other to a 0 1 tertiary care hospital. Finally, Clostridioides difficile 0 1 UNEX surveillance was able to diagnose Mycobacterium Clostridium perfringens 1 2 tuberculosis complex in a Coxsackievirus B5 2 0 55 year-old male who had succumbed to accidental head 0 1 injuries. Granulomatous lesions Enterobacter spp. 0 1 in the were noted on Escherichia coli 1 3 autopsy, and following the diagnosis at IDPB, a public Group A Streptococcus/Streptococcus pyogenes 1 2 health contact investigation was Group B Streptococcus 1 2 initiated. No secondary TB cases Haemophilus influenzae 5 0 were identified. Influenza A virus (no hemagglutinin typing information available) 0 3 Varicella and Zoster Influenza A – H1 1 0 In 2018, 325 varicella cases Influenza A – H3 5 0 (5.8 per 100,000 population) Influenza B 2 1 were reported. One hundred Influenza C 1 0 ninety-seven (61%) were from the metropolitan area. Cases Jamestown Canyon virus 2 0 ranged from 19 days to 73 Klebsiella pneumoniae 2 1 years of age. Forty-one cases (13%) were <1 year, 108 (33%) Legionella pneumophila serogroup 1 2 0 were 1-6 years, 86 (26%) were Mycobacterium tuberculosis 0 1 7-12 years, 23 (7%) were 13-17 Parainfluenza virus type 2 2 0 years, and 67 (21%) were ≥18 years of age. Eight cases were Parainfluenza virus type 3 2 1 hospitalized; Parainfluenza virus type 4 1 0 3 were <1 year, 3 were 4-15 years, and 2 were >18 years of 1 2 age. Seven of the hospitalized Psuedomonas spp. 0 1 cases had never been Pseudomonas putida 0 1 vaccinated; 3 were underage for vaccination, 1 was unvaccinated Respiratory syncytial virus 6 1 due to parental refusal, 1 had Rhinovirus 1 0 a medical contraindication to Staphylococcus aureus 6 5 vaccination, and 2 were adults who had never been offered the Staphylococcus aureus - MRSA 1 4 vaccine. In addition, there was Staphylococcus spp. 3 1 1 case that was reported while already hospitalized, and was Streptococcus spp. 6 0 likely a nosocomial infection. Streptococcus anginosus 0 1 There were no varicella-related Streptococcus constellatus 0 1 deaths. Streptococcus dysgalactiae 0 1 Varicella cases are often Streptococcus pneumoniae 7 6 identified by parents/guardians reporting to schools and West Nile virus 5 0 childcare facilities, rather * Some cases had multiple pathogens identified as possible coinfections contributing to illness/death. than directly reported by a **MED-X includes pathogens identified by the ME. If the cause was found through testing at MDH/CDC it is clinician. Of the 325 cases for included in the UNEX column. which information regarding 26 DCN 46;1 2019 diagnosis was available, 222 or disease, 31 had meningitis, 20 for all 16 cases; 7 were white, (68%) had visited a health care had cellulitis or other bacterial 4 were black, 3 were Asian/ provider, 27 (8%) had consulted superinfection, 4 had encephalitis, Pacific Islander, 1 was American a provider or clinic by telephone, 1 had meningioencephalitis, 11 Indian/Alaskan Native, and 1 was 1 had been identified by a school had Ramsay-Hunt Syndrome, and multiracial. No cases were of health professional, and 75 (23%) 2 had pneumonia. Cases with Hispanic ethnicity. had not consulted a health care disseminated rash or disease provider. Of the 317 cases for tended to be older than cases with Two hundred forty-two reports which information regarding meningitis without dissemination of newly identified cases of laboratory testing was available, (median age of 62 vs. 44 years), confirmed chronic HBV infection 117 (37%) had testing performed. and were more likely to have were received in 2018. A total of Ten percent of cases occurred as immunocompromising conditions 25,335 persons are estimated to part of an outbreak, defined as ≥5 or immunosuppressive drug be alive and living in Minnesota cases in the same setting. Three treatment (83% vs. 46%). Four with chronic HBV infection. The outbreaks occurred in schools. deaths occurred, 2 had meningitis, median age of chronic HBV cases Two were public schools, and one 1 had meningitis and Ramsay-Hunt in Minnesota is 46 years. was a private school. The largest Syndrome, and 1 had cellulitis or outbreak had 13 cases; 1 case was other bacterial superinfection. All In 2018, there were no perinatal partially vaccinated, and 12 were deaths were in cases ≥50 years of hepatitis B infections identified unvaccinated. Of the unvaccinated age. Fifteen percent of cases ≥50 in infants born to hepatitis cases, 9 were due to parental years of age had received zoster B-positive mothers. Three refusal, 1 was unvaccinated due to vaccine. hundred seventy-eight infants a previous report of disease, and 2 born to hepatitis B-positive cases were unvaccinated because Viral Hepatitis A women during 2017 had post- their parents reported they forgot serologic testing demonstrating to vaccinate. In 2018, 16 cases of hepatitis no infection. A (0.3 per 100,000 population) Zoster cases in children <18 years were reported. Nine cases were Viral Hepatitis C of age are reportable in Minnesota; residents of the metropolitan area. 61 cases were reported in 2018. Ten cases were male. The median In 2018, 60 cases of acute Cases may be reported by school age of cases was 48 years (range hepatitis C virus (HCV) infection health personnel, child care 20 to 87). Race was known for 15 (1.1 per 100,000) were reported. staff, or healthcare providers. cases; 9 (56%) were white, 3 (19%) In 2012, the case definition Ages ranged from 1 to 17 years were black, 2 (13%) were Asian/ for acute hepatitis C changed (median 10 years). Varicella vaccine Pacific Islander, and 1 (6%) was to include documented became a requirement for entry reported as other race. One (6%) asymptomatic seroconversion. into kindergarten and 7th grade in case was known to be of Hispanic Of the 60 cases, 17 (28%) were 2004, and the incidence of zoster ethnicity. asymptomatic, laboratory- in children has declined from 15.7 confirmed acute infection. per 100,000 population in 2006 to Six cases were associated with 4.7 per 100,000 population in 2018. international travel. Four cases had Thirty-three (55%) cases resided In 2018, the PHL performed strain risk factors that have been seen in Greater Minnesota. The typing on specimens from 13 cases. in national outbreaks, including median age of all cases was 29 Twelve of these cases had been injection and non-injection drug years (range, 19 to 63). Twenty- vaccinated and of these, 11 (92%) use, homelessness/transient seven (45%) cases were male. were positive for the vaccine strain housing, and men who have sex Race was known for 56 cases; and 1 (8%) was positive for the with men. No risk factor was of those, 37 (62%) were white, wild type virus. The 1 unvaccinated identified for the 6 remaining 16 (27%) were American Indian/ case was positive for the wild type cases. No outbreaks occurred. Alaska Native, 1 (2%) was black, virus. Although the vaccine strain 1 (2%) was Asian, and 1 (2%) can reactivate and cause zoster, Viral Hepatitis B was reported as other race. One our data suggest that the incidence (2%) case was known to be of of zoster is lower in vaccinated In 2018, 16 cases of acute Hispanic ethnicity. children than in unvaccinated hepatitis B virus (HBV) infection children, which is consistent with (0.3 per 100,000 population) MDH received 1,501 reports previously published findings. were reported. In 2012, the case of newly identified chronic definition for acute hepatitis B hepatitis C infections in 2018. Zoster with dissemination or was revised to include laboratory In 2016, the case definition for complications (other than post- confirmed asymptomatic acute chronic hepatitis C changed herpetic neuralgia) in persons of cases. Five of the 16 cases were to exclude those reported as any age is also reportable; 89 such asymptomatic, laboratory- having resolved their infection. cases were reported, and 83 were confirmed infections. A total of 33,856 persons are hospitalized. Cases ranged from 13 estimated to be alive and living to 92 years of age, with a median The median age of cases was 46 in Minnesota with chronic HCV age of 61. Fifty-six (63%) had co- years (range 22 to 69). Eleven infection. The median age of morbidities or were being treated (69%) cases were residents of the these cases is 58 years. with immunosuppressive drugs. metropolitan area. Twelve (75%) Thirty-three had disseminated rash cases were male. Race was known DCN 46;1 2019 27 Emerging Infections in Clinical Practice & Public Health November 15, 2019 Radisson Blu-Mall of America Emerging Pathogens and Innovative Approaches Bloomington, MN

7:00 am Registration and Continental Breakfast

7:55 Welcome and Introductions

8:00 Keynote: Climate Change and Microbes: The Good, the Bad, and the Ugly 8:45 Questions and Discussion Phillip Peterson, MD, University of Minnesota

9:00 Challenges and Opportunities for Public Health in the New Era of Molecular Diagnostics 9:30 Questions and Discussion Gregory L. Armstrong, MD, Centers for Disease Control and Prevention

9:45 Ebola in the DRC 10:15 Questions and Discussion Mary Choi, MD, Centers for Disease Control and Prevention

10:30 Refreshment Break

10:45 Hot Topics 11:15 Questions and Discussion Richard Danila, PhD, MPH, Minnesota Department of Health

11:30 Influenza Vaccines and Impact on Disease 12:00 pm Questions and Discussion Brendan Flannery, PhD, Centers for Disease Control and Prevention

12:15 Lunch

1:15 CDI Prevention: Current and Future 1:45 Questions and Discussion Dale Gerding, MD, Hines Veterans Affairs Hospital, Loyola University Stritch School of Medicine

2:00 Cases from the Travel Desk 2:30 Questions and Discussion Abinash Virk, MD, Mayo Clinic

2:45 Refreshment Break

3:00 Outpatient Antimicrobial Stewardship: It Can be Done Effectively and Well 3:30 Questions and Discussion Kati Shihadeh, PharmD, BCIDP, Denver Health Medical Center

3:45 Challenging Cases of Public Health Interest Moderator: Dimitri Drekonja, MD, MS, Minneapolis VA Healthcare System Public Health Expert: Stacy Holzbauer, DVM, MPH Panelists: TBD

4:30 Evaluations & Adjourn

Faculty and Curriculum Subject to Change

28 DCN 46;1 2019 Emerging Infections in Clinical Practice & Public Health November 15, 2019

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