MINNESOTA DEPARTMENT ISEASE ONTROL EWSLETTER OF HEALTH D C N

Volume 39, Number 1 (pages 1-28) 2012 Annual Summary of Communicable Diseases Reported to the Minnesota Department of Health, 2011

Introduction Act (Section 13.38). Provisions of rates in this report were Assessment of the population’s the Health Insurance Portability and calculated using disease-specifi c health is a core public health function. Accountability Act (HIPAA) allow for numerator data collected by MDH and Surveillance for communicable routine disease reporting without a standardized set of denominator diseases is one type of assessment. patient authorization. data derived from U.S. Census data. Epidemiologic surveillance is the Disease incidence is categorized as systematic collection, analysis, and Since April 1995, MDH has participated occurring within the seven-county Twin dissemination of health data for as an Emerging Program Cities metropolitan area (metropolitan the planning, implementation, and (EIP) site funded by the Centers area) or outside of it in Greater evaluation of health programs. The for Disease Control and Prevention Minnesota. Minnesota Department of Health (CDC) and, through this program, (MDH) collects information on has implemented active hospital- and certain infectious diseases for the laboratory-based surveillance for Human anaplasmosis (formerly purposes of determining disease several conditions, including selected known as human granulocytic impact, assessing trends in disease invasive bacterial diseases, foodborne ) is caused by Anaplasma occurrence, characterizing affected diseases, and hospitalized infl uenza phagocytophilum, a rickettsial organism populations, prioritizing control efforts, cases. transmitted to humans by bites from and evaluating prevention strategies. Ixodes scapularis (the blacklegged Prompt reporting allows outbreaks to Isolates for with certain tick or deer tick). In Minnesota, the be recognized in a timely fashion when diseases are required to be submitted same tick also transmits the control measures are most likely to be to MDH (Table 1). The MDH Public etiologic agents of , effective in preventing additional cases. Health Laboratory (PHL) performs babesiosis, one form of human microbiologic evaluation of isolates, ehrlichiosis, and a strain of Powassan In Minnesota, communicable disease such as pulsed-fi eld gel electrophoresis virus. A. phagocytophilum can also be reporting is centralized, whereby (PFGE), to determine whether isolates transmitted by blood transfusion. reporting sources submit standardized (e.g., enteric pathogens such as report forms to MDH. Cases of disease Salmonella and In 2011, a record number of 782 are reported pursuant to Minnesota O157:H7, and invasive pathogens confi rmed or probable anaplasmosis Rules Governing Communicable such as meningitidis) are cases (14.7 cases per 100,000 Diseases (Minnesota Rules 4605.7000 related, and potentially associated with population) were reported (Figure 1). - 4605.7800). The diseases listed in a common source. Testing of submitted The median number of 298 cases Table 1 (page 2) must be reported isolates also allows detection and (range, 139 to 782 cases) reported to MDH. As stated in the rules, monitoring of resistance, from 2004 through 2011 is also physicians, health care facilities, which continues to be an important continued on page 4 laboratories, veterinarians, and others problem (see pp. 26-27). are required to report these diseases. Reporting sources may designate Table 2 summarizes cases of selected an individual within an institution communicable diseases reported to perform routine reporting duties during 2011 by district of the patient’s (e.g., an preventionist for a residence. Pertinent observations for Inside: hospital). Data maintained by MDH some of these diseases are presented are private and protected under the below. Antimicrobial Susceptibilities of Minnesota Government Data Practices Selected Pathogens, 2011...... 26 Table 1. Diseases Reportable to the Minnesota Department of Health Report Immediately by Telephone Anthrax () a Q () a Botulism ( botulinum) (animal and human cases and suspected cases) (Brucella spp.) a Rubella and congenital rubella syndrome a ( cholerae) a Severe Acute Respiratory Syndrome (SARS) ( diphtheriae) a (1. Suspect and probable cases of SARS. 2. Cases of health Hemolytic uremic syndrome a care workers hospitalized for or acute respiratory Measles (rubeola) a distress syndrome.) a () Smallpox (variola) a (all invasive disease) a, b () a Orthopox virus a Unusual or increased case incidence of any suspect ( pestis) a infectious illness a Poliomyelitis a Report Within One Working Day Amebiasis (Entamoeba histolytica/dispar) (Plasmodium spp.) Anaplasmosis (Anaplasma phagocytophilum) (caused by viral agents) Arboviral disease (including but not limited to, Mumps LaCrosse , eastern equine encephalitis, western Neonatal , less than 7 days after birth ( isolated from equine encephalitis, St. Louis encephalitis, and a sterile site, excluding coagulase-negative West Nile virus) Staphylococcus) a, b Babesiosis (Babesia spp.) Pertussis ( pertussis) a Blastomycosis (Blastomyces dermatitidis) Psittacosis (Chlamydophila psittaci) (Campylobacter spp.) a Retrovirus infection Cat scratch disease (infection caused by spp.) Reye syndrome ( ducreyi) c Rheumatic fever (cases meeting the Jones Criteria only) trachomatis infection c Rocky Mountain (, R. canada) , including typhoid (Salmonella spp.) a Cryptosporidiosis (Cryptosporidium spp.) a (Shigella spp.) a Cyclosporiasis (Cyclospora spp.) a (-intermediate S. aureus [VISA], Dengue virus infection vancomycin-resistant S. aureus [VRSA], and death or critical Diphyllobothrium latum infection illness due to community-associated S. aureus in a previously Ehrlichiosis (Ehrlichia spp.) healthy individual) a Encephalitis (caused by viral agents) Streptococcal disease (all invasive disease caused by Groups A Enteric E. coli infection (E. coli O157:H7, other enterohemorrhagic and B streptococci and S. pneumoniae) a, b [Shiga -producing] E. coli, enteropathogenic E. coli, (Treponema pallidum) c enteroinvasive E. coli, enterotoxigenic E. coli) a (Clostridium tetani) Enterobacter sakazakii (infants under 1 year of age) a Toxic syndrome a Giardiasis (Giardia lamblia) Toxoplasmosis (Toxoplasma gondii) () c Transmissible spongiform Haemophilus infl uenzae disease (all invasive disease) a,b Trichinosis (Trichinella spiralis) Hantavirus infection Tuberculosis (Mycobacterium tuberculosis complex) (Pulmonary or (all primary viral types including A, B, C, D, and E) extrapulmonary sites of disease, including laboratory (Histoplasma capsulatum) confi rmed or clinically diagnosed disease, are reportable. Human immunodefi ciency virus (HIV) infection, including Latent tuberculosis infection is not reportable.) a Acquired Immunodefi ciency Syndrome (AIDS) a, d (Rickettsia spp.) Infl uenza (unusual case incidence, critical illness, or laboratory Unexplained deaths and unexplained critical illness confi rmed cases) a (possibly due to infectious cause) a Kawasaki disease Varicella-zoster disease Kingella spp. (invasive only) a, b (1. Primary []: unusual case incidence, critical Legionellosis (Legionella spp.) a illness, or laboratory-confi rmed cases. 2. Recurrent []: (Hansen’s disease) (Mycobacterium leprae) unusual case incidence, or critical illness.) a (Leptospira interrogans) Vibrio spp. a (Listeria monocytogenes) a Yellow fever Lyme disease () , enteric (Yersinia spp.) a

Sentinel Surveillance (at sites designated by the Commissioner of Health) Methicillin-resistant Staphylococcus aureus a, b Clostridium diffi cile a Carbapenem-resistant spp. and carbapenem-resistant Acinetobacter spp. a a Submission of clinical materials required. If a rapid, non-culture assay is used b Isolates are considered to be from invasive disease if they are for diagnosis, we request that positives be cultured, and isolates submitted. If isolated from a normally sterile site, e.g., blood, CSF, joint fl uid, this is not possible, send specimens, nucleic acid, enrichment broth, or other etc. appropriate material. Call the MDH Public Health Laboratory at 651-201-4953 c Report on separate Sexually Transmitted Disease Report Card. for instructions. d Report on separate HIV Report Card.

2 DCN 39;1 2012 Table 2. Cases of Selected Communicable Diseases Reported to the Minnesota Department of Health by District of Residence, 2011 District (population per U.S. Census 2009 estimates) Metropolitan (2,810,414) Northwestern (153,218) Northeastern (320,342) Central (715,467) West Central (229,186) South Central (286,956) (486,517) Southeastern Southwestern (218,293) Disease Unknown Residence Total (5,220,393) Anaplasmosis 201 121 106 280 32 7 30 5 0 782 Arboviral disease LaCrosse 0 0 0 0 0 0 1 0 0 1 West Nile 2 0 0 0 0 0 0 0 0 2 Babesiosis 12 14 6 25 8 0 6 1 0 72 Campylobacteriosis 464 15 45 159 57 49 142 64 0 995 Cryptosporidiosis 47 6 37 31 39 16 87 44 0 307 Escherichia coli O157 infection 68 1 4 28 11 7 19 8 0 146 Hemolytic uremic syndrome 5 0 0 4 0 1 1 1 0 12 Giardiasis 386 17 53 59 18 9 55 24 65 686 disease 34 2 3 11 2 2 12 5 0 71 HIV infection other than AIDS 217 1 5 9 1 7 4 4 0 248 AIDS (cases diagnosed in 2010) 137 0 6 12 3 3 9 2 1 173 Legionellosis 20 0 1 0 1 2 7 0 0 31 Listeriosis 2 1 0 0 1 0 2 0 0 6 Lyme disease 510 81 119 314 43 17 108 9 0 1,201 Meningococcal disease 7 0 0 1 1 0 0 0 0 9 Mumps 2 0 0 0 0 0 0 0 0 2 Pertussis 595 16 33 305 17 50 88 39 0 1,143 Salmonellosis 418 19 25 88 24 30 76 21 0 701 Sexually transmitted diseases 12,207 295 716 1,311 311 564 1,253 338 765 17,760 - genital infections 11,320 273 845 1,358 343 552 1,133 346 728 16,898 Gonorrhea 1,840 26 60 114 25 28 76 23 91 2,283 Syphilis, total 321 2 6 14 1 3 10 2 7 366 Primary/secondary 124 1 0 6 0 3 3 0 2 139 Early latent* 111 0 3 3 0 0 1 2 1 121 Late latent** 86 1 3 5 1 0 6 0 4 106 Congenital 0 0 0 0 0 0 0 0 0 0 Other*** 0 0 0 0 0 0 0 0 0 0 Shigellosis 76 1 0 5 0 0 3 2 0 87 pneumoniae disease 244 35 49 100 24 40 47 43 0 582 Streptococcal invasive disease - Group A 115 8 23 21 16 11 26 11 0 231 Streptococcal invasive disease - Group B 293 22 41 60 22 30 49 18 0 535 (Staphylococcal) 3 0 0 0 0 1 0 0 0 4 Tuberculosis 102 4 2 6 4 0 13 6 0 137 Viral hepatitis, type A 14 0 4 1 1 1 2 4 0 0 Viral hepatitis, type B (acute infections only, not perinatal) 14 0 0 3 1 0 1 1 0 20 Viral hepatitis, type C (acute infections only) 8 0 5 3 1 0 0 1 0 18 * 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

DCN 39;1 2012 3 considerably higher than the median Minnesota; it will probably be present in II or “deer tick virus”) that is transmitted number of cases reported annually from the state to some extent every year. The by I. scapularis. The virus can cause 1996 to 2003 (median, 56 cases; range, disease risk to humans, however, will encephalitis or meningitis, and long- 14 to 149). Five hundred three (64%) likely continue to be higher in central term sequelae occur in approximately cases reported in 2011 were male. The and western Minnesota where the half of patients. Approximately 10-15% median age of cases was 58 years primary mosquito vector, Culex tarsalis, of cases are fatal. Since 2008, 17 (range, 2 to 92 years),18 years older is most abundant. cases (1 fatal) of POW disease have than the median age of Lyme disease been reported in Minnesota residents. cases. Onsets of illness were elevated All of the WNV test kits currently Most had neuroinvasive disease (10 from May through July and peaked in available are labeled for use on serum encephalitis and 5 meningitis) but 2 June (32% of cases). In 2011, 27% to aid in a presumptive diagnosis of were non-neuroinvasive POW fever of anaplasmosis cases (210 of 778 WNV infection in patients with clinical cases. Fourteen (82%) cases were cases with known information) were symptoms of neuroinvasive disease. male. Median age was 49 years (range, hospitalized for their infection, for a Positive results from these tests should 3 mos. to 70 years) and 6 (35%) median duration of 4 days (range, 1 to be confi rmed at the MDH PHL or CDC. were immunocompromised. Fourteen 17 days). (82%) had onset of illness between During 2011, 1 case of LaCrosse May through August and 3 (18%) had Arboviral Diseases encephalitis was reported. The disease, October or November onsets. Eleven Mosquito-borne Arboviruses which primarily affects children, is of the 17 cases were reported in 2011. LaCrosse encephalitis and Western transmitted through the bite of infected Cases were exposed to ticks in several equine encephalitis historically Aedes triseriatus (Eastern Tree Hole) north-central Minnesota counties. have been the primary arboviral mosquitoes. Persons are exposed MDH has also identifi ed POW virus- encephalitides found in Minnesota. to infected mosquitoes in wooded positive ticks at sites in all four counties During July 2002, West Nile virus or shaded areas inhabited by this that have been investigated to date (WNV) was identifi ed in Minnesota mosquito species, especially in areas (Clearwater, Cass, Pine, and Houston). for the fi rst time; subsequently, 465 where water-holding containers (e.g., Thus, the virus appears to be widely human cases (including 15 fatalities) waste tires, buckets, or cans) that distributed in the same wooded parts were reported from 2002 to 2011. In provide mosquito breeding habitats of the state that are to other 2011, WNV cases were reported from are abundant. From 1985 through tick-borne diseases transmitted by I. 43 states and the District of Columbia; 2011, 126 cases were reported from 21 scapularis. nationwide, 712 human cases of WNV southeastern Minnesota counties, with disease were reported, including 43 a median of 4 cases (range, 0 to 13 POW virus testing is not widely fatalities. The largest WNV case counts cases) reported annually. The median available; however, the MDH PHL is during 2011 occurred in California (158 case age was 6 years. Disease onsets available to test cerebrospinal fl uid and cases), Arizona (69), and Mississippi have been reported from June through serum specimens from suspect cases (52). September, but most onsets have (i.e., patients with viral encephalitis or occurred from mid-July through mid- meningitis of unknown etiology). In Minnesota, 2 cases of WNV disease September. were reported in 2011 (the lowest Babesiosis annual case total to date). One was a Tick-borne Arbovirus Babesiosis is a malaria-like illness fatal encephalitis case, and the other Powassan virus (POW) is a tick-borne caused by the protozoan Babesia case had West Nile (WN) fever. Both fl avivirus that includes a strain (lineage microti or other Babesia organisms. B. cases were elderly (≥ 65 years). While most past WNV disease cases occurred Figure 1. Reported Cases of Anaplasmosis, among residents of western and central Babesiosis, and Lyme Disease, Minnesota, 1996-2011 Minnesota, both 2011 cases were 1,300 Hennepin County residents. Similar to 1,200 Lyme disease previous years, onset of symptoms for 1,100 Human anaplasmosis both cases occurred within the typical Babesiosis high risk period of mid to late summer 1,000 (August for both cases). 900 800 WNV is maintained in a mosquito- 700 to-bird cycle. Several mosquito and bird species are involved 600 in this cycle, and regional variation in 500 vector and reservoir species exists. 400 Number of Reported Cases Interpreting the effect of weather 300 on WNV transmission is extremely complex, leading to great diffi culty 200 in predicting how many people will 100 become infected in a given year. WNV 0 appears to be established throughout 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year of Diagnosis

4 DCN 39;1 2012 microti is transmitted to humans by bites during the week prior to illness onset. were resistant to fl uoroquinolones. from I. scapularis (the blacklegged tick The most common travel destinations or deer tick), the same vector that trans- were Europe (n=42), Central or South In June 2009, a non-culture based test mits the agents of Lyme disease, hu- America or the Caribbean (n=41), Asia became commercially available for the man anaplasmosis, one form of human (n=31), and Mexico (n=21). qualitative detection of Campylobacter ehrlichiosis, and a strain of Powassan in stool. Three hundred virus. Babesia parasites can also be There were three outbreaks of seventy-seven patients were positive for transmitted by blood transfusion. campylobacteriosis identifi ed in Campylobacter by a non-culture based Minnesota in 2011. In late June- test conducted in a clinical laboratory In 2011, a record number of 72 con- early July, an outbreak of C. jejuni in 2011. However, only 137 (36%) of fi rmed and probable babesiosis cases infections was associated with raw the specimens were subsequently (1.4 per 100,000 population) were milk consumption from a farm in culture-confi rmed and therefore met the reported, a 29% increase over the previ- Benton County; 2 culture-confi rmed surveillance case defi nition for inclusion ous record of 56 cases in 2010. The cases were identifi ed. In July, an in MDH case count totals. median number of 27 cases (range, 9 outbreak of quinolone-resistant C. coli to 73) reported from 2004 through 2011 infections was associated with raw Clostridium diffi cile is considerably higher than the median milk consumption from a farm in Todd Clostridium diffi cile is an anaerobic, number of 2 cases (range, 0 to 7) from County ; 3 culture-confi rmed cases spore-forming, Gram-positive bacillus 1996 to 2003. Fifty-two (72%) babesio- were identifi ed. In July, an outbreak that produces two pathogenic : sis cases reported in 2011 were male. of C. jejuni infections was associated A and B. C. diffi cile infections (CDI) The median age of cases was 59 years with masonry workers at a dairy farm; 2 range in severity from mild to (range, 3 to 90 years). Onsets of illness culture-confi rmed cases were identifi ed. fulminant colitis and death. Transmis- peaked in the summer months, with 49 sion of C. diffi cile occurs primarily in (69%) of 71 cases with known onset A primary feature of public health healthcare facilities, where environmen- occurring from June through August. In importance among Campylobacter tal contamination by C. diffi cile spores 2011, 27 (38%) cases were hospitalized cases was the continued presence and exposure to antimicrobial drugs for their infection, for a median duration of Campylobacter isolates resistant are common. The primary risk factor of 4 days (range, 2 to 17 days). At least to fl uoroquinolone (e.g., for development of CDI in healthcare 1 reported case died from complications ciprofl oxacin), which are commonly settings is recent use of , of babesiosis in 2011. used to treat campylobacteriosis. In particularly , cephalospo- 2011, the overall proportion of quinolone rins, and fl uoroquinolones. Other risk Campylobacteriosis resistance among Campylobacter factors for CDI acquisition in these Campylobacter continues to be the isolates tested was 27%. However, settings are age greater than 65 years, most commonly reported bacterial 80% of Campylobacter isolates from severe underlying illness, intensive care enteric in Minnesota (Figure patients with a history of foreign travel unit admission, nasogastric intubation, 2). There were 995 cases of culture- during the week prior to illness onset, and longer duration of hospital stay. confi rmed Campylobacter infection regardless of destination, were resistant reported in 2011 (18.8 per 100,000 to fl uoroquinolones. Sixteen percent of A marked increase in the number of population). This is similar to the Campylobacter isolates from patients cases of CDI and mortality due to CDI 1,007 cases reported in 2010 but a who acquired the infection domestically has been noted across the United 10% increase from the median annual continued... number of cases reported from 2001 to 2010 (median, 903 cases; range, Figure 2. Reported Cases of Campylobacter, Salmonella, Shigella, 843 to 1,007). In 2011, 47% of cases and Escherichia coli O157:H7 Infection, Minnesota, 1996-2011 occurred in people who resided in 1200 the metropolitan area. Of the 915 Campylobacter Shigella Campylobacter isolates confi rmed and Salmonella E.coli O157 identifi ed to species by MDH, 87% were 1000 C. jejuni and 11% were C. coli.

800 The median age of cases was 35 years (range, 3 weeks to 98 years). Forty-two percent of cases were between 20 and 600 49 years of age, and 13% were 5 years of age or younger. Fifty-four percent of

Number of Cases 400 cases were male. Seventeen percent of cases were hospitalized; the median length of hospitalization was 4 days. 200 Fifty-two percent of infections occurred during June through September. Of the 931 (94%) cases for whom data 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 were available, 158 (17%) reported travel outside of the United States Year of Diagnosis

DCN 39;1 2012 5 States, Canada, and England. Most 258 were interviewed and confi rmed During 2011, 44 cases of CRE were notable was a series of large-scale as CA cases. Sixty percent of CA reported. The median age of cases was protracted outbreaks in Quebec fi rst cases reported use in the 12 58 years (range, 1 month to 91 years); reported in March 2003. During this weeks prior to illness onset date. Most 20 (45%) were male and 23 (52%) period, Quebec hospitals reported a common uses of antibiotics included were residents of the metropolitan 5-fold increase in healthcare-acquired treatment of ear, sinus or upper respira- area. Urine (25) was the most common CDI. These and other healthcare tory infections (34%), dental procedures source followed by respiratory tract facility (e.g., long-term care facilities) (15%), and prior CDI (12%). (7), peritoneal fl uid (5), blood (4), outbreaks have been associated with wound (2), and other body fl uid (1). the emergence of a new more virulent Carbapenem-resistant Two isolates of different species were strain of C. diffi cile, designated North Enterobacteriaceae (CRE) detected in 1 case; CRE species American pulsed-fi eld gel electrophore- Enterobacteriaceae are a large family varied: 33/44 (75%) were represented sis type 1 (NAP1), toxinotype III. of Gram-negative bacilli (GNB) that by E. cloacae (23) and K. pneumoniae can cause community- and healthcare- (10). Twenty-one (48%) cases were Community-associated CDI is also associated infections. Carbapenem- hospitalized at the time of culture (12 receiving increased attention. Sev- resistant Enterobacteriaceae (CRE) are hospitalized >3 days prior to culture); eral cases of serious CDI have been resistant to most available antibiotics. median length of stay (LOS) was 27 reported in what have historically Some CRE bacteria harbor resistance days (range, 2 to 238). Twenty-three been considered low-risk populations, genes that produce chromosomally- or (52%) cases were identifi ed in other including healthy persons living in the -mediated enzymes known as healthcare settings including ER/ community and peripartum women. At carbapenemases. Plasmid-mediated outpatient clinics (15), long-term acute least 25% of these cases had no history carbapenemases, such as the care hospitals (6), and long-term care of recent healthcare or antimicrobial carbapenemase facilities (2). exposure. (KPC), can easily spread between bacteria of similar species. Forty-one isolates from 40 cases were

In 2009, as part of the EIP, we initiated tested by PCR for the blaKPC gene; 21 population-based, sentinel surveil- KPC is the most common plasmid- (51%) were KPC positive. Of these, lance for CDI at 10 hospital laboratories mediated carbapenemase found in 12 (57%) were cultured from urine, 5 serving Stearns, Benton, Morrison, and the United States. Since 2009, several (24%) respiratory tract, 2 (9%) blood, 1 Todd Counties. A CDI case is defi ned types of metallo-β-lactamase (MBL)- (5%) peritoneal fl uid, and 1 (5%) other as a positive C. diffi cile toxin assay producing Enterobacteriaceae have body fl uid. KPC-positive isolates were on an incident stool specimen from a been reported in the United States, E. cloacae (11), K. pneumoniae (9), resident of one of the four counties. A including New Delhi MBL (NDM) and and C. freundii (1). The median age CDI case is classifi ed as healthcare Verona Integron-encoded MBL (VIM). of KPC positive cases was 64 years facility-onset (HCFO) if the initial speci- MBL-producing bacteria are more (range, 6 months to 91 years); 9 (43%) men was collected greater than 3 days common outside the United States. were male; 11 (52%) were residents after admission to a healthcare facil- of the metropolitan area; and 9 (43%) ity. Community-onset (CO) cases who CRE infections most commonly were hospitalized at the time of culture had an overnight stay at a healthcare occur among patients with co-morbid (6 hospitalized >3 days prior to culture). facility in the 12 weeks prior the initial conditions, invasive devices, and who Median LOS was 27 days (range, 5 to specimen are classifi ed as CO-HCFA, have received extended courses of 238). Other cases were detected in ER/ whereas CO cases without documented certain antibiotics. outpatient clinics (5), long-term acute overnight stay in a healthcare facility in care hospitals (6), and long-term care the 12 weeks prior the initial specimen MDH fi rst detected a KPC-producing facilities (1). result are classifi ed as CA. A more de- Enterobacteriaceae isolate in February tailed set of case defi nitions is available 2009, and began statewide passive Two KPC-negative isolates (1 E. coli upon request. CRE surveillance. As part of this and 1 K. pneumoniae) were confi rmed surveillance, laboratories submit NDM positive by CDC. Both isolates In 2011, 472 incident cases of CDI were isolates from CRE cases to the PHL for came from a single outpatient urine reported in the four sentinel coun- further characterization. culture. This case had recently ties (190.9 per 100,000 population). returned to the United States after Sixty-three percent of these cases were In 2011, we adopted a standardized being hospitalized during a trip to India classifi ed as CA, 19% as HCFO, and CRE case defi nition developed by where NDM is known to be present in 18% as CO-HCFA. The median ages CDC and states participating in the hospitals. for CA, HCFO, and CO-HCFA cases EIP Gram-negative Surveillance were 48 years, 79 years, and 57 years, Initiative. This CRE defi nition includes In summary, approximately half of respectively. Thirty-nine percent of CA Enterobacteriaceae that are non- the CRE cases reported were KPC cases reported antibiotic usage in the 2 susceptible to a carbapenem (excluding positive. Active surveillance testing weeks prior to stool specimen collection ) and resistant to all tested should be considered when a patient compared to 67% of HCFO cases and third generation (2011 with previously unrecognized CRE 56% of CO-HCFA cases. Of the 304 CSLI breakpoints). or hospital-onset CRE infections is putative CA cases eligible for interview, identifi ed. No outbreaks or transmission

6 DCN 39;1 2012 of CRE were reported among facilities limit testing to patients who have of hospitalization was 4 days (range, 1 that conducted active surveillance symptoms characteristic of the disease to 61 days). One case died. testing during 2011. cryptosporidiosis. In addition to the 146 culture-confi rmed Cryptosporidiosis Dengue E. coli O157 cases, 115 cases of Shiga- During 2011, 307 cases of Dengue fever and the more clinically toxin producing E. coli (STEC) infec- cryptosporidiosis (5.8 per 100,000 severe dengue hemorrhagic fever tion were identifi ed in 2011. Of those, population) were reported. This is 55% (DHF) is one of the most frequently culture-confi rmation was not possible higher than the median number of occurring mosquito-borne diseases in 13, and therefore it is unknown if cases reported annually from 1998 to worldwide, with an estimated 50-100 those were O157 or another serogroup. 2010 (median, 198 cases; range, 91 million cases (including approximately Among the remaining 102 cases of to 389). The median age of cases in 500,000 DHF cases and over 20,000 STEC other than O157, E. coli O26 2011 was 27 years (range, 3 months to fatalities) each year. Four serotypes of accounted for 24 cases, E. coli O111 92 years). Children 10 years of age or dengue virus are transmitted to humans for 22, and E. coli O103 for 21. These younger accounted for 21% of cases. through the bite of certain Aedes genus three serogroups represented 66% of all Fifty percent of cases occurred during mosquitoes (e.g., Aedes aegypti). non-O157 STEC. July through October. The incidence of The risk is widespread in tropical cryptosporidiosis in the Southwestern, or subtropical regions around the In 2011, an outbreak caused in party Southeastern, West Central, and world, especially where water-holding by non-O157 STEC was identifi ed Northeastern districts (20.2, 17.8, 17.0, containers (e.g., waste tires, buckets, among individuals who visited an apple 11.5 cases per 100,000, respectively) or cans) provide abundant mosquito orchard in October. In total, 14 cases was signifi cantly higher than the breeding habitat. were identifi ed, including 5 laboratory- statewide incidence. Only 47 (15%) confi rmed E. coli O111:NM cases and 3 reported cases occurred among In 2011, 6 cases (0.11 per 100,000 laboratory-confi rmed Cryptosporidium residents of the metropolitan area (1.7 population) of dengue fever were parvum cases. Consuming samples per 100,000). Fifty-two (17%) cases reported in Minnesota residents. This of unpasteurized apple cider from a required hospitalization, for a median of was lower than the median of 10 cases pressing demonstration was associated 4 days (range, 2 to 66 days). per year (range, 6 to 20) in the 90 cases with illness. E. coli O111:NM was reported from 2004-2011. In 2011, the isolated from a calf at the orchard’s Three outbreaks of cryptosporidiosis median case age was 32 years (range, petting zoo. were identifi ed in 2011, accounting for 17 to 61 years). Four cases (67%) 7 laboratory-confi rmed cases. One resided within the metropolitan area, Six E. coli O157:H7 outbreaks were recreational waterborne outbreak including 3 cases in Dakota County. identi fi ed during 2011. Four outbreaks occurred among swimmers on a high Onset of symptoms occurred from involved foodborne transmis sion school swim team, including 11 cases February through November. All of the (including two outbreaks with cases in (2 laboratory-confi rmed). One outbreak cases represented imported infections multiple states) one involved animal of cryptosporidiosis associated with acquired out of state or abroad. Most contact, and one involved person-to- drinking unpasteurized apple cider at cases had traveled to Latin America (3) person transmission. The six outbreaks an apple orchard where a petting zoo or Asia (2) but 1 had potential exposure resulted in a median of 3 culture- was present accounted for 4 cases (3 to the virus in Florida. confi rmed cases per outbreak (range, 2 laboratory-confi rmed). One outbreak at to 8 cases). a daycare accounted for 2 cases (both Escherichia coli O157 and Other laboratory confi rmed). Shiga-toxin Producing E. coli An outbreak of E. coli O157:H7 infec- Infection, and Hemolytic Uremic tions associated with animal contact at In a paper published in Clinical Syndrome a county fair occurred in August; both Infectious Diseases in April 2010, cases reported contact with goats. Two we reported an evaluation of rapid During 2011, 146 culture-confi rmed culture-confi rmed cases with the same assays used by Minnesota clinical cases of Escherichia coli O157 infec- PFGE subtype were identifi ed. laboratories for the diagnosis of tion (2.8 per 100,000 population) were cryptosporidiosis. The overall positive reported. The number of reported cases In July, 3 cases of E. coli O157:H7 predictive value of the rapid assays is similar to the median number of infec tion were associated with a private was 56%, compared to 97% for non- cases reported an nually from 1997 to event. Fresh fruit was associated with rapid assays. The widespread use 2010 (median, 151 cases; range, 110 illness. The fruit was prepared in a of rapid assays could be artifi cially to 219). During 2011, 68 (47%) cases household in which household members contributing to the increased number occurred in the metropolitan area. had recently visited a goat farm from of reported cases of cryptosporidiosis. One hundred nineteen (82%) cases which E. coli O157:H7 was isolated. Rapid assay-positive specimens should occurred during May through October. be confi rmed with other methods. It is The median age of the cases was 19 In July, 3 cases of E. coli O157:H7 important that health care providers years (range, 1 to 90 years). Twenty- infec tion were associated with person- are aware of the limitations and proper one percent of the cases were 4 years to-person transmission in a day care. use of rapid assays in the diagnosis of age or younger. Sixty (41%) cases The had contact with goats of cryptosporidiosis and that they were hospitalized; the median duration at a farm from which E. coli O157:H7 with the same PFGE subtype was continued... DCN 39;1 2012 7 isolated. (1.3 per 100,000 population) were have died. reported in 2011. Cases ranged in age During September - October, 4 cases of from newborn to 97 years (median, The annual number of AIDS cases E. coli O157:H7 infec tion in Minnesota 68 years). Allowing for more than reported in Minnesota increased residents were part of a multi-state one syndrome per case, 39 (55%) steadily from the beginning of the outbreak that resulted in 26 cases in 14 cases had pneumonia, 15 (21%) had through the early 1990s, states. Pre-packaged romaine lettuce bacteremia without another focus of reaching a peak of 361 cases in 1992. was implicated as the vehicle. infection, 7 (10%) had meningitis, 5 Beginning in 1996, the annual number (7%) had , 3 (4%) had of new AIDS diagnoses and deaths In October, 2 cases of E. coli O157:H7 otitis, 2 (3%) had , and 1 (1%) among AIDS cases declined sharply, infec tion in Minnesota residents each had septic , , primarily due to better antiretroviral were part of a multi-state outbreak and empyema. Six (8%) cases died. therapies. In 2011, 182 new AIDS that resulted in 58 cases in 9 states. cases (Figure 3) and 61 deaths among Romaine lettuce was implicated as the Of 62 H. infl uenzae isolates for which persons living with HIV infection were vehicle. This investiga tion resulted in a typing was performed at MDH, 7 (11%) reported. recall of the implicated product. were type f, 3 (5%) type b, 3 (5%) type e, 2 (3%) type a, and 47 (76%) were The number of HIV (non-AIDS) Hemolytic Uremic Syndrome (HUS) untypeable. diagnoses has remained fairly constant In 2011, 12 HUS cases were reported. over the past decade from 2002 The number of reported cases Three cases of type b (Hib) disease through 2011, at approximately 230 represents a 29% decrease from the occurred in 2011, compared to 1 case cases per year. With a peak of 280 median number of cases reported in 2010, 2 cases in 2009, and 5 cases newly diagnosed HIV (non-AIDS) cases annually from 1997 to 2010 (median in 2008. One of the Hib cases was in 2009, the past 2 years have seen 17 cases; range, 10 to 25). In 2011, identifi ed in a child <1 year of age promising decreases with 248 in 2010 the median age of HUS cases was 4 who presented with meningitis. The (a 13% decrease) and 219 in 2011 (a years (range, 1 to 88 years); 10 of the other Hib cases were in adults >50 12% decrease). By the end of 2011, 12 cases occurred in children. All 12 years of age. One patient presented an estimated 7,136 persons with HIV/ cases were hospitalized, with a median with pnuemonia and the other with AIDS were assumed to be living in hospital stay of 14 days (range, 9 to 61 epiglottitis and an . All 3 cases Minnesota. days). There was 1 fatal case. From survived. 1997 through 2011, the overall case Historically, and in 2011, over 80% fatality rate was 5.3%. All 12 HUS cases The 6 deaths occurred in patients (251/292) of new HIV infections (both reported in 2011 were post-diarrheal. ranging in age from 68 to 97 years. HIV [non-AIDS] and AIDS at fi rst E. coli O157:H7 was cultured from the Five cases presented with pneumonia diagnosis) reported in Minnesota stool of 9 (75%) cases; the remaining (of these, 1 also had septic shock) occurred in the metropolitan area. 3 (25%) HUS cases were positive for and 1 case presented with bacteremia However, HIV or AIDS cases have E. coli O157:H7 by . In 2011, without another focus of infection. All 6 been diagnosed in residents of more there were no outbreak-associated HUS cases had H. infl uenzae isolated from than 90% of counties statewide. HIV cases. blood and all had underlying medical infection is most common in areas with conditions. Of the 6 cases who died, 4 higher population densities and greater Giardiasis case-isolates were untypeable, 1 was poverty. During 2011, 692 cases of Giardia serotype f, and 1 was serotype e. infection (13.1 per 100,000) were The majority of new HIV infections reported. This represents a 35% HIV Infection and AIDS in Minnesota occur among males. decrease from the median number of The incidence of HIV/AIDS in Trends in the annual number of new cases reported annually from 1998 Minnesota remains moderately low. HIV infections diagnosed among males through 2010 (median, 1,059 cases; In 2010, state-specifi c AIDS rates differ by race/ethnicity. New infections range, 678 to 1,556). Historically, a ranged from 0.5 per 100,000 population occurred primarily among white males substantial proportion of Giardia cases in Vermont to 22.1 per 100,000 in in the 1980s and early 1990s. Whites has represented positive tests during Maryland. Minnesota had the 14th still comprise the largest proportion routine screenings of recent immigrants lowest AIDS rate (4.0 cases per of new HIV infections among males, and refugees. 100,000). Similar comparisons for HIV but new infections among white males (non-AIDS) incidence rates are not decreased between 1991 and 2000, The median age for all cases reported possible because some states only from 297 to 101. However, since in 2011 was 23 years (range, 2 weeks began named HIV (non-AIDS) reporting then the trend has reversed, and in to 89 years). Seventeen percent of recently. 2011 there were 129 new infections cases were less than 5 years of age, among white males (28% increase). and 20% of cases were over 50 years As of December 31, 2011, a cumulative The decline among U.S.-born black of age. total of 9,785 cases of HIV infection males has been more gradual, falling (5,997 AIDS cases and 3,788 HIV [non- from a peak of 79 new infections in Haemophilus infl uenzae AIDS] cases) had been reported among 1992 to a low of 33 new infections in Seventy-one cases of invasive Minnesota residents. Of the 9,785 HIV/ 2003. Since 2004 the number of cases Haemophilus infl uenzae disease AIDS cases, 3,347 (34%) are known to among African American males has

8 DCN 39;1 2012 been stable at around 40 cases per biological cause of disparities in the to-male sex. Among young females, year. While during the past several occurrence of HIV, but instead race can all 35 new cases were attributed to years the number of cases in this group be used as a proxy for other risk factors, heterosexual sex. has trended upwards, with 58 cases including lower socioeconomic status diagnosed in 2010 and a peak of 64 and education. Since the beginning of the HIV in 2009, the number is back down in epidemic, male-to-male sex has been 2011 with 43 new HIV diagnoses. The A population of concern for HIV infection the predominant mode of exposure to number of HIV infections diagnosed is adolescents and young adults (13 HIV reported in Minnesota, although among Hispanic males decreased in to 24 years of age). The number of the number and proportion of new HIV 2011 to 19 from 29 in 2010. The number new HIV infections among males in infections attributed to men who have of new infections among African-born this age group has remained higher sex with men (MSM) has declined since males increased in 2011 to 17 from 13 than new infections among females 1991. In 1991, 70% (318/455) of new in 2010. This represents a decrease since 1999. Since 2001, Minnesota has HIV infections were attributed to MSM of 34% among Hispanic males and an seen a steady increase in new cases (or MSM who also inject drugs); in increase of 31% among African-born among males in this age group, with 2011, this group accounted for 53% of males from 2010 to 2011. 47 cases reported in 2011. Since 2001, new infections (156/292). the number of cases among young Females account for an increasing males has increased by over 250%. The The number and percentage of HIV percentage of new HIV infections, number of new HIV infections among infections in Minnesota that are from 11% of new infections in 1990 to females in this age group increased attributed to injection drug use has 25% in 2011. Trends in HIV infections slightly between 2007 and 2009, (from declined over the past decade for men diagnosed annually among females 13 cases to 18 cases), but decreased and women, falling from 12% (54/455) also differ by race/ethnicity. Early in to 11 cases in 2010 and that trend of cases in 1991 to 1% (2/292) in 2011. the epidemic, whites accounted for the continued 2011 with 8 cases. From Heterosexual contact with a partner majority of newly diagnosed infections 2009 to 2011, the majority (55%) of new who has or is at increased risk of HIV in women. Since 1991, the number of infections among male adolescents and infection is the predominant mode of new infections among women of color young adults were among youth of color exposure to HIV for women. Ninety- has exceeded that of white women. The (108/195), with young African American fi ve percent of 205 new HIV diagnoses annual number of new HIV infections males accounting for 65% of the cases among women between 2009 and diagnosed among U.S.-born black among young males of color. During 2011 can be attributed to heterosexual females had remained stable at 22 or the same time period, young women exposure after re-distributing cases with fewer cases during 2001 to 2004, but of color accounted for 63% (22/35) unspecifi ed risk. increased to 28 new cases in both 2005 of the cases diagnosed, with young and 2006. In 2011 there were 21 new African American women accounting for Historically, race/ethnicity data for HIV/ infections diagnosed among U.S.-born 32% of cases among young women of AIDS in Minnesota have grouped U.S.- black females. In contrast, the number color. Between 2009 and 2011 after re- born blacks and African-born persons of new infections among African-born distributing those with unspecifi ed risk, together as “black.” In 2001, we began females increased greatly from 4 cases 96% (188/195) of new cases among analyzing these groups separately, and in 1996 to 39 in 2002. However, since young males were attributed to male- a marked trend of increasing numbers 2002 the number of new HIV infections in African-born females has decreased, Figure 3. HIV/AIDS in Minnesota: with 17 new cases diagnosed in 2006. Number of New Cases, Prevalent Cases, and Deaths by Year, 1996-2011 In 2011 the number of new cases among African-born women was 27, 500 7000

s HIV Infection* AIDS^

making up 36% of all new diagnoses HIV/AIDS w/ Living Persons of No. 6000 among women. The annual number All Deaths** Living HIV/AIDS 400 of new infections diagnosed among 5000 Hispanic, American Indian, and Asian 300 females is small, with 10 or fewer cases 4000 annually in each group. 3000 200 Despite relatively small numbers 2000 of cases, persons of color are 100 disproportionately affected by HIV/ 1000 AIDS in Minnesota. In 2011, non-white Death & Cases HIV/AIDS New of No. men comprised approximately 17% 0 0 of the male population in Minnesota 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year and 41% of new HIV infections among * Includes all new cases of HIV infection (both HIV (non-AIDS) and AIDS at first diagnosis) diagnosed within a men. Similarly, persons of color given calendar year comprised approximately 13% of the ** Deaths among AIDS cases, regardless of cause ^ Includes all new cases of AIDS diagnosed within a given calendar year, including AIDS at first diagnosis. This female population and 81% of new includes refugees in the HIV+ Resettlement Program, as well as other refugee/immigrants diagnosed with HIV infections among women. It bears AIDS subsequent to their arrival in the United States noting that race is not considered a continued... DCN 39;1 2012 9 of new HIV infections among African- locally with no material available to the Two (6%) cases were identifi ed through born persons was observed. In 2011, PHL for testing for further subtyping. the UNEX/MED-X programs, 15 (45%) there were 44 new HIV infections from hospital surveillance, 8 (24%) reported among Africans. While African- Among hospitalized cases, 22% were through death certifi cate review, 7 born persons comprise less than 1% of 0-18 years of age, 22% were 19-49 (21%) from nursing home outbreaks, the state’s population, they accounted years of age, and 56% were 50 years and 1 (3%) through other methods. for 15% of all HIV infections diagnosed of age and older. Median age was 54.4 in Minnesota in 2011. years. Forty-fi ve percent of cases were Laboratory Data residents of the metropolitan area. The Minnesota Laboratory System HIV perinatal transmission in the United Of the 248 metropolitan area cases, (MLS) Laboratory Infl uenza Surveillance States decreased 81% between 1995 98 (39%) cases were also diagnosed Program is made up of more than 310 and 1999. The trend in Minnesota has with pneumonia. One (<1%) had an clinic- and hospital-based laboratories, been similar but on a much smaller invasive bacterial co-infection. Twenty- voluntarily submitting testing data on scale. While the number of births to three (9%) required admission into an a weekly basis. These laboratories HIV-infected women increased nearly intensive care unit. Of these, 6 (26%) perform rapid testing for infl uenza and 7-fold between 1990 and 2011, the rate were placed on mechanical ventilation. respiratory syncytial virus (RSV). Signifi - of perinatal transmission decreased Ninety-four percent of adult and 47% of cantly fewer labs perform viral culture 6-fold, from 18% in 1990 to 1995 to pediatric cases had at least one chronic testing (6 labs) for infl uenza, RSV, and 3% in 1996–2006. The overall rate of medical condition that would put them other respiratory viruses. Five laborato- transmission for 2009 to 2011 was 1.0% at increased risk for infl uenza disease. ries perform PCR testing for infl uenza with no HIV-positive births from HIV- and three also perform PCR testing for infected mothers in Minnesota in 2011. Deaths other respiratory viruses. The PHL also Since the H1N1 , we have provides further characterization of sub- Infl uenza increased our efforts to identify deaths mitted infl uenza isolates to determine Several surveillance methods are em- related to infl uenza. Infl uenza-associat- the hemagglutinin serotype to indicate ployed for infl uenza. Surveillance data ed deaths are reported through several coverage. Tracking laboratory are summarized by infl uenza season systems including hospital surveillance, results assists healthcare providers (generally October-April) rather than Unexplained Critical Illnesses and with patient diagnosis of infl uenza-like calendar year. Deaths of Possible Infectious Etiology illness and provides an indicator of the (UNEX) reporting, Medical Examiner progression of the infl uenza season Hospitalized Cases Infectious Deaths (MED-X) surveil- as well as of disease in the Surveillance for pediatric (<18 years of lance, death certifi cate review, nursing community. age), laboratory-confi rmed hospitalized home outbreak investigations, as well cases of infl uenza in the metropoli- as other sources. All reported cases are Between October 2, 2011 and May 19, tan area was established during the investigated to determine if there was 2012, virology laboratories reported 2003-2004 infl uenza season. During a positive infl uenza laboratory result 86 viral cultures positive for infl uenza. the 2006-2007 season, surveillance and symptoms of an infectious process Of these, 71 (83%) were positive for was expanded to include adults. For consistent with infl uenza without recov- infl uenza A and 15 (17%) were positive the 2008-2009 season, surveillance ery to baseline prior to death. In a small for infl uenza B. The number of positive was expanded statewide, although number of cases there may not be a infl uenza cultures peaked during the the collection of clinical information positive infl uenza laboratory result due week of March 11 - March 17, 2012 at on hospitalized cases was limited to to the lack of specimens taken, in which 14. Between October 2, 2011 and May metropolitan area residents only. Dur- case the person must have infl uenza 19, 2012, laboratories reported data ing the 2011-2012 season (October 2, noted as a cause of death on the death on 11,459 infl uenza PCR tests, 1,437 2011 – April 30, 2012), we requested certifi cate, or the person must have (13%) of which were positive for infl u- clinicians collect a throat or nasopha- had direct contact with a laboratory- enza. Of these, 60 (4%) were positive ryngeal swab, or other specimen from confi rmed infl uenza case to be included for infl uenza A 2009 H1N1, 949 (66%) all patients admitted to a hospital with as an infl uenza-related death. were positive for infl uenza A/(H3), 295 suspect infl uenza, and submit the speci- (21%) were positive for infl uenza A-not men to the PHL for infl uenza testing. For the 2011-2012 infl uenza season, subtyped, 60 (4%) were positive for there were 33 infl uenza-associated infl uenza A non-typeable, 71 (5%) were During the 2011-2012 infl uenza season, deaths (16 infl uenza A-type unspeci- positive for infl uenza B, and 2 (0.1%) 552 laboratory-confi rmed hospitaliza- fi ed, 13 infl uenza A-H3, and 4 infl uenza were positive for both infl uenza A and B. tions for infl uenza (10.4 hospitalizations B). The median age was 86 years; 1 Between October 2, 2012 and May 19, per 100,000 persons compared to 18.3 (3%) 25-49 years, 2 (6%) 50-64 years, 2012, 348 infl uenza isolates were fur- per 100,000 during the 2010-2011 5 (15%) 64-79 years, and 25 (76%) age ther characterized in the PHL; 20 (6%) infl uenza season) were reported. Since 80 and up. Thirty percent of cases were were characterized as infl uenza A 2009 October 2, 2011, hospitalized cases of from the metropolitan area. Thirty-one H1N1, 267 (77%) were characterized as infl uenza have included 522 that were (94%) had underlying medical condi- infl uenza A/(H3), 9 (3%) were character- infl uenza A (295 H3, 18 2009 H1N1, tions, and 23 (70%) were hospitalized ized as infl uenza A-type unspecifi ed, 8 and 209 unknown A type), 29 that were for their illness. Twenty-one (64%) were (2%) were characterized as infl uenza infl uenza B, and 1 was infl uenza type residents of a long-term care facility. B/Brisbane-like, and 44 (13%) were unknown. The unknown type was tested infl uenza B/Wisconsin-like.

10 DCN 39;1 2012 parainfl uenza virus 4, 22 (2%) coronavi- legionellosis (Legionnaires’ disease Infl uenza Sentinel Surveillance rus C229E, 11 (1%) coronavirus OC43, [LD]) were reported including 20 cases We conduct sentinel surveillance for 9 (1%) coronavirus HKU1, and 4 (0.4%) (65%) among residents of the metropol- infl uenza-like illness (ILI; fever ≥100° coronavirus NL63. itan area and 11 cases among greater F and and/or sore throat in the Minnesota residents. Four (13%) cases absence of known cause other than ILI Outbreaks (Schools and Long Term died. Older adults were more often af- infl uenza) through outpatient medical Care Facilities) fected, with 28 (90%) cases occurring providers including those in private Between 1988 and 2009, a probable among individuals 50 years of age and practice, public health clinics, urgent ILI outbreak in a school was defi ned as older (median, 62.5 years; range, 37 care centers, emergency rooms, and a doubled absence rate with all of the to 88 years). Sixteen (52%) cases had university student health centers. For following primary infl uenza symptoms onset dates in June through Septem- these data there are 22 sites in 18 reported among students: rapid onset, ber. Travel-associated legionellosis ac- counties. Participating providers report fever, illness lasting 3 or more days, counted for 7 (23%) cases, defi ned as the total number of patient visits each and at least one secondary infl uenza spending at least 1 night away from the week and number of patient visits for symptom (e.g., myalgia, headache, case’s residence in the 10 days before ILI by age group (0-4 years, 5-24 years, cough, coryza, sore throat, or chills). A onset of illness. 25-64 years, >65 years). Percentage of possible ILI outbreak in a school was ILI peaked during the week of Decem- defi ned as a doubled absence rate with The criteria for confi rmation of a case ber 25-31, 2011 at 3.3%. reported symptoms among students, requires a clinically compatible case including two of the primary infl uenza and at least one of the following: 1) Infl uenza Incidence Surveillance Project symptoms and at least one secondary isolation of any Legionella organism MDH was one of 12 nationwide sites infl uenza symptom. Prior to the 2009- from respiratory , lung tissue, to participate in an Infl uenza Incidence 2010 infl uenza season, the number of pleural fl uid, or other normally sterile Surveillance Project for the 2011-2012 schools reporting probable infl uenza fl uid by culture, or 2) detection of L. infl uenza season. Four clinic sites outbreaks has ranged from a low of 38 pneumophila serogroup 1 in reported the number of ILI patients and schools in 20 counties in 1996-1997 to urine using validated reagents, or 3) acute respiratory illness (ARI; recent 441 schools in 71 counties in 1991- seroconversion of fourfold or greater onset of at least two of the following: 1992. rise in specifi c serum antibody titer to , sore throat, cough, or fever) L. pneumophila serogroup 1 using vali- patients divided by the total patients The defi nition of ILI outbreaks changed dated reagents. A single antibody titer seen by the following age groups: <1 beginning with the 2009-2010 school at any level is not of diagnostic value year, 1-4 years, 5-17 years, 18-24 year. Schools reported when the num- for LD. The American Thoracic Society, years, 25-64 years, and ≥65 years, ber of students absent with ILI reached in collaboration with the Infectious Dis- each week. These clinics also per- 5% of total enrollment, or when three eases Society of America, recommends formed rapid infl uenza testing on all or more students with ILI are absent urinary antigen assay and culture of re- ILI patients and reported results to us. from the same elementary classroom. spiratory secretions on selective media Clinical specimens were collected on Ninety-one schools in 36 counties for detection of LD. Culture is particu- the fi rst 10 patients with ILI and the fi rst reported ILI outbreaks during the 2011- larly useful because environmental and 10 patients with ARI for PCR testing 2012 school year. During the previous clinical isolates can be compared by at the PHL for infl uenza and 12 other school year 218 schools in 50 counties molecular typing in outbreaks and in respiratory pathogens. Minimal demo- reported ILI outbreaks. During the 2009- investigations of healthcare-associated graphic information and clinical data 2010 school year, 1,302 schools in 85 LD. were provided with each specimen. counties reported ILI outbreaks. Listeriosis From July 31, 2011 – May 19, 2012, An infl uenza outbreak is suspected in Six cases of listeriosis were re- these clinics saw 1,865 ILI and 8,390 a long-term care facility (LTCF) when ported during 2011. Five cases were ARI patients. They submitted 913 three or more residents in a single hospitalized, and 4 (66%) died. The specimens for infl uenza and respira- unit present with a cough and fever or median age of the cases was 76 years tory pathogen testing, 61 (7%) of which chills during a 48- to 72-hour period. (range, 56 to 87 years). Five (83%) were positive for infl uenza. Of those, An infl uenza outbreak is confi rmed cases had Listeria monocytogenes 10 (16%) were positive for infl uenza A when at least one resident has a posi- isolated from blood. One case had 2009 H1N1, 43 (70%) were positive for tive culture, PCR, or rapid antigen test L. monocytogenes isolated from a infl uenza A/(H3), 3 (5%) were posi- for infl uenza. Forty-one facilities in 26 wound. None of the cases were part tive for infl uenza A-type unspecifi ed, counties reported outbreaks during the of a recognized outbreak. The 6 cases and 5 (8%) were positive for infl uenza 2011-2012 infl uenza season. Surveil- reported in 2011 is similar to the me- B. In addition to infl uenza, the follow- lance for outbreaks in LTCFs began in dian annual number of cases reported ing pathogens were detected by PCR: the 1988-1989 season. The number from 1996 through 2010 (median, 7 43 (5%) adenovirus, 18 (2%) human of LTCFs reporting ILI outbreaks has cases; range, 3 to 19). metapneumovirus, 75 (8%) respira- ranged from a low of 3 in 2008-2009 to tory syncytial virus (RSV), 170 (19%) a high of 140 in 2004-2005. Elderly persons, immunocompromised rhinovirus, 36 (4%) parainfl uenza virus individuals, pregnant women, and 1, 14 (2%) parainfl uenza virus 2, 2 Legionellosis neonates are at highest risk for acquir- (0.2%) parainfl uenza virus 3, 7 (0.8%) During 2011, 31 confi rmed cases of ing listeriosis. Listeriosis generally continued... DCN 39;1 2012 11 manifests as meningoencephalitis and/ summer months and peaked in June or septicemia in neonates and adults. and July (26% and 44% of EM cases, Twenty-one of the 26 cases were as- Pregnant women may experience a respectively), corresponding to the peak sociated with an outbreak in Hennepin mild febrile illness, abortion, premature activity of nymphal I. scapularis ticks in County occurring in February through delivery, or stillbirth. In healthy adults mid-May through mid-July. Most cases April, 3 cases were associated with an and children, symptoms usually are in 2011 either resided in or traveled to outbreak in Dakota County in August, mild or absent. L. monocytogenes endemic counties in north-central, east- and 2 unrelated cases occurred in Hen- can multiply in refrigerated foods. Per- central, or southeast Minnesota, or in nepin and LeSueur Counties during the sons at highest risk should: 1) avoid western Wisconsin. time of the spring outbreak. soft cheeses (e.g., feta, Brie, Camem- bert, blue-veined, and Mexican-style Malaria Of the 21 Hennepin County outbreak cheeses) and unpasteurized milk; 2) Malaria is a febrile illness caused by cases, 19 (90%) were laboratory- thoroughly heat/reheat deli meats, hot several protozoan species in the genus confi rmed; 11 (52%) were confi rmed dogs, other meats, and leftovers; and 3) Plasmodium. The parasite is transmitted both by serology and PCR, 8 (42%) by wash raw vegetables. to humans by bites from infected PCR only. Genotyping was performed Anopheles genus mosquitoes. The for 9 cases, including the index case, Lyme Disease risk of malarial infection is highest in and was B3, a genotype circulating Lyme disease is caused by Borrelia the tropical and sub-tropical regions of in Sub-Saharan Africa. All 3 Dakota burgdorferi, a spirochete transmitted the world. Although local transmission County outbreak cases were laboratory- to humans by bites from I. scapularis of malaria frequently occurred in confi rmed; 1 by PCR only; the other (the blacklegged tick or deer tick) in Minnesota over 100 years ago, all of the 2 were confi rmed by both PCR and Minnesota. In Minnesota, the same cases reported in Minnesota residents IgM serology, and 1 of these was also tick vector also transmits the agents of since that time likely have been culture-confi rmed. The source case was babesiosis, human anaplasmosis, one imported infections acquired abroad. genotype B3. The 2 unrelated cases form of human ehrlichiosis, and a strain were laboratory-confi rmed by both PCR of Powassan virus. In 2011, 47 malaria cases (0.9 per and IgM serology. 100,000 population) were reported in In 2011, 1,201 confi rmed Lyme dis- Minnesota residents, slightly above The source case of the Hennepin ease cases (22.6 cases per 100,000 the 2000 to 2011 annual median of County outbreak was a 30 month-old population) were reported (Figure 40 cases (range, 29 to 50). Thirty- U.S.-born child of Somali descent 1). In addition, 953 probable cases two (68%) cases were identifi ed with who had traveled to Kenya. Measles (physician-diagnosed cases that did P. falciparum, 7 (15%) with P. vivax, was transmitted to 3 contacts at a not meet clinical evidence criteria for a 3 (6%) with P. ovale, 2 (4%) with drop-in childcare center (including the confi rmed case but that had laboratory P. malariae, and 3 (6%) with mixed fi rst identifi ed case) and 1 household evidence of infection) were reported. Plasmodium species infections. The contact. Subsequent cases resulted in The 1,201 confi rmed cases represent a median age of cases was 33 years exposures in two homeless shelters (8), 7% decrease from the 1,293 confi rmed (range, 1 to 75 years). Of 35 cases of two healthcare facilities (3), two house- cases reported in 2010 but higher than known race, 24 (69%) were black, 8 holds (3), and another childcare center the 1,065 confi rmed cases reported (23%) were white, and 3 (9%) were (1). One case’s specifi c exposure was in 2009. The median number of 1,058 Asian. Eighty-three percent of cases unknown but was considered a com- cases (range, 913 to 1,293 cases) resided in the metropolitan area, munity exposure. Fourteen (67%) cases reported from 2004 through 2011 is including 27 (57%) in Hennepin or were hospitalized (mean 4 days; range considerably higher than the median Ramsey Counties. Of the 31 cases with 2-7 days). number of cases reported annually from known country of birth, 11 (35%) were 1996 through 2003 (median, 373 cases; born in the United States. Thirty-eight The median age of the Hennepin range, 252 to 866). Seven hundred fi fty (81%) cases in 2011 likely acquired County outbreak cases was 12 months (62%) confi rmed cases in 2011 were malaria in Africa. Six cases were (range, 4 months to 51 years). Nine male. The median age of cases was 40 likely acquired in Asia, 1 in Oceana, (43%) cases were black and of non- years (range, <1 to 91 years). Physi- 1 in Central America, and 1 in the Somali descent, 8 (38%) were of Somali cian-diagnosed migrans (EM) Caribbean. Twenty-three countries were descent, 3 (14%) were American Indian, was present in 863 (72%) cases. Three considered possible exposure locations and 1(5%) was white. hundred seventy-two (31%) cases had for malarial infections, including Liberia one or more late manifestations of Lyme (10), Nigeria (7), and Ghana (5). None of these outbreak cases were disease (including 262 with a history of known to have been age-appropriately objective joint swelling, 89 with cranial Measles vaccinated. Sixteen (76%) cases were neuritis, 9 with acute onset of 2nd or Twenty-six cases of measles were known to be unvaccinated; of those, 7 3rd degree atrioventricular conduction reported in 2011. This is the highest (44%) were too young to have received defects, 8 with radiculoneuropathy, 7 number of cases in Minnesota since measles vaccine in accordance with the with lymphocytic meningitis, and 1 with 1991. A total of 6 cases were reported routine schedule, and 9 (56%) were of encephalomyelitis) and confi rmation during the previous 5 years, including age but unvaccinated. Of these 9 un- by Western immunoblot (positive IgM 3 unrelated cases in 2010. The most vaccinated cases, 2 (22%) were behind ≤30 days post-onset or positive IgG). recent known transmission of measles on , and 7 (78%) were Onsets of illness were elevated in the within Minnesota occurred in 1991. unvaccinated because of incorrectly

12 DCN 39;1 2012 perceived safety concerns, 6 (86%) of Sixty percent of the cases occurred in facility, and renal dialysis. whom were children of Somali descent. the metropolitan area. Eight cases had Three (14%) of the outbreak cases meningitis, 4 had bacteremia without In 2005, as part of the EIP Active had unknown history. One another focus of infection, 2 had septic Bacterial Core surveillance (ABCs) additional case, a healthcare worker arthritis, and 1 had pneumonia. There system, we initiated population-based with unknown vaccination status, were no fatalities. All cases were invasive MRSA surveillance in Ramsey had documented history of a positive sporadic with no epidemiologic links. County. In 2005, the incidence of measles IgG serologic test result. The invasive MRSA infection in Ramsey remaining case was a child vaccinated In 2011, 1 case-isolate demonstrated County was 19.8 per 100,000 and was at 11 months of age, younger than the intermediate resistance to 19.4, 18.5 and 19.9 per 100,000 in recommended 12 months of age. and , as well as resistance 2006, 2007, and 2008, respectively. to /sulfamethoxazole. In 2008, surveillance was expanded The source case of the Dakota County One additional case-isolate to include Hennepin County. The outbreak was a 12 month-old U.S.- born demonstrated intermediate resistance incidence rate for MRSA infection in child of Ethiopian descent who had trav- to penicillin. Seven additional case- Ramsey and Hennepin Counties was eled to Kenya. Measles was transmitted isolates demonstrated resistance 17.0, 14.0, and 18.2 per 100,000 in to 2 other individuals; 1 was exposed to trimethoprim/sulfamethoxazole. 2009, 2010, and 2011, respectively in a private home and the other in a There were no 2011 case-isolates (2011: Ramsey 19.9/100,000 and Hen- clinic setting. Two cases were hospital- with ciprofl oxacin resistance. In 2008, nepin 17.4/100,000). MRSA was most ized; 1 for 4 days and the other for 27 2 isolates from cases occurring in frequently isolated from blood (66%), days. The critically ill case developed northwestern Minnesota had nalidixic and 14% (42/302) of the cases died. pneumonitis and required ventilator acid MICs >8 μg/ml and ciprofl oxacin The rate of invasive MRSA infection support for 15 days. The age range of MICs of 0.25 μg/ml indicative of acquired in hospitals (hospital-onset or the cases was 12 months to 43 years. resistance. nosocomial) decreased from 5.4 per Two cases were black and of Ethiopian 100,000 in 2005 to 1.8 in 2011. Twelve descent and 1 case was white. The In 2011, meningococcal conjugate percent (37/302) of 2011 reported source case was too young to have re- vaccine (Menveo), previously licensed cases had no reported healthcare-as- ceived measles vaccine in accordance for 11-15 year-olds in 2010, was sociated risk factors in the year prior to with the routine schedule, and missed extended for licensed use in the United infection. Please refer to the MDH Anti- the opportunity for early vaccination States to 9 months of age. Menactra biogram for details regarding antibiotic prior to international travel at 9 months was licensed for use in the United susceptibility testing results (pp. 26-27). of age. One case was not vaccinated States in January 2005 for persons because of incorrectly perceived safety aged 11 to 55 years, and was the fi rst Vancomycin-intermediate (VISA) concerns, and 1 case had unknown meningococcal polysaccharide-protein and vancomycin-resistant S. aureus vaccination history. for serogroups (VRSA) are reportable in Minnesota, A,C,Y, and W-135 (MCV4). In 2007, as detected and defi ned according The 2 additional unrelated cases oc- the license was approved to include to Clinical and Laboratory Standards curred in white adults ages 27 and 34 2 to 10 year-olds. The U.S. Advisory Institute approved standards and years. These cases resulted from expo- Committee on Practices recommendations: a Minimum Inhibi- sure in India and Florida, respectively. and American Academy of Pediatrics tory Concentration (MIC)=4-8 ug/ml for Genotypes were D8 (endemic to West recommend immunization with either VISA and MIC≥16 ug/ml for VRSA. Pa- Africa and India) and D4 (a genotype vaccine routinely at age 11-12 years tients at risk for VISA and VRSA gener- with many endemic locations), respec- or at high school entry and a booster ally have underlying health conditions tively. One had a documented history of dose at age 16, as well as for college such as and end stage renal 2 doses of measles vaccine; the other freshmen living in dormitories, and disease requiring dialysis, previous had unknown vaccination history. The other groups in the licensed age MRSA infections, recent hospitaliza- cases were unrelated to the outbreak range previously determined to tions, and recent exposure to vancomy- cases and to each other; no second- be at high risk. In 2006, MDH in cin. There have been no VRSA cases ary cases were identifi ed in Minnesota, collaboration with the CDC and other in Minnesota. We confi rmed 1 VISA although the Florida exposure resulted sites nationwide, began a case-control case in 2000, 3 cases in 2008, 3 cases in 5 additional cases in two states. study to examine the effi cacy of MCV4 in 2009, and 2 cases in 2010. In 2011, and the study continues. 5 VISA cases were reported; 2 were Meningococcal Disease methicillin-susceptible SA (MSSA) and Fifteen cases of Neisseria meningitidis Methicillin-Resistant Staphylococ- 3 were MRSA. The MSSA cases had a invasive disease (0.28 per 100,000 cus aureus (MRSA) history of immunosuppression; inter- population) were reported in 2011, Strains of Staphylococcus aureus estingly, there was no prior history of compared to 9 cases in 2010. There that are resistant to methicillin and all MRSA or recent exposure to vancomy- were 8 serogroup B cases, 5 serogroup available beta-lactam antibiotics are cin. The MRSA cases had a history of Y, and 1 serogroup W135, and 1 not referred to as methicillin-resistant S. diabetes or chronic renal insuffi ciency. groupable. aureus (MRSA). Traditional risk fac- One MRSA isolate was daptomycin- tors for healthcare-associated (HA) nonsusceptible. Cases ranged in age from 5 months to MRSA include recent hospitalization or 98 years, with a median of 48 years. surgery, residence in a long-term care Critical illnesses or deaths due to continued... DCN 39;1 2012 13 community-associated (CA) S. aureus of sporadic parotitis including parain- children, older individuals, and persons infection (both methicillin-susceptible fl uenza virus types 1 and 3, Epstein- previously immunized may not have and-resistant) are reportable in Min- Barr virus, infl uenza A virus, group A the typical “whoop” associated with nesota. From 2005-2011, 106 cases of , echovirus, lymphocytic pertussis. Post-tussive was critical illness or death due to com- choriomeningitis virus, human immuno- reported in 283 (43%) of the cases. munity-associated S. aureus infection defi ciency virus, and other noninfectious Infants and young children are at were reported: 8 (2005), 14 (2006), causes such as drugs, tumors, and the highest risk for severe disease 16 (2007), 19 (2008), 20 in 2009, 17 immunologic diseases. and complications. Pneumonia was (2010), and 12 (2011); 56 (53%) were diagnosed in 21 (3%) cases, 49 (7%) of MRSA and 50 (47%) MSSA. Twenty-six Neonatal Sepsis whom were <1 year of age. Nineteen (46%) MRSA cases were male and the Statewide surveillance for neonatal (3%) cases were hospitalized; 10 (52%) median age was 35 years (12 days-88 sepsis includes reporting of any of the hospitalized patients were <6 years); 28 (56%) MSSA cases were bacteria (other than coagulase-negative months of age. male and the median age was 16 years Staphylococcus) isolated from a sterile (1 day-78 years). Multifocal infections site in an infant <7 days of age, and Due to waning immunity from either occurred in 25 cases; 17 MRSA, 8 mandatory submission of isolates. natural infection or vaccine, pertussis MSSA. Pneumonia was most frequent can affect persons of any age. The with 31 MRSA and 20 MSSA cases, and In 2011, 56 cases of neonatal sepsis disease is increasingly recognized in accounted for 21 (68%) deaths. One (0.82 cases per 1,000 live births) older children and adults. During 2011, MRSA and 8 MSSA had TSS; 3 MRSA were reported compared to 58 cases cases ranged in age from <1 week and 8 MSSA had endocarditis (5/11 (0.82 cases per 1,000 live births) in to 77 years. Ninety-four (14%) cases fatal); 20 MRSA and 7 MSSA had skin 2010. Among these cases, all were occurred in adolescents 13 to 17 years structure infections. Death occurred in identifi ed via blood or cerebral spinal of age, 148 (22%) in adults 18 years of 15 (28%) MRSA and 16 (32%) MSSA fl uid (CSF). Most cases (86%) were age and older, 278 (42%) in children cases. culture-positive within the fi rst 2 days 5-12 years of age, 117 (18%) in children of life. In 2011, group B Streptococcus 6 months through 4 years of age, and PFGE typing and toxin PCR were was the most common bacteria isolated 25 (4%) in infants <6 months of age. performed on 45 MRSA and 42 MSSA (21) followed by Escherichia coli (17), The median age of cases was 11 years. isolates. Most MRSA isolates belonged Streptococcus viridians (3), other to clonal groups associated with CA Streptococcus spp. (3), Staphylococcus Infection in older children and adults USA types (80% USA300). There was aureus (3), spp. (3), may result in exposure of unprotected no change in the number of USA300 Actinomyces spp. (2), and 1 each infants who are at risk for the most MRSA cases over time. MSSA isolates Haemophilus infl uenzae, Klebsiella severe consequences of infection. were in clonal groups associated with pneumoniae, group D Streptococcus, During 2011, 49 pertussis cases were CA and healthcare-associated USA and . reported in infants <1 year of age. A types. likely source of exposure was identifi ed Pertussis for 16 (33%) cases; 6 (31%) were Mumps During 2011, 662 cases of pertussis infected by adults 18 years of age During 2011, 2 cases of mumps were (12 per 100,000 population) were and older, 1 (6%) was infected by an reported. Both cases were laboratory- reported. Pertussis annual incidence adolescent 13 to 17 years of age, and confi rmed; 1 was confi rmed by PCR in Minnesota exceeded this number 9 (50%) were infected by a child <13 and the other by IgM serology. Neither every year since 2007, when 393 cases years of age. For the 33 (67%) cases case was epidemiologically linked, (7.6 per 100,000 population) were with no identifi ed source of infection, demonstrating that infec- reported. Laboratory confi rmation was the source was likely from outside the tions are occurring, and suggesting that available for 428 (65%) cases, 8 (2%) household. Vaccinating adolescents mumps is underdiagnosed. of which were confi rmed by culture and and adults with Tdap will decrease the 420 (98%) of which were confi rmed incidence of pertussis in the community Both cases were adults between 30 and by PCR. In addition to the laboratory- and thereby minimize infant exposures. 50 years of age (born after 1957). Nei- confi rmed cases, 135 (20%) cases were ther case had documentation of mumps epidemiologically linked to laboratory- Although unvaccinated children are vaccine; however, 1 case reported confi rmed cases, and 97 (15%) met at highest risk for pertussis, fully being immunized, and the other case the clinical case defi nition only. Three immunized children may also develop reported having mumps in childhood. hundred forty-nine (53%) of the the disease. Disease in those previously reported cases occurred in residents of immunized is usually mild. Effi cacy for Mumps surveillance is complicated the metropolitan area. currently licensed is estimated by nonspecifi c clinical presentation in to be 71 - 84% in preventing serious nearly half of cases, asymptomatic in- Paroxysmal coughing was the most disease. Of the 154 cases who were fections in an estimated 20% of cases, commonly reported symptom. Six 7 months to 6 years of age, 107 (69%) and suboptimal sensitivity and specifi c- hundred thirty-three (96%) cases were known to have received at least a ity of serologic testing. Mumps should experienced paroxysmal coughing. primary series of 3 doses of DTP/DTaP not be ruled out solely on the basis of Almost one third (200, 30%) reported vaccine prior to onset of illness; 43 negative laboratory results. Providers whooping. Although commonly referred (28%) received fewer than 3 doses and are advised to test for other causes to as “,” very young were considered preventable cases.

14 DCN 39;1 2012 Vaccine history was unavailable for the remaining 4 (3%) cases. Figure 4. Rabid Animals by County MDH reporting rules require that Minnesota, 2011 clinical isolates of Kittson Roseau Lake (n=55) of the be submitted to the PHL. Of the 8 Woods culture-confi rmed cases, 6 of the Marshall isolates were received and sub-typed Koochiching by PFGE with 6 distinct PFGE patterns Beltrami St. Louis Pennington identifi ed. In 2011 no case-isolates of Polk Cook

Red Lake pertussis were tested in Minnesota for Lake Clear susceptibility to , ampicillin, Water Itasca or trimethoprim-sulfamethoxazole.

However, nationally isolates have had Norman Mahnomen Hubbard low minimum inhibitory concentrations, Cass falling within the reference range Clay Becker for susceptibility to the antibiotics Aitkin evaluated. Only 11 erythromycin- Wadena Crow Wing resistant B. pertussis cases have been Carlton Wilkin Ottertail identifi ed in the United States to date. Pine Species No. Todd Mille Skunk 16 Laboratory tests should be performed Lacs Kanabec Grant Douglas Bat 28 on all suspected cases of pertussis. Morrison Culture of B. pertussis requires Cow/Bison 6 Benton inoculation of nasopharyngeal mucous Traverse Stevens Pope Stearns Isanti Cat 4 Big Stone on special media and incubation for Sherburne Dog 1 Chisago Swift 7 to 10 days. However, B. pertussis Kandiyohi Anoka Meeker Wright Wash- is rarely identifi ed late in the illness; ing- Chippewa Ram- ton Hennepin sey therefore, a negative culture does 4 Lac Qui Parle McLeod Carver not rule out disease. A positive PCR Renville Yellow Medicine Scott result is considered confi rmatory in Dakota Sibley Lincoln patients with a 2-week history of cough Lyon Redwood Rice Goodhue Nicollet illness. PCR can detect non-viable Le Wabasha Sueur organisms. Consequently, a positive Brown Pipestone Waseca Blue Earth Olmsted PCR result does not necessarily Murray Cottonwood Watonwan Steele Dodge Winona indicate current infectiousness. Patients Rock Nobles Jackson Martin Faribault Freeborn Fillmore Houston with a 3-week or longer history of Mower cough illness, regardless of PCR result, may not benefi t from antibiotic therapy. Cultures are necessary for Rabies were skunks. molecular and epidemiologic studies Rabies is caused by the rabies virus, and for drug susceptibility testing. which is highly antigenic, only infects From 2003 to 2011, 22,069 animals Whenever possible, culture should be mammals, and has been identifi ed were submitted for rabies testing. The done in conjunction with PCR testing. worldwide. In Minnesota, the reservoir median number of positive animals Serological tests are not standardized species are the skunk and multiple bat reported annually was 59 (range, 39 and are not acceptable for laboratory species. to 94). From 2003 to 2011, 247/512 confi rmation at this time. (48%) skunks, 43/547 (8%) cattle, In 2011, 55 (2%) of 2,385 animals 189/5,667 (3%) bats, 27/6,209 (0.4%) Pertussis remains endemic in submitted for testing were positive dogs, 35/7,071 (0.5%) cats, and 0/732 Minnesota despite an effective for rabies (Figure 4). This is similar (0%) raccoons that were submitted vaccine and high coverage rates to 2010, when 59 (2%) of 2,508 tested positive for rabies. From 1988 with the primary series. Reported animals tested positive. The majority to 2011, 3 raccoons tested positive for incidence of pertussis has consistently of positive animals in 2011 were bats rabies; these occurred in 1989, 1990, increased over the past 10 years, (28/55 [50%]), followed by skunks and 1993. particularly in adolescents and (16/55 [30%]), cattle (5/55 [10%]), cats adults. One of the main reasons for (4/55 [7%]) and dogs (1/55 [2%]). No Salmonellosis the ongoing circulation of pertussis raccoons or horses tested positive During 2011, 701 culture-confi rmed is that vaccine-induced to for rabies in 2011 and there were no cases of Salmonella infection (13.2 per pertussis wanes approximately 5-10 human cases. The years 2008, 2009, 100,000 population) were reported. This years after completion of the primary and 2011 are the only ones in which represents a 5% increase from the me- series, leaving adolescents and adults bats have comprised the greatest dian annual number of cases reported susceptible. number of positive animals; all other from 2001 to 2010 (median, 668 cases; years the majority of positive animals range, 578 to 755). Of the 91 serotypes continued... DCN 39;1 2012 15 identifi ed in 2011, 5 serotypes, S. serotypes and a total of 124 cases in 27 Enteritidis (173), S. Typhimurium (105), In May, 1 case of S. Altona infec- states. Small turtles were implicated as S. I 4,[5],12:i:- (60), S. Newport (55), tion was associated with a multi-state the vehicles in the outbreak. and S. Infantis (20) accounted for 59% outbreak that involved 45 cases in 15 of cases. Salmonella was isolated from states. Contact with baby chicks origi- In September, 8 cases of S. Enteritidis stool in 615 (88%), urine in 44 (6%), nating from a single mail order hatchery infection were associated with con- and blood in 32 (5%) cases. Other in Ohio was identifi ed as the cause of sumption of shell eggs from an organic specimen sources included , the outbreak. egg supplier in Minnesota. Environ- bone, , placenta, tissue, mental samples from the egg belt at the leg laceration, and a toe swab. There In June, 11 cases of S. Muenchen infec- supplier’s packing plant tested positive were 3 cases of S. Typhi infection; 2 tion were associated with a multi-state for the outbreak strain of Salmonella, had travelled to India and 1 to Pakistan. outbreak involving 24 cases in 7 states. and a recall and press release were There were 3 cases of S. Paratyphi A Commercially distributed iceberg lettuce issued. infection; 1 had travelled internationally was the suspected vehicle. (India). From May through December, 16 cases In June, 1 case of S. Uganda infection of Salmonella infection (including 14 S. Of the 648 cases interviewed about was part of a multi-state outbreak of I 4,[5],12:i:- cases, 2 S. Rissen cases, travel history, 91 (14%) had traveled 13 cases in 7 states. Cantaloupe was and 1 S. Infantis case) were part of an internationally during the week prior to the likely vehicle, but the source of the outbreak associated with exposure to their illness onset. Cases who reported cantaloupe was not identifi ed. live animal slaughter markets. Envi- Asian race had a higher incidence ronmental samples from one market (25.4 per 100,000 population) than any In July, 4 cases of S. Newport infection yielded these 3 Salmonella serotypes other reported race (Black, 15.7; Na- were part of a multi-state outbreak of 6 as well as 7 additional serotypes. tive American, 12.8; White, 10.7). One cases in Minnesota and North Dakota Disease prevention measures at the 81-year-old case died of congestive that was associated with sandwich markets are being implemented. heart failure secondary to type 2 diabe- chain restaurants. Epidemiological and tes mellitus 8 days after S. Javiana was traceback investigations suggested that Sexually Transmitted Diseases isolated from a urine sample. cucumbers or tomatoes were the likely (STDs) vehicle. Active surveillance for gonorrhea and Seventy-three cases were part of 13 chlamydia involves cross-checking Salmonella outbreaks identifi ed in In July, 8 cases of S. Typhimurium laboratory-reported cases against cases 2011. Eight outbreaks involved cases infection were associated with an reported by clinicians. Although both in multiple states. Ten of the outbreaks outbreak at a Mexican-style restaurant. laboratories and clinicians are required involved foodborne transmission and The outbreak occurred during the State to report STDs independently of each three outbreaks were due to animal of Minnesota government shutdown and other, a laboratory-reported case is contact. The 13 outbreaks resulted in therefore we were unable to perform not considered a case for surveillance a median of 3 culture-confi rmed cases an ingredient-specifi c investigation and purposes until a corresponding case per outbreak (range, 1 to 16 cases). analysis. The ultimate source of the report is submitted by the clinical facility. outbreak was not identifi ed. Case reports contain demographic In February, 3 cases of S. Enteritidis and clinical information that is not infection were part of an outbreak at In August, 14 cases of S. Typhimurium available from laboratory reports. When a wedding reception. An undercooked infection were likely associated with a laboratory report is received but no chicken dish was the suspected ve- consumption of seedless watermelon corresponding case report is received hicle. that traced back to companies in the within 45 days, we mail a reminder same area in Indiana. Five of the cases letter and case report form to the clinical In February, 3 cases of S. Agona infec- attended a family gathering where the facility. Active surveillance for syphilis tion were part of a multi-state outbreak watermelon was served. involves immediate follow-up with the of 106 cases in 25 states. Papayas clinician upon receipt of a positive imported from Mexico by a single dis- In August, 1 case of S. I 4,[5],12:i:- in- laboratory report. Cases of chancroid tributor in Texas were implicated as the fection was associated with an ongoing are monitored through a mostly passive vehicle and a national recall was initi- multi-state outbreak associated with ro- surveillance system. ated. Sampling of papayas from Mexico dents used to feed reptiles. Frozen mice virus and human papillomavirus during the outbreak showed a 15.6% from a pet store in another state where infections are not reportable. Salmonella contamination rate. a case purchased mice tested positive for the outbreak strain. The same strain Although overall incidence rates for In April, 2 cases of S. Heidelberg infec- was the cause of a 2010 outbreak as- STDs in Minnesota are lower than tion were part of a multi-state outbreak sociated with feeder rodents; this strain those in many other areas of the United involving two strains of S. Heidelberg may now be endemic in feeder rodent States, certain population subgroups in and 136 cases in 34 states. Commer- populations in the United States. Minnesota have very high STD rates. cially distributed ground turkey products Specifi cally, STDs disproportionately were implicated as the vehicle. The In August, 1 case of S. Sandiego infec- affect adolescents, young adults, and outbreak led to a national consumer tion was part of a multi-state outbreak persons of color. alert and a ground turkey recall. involving 5 strains of 3 Salmonella

16 DCN 39;1 2012 Chlamydia Table 3. Number of Cases and Rates (per 100,000 persons) Chlamydia trachomatis infection is the of Chlamydia, Gonorrhea, Syphilis and Chancroid - Minnesota, 2007-2011 most commonly reported infectious disease in Minnesota. In 2011, 16,898 2007 2008 2009 2010 2011 chlamydia cases (319 per 100,000 Disease No. Rate No. Rate No. Rate No. Rate No. Rate population) were reported, representing Chlamydia 13,480 259 14,414 275 14,369 272 15,509 292 16,898 319 a 9% increase from 2010 (Table 3). Gonorrhea 3,479 67 3,054 58 2,328 44 2,149 41 2,283 43 Adolescents and young adults are at highest risk for acquiring chlamydial Syphilis, Total 186 3.6 263 5.0 215 4.1 351 6.6 366 6.9 infection (Table 4). The chlamydia rate Primary/Secondary 59 1.1 116 2.2 71 1.3 150 2.8 139 2.6 55 1.4 121 is highest among 20 to 24-year-olds Early Latent 1.1 47 0.9 46 0.9 74 2.3 Late Latent 72 1.4 100 1.9 97 1.8 126 2.4 106 2.0 (1,907 per 100,000), with the next Other* 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 highest rate among 15 to 19-year-olds Congenital** 0 0.0 0 0.0 1 1.4 1 1.5 0 0.0 (1,385 per 100,000). The incidence of chlamydia among adults 25 to 29 Chancroid 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 years of age (719 per 100,000) is D* Includes unstaged neurosyphilis, latent syphilis of unknown duration, and late syphilis with clinical considerably lower but has increased D manifestations. in recent years. The chlamydia rate ** Congenital syphilis rate per 100,000 live births. among females (443 per 100,000) is Note: Data exclude cases diagnosed in federal or private correctional facilities. more than twice the rate among males (193 per 100,000), a difference most Table 4. Number of Cases and Incidence Rates (per 100,000 persons) likely due to more frequent screening of Chlamydia, Gonorrhea, and Primary/Secondary Syphilis among women. by Residence, Age, Race/Ethnicity, and Gender - Minnesota, 2011

The incidence of chlamydia infection Chlamydia Gonorrhea Syphilis is highest in communities of color Demographic Group No. Rate No. Rate No. Rate (Table 4). The rate among blacks (1,768 per 100,000) is 11 times higher Total 16,898 319 2,283 43 139 2.6 than the rate among whites (166 per Residence* 100,000). Although blacks comprise Minneapolis 3,246 848 809 211 58 15.2 approximately 5% of Minnesota’s St. Paul 2,165 759 376 132 14 4.9 population, they account for 29% Suburban** 5,909 271 655 30 52 2.4 of reported chlamydia cases. Rates Greater Minnesota 4,850 198 352 14 13 0.5 among Asian/Pacifi c Islanders (320 per 100,000), Hispanics (434 per Age 100,000), and American Indians (780 <15 years 162 15 21 2 0 0.0 15-19 years 5,094 1,385 585 159 3 0.8 per 100,000) are over two to four times 20-24 years 6,784 1,907 807 227 26 7.3 higher than the rate among whites. 25-29 years 2,681 719 392 105 26 7.0 30-34 years 1,097 320 188 55 16 4.7 Chlamydia infections occur throughout 35-44 years 800 117 187 27 32 4.7 the state, with the highest reported >45 years 280 13 103 5 36 1.7 rates in Minneapolis (848 per 100,000) and St. Paul (759 per 100,000). While Gender Male 5,067 193 988 38 134 5.1 there was an overall increase of 9% Female 11,824 443 1,293 48 5 0 across the state in 2011 the greatest Transgender^^ 7 - 2 - - - increase for chlamydia was seen in the suburban area (metropolitan area Race^/Ethnicity excluding Minneapolis and St. Paul) White 7,494 166 726 16 98 2.2 with an increase of 15%, shown in Table Black 4,851 1,768 1,152 420 24 8.7 4. American Indian 475 780 63 103 1 1.6 Asian/PI 692 320 33 15 6 2.8 Other ^^ 847 - 97 - 9 - Gonorrhea Unknown^^ 2,539 - 212 - 1 - Gonorrhea, caused by Neisseria Hispanic^^^ 1,087 434 92 37 10 4 gonorrhoeae, is the second most commonly reported STD in Minnesota. * Residence information missing for 728 cases of chlamydia and 91 cases of gonorrhea. In 2011, 2,283 cases (43 per 100,000 ** Suburban is defi ned as the seven-county metropolitan area (Anoka, Carver, Dakota, population) were reported, representing Hennepin, Ramsey, Scott, and Washington Counties), excluding the cities of Minneapolis and St. Paul. a 5% increase from 2010. This is the ^ Case counts include persons by race alone. Population counts used to calculate results fi rst increase in reported gonorrhea include race alone or in combination. cases since 2007 (Table 3). ^^ No comparable population data available to calculate rates. ^^^ Persons of Hispanic ethnicity may be of any race. Note: Data exclude cases diagnosed in federal or private correctional facilities. Adolescents and young adults are at continued...

DCN 39;1 2012 17 greatest risk for gonorrhea (Table 4), 2011, there were 139 cases of primary/ to ampicillin. The ampicillin-resistant with incidence rates of 159 per 100,000 secondary syphilis in Minnesota (2.6 isolate (S. Sonnei) was also resistant to among 15 to 19-year-olds, 227 per cases per 100,000 persons). This Sxt, (T), streptomycin (S), 100,000 among 20 to 24-year olds, and represents a decrease of 8% compared sulfasoxizole (Su), and cephalothin. 105 per 100,000 among 25 to 29-year- to the 149 cases (2.8 per 100,000 Five other isolates with Sxt resistance olds. Gonorrhea rates for males (38 per population) reported in 2010. had resistance phenotype SSuTSxt. All 100,000) and females (48 per 100,000) isolates tested were S. Sonnei except 1 are comparable. Communities of color Early Syphilis SSuTSxt isolate that was S. Boydii. are disproportionately affected by In 2011, the number of early syphilis gonorrhea, with nearly one half of cases cases increased by 16%, with 260 Streptococcus pneumoniae Invasive reported among blacks. The incidence cases occurring compared to 224 Disease of gonorrhea among blacks (420 per cases in 2010. The incidence remains Statewide active surveillance for 100,000) is 26 times higher than the highly concentrated among MSM. Of invasive Streptococcus pneumoniae rate among whites (16 per 100,000). the early syphilis cases in 2011, 246 (pneumococcal) disease began in Rates among Asian/Pacifi c Islanders (95%) occurred among men; 218 (88%) 2002, expanded from the metropolitan (15 per 100,000), Hispanics (37 per of these men reported having sex with area, where active surveillance was 100,000), and American Indians (103 other men; 57% of the MSM diagnosed ongoing since 1995. In 2011, 582 per 100,000) are up to six times higher with early syphilis were co-infected with (11.0 per 100,000) cases of invasive than among whites. HIV. pneumococcal disease were reported. By age group, annual incidence rates Gonorrhea rates are highest in the cities Congenital Syphilis per 100,000 were 14.1 cases among of Minneapolis and St. Paul (Table 4). No cases of congenital syphilis were children aged 0-4 years, 2.5 cases The incidence in Minneapolis (211 per reported in Minnesota in 2011 (Table 3). among children and adults aged 5-39 100,000) is nearly two times higher than years, 11.1 cases among adults 40-64 the rate in St. Paul (132 per 100,000), Chancroid years, and 39.8 cases among adults seven times higher than the rate in the Chancroid continues to be very rare in aged 65 years and older. suburban metropolitan area (30 per Minnesota. No cases were reported in 100,000), and 15 times higher than 2010. The last case was reported in In 2011, pneumonia occurred most the rate in Greater Minnesota (14 per 1999. frequently (63% of infections), followed 100,000). Geographically in 2011, St. by bacteremia without another focus Paul saw the largest increase in cases Shigellosis of infection (19%), and pneumococcal at 35% and Minneapolis saw an 8% During 2011, 87 culture-confi rmed meningitis (6%). Seventy-one (12%) increase in cases. cases of Shigella infection (1.6 per cases died. Health histories were 100,000 population) were reported. available for 67 (94%) of the 71 The emergence of quinolone-resistant This represents a 32% increase from cases who died. Of these, 62 had an N. gonorrhoeae (QRNG) in recent the 66 cases reported in 2010, but a underlying health condition reported. years has become a particular concern. 46% decrease from the median number The conditions most frequently Due to the high prevalence of QRNG of cases reported annually from 2001 reported were chronic obstructive in Minnesota as well as nationwide, to 2010 (median, 162.5; range, 66 to pulmonary disease (19), atherosclerotic quinolones are no longer recommended 493). S. sonnei accounted for 73 (84%) cardiovascular disease (19), smoking for the treatment of gonococcal cases, S. fl exneri for 11 (13%), and (14), solid organ malignancy (14), infections. S. boydii for 3 (3%). Cases ranged in and diabetes (10). In 1999, the year age from 1 to 72 years (median, 36 before the pediatric pneumococcal Syphilis years). Forty-three percent of cases conjugate vaccine (Prevnar [PCV- Surveillance data for primary and were males 18 to 55 years of age. Ten 7]) was licensed, the rate of invasive secondary syphilis are used to monitor percent of cases were ≤5 years of age. pneumococcal disease among children morbidity trends because they represent Nineteen (22%) cases were hospital- < 5 years in the metropolitan area recently acquired infections. Data for ized. Of the 75 cases for which travel in- was 111.7 cases/100,000. Over the early syphilis (which includes primary, formation was available, 17 (23%) trav- years 2000-02 there was a major secondary, and early latent stages elled internationally (12 of 65 [19%] S. downward trend in incidence in this of disease) are used in outbreak sonnei, 4 of 9 [44%] S. fl exneri, and 1 age group (Figure 5). Rates in each of investigations because they represent of 1 S. boydii). Eighty-seven percent of the subsequent 9 years were level or infections acquired within the past 12 cases resided in the metropolitan area, somewhat higher, although there has months and signify opportunities for including 48% in Hennepin County and not been a continuing upward trend disease prevention. 22% in Ramsey County. No outbreaks (Figure 5). Based on the distribution of shigellosis were identifi ed in 2011. of serotypes among isolates from Primary and Secondary Syphilis these cases, this increase was limited The incidence of primary/secondary Every tenth Shigella isolate received to disease caused by non-vaccine syphilis in Minnesota is lower than that at MDH is tested for antimicrobial serotypes (i.e. serotypes other than of chlamydia or gonorrhea (Table 3), resistance. Nine isolates were tested the 7 included in PCV-7) (Figure 5). but has remained elevated since an in 2011; 89% (8 isolates) were resis- This small degree of replacement outbreak began in 2002 among men tant to trimethoprim-sulfamethoxazole disease due to non-PCV-7 serotypes, who have sex with men (MSM). In (Sxt) and 11% (1 isolate) were resistant similar to that seen in other parts of the

18 DCN 39;1 2012 country, has been far outweighed by the had , and 25 (11%) cases had 25 deaths, were reported in 2011. declines in disease caused by PCV- an abscess. Of the 73 cellulitis cases These cases were those in which group 7 serotypes. This trend supports the (10 cases had both cellulitis and an B Streptococcus (GBS) was isolated need for ongoing monitoring, however, abscess), 74% had a positive blood from a normally sterile site. The largest because further increases due to non- culture and 15% had a positive joint number of GBS cases reported since vaccine serotypes are possible. culture for GAS. There were 32 (14%) surveillance was initiated in 1995 was cases of pneumonia and 21 (9%) 454, reported in 2009. In March 2010, the U.S. Food and Drug cases of necrotizing (2 cases Administration approved a new 13-va- had both pneumonia and necrotizing By age group, annual incidence was lent pediatric pneumococcal conjugate fasciitis). Twenty-four (10%) cases had highest among infants <1 year of age vaccine (PCV-13 [Prevnar 13]) which and/or . (52.2 per 100,000 population) and replaced PCV-7. The new vaccine Twelve (5%) cases were residents of 12 those aged 70 years or older (39.1 provides protection against the same different long-term care facilities. per 100,000). Sixteen (64%) of the 25 serotypes in PCV-7, plus 6 additional deaths were among those age 65 years serotypes (serotypes 1, 3, 5, 6A, 7F, The 17 deaths included 3 cases of and older. Fifty-four percent of cases and 19A). Since 2007, the majority of bacteremia without another focus of were residents of the metropolitan area. invasive pneumococcal disease cases infection, 3 cases of septic shock, Bacteremia without a focus of infection among children <5 years of age have 2 cases with cellulitis, 2 cases of occurred most frequently (25% of been caused by the 6 new serotypes pneumonia, 2 cases of urinary tract infections), followed by cellulitis (23%), included in PCV-13 (Figure 5). In 2011, infection/urosepsis, and 1 case of septic osteomyelitis (13%), septic arthritis 30% of cases occurring among Min- arthritis. The remaining 4 cases had (7%), pneumonia (7%), and meningitis nesotans of all ages were caused by 3 multiple syndromes including 2 cases (2%). The majority (70%) of cases had of the new PCV-13-included serotypes: of pneumonia and septic shock; 1 case GBS isolated from blood; other isolate 19A (11%), 3 (10%), and 7F (9%). of and cellulitis; and sites included bone (14%) and joint fl uid 1 case of necrotizing fasciitis, septic (11%). Of the 560 isolates submitted for shock, and pneumonia. The deaths 2011 cases, 133 (24%) isolates were occurred in persons ranging in age Thirty-fi ve cases were infants or resistant to penicillin using meningitis from 33 years to 94 years (median, pregnant women (maternal cases), breakpoints. Using non-meningitis 70 years). Five fatal cases had no compared to 52 cases in 2010. Twenty- breakpoints, 8 (1%) of 560 isolates underlying medical conditions reported. one infants developed early-onset were resistant to penicillin and 32 (6%) Of the 12 cases with underlying medical disease (occurred within 6 days of exhibited intermediate level resistance conditions the most frequently reported birth [0.31 cases per 1,000 live births]), (Note: CLSI penicillin breakpoints were diabetes (6) and congestive heart and 11 infants developed late-onset changed in 2008; refer to the MDH failure (4). disease (occurred at 7 to 89 days of Antibiogram on pages 26-27) Multi-drug age [0.16 cases per 1,000 live births]). resistance (i.e., high-level resistance Streptococcal Invasive Disease – One stillbirth/spontaneous abortion was to two or more antibiotic classes) was Group B associated with 1 of 3 maternal GBS exhibited in 144 (26%) isolates. Five hundred thirty-fi ve cases of infections. invasive group B streptococcal disease Streptococcal Invasive Disease – (10.1 per 100,000 population), including Since 2002, there has been a Group A We have been conducting active Figure 5. Invasive Pneumococcal Disease Incidence Among Children <5 Years surveillance for invasive disease caused of Age, by Year and Serotype Group, Metropolitan Area, 1999-2001; by group A Streptococcus (GAS, [also Minnesota, 2002-2011 known as ]) 125 since 1995. Invasive GAS is defi ned as GAS isolated from a usually sterile site such as blood, cerebral spinal fl uid, or 100 Unknown Serotype Other Serotypes from a wound when accompanied with Additional Serotypes in PCV-13 necrotizing fasciitis or streptococcal Serotypes in PCV-7 toxic shock syndrome (STSS). 75

Two hundred thirty-one cases of invasive GAS disease (4.3 per 50 100,000), including 17 deaths, were Cases/100,000 reported in 2011, compared to 158 cases and 13 deaths in 2010. Ages 25 of cases ranged from 1 to 98 years (median, 55 years). Fifty percent 0 of cases were residents of the 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 metropolitan area. Forty-one (18%) Year of Diagnosis cases had bacteremia without another PCV-13 contains the 7 serotypes in PCV-7 (4,6B,9V,14,18C,19F and 23F) plus 6 additional serotypes (1,3,5,6A,7F and 19A) focus of infection, 73 (32%) cases continued... DCN 39;1 2012 19 recommendation for universal prenatal illness), hypotension (SBP ≤ 90 mm Hg population). In contrast, 66 TB cases screening of all pregnant women at for adults or less than fi fth percentile by occurred among blacks (22.1/100,000), 35 to 37 weeks gestation. In light of age for children aged <16 years), multi- 40 among Asians (17.5/100,000), and 3 this, we reviewed the maternal charts system involvement (>3 of the following: among American Indians (4.7/100,000). for all early-onset cases reported in vomiting or diarrhea at onset of illness; The majority (62/66, or 94%) of black 2011. Overall, 12 (57%) of 21 women severe myalgia or creatine phospho- TB cases reported in Minnesota in 2011 who delivered GBS-positive infants kinase level at least twice the upper were foreign-born. There were no TB underwent prenatal screening for limit of normal; vaginal, oropharyngeal, cases reported among individuals who GBS. Of these, 5 (42%) were positive, or conjunctival hyperemia; blood urea self-reported being multi-racial. 6 (50%) negative, and 1 (8%) had nitrogen or creatinine at least twice an unknown result. Two of the seven the upper limit of normal for labora- The most distinguishing characteristic women who did not receive prenatal tory or urinary sediment with pyuria of the epidemiology of TB disease in screening were screened upon (>5 leukocytes per high-power fi eld) in this state continues to be the large admission to the hospital and prior the absence of ; proportion of cases that occur among to delivery. Of the two women for total bilirubin, alanine aminotransferase persons born outside the United States. whom it was unknown if they received enzyme, or aspartate aminotransferase Eighty-fi ve percent of cases reported prenatal screening, one was screened enzyme levels at least twice the upper in 2011 occurred among foreign-born upon admission to the hospital and limit of normal for laboratory; platelets persons. In contrast, 63% of TB cases prior to delivery. Among the 21 less than 100,000/mm3; disorientation reported nationwide in 2011 were women who delivered GBS-positive or alterations in consciousness with- foreign-born. The 116 foreign-born TB infants, 11 (52%) received intrapartum out focal neurologic signs when fever cases reported in Minnesota during antimicrobial prophylaxis (IAP). Of the and hypotension are absent); negative 2011 represented 25 different countries fi ve women with a positive GBS screen, results for blood or cerebrospinal fl uid of birth; the most common region of four (80%) received IAP. cultures (blood culture may be positive birth among these patients was sub- for Staphylococcus aureus) or negative Saharan Africa (53%), followed by Tetanus serologies for Rocky Mountain spot- South/Southeast Asia (28%), and Latin One case of tetanus was reported ted fever, leptospirosis, or measles (if America (including the Caribbean) during 2011. The case occurred in a done). (13%) (Figure 7). Among U.S.-born 24-year-old white male with a his- pediatric TB cases, 80% (8 of 10) have tory of receiving the primary series of Tuberculosis at least one foreign-born parent. The DTaP (diphtheria and tetanus toxoids During 2011, 137 cases of tuberculosis ethnic diversity among foreign-born TB and acellular ) on a (TB) disease (2.6 cases per 100,000 cases in Minnesota refl ects the unique delayed schedule; the patient had not population) were reported, compared and constantly changing demographics received a booster for 12 years. There to 135 cases in 2010. Although this of immigrant and other foreign-born was no known injury or wound; how- represents an increase of 1% in the populations arriving statewide. ever, the patient had signifi cant dental number of cases and a 4% increase in caries and fractured teeth. A possible the incidence rate compared to 2010, Among foreign-born TB cases reported tooth infection or abscess was docu- the number of cases reported annually in Minnesota during 2011, 16% were mented. He received tetanus immune has decreased 42% since 2007, when diagnosed with TB disease less than globulin (TIG) between 7-23 hours after 238 cases (the highest number in the 12 months after arriving in the United illness onset as well as a past decade) were reported. From States, and an additional 13% were of Tdap (tetanus, diphtheria and acellu- 2010 to 2011, the number of TB cases diagnosed 1 to 2 years after their arrival lar pertussis vaccine). The case left the reported among U.S.-born persons in this country. Many of these cases, medical facility against medical advice in Minnesota decreased 16%, while particularly those diagnosed during and further follow-up was unsuccessful. cases among foreign-born persons their fi rst year in the United States, increased 5%. In 2011, Minnesota’s likely represent persons who acquired Toxic Shock Syndrome TB incidence rate was below the TB infection prior to immigrating and In 2011, 4 cases of suspect or probable national rate (3.4 cases per 100,000 began progressing to active TB disease staphylococcal toxic shock syndrome population) but slightly higher than the shortly after arriving in the United (TSS) were reported. Of the reported median rate among 51 U.S. states and States. Of 17 TB cases 15 years of cases, all were female, the median age reporting areas (2.4 cases per 100,000 age or older who were diagnosed in was 14 years (range, 12 to 19 years), population) and well above the U.S. Minnesota within 12 months of arriving and all were menstrual-associated with Healthy People 2020 objective of 1.0 in the United States and who arrived tampon use reported. case per 100,000 population (Figure 6). as immigrants or refugees, only 1 had Seven (5%) of the TB cases reported any TB-related condition noted in their Staphylococcal toxic shock syndrome in Minnesota in 2011 died due to TB or pre-immigration medical examination with isolate submission (if isolated) is TB-related causes. reports. These fi ndings highlight the reportable to MDH within 1 working day. need for clinicians to have a high We follow the 2011 CDC case defi ni- The incidence of TB disease is index of suspicion for TB among tion which includes fever (temperature disproportionately high in racial newly arrived foreign-born persons, ≥102.0°F or 38.9°C), (diffuse minorities in the United States and regardless of the results of medical macular erythroderma), desquama- in Minnesota. In 2011, 13 TB cases exams performed overseas. tion (within 1-2 weeks after onset of occurred among whites (0.3/100,000

20 DCN 39;1 2012 risk category among TB cases reported Figure 6. Tuberculosis Incidence Rates per 100,000 Population, in Minnesota in recent years illustrates United States and Minnesota, 1997-2011 the importance of TB screening and, if indicated, treatment for LTBI among patients with underlying medical conditions that increase the risk for progression from LTBI to active TB disease. Following these underlying medical conditions, the next most common risk factor among TB cases was substance abuse (including alcohol abuse and/or illicit drug use), with 5% of TB cases reported in 2011 having a history of substance abuse during the 12 months prior to their TB diagnoses. Three (2%) of the 137 TB cases reported in Minnesota during 2011 were infected with HIV. The percentage of new TB cases with HIV co-infection in Minnesota remains less than that among TB cases reported nationwide (7.9% of those with an HIV Figure 7. Foreign-Born Tuberculosis Cases by Region of Birth test result). Other risk groups, such as and Year of Diagnosis, Minnesota, 2007-2011 correctional facility inmates, homeless persons, and residents of nursing homes, each represented 1% of TB cases reported during 2011.

Twenty-fi ve (29%) of the state’s 87 counties had at least 1 case of TB disease in 2011. The large majority (74%) of cases occurred in the metropolitan area, particularly in Hennepin (43%) and Ramsey (23%) counties, both of which have public TB clinics. Nine percent of TB cases reported statewide during 2011 occurred in the fi ve suburban metropolitan counties (i.e., Anoka, Dakota, Carver, Scott, and Washington). Olmsted County, which also maintains a public TB clinic, The majority (80%) of TB cases Aside from foreign-born persons, represented 7% of cases reported in reported in Minnesota during 2011 were individuals with other risk factors 2011. The remaining 19% of cases identifi ed as a result of presenting with comprise much smaller proportions occurred in primarily rural areas of symptoms for medical care. Various of the TB cases in Minnesota. Among Greater Minnesota. We calculate targeted public health interventions cases reported in 2011, 20% (27) of TB county-specifi c annual TB incidence identifi ed the remaining 20% of cases. cases occurred among persons with rates for Hennepin, Ramsey, and Such methods of case identifi cation certain medical conditions (excluding Olmsted counties, as well as for the traditionally are considered high HIV infection) that increase the risk for fi ve-county suburban metropolitan priority, core TB prevention and progression from latent TB infection area and collectively for the remaining control activities; they include TB (LTBI) to active TB disease (e.g., 79 counties in Greater Minnesota. In contact investigations (4%), follow-up diabetes, prolonged or 2011, the highest TB incidence rate evaluations subsequent to abnormal other immunosuppressive therapy, end statewide was reported in Olmsted fi ndings on pre-immigration exams stage renal disease, etc.). Notably, County (6.2 cases per 100,000 performed overseas (1%), and these patients represent the largest population), followed by Ramsey domestic refugee health assessments annual proportion of TB cases reported County (6.1 cases per 100,000 (1%). Notably, however, an additional with such medical conditions since population) and Hennepin County (5.1 13% of TB cases were identifi ed at least 1993, when we initiated an cases per 100,000 population). In 2011, through a variety of other means (e.g., electronic surveillance database the incidence rates in the fi ve-county occupational screening) that typically that included data on TB-related risk suburban metropolitan area (1.0 cases are considered lower priority activities. factors among reported cases. This per 100,000 population) and Greater observation of a trend toward a growing Minnesota (1.1 cases per 100,000 continued... DCN 39;1 2012 21 population) were considerably lower in recent years (particularly a marked There were 137 cases that met criteria than that in the state overall (2.6 cases decline since 2006 in the number of for UNEX surveillance (115 deaths and per 100,000 population). those arriving in Minnesota from sub- 22 critical illnesses) in 2011, compared Saharan Africa) and changes initiated to 172 cases in 2010. Of the 137, 81 The prevalence of drug-resistant TB in 2007 in the technical instructions for (59%) were reported by providers, 55 in Minnesota, particularly resistance the overseas medical examinations (40%) were found by death certifi cate to isoniazid (INH) and multi-drug required for refugees and some new review, and 1 (1%) was found through resistance (i.e., resistance to at least immigrants. other reporting methods. Sixty- INH and rifampin), historically has two (45%) cases presented with exceeded comparable national fi gures. Unexplained Critical Illnesses respiratory symptoms; 27 (20%) with In 2011, of 109 culture-confi rmed TB and Deaths of Possible Infectious sudden unexpected death; 14 (10%) cases with drug susceptibility results Etiology (UNEX) and Medical with cardiac symptoms; 12 (9%) with available, 22 (22%) were resistant Examiner Infectious Deaths neurologic symptoms; 12 (9%) with to at least one fi rst-line anti-TB drug Surveillance (MED-X) shock/sepsis; 7 (5%) with an illness (i.e., INH, rifampin, pyrazinamide, or Surveillance for unexplained critical that did not fi t a defi ned syndrome; 2 ethambutol), including 12 (12%) cases illnesses and deaths of possible (1%) with gastrointestinal illness; and that were resistant to INH. Three (3%) infectious etiology (UNEX) began 1 with a genitourinary illness. The age cases of multidrug-resistant (MDR) TB September 1995. Focus is given of cases ranged from newborn to 87 were reported in 2011. One case of to cases < 50 years of age with no years. The median age was 9 years extensively drug resistant (XDR) TB signifi cant underlying conditions; among 81 reported cases, and 45.5 occurred in Minnesota in 2006. however, any case should be reported years among 56 non-reported cases regardless of the patient’s age or found through active surveillance. Another clinical characteristic of underlying medical conditions to Forty-eight percent resided in the particular signifi cance is the high determine if further testing conducted metropolitan area and 60% were male. proportion of extrapulmonary TB or facilitated by MDH may be disease in Minnesota. Over half (53%) indicated. In addition to provider There were 335 MED-X cases in 2011; of foreign-born TB cases and 43% reporting, death certifi cates are 108 of these also met UNEX criteria. of U.S.-born TB cases reported in reviewed for any deaths in persons The median age of the cases was 38 2011 had an extrapulmonary site of <50 years of age with no apparent years, and 61% were male. There disease. Among extrapulmonary TB signifi cant underlying conditions were 211 (63%) cases found through cases, by far the most common sites for possible unexplained infectious death certifi cate review. MEs reported of TB disease were lymphatic (51%), syndromes. 122 (36%) cases. The most common followed by bone/joint (15%), pleural syndrome was pneumonia/upper (13%), and various other sites that each In 2006, we began Medical Examiner respiratory infection (n=137 [41%]). represented less than 10% of such Infectious Deaths Surveillance Of the 335 cases, 117 (35%) were cases. (MED-X) to evaluate all medical confi rmed to have had an infectious examiner (ME) cases for infectious- cause, 130 (39%) had possible The national goal of TB elimination by related deaths. MEs report explained infectious causes, and 88 (26%) were 2010, which was established in 1989 by and unexplained cases to us. non-infectious or unknown cause. the Advisory Council for the Elimination Unexplained deaths in previously Pathogens determined to be related to of Tuberculosis in partnership with the healthy individuals < 50 years of age the cause of death are described below CDC, remains unmet, both nationally are included regardless of infectious (Table 5). and in Minnesota. The incidence of TB hallmarks; this primarily includes disease reported annually in the United Sudden Unexplained Infant Deaths There were 148 cases that had States has decreased each year since (SUIDs). In addition, we review specimens tested at the PHL and/ 1993, albeit at a decelerating rate of death certifi cates for any case in or the IDPB. Thirty cases had decline in recent years. In Minnesota, which an autopsy was performed pathogens identifi ed as confi rmed or the incidence of TB disease increased by an ME with a potential infectious probable cause of illness, including throughout much of the 1990s and cause of death. Cases found through 22 UNEX cases (Table 5). Among fl uctuated during the past decade, death certifi cate review are also 43 unexplained deaths occurring in with peaks in 2001 (239 cases) and considered for UNEX surveillance if those <50 years of age without any 2007 (238 cases). From 2008 through they are <50 years of age and have no immunocompromising conditions, 17 2010, the statewide TB incidence rate immunocompromising conditions. (40%) were explained by UNEX testing. decreased an average of 17% per year. ME surveillance detected an additional The signifi cant and largely sustained Testing of pre-mortem and post- 24 cases with pathogens identifi ed by annual decreases in Minnesota’s TB mortem specimens is conducted MEs as the cause of death (Table 5). incidence rate since 2007 appear to at the PHL and the CDC Infectious Cases with pathogens of public health be optimistic indicators of a real and Diseases Pathology Branch (IDPB). importance detected included a 33 substantial reduction in the occurrence Cases are excluded from UNEX if they year-old previously healthy male who of TB in Minnesota. This decline likely is are determined to be explained by died suddenly after a 1-week history attributable to several factors, including providers, are not critically ill, or have of an upper respiratory infection. dramatic decreases in the number of no infectious disease hallmarks. At autopsy he was found to have primary refugees resettling in Minnesota bilateral acute bronchopneumonia.

22 DCN 39;1 2012 We identifi ed Group A Streptococcus from bilateral lung cultures. A 5-month Table 5. UNEX/MED-X Cases with Pathogens Identifi ed as Confi rmed, old was found unresponsive and died Probable, or Possible Cause of Illness, 2011* with a history of illness and with sick Pathogen Identifi ed UNEX (n=22) MED-X (n=24)** contacts. PCR testing detected human Aspergillus fumigatus 1 metapneumovirus as the likely cause Bocavirus 2 of infection. A 14 year-old previously 1 healthy female died after history of 1 an infl uenza-like illness. We detected Cytomegalovirus 1 Enterobacter aerogenes 1 infl uenza B virus and methicillin- Enterovirus 1 1 resistant Staphylococcus aureus. Escherichia coli 2 Group A Streptococcus 2 3 Varicella and Zoster Group B Streptococcus 3 Unusual case incidence, individual criti- Haemophilus infl uenzae 2 cal cases, and deaths due to varicella Hepatitis C virus 1 and zoster are reportable. The report- 2 1 ing rules allow for the use of a sentinel Human immunodefi ciency virus 2 Infl uenza A virus 1 school surveillance system to monitor Infl uenza A-H1N1 1 varicella and zoster incidence until the Infl uenza B virus 1 system no longer provides adequate Klebsiella pneumoniae 1 1 data for epidemiological purposes, at Listeria monocytogenes 1 which time case-based surveillance will Metapneumovirus 3 be implemented. This summary repre- Neisseria meningitidis 1 sents the sixth full year of surveillance. Parainfl uenza virus 3 1 Picornavirus 1 Pneumocystis spp. 1 Six cases of critical illness, but no 3 deaths, due to varicella were reported. Respiratory syncytial virus 1 All 6 were hospitalized for 4 to 8 days. Rhinovirus 1 Complications included meningitis and Staphylococcus aureus 3 1 bacterial super-infection. Two cases Staphylococcus aureus-MRSA 2 had an underlying medical condi- Staphylococcus spp. 1 tion and recent history of treatment Streptococcus agalactiae 1 Streptococcus pneumoniae 4 2 with immunosuppressive drugs. Both Streptococcus viridians 1 were children with juvenile and bo th were being treated * Some cases had multiple pathogens identifi ed as possible coinfections contributing to with methotrexate. The other cases had illness/death. no or unknown underlying conditions ** MED-X includes pathogens identifi ed by the Medical Examiner. If the cause was found and were not known to be immunosup- through testing at MDH/CDC it is included in UNEX column. pressed. Five cases had not received ranged from 5 to 15 (median, 8.5) dur- expected to occur during a school year varicella-containing vaccine; 2 were ing the 2011-2012 school year com- among the 898,717 total school-aged adults, 2 were not vaccinated due to pared with 5 to 11 (median, 5) during children representing 0.07% of this parental refusal, and 1 was a very the 2010-2011 school year. population, for an incidence rate of 70.5 recent immigrant to the United States. per 100,000 population. Most cases Vaccination history for the other case, Surveillance data also include individual occurred among elementary school stu- age 20, was unknown. cases from sentinel schools through- dents, with an estimated incidence rate out Minnesota; these data are used to of 130.2 per 100,000 (536 of 411,536). An outbreak of varicella in a school is extrapolate to the statewide burden of defi ned as 5 or more cases within a sporadic disease. Eighty schools were Case-based reporting of varicella in 2-month period in persons <13 years selected and participated throughout all child care settings was initiated in of age, or 3 or more cases within a the 2011-2012 school year. A case of February 2010. In 2011, we received 2-month period in persons 13 years of varicella is defi ned as an illness with reports of 56 cases from 40 facili- age and older. An outbreak is consid- acute onset of diffuse (generalized) ties. Fifty-four (96%) were <6 years of ered over when no new cases occur maculopapulovesicular rash without age. By comparison, 111 cases were within 2 months after the last case is no other apparent cause; however, sentinel reported from February to December longer contagious. During the 2011- sites have been requested to also 2010. 2012 school year, we received reports report possible breakthrough infection of outbreaks from eight schools in eight that may present atypically. During the All suspected or confi rmed cases of counties involving 69 students and 2011-2012 school year, 35 cases were zoster with disseminated disease or no staff. By comparison, we received reported from 19 schools. None of the complications other than post-herpetic reports of outbreaks from fi ve schools in schools reported a cluster of cases that neuralgia, irrespective of age, are fi ve counties involving 31 students and met the outbreak defi nition. Based on reportable. During 2011, 50 cases no staff during the 2010-2011 school these data, an estimated 632 sporadic were reported; 44 were hospitalized. year. The number of cases per outbreak cases of varicella would have been Twenty-four cases were 60 years of age continued... DCN 39;1 2012 23 or older; 17 were 30 to 59 years of age; residents of the metropolitan area, 13 and 39 years of age. Six (30%) were and 9 were <30 years of age. Twenty- including 12 residents of Hennepin or black, 4 (20%) were white, 1 (5%) was three (46%) had underlying conditions Ramsey Counties. Fifteen (56%) of Asian, and 1 (5%) was multi-racial; or were being treated with immunosup- the cases were female. Cases ranged race was unknown for 8 (40%) cases. pressive drugs. Fifteen cases had dis- in age from 3 to 86 years (median, 27 No case was known to be of Hispanic seminated disease, 14 had meningitis, years). Nine (33%) were white, 4 (15%) ethnicity. Incidence rates were higher 9 had encephalitis or meningoencepha- were Asian, 2 (7%) were black, 1 (4%) among blacks (2.0 per 100,000) and litis, 7 had bacterial super-infection, and was American Indian, and 1 (4%) was Asians (0.4 per 100,000) than among 7 had severe ocular involvement. Two multi-racial; race was unknown for 10 non-Hispanic whites (0.1 per 100,000). cases with encephalitis subsequently (37%) cases. Hispanic ethnicity was died. reported for 2 cases (0.8 per 100,000). In addition to the 20 cases, 1 perinatal infection was identifi ed in We currently conduct zoster surveil- A risk factor was identifi ed for 20 (74%) an infant who tested positive for HBsAg lance in all schools. During the 2011- of the cases, 2 of whom had known during post-vaccination screening 2012 school year, 62 cases were exposure to a confi rmed hepatitis A performed between 9 and 15 months reported from schools in 27 counties, case. These persons became infected of age. The perinatal case was born representing 0.01% of the total school following exposure to a close contact, in 2010. The perinatal infection population of 898,717 for an incidence representing missed opportunities to occurred in an infant identifi ed through rate of 6.2 per 100,000 population. administer immune globulin or HAV a public health program that works Ages ranged from 6 to 18 years. As vaccine. Of the remaining 18 cases to ensure appropriate prophylactic compared to varicella, which is often di- with a risk factor identifi ed, 12 were treatment of infants born to HBV- agnosed by school heath personnel and associated with travel. Of these 12 infected mothers. The infected infant parents, most (91%) of the 58 zoster cases, 2 traveled to Mexico, Central, or was born in the United States and had cases for whom an interview could be South America. received hepatitis B immune globulin obtained were provider-diagnosed. All and 3 doses of in cases of zoster in individuals <18 years In 2011, there were no newly identifi ed accordance with the recommended of age are reportable. Additional cases outbreaks of hepatitis A. Two cases schedule and was therefore considered in children <18 years old were reported were associated with an outbreak in a treatment failure. Despite this failure, by child care sites (4 cases) and by Cottonwood County that began in 2010 the success of the public health providers (44 cases). In addition, death and resulted in 13 total cases. prevention program is demonstrated certifi cate data were reviewed to identify by the fact that an additional 357 zoster-related deaths in 2011. Three Viral Hepatitis B infants born to HBV-infected women deaths were identifi ed; all were >60 In 2011, 20 cases of symptomatic acute during 2010 had post-serologic testing years of age. hepatitis B virus (HBV) infection (0.4 demonstrating no infection. per 100,000 population) were reported, Since 2006, the U.S. Advisory Commit- with no deaths. In addition to these Viral Hepatitis C tee on Immunization Practices has rec- cases, 1 individual with documented In 2011, 18 cases of symptomatic acute ommended 2 doses of varicella vaccine asymptomatic seroconversion was hepatitis C virus (HCV) infection (0.3 for children. The Minnesota school im- reported. per 100,000) were reported. In addition munization law has required 2 doses of to the 18 cases, 4 individuals with vaccine for students entering kindergar- We also received 689 reports of newly asymptomatic, laboratory-confi rmed ten and grade 7 since 2010. Students identifi ed cases of confi rmed chronic acute HCV infection were reported. who will be in grades 3-6 and grades HBV infection in 2011. Prior to 2009, 10-12 during the 2012-2013 school year confi rmed and probable chronic cases Eleven (61%) cases resided in Greater were beyond kindergarten or beyond were reported in the year in which they Minnesota. The median age of all grade 7 when the law was implemented were fi rst reported. Beginning in 2009, cases was 28 years (range, 20 to 53 and therefore were not included in the only confi rmed cases are reported, and years). Nine (50%) cases were male. requirement. Children in these grades cases are reported in the year in which Eleven (61%) were white, 3 (17%) were should be evaluated to determine case-confi rming data are available. A American Indian, 2 (11%) were of other whether they need a second dose of total of 20,216 persons are assumed race, and 1 (1%) was black; race was varicella vaccine, particularly given the to be alive and living in Minnesota unknown for 1 (1%) case. increased severity of varicella in older with chronic HBV. The median age of children and adults. Older adolescents chronic HBV cases in Minnesota is 42 We received 1,793 reports of newly and adults should also be evaluated for years. identifi ed anti-HCV positive persons varicella immunity (history of varicella in 2011, the vast majority of whom are disease or 2 doses of varicella vaccine Acute cases ranged in age from 18 to chronically infected. A total of 37,303 at least 4 weeks apart) and offered 59 years (median, 45 years). Fourteen persons are assumed to be alive and varicella vaccine if indicated. (70%) cases were residents of the living in Minnesota with past or present metropolitan area, including 5 (25%) HCV infection. The median age of these Viral Hepatitis A in Hennepin County and 5 (25%) cases is 55. Because most cases are In 2011, 27 cases of hepatitis A (HAV) in Ramsey County. Fifteen (75%) asymptomatic, medical providers are (0.5 per 100,000 population) were cases were male and 6 (30%) were encouraged to consider each patient’s reported. Thirteen (48%) cases were adolescents or young adults between risk for HCV infection to determine the

24 DCN 39;1 2012 need for testing. Patients for whom testing is indicated include: persons with past or present injection drug use; recipients of transfusions or organ transplants before July 1992; recipients of clotting factor concentrates produced before 1987; persons on chronic hemodialysis; persons with persistently abnormal alanine aminotransferase levels; healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures to HCV-positive blood; and children born to HCV-positive women. Infants born to HCV-infected mothers should be tested at 12 to 18 months of age, as earlier testing tends to refl ect maternal antibody status. Persons who test positive for HCV should be screened for susceptibility to hepatitis A and B virus infections and immunized appropriately.

DCN 39;1 2012 25 Antimicrobial Susceptibilities of Selected Pathogens, 2011

On the following pages is the Antimicrobial Susceptibilities of Selected Pathogens, 2010, a compilation of antimicrobial sus- ceptibilities of selected pathogens submitted to MDH during 2010 in accordance with Minnesota Rule 4605.7040. Because a select group of isolates is submitted to MDH, it is important to read the notes entitled “Sampling Methodology” and “Trends, Comments, and Other Pathogens.” Please note the data on inducible clindamycin resistance for Group A and B Streptococcus

Trends, Comments, and Other Pathogens 1 Campylobacter spp. &LSURÀR[DFLQVXVFHSWLELOLW\ZDVGHWHUPLQHGIRUDOOLVRODWHV Q  2QO\RILVRODWHVIURPSDWLHQWVUHWXUQLQJIURPIRUHLJQWUDYHO Q  ZHUHVXVFHSWLEOHWRTXLQRORQHV6XVFHSWLEOLWLHVZHUHGHWHUPLQHGXVLQJ&/6,VWDQGDUGVIRUCampylobacter, or Enterobacteriaceae where Campylobacter standards were unavailable. 2 Antimicrobial treatment for uncomplicated gastroenteritis due to Salmonella is not generally recommended. (non-typhoidal) 3 Shigella spp. 7KHQXPEHURILVRODWHVWHVWHGLQZDVYHU\ORZ,QRILVRODWHVZHUHVXVFHSWLEOHWR6;7)RUFDVHVLQZKLFK WUHDWPHQWLVUHTXLUHGDQGVXVFHSWLELOLW\LVXQNQRZQRUDQDPSLFLOOLQDQG6;7UHVLVWDQWVWUDLQLVLVRODWHGSDUHQWHUDOFHIWULD[RQHD ÀXRURTXLQRORQH VXFKDVFLSURÀR[DFLQ RUD]LWKURP\FLQVKRXOGEHJLYHQ Red Book) 4 Neisseria gonorrhoeae Routine resistance testing for Neisseria gonorrhoeae by MDH PHL was discontinued in 2008. Susceptibility results were obtained from the CDC Regional Laboratory in Cleveland, Ohio, and are for isolates obtained through the Gonococcal Isolate Surveillance 3URJUDP7KHLVRODWHVWHVWHGZHUHUHFHLYHGIURPWKH5HG'RRU&OLQLFLQ0LQQHDSROLV5HVLVWDQFHFULWHULDIRUFH¿[LPH FHIWULD[RQHFHISRGR[LPHDQGD]LWKURP\FLQKDYHQRWEHHQHVWDEOLVKHGGDWDUHÀHFWUHGXFHGVXVFHSWLELOLW\XVLQJ&/6,DQG&'& provisional breakpoints (minimum inhibitory concentration >ȝJPO>ȝJPO>ȝJPODQG>ȝJPOUHVSHFWLYHO\  Also, the number of N. gonorrhoeae isolates submitted for testing decreased from 72 in 2010 to 47 in 2011. 5 Neisseria meningitidis ,QFDVHLVRODWHZDVLQWHUPHGLDWHWRSHQLFLOOLQDQGDPSLFLOOLQDVZHOODVUHVLVWDQWWR6;72QHDGGLWLRQDOFDVHLVRODWHZDV LQWHUPHGLDWHWRSHQLFLOOLQ6HYHQFDVHLVRODWHVZHUHUHVLVWDQWWR6;77KHUHZHUHQRFDVHLVRODWHVZLWKFLSURÀR[DFLQUHVLVWDQFH,Q LVRODWHVIURPFDVHVRFFXUULQJLQQRUWKZHVWHUQ01KDGQDOLGL[LFDFLG0,&V!—JPODQGFLSURÀR[DFLQ0,&VRI—JPO indicative of resistance. 6 Group A Streptococcus The 206 isolates tested represent 89% of 231 total cases. Among 18 erythromycin-resistant, clindamycin-susceptible or intermediate isolates 13 (72%) had inducible resistance to clindamycin for a total of 94% that were susceptible to clindamycin and did not exhibit inducible clindamycin resistance. 7 Group B Streptococcus 100% (21/21) of early-onset infant, 91% (10/11) of late-onset infant, 67% (2/3) of maternal, and 88% (440/500) of other invasive GBS cases were tested. Among 109 erythromycin-resistant, clindamycin susceptible or intermediate isolates 66 (61%) had inducible resistance to clindamycin for a total of 59% (277/473) that were susceptible to clindamycin and did not exhibit inducible clindamycin resistance. 52% (17/33) of infant and maternal cases were susceptible to clindamycin and did not exhibit inducible clindamycin resistance. 8 Streptococcus pneumoniae The 560 isolates tested represent 96% of 582 total cases. Reported above are the proportions of case-isolates susceptible by PHQLQJLWLVEUHDNSRLQWVIRUFHIRWD[LPHFHIWULD[RQH LQWHUPHGLDWH ȝJPOUHVLVWDQW>ȝJPO DQGSHQLFLOOLQ UHVLVWDQW >ȝJPO %\QRQPHQLQJLWLVEUHDNSRLQWV LQWHUPHGLDWH ȝJPOUHVLVWDQW>ȝJPO   RILVRODWHVZHUH VXVFHSWLEOHWRFHIRWD[LPHDQGFHIWULD[RQH%\QRQPHQLQJLWLVEUHDNSRLQWV LQWHUPHGLDWH ȝJPOUHVLVWDQW>ȝJPO  93% (519/560) of isolates were susceptible to penicillin. Isolates were screened for high-level resistance to rifampin at a single 0,&DOOZHUH<ȝJPO8VLQJPHQLQJLWLVEUHDNSRLQWV  RILVRODWHVZHUHUHVLVWDQWWRWZRRUPRUHDQWLELRWLFFODVVHV DQG  ZHUHUHVLVWDQWWRWKUHHRUPRUHDQWLELRWLFFODVVHV &/6,DOVRKDVEUHDNSRLQWVIRURUDOSHQLFLOOLQ9UHIHUWRWKH most recent CLSI recommendations for information). 9 +aemophilus inÀuen]ae In 2011, 22 (36%) of the case-isolates were resistant to ampicillin and produced ß-lactamase, but (all) were susceptible to amoxicillin-clavulanate, which contains a ß-lactamase inhibitor. 10 Mycobacterium tuberculosis 1DWLRQDOJXLGHOLQHVUHFRPPHQGLQLWLDOIRXUGUXJWKHUDS\IRU7%GLVHDVHDWOHDVWXQWLO¿UVWOLQHGUXJVXVFHSWLELOLW\UHVXOWVDUHNQRZQ (TB) Of the 22 drug-resistant TB cases reported in 2011, 21 (95%) were in foreign-born persons, including the three multidrug-resistant 0'57% FDVHV LHUHVLVWDQWWRDWOHDVWLVRQLD]LGDQGULIDPSLQ UHSRUWHGLQ7KHUHZHUHQRFDVHVRIH[WHQVLYHO\GUXJ UHVLVWDQW7% ;'57%  LHUHVLVWDQFHWRDWOHDVW,1+ULIDPSLQDQ\ÀXRURTXLQRORQHDQGDWOHDVWRQHVHFRQGOLQHLQMHFWDEOHGUXJ  Invasive methicillin-resistant 301 cases of invasive MRSA infection were reported in 2011 in Ramsey and Hennepin Counties, of which 202 (67%) were from Staphylococcus aureus blood. 80% (241/301) had an isolate submitted and antimicrobial susceptibility testing conducted. Of cases with an isolate, (MRSA)   ZHUHHSLGHPLRORJLFDOO\FODVVL¿HGDVKHDOWKFDUHDVVRFLDWHG$GGLWLRQDOVXVFHSWLELOLWLHVZHUHDVIROORZV WROLQH]ROLGDQGWHODYDQFLQWRGDSWRP\FLQGR[\F\FOLQHJHQWDPLFLQPLQRF\FOLQHYDQFRP\FLQULIDPSLQ6;7 WRWHWUDF\FOLQHWROHYRÀR[DFLQWRHU\WKURP\FLQ,VRODWHVZHUHVFUHHQHGIRUPXSLURFLQUHVLVWDQFHZLWKH[KLELWLQJ KLJKOHYHOUHVLVWDQFH 0,&!XJPO   ZHUHVXVFHSWLEOHWRFOLQGDP\FLQE\EURWKPLFURGLOXWLRQKRZHYHURI isolates that were clindamycin susceptible or intermediate and erythromycin resistant were found to have inducible resistance to clindamycin (32% susceptible and negative for inducible clindamycin resistance). For community-associated (CA) cases ZLWKLVRODWHV VXVFHSWLELOLWLHVZHUHDVIROORZVWRGDSWRP\FLQGR[\F\FOLQHJHQWDPLFLQOLQH]ROLGPLQRF\FOLQH PXSLURFLQULIDPSLQWHWUDF\FOLQHWHODYDQFLQYDQFRP\FLQWR6;7WROHYRÀR[DFLQWRHU\WKURP\FLQ   ZHUHVXVFHSWLEOHWRFOLQGDP\FLQE\EURWKPLFURGLOXWLRQKRZHYHURILVRODWHVWKDWZHUHFOLQGDP\FLQVXVFHSWLEOHRULQWHUPHGLDWH and erythromycin resistant were found to have inducible clindamycin resistance (85% susceptible and negative for inducible clindamycin resistance). In addition to invasive MRSA surveillance, MDH received 5 reports of isolates (3 MRSA and 2 MSSA) with intermediate resistance to vancomycin (MIC 4-8 —g/ml). Bordetella pertussis In 2011 no cases of pertussis were tested for susceptibility in Minnesota. Nationally, only 11 erythromycin-resistant B. pertussis FDVHVKDYHEHHQLGHQWL¿HGWRGDWH

Carbapenem-resistant Of 41 CRE isolates submitted from 40 cases, 21 (51%) were blaKPC positive by PCR including 11 (52%) E. cloacae, 9 (43%) Enterobacteriaceae (CRE) K. pneumoniae, and 1 (5%) C. freundii. 11 (52%) were residents of the 7-county metro area. Two submitted isolates were positive

for blaNDM-1 by PCR: 1 E. coli and 1 K. pneumoniaeIURPWKHVDPHFDVH7KHGH¿QLWLRQRI&5(LVEDVHGRQ&/6,EUHDNSRLQWV and includes Enterobacteriaceae that are nonsusceptible to a carbapenem (excluding ertapenem) and resistant to all tested third generation cephalosporins. Due to their intrinsic resistance to imipenem, additional criteria apply for all species of Proteus, Providencia, and Morganella. Escherichia coli O157:H7 Antimicrobial treatment for E. coli O157:H7 infection is not recommended.

26 DCN 39;1 2012 10† 8†§

Antimicrobial Susceptibilities 2‡ 2† 9†§ 7†§

of Selected Pathogens, 2011 6†§ 4

5†§

ae 1‡ ] uen spp. À 3‡ Typhimurium Typhimurium Streptococcus Streptococcus spp. Sampling Methodology † all isolates tested Salmonella enterica ‡ ~10% sample of statewide isolates received at MDH aemophilus in

§ isolates from a normally sterile site Campylobacter Salmonella Other serotypes (non-typhoidal) Shigella Neisseria gonorrhoeae Neisseria meningitidis Group A Group B Streptococcus pneumoniae Mycobacterium tuberculosis +

Number of Isolates Tested 91 105 50 9 47 15 206 473 560 62 101 % Susceptible amoxicillin 91 ampicillin 79 94 89 93 100 100 65 penicillin 0 87 100 100 76 FH¿[LPH 98 100 94 sodium 87 100

ß-lactam antibiotics 100 100 90 100 100 100 100 100 100 90 meropenem 100 90 100

FLSURÀR[DFLQ 731 100 100 100 72 100 100 OHYRÀR[DFLQ 100 99 99 99 D]LWKURP\FLQ 99 100 100 97 erythromycin 99 9150 66 clindamycin 99/946 72/597 89 chloramphenicol 83 98 100 99 98 99

Other antibiotics spectinomycin 100 tetracycline 58 21 96 86 97 WULPHWKRSULPVXOIDPHWKR[D]ROH 6;7 99 98 0 47 77 84 vancomycin 100 100 100

ethambutol 98 LVRQLD]LG 88 S\UD]LQDPLGH 87 rifampin TB antibiotics 100 100 97

and community associated methicillin-resistant Staphylococcus aureus. The MDH Antibiogram is available on the MDH Web site at: www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/antibiogram.html.

Laminated copies can be ordered from: Antibiogram, Minnesota Department of Health, Acute Disease Investigation and Control Section, PO Box 64975, St. Paul, MN 55164 or by calling 651-201-5414.

continued... DCN 39;1 2012 27 625 Robert Street North U.S. POSTAGE PAID PRESORTED STANDARD P.O. Box 64975 TWIN CITIES MN Saint Paul, Minnesota 55164-0975 PERMIT NO. 171

Edward P. Ehlinger, M.D., M.S.P.H., Commissioner of Health

Division of Infectious Disease Epidemiology, Prevention and Control

Ruth Lynfi eld, M.D...... State Epidemiologist Richard N. Danila, Ph.D., M.P.H...... Editor/Assistant State Epidemiologist David Determan ...... Production

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