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MINNESOTA DEPARTMENT OF HEALTH D ISEASE C ONTROL N EWSLETTER Volume 34, Number 3 (pages 25-52) May/August 2006 The Future of this Newsletter: A Message from Commissioner Dianne Mandernach I want to apologize for a confusing The Minnesota Department of Health make MDH publications even more announcement that was placed in the (MDH) takes pride in providing over 45 accessible on other websites. March/April 2006 issue of the Disease newsletters on various subjects, all of Control Newsletter (DCN) regarding which are posted on the agency’s To access future issues of the the termination of future publication. website, and available electronically. Disease Control Newsletter please Let me clarify that the DCN will I’d like to thank those who expressed go to this link: remain accessible in an electronic their viewpoints on this topic and for www.health.state.mn.us/divs/idepc/ format. the strong support for continuing newsletters/dcn/index.html and click electronic newsletter publications. on “Subscribe.” Subscribers will In an effort to improve efficiency, automatically be notified by email respect our resources, and evolve with MDH greatly values its relationships when the next DCN is posted on the changing business practices, I with physicians, health professionals, MDH website. To subscribe to other requested that agency newsletters and the public health community agency newsletters, go to: www.health. transition from printed mailings to across Minnesota. Previous state.mn.us, go to the left column and electronic format whenever possible. discussions with the Minnesota Board click on “Subscribe to News.” This transition was not intended to of Medical Practice and the Minnesota cause any agency newsletter to be Medical Association indicate that Thank you for your interest in public discontinued. electronic communication is becoming health issues and the work of MDH. the preferred method of reaching their Your partnership is important in members. By partnering with these working together to improve the health entities, new opportunities exist to of all Minnesotans. Annual Summary of Communicable Diseases Reported to the Minnesota Department of Health, 2005 Introduction ing control efforts, and evaluating Assessment of the population’s health prevention strategies. Prompt is a core public health function. reporting allows outbreaks to be Surveillance for communicable recognized in a timely fashion when Inside: diseases is one type of assessment. control measures are most likely to be Epidemiologic surveillance is the effective in preventing additional Recommended Childhood and systematic collection, analysis, and cases. Adolescent Immunization dissemination of health data for the Schedules, Minnesota, 2006......43 planning, implementation, and evalua- In Minnesota, communicable disease Antimicrobial Susceptibilities of tion of health programs. The Minne- reporting is centralized, whereby Selected Pathogens, 2005..........49 sota Department of Health (MDH) reporting sources submit standardized 12th Annual Emerging Infections collects information on certain infec- report forms to MDH. Cases of disease in Clinical Practice and Public tious diseases for the purposes of are reported pursuant to Minnesota Health Conference November determining disease impact, assessing Rules Governing Communicable 2-3(half-day), 2006, Program and trends in disease occurrence, charac- Diseases (MN Rules 4605.7000 - Registration..................................51 terizing affected populations, prioritiz- continued on page 27 Table 1. Diseases Reportable to the Minnesota Department of Health Report Immediately by Telephone Anthrax (Bacillus anthracis) a Q fever (Coxiella burnetii) a Botulism (Clostridium botulinum) Rabies (animal and human cases and suspected cases) Brucellosis (Brucella spp.) a Rubella and congenital rubella syndrome a Cholera (Vibrio cholerae) a Severe Acute Respiratory Syndrome (SARS) Diphtheria (Corynebacterium diphtheriae) a (1. Suspect and probable cases of SARS. 2. Cases of health Hemolytic uremic syndrome a care workers hospitalized for pneumonia or acute respiratory Measles (rubeola) a distress syndrome.) a Meningococcal disease (Neisseria meningitidis) (all invasive Smallpox (variola) a disease) a, b Tularemia (Francisella tularensis) a Orthopox virus a Unusual or increased case incidence of any suspect Plague (Yersinia pestis) a infectious illness a Poliomyelitis a Report Within One Working Day Amebiasis (Entamoeba histolytica/dispar) Malaria (Plasmodium spp.) Anaplasmosis (Anaplasma phagocytophilum) Meningitis (caused by viral agents) Arboviral disease (including but not limited to, Mumps LaCrosse encephalitis, eastern equine encephalitis, western Neonatal sepsis, less than 7 days after birth (bacteria isolated from equine encephalitis, St. Louis encephalitis, and a sterile site, excluding coagulase-negative West Nile virus) Staphylococcus) a, b Babesiosis (Babesia spp.) Pertussis (Bordetella pertussis) a Blastomycosis (Blastomyces dermatitidis) Psittacosis (Chlamydophila psittaci) Campylobacteriosis (Campylobacter spp.) a Retrovirus infection Cat scratch disease (infection caused by Bartonella spp.) Reye syndrome Chancroid (Haemophilus ducreyi) c Rheumatic fever (cases meeting the Jones Criteria only) Chlamydia trachomatis infection c Rocky Mountain spotted fever (Rickettsia rickettsii, R. canada) Coccidioidomycosis Salmonellosis, including typhoid (Salmonella spp.) a Cryptosporidiosis (Cryptosporidium spp.) a Shigellosis (Shigella spp.) a Cyclosporiasis (Cyclospora spp.) a Staphylococcus aureus (vancomycin-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 toxin-producing] E. coli, enteropathogenic E. coli, Syphilis (Treponema pallidum) c enteroinvasive E. coli, enterotoxigenic E. coli) a Tetanus (Clostridium tetani) Enterobacter sakazakii (infants under 1 year of age) a Toxic shock syndrome a Giardiasis (Giardia lamblia) Toxoplasmosis (Toxoplasma gondii) Gonorrhea (Neisseria gonorrhoeae) c Transmissible spongiform encephalopathy Haemophilus influenzae disease (all invasive disease) a,b Trichinosis (Trichinella spiralis) Hantavirus infection Tuberculosis (Mycobacterium tuberculosis complex) (Pulmonary or Hepatitis (all primary viral types including A, B, C, D, and E) extrapulmonary sites of disease, including laboratory Histoplasmosis (Histoplasma capsulatum) confirmed or clinically diagnosed disease, are reportable. Human immunodeficiency virus (HIV) infection, including Latent tuberculosis infection is not reportable.) a Acquired Immunodeficiency Syndrome (AIDS) a, d Typhus (Rickettsia spp.) Influenza (unusual case incidence, critical illness, or laboratory Unexplained deaths and unexplained critical illness confirmed cases) a, e (possibly due to infectious cause) a Kawasaki disease Varicella-zoster disease Kingella spp. (invasive only) a, b (1. Primary [chickenpox]: unusual case incidence, critical Legionellosis (Legionella spp.) a illness, or laboratory-confirmed cases. 2. Recurrent [shingles]: Leprosy (Hansen’s disease) (Mycobacterium leprae) unusual case incidence, or critical illness.) a Leptospirosis (Leptospira interrogans) Vibrio spp. a Listeriosis (Listeria monocytogenes) a Yellow fever Lyme disease (Borrelia burgdorferi) Yersiniosis, enteric (Yersinia spp.) a Sentinel Surveillance (at sites designated by the Commissioner of Health) Methicillin-resistant Staphylococcus aureus a Submission of clinical materials required. If a rapid, non- b Isolates are considered to be from invasive disease if they are culture assay is used for diagnosis, we request that positives isolated from a normally sterile site, e.g., blood, CSF, joint fluid, be cultured, and isolates submitted. If this is not possible, etc. send specimens, nucleic acid, enrichment broth, or other c Report on separate Sexually Transmitted Disease Report Card. appropriate material. Call the MDH Public Health Laboratory d Report on separate HIV Report Card. at 651-201-4953 for instructions. e For criteria for reporting laboratory confirmed cases of influenza, see www.health.state.mn.us/divs/idepc/dtopics/ reportable/index.html. 26 DCN 34;3 May/August 2006 Table 2. Cases of Selected Communicable Diseases Reported to the Minnesota Department of Health, by District of Residence, 2005 District* (population per U.S. Census 2005 estimates) Southwestern South Central Northwestern Southeastern Northeastern West Central Metropolitan (2,746,987) (5,132,799) Residence Unknown (154,939) (322,193) (690,953) (228,422) (285,218) (480,603) (223,484) Central Total Disease Anaplasmosis 52 8 20 99 0 0 7 0 0 186 Arboviral disease LaCrosse 2 0 0 0 0 0 0 0 0 2 West Nile 7 2 1 6 14 3 2 10 0 45 Campylobacteriosis 417 5 34 100 40 57 131 59 0 843 Cryptosporidiosis 26 1 12 33 17 13 34 30 0 166 Escherichia coli O157 infection 59 3 1 22 2 9 18 7 0 121 Hemolytic Uremic Syndrome 4 0 0 7 0 3 3 0 0 17 Giardiasis 932 11 47 94 12 33 94 18 0 1,241 Haemophilus influenzae invasive disease 22 1 3 11 5 3 5 3 0 53 HIV infection other than AIDS 198 0 5 4 0 3 3 6 3 222 AIDS (cases diagnosed in 2005) 141 2 8 10 0 4 5 6 1 177 Legionellosis 24 0 0 2 0 2 6 0 0 34 Listeriosis 12 0 0 0 0 0 2 1 0 15 Lyme disease 399 46 70 251 29 15 102 6 0 918 Meningococcal disease 11 0 0 2 1 0 2 0 0 16 Mumps 5 0 0 1 0 0 0 0 0 6 Pertussis 705 31 103 232 60 105 259 76 0 1,571 Salmonellosis 320 10 27 69 22 34 57 41 0 580 Sexually transmitted diseases* 11,122 317 734 1,101 191 502 909 356 643 15,875 Chlamydia trachomatis - genital infections 8,081 288 631 945 173 434 800 326 509 12,187 Gonorrhea 2,856 29 100 150 16 65 105 28 132 3,481 Syphilis, total 185 0 3 6 2 3 4 2 2 207 Primary/secondary 67 0 1 0 2 0 0 0 0 70 Early latent** 43 0 0 1 0 0 1 0 1 46 Late latent*** 70 0 1 5 0 3 2 2 1 84 Congenital 2 0 0 0 0 0 0 0 0 2 Other 3 0 1 0 0 0 1 0 0 5 Chancroid 0 0 0 0 0 0 0 0 0 0 Shigellosis 64 0 1 6 1 13 5 6 0 96 Streptococcus pneumoniae invasive disease 313 20 32 74 32 35 65 25 0 596 Streptococcal invasive disease - Group A 62 3 12 15 3 13 12 2 0 122 Streptococcal invasive disease - Group B 190 12 17 47 17 13 28 10 0 334 Tuberculosis 165 0 3 3 0 4 18 6 0 199 Viral hepatitis, type A 27 1 1 4 1 2 0 0 0 36 Viral hepatitis, type B (acute infections only, not perinatal) 25 1 2 5 4 1 3 1 0 42 Viral hepatitis, type C (acute infections only) 5 1 2 5 0 1 1 0 0 15 Yersiniosis 6 0 1 4 1 0 5 1 0 18 *Cases for which the patient’s residence is unknown are assigned the geographic location of the reporting clinic ** Duration <1 year *** Duration >1 year; Includes neurosyphillis County Distribution within Districts Metropolitan - Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, Washington Northwestern - Beltrami, Clearwater, Hubbard, Kittson, Lake of the Woods, Marshall, Pennington, Polk, Red Lake, Roseau Northeastern - Aitkin, Carlton, Cook, Itasca, Koochiching, Lake, St. Louis Central - Benton, Cass, Chisago, Crow Wing, Isanti, Kanabec, Mille Lacs, Morrison, Pine, Sherburne, Stearns, Todd, Wadena, Wright West Central - Becker, Clay, Douglas, Grant, Mahnomen, Norman, Otter Tail, Pope, Stevens, Traverse, Wilkin South Central - Blue Earth, Brown, Faribault, LeSueur, McLeod, Martin, Meeker, Nicollet, Sibley, Waseca, Watonwan Southeastern - Dodge, Fillmore, Freeborn, Goodhue, Houston, Mower, Olmsted, Rice, Steele, Wabasha, Winona Southwestern - Big Stone, Chippewa, Cottonwood, Jackson, Kandiyohi, Lac Qui Parle, Lincoln, Lyon, Murray, Nobles, Pipestone, Redwood, Renville, Rock, Swift, Yellow Medicine 4605.7800) which were recently report these diseases. Reporting Accountability Act (HIPAA) allow for updated (See “Revisions to the sources may designate an individual routine disease reporting without Communicable Disease Reporting within an institution to perform routine patient authorization. Rule” in the May/June 2005 issue [vol reporting duties (e.g., an infection 33. no. 3] of the Disease Control control professional for a hospital). Since April 1995, MDH has participated Newsletter [DCN]). The diseases listed Data maintained by MDH are private as an Emerging Infections Program in Table 1 (page 26) must be reported and protected under the Minnesota (EIP) site funded by the Centers for to MDH. As stated in the rules, physi- Government Data Practices Act Disease Control and Prevention (CDC) cians, health care facilities, laborato- (Section 13.38). Provisions of the and, through this program, has ries, and veterinarians are required to Health Insurance Portability and continued... DCN 34;3 May/August 2006 27 implemented active hospital- and case-patients (4%) also had objective species is likely. In 2005, cooler than laboratory-based surveillance for evidence of Lyme disease. The risk for normal spring weather may have several conditions, including selected HA is highest in many of the same shortened the time period available for invasive bacterial diseases and food- Minnesota counties where the risk of WNV to amplify efficiently between borne diseases. Lyme disease is greatest, including birds and mosquitoes, likely contribut- Aitkin, Cass, Crow Wing, and Pine ing to the reduced incidence. Interpret- Isolates for pathogens associated with Counties. ing the effect of weather on WNV certain diseases are required to be transmission is extremely complex, submitted to MDH (Table 1). The MDH For a discussion of the recent increase leading to great difficulty in predicting Public Health Laboratory performs in tick-borne disease in Minnesota and how many people will become infected microbiologic evaluation of isolates, the distribution of ticks that transmit HA in a given year. WNV appears to be such as pulsed-field gel electrophore- and other tick-borne diseases, see established throughout Minnesota; it sis (PFGE), to determine whether “Expansion of the Range of Vector- will probably be present in the state to isolates (e.g., enteric pathogens such borne Disease in Minnesota” in the some extent every year. The disease as Salmonella and Escherichia coli March/April 2006 issue (vol. 34, no. 2) risk to humans, however, will likely O157:H7 and invasive pathogens such of the DCN. continue to be higher in central and as Neisseria meningitidis) are related, western Minnesota where the primary and potentially associated with a Arboviral Disease moaquito vector, Culex tarsalis, is most common source. Testing of submitted LaCrosse encephalitis and Western abundant. Locally acquired cases of isolates also allows detection and equine encephalitis historically have WNV remain absent in the northeast- monitoring of antimicrobial resistance, been the primary arboviral encephaliti- ern third of Minnesota, which corre- which continues to be an important des found in Minnesota. During July sponds to the region where Cx. tarsalis problem. 2002, West Nile virus (WNV) was is rare or absent. identified in Minnesota for the first Table 2 summarizes cases of selected time. In 2005, WNV cases were During 2005, two cases of LaCrosse communicable diseases reported reported from 43 states and the District encephalitis were reported; both in during 2005 by district of the patient’s of Columbia; nationwide, 3,000 human members of the same family. The residence. Pertinent observations for cases of WNV disease were reported, disease, which primarily affects some of these diseases are discussed including 119 fatalities. The largest children, is transmitted through the bite below. WNV outbreaks during 2005 occurred of infected Aedes triseriatus (Eastern in California (880 cases), Illinois (252 Tree Hole) mosquitoes. Persons are Incidence rates in this report were cases), and South Dakota (229 cases). exposed to infected mosquitoes in calculated using disease-specific wooded or shaded areas inhabited by numerator data collected by MDH and In Minnesota, 45 cases of WNV this mosquito species, especially in a standardized set of denominator data disease were reported in 2005 (down areas where water-holding containers derived from U.S. Census data. from 148 cases in 2003). Twenty- (e.g., waste tires, buckets, or cans) Disease incidence may be categorized seven (60%) case-patients had West that provide mosquito breeding as occurring within the seven-county Nile (WN) fever; 13 (29%) had en- habitats are abundant. From 1985 Twin Cities metropolitan area or cephalitis, and five (11%) had meningi- through 2005, 121 cases were re- outside of it (Greater Minnesota). tis. The median age of all WN case- ported from 20 southeastern Minne- patients was 52 years (range, 26 to 82 sota counties, with a median of six Anaplasmosis years); WN encephalitis patients cases (range, 2 to 13 cases) reported Human anaplasmosis (HA) is the new tended to be younger than in recent annually. Disease onsets have been nomenclature for the disease formerly years (2005 median, 60 years; range reported from June through Septem- known as human granulocytic 36-82 years, vs. 2003-2004 median, ber, but most onsets have occurred ehrlichiosis. HA (caused by the 74 years; range, 38 to 96 years). Three from mid-July through mid-September. rickettsia Anaplasma phagocytophilum) WN encephalitis patients (82, 76, and is transmitted to humans by Ixodes 36 years old) died from their illness. Campylobacteriosis scapularis (deer tick or blacklegged The 36-year-old patient had pre- Campylobacter continues to be the tick), the same tick that transmits Lyme existing health problems. Twenty-nine most commonly reported bacterial disease. cases (64%) occurred among resi- enteric pathogen in Minnesota. There dents of western and southcentral were 843 cases of culture-confirmed HA case numbers increased from 139 Minnesota. The earliest case-patient Campylobacter infection reported in cases in 2004 (2.8 per 100,000 had onset of symptoms on June 29; 2005 (16.4 per 100,000 population). population) to a record high of 186 the latest on September 26. Similar to This represents a 6% decline from the cases (3.6 per 100,000 population) in previous years, the peak in illness 896 cases reported in 2004, continuing 2005. One hundred twenty-seven onsets was from July 15 through a trend in which the number of Campy- (68%) case-patients reported in 2005 September 15 (31 [69%] cases). lobacter cases has declined each year were male. The median age of case- since 2000 (Figure 1). The median patients was 57 years (range, 2 to 92 The field ecology of WNV is complex. annual number of cases reported from years). The peak in onsets of illness The virus is maintained in a mosquito- 2000 to 2004 was 941 (range, 896 to occurred in June and July (116 cases to-bird transmission cycle. Several 1,079). In 2005, 51% of cases oc- [62%]). Co-infections with Lyme mosquito and bird species may be curred in people who resided outside disease and HA can occur from the involved in this cycle, and regional the Twin Cities metropolitan area. Of same tick bite; during 2005, eight HA variation in vector and reservoir the 745 Campylobacter isolates 28 DCN 34;3 May/August 2006 confirmed and identified to species by due largely to the use of both occurred in child daycare settings MDH, 91% were C. jejuni and 7% were fluoroquinolones in poultry (the primary (three confirmed cases for one C. coli. source of Campylobacter for humans) outbreak and three confirmed cases in the United States, which began late plus one probable case for the second) The median age of case-patients was in 1995. In 2005, 9% of C. jejuni with person-to-person transmission 32 years (range, 1 month to 94 years). isolates from patients who acquired the responsible for the cases. Sixty-seven percent of cases were infection domestically were resistant to between 20 and 49 years of age, and fluoroquinolones. Because of the Escherichia coli O157 Infection and 16% were 5 years of age or younger. public health risk associated with the Hemolytic Uremic Syndrome (HUS) Fifty-seven percent of cases were use of fluoroquinolones in poultry, the During 2005, 121 culture-confirmed male. Thirteen percent of case-patients United States Food and Drug Adminis- cases of Escherichia coli O157 were hospitalized; the median length of tration (FDA) withdrew the approval of infection (2.4 per 100,000 population) hospitalization was 2 days. Forty-nine enrofloxacin (a veterinary were reported. This represents a 10% percent of infections occurred during fluoroquinolone) for use in poultry in increase from the 110 cases reported June through September. Of the 778 September 2005. in 2004 and a 33% decrease from the (92%) case-patients for whom data median number of cases reported were available, 187 (24%) reported Cryptosporidiosis annually from 1997 to 2004 (median, travel outside of the United States During 2005, 166 confirmed cases of 181 cases; range, 110 to 219). Fifty- during the week prior to illness onset. cryptosporidiosis (3.2 per 100,000 nine (49%) cases occurred in the Twin The most common travel destinations population) were reported. This is Cities metropolitan area. The remain- were Mexico (n=58), Asia (n=36), similar to the median number of cases ing 62 cases occurred throughout Central or South America or the reported annually from 1996 to 2004 Greater Minnesota. One hundred two Caribbean (n=35), and Europe (n=34). (median, 173 cases; range, 81 to 242). (84%) cases occurred during May There were no outbreaks of campylo- The median age of case-patients in through October. The median age of bacteriosis identified in 2005. 2005 was 19 years (range, 4 months to case-patients was 15.5 years (range, 1 87 years). Children 10 years of age or to 83 years). Forty-six (38%) case- A primary feature of public health younger accounted for 35% of cases. patients were hospitalized; the median importance among Campylobacter Fifty-two percent of cases occurred duration of hospitalization was 3 days cases was the continued presence of during July through October. The (range, 1 to 33 days). Campylobacter isolates resistant to incidence of cryptosporidiosis in the fluoroquinoline antibiotics (e.g., Southwestern, West Central, and Three E. coli O157 outbreaks were ciprofloxacin), which are commonly Southeastern districts (13.4, 7.4, and identified during 2005. One of these used to treat campylobacteriosis. In 7.1 cases per 100,000 population, outbreaks was foodborne, associated 2005, the overall proportion of respectively) was significantly higher with consumption of prepackaged quinolone resistance among Campylo- than the statewide incidence. Only 26 nationally distributed lettuce salad. bacter isolates tested was 22%. (16%) reported cases occurred among This outbreak resulted in 23 confirmed However, 67% of C. jejuni isolates residents of the Twin Cities metropoli- cases in Minnesota, two confirmed from patients with a history of foreign tan area (1.0 per 100,000 population). cases in Wisconsin, and one confirmed travel, regardless of destination, during Thirty-two (19%) case-patients case in Oregon. There were two the week before illness onset were required hospitalization, for a median associated cases of hemolytic uremic resistant to fluoroquinolones. Domesti- of 3 days (range, 1 to 11 days). One syndrome (HUS). There was one cally-acquired quinolone-resistant C. case-patient was known to be HIV- daycare-associated outbreak of E. coli jejuni infections have also increased in infected. Two outbreaks of cryptospo- O157, resulting in seven confirmed recent years. This increase likely is ridiosis were identified during 2005; cases and two cases of HUS. The route of transmission was likely person-to-person. There was one Figure 1. Reported Cases of Campylobacter, Salmonella, Shigella, and waterborne outbreak of E. coli O157, at Escherichia coli O157:H7 Infection, Minnesota, 1996-2005 a swimming beach, resulting in four confirmed cases. There were no associated HUS cases. In 2005, 17 HUS cases were reported. There were no fatal cases. From 1997 to 2005, the median annual number of reported HUS cases in Minnesota was 15 (range, 9 to 25), and the overall case fatality rate was 7.6%. In 2005, the median age of HUS case-patients was 6 years (range, 1 to 58 years); all cases but one occurred in children. All 17 case-patients were hospitalized, with a median hospital stay of 11 days (range, 2 to 70 days). Fifteen of the 17 HUS cases reported in 2005 were continued... DCN 34;3 May/August 2006 29 post-diarrheal. E. coli O157:H7 was camping or hiking prior to onset, and The five deaths occurred in patients cultured from the stool of nine (53%) 41% reported swimming or entering ranging in age from newborn to 91 case-patients. No non-O157 shiga water. Forty-five percent of adult case- years. Four case-patients presented toxin-producing E. coli were isolated patients reported having children in with pneumonia and one with bacter- from case-patients. E. coli O157 their households; 48% of those case- emia without another focus of infec- serology was positive in three HUS patients had children in diapers. tion. All case-patients had H. patients with a negative stool culture. Twenty-six percent of adults reported influenzae isolated from blood. Three changing a diaper prior to onset. had significant underlying medical Giardiasis Among pediatric cases, 31% of conditions, including the premature During 2005, 1,241 cases of Giardia interviewed parents reported that their newborn (29 weeks gestation). Four of infection (24.2 per 100,000 population) child had contact with a childcare the isolates from the five deceased were reported. This represents an 11% setting prior to and/or during illness. case-patients were untypeable isolates decrease from the 1,398 cases and one isolate was serotype f. reported in 2004; however, this figure Haemophilus influenzae Invasive is greater than the median number of Disease HIV Infection and AIDS cases reported annually from 1996 Fifty-three cases of invasive Surveillance for AIDS has been through 2004 (median, 1,098 cases; Haemophilus influenzae disease (1.0 conducted in Minnesota since 1982. In range, 851 to 1,556). Of the total per 100,000 population) were reported 1985, when the FDA approved the first number of Giardia cases for 2005, 697 in 2005. Case-patients ranged in age diagnostic test for HIV, Minnesota (56%) represented positive tests from newborn to 98 years (median, 62 became the first state to make HIV during routine screenings of recent years). Twenty (38%) case-patients had infection a reportable condition; 43 immigrants and refugees. pneumonia, 20 (38%) had bacteremia states now require HIV infection without another focus of infection, two reporting. The median age for all case-patients (4%) had meningitis, and 11 (21%) had reported in 2005 was 11 years (range, other conditions. Five (9%) deaths The incidence of HIV/AIDS in Minne- 3 months to 91 years). The median were reported among these case- sota is moderately low. In 2004, state- age among non-immigrant cases was patients. specific AIDS incidence rates per 34 years (range, 6 months to 91 100,000 population ranged from 0.8 in years). As in previous years, cases Of 47 H. influenzae isolates for which Montana to 39.7 in New York, with 4.3 were clustered among children less typing was performed at MDH, 13 cases per 100,000 population reported than 5 years of age (28%); only 11% of (28%) were type f, two (4%) type a, one in Minnesota. Similar comparisons for cases were over 50 years of age. (2%) type e, one (2%) type b, and 30 HIV (non-AIDS) incidence rates are not Overall, 3% of case-patients were (64%) were untypeable. possible, because some states only hospitalized; 8% of case-patients over began HIV (non-AIDS) reporting 50 years of age were hospitalized. One case of type b (Hib) disease recently. There was one outbreak of giardiasis occurred in 2005, compared to two in Minnesota in 2005; the outbreak cases in 2004, and five cases in 2003. As of December 31, 2005, a cumula- (seven cases) occurred in a child The 2005 Hib case occurred in an adult tive total of 7,824 cases of HIV daycare setting with person-to-person older than 30 who had significant infection have been reported, 4,812 transmission. underlying medical conditions. The AIDS cases and 3,012 HIV (non-AIDS) case-patient had bacteremia and cases. Of these HIV/AIDS case- MDH began systematically interviewing survived. cases of giardiasis in January 2002 to better characterize the illness and Figure 2. HIV (non-AIDS) and AIDS Cases by Year of Diagnosis, and AIDS evaluate potential risk factors for Deaths by Year of Death, Minnesota, 1990-2005 infection. In 2004, 75% of the non- immigrant cases were interviewed. The symptoms most commonly reported by case-patients included diarrhea (95%), fatigue (78%), abdominal pain (77%), gas or bloating (77%), weight loss (67%) and nausea (65%); less com- monly reported symptoms included vomiting (38%), and fever (30%). The median duration of diarrhea was 22 days (range, 1 to 212 days). Case-patients were interviewed about potential exposures during the 14 days prior to their illness onset. Forty-one percent of interviewed case-patients reported traveling prior to their onset. Among travelers, 46% reported travel outside the United States. Nineteen percent of case-patients reported 30 DCN 34;3 May/August 2006 patients, 2,772 (35%) are known to Females account for an increasing and abroad, nearly 40% of the recent have died. percentage of new HIV infections, from syphilis cases in Minnesota among 10% of new infections in 1990 to 29% MSM were co-infected with HIV, some The annual number of AIDS cases over the past few years. Trends in HIV for many years. “Burn out” from reported in Minnesota increased infections diagnosed annually among adopting safer sexual practices and steadily from the beginning of the females also differ by race/ethnicity. exaggerated confidence in the efficacy epidemic through the early 1990s, Early in the epidemic, whites ac- of HIV treatments may be contributors reaching a peak of 370 cases in 1992. counted for the majority of newly to resurging risky sexual behavior Beginning in 1996, the annual number diagnosed infections in women. Since among MSM. CDC recommends of new AIDS diagnoses, and deaths 1991, the number of new infections annual screening for sexually transmit- among AIDS case-patients, declined among women of color has exceeded ted diseases (including HIV and sharply, primarily due to new that of white women. The annual syphilis) for sexually active MSM and antiretroviral therapies, which delay the number of new HIV infections diag- more frequent screening for MSM who progression from HIV infection to AIDS nosed among U.S.-born black females report sex with anonymous partners or and improve survival. In 2005, 177 new had remained stable at 20 or fewer in conjunction with drug use. AIDS cases and 50 deaths among cases the past 4 years, but increased AIDS patients were reported (Figure to 28 new cases in 2005. During the The number and percentage of HIV 2). same time period the number of new infections in Minnesota that are infections among African-born females attributed to injection drug use have The annual number of newly diag- increased greatly from 18 cases in declined over the past decade for men nosed HIV (non-AIDS) cases reported 2000 to 33 in 2004. In 2005, 28 new and women, falling from 17% (80/470) in Minnesota has remained fairly cases were diagnosed in this group. of cases in 1991 to 1% (3/304) in constant since the mid-1990s, with 222 The annual number of new infections 2005. Heterosexual contact with a reported in 2005. This trend, coupled diagnosed among Hispanic, American partner who has or is at increased risk with improved survival, has led to an Indian, and Asian females is small, of HIV infection is the predominant increasing number of persons in with 10 or fewer cases annually in mode of exposure to HIV for women. Minnesota living with HIV or AIDS. each group. Eighty percent of 88 new HIV diag- Approximately 5,200 persons with HIV/ noses among women in 2005 can be AIDS were residing in Minnesota at the Despite relatively small numbers of attributed to heterosexual exposure end of 2005. cases, persons of color are dispropor- after re-distributing those with unspeci- tionately affected by HIV/AIDS in fied risk (Lansky A, et al. A method for Historically, and in 2004, nearly 90% Minnesota. In 2005, non-white men classification of HIV exposure category (264/304) of new HIV infections (both comprised approximately 12% of the for women without HIV risk information. HIV [non-AIDS] and AIDS at first male population in Minnesota and 37% MMWR 2001; 50[RR-6]:29-40). diagnosis) reported in Minnesota occur of new HIV infections among men. in the Twin Cities metropolitan area. Similarly, persons of color comprised Historically, race/ethnicity data for HIV/ However, HIV or AIDS cases have approximately 11% of the female AIDS in Minnesota have grouped U.S.- been diagnosed in residents of more population and 74% of new HIV born blacks and African-born persons than 80% of counties statewide. HIV infections among women. It bears together as “black.” In 2001, MDH infection is most common in areas with noting that race is not considered a began analyzing these groups sepa- higher population densities and greater biological cause of disparities in the rately, and a marked trend of increas- poverty. occurrence of HIV, but instead race is ing numbers of new HIV infections a marker for other risk factors, includ- among African-born persons was The majority of new HIV infections in ing lower socioeconomic status and observed. In 2005, there were 48 new Minnesota occur among males. Trends education. HIV infections reported among in the annual number of new HIV Africans. While African-born persons infections diagnosed among males Since the beginning of the HIV comprise less than 1% of the state’s differ by race/ethnicity. New infections epidemic, male-to-male sex has been population, they accounted for 16% of occurred primarily among white males the predominant mode of exposure to all HIV infections diagnosed in Minne- in the 1980s and early 1990s. Although HIV reported in Minnesota, although sota in 2005. Until recently, culturally whites still comprise the largest the number and proportion of new HIV specific HIV prevention messages proportion of new HIV infections infections attributed to men who have have not been directed to African among males, the number of new sex with men (MSM) have declined communities in Minnesota. Taboos and infections in this population has since 1991. In 1991, 69% (324/470) of other cultural barriers make it challeng- decreased since 1991. In contrast to new HIV infections were attributed to ing to deliver such messages and to declining numbers of new HIV infec- MSM (or MSM who also inject drugs); connect HIV-infected individuals with tions among white males, the decline in 2005, this group accounted for 52% prevention and treatment services. among U.S.-born black males has of new infections (158/304). However, However in 2005, several African been more gradual, falling from a peak current attitudes, beliefs, and unsafe agencies were awarded HIV preven- of 81 new infections in 1992 to 38 new sexual practices documented in tion funds to initiate and in some cases infections in 2005. The number of HIV surveys among MSM nationwide, and continue prevention programs in these infections diagnosed among Hispanic a current epidemic of syphilis among communities. Additionally, collabora- and African-born males has increased MSM, documented in Minnesota and tions between MDH, the Minnesota annually, with 17 and 20 new infec- elsewhere, warrant concern. Similar to Department of Human Services, and tions, respectively, diagnosed in 2005. syphilis increases in other U.S. cities continued... DCN 34;3 May/August 2006 31 community-based organizations No pediatric, influenza-related deaths including 128 deaths have been serving African-born persons in were identified during the 2005-6 confirmed since January 2003, with an Minnesota are continuing to address influenza season. Two cases of overall case-fatality rate of 57%. Ten these complex issues. influenza-related encephalopathy were countries in Asia and Africa have identified. These included a 10-year- reported human cases of avian Influenza old male of unknown race with history influenza. Minnesota utilizes guidelines The Public Health Laboratory isolated of renal disease, and an 18-year-old developed by the CDC to assess ill influenza for the first time of the 2005- Asian male with no known underlying patients returning from affected 6 influenza season from a Minnesota medical conditions. Onsets occurred in countries. Currently, no cases of H5N1 resident on December 5, 2005, which March 2006 and November 2005, have been identified in Minnesota or represented an average start of respectively. the United States. Although person-to- activity. Since 1990-91, the first isolate person spread of H5N1 has likely typically has been between mid- A probable outbreak of influenza-like occurred in situations of very close November and mid-December. illness (ILI) in a school is defined as a contact, sustained person-to-person Influenza activity was sporadic in doubled absence rate with all of the spread has not been demonstrated. Minnesota until mid-January and didn’t following primary influenza symptoms peak until the second week in March. A reported among students: rapid onset, Listeriosis similar activity pattern was seen fever of >101º F, illness lasting 3 or Fifteen cases of listeriosis were nationally. more days, and at least one secondary reported during 2005. All 15 case- influenza symptom (e.g., myalgia, patients were hospitalized, and two Influenza surveillance relies on headache, cough, coryza, sore throat, died. The median age was 67 years reporting of selective individual cases chills). A possible ILI outbreak in a (range, 0 to 90 years). One case was a from clinics, hospitals, and laborato- school is defined as a doubled neonate born at 28 weeks of gestation, ries, as well as outbreak reporting from absence rate with reported symptoms hospitalized for 18 days; this case- schools and long-term care facilities. among students including two of the patient survived. Eleven cases had The current system for reporting primary influenza symptoms and at Listeria monocytogenes isolated from outbreaks has been in place since the least one secondary influenza symp- blood, two from cerebral spinal fluid, 1995-96 influenza season, and a tom. During the 2005-6 season, MDH one from joint fluid, and one from Sentinel Provider Influenza Network received reports of probable ILI peritoneal fluid. None of the cases was initiated in 1998-99 to conduct outbreaks from 116 schools in 40 were associated with a recognized active surveillance. Twenty-seven counties throughout Minnesota and outbreak. sentinel sites participated during the possible outbreaks in 81 schools in 30 2005-6 season. While the program has counties. Since 1988-89, the number The 15 cases reported in 2005 surpassed its goal of 20 sentinel sites of schools reporting suspected represent a sharp increase from the (i.e., one site per 250,000 population), influenza outbreaks has ranged from a five cases seen in 2004. From 2000 MDH plans to expand the network to low of 38 schools in 20 counties in through 2004, the number of cases ensure sites represent all areas of the 1996-97 to a high of 441 schools in 71 reported ranged from four to eight state. Clinics are particularly needed in counties in 1991-92. cases per year (median, 5 cases). The northern and southern areas of the number of cases reported in 2005 is state where coverage is sparse. An ILI outbreak is suspected in a long- comparable to the number of cases term care facility when three or more reported during 1997-1999, when 17 to In response to increasing influenza- residents in a single unit present with a 19 cases were reported per year. related encephalitis cases in children cough and fever (>101º F) or chills in Japan and reports of severe during a 48 to 72 hour period. An ILI Elderly persons, immunocompromised influenza in pregnant women in the outbreak is confirmed when at least individuals, pregnant women, and United States, enhanced influenza one resident has a positive culture or neonates are at highest risk for surveillance was implemented during rapid antigen test for influenza. Fifty acquiring listeriosis. Listeriosis the 2003-4 influenza season and has facilities in 20 counties reported generally manifests as meningoen- continued through the 2005-6 season. confirmed or suspected ILI outbreaks cephalitis and/or septicemia in neo- MDH requested reports of suspected in 2005-6. In all 50 facilities, influenza nates and adults. Pregnant women or confirmed cases of influenza-related was laboratory-confirmed by rapid may experience a mild febrile illness, encephalopathy or encephalitis in tests or culture. Since 1988-1989, the abortion, premature delivery, or children < 18 years of age, suspected number of long-term care facilities stillbirth. In healthy adults and children, or confirmed influenza-related deaths reporting ILI outbreaks has ranged symptoms usually are mild or absent. in children < 18 years of age, sus- from a low of six in 1990-91 to a high L. monocytogenes can multiply in pected or confirmed cases of influenza of 140 in 2004-5. refrigerated foods. and staphylococcal co-infection, suspected or confirmed influenza in The highly pathogenic avian strain of Lyme Disease hospitalized pregnant women, and influenza A (H5N1) continues to In 2005, 918 confirmed Lyme disease suspected cases of novel influenza. circulate in Southeast Asia while cases (17.9 cases per 100,000 Surveillance initiated in 2003 in the expanding to areas of Europe and population) were reported (Figure 3). Twin Cities metropolitan area to Africa, causing illness in poultry and This represents a 10% decrease from monitor influenza-related pediatric humans. The World Health Organiza- the record number of 1,023 (20.0 hospitalizations was also continued tion (WHO) reported on June 6, 2006 cases per 100,000 population) in 2004, through the 2005-6 season. that a total of 225 human cases but is markedly higher than the median 32 DCN 34;3 May/August 2006 number of cases reported annually of Lyme disease case exposures (124 tis. All cases were sporadic, with no from 1996 through 2004 (median, 464 [20%] of 612 cases). Risk for Lyme definite epidemiologic links. cases, range 252 to 1,023). In 2005, disease continues to be high in certain an additional 19 cases were classified counties at the northern and western One death occurred among cases as probable Lyme disease. Five edges (Becker, Beltrami, Clearwater, reported in 2005. An infant male died hundred seventy-one (62%) confirmed Hubbard, and Itasca Counties) and of bacteremia attributed to serogroup case-patients in 2005 were male. The southeastern edge (Houston County) B. The probable case, a 17-year-old median age of case-patients was 39 of Minnesota’s endemic area. male with a positive PCR and years (range, 1 to 90 years). Physi- serogroup B N. meningitidis isolated cian-diagnosed erythema migrans was For a discussion of the recent increase from an autopsy culture, died of present in 730 (80%) cases. Two in tick-borne disease in Minnesota and meningitis. hundred twenty-three (24%) cases had the distribution of ticks that transmit at least one late manifestation of Lyme Lyme disease and other tick-borne In the spring of 2002, MDH in collabo- disease (including 167 with a history of diseases, see “Expansion of the Range ration with CDC and other EIP sites objective joint swelling and 42 with of Vector-borne Disease in Minnesota” nationwide, began a case-control study cranial neuritis) and confirmation by a in the March/April 2006 issue (vol. 34, of risk factors for meningococcal positive Western blot test. Eight (1%) no. 2) of the DCN. disease among high school students in Lyme disease cases in 2005 also had Minnesota. One probable serogroup B objective evidence of human anaplas- Meningococcal Disease case, described previously, occurred mosis, another tick-borne disease Sixteen cases of Neisseria meningitidis among high school students in 2005. transmitted by Ixodes scapularis (deer invasive disease (0.3 per 100,000 tick or blacklegged tick). Onsets of population) were reported in 2005, In January 2005, a meningococcal illness peaked in July (43% of cases), compared to 24 cases in 2004. There polysaccharide-protein conjugate corresponding to the peak activity of were six (38%) serogroup B cases, five vaccine for serogroups A,C,Y, and W- nymphal Ixodes scapularis in mid-May (31%) serogroup C cases, and five 135 (MCV4) was licensed for use in through mid-July. (31%) serogroup Y cases. In addition, the United States for persons aged 11 there was one culture-negative to 55 years. The Advisory Committee Three hundred ninety-nine (43%) suspected case and one autopsy on Immunization Practices (ACIP) and cases occurred among residents of the culture-positive probable case of American Academy of Pediatrics (AAP) Twin Cities metropolitan area. How- meningococcal disease, that were recommend immunization with the new ever, only 64 (10%) of 612 case- positive by polymerase chain reaction vaccine at age 11-12 years or at high patients with known exposure likely (PCR) in the Public Health Laboratory. school entry as well as for college were exposed to infected I. scapularis freshmen living in dormitories and in metropolitan counties, primarily Case-patients ranged in age from 3 other groups previously determined to Anoka and Washington Counties. Most months to 82 years, with a mean of 24 be at high risk in the licensed age case-patients either resided in or years. Sixty-nine percent of the cases range. In addition to the high school traveled to endemic counties in east- occurred in the Twin Cities metropoli- student described previously whose central Minnesota or western Wiscon- tan area. Ten (63%) case-patients had serogroup was not covered in the sin. As in 2004, Crow Wing County bacteremia without another focus of vaccine, there was one case in an continued to have the highest number infection, and six (38%) had meningi- adolescent in 2005, a 12-year-old with serogroup Y disease. No cases were Figure 3. Reported Cases of Lyme Disease and Human Anaplasmosis identified as college students. See (HA) in Minnesota, 1996-2005* page 44 for MCV4 recommendations. Methicillin-Resistant Staphylococcus aureus (MRSA) Strains of Staphylococcus aureus that are resistant to methicillin and all beta- lactam antibiotics are referred to as methicillin-resistant Staphylococcus aureus (MRSA). Traditional risk factors for healthcare-associated (HA) MRSA include recent hospitalization or surgery, residence in a long-term care facility, and renal dialysis. In 1997, MDH began receiving reports of healthy young patients with MRSA infections. These patients had onset of their MRSA infections in the community and appeared to lack the established risk factors for MRSA. Although most of the reported infections were not severe, some resulted in serious continued... DCN 34;3 May/August 2006 33 illness or death. Strains of MRSA PFGE subtypes, and antibiotic Mumps cultured from persons without susceptibility patterns have been Six cases of mumps were reported to healthcare-associated risk factors for identified during the 6 years of CA- MDH during 2005; a total of 29 mumps MRSA are now known as community- MRSA sentinel surveillance. CA-MRSA cases were reported between 2000- associated MRSA (CA-MRSA). infections reported from the 12 2005. All six cases were reported sentinel surveillance sites have between October and December. CA-MRSA is defined as: a positive increased from 131 cases (12% of all culture for MRSA from a specimen MRSA infections reported) in 2000 to Four (67%) of the case-patients were obtained < 48 hours of admission to a 1,004 cases (34% of total MRSA white, non-Hispanic females ages 13, hospital; in a patient with no history of infections reported) in 2005. 34, 38, and 53 years. One case-patient prior MRSA infection or colonization; was a 48-year-old white, non-Hispanic no presence of indwelling percutane- MRSA is resistant to all beta-lactam male. The sixth case was a 7-year-old ous devices or catheters at the time of antimicrobials and beta-lactams female of unknown race and ethnicity. culture; and no history of hospitaliza- should no longer be used as the sole The 7 and 13-year-old case-patients tion, surgery, residence in a long-term empiric therapy for severely ill patients had a documented history of two care facility, hemodialysis, or perito- whose infections may be staphylococ- doses of mumps-containing vaccine. neal dialysis in the year prior to the cal in origin. However, all 2005 CA- The 34-year-old had a history of one positive MRSA culture. MRSA isolates tested to date have dose of mumps-containing vaccine. been susceptible to linezolid, synercid, The other three cases had no known MDH initiated active surveillance for rifampin, and vancomycin and most history of vaccination for mumps. One CA-MRSA at 12 sentinel hospital CA-MRSA isolates were susceptible to adult female case-patient was hospital- laboratories in January 2000. The trimethoprim-sulfamethoxazole (99%), ized for one day for clinical complica- laboratories (six in the Twin Cities gentamicin (99%), tetracycline (94%), tions including mastitis and oophritis; metropolitan area and six in Greater clindamycin (90%), and ciprofloxacin the adult male case-patient had Minnesota) were selected to represent (63%). Conversely, only 14% of CA- orchitis. Including 2004 and 2005, various geographic regions of the MRSA isolates in 2005 were suscep- eight of the 10 cases reported have state. Sentinel sites report all cases of tible to erythromycin. occurred in adults, highlighting the MRSA identified at their facilities and need to assess the mumps immuniza- submit all CA-MRSA isolates to MDH. The CDC classifies MRSA isolates into tion status of adults. The purpose of this surveillance is to pulsed-field types (PFTs) (currently determine demographic and clinical USA100-1200) based on genetic No source case was identified for four characteristics of CA-MRSA infections relatedness. (McDougal, L. et. al. of the cases. Three cases were in Minnesota, to identify possible risk Pulsed-field gel electrophoresis typing epidemiologically linked, including a factors for CA-MRSA, and to identify of oxacillin-resistant Staphylococcus 48-year-old index case with no known the antimicrobial susceptibility patterns aureus isolates from the United States: exposure, a 53-year-old household and molecular subtypes of CA-MRSA Establishing a national database. J contact who developed symptoms 15 isolates. A comparison of CA- and HA- Clin Microbiol. 2003;41:5113-20). CA- days after the index case’s onset, and MRSA using sentinel site surveillance MRSA isolates are most often classi- a 38-year-old co-worker of the house- data from 2000 demonstrated that CA- fied as PFT USA300 or USA400. In hold contact who subsequently and HA-MRSA differ demographically Minnesota, the predominant CA-MRSA developed symptoms 19 days later. and clinically, and that their respective PFT has changed dramatically over isolates are microbiologically distinct time. In 2000, 63% of CA-MRSA All six cases were laboratory confirmed (Naimi, T., et al. Community-onset and isolates were USA400 and 4% were by positive mumps IgM serology. Two healthcare-associated methicillin- USA300. In 2005, only 14% of CA- cases were additionally verified by a resistant Staphylococcus aureus in MRSA isolates were USA400 and 66% demonstrated rise in serum IgG Minnesota. JAMA. 2003;290(22):2976- were USA300. Because USA400 between acute and convalescent 84.) isolates are much more likely than specimens. One other case was also USA300 isolates to demonstrate confirmed by mumps virus isolation In 2005, 2,955 cases of MRSA infec- inducible clindamycin resistance (ICR) from a throat specimen. tion were reported to MDH by the 12 on disk diffusion testing, the change in sentinel hospital laboratories. Thirty- the predominant CA-MRSA PFT has Both IgM and IgG serologic testing as four percent (1,004/2,955) of these also been associated with a decrease well as viral culture should all be cases were classified as CA-MRSA; in the proportion of erythromycin- performed on suspect mumps cases. 64% (1,904/2,955) were classified as resistant, clindamycin-sensitive CA- False-positive indirect immunofluores- HA-MRSA, and 2% (47/2,955) could MRSA isolates demonstrating ICR cent antibody (IFA) tests for mumps not be classified. Isolates were from 93% in 2000 to 12% in 2005. IgM have been reported, particularly in received from 931 (93%) of the 1,004 persons who have been vaccinated for CA-MRSA cases. To date, antimicro- Critical illnesses or deaths due to mumps. Mumps can be confirmed by bial susceptibility testing has been community-associated S. aureus viral culture of buccal swabs, throat completed on 514 (55%) and pulsed- infection (both methicillin-susceptible swabs, urine, or spinal fluid speci- field gel electrophoresis (PFGE) and -resistant) are now reportable in mens. Specimens for viral culture subtyping has been completed for 309 Minnesota, as is vancomycin-interme- should be collected during the first 5 (33%) of these isolates. diate and vancomycin-resistant S. days of illness. aureus. Notable trends in total case numbers, 34 DCN 34;3 May/August 2006 Pertussis cases. Ninety-two (6%) of the total No cases of erythromycin-resistant B. During 2005, 1,571 (30.6/100,000 cases occurred in infants less than 6 pertussis have been identified in population) cases of pertussis were months of age, and 178 (11%) Minnesota since the first case was reported in Minnesota representing a occurred in children 6 months through identified in October 1999. Statewide, continuation of the increase first seen 4 years of age. Age was unknown for all 1,155 other isolates tested to date in 2004 when 1,368 cases reported in one case. have had low minimum inhibitory Minnesota. This increase occurred concentrations, falling within the nationally as well, and may be attribut- Infection in older children and adults reference range for susceptibility to the able to several factors including may result in exposure of unprotected antibiotics evaluated. Only eight other increased awareness of pertussis infants who are at risk for the most erythromycin-resistant B. pertussis among health care providers and the severe consequences of infection. cases have been identified to date in public, increased availability of more During 2005, 102 cases of pertussis the United States. sensitive diagnostic testing using PCR, were reported in infants less than 1 as well as a true increase in incidence. year of age. A likely source of expo- Laboratory tests should be performed Laboratory confirmation was available sure was identified for 49 (48%) on all suspected cases of pertussis. for 1,096 (70%) cases; 115 (10%) were cases; 33 (67%) were infected by Culture of B. pertussis requires confirmed by culture, and 981 (90%) adults 18 years of age and older, six inoculation of nasopharyngeal mucous were confirmed by PCR. In addition to (12%) were infected by an adolescent, on special media and incubation for 7 the laboratory-confirmed cases, 215 and 10 (20%) were infected by a child to 10 days. However, B. pertussis is (14%) cases were epidemiologically less than 13 years of age. Fifty-three rarely identified late in the illness; linked to culture-confirmed cases, and (52%) cases had no identified source therefore, a negative culture does not 260 (17%) met the clinical case of infection. For these cases, the rule out disease. A positive PCR result definition. Seven hundred five (45%) of source of infection was likely outside is considered confirmatory in patients the reported cases occurred in resi- the household. with a 2-week history of cough illness. dents of the Twin Cities metropolitan PCR can detect non-viable organisms. area. Although unvaccinated children are at Consequently, a positive PCR result highest risk for pertussis, fully immu- does not necessarily indicate current Paroxysmal coughing is the most nized children may also develop infectiousness. Patients with a 3-week commonly reported symptom. In 2005, disease. Disease in those previously or longer history of cough illness, 1,519 (97%) of the case-patients immunized is usually mild. Efficacy for regardless of PCR result, may not experienced paroxysmal coughing. currently licensed vaccines is esti- benefit from antibiotic therapy. Cultures Over one third (475, 30%) reported mated to be 71% to 84% in preventing are necessary for molecular and whooping. Although commonly referred serious disease, but waning immunity epidemiologic studies and for drug to as “whooping cough,” very young begins approximately 3 years after the susceptibility testing. Whenever children, older individuals, and persons last dose of DTaP. Of the 863 case- possible, culture should be done in previously immunized may not have patients who were 7 months to 15 conjunction with PCR testing. Direct the typical “whoop” associated with years of age, 615 (71%) are known to fluorescent antibody (DFA), provides a pertussis. Post-tussive vomiting was have received at least a primary series rapid presumptive diagnosis of reported in 749 (48%) of the cases. of three doses. Of the 203 cases in pertussis; however, because both Four hundred eighty-four (31%) case- persons 7 months through 6 years of false-positive and false-negative patients reported apnea. Infants and age, 34 (17%) received fewer than results can occur, DFA tests should not young children are at the highest risk three doses of DTP/DTaP vaccine be relied upon solely for laboratory for severe disease and complications. before onset of illness, and were confirmation. Serological tests are not Pneumonia was diagnosed in 44 (3%) considered preventable cases, 29 standardized and are not acceptable case-patients, 14 (32%) of whom were (14%) of cases in this age group had for laboratory confirmation. less than 18 months of age. Thirty-two unknown vaccine history. (2%) case-patients were hospitalized; Pertussis booster vaccines licensed in 23 (72%) of the hospitalized patients MDH reporting rules require that 2005 for persons 10 years of age and were younger than 6 months of age. clinical isolates of Bordetella pertussis older will help to decrease the inci- be submitted to the Public Health dence and transmission of pertussis in Due to waning immunity, either of Laboratory. Of the 115 culture- the community. The ACIP recommends natural infection or vaccine, pertussis confirmed cases, 100% of the isolates the routine use of Tdap vaccines in can affect persons of any age. The were received and subtyped by PFGE adolescents aged 11-18 years in place disease is increasingly recognized in and tested for antibiotic susceptibility of tetanus and diphtheria toxoids (Td) older children and adults; however, it is to erythromycin, ampicillin, and vaccines. See page 46 for more not clear whether it is a true increase trimethoprim-sulfamethoxazole. information. or due to changes in surveillance and Twenty-two distinct PFGE patterns reporting. During 2005, case-patients were identified; 11 of these patterns Salmonellosis ranged in age from 1 day to 83 years. occurred in only a single case isolate. During 2005, 580 culture-confirmed Four hundred twenty-three (27%) The two most common patterns cases of Salmonella infection (11.3 per cases occurred in persons 13 to 17 identified accounted for 53 (46%) of 100,000 population) were reported. years of age. Five hundred five (32%) the total isolates and they occurred This represents a 10% decrease from cases occurred in persons 18 years of throughout the year. the 643 cases reported in 2004 and a age and older. Persons 5-12 years of 7% decrease from the median annual age accounted for 24% (372) of all continued... DCN 34;3 May/August 2006 35 number of cases reported from 1996 to that was incorporated in the ice cream episode of STD is not considered a 2004 (median, 626 cases; range, 576 without being cooked first. case for surveillance purposes until a to 693) (Figure 1). Four serotypes, S. corresponding case report is submitted Enteritidis (130 cases) S. Typhimurium From June through August, five S. by a clinical facility. Additionally, case (120 cases), S. Newport (44 cases), Manhattan cases were identified. A reports contain critical demographic and S. Heidelberg (27 cases) ac- case-control study found that illness and clinical information that is not counted for 55% of cases reported in was statistically associated with available from laboratory reports. 2005. There were six cases of S. Typhi cilantro and pork. Two of the cases When a laboratory report is received infection. Three of the S. Typhi case- attended a funeral where pork and but no corresponding case report is patients traveled internationally (India, cilantro sandwiches were served. The received within 45 days, MDH mails a Pakistan Ethiopia) and developed remaining cases had eaten pork and/ reminder letter and case report form to symptoms during their travel or within or cilantro in their homes. the corresponding clinical facility. 2 weeks of their return; one case- Cases of syphilis and chancroid are patient arrived in the United States An outbreak of S. Enteritidis infections monitored through a mostly passive from Thailand approximately 3 months associated with eating frozen, surveillance system. Herpes simplex prior to the specimen collection date; microwaveable, stuffed chicken virus and human papillomavirus one case-patient immigrated from products was identified in 2005. Four infections are not reportable. Thailand 15 months prior to specimen case-patients had onsets in August collection; and one case-patient was a though December. Additional cases Although overall incidence rates for Hmong immigrant (immigration date with onsets in 2006 are still being STDs in Minnesota are lower than unknown). Six percent of salmonellosis reported, so the investigation contin- those in many other areas of the case-patients were less than 1 year of ues. This was the third outbreak in United States, certain population age, and 25% were 12 years of age or Minnesota associated with this type of subgroups in Minnesota have very younger. Twenty-six percent of case- chicken product since 1998. As a high STD rates. Specifically, STDs patients were hospitalized for their result, the United States Department of disproportionately affect adolescents, infection. Of 525 case-patients that Agriculture has required label changes young adults, and persons of color. were interviewed, 108 (21%) traveled to more clearly identify this product as internationally during the week prior to raw, and to have more adequate Chlamydia their illness onset. cooking instructions. Chlamydia trachomatis infection is the most commonly reported STD in A 78 year-old case-patient died. The In addition to the four outbreaks in Minnesota. In 2005, 12,187 chlamydia case-patient was hospitalized for Minnesota, 11 S. Enteritidis cases cases (248 per 100,000 population) nearly 2 months for gastrointestinal were part of an outbreak at all- were reported, representing a 5% symptoms. During her hospitalization, inclusive resorts in Jamaica during increase from 2004 (Table 3). S. Typhimurium was isolated from a January and February. A total of 70 diverticular abscess. cases from 12 states were identified. Adolescents and young adults are at The CDC collaborated with Jamaican highest risk for acquiring chlamydial Four outbreaks of salmonellosis were authorities in the investigation. The infection (Table 4). The chlamydia rate identified in 2005. All four outbreaks outbreak was associated with eggs is highest among 20 to 24-year-olds involved foodborne transmission. from a local farm. Pooling of eggs at (1,496 per 100,000 population), with the resorts, and cross-contamination of the next highest rate among 15 to 19- Four S. Heidelberg cases with illness other foods most likely contributed to year-olds (989 per 100,000). The onsets in January through March the outbreak. The S. Enteritidis phage- incidence of chlamydia among adults reported eating frozen, microwaveable type and PFGE pattern were previ- 25 to 29 years of age (620 per stuffed chicken products during the ously not known to be endemic to 100,000) is considerably lower but has week before illness onset. The Jamaica. Local farms were devastated increased in recent years. The implicated product is a raw chicken by Hurricane Ivan in 2004, and may chlamydia rate among females (355 product coated with a pre-browned have been repopulated with birds from per 100,000) is more than twice the breading that gives the appearance of the United States (where this phage- rate among males (138 per 100,000). being cooked. Products from a case- type and PFGE pattern are endemic). This difference is likely due to more patient’s home and product with the Three additional cases of S. Enteritidis frequent screening among women. same production date purchased at the of the same PFGE pattern were grocery store tested positive for S. identified in Minnesota in travelers to The incidence of chlamydia infection is Heidelberg. Jamaica from May through October, highest in communities of color (Table after the investigation ended. 4). The rate among blacks (1,535 per A multi-state outbreak of S. 100,000 population) is over 13 times Typhimurium infections associated with Sexually Transmitted Diseases higher than the rate among whites cake batter flavored ice cream from a Active surveillance for gonorrhea and (115 per 100,000). Although blacks national chain of ice cream shops was chlamydia was initiated in January comprise approximately 4% of identified by MDH in June. Twenty-six 2002. This involves cross-checking Minnesota’s population, they account cases were identified in nine states; laboratory-reported cases against for 26% of reported chlamydia cases. five of those cases were Minnesota cases reported by clinicians. Although Rates among Asian/Pacific Islanders residents. Case-patients had onsets of both laboratories and clinical facilities (282 per 100,000), American Indians illness from May through July. The are required to report STDs (512 per 100,000), and Hispanics (624 source of contamination was cake mix independently of each other, an 36 DCN 34;3 May/August 2006 per 100,000) are over two to five times Table 3. Number of Cases and Incidence Rates (per 100,000 population) higher than the rate among whites. of Chlamydia, Gonorrhea, and Syphilis, Minnesota, 2001-2005 Chlamydia infections occur throughout 2001 2002 2003 2004 2005 the state, with the highest reported Disease No. Rate No. Rate No. Rate No. Rate No. Rate rates in Minneapolis (717 per 100,000 8,369 170.0 10,118 206.0 10,807 220.0 11,601 236.0 12,187 248.0 Chlamydia population) and St. Paul (598 per 100,000). In 2005, the greatest Gonorrhea 2,708 55.0 3,050 62.0 3,237 66.0 2,957 60.0 3,481 71.0 increases for chlamydia have been seen in the suburbs and Greater Syphilis, Total 135 2.7 149 3.0 198 4.0 145 2.9 207 4.2 Minnesota with increases of 9 percent Primary/ and 6 percent respectively. Secondary 33 0.7 59 1.2 48 1.0 27 0.5 70 1.4 Early Latent 16 0.3 23 0.5 45 0.9 21 0.4 46 0.9 Late Latent* 81 1.6 65 1.3 105 2.1 95 1.9 84 1.7 Gonorrhea Other 3 0.1 1 0.00 0 0.0 1 0.02 5 0.1 Gonorrhea, caused by Neisseria 2 Congenital** 2 3.0 1 1.5 0 0.0 1 1.4 2.8 gonorrhoeae, is the second most Chancroid 1 0.0 0 0.0 0 0.0 0 0.0 0 0.0 commonly reported STD in Minnesota. D In 2005, 3,481 cases (71 per 100,000 Late latent syphilis includes neurosyphillis *D population) were reported, represent- Congenital syphilis rate per 100,000 live births **D ing an increase of 18% from 2004 Note: Data exclude cases diagnosed in federal or private correctional facilities (Table 3). Adolescents and young adults are at Table 4. Number of Cases and Incidence Rates (per 100,000 population) greatest risk for gonorrhea (Table 4), of Chlamydia, Gonorrhea, and Primary/Secondary Syphilis with incidence rates of 213 per by Residence, Age, Gender, and Race/Ethnicity, Minnesota, 2005 100,000 population among 15 to 19- year-olds, 320 per 100,000 among 20 Chlamydia Gonorrhea Syphilis to 24-year olds, and 199 per 100,000 Demographic Group No. Rate No. Rate No. Rate among 25 to 29-year-olds. Gonorrhea rates for males (65 per 100,000) and Total 12,187 248 3,481 71 70 females (77 per 100,000) are compa- Residence* rable. Communities of color are Minneapolis 2,742 717 1,274 333 42 11.0 disproportionately affected by gonor- St. Paul 1,718 598 684 238 8 2.8 rhea, with 45% of cases reported Suburban** 3,621 184 898 46 17 0.9 among blacks. The incidence of Greater Minnesota 3,597 158 493 22 3 0.1 gonorrhea among blacks (775 per 100,000) is approximately 35 times Age higher than the rate among whites (23 <15 years 132 12 36 3 0 0.0 per 100,000). Rates among American 15-19 years 3,703 989 797 213 1 0.3 Indians (118 per 100,000) and Hispan- 20-24 years 4,823 1,496 1,033 320 7 2.2 ics (85 per 100,000) are approximately 25-29 years 1,982 620 636 199 9 2.8 30-34 years 822 233 346 98 9 2.5 four to five times higher than among 35-44 years 560 68 432 52 28 3.4 whites. The rate among Asian/Pacific >45 years 165 10 201 12 16 1.0 Islanders (31 per 100,000) is similar to that among whites. Gender Male 3,364 138 1,571 65 67 2.8 Gonorrhea rates are highest in the Female 8,814 355 1,906 77 2 0.1 cities of Minneapolis and St. Paul Transgender^^ 9 --- 4 --- 1 --- (Table 4). The incidence in Minneapolis (333 per 100,000 population) is nearly Race^/Ethnicity White 4,980 115 976 23 55 1.3 1.5 times the rate in St. Paul (238 per Black 3,115 1,535 1,574 775 8 3.9 100,000), seven times higher than the American Indian 415 512 96 118 1 1.2 rate in the suburban metropolitan area Asian 475 282 53 31 1 0.6 (46 per 100,000), and 15 times higher Other 248 --- 71 --- 4 --- than the rate in Greater Minnesota (22 Unknown^^ 2,954 --- 711 --- 1 --- per 100,000). Hispanic^^^ 895 624 122 85 5 3.5 Quinolone-resistant Neisseria gonorrhoeae * Residence information missing for 509 chlamydia cases and 132 gonorrhea cases. ** Suburban is defined as the seven-county metropolitan area (Anoka, Carver, Dakota, While the overall rate of gonorrhea has Hennepin, Ramsey, Scott, and Washington Counties), excluding cities of Minneapolis and stayed relatively constant over the past St. Paul 3 years, the prevalence of quinolone- ^ Case counts include persons by race alone. Population counts used to calculate results resistant N. gonorrhoeae (QRNG) has include race alone or in combination. ^^ No comparable population data available to calculate rates increased approximately five-fold from ^^^ Persons of Hispanic ethnicity may be of any race continued... Note: Data exclude cases diagnosed in federal or private correctional facilities DCN 34;3 May/August 2006 37 1.4% in 2003 to 6.8% in 2005. Of 2004, and a 57% decrease from the by age group were similar between concern is the high prevalence among median number of cases reported these two geographic regions. For men who have sex with men (MSM), annually from 1999 to 2004 (median, example, there were 11.4 cases of which has increased from 0% in 2002, 222 cases, range, 68 to 904). invasive pneumococcal disease per to 8.9% in 2003, to 26.9% in 2004, and 100,000 Twin Cities metropolitan area to 30% in 2005. As a result, In 2005, S. sonnei accounted for 68 residents, and 11.9 cases per 100,000 fluoroquinolones (e.g. ciprofloxacin) (71%) cases, S. flexneri for 27 (28%), residents of Greater Minnesota. By age are no longer recommended for and S. boydii for 1 (1%). Case-patients group, annual incidence rates per treating gonorrhea in men with male ranged in age from 3 month to 77 100,000 Twin Cities area residents and sexual partners in Minnesota. years (median, 14 years). Forty-seven Greater Minnesota residents were, percent of case-patients were less than respectively, 27.4 and 21.3 cases Syphilis 10 years of age; children less than 5 among children aged 0-4 years; 3.6 Surveillance data for primary and years of age accounted for 26% of and 3.5 cases among children and secondary syphilis are used to monitor cases. Sixteen (17%) case-patients adults aged 5-39 years, 12.1 and 10.1 morbidity trends because they repre- were hospitalized. Sixty-seven percent cases among adults 40-64 years, and sent recently acquired infections. Data of case-patients resided in the Twin 39.2 and 40.7 cases among adults for early syphilis (which includes Cities metropolitan area, with 33% of aged 65 years and older. primary, secondary, and early latent all case-patients residing in Hennepin stages of disease) are used in out- County. In 2005, pneumonia accounted for 318 break investigations because they (53%) cases of invasive pneumococcal represent infections acquired within the One waterborne outbreak of shigellosis disease among all cases (i.e., those past 12 months and signify opportuni- occurred in Minnesota in 2005. Seven infections accompanied by bacteremia ties for disease prevention. confirmed S. sonnei cases were or isolation of pneumococci from identified among people who swam at another sterile site such as pleural Primary and Secondary Syphilis a beach in Carver County on July 9. fluid). The 170 pneumonia cases Although the incidence of primary/ That day, the well that served the among Twin Cities area residents secondary syphilis in Minnesota is changing house, toilets, handsinks, accounted for a similar proportion of all lower than that of chlamydia or shower, and drinking fountain failed. invasive disease in that group (54%) gonorrhea (Table 3), the rate almost Three portable toilets were provided for as the proportion among residents of tripled in 2005. Seventy cases of beach-goers. The National Weather Greater Minnesota (148 cases, 52%). primary/secondary syphilis (1.4 per Service reported a high temperature of Bacteremia without another focus of 100,000 population) were reported in 92ºF, and reports from Carver County infection accounted for 211 (35%) 2005 compared to 27 (0.5 per 100,000 Parks and case interviews indicated cases statewide, including 103 (33%) population) cases in 2004. that the beach was heavily utilized that cases in Twin Cities area residents and day. It is unclear how the beach water 108 (38%) cases in Greater Minnesota Early Syphilis was initially contaminated; however, as residents. Pneumococcal meningitis In 2005, the number of early syphilis Shigella is strictly a human pathogen, accounted for 30 (5%) cases state- cases increased by 142 percent with presumably the beach was contami- wide, including 14 (4%) of cases in 116 cases occurring in 2005 compared nated by an ill beach-goer. The lack of Twin Cities area residents and 16 (6%) to 48 cases in 2004. The incidence in changing facilities and handwashing cases in Greater Minnesota residents. particular, is the highest amongst men sinks likely contributed to the outbreak. Forty-four patients with invasive who have sex with men (MSM). Of the pneumococcal disease died (7%); 6% 116 early syphilis cases in 2005, 109 Every tenth Shigella isolate received at (20) of case-patients who were Twin (94%) occurred among men; 100 MDH was tested for antimicrobial Cities area residents and 8% (24) of (92%) of these men reported having resistance. Ten isolates were tested in case-patients who were Greater sex with other men; 38% of the MSM 2005; 40% were resistant to ampicillin, Minnesota residents. diagnosed with early syphilis were co- 50% were resistant to trimethoprim- infected with HIV. sulfamethoxazole, and 20% were In 1999, the year before the pediatric resistant to both ampicillin and pneumococcal conjugate vaccine Congenital Syphilis trimethoprim-sulfamethoxazole. (Prevnar, Wyeth-Lederle [PCV-7]) was Two cases of congenital syphilis were licensed, the rate of invasive pneumo- reported in Minnesota in 2005 (Table Streptococcus pneumoniae Invasive coccal disease among children < 5 3). Disease years in the Minneapolis-St. Paul Statewide active surveillance for metropolitan area was 111.7 cases/ Chancroid invasive Streptococcus pneumoniae 100,000. Over the years 2000-2002 Chancroid continues to be very rare in (pneumococcal) disease began in there was a major downward trend in Minnesota. No cases were reported in 2002, expanded from the Twin Cities incidence in this age group (Figure 4). 2005. metropolitan area, where active Compared with the lowest rate in 2002 surveillance has been ongoing since (22.5 cases/100,000) the incidence Shigellosis 1995. In 2005, 596 cases of invasive rate in this age group increased During 2005, 96 culture-confirmed pneumococcal disease were reported, slightly in the 3 following years, to 25.8 cases of Shigella infection (1.9 per including 313 cases among Twin Cities cases/100,000 in 2003, 29.0 cases/ 100,000 population) were reported metropolitan area residents, and 283 100,000 in 2004 and 27.4 cases/ (Figure 1). This represents a 41% cases among residents of Greater 100,000 in 2005 (Figure 3). Based on increase from the 68 cases reported in Minnesota. Incidence rates overall, and the distribution of serotypes among 38 DCN 34;3 May/August 2006 isolates from these cases, this in- MDH Antibiogram (see pages 49-50), The three remaining fatal cases had crease was limited to disease caused which gives detailed antimicrobial bacteremia with cellulitis. The deaths by non-vaccine serotypes (i.e. sero- susceptibility results of isolates tested occurred in persons ranging in age types other than the seven included in at the Public Health Laboratory from from 49 to 90 years. For the eight PCV-7) (Figure 3). This small degree of 2005 cases, and is available to deaths in patients with known health replacement disease due to non-PCV- download on the MDH website at: histories, significant underlying medical 7 serotypes, similar to that seen in www.health.state.mn.us/divs/idepc/ conditions were reported for all of the other parts of the country, has been far dtopics/antibioticresistance/ cases. outweighed by the declines in disease antibiogram.html. caused by PCV-7 serotypes. This trend Isolates were available for 115 (94%) supports the need for ongoing monitor- Streptococcal Invasive Disease - cases, all were subtyped using PFGE; ing, however, because further in- Group A 59 different molecular subtypes were creases due to non-vaccine serotypes One hundred twenty-two cases of identified. Thirty-eight subtypes were are possible. In Figure 3 rates of invasive group A streptococcal (GAS) represented by one isolate each; other invasive pneumococcal disease disease (2.4 per 100,000 population), subtypes were represented by two to among adults aged > 65 years are including nine deaths, were reported in 17 isolates each. No epidemiologic also shown by serotypes included and 2005, compared to 146 cases and 18 links were noted among cases with not included in PCV-7. Declines in deaths in 2004. Ages of case-patients indistinguishable subtypes. incidence in this age group, particularly ranged from 1 month to 96 years in disease due to PCV-7 serotypes (mean, 49 years). Fifty-one percent of The deaths were distributed among have been observed elsewhere in the case-patients were residents of the nine different PFGE subtypes with no United States and are likely attributable Twin Cities metropolitan area. Thirty- two deaths attributed to the same to herd immunity from use of PCV-7 nine (32%) case-patients had cellulitis subtype. among children. with bacteremia and 36 (30%) case- patients had bacteremia without Streptococcal Invasive Disease - Of the 532 isolates submitted for 2005 another focus of infection. There were Group B cases, 46 (9%) were highly resistant to 14 (12%) cases of primary pneumonia Three hundred thirty-four cases of penicillin and 75 (14%) exhibited and eight (7%) cases of necrotizing group B streptococcal invasive disease intermediate-level resistance; 92 fasciitis. Eight (7%) case-patients had (6.5 per 100,000 population), including isolates (17%) exhibited multi-drug septic arthritis and/or osteomyelitis, 22 deaths, were reported in 2005. resistance (i.e. high-level resistance to and two (2%) had streptococcal toxic These cases were those in which two or more drug classes). The shock syndrome (STSS) accompanied group B Streptococcus (GBS) was proportion of isolates submitted from by soft tissue infections. Ten (8%) isolated from a normally sterile site; Greater Minnesota residents with high- case-patients were residents of long- seven cases of miscarriage or stillbirth or intermediate-level resistance to term care facilities. None of the in which GBS was cultured from the penicillin (48/235, 20%) was somewhat facilities had more than one case- placenta were also reported. lower than the proportion from Twin patient. Cities area residents (73/297, 25%) but Overall, 142 (43%) cases presented the difference was not statistically The nine deaths included five cases of with bacteremia without another focus significant. S. pneumoniae is one of bacteremia without another focus of of infection. The other most common several pathogens included in the infection and one case of pneumonia. types of infection were cellulitis (17%), arthritis (9%), pneumonia (7%), Figure 4. Invasive Pneumococcal Disease Incidence Among osteomyelitis (7%), and meningitis Children <5 Years and Adults >65 Years, by Year and Serotype, (4%). The majority (75%) of cases had Seven County Twin Cities Metropolitan Area, 1999-2005 GBS isolated from blood only. Fifty- seven percent of cases occurred among residents of the Twin Cities metropolitan area. Thirty-two (10%) case-patients were infants less than 1 year of age, and 163 (49%) were 60 years of age or older. Forty-four cases of infant (early-onset or late-onset) or maternal GBS disease were reported, compared to 57 cases in 2004. Fifteen infants developed invasive disease within 6 days following birth (0.21 cases per 1,000 live births), and 17 infants became ill at 7 to 89 days of age. Seven stillbirths or spontaneous abortions were associated with 12 maternal invasive GBS infections. Year of Diagnosis Year of Diagnosis continued... DCN 34;3 May/August 2006 39 From 1997 to 2005, there were 230 tive of 1.0 case per 100,000 population disease or latent TB infection among early-onset disease cases reported, (Figure 5). patients who originate from regions and 12 infants died. Forty-five infants where TB is endemic. were born at less than 37 weeks’ The most distinguishing characteristic gestation and accounted for 20% of of the epidemiology of TB disease in The majority (74%) of foreign-born TB early-onset cases. Bacteremia without Minnesota is the very large proportion case-patients reported in Minnesota in another focus of infection (78%) was of TB cases reported among foreign- 2005 were 15 to 44 years of age, the most common type of infection in born persons, which has averaged whereas only 30% of U.S.-born TB these early-onset cases, followed by 81% over the past 5 years. In 2005, cases occurred among persons in this pneumonia (13%) and meningitis (7%). 173 (87%) new TB cases in Minnesota age category. In contrast, 47% of U.S.- The Prevention of Perinatal Group B occurred in persons born outside the born TB case-patients were 45 years of Streptococcal Disease, Revised United States. This exceptionally high age or older. The proportion of pediat- Guidelines from CDC published in percentage of foreign-born TB cases ric patients (less than 15 years of age) August 2002 include the following key reported in 2005 represents the largest was considerably larger among U.S.- changes: the recommendation for proportion of foreign-born cases born TB cases than among foreign- universal prenatal screening of all reported in Minnesota since 1992, born cases (23% versus 8%, respec- pregnant women at 35 to 37’ weeks when MDH began collecting data on tively), although most of the U.S.-born gestation and updated prophylaxis TB case-patients’ countries of birth. In pediatric cases were children born in regimens for women with penicillin contrast, 54% of TB cases reported the U.S. to foreign-born parents allergies. In light of these revised nationwide in 2005 were foreign-born. (Figure 7). These first-generation U.S.- guidelines, MDH reviewed the mater- born children appear to experience an nal charts for all 15 early-onset cases The 173 foreign-born TB case-patients increased risk of TB disease that more reported during 2005. Overall, 11 reported in Minnesota during 2005 closely resembles that of foreign-born (73%) of 15 women who delivered represent 31 different countries of persons. Presumably, these children GBS-positive infants underwent birth. The most common region of birth may be exposed to TB as a result of prenatal screening for GBS. Of these, among foreign-born TB cases reported travel to their parents’ country of origin three (27%) women were positive and in 2005 was sub-Saharan Africa (58%), and/or visiting or recently arrived family eight (73%) women were negative. followed by South/Southeast Asia members who may be at increased risk Among the four women who did not (24%) (Figure 6). The ethnic diversity for TB acquired overseas. receive prenatal screening for GBS, among these foreign-born TB cases one (25%) was screened upon reflects the unique and constantly Aside from foreign-born persons, other admission to the hospital and prior to changing demographics of immigrant high-risk population groups comprise delivery of her infant. Among the 15 and other foreign-born populations much smaller proportions of the TB women of infants with invasive GBS arriving in Minnesota. This diversity cases reported in Minnesota, each disease, four (27%) received intrapar- also poses significant challenges in representing less than 10% of cases tum antimicrobial prophylaxis (IAP). providing culturally and linguistically diagnosed statewide. Among TB cases One of the three women with a positive appropriate TB prevention and control reported in 2005, substance abuse GBS screening result received IAP. services for populations most affected (including alcohol abuse and/or illicit MDH continues to follow the incidence by and at risk for TB in Minnesota. drug use) was the most common of of GBS disease among infants, these other risk factors, with approxi- screening for GBS among pregnant Persons 15 years of age or older who mately 7% of TB case-patients having women, and the use of IAP for GBS- arrive in the United States as immi- a history of substance abuse during positive pregnant women during labor grants or refugees receive a medical the 12 months prior to their TB and delivery. evaluation overseas that includes diagnosis. The percentage of TB cases screening for pulmonary TB disease. in Minnesota with HIV co-infection has Tuberculosis Among 173 foreign-born persons who increased over the past 5 years yet While the number of cases of tubercu- were diagnosed with TB disease in remains less than that among all TB losis (TB) disease reported nationally Minnesota during 2005, 119 (69%) cases reported nationwide. Twelve has decreased each year since 1993, were diagnosed less than 5 years after (6%) of the 199 TB cases reported in the incidence of TB in Minnesota arriving in this country. Of 39 TB case- Minnesota during 2005 were infected increased throughout much of the patients 15 years of age or older who with HIV; eight (67%) of those HIV- 1990s and peaked at 239 TB cases were diagnosed within 12 months of infected TB case-patients were foreign (4.8 cases per 100,000 population) in their arrival in the United States and born, including five persons from 2001. In 2005, 199 new cases of TB who arrived as immigrants or refugees, Ethiopia and one person each from disease (3.8 cases per 100,000 only seven (18%) had any TB-related Cameroon, China, and Liberia. Other population) were reported in Minne- conditions noted in their pre-immigra- risk groups such as homeless persons, sota, which represents a plateau tion medical exams performed over- correctional facility inmates, and following a 3-year decline in the seas. These findings highlight the need residents of nursing homes each incidence of TB that occurred from for clinicians to have a high index of represented only 1-2% of TB cases 2002 through 2004. Although the suspicion for TB among newly arrived reported in 2005. statewide incidence of TB disease is foreign-born persons, regardless of the less than the national rate (4.8 cases results of medical exams performed Twenty-three (26%) of the state’s 87 per 100,000 population in 2005), the overseas. Health care providers should counties reported at least one case of incidence rate in Minnesota exceeds pursue thorough screening, evaluation, TB disease in 2005, with the majority the U.S. Healthy People 2010 objec- and, if indicated, treatment of active TB (83%) of cases occurring in the Twin 40 DCN 34;3 May/August 2006 Cities metropolitan area, particularly in Figure 5. Tuberculosis Incidence Rates per 100,000 Population, Hennepin (50%) and Ramsey (18%) United States and Minnesota, 1992-2005 counties, both of which have public TB clinics. Fifteen percent of TB cases occurred in the five suburban Twin Cities metropolitan counties (i.e., Anoka, Dakota, Carver, Scott, and Washington). Olmsted County, which maintains a public TB clinic staffed jointly by the Olmsted County Health Department and Mayo Clinic, repre- sented 5% of TB cases reported statewide in 2005. The remaining 12% of cases occurred in primarily rural areas of Greater Minnesota. In 2005, the highest TB incidence rate state- wide (8.6 cases per 100,000 popula- tion) was reported in Hennepin County, followed by Olmsted County (7.3 cases per 100,000 population) and Ramsey County (7.0 cases per 100,000 population). Drug-resistant TB is a critical concern Figure 6. Foreign-Born Tuberculosis Cases by Region of Birth and in the prevention and control of TB in Year of Diagnosis, Minnesota, 2001-2005 Minnesota, as well as nationally and globally. The prevalence of drug- resistant TB in Minnesota, particularly resistance to isoniazid (INH) and multi- drug resistance, exceeds comparable national figures. In 2005, 15 (10%) of 151 culture-confirmed TB cases were resistant to at least one first-line anti- TB drug (i.e., INH, rifampin, pyrazina- mide, or ethambutol). In particular, 13 (9%) cases were resistant to INH, and four (3%) cases were multidrug- resistant (i.e., resistant to at least INH and rifampin). These data represent a decrease in the prevalence of any first- line drug resistance and INH-resis- tance in 2005. In comparison, from 2001 through 2004, the average annual prevalence of any first-line drug resistance among culture-confirmed Figure 7. Tuberculosis Cases by Age Group and Place of Birth TB cases in Minnesota was 17%, and Minnesota, 2001-2005 the average prevalence of INH- resistance was 14%. In previous years, drug resistance has been considerably more common among foreign-born TB cases than among U.S.-born cases in Minnesota. In 2005, however, both INH resistance and multidrug-resistant (MDR)-TB were more common among U.S.-born TB cases than among foreign-born cases (10% versus 8%, and 5% versus 2%, respectively). Of particular concern, nine (38%) of 24 multidrug-resistant TB (MDR-TB) cases reported during the past 5 years (2001-2005) were resistant to all four first-line drugs. These nine pan- resistant MDR-TB case-patients represented seven different countries continued... DCN 34;3 May/August 2006 41 of birth (i.e., one each from Ethiopia, symptoms; one presented with sudden were positive for Streptococcus Laos, Moldova, South Korea, and unexpected death (SUD); one pre- pneumoniae. A postmortem blood Thailand, and two each from Somalia sented with hepatic symptoms; and sample also had a positive PCR result and the United States). One of the two two had illnesses that did not fit a for S. pneumoniae. A 50-year-old male U.S.-born pan-resistant patients had defined syndrome. Case-patients with who died of a respiratory syndrome resided in Africa for several years; the respiratory symptoms ranged from 4 had immunohistochemical test results other was a young child infected by a months to 60 years of age; those with of a lung sample that were positive for foreign-born family member. sepsis were 17 to 77 years of age; the S. pneumoniae and a PCR test result neurologic case-patients were 1 month of a lung sample that was positive for The epidemiology of TB in Minnesota to 65 years of age; the cardiac case- picornavirus. highlights the need to support global patients were 13 and 73 years of age; TB elimination strategies, as well as the sudden unexpected death was 11 Viral Hepatitis A local TB prevention and control months of age; the hepatic case- In 2005, 36 cases of hepatitis A (0.7 activities targeted to foreign-born patient was 17 years of age; and the per 100,000 population) were reported. persons. TB in Minnesota occurs case-patients without a defined Twenty-seven (75%) case-patients primarily, although not exclusively, syndrome were 43 and 72 years of were residents of the Twin Cities among foreign-born persons, with TB age. Nine patients with respiratory metropolitan area, including 15 (56%) case-patients representing many symptoms, four patients with sepsis, residents of Hennepin or Ramsey countries of origin and varied cultural two patients with neurologic symptoms, Counties. Thirty-one (86%) of the backgrounds. Although the incidence of and seven patients with a cardiac cases were male. Case-patients TB in Minnesota is less than the syndrome died as did one patient with ranged in age from 3 to 66 years national rate, the prevalence of drug- without a defined syndrome. Thirty (median age, 25 years). Race was resistant TB in Minnesota is high and patients resided in the Twin Cities reported for 25 (69%) cases, of whom extrapulmonary sites of disease are metropolitan area, 16 case-patients 20 (80%) were white, 4 (16%) were common, especially among foreign- resided in Greater Minnesota, and 10 black, and one (4%) was of unknown born cases. The proportion of TB cases case-patients were out-of-state race. No cases have been reported in occurring in persons under 15 years of residents hospitalized in Minnesota. American Indians since 2002. The age in Minnesota exceeds the compa- incidence rate of hepatitis A in Ameri- rable figure nationally, with many of Thirteen cases were eligible for the can Indians declined steadily from 10.4 these children being born to foreign- CDC project (five respiratory, one per 100,000 population in 1999 to 6.0, born parents. These trends suggest sepsis, two neurologic, four cardiac 3.7, and 2.5 per 100,000, respectively, that the incidence of TB in Minnesota is case(s); and one SUD). Specimens in 2000, 2001, and 2002 demonstrat- not likely to decrease in the foresee- were obtained for testing at MDH or ing the success of targeted immuniza- able future. CDC for 10 cases. Probable etiologies tion efforts initiated in 1999. Hispanic were established for two cases. A 34- ethnicity was reported for eight cases Unexplained Critical Illnesses and year-old female who died with respira- (5.6 per 100,000). Deaths of Possible Infectious tory symptoms had positive 16s PCR Etiology tests for Fusobacterium necrophorum One (3%) case-patient was an em- Surveillance for unexplained critical from tonsil and peritonsillar soft tissue ployee of a food-serving establish- illnesses and deaths of possible samples. A 44-year-female who died ment. No community transmission of infectious etiology began in September with a shock/sepsis syndrome had hepatitis A was identified. 1995. Any case should be reported, immunohistochemical testing of regardless of the patient’s age or multiple organ samples that were Of the 36 cases, a risk factor was underlying medical conditions. A positive for Staphylococcus aureus. identified for 27 (75%). Seven (26%) subset of cases (persons up to 49 PCR testing of a blood sample was had known exposure to a confirmed years of age with no underlying also positive for S. aureus. hepatitis A case. Four of these per- medical conditions who died of sons, in two separate households, apparent non-nosocomial infectious Testing was also provided at MDH and/ became infected following exposure to processes) are eligible for testing or CDC at the physician’s request for a close contact, representing missed performed at CDC as part a special 22 of the 43 cases that were not opportunities to administer immune project. For cases not eligible for the eligible for the CDC project. Probable globulin. Two cases were household CDC project, some testing may be etiologies were found for four of these contacts of two children in the same available at MDH or CDC, at the cases. A young child with a critical household who were adopted from physician’s request. illness and history of travel in China Liberia. One case was a close contact had positive PCR tests of a nasopha- of a foreign-born, adopted child. Sixty-seven cases (32 deaths and 35 ryngeal sample for respiratory syncytial critical illnesses) were reported in virus and picornavirus. A 23-year-old Of the remaining 20 (74%) cases with 2005, compared to 52 cases in 2004. female with a critical illness and a risk factor identified, 19 (95%) were The cause(s) of illness subsequently exposure and symptoms compatible associated with travel. Of these 19, 13 were determined for 11 cases. Among with rat-bite fever had positive 16s (68%) traveled to Mexico or South the remaining 56 cases, 15 case- PCR results of a blood sample for America, two of whom reported patients presented with respiratory Streptobacillus moniliformis. A 40- consuming raw shellfish. One addi- symptoms; eight presented with shock/ year-old asplenic male who died of tional case with no travel history sepsis; 20 presented with neurologic shock/sepsis had immunohistochemi- reported consuming raw shellfish. Nine symptoms; nine presented with cardiac cal tests of multiple organ samples that (25%) cases did not report any known 42 DCN 34;3 May/August 2006 exposure or risk factors; however, two only male partners, and one (5%) male Viral Hepatitis C had contact with a household member reported both male and female In 2005, 15 cases of acute hepatitis C enrolled in a childcare center. Young partners. Eleven (26%) case-patients virus (HCV) infection were reported. children infected with hepatitis A are reported having contact with a known Twelve (80%) of these case-patients often asymptomatic or have mild carrier of hepatitis B surface antigen had clinical symptoms, and three illness, but are efficient transmitters of (HBsAg), 10 (91%) of whom reported (20%) were asymptomatic, laboratory- disease. the contact as sexual. Three (7%) confirmed cases. Eleven (73%) case- case-patients reported using needles patients resided in Greater Minnesota. Viral Hepatitis B to inject drugs, one (2%) received a The median age was 29 years (range, In 2005, 42 cases of acute hepatitis B body piercing within 6 months prior to 19 to 50 years). Eleven (73%) case- virus (HBV) infection (0.8 per 100,000) onset of symptoms, and two (5%) patients were male. Twelve (80%) were were reported, with no deaths. The case-patients reported a recent history white, non-mixed race; one (7%) was age of case-patients ranged from 19 to of blood transfusion. (A case-patient white and American Indian; and two 60 years (median, 39 years). All 42 may report more than one risk factor.) (13%) were of unknown race. cases were laboratory-confirmed. Thirty-six (86%) of these case-patients Hepatitis B vaccine has been available Among the 15 case-patients, 10 (67%) had clinical symptoms, and two (5%) since 1982, yet it continues to be reported using needles to inject drugs. had documented asymptomatic underutilized in persons at greatest Two (13%) case-patients had sexual seroconversions. Twenty-five (60%) risk of infection. A large proportion of contact with a known anti-HCV-positive were residents of the Twin Cities hepatitis B case-patients identified risk partner within 6 months prior to onset metropolitan area, including 16 (64%) factors for sexual transmission; of symptoms; three (20%) had a recent in Hennepin County and five (20%) in therefore, health care providers should tattoo. (A case-patient may report more Ramsey County. Twenty-eight (67%) discuss the need for HBV testing and than one risk factor.) cases were male, and 21 (50%) were vaccination with at-risk patients, MDH received more than 2,600 reports adolescents or young adults between including all unvaccinated adoles- of newly identified anti-HCV-positive 13 and 39 years of age. Twenty (48%) cents, young adults, and patients seen persons in 2005, the vast majority of were white, 13 (31%) were black, four for other sexually transmitted dis- whom are chronically infected. Be- (10%) were Asian, and one (2%) was eases. cause most cases are asymptomatic, American Indian; race was unknown medical providers are encouraged to for four (10%) cases. One (2%) case- In addition to the 42 hepatitis B cases, consider each patient’s risk for HCV patient was of Hispanic ethnicity. four perinatal infections were identified infection to determine the need for Although the majority of cases were in infants who tested positive for testing. Patients for whom testing is white, incidence rates were higher HBsAg during post-vaccination indicated include: persons with past or among blacks (7.6 per 100,000), screening performed between 9 and present injecting drug use; recipients Asians (2.8 per 100,000), and Hispan- 15 months of age. All four perinatal of transfusions or organ transplants ics (0.7 per 100,000) than among non- infections occurred in infants identified before July 1992; recipients of clotting Hispanic whites (0.3 per 100,000). through a public health program that factor concentrates produced before works to ensure appropriate prophy- 1987; persons on chronic hemodialy- Twenty-six (62%) of the 42 case- lactic treatment of infants born to HBV- sis; persons with persistently abnormal patients were interviewed regarding infected mothers. The infants were alanine aminotransferase levels; possible modes of transmission. born in the United States and had healthcare, emergency medical, and Nineteen (73%) reported having received hepatitis B immune globulin public safety workers after needle sexual contact with one or more and three doses of hepatitis B vaccine sticks, sharps, or mucosal exposures partners within 6 months prior to onset in accordance with the recommended to HCV-positive blood; and children of symptoms, four (21%) of whom schedule (i.e., were treatment fail- born to HCV-positive women. Infants reported sexual contact with two or ures). Despite these treatment failures, born to HCV-infected mothers should more partners. Of those reporting the success of the public health be tested at 12 to 18 months of age, as sexual activity, eight (42%) females prevention program is demonstrated earlier testing tends to reflect maternal reported only male partners, seven by the fact that an additional 344 antibody status. Persons who test (37%) males reported only female infants born to HBV-infected women positive for HCV should be screened partners, three (16%) males reported during 2004 had post-serologic testing for susceptibility to hepatitis A and B demonstrating no infection. virus infections and immunized appropriately. Recommended Childhood and Adolescent, and Adult Immunization Schedules, Minnesota, 2006 There are several changes to the Advisory Committee on Immunization Committee (MIPAC) reviews the Childhood and Adolescent and the Practices (ACIP), the American schedules and, as necessary, sug- Adult Immunization Schedules, Academy of Pediatrics, and the gests modifications specific to Minne- Minnesota, 2006. Both schedules American Academy of Family Physi- sota. Color copies are available on the consolidate recommendations of cians. In addition, the Minnesota Minnesota Department of Health web national advisory bodies such as the Immunization Practices Advisory site at: www.health.state.mn.us/ DCN 34;3 May/August 2006 43 immunize or by calling the MDH at between receipt of Td and Tdap is Measles, mumps, rubella, and (651) 201-5503 or 800-657-3970. encouraged. varicella (MMRV) A new vaccine that combines measles, Overview of Changes: New Vaccines Meningococcal vaccination mumps, and rubella (MMR) with and Recommendations In January 2005 the FDA licensed varicella, was made available in the fall In 2005 the U. S. Food and Drug MCV4 for persons 11 through 64 years of 2005. This vaccine can be used Administration (FDA) approved four of age. ACIP recommends that all when both doses (MMR and varicella) new vaccine products: a meningococ- children at age 11-12 years, as well as are indicated and neither dose is cal conjugate, four-valent (MCV4) adolescents at high school entry (15 contraindicated. MMRV is licensed for vaccine; two tetanus, reduced- years of age), receive a dose of MCV4. use in children ages 12 months through diphtheria, and acellular pertussis They also recommend that college 12 years. ACIP recommends that in a (Tdap) vaccines for adolescents and freshmen living in dormitories be varicella outbreak, a second dose is adults; and a vaccine combining vaccinated with MCV4 or with menin- indicated. measles, mumps, and rubella with gococcal polysaccharide vaccine varicella (MMRV). Additionally, the FDA (MPSV). Children who are at risk for Changes to the Adult Immunization approved supplemental license invasive meningococcal disease Schedule applications for two new hepatitis A should also receive meningococcal vaccine products for children age 12 vaccination. At-risk children 2 through Tetanus, reduced-diphtheria, and months and older, and the ACIP 10 years of age should receive MPSV, acellular pertussis (Tdap) approved revised hepatitis B recom- and those age 11 years and older can A single dose of Tdap is now recom- mendations for children in June 2005 receive MCV4. mended for adults under 65 years of and for adults in October 2005. age in place of their 10-year booster The market demand for MCV4 has dose of Td. Tdap is also recommended Changes to the Childhood and exceeded the currently available for adults having close contact with Adolescent Immunization Schedule supply. As a result, it is recommended infants under 12 months of age (e.g., that health care providers defer the parents of infants, childcare providers, Hepatitis B routine administration of MCV4 at the healthcare workers). Providers may use ACIP recommendations stress the 11-12 year old immunization visit. an interval as short as 2 years from the importance of the birth dose to further Once supply is restored, that recom- most recent dose that contained the reduce the incidence of missed mendation should resume with catch- tetanus toxoid. treatment of infants born to HBsAg- up at age 15 years for children who positive women. In reviewing current were previously deferred. Hepatitis B state data, MIPAC has further stressed The percentage of at-risk adults who the importance of giving that first dose Hepatitis A are vaccinated against hepatitis B within 12 hours of birth, since the The incidence of hepatitis A disease remains low, even though recommen- purpose of that dose is to provide a has decreased dramatically since the dations have existed for over 30 years. safety net for infants. implementation of hepatitis A vaccina- However, the new hepatitis B recom- tion — particularly in targeted popula- mendations approved by the ACIP in Tetanus, reduced-diphtheria toxins, tions. Geographical areas targeted for October 2005 focus on implementation and acellular pertussis (Tdap) routine vaccination now have rates of activities at the provider level, not a With the availability of two new Tdap disease lower than the national change in the schedule itself. The products, ACIP now recommends that average. In an effort to sustain these recommendations stress that a single dose of Tdap be given in place reduced rates and to move toward a healthcare settings serving adults at of the Td booster usually given at the greater reduction in overall disease risk for hepatitis B disease should 11- to 12-year-old well-child visit. burden across the nation, ACIP now implement systems (e.g., standing Adolescents ages 13-18 years who recommends that all infants receive orders, routine screening) to provide missed their Td booster should also the hepatitis A vaccination series at 1 routine hepatitis B vaccination. Such receive Tdap. The new products are year of age (12-23 months). The settings include STD clinics, correc- intended for use in individuals who series includes two doses given 6 tional institutions, dialysis units, HIV/ have previously completed their months apart. STD screening programs, and chemical childhood DTP/DTaP vaccination dependency treatment centers. series. However, ACIP recommends Influenza that Tdap can be used as one of the A new indication for influenza vaccina- Meningococcal vaccination doses in the three-dose primary series tion has been added to the childhood The new four-valent meningococcal for previously unvaccinated persons schedule. Influenza vaccine should be conjugate vaccine (MCV4) should be age 10 or 11 years and older, depend- given to children age 6 months and given to persons under age 55 years of ing on the product used (e.g., Boostrix older with any condition (e.g., cognitive age who are at risk of invasive disease is licensed for persons age 10 through dysfunction, spinal cord injury, seizure or who have increased risk of expo- 18 years, and Adacel is licensed for disorder, or other neuromuscular sure. Meningococcal four-valent persons age 11 through 64 years). disorder) that can compromise polysaccharide vaccine (MPSV4) is an Adolescents ages 11-18 years who respiratory function or the handling of acceptable alternative when MCV4 is received Td, but not Tdap, may receive respiratory secretions or that can unavailable. a dose of Tdap. An interval of 5 years increase the risk of aspiration. 44 DCN 34;3 May/August 2006 Recommended Childhood and Adolescent Immunization Schedule Minnesota * 2006 **Chart must be used with guidelines below** Age 1 2 4 6 12 15 18 24 4-6 11-12 13 -14 15 16 -18 Vaccine Birth month months months months months months months months years years years years years Hepatitis B1 HepB HepB HepB HepB series Diphtheria, Tetanus, DTaP DTaP DTaP Tdap DTaP DTaP Tdap Pertussis2 Haemophilus Hib Hib Hib Hib influenzae type b3 Inactivated IPV IPV IPV IPV Poliovirus Measles, Mumps, MMR MMR 4 MMR Rubella4 Varicella5 Varicella Varicella Vaccines within MCV4 MCV4 Meningococcal6 broken line are for selected populations MPSV4 MCV4 Pneumococcal 7 PCV PCV PCV PCV PCV PPV Influenza8 Influenza (yearly) Influenza (yearly) Hepatitis A9 HepA series HepA series Guidelines: This schedule is for children through age 18 years. It indicates the recom- administer those vaccines not previously given. Additional vaccines may be licensed and mended ages for routine administration of childhood vaccines licensed as of January 1, recommended during the year. Licensed combination vaccines may be used whenever any 2006. Any dose not given at the recommended age should be given at any subsequent visit components of the combination are indicated and FDA-licensed for use, and the vaccine’s when indicated and feasible. Indicates age groups that warrant special effort to other components are not contraindicated. Consult the manufacturers’ package inserts for detailed recommendations. Range of recommended ages Catch-up vaccination Preadolescent assessment 1. Hepatitis B (hepB): All infants should receive monovalent hepB vaccine within 12 hours of 5. Varicella (Var): Varicella vaccine is recommended at any visit at age >12 months for sus- birth and before hospital discharge. ceptible children, i.e., those who lack a reliable history of chickenpox. Susceptible persons Infants born to HBsAg-positive mothers should receive hepB and 0.5mL hepatitis B im- age >13 years should receive 2 doses given at least 4 weeks apart. mune globulin (HBIG) at separate sites within 12 hours of birth. Test these infants for HBsAg 6. Meningococcal (MCV4): Meningococcal conjugate vaccine (MCV4) should be given to all and antibody to HBsAg (anti-HBs) at age 12 months (no earlier than age 9 months). children at age 11-12 years, as well as to unvaccinated adolescents at high school entry Infants born to mothers whose HBsAg status is unknown should receive hepB-1 within (age 15 years). Unvaccinated college freshmen living in dormitories should also be vacci- 12 hours of birth. Maternal blood should be drawn as soon as possible to determine the nated, preferably with MCV4, although meningococcal polysaccharide vaccine (MPSV4) is mother’s HBsAg status. If the HBsAg test is positive, the infant should receive 0.5mL of an acceptable alternative. Those age >2 years at risk for invasive meningococcal disease HBIG as soon as possible (within 7 days of birth). (e.g., anatomic or functional asplenia, terminal complement deficiencies) should receive Completing the hepB vaccination series: Only monovalent hepB vaccine can be used meningococcal vaccine – MPSV4 for children age 2 through 10 years; MCV4 for children for doses given before age 6 weeks. Monovalent or combination vaccine containing hepB age 11 years and older. may be used to complete the series. Four doses of hepB may be administered when a birth nd dose is given. The 2 dose should be given at age 1-2 months, except for combination 7. Pneumococcal: The 7-valent pneumococcal conjugate vaccine (PCV) is recommended vaccines that cannot be administered before age 6 weeks. If monovalent hepB is used for for all children age 2-23 months and for certain children age 24-59 months. The final dose in the series, the dose at 4 months is not needed. The final dose in the vaccination series (3 rd the series should be given at age >12 months. th or 4 dose) should be given at age 6-18 months, but not before age 24 weeks. Pneumococcal polysaccharide vaccine (PPV) is recommended in addition to PCV for certain high-risk groups, age >2 years. See MMWR 2000;49(RR-9):1-35. 2. Diphtheria, tetanus, and acellular pertussis (DTaP): DTaP-4 may be given as early as age 12 months if at least 6 months have passed since DTaP-3 and the child is unlikely to 8. Influenza: Influenza vaccine is recommended annually for children age 6–23 months be- return at age 15-18 months. The final dose should be given at age >4 years. cause they are at substantially increased risk for influenza-related hospitalizations. It also is Tdap (tetanus and diphtheria toxoids and acellular pertussis, for adolescents) is recom- recommended for children age >2 years with certain risk factors including, but not limited to, mended at age 11-12 years, as well as those ages 13-18 years, who have completed the asthma, cardiac disease, sickle cell disease, HIV, and diabetes. See MMWR 2005;54 [RR- childhood DTP/DTaP series and not received a Td booster dose. Subsequent tetanus and 8]:1-44. Children age >2 years who are household contacts of at-risk persons, including diphtheria toxoids (Td) are recommended every 10 years. infants age <6 months, should also be vaccinated. Other children wishing to obtain immu- nity may be vaccinated. For healthy persons age 5-49 years, the intranasally administered 3. Haemophilus influenzae type b (Hib) conjugate: If PRP-OMP (PedvaxHIB or Comvax) is live-attenuated influenza vaccine (LAIV) is an acceptable alternative to the intramuscular given at ages 2 and 4 monrhs, a Hib dose at 6 months is not required. Do not use trivalent inactivated influenza vaccine (TIV). See MMWR 2003;52(RR-13):1-8. Children re- st DTaP/Hib combination products for the 1 , 2 nd, or 3 rd doses (primary series). Use any Hib ceiving TIV should receive the age-appropriate dosage: 0.25mL if age 6-35 months or 0.5mL conjugate vaccine as a booster. The final dose in the series should be given at age >12 if age >3 years. Children age <8 years who are receiving influenza vaccine for the first time months. should receive 2 doses separated by >4 weeks following a dose of TIV and 6 weeks follow- 4. Measles, mumps, rubella (MMR): MMR-2 is recommended at age 4-6 years but may be ing a dose of LAIV. given during any visit, provided at least 4 weeks have elapsed since MMR-1 and both doses 9. Hepatitis A (hepA): HepA is recommended for all children at 1 year of age. The 2 doses in are given at age >12 months. Those who have not received a 2 nd dose should do so by age the series should be administered at least 6 months apart. Additionally, give hepA vaccine 11-12 years. to children and adolescents who are at increased risk of infection, as defined by ACIP*. Based on recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP), and endorsed by the Minnesota Immunization Practices Advisory Committee of the Minnesota Department of Health. DCN 34;3 May/August 2006 45 For Children and Adolescents Who Start Late or Who Are >1 Month Behind The tables below give catch-up schedules and minimum intervals between doses for children who have delayed immunizations. There is no need to restart a vaccine series regardless of the time that has elapsed between doses. Use the chart appropriate for the child’s age. Footnotes apply to both charts. Catch-up schedule for children age 4 months through 6 years Minimum Minimum Interval Between Doses Vaccine Age for Dose 1 Dose 1 to Dose 2 Dose 2 to Dose 3 Dose 3 to Dose 4 Dose 4 to Dose 5 Diphtheria, Tetanus, 6 weeks 4 weeks 4 weeks 6 months 6 months1 Pertussis Inactivated Poliovirus 6 weeks 4 weeks 4 weeks 4 weeks2 Hepatitis B3 Birth 4 weeks 8 weeks (and 16 wks after 1st dose) Measles, Mumps, 12 months Rubella4 Varicella 12 months 4 weeks 6 4 weeks If current age <12 months If 1 st dose given at age <12 months 8 weeks (as final dose)6 8 weeks (as final dose) This dose only necessary for Haemophilus 8 weeks (as final dose) If current age >12 months and 2 nd dose 6 weeks If 1st dose given at age 12-14 months given at age <15 months children age 12 months to 5 years influenzae type B5 who received 3 doses before age No further doses needed No further doses needed 12 months If 1 st dose given at age >15 months If previous dose given at age >15 months 4 weeks If 1 st dose given at age <12 months and 4 weeks current age <24 months If current age <12 months 8 weeks (as final dose) 8 weeks (as final dose) 8 weeks (as final dose) This dose only necessary for Pneumococcal 5 6 weeks If 1st dose given at age >12 months or current If current age >12 months children age 12 months to 5 age 24-59 months years who received 3 doses No further doses needed before age 12 months No further doses needed For healthy children if previous dose given st For healthy children if 1 dose given at age >24 months at age >24 months Catch-up schedule for children age 7 through 18 years Minimum Interval Between Doses Vaccine Dose 1 to Dose 2 Dose 2 to Dose 3 Dose 3 to Booster Dose 6 months Tetanus, if 1st dose given at age <12 months and current age <11 4 weeks 6 months years; otherwise Diphtheria7 5 years Inactivated 4 weeks 4 weeks Poliovirus8 Hepatitis B 4 weeks 8 weeks (and 16 weeks after 1st dose) Measles, Mumps, 4 weeks Rubella Varicella 9 4 weeks 1. DTaP: The 5 dose is not necessary if the 4th dose was given after the 4 th birthday. th 5. Hib and/or PCV: Vaccine is not generally recommended for children age >5 years. 2. IPV: The 4 th dose is not necessary in an all-IPV or all-OPV schedule if the 3 rd dose was 6. Hib: If current age is <12 months and 1st and 2 nd doses were PRP-OMP (PedvaxHIB or th rd given after the 4 birthday. If both OPV and IPV were given as part of a series, a total of ComVax [Merck]), the 3 (and final) dose should be given at age 12-15 months and at nd 4 doses should be given, regardless of the child’s current age. least 8 weeks after the 2 dose. 3. HepB: All children and adolescents who have not been immunized against hepatitis B 7. Td/Tdap: Adolescent Tdap may be substituted for one of the doses in a primary catch-up should begin the hepB vaccination series during any visit. Providers should make spe- series or as a booster if age appropriate for Tdap. A 5-year interval from the last Td dose is cial efforts to immunize children who were born in, or whose parents were born in, areas encouraged when Tdap is used as a booster dose. of the world where hepatitis B virus infection is moderately or highly endemic. 8. IPV: Vaccine is not generally recommended for persons age >18 years. nd 4. MMR: The 2 dose of MMR is recommended routinely at age 4-6 years but may be 9. Varicella: Give to all susceptible children and adolescents. If the adolescent is age >13 given earlier if desired. years, 2 doses are needed. Reporting Adverse Reactions Disease Reporting Report adverse reactions to vaccines through the federal Vaccine Adverse Event Report suspected cases of vaccine-preventable diseases to the local health department or to Reporting System (V.A.E.R.S.). For information on reporting reactions following vaccines the Minnesota Department of Health, P.O. Box 64975, St. Paul, MN 55164-0975, 651-201-5414 administered by private clinics, call the 24-hour national toll-free information line, 800-822- or toll-free 877-676-5414. 7967. You may also visit www.vaers.hhs.gov. Report reactions to vaccine administered in public clinics to the Minnesota Department of Health, 651-201-5414 or toll-free 877-676- 5414. 46 DCN 34;3 May/August 2006 Recommended Adult Immunization Schedule, 2006 **Chart must be used with footnotes below** Age 19-49 years 50-64 years >65 years Vaccine Tetanus, Diphtheria (Td)1* 1-dose booster every 10 years Tetanus, Diphtheria, Pertussis (Tdap)1* Measles, Mumps, Rubella 1 or 2 doses 1 dose 2* (MMR) 2 doses (0, 4-8 weeks) 2 doses (0, 4-8 weeks) Varicella3* Vaccines below broken line are for selected populations Influenza4* 1 dose annually 1 dose annually Pneumococcal (polysaccharide)5 1-2 doses 1 dose Hepatitis A6* 2 doses (0, 6 months) Hepatitis B7* 3 doses (0, 1-2, 4-6 months) Meningococcal8 1 or more doses *Covered by the Vaccine Injury Compensation Program (see back for more information) For all persons in this category who meet the age require- Recommended if some other risk factor is present (e.g., based ments and who lack evidence of immunity (e.g., lack on medical, occupational, lifestyle, or other indications) documentation of vaccination or have no evidence of prior infection) 1. Tetanus and Diphtheria (Td) and Tetanus, Diphtheria and Pertussis alcoholism, cirrhosis, CSF leaks, functional or anatomic asplenia, HIV (Tdap): Tdap is now recommended for adults age <65 years in place infection, malignancy, chronic renal failure, nephrotic syndrome, or if of their 10-year booster dose of Td. Tdap is also recommended for receiving immunosuppressive chemotherapy. Routine revaccination of adults having close contact with infants age <12 months (e.g., parents immunocompetent adults previously vaccinated with PPV is not of infants, child care providers, healthcare workers). Providers may recommended; however, a one-time revaccination is recommended if a use an interval as short as 2 years since the most recent tetanus person was vaccinated >5 years previously and either was age <65 years toxoid-containing vaccine. All previously unvaccinated adults should when first vaccinated and is now age >65 years, or is at highest risk for complete a 3-dose primary series of Td. Tdap may be used for 1 of invasive pneumococcal infection as defined by ACIP. the 3 doses of the primary series in adults age <65 years. Td is 6. Hepatitis A: Give 2 doses of hepatitis A vaccine, 6 months apart to adults recommended every 10 years as a booster for adults age >65 years at increased risk for infection with hepatitis A virus (HAV). Populations at and older. risk include persons traveling to or working in countries with intermediate 2. Measles, Mumps, Rubella: Adults born before 1957 are considered to high rates of HAV, men who have sex with men, persons who use naturally immune. Adults born in 1957 or later should receive 1 dose of street drugs, persons with chronic liver disease, persons with clotting MMR vaccine. Some adults may need 2 doses given not less than 4 factor disorders, and persons working with HAV in research settings or weeks apart (e.g., college students, those working in healthcare facilities, with HAV-infected primates. Other adults wishing to obtain immunity may and international travelers). also be vaccinated. 3. Varicella: Administer varicella vaccine as 2 doses separated by 4-8 7. Hepatitis B: Give 3 doses of hepatitis B vaccine at intervals of 0, 1, and weeks, to all susceptible adults, particularly those who will have close 6 months to all at-risk adults. Indications grouped by risk are as follows. contact with persons at high risk for serious complications (i.e., Occupational: healthcare workers, public safety workers, persons in healthcare workers and family contacts of immunocompromised training for medicine, dentistry, nursing, laboratory technology, and other persons). Pregnant women should be assessed for immunity to varicella allied health professions. Behavioral: injection-drug users, persons with and if susceptible, vaccinated in the immediate postpartum period. more than one sex partner in the previous 6 months, persons with a Evidence of immunity includes persons born in the U.S. before 1966, recently acquired STD or a client of an STD clinic, men who have sex persons born in the U.S. between 1966 and 1997 who recall a history of with men. Other: household contacts and sex partners of persons with varicella disease (either physician, parental, or self report), persons chronic hepatitis B virus (HBV) infection, clients and staff of institutions with a history of herpes zoster, documentation of vaccination, or for the developmentally disabled, inmates, and international travelers laboratory evidence of immunity. who will be in countries with high or intermediate prevalence of HBV for 4. Influenza: Administer influenza vaccine annually to all adults age >50 >6 months. years, additionally, give to adults with chronic conditions that increase 8. Meningococcal: Give meningococcal conjugate vaccine (MCV4) to adults their risk of complications of influenza including, cardiac and pulmonary age <55 years at-risk of invasive disease or with increased risk of exposure. disorders, metabolic diseases (including diabetes), renal dysfunctions, Vaccinate adults with terminal complement component deficiencies, hemoglobinopathies, immunosuppression, and conditions that can anatomic or functional asplenia, as well a persons traveling to countries compromise respiratory function or the handling of respiratory secretions with endemic meningococcal disease, military recruits, lab workers working (e.g., cognitive disorder, spinal cord injury, neuromuscular or seizure with N. meningitidis, and college freshmen who will be living in dormitories. disorder). Also, give to household contacts, caregivers and healthcare Meningococcal polysaccharide vaccine (MPSV4) is available for adults workers of those in the above risk categories. Adults living with or age >55 years who have the above risk factors. MPSV4 is an acceptable providing out-of-home care to infants age <6 months should also receive alternative when MCV4 is unavailable. For adults who have previously annual influenza vaccination. Any adult wishing to reduce the likelihood received MPSV4, revaccination may be necessary 5 years following initial of becoming ill with influenza may be vaccinated. vaccination for persons remaining at risk of meningococcal disease. The 5. Pneumococcal: Give pneumococcal polysaccharide vaccine (PPV) to use of MCV4 for adults age 55 years and younger is preferred. For those all adults age >65 years; and those age <65 years with chronic age >55 years, MPSV4 is acceptable for revaccination. Recommendations cardiovascular disease, chronic pulmonary disease, diabetes mellitus, for revaccination following MCV4 are pending. DCN 34;3 May/August 2006 47 Catch-Up Schedule and Minimum Intervals for Adults For any vaccine given in a series, it is not necesary to start over. Refer to the table below for recommended “catch-up” schedule and minimum intervals between doses. Determine the number of previous doses of each vaccine received, find that number in the first column, and read across to the appropriate column for the next dose(s) and minimum interval(s). Doses to be given and minimum intervals from previous dose for adults >19 years Number of previous doses of each vaccine First dose Second dose Third dose Booster dose Tetanus, Diphtheria (Td) Td: 4 weeks after 1st dose Td: 6 months after 2nd dose Td: 10 years after completion of Tetanus, Diphtheria, Pertussis (Tdap) the primary series or since last booster dose Mealses, Mumps, Rubella (MMR) MMR: 4 weeks after 1st dose Pneumococcal (PPV) PPV: 5 years after 1st dose for those who received 1st dose at None <65 years and are now >65 years, or who are at highest risk for pneumococcal infection Hepatitis A (HAV) HAV: 6 months after 1st dose Hepatitis B (HBV) HBV: 4 weeks after 1st dose HBV: 8 weeks after 2nd dose when catching up final dose; for an accelerated schedule the 3rd dose cannot be given sooner than 4 months after the 1st dose Varicella Varicella: 4 weeks after 1st dose One Two Three Guidelines for Patients with an Incomplete or Nonexistent Vaccine History • • For adult patients who are refugees or immigrants, provide vac- This catch-up schedule must be used together with the guide- lines printed on the previous page. cinations as you would for any other adult patient. Translations • Use all opportunities to assess the vaccination status of adult of foreign vaccine terms and vaccine products can be found in patients. At age 50, give a Tdap or Td (unless a dose has been the MDH Provider’s Guide to Immunizations or on the MDH web given in the previous 10 years) and evaluate for risk factors for site: www.health.state.mn.us/immunize. pneumococcal and other vaccine-preventable diseases. • Patients age 18 years or older, including foreign-born adults, do • If patient has started a series (e.g., HBV) but not completed it, not need polio vaccination unless they are traveling to a country continue where he/she left off. Never restart a series of any vac- where wild poliovirus still exists. cine (exception: oral typhoid vaccine in some situations). • A Mantoux test can be administered simultaneously with any • MMR and varicella vaccines can be given at the same visit. If not live or inactivated vaccine. If the patient already received MMR given simultaneously, they must be separated by at least 4 weeks. or varicella vaccine, the Mantoux test must be delayed for at least 4 weeks after the MMR or varicella; if the Mantoux was • Patients do not need measles, mumps, and/or rubella vaccine if applied first, any vaccine, including MMR and varicella, can be they were born before 1957, have lab evidence of immunity, or given at any time. (for measles/mumps only) have physician-diagnosed disease his- tory. Consider vaccinating women born before 1957 who may • Count only vaccinations that are well documented (i.e., includ- become pregnant and do not have lab evidence of immunity or ing month, year, and preferably, day of vaccination). If no docu- physician-diagnosed disease. mentation exists, assume the patient is unvaccinated. It is al- ways better to vaccinate when in doubt, rather than miss an op- portunity to provide protection. *Vaccine Injury Compensation Program Reporting Adverse Reactions When vaccinating adults with vaccines covered by the Vaccine Injury Compensation Report adverse reactions to vaccines through the federal Vaccine Adverse Event Program, a Vaccine Information Statement (VIS) must be given each time the patient Reporting System (VAERS).For information on reporting reactions following vaccines receives the vaccine. The date of the edition of VIS given and date that the VIS was administered by private clinics, call the 24-hour national toll-free information line, 800-822- provided to the patient must be documented in the clinic/patient record. Other required 7967. You may also visit . Report reactions to vaccine administered in public clinics to the documentation includes dates of vaccination, name of the vaccine, manufacturer, and lot Minnesota Department of Health, 651-201-5414 or toll-free 877-676-5414. number; and name, address, and title of the individual who administered the vaccine. The most current VISs can be downloaded from the MDH website at: Disease Reporting www.health.state.mn.us/immunize. Report suspected cases of vaccine-preventable diseases to the local health department or to the Minnesota Department of Health, P.O. Box 64975, St. Paul, MN 55164-0975, 651-201-5414 or toll-free 877-676-5414. 48 DCN 34;3 May/August 2006 Antimicrobial Susceptibilities of Selected Pathogens, 2005 On the following pages is the Antimicro- Comments, and Other Pathogens.” mn.us/divs/idepc/dtopics/ bial Susceptibilities of Selected Please note the data on inducible antibioticresistance/antibiogram.html). Pathogens, 2005, a compilation of clindamycin resistance for Group A and antimicrobial susceptibilities of selected B Streptococcus and community Limited laminated copies can be pathogens submitted to MDH during associated methicillin resistant Staphy- ordered from: Antibiogram, Minnesota 2005 in accordance with Minnesota lococcus aureus Department of Health, Acute Disease Rule 4605.7040. Because a select Investigation and Control Section, PO group of isolates is submitted to MDH, it The MDH Antibiogram is available on Box 64975, St. Paul, MN 55164 or by is important to read the notes entitled the MDH Web site at: www.health.state. calling (651) 201-5414. “Sampling Methodology” and “Trends, continued... DCN 34;3 May/August 2006 49 50 DCN 34;3 May/August 2006 12th Annual Emerging Infections in Clinical Practice and Public Health Conference November 2-3(half-day), 2006 Program Includes: Travel Medicine: Immigrant Health Issues: Infections in the Special Host: • Keynote: Infections in Travelers - • Health Issues of Immingrants - • Intravascular Devices - Larry Martin Cetron, MD, Centers for Patricia Walker, MD, DTMT& H Baddour, MD Disease Control and Protection • Tuberculosis in Minnesota - David • Transplant Recipients - Jo-anne • Malaria - Chandy John, MD, MS Williams, MD van Burik, MD • Amebiasis - Jonathan Ravdin, MD • Panel Discussion with Case • Infections in Patients on TNF Vignettes - Drs. Cetron, John, Inhibitors - Robert Orenstein, DO Ravdin, Walker, Williams • Infections in Diabetics - Elie Berbari, MD continued... 12th Annual Emerging Infections in Clinical Practice and Public Health Conference, November 2-3 (half-day), 2006 Hilton Downtown Minneapolis REGISTRATION FORM PLEASE PRINT OR TYPE: MAIL TO: Emerging Infections Conference Name Office of Continuing Medical Education 200 Oak St. SE, Suite 190 Affiliation Minneapolis, MN 55455 or Fax to: 612-626-7766 Department Phone: 612-626-7600 or 1-800-776-8636 Address or E-Mail: firstname.lastname@example.org Home Office PAYMENT METHOD Mail Stop Check (payable to University of Minnesota) City State Zip VISA MasterCard American Express Office Telephone Number E-mail Cardholder Name Degree Card No. Specialty Exp. Date Signature On or Before After Registration Fees: October 5 October 5 Physician $175 $200 Non-Physician & Retired Physician $135 $160 Resident/ Fellow $135 $160 Medical Industry Professional $175 $200 University of Minnesota and Mayo Clinic $135 Physician $110 Non-Physician $75 $100 Resident/Fellow/Student $25 $25 (School of Public Health) More Information at www.cme.umn.edu (Click on “Course Calendar”) DCN 34;3 May/August 2006 51 Emerging Infections Conference Program (Cont’d) • Keynote: Respiratory Infections - • Keynote: Diagnosis and Treatment • Hot Topics from MDH - Richard John Williams, MD, Vanderbilt of C. difficile - Dale N. Gerding, Danila, PhD, MPH University MD, Loyola University • Human Rights and Emerging • Prevention of Urinary Tract • Basic Science: Apoptosis - Andrew Infections - Steve Miles, MD Infections - James Johnson, MD Badley, MD • Pandemic Influenza Update - • Zoonoses- Jeff Bender, DVM, MS Michael T. Osterholm, PhD, MPH Dianne Mandernach, Commissioner of Health To access the Disease Control Newsletter Division of Infectious Disease Epidemiology, Prevention and Control go to this link; www.health.state.mn.us/divs/ Harry F. Hull, M.D..............................................................State Epidemiologist idepc/newsletters/dcn/ndex.html and click on “Subscribe.” Richard N. Danila, Ph.D., M.P.H..............Editor/Assistant State Epidemiologist Valerie Solovjovs....................................................................Production Editor 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).
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