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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: cmereg@umn.edu
        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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