Hot Topics from the Minnesota Department of Health

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Hot Topics from the Minnesota Department of Health

• Ruth Lynfield, MD
• Minnesota Department of Health

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Case 1

• 6 month-old boy presented with fever and cough
  February 15, 2008
• Presented to Emergency Room May 12, 2008 with
  coughing fits
• Returned May 15, 2008
• Chest x-ray
• pleural effusion, right lung consolidation

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Source Case Investigation

• Child born in U.S. to Guatemalan immigrants
• TB positive, pansensitive
• Parents TST positive, latent TB infection
• 4 siblings, 2 cousins - active TB
• All started on TB treatment
• Did NOT find source of infection
• Father active in community
• Promoted band, practiced at his house

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TB Cases
Index Case
4/08
5/08
3/08
2/08
1/08
12/07
6/08
Patient A
Patient B
Case reported
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Patient C

• 24-year-old Guatemalan male
• October 2007 - Onset of illness
• December 2007 - Urgent Care, bronchitis

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Patient C (cont.)

• June 2008 - hospitalized
• Productive cough
• Loss 30 lbs
• Fever
• Pneumonia
• CXR
• Right lobe infiltrate
• Hilar lymphadenopathy
• TST negative
• Sputum, smear culture positive July 2008

• Pansensitive M. tuberculosis
• Treatment INH, rifampin, ethambutol, PZA

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Contact Investigation Patient C

• Household 3 roommates
• Girlfriend, 3 contacts (neighboring county)
• Work contacts - cleaning crew
• Clean kill-room floor of meat processing plant
• Crew supervisor ? find additional contacts
• Social contacts
• Singer in band lead by father of index case

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TB Cases
Index Case
4/08
3/08
2/08
1/08
12/07
5/08
6/08
A
B
C
Infectious period 10/07 6/08
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Patient D

• July 9, 2008
• 19 year-old Guatemalan male
• Hospitalized with cavitary pneumonia
• TST positive, smear negative, culture positive
• Symptoms starting May 2008
• Same cleaning shift as Patient C
• Not a direct contact, possibly carpooled
• Same church community

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Priority Levels for Contact Investigations

• Priority
  Estimate
• High Household contacts of adult cases
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• Members in singing group(s) lt15
• Van-riders/carpool to work lt10
• Child audience of band ?
• Church members lt100
• Medium Workplace contacts lt30
• Healthcare workers ?
• Soccer team lt10
• Low 1-time adult audience members gt100?
• (Mothers Day event baptism)

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4 additional active TB cases

• 4-year-old household contact of source case
• Two 4-year-old contacts
• Church community
• Mothers boyfriend in band
• Band practiced in home
• 37-year-old female community contact
• Visited church rarely

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Summary - Outbreak

• 14 active TB cases
• 10 cases 13 years
• 4 adult cases
• Guatemalan
• Lived in U.S. between 1 11 years

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Case 2

• 19 y.o. male college student
• Onset 12/8 of fever and headache followed in 7
  hours by diarrhea (5 stools/24 hours), muscle
  aches, chills, backache
• Fever 101-104
• Admitted to hospital 12/10

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Case 2 (cont.)

• Treated with fluids, no antibiotics
• Discharged on 12/12
• Completely recovered on 12/18
• Consumed peanut butter at college cafeteria

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Minnesota S. Typhimurium Investigation

• November 17-24
• MDH received 3 outbreak isolates
• December 10-19
• MDH received 8 additional outbreak isolates
• Both primary PFGE patterns represented
• First 8 interviewed cases reported eating peanut
  butter
• Suspicious, but not enough evidence to implicate
  one product, or even peanut butter overall, as
  the vehicle

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Minnesota S. Typhimurium Investigation (cont.)

• December 22
• Medical director of LTCF (LTCF A) in northern MN
  reports confirmed Salmonella infections in 3
  residents
• Specimens from 2 other residents pending
• Ultimately confirmed
• All five cases confirmed with outbreak strain of
  S. Typhimurium

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Long-Term Care Facility A

• Cases in 2 of 3 separate houses
• Houses did not share staff and residents did not
  interact
• Meals for all houses prepared in a central
  kitchen
• No kitchen staff reported recent GI illness
  symptoms
• Snack foods kept at each house and served by
  house staff

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Minnesota S. Typhimurium Investigation (cont.)

• December 22
• Single S. Typhimurium outbreak case reported in
  resident of second LTCF (LTCF B) in same city as
  LTCF A
• December 26-28
• Two outbreak cases interviewed, attended same
  elementary school
• Menus, food invoices from LTCF A, LTCF B,
  elementary school obtained

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Minnesota S. Typhimurium Investigation (cont.)

• LTCF A, LTCF B, elementary school all purchased
  food from a common distributor in Fargo, North
  Dakota
• Only food common to the 3 institutions was King
  Nut Creamy Peanut Butter
• Open tub of King Nut peanut butter collected from
  LTCF A by Minnesota Department of Agriculture on
  January 5

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Minnesota S. Typhimurium Investigation (cont.)

• January 6
• Info obtained about S. Typhimurium outbreak case
  reported in resident of third LTCF (LTCF C) in
  same city as LTCFs A, B
• Case died
• In weeks prior to onset, case had consumed only a
  few solid food items, including peanut butter and
  toast
• LTCF C also served King Nut Creamy Peanut Butter

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Minnesota S. Typhimurium Investigation (cont.)

• January 9, 2009
• Case count at 30
• Five additional cases related to institutions
  that received King Nut peanut butter from ND
  distributor A
• 2 worked at LTCFs
• 2 attended separate universities
• 1 ate at a county courthouse cafeteria

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Salmonella Typhimurium PFGEJanuary 11-12, 2009
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Locations of Company A Distributors Selling
KingNut Peanut Butter
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• State health depts. report cases had eaten
  Austin, Keebler PB crackers
• Plant in NC that makes these crackers found to
  use PCA peanut paste

• Outbreak strain of S. Typhimurium
• isolated from Austin PB crackers

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Minnesota Outbreak Cases(n 43)

• Age range, 4 mos. 94 yrs
• 16 (37 hospitalized)
• 3 deaths
• 24 (56) with exposure to King Nut PB
• 14 LTCF residents, 9 at work or school, 1 at a
  retail ice cream store
• 11 (26) likely associated with Austin/Keebler PB
  crackers
• 8 (19) undetermined exposure

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1st 11 cases in MN
Institutional link, Implication of PB
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Team Diarrhea Fall 2007
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Reportable Bacterial Enteric Pathogen
Surveillance in Minnesota

• Isolates must be submitted to the Minnesota
  Department of Health
• Real-time pulsed-field gel electrophoresis (PFGE)
  subtyping of all isolates
• Routine, real-time interviews of all cases

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Interviewing Cases Minnesota Basic Philosophy

• Interview all cases ASAP
• Collect details on specific exposures
• Dates
• Restaurant, grocery store names
• Brand names
• Open-ended food histories
• Follow-up interesting hypotheses aggressively
• Re-interview cases with specifc questions,
  conduct tracebacks, food testing, etc.

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Confirmed Foodborne Outbreaks, Minnesota,
1995-2008
Confirmed Foodborne Outbreaks
Year of Outbreak
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Case 3

• 1 year-old from suburban Dakota County
• June 23 whitish plaques seen in mouth petechial
  rash develops over trunk and extremities
• July 1 fever, congestion, profoundly
  thrombocytopenic
• July 3 acute respiratory failure, renal and
  liver failure, disseminated intravascular
  coagulation, died

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Case 3 (cont.)

• Reported to MDH as unexplained death
• Patient reported to have tick bite on head June
  22 no travel away from home, family members
  hiked in nearby county nature park

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Case 3 (cont.)

• Post-mortem skin sample IHC positive for RMSF
  (possible cross reactivity) and PCR-positive for
  R. rickettsia

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Rocky Mountain Spotted Fever (RMSF)
http//www.cdc.gov/ncidod/dvrd/rmsf/Laboratory.htm
http//www.cdc.gov/ncidod/dvrd/rmsf/Signs.htm

• Agent Rickettsia rickettsii
• Vector Dermacentor spp (wood ticks, dog ticks)

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Case 4

• 3 yo male developed fever, irritability and sore
  throat
• Brought to ER where he was noted to have drooling
  and difficulty breathing

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Hib Cluster in Minnesota

• 5 Hib cases in 2008, highest number of reported
  cases since 1992
• Age range 5 months -- 3 years
• 1 death in a 7 month old (last death in 1991)

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Total Number of Cases of Haemophilus influenzae
Type B (Hib) in Children lt72 Months of Age,
1983-2008
Polysaccharide vaccine licensed
Conjugate vaccine licensed for gt18 mo. olds
Conjugate vaccine licensed for infants
Number of Cases
Year
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Hib Cases in Children lt5 years,Minnesota,
1992-2008
Year
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Characteristics of Hib cases in MN

• Three of five children unvaccinated due to parent
  refusal
• All from different counties
• Clustered in a central band across the state
• Cases had no known relationship with each other
• None enrolled in group child care

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Characteristics of Hib Cases, Minnesota 2008
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Hib Vaccine Shortage

• Dec. 2007 ? Merck announced voluntary recall of
  10 lots of Hib vaccines
• Suspension of Hib vaccines production
• Oct. 2008 ? Merck announced need for additional
  manufacturing change requiring regulatory filing
• Recommendations during shortage
• Continue primary series beginning at 2 months
• Temporarily defer booster dose except to children
  at high risk

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MDHs Public Health Response

• Communications (LPH, healthcare providers, press
  release, MMWR)
• Working with vaccination providers and other
  partners to resolve any local supply problem (and
  use of Pentacel)
• Evaluation to describe extent of Hib carriage in
  affected communities ? understand reasons why
  some children not vaccinated

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Hib Carriage Survey

• February 2March 20, 2009
• Enrolled 1630 children at 18 clinics
• 52 male
• 56 aged lt24 months
• H. influenzae in 394 (24) children
• No Hib
• 78 (5) of parents reported not vaccinating their
  children

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Case 5

• 2 year old previously well child developed fever
  and cough for several days
• Fever increased and child became lethargic
• Brought to ER where found to be in respiratory
  failure and cardiac arrest

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H1N1 Novel Influenza Surveillance in Minnesota

• All hospitalizations with suspect influenza
• Swab sent to MN Dept Health (MDH) for RT-PCR
  testing (H1N1 novel, for county metro seasonal
  A H1/H3, seasonal B)
• Outpatient sentinel sites- 27 sites report ILI
  weekly
• 5 sites send 10 swabs per week for RT-PCR
• Remainder 2 swabs per week

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H1N1 Novel Influenza Surveillance in Minnesota
(cont.)

• School outbreaks of ILI (reporting of 5 absences
  in school due to ILI or gt 3 students in one
  classroom)
• Long-term care facility outbreaks of ILI
• Deaths due to suspect influenza
• Unusual clusters

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H1N1 Novel Influenza Surveillance in Minnesota
Goals

• Estimate the burden of disease in Minnesota
• Identify populations at increased risk of
  morbidity and mortality
• Identify changes in severity of illness
• Use data to develop/adjust infection and control
  guidance

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H1N1 Cases in Minnesota Preliminary Data

• As of September 28 298 hospitalized confirmed
  cases
• Median age 12 years (range 0-91 years)
• 68 of hospitalizations lt25 years
• Median length of stay 3 days
• 15 in ICU
• 36 of hospitalized cases had asthma 64 of
  hospitalized had an underlying condition
• 3 deaths 2 children (one no underlying
  conditions), 1 elderly
• others under investigation

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Hospitalized Cases of Influenza by Week of
Admission, MN 10/1/08 8/30/09
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Sentinel Sites, MN Preliminary Data
Only small number of sites continued reporting
through summer and prior to Oct 1
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National ILI Activity (CDC)
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National ILI Activity
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Vaccine
Photo Credit James Gathany, CDC
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Novel H1N1 Vaccine

• Anticipate that will come in batches beginning in
  late October 2009
• Likely 2 doses for children under 10 years
• Prioritize healthcare, emergency service workers
  and highest risk groups for severe disease with
  H1N1 pregnancy, caring for children lt 6 months
  of age, people up to age 24 years and those 25-64
  years with high risk conditions
• When enough vaccine in state everyone 25-64
  years and then rest of population
• Surveillance for adverse effects- Guillain Barre
  Syndrome

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H1N1 Vaccine Delivery

• Federal government contracted with several
  manufacturers to produce vaccine and will be
  provided to vaccinators at no cost
• Centralized distribution (McKesson)
• Vaccine shipped continuously
• MDH requires pre-registration for clinics
  intending to give vaccine
• MN Vaccine Registry (MIIC-MN Immunization
  Information Connection)

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H1N1 Vaccine Distribution

• Minnesota vaccine delivery plan
• Vaccine will be available in many of the same
  locations people currently get seasonal flu
  shots
• Local public health, medical clinics, college
  health centers, pharmacies, etc
• New locations
• Schools, ob/gyn clinics

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Acknowledgements

• Infection Preventionists and other clinicians and
  microbiologists in Minnesota
• Local Public Health
• Epidemiologists, Laboratorians and Student
  Workers at the Minnesota Department of Health