1994 Missouri Epidemiologist Volume 16

108 Pages·1994·77.6 MB·English

by  Missouri Department of Health, Division of Environmental Health and Epidemiology Services

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\l / l M R2 8 1994
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Volume XVI, Number I January-February 1994
Laboratory Testing for E. Coli 01 S7: H7 Prior to the First
Year of Reporting in Missouri
Michael Fobbs
E.coli OI57:H7 is a bacterium respon also used to confirm E. coli O1 57 by 18 ally observant of the potential for out
sible for gastrointestinal illness with of the 27 laboratories (f,6.6%). During breaks within communities in the state.
bloody diarrhea as a common symptom. this same time period, 19 (70.4%) sent
Its importance can be demonstrated by a their E. coli 0157 isolates to the State New surveys to determine the current
multistate outbreak of over 500 cases Public Health Laboratory (SPHL) to test levels of laboratory testing for E. coli
associated with a restaurant chain in the for the H7 antigen. The SPHL and other 0157 will be initiated in the near future
fall and spring of 1992-93. The largest reference laboratories are the only ones now that baseline levels have been es
waterborne outbreak reported in the lit capable of testing for the H7 antigen. tablished. Any increase in the nwnber
erature to date, with over 243 cases of E. The Centers for Disease Control and oflaboratories doing this type of testing
coli 0157:H7, occurred in Cabool, Prevention also receives E. coli O1 57 will increase the effectiveness of dis
Missouri in December 1989 - January isolates for H7 testing and less than 1 ease surveillance and subsequent con
1990. percent are some other antigen. trol measures for this bacteria by allow
ing us to determine the demqgraphics
E. coli O1 57: H7 was made reportable in Of the 27 laboratories that tested for E. of the disease and whether any geo
Missouri effective June 25, 1992. In the coli O1 57 only 8 (29 .6%) did routine graphic clustering is occurring. Please
periodfromJuly 1992throughJuly 1993, testing of stool samples for it. At 12 continue to report suspected E. coli
24 cases have been reported to the (44.4%) laboratories testing was done if 0157 infections and send isolates to
Departmentof Health's Bureau of Com there was bloody diarrhea and at 17 the State Public Health Laboratory.
municable Disease Control. laboratories (62.9%) it was done at the
Inside this Issue ...
physician's request whetherornot there
A survey was sent to 169 microbiology was bloody diarrhea. One lab tested all Page
laboratories in the state to determine the stool samples from April through De
backgroundlevelofE. coli 0157:H7 in cember, but only tested at the doctor's 2 Results of the Special
the twelve months before it became a request during the months of January Invasive Bacterial Infections
reportable condition (07/01/91- 06/30/ through March. Study Missouri, 1993
92).
In the period from July 1991 through 5 Compliance with Universal
Precautions: What
Responses were received from 135 June 1992, the surveyed laboratories
Healthcare Professionals
(79.9%) laboratories. A total of 27 reported they had 30 specimens test posi
Need to Know
(20.0%) laboratories stated that they tive for E. coli 0157. This is consistent
tested for E. coli O1 57. Of these, 26 with the 24 cases reported from July 7 Bi-Monthly Morbidity
(96.3%) stated that they used Sorbitol 1992 through July 1993. While there Report
MacConkey (SMAC) agar plates to de have been no confirmed waterborne or
tect E.coli 0157. The other laboratory foodborne outbreaks during these time 10 Update: Hantavirus Pulmo
did not describe their procedure in de periods, the significant number of cases nary Syndrome -U.S. 1993
tail. A latex agglutination procedure was reported should remind us to be continu-
14 Influenza Update
DEDICATED TO THE PROMOTION OF HEALTH THROUGH THE PREVENTION AND CONTROL OF DISEASE
Results of the Special Invasive Bacterial Infections Study
Missouri 1992
Marty Huber, R.N.
As reported in the January-February
Table 1. Invasive infections by selected pathogens* Missouri 1992.
1992 issue of the Missouri Epidemiolo
gist, Missouri is one of six sites partici Cases Reported to Cases Discovered during Total
Local or State H.D. Laboratory Review Cases
pating in active, laboratory-based sur
veillance for invasive infections caused Haemophilus influenzae
by Haemophilus influenzae, Neisseria Meningitis 14 0 14
meningitidis, Listeria monocytogenes, Other Invasive 30 38 (55.9%) 68
and Group B streptococcus (GBS). The
Listeria monocytogenes 15 2 (11.8%) 17
Special Invasive Bacterial Infections
Study, which began in Missouri in Janu Neisseria meningitidis 36 3 (7.7%) 39
ary 1992, is being conducted by the
*1be number of cases of these diseases in this report will differ from the number of cases
Centers for Disease Control and Preven reported in the annual report because the study uses the date of culture, whereas other
tion (COC). Active surveillance for this reports use the date the case was reported.
study involves review by project staff of
microbiology records in each participat through the usual reporting system and H. flu disease in the state as evidenced
ing hospital/laboratory. All hospitals and those found by laboratory review are by the decrease in H.flu meningitis from
laboratories in the state are participating
shown in Table 1. a high of 172 cases in 1986 to only 14
in the study, with the exception of 13
cases in 1992.
Kansas City hospitals, which, through
Significant numbers of non-reported
the Kansas City Health Department, cases of H. influenzae invasive disease Group B streptococcus has long been
declined to participate.
were found on laboratory review. Con known to cause serious invasive dis
sequently, comparison of the total num ease, and the occurrence of sporadic
It was expected that with active surveil ber of 1992 cases with the numbers of cases as well as outbreaks of the disease,
lance, an increased number of cases of
reported cases from prior years will likely has often led to intense scrutiny for
H. influenzae, L. monocytogenes and
not be valid. However, one can state additional cases for a s~ort period of
meningococcal disease would result,
with reasonable confidence that the ad time. However, when no more cases
even though these diseases have been
vent of Hib vaccine use in 1985, com occurred, interest in GBS was often lost
reportable by law to the local public
bined with the 1991 recommendation as attention turned to other, more com
health unit or the Bureau of Communi
that Hib immunization begin at two mon infections. Reporting of GBS dis
cable Disease Control for several years.
months of age, has reduced invasive ease has not been required in Missouri
The number of 1992 cases reported
or most other states.
Table 2. Adult invasive group B streptococcal disease infections and deaths by race and age group, Missouri 1992
White Black Asian/Pacific Islander Unknown Totals
Age Group Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths
15-19 years 7 - 3 - - - - - 10 -
20-29 years 42 2 25 - 2 - - - 69 2
30-39 years 28 - 8 1 - - 1 - 37 1
40-49 years 21 - 1 - - - - - 22 -
50-59 years 10 1 5 - - - - - 15 1
60-69 years 29 3 5 1 - - - - 34 4
70-79 years 34 4 6 - - - - - 40 4
80-89 years 39 8 3 2 - - - - 42 10
90-99 years 10 4 2 - - - - - 12 4
Totals 220 22 58 4 2 - 1 - 281 26
Percent of total
adult cases/deaths 78.3 84.6 20.6 15.4 0.7 0.4 100 100
2 Missouri Epidemiologist
Through the Special Invasive Bacterial were 38-39 weeks gestation, with an The complete Missouri 1992 study re
Infections Study, COC is seeking to other 11 (10.9%) being 36-37 weeks port will be sent to all Missouri hospi
determine the true incidence and nature gestation. A total of 22 (21.8%) were tals/laboratories.
of GBS invasive disease in a population significantly premature (more than four
of approximately 20 million persons. weeks). Of these, six (27.3%) were less Single copies of the report are avail
The study began in 1990 in four areas than30weeksgestationandfour(66.7%) able upon request from the Bureau of
(the state of Oklahoma, metropolitan of these babies died or were stillborn. Communicable Disease Control at
areas of Atlanta and San Francisco and [phone].
four counties in Tennessee) having a
total population of 10.1 million. (The
results of the 1990 surveillance were Table 3 Infant invasive group B streptococcal disease infections and
reported in the Morbidity and Mortality deaths by race and age at onset, Missouri 1992.
Weekly Report, Vol. 41/No. SS-6). Mis
White Black Totals
souri and Maryland were added to the
Cases Deaths Cases Deaths Cases Deaths
study in late 1991.
Earlyonset(<7 days) 73 4 27 3 100 7
During 1992,412casesofinvasiveGBS Late onset (8-90 days) 13 10 23
disease were identified in Missouri.
Despite biweekly telephone calls by Totals 86 4 37 3 123 7
project staff to all participating microbi Percent of total
infant cases/deaths 69.9 57.1 30.1 42.9 100 JOO
ology laboratories to collect reports of
new cases, 144(35.0%)werefoundonly
State Public Health Laboratory Report
through subsequent laboratory record
reviews. Newborn Screening - Hypothyroidism, Phenylketonuria,
Galactosemia and Hemoglobinopathies
GBS disease in Missouri led to 33 deaths,
James Baumgartner, B.S., M.B.A., Chief, Metabolic Disease Unit
for a case fatality rate of 8.0 percent. Of
the 26 adults ~15 years) who died, only Sept. 93 Oct. 93 Total YTD
eight were younger than 70 years. Two
were in their 20s, one was 35-years-old, Specimens Tested 10,357 9,675 98,505
one was 54, one 64, two were 67 and one
Initial (percent) 64.8% 64.6% 65,690
was 68. White persons accounted for
Repeat (percent) 35.2% 35.4% 32,915
84.6 percent of all adult GBS deaths;
blacks accounted for 15.4 percent. See Specimens: Unsatisfactory 139 110 1082
Table 2.
HT Borderline 726 729 7155
There were 123 cases in infants (<90
HT Presumptive 29 30 249
days of age) comprising 29 .9 percent of
the total number of cases of GBS dis
ease. One hundred (81.3%) cases were PKU Borderline 28 10 184
early onset (<7 days of age). Seven of PKU Presumptive Positive 2 2 12
these infants died or were stillborn, for a
case fatality rate of 7 .0 percent for early
GAL Borderline 28 27 324
onset disease. All deaths were within
two days of birth. Four deaths (57.1%) GAL Presumptive Positive 3 3 37
were in white infants, and three (42.9%)
were in black infants, while 86 (69.9%) FAS (Sickle cell trait) 91 69 930
cases were white and 37 (30.1 %) were
FAC (Hb C trait) 32 23 280
black. (No other racial groups were rep
.FAX (Hb variant) 20 14 141
resented in infants <90 days of age.) See
Table 3. FS (Sickle cell disease) 4 1 24
FSC (Sickle C disease) 2 4 22
Gestational age (<31 days of age) is
FC (Hb C disease) 0 0 0
known forlOl cases. Thirty-six(35.6%)
were full term (40weeks) and 10(9.9%)
HT= Hypothyroidism, PKU=Phenylketonu ria, GAL=Galactosemia, Hb=Hemoglobin,
were41-42 weeks. Twenty-two (21.8%)
YTD = Year to Date
January-February 1994 3
Statement on Tuberculosis Screening Welcome to
January 1994 Jennifer Atkins,
Production
The following statement was issued by the Missouri Advisory Committee for the
Elimination of Tuberculosis (MACET).
Manager
In this time of increasing national tuber reading the test. The reading consists of H. Denny Donnell, Jr., M.D.
culosis morbidity and with the looming observing the presence or absence of
Jennifer Atkins bas taken over as pro
threat of multi-drug resistant TB facing induration by inspection and palpation
duction manager with this issue of the
the nation and Missouri, it is essential of the arm. All reactions shall be mea
Missouri Epidemiologist. She is the
that all health care professionals screen sured and recorded in millimeters of
newly appointed Clerk IV for the Office
ing for tuberculosis use the most effec induration. Erythema should be disre
of Epidemiology as of December 1993.
tive tool available. garded.
She comes to this position from the
The Missouri Advisory Committee for When utilizing skin tests to detect TB health education section of the Bureau
of HIV/A IDS Prevention where she as
the Elimination of Tuberculosis and the infection, interpretations should be
sisted in creating various educational
Missouri Department of Health strongly based upon the Mantoux test only.
prevention materials.
advise the use of the PPD Mantoux Since there is no reliable method of
method as the test ofc hoice when screen distinguishing between a BCG and tu
ing individuals for tuberculosis. berculin reaction, individuals with a
history ofBCG should be tested with a
The Mantoux PPD testis an intracutane Mantoux PPD, and if found to have a
ous test to detect delayed hypersensitiv significant reaction, should be consid
ity in persons infected with ered as indicating infection with
M. tuberculosis. M. tuberculosis.
Farewell to EIS
It is administered by the intracutaneous More detailed information can be ob Officer, Carol
injection 0.1 ml. of PPD containing 5 tained by referring to the Department of
tuberculin units on the volar or dorsal Health, Bureau of Tuberculosis Control Friedman
surface of the forearm. Reading occurs Manual, and the CDC/A TS guidelines
48 to 72 hours after injection. The on tuberculin skin testing. The latter is H. Denny Donnell Jr., M.D.
reading should be done by a skilled available from the American Lung As
Dr. Carol Friedman, who worked with
health care worker or medical profes sociation of Eastern and Western Mis
the Missouri Department of Health as a
sional knowledgeable about the antigen souri at [phone].
CDC sponsored Epidemiologic Intelli
and the technique of administering and
gence Officer, completed her two-year
assignment at the end ofJ une 1993 and
is now working with the CDC in her
Thanks to Diane Rackers, Production
home state of Texas. In her new post,
Dr. Friedman will monitor and promote
Manager
the progress toward the objectives es
H. Denny Donnell Jr., M.D. tablished for the year 2000. Before
leaving Missouri she worked with the
Diane Rackers bas been promoted to a manager for the Missouri Epidemiolo St. Louis City Department of Health for
Health Program Representative I, and gist since January .1991. Using the a five-~onth interval developing and
began work with the Hazardous Sub Pagemaker program to compose 14 is supporting the work of the St. Louis
stances Emergency Events Surveillance sues and coordinate the work of moving Task Force on Syphilis. Her work in
(HSEES) program for the Bureau of articles from the planning stage through Missouri was greatly appreciated and
Environmental Epidemiology inNovem the editorial process to final format and was reflected in the articles she wrote for
·ber 1993. She bad been employed for24 distribution of the published issue. Our the Missouri Epidemiologist. She was
1/2 years in secretarial positions with sincere thanks and congratu-lations go involved in several investigations of
this agency and bad served as secretary out to her and we wish her great success outbreaks, provided consultations on a
for Dr. Denny Donnell for 22 of those with the new endeavor. wide range of topics, helped with sur
years. She capably served as production veillance issues and helped to edit the
Missouri Epidemiologist.
4 Missouri Epidemiologist
Compliance with Universal Precautions: What Health Care
Professionals Need to Know
Caryl Collier, R.N., M.P.H., C.I.C.
As of August 3, 1993, the Centers for Missouri is not one of the states with its OSHA standard for blood borne patho
Disease Control and Prevention (CDC) own Occupational Safety and · Health gens.
was aware of 37 health care workers Office, the public sector is generally
(HCWs) in the United States who exempt from the federal rule except for 19 CSR 30-40.047-(to be published as a
seroconverted from negative to positive ambulance workers, who were brought final rule next year) will establish man
for the human immunodeficiency virus under the OSHA requirement by state datory procedures to facilitate fact find
(HIV) following occupational exposure rule (see discussion below). Missouri ing and follow-up recommendations
to blood and body fluids. Of these 37 public sector employers include state subsequent to communicable disease
HCWs, 32 experienced a percutaneous and local governments which subsidize exposures (possible or definite) incurred
exposure, 4 had a mucocutaneous expo county health departments, borne health by emergency response personnel. The
sure and 1 sustained both organizations, fire safety and law en rule will stipulate the appropriate re
percutaneous and mucocutaneous ex forcement personnel, schools, hospitals porting mechanism for emergency re
posures. There are 78 other HCW s who and nursing homes. sponse personnel who acknowledge a
are HIV positive or have AIDS who did blood and body fluid exposure. The rule
not report other risk factors for HIV Although there is no federal law to man will also stipulate the responsibility of
infection but reported occupational ex date public sector employers to comply the medical facility and designated of
posure to blood, body fluids, or HIV with the OSHA blood borne pathogens ficers in notifying emergency response
infected laboratory materials; however, rule, thereisstatelaw, 191.650, 191.656, personnel of their possible exposure to
there is no documentation of the pre 191.694 RSMo Supplement 1992, re certain diagnosed communicable dis
exposure HIV status and subsequent quiring all Missouri licensed health care eases. A companion rule 19 CSR 30-
seroconversion for these 78 persons. professionals and licensed health care 40.048 will mandate relevant training
facilities to practice universal precau on universal precautions and other re
CDC estimates that approximately 8,000 tions as recommended by CDC. This lated activities. Both rules are autho
HCWs become infected with hepatitis statute also requires that health care pro rized by a new section, 192.806-1 RS Mo
B yearly and that approximately 200 fessionals and facilities comply with (1993 supplement).
HCWs die each year of complications CDC guidelines on disinfection and ster
from this infection. ilization of reusable invasive devices. The Department of Health recommends
Health care facilities will need to show that all public entities establish policies
In response to the morbidity and mortal proof that instruction on infection con and procedures that meet the require
ity resulting from occupational expo trol procedures has been provided to.a ll ments of the federal OSHA blood borne
sures to blood borne pathogens, the patient care personnel. In addition, all pathogens rule. In so doing, an expo
Occupational Safety and Health Ad health care professionals who perform surecontrol plan should be written which
ministration (OSHA) published its final invasive procedures must receive train outlines how the employer intends to
rule, 29 CFRPart 1910.1030, "Occupa ing, approved by the Missouri Depart eliminate or minimize employee expo
tional Exposure to Blood Borne Patho ment of Health, on infection control sures to blood borne pathogens. A ge
gens" in the December 6, 1991, Federal procedures relevant to HIV and related neric sample exposure control plan can
Register. OSHA authority extends to diseases, including universal precautions be obtained from OSHA or the Bureau
all private sector employers with one.or and prevention of percutaneous injuries. of Communicable Disease Control (314)
more employees as well as federal civil 751-6115.
ian employers. States administering As of April 26, 1990, all ambulance
their own occupational safety and health services were required to follow CDCs Booklets and fact sheets on OSHA stan
programs through plans approved un "Guidelines for Prevention of Trans dard 29 CFR Part 1910.1030 can be
der section 18(b) of the Occupational mission of Human Immunodeficiency obtained from OSHA Publications, 200
Safety and Health Act of 1970 must Virus and Hepatitis B Virus to Health Constitution Avenue, N.W., Room
adopt standards and enforce require Care and Public Safety Workers," N3101, Washington, DC 20210 or by
ments that are at least as effective as MMWR, June 23, 1989, Vol. 38 No. S- calling (202)-219-8148. A videotape
federal requirements. There are cur 6. Effective February 1993, the rule, 19 can be obtained from OSHA for a fee by
rently 25 states and territories that have CSR 30.045, "Communicable Disease calling the National Audio-Visual Cen
their own state plans. Of those, 23 cover Policy" for ambulance services was up ter [phone].
the private and public sectors and 2 graded to require compliance with the
cover the public sector only. Because ( continued on page 9)
January-February 1994 5
Latex Allergies Problematic for Some Patients and Health
Care Workers
Caryl Collier, R.N., M.P.H., C.I. C.
Severe latex hypersensitivity (allergy) ral rubber because of production meth latex and/or natural and cured rubber
in several health care workers bas been ods, i.e., washing of raw latex? It is vary from'mild eczema or skin rash to
reported to the Missouri Department of known that glove antigen content varies hives (local and systemic), rhinitis,
Health's, Bureau of Communicable Dis from brand to brand and lot to lot. The conjunctivitis, broncbospasm or asthma
ease Control. These reports, along with antigens can be those in the rubber itself and anapbylaxis. Some of these reac
inquiries about alternatives to latex, ini as well as those added during production tions are similar to drug or stinging
tiated a literature search and contact of the commercial product, including insect venom responses in which the
with resource persons from the Centers powders in gloves. Rubber antigens can throat muscles contract and cardiac shock
for Disease Control and Prevention be attached to glove powder or corn ensues quickly. In some persons, mild
(CDC), the UnitedStatesFoodandDrug starch particles in the gloves. symptoms occur upon initial exposure
Administration (FDA), and the Ameri to latex, but after repeated exposures,
can College of Allergy and Immunol Researchers estimate that latex allergy severe symptoms develop which can
ogy (ACAi). exists in less than 1 percent of the gen lead to death if not quickly recognized
eral population and 6 percent to 14 per and treated.
In order to prevent transmission of blood cent of health care workers. Unpub
borne pathogens, CDC recommended, lished studies indicate that subsegments Preliminary recommendations of the
and the Occupational Safety and Health of health care workers are being identi ACAi were published in March 1992.
Administration mandated, Universal fied with much higher latex allergy rates. They contain two essential components:
Precautions; consequently, during the High risk patient populations are those
past six years, health care workers have requiring multiple exposures to latex 1. Latex allergy identification:
been wearing more gloves than ever during medical/surgical procedures. 1) a careful history (questions about
before. Many of these gloves are made Case reports and surveys reveal a bigb itching, rash or wheezing after wear
oflatex, which provides excellent tactile rate of sensitization in persons with spina ing latex gloves, after having a medi
contact in surgical or examination pro bifida/myelomeningocele (FDA reports cal procedure performed or inflating
cedures. A spokesperson from Market 18-40%) and persons with urogenital a toy balloon) and 2) conduct skin
Intelligence Research Corporation in abnormalities, requiring recurrent instru prick tests for latex in experimental
Mountain View, California, quotes a mentation of the genitourinary tract. Also settings with protocols to manage
1993 report, "Disposable Medical Prod included in bigb risk patient populations anapbylactic reactions. Serum tests
ucts Market Study" (#897-54), by say are those receiving barium enema pro for latex-specific IgE, currently per
ing that total U.S. medical glove (latex cedures with a latex balloon tip. (The formed on a research basis at several
and vinyl) expenditure was $426 mil FDA says these balloon tips are no longer laboratories, may confirm a suspected
lion in 1992, up from $385 million in being manufactured with latex, but some diagnosis in many cases but pres
1989. Projected expenditure in 1999 for with latex still remain on the market.) ently lack sensitivity to identify all
latex and vinyl gloves is $782 million. Other patients having allergic reactions patients with true latex allergy.
Coincident with an increase in exposure to latex include those receiving oral,
to latex comes the potential for an in vaginal and rectal examinations with 2. Latex avoidance procedures:
crease in reports of latex hyper sensitiv latex gloves, those with rubber orth 1) "latex-sensitive" wristbands and
ity. odontic appliances, rubber dental dams, labeling of patient charts; 2) a list of
those inhaling aerosolized latex and those all products and medical procedures
Allergies to latex have been recognized exposed inadvertently to latex from rub utilizing latex; 3) a list of safe items
in patients, and rubber industry workers ber stoppers and injection ports during for latex-sensitive persons; 4) latex
in many reports from investigators since intravenous administration. According free surgical suites for elective sur
1979. As of April 1992, over 600 seri to the ACAi, the majority of patients gery on patients having bad latex
ous reactions to latex have been reported who develop latex hypersensitivity have caused anaphylaxis and/or
to the FDA, including at least 16 ana a history of some prior allergic condi myelomeningocele and 5) provision
pbylactic fatalities. However, investi tion, e.g., bay fever. Thus, exposure to of synthetic latex or non-latex prod
gators are not sure what an increase in latex antigens occurs by direct contact ucts for health care workers showing
reports really mean. Does it mean in through cutaneous, mucosal, parenteral signs of latex contact dermatitis or
creased exposure and sensitization to and inhaled routes. latex hypersensitivity.
latex? Better diagnosis of latex aller
gies? Increased protein content of natu- The symptoms of hypersensitivity to (c ontinued on page 9)
6 Missouri Epidemiologist
.....
" _} ma Missouri Department of Health
~ 7 .. J .=:i. Disease Prevention -Communicable Disease Control Reporting Period •
.-~"..~' - ,.l.,iL.-J.. ' I ~'-"I"r "-i· \~ 'L:I 07,,(I)i ~'l0 N.WB. IMNOE NTCDH DLisYStrE iM ctsO S.W.R BIF.D.D IT01Y.H. . ER R EPKAOCNITRSYA TS LCOSIUTTYI.S WcSoUT.I.S GSRPcEGoEfN.l DE ST2A TMESO TellOrplTHtA eLmS berF/OORc tCoUbMeUFrLO,A R1T I9V9EM3 SE YDIRA N
Vaccine Preventable Dis.
Chickennox 135 35 39 122 68 38 0 0 0 0 437 562 7900 8158 7128
Diphtheria 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Hib Menineitis 0 1 1 2 0 0 0 0 0 0 4 4 9 14 n
Hib Other Invasive 2 1 4 2 0 2 1 3 2 0 17 11 sn 30 **
Influenza 1 0 0 0 0 0 0 0 0 0 1 0 ?'iO f.? 1J_')
Measles 0 0 0 0 0 0 0 0 0 0 0 0 1 0 2
Mumos 3 0 0 0 0 1 0 0 3 0 7 6 32 35 1'i
Pertussis 11 0 2 2 'i 1 0 12 11 0 44 11 121 97 ()1
Polio 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ()
Rubella 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1
Tetanus 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1
Viral Hepatitis
A 10 3 12 3 4 7 8 100 58 25 230 364 1293 1028 615
B 'i ?. f. 1 'i 7 C) ?f. 1R 'i Rf. R1 40?. L1?7 LiOR
Non A-Non B 0 0 0 1 0 0 6 0 0 0 7 'i 4? ?1 '11
Unspecified 0 0 0 0 2 0 0 0 0 0 2 0 8 9 14
Meningitis
Aseotic 21 4 21 7 11 5 6 1 11 7 94 91 233 233 203
Menineococcal 2 0 0 1 1 1 1 2 2 0 10 5 49 20 28
Other 1 1 0 0 0 0 0 3 3 0 8 6 57 37 49
Enteric Infections
Camovlobacter 13 4 8 15 12 9 10 8 23 12 114 129 532 535 470
Salmonella 1C ) 1 11 26 11 11 11 11 17 1 125 86 412 162 'i90
Shieella 'i 0 6 6 1 23 l 'i 8 20 1 R'i 112 570 f.''2 169
Typhoid Fever 0 0 0 0 0 0 0 0 0 0 0 1 2 2 2
Parasitic Infections
Amebiasis 0 1 1 0 0 1 7 2 3 0 15 4 44 23 21
Giardiasis 21 4 17 11 13 26 28 8 43 19 190 199 590 625 664
Sexually Transmitted Dis.
ATOS 8 1 10 2 6 4 1 28 27 27 1 115 148 1528 567 472
Gonorrhea 72 28 94 80 57 19 550 1499 581 0 2980 2708 11161 12433 14869
Genital Hemes 16 17 'i 1 21 66 1() 166 1L11 147 0 6RR 'i74 1114 ?054 2714
Noneonoc. urethritis ?1 12 41 21 'i 0 ?'i4 'i89 1 f.R 14 1l ?Q 1( )()f. 'i1Rl 'iR76 6183
Prim. & Sec. svohilis 4 3 0 10 3 5 29 205 58 1 318 234 1243 980 216
Tuberculosis
Extranulmonarv 0 0 1 1 2 0 0 0 3 2 1 10 4 36 32 33
Pulmonarv 2 0 4 6 8 2 1 2 6 4 0 35 30 }RO 159 169
Zoonotic
Animal Bites 122 22 69 102 39 70 0 0 503 4 931 1181 5344 5779 3875
Psittacosis 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0
Rabies Animal) 1 0 0 2 1 0 0 0 4 1 9 16 28 34 11
Rocky Mtn. Sp. Fever 1 0 1 2 1 0 0 0 0 0 'i 'i ')() ?4 11
Tularemia 0 1 2 1 0 0 0 0 0 0 4 4 16 34 35
Low Frequency Diseases Outbreaks
Anthrax Encephalitis (viral/arbo-viral) Malaria Foodbome -1
Botulism Granuloma lnguinale Plague Waterborne
Brucellosis Kawasaki Disease Rabies (human) Nosocomial
Chancroid Legionellosis Reye's Syndrome Pediculosis
Cholera Leptospirosis Rheumatic fever, acute Scabies -5
Cryptosporidiosis Lymphogranuloma Venereum -1 Toxic Shock Syndrome Other
Encephalitis (infectious) -5 Trichinosis Citrobacter bacteremia -1
*Reporting Period Beginning August 29: Ending October 30, 1993. Hepatitis A -2
••Totals do not include KC, SLC, SLCo, or Springfield Shigella -1
***State and Federal Institutions
U Data not available Due to data editing, totals may change.
January-February 1994 7
DISEASE REPORTS, SEPTEMBER/OCTOBE.R IJ 5 YEAR MEDIAN
1993 AND 5 YEAR MEDIAN
■ 1993
HEPATITIS A
HEPATITIS B
CAMPYLOBACTER
GIARDIA
SALMONELIA
Sl-llGELlA
0 20 40 60 80 100 120 140 160 180 200 220 240
5 YEAR MEDIAN= 1988-1992
NUMBER OF CAS~
II 5 YEAR MEDIAN
MENINGOCOCCAL MENINGffiS ■ 1993
1-llB MENINGms
OTHER 1-llB DISEASE*
ASEPTIC MENINGms
0 20 30 40 50 60 70 80 90 100
5 YEAR MEDIAN= 1988-1992 NUMBER OF CASES
* 5 YEAR MEDIAN NOT AVA ll.ABLE
VIRAL HEPATITIS
Hepatitis A decreased 36.8%, from 364 cases in September/October 1992 to 230 during the same period in 1993. This is an increase
of 98.3% from the five year median of 116 cases. Hepatitis B, at 86 cases, is up 3.6% from 83 cases in 1992. This is an increase of
6.5% from the five year median of 92 cases.
ENTERICS
Campylobacter decreased 11.6%, from 129 cases in 1992 to 114 in 1993. This is an increase of 29.5% from the five year median of
88 cases. Salmonella, at 125 cases, is up 45.3% from 86 cases in 1992 and down 0.8% from the five year median of 126 cases.
Shigellosis decreased 24.1% from 112 cases in 1992 to 85 in 1993. It increased 37.1 % from the five year median of 62 cases.
PARASITES
Giardiasis, at 190 cases, is down 4.5% from 199 cases in 1992. It is 0.5% above the five year median of 189 cases.
MENINGITIS
Aseptic meningitis increased 3.3%, from 91 cases in 1992 to 94 in 1993. This is an increase of 51.6% from the five year median of
62 cases. Meningococcal meningitis increased 100%, from 5 cases in 1992 (which is also the five year median) to 10 cases in 1993.
BIB DISEASE
There were 4 cases ofHib meningitis reported for the1993 period, which is the same as 1992. This is down 55.5% from the five
year median of 9 cases. The Bacterial Infections Surveillance Project continues to affect reporting of other invasive Hib disease; it
increased 54.5%, from 11 cases in 1992 to 17 in 1993. There is no five year median available for other invasive Hib disease
8 Missouri Epidemiologist
Latex Allergies
(continued from page 6)
Active research efforts to understand same regimen bas been recommended For more information on the project and
the causes and treatment of latex al by other authors to be used preceding participant responsibilities, contact:
lergy are continuing and new findings major surgical and dental procedures in Siiri N. Bennett, M.D.
are anticipated by ACAi. One re latex-allergic patients; however, Dr. E. Hospital Infections Program
searcher of latex allergy is Dr. Jay Slater, author of, "Allergic reactions to MS A-07
Portnoy, Chief of Allergy at Children's natural rubber," Annals of Allergy, Vol. Centers for Disease Control
Mercy Hospital in Kansas City. Dr. 68, March 1992, warns thatanaphylaxis and Prevention
Portnoy is testing (when indicated) for has occurred in rubber-sensitive indi 1600 Clifton Road NE
latex allergy in employees and in chil viduals in spite of this regimen; conse Atlanta, GA 30333
dren under 18 years of age who are quently, the regimen cannot be an alter Phone: [phone]
inpatients or outpatients. Dr. Portnoy native to antigen avoidance. Fax: [phone]
echoes the FDA Medical Alert: "Aller
gic Reactions to Latex-Containing Plant physiologists, such as Katrina Barry Page, Director
Medical Devices," March 29, 1991, in Comish of USDA's Agricultural Re Environmental Technology Programs
saying that hypoallergenic gloves might search Service, are working on aller Health Industry
be satisfactory for latex allergic health gen-freerubberextractedfrom the stems Manufacturers Association
care workers, but latex-free gloves are and bark of the guayule bush which 1200 G. Street NW, Suite 400
necessary for contact with latex-aller grows wild in Arizona and Mexico. The Washington, OC 20005
gic patients. The Task Force for Latex rubber from this bush appears to be free
Allergy at Children's Mercy Hospital of the allergy-causing proteins found in For more information, contact Caryl
has developed a comprehensive set of latex made from the tropical rubber Collier at [phone].
recommendations, which were revised tree. If research shows this to be the
July 16, 1993, for identifying and man case, then products such as medical
aging persons with latex-allergies. For gloves, toys and clothing could be manu
Universal Precautions
more information, persons may call factured free of latex. However.even if
[phone]. this is possible, there is always the po (c ontinued from page 5)
tential, according to Sharon Dillard of
Consultation on compliance with the
Cotton liners for gloves and non-latex the FDA, that allergy-prone individuals
OSHA standard can be obtained from
surgical/examination gloves are avail will develop sensitivities to the proteins
the following sources: Missouri Onsite
able from several manufacturers, as are in a new naturally-derived product.
Safety and Health Consultation Ser
non-rubber bladder catheters, enema
vices, Division of Labor Standards at
tubes, endotracheal tubes, paper tape, Soon to be published in the Federal
[phone]; Missouri Department
clear plastic face masks, and non-latex Register for public comment is the FDA
of Health's, Bureau of Dental Health at
tourniquets. A health care worker could decision to require labels on products
( 314) 751-6247;MissouriDepartment
wear a non-latex glove over the latex containing latex, thus alerting latex
of Health's, Bureau of Communicable
glove if the patient is sensitive. If both allergic persons to avoid the products.
Disease Control, 314-751-6115; Kan
the health care worker and patient are All reactions to latex should be reported
sas safety and health consultation: 913-
sensitive, a latex middle glove could be to the FDA at [phone].
296-4386. Consultation can also be
used. FDA is recommending double
obtained from the OSHA area offices -
gloving when vinyl gloves are neces The Health Industry Manufacturers As
Kansas City: [phone] or (816)
sary because of greater porosity occur sociation (HIMA) and the COC are col
483-9531; St. Louis area office: (800)
ring in the vinyl manufacturing pro laborating on a study of reactions to
392-7743 or [phone] and from
cess. However, COC does not recom latex-containing products. The purpose
the OSHA regional office: (816) 426-
mend latex rather than vinyl gloves of this study is to determine the preva
5861.
when quality control standards are lence and type of natural rubber latex
equal. reactions among workers at a wide va
riety of heal th care facilities and natural
Some authors recommend that a regi rubber latex manufacturing plants na Notice to Readers:
men of medication with corticoster tionwide. The previous issue of the Missouri Epi
oids, H1 antagonists, ephedrine, and demiologist was July-October. The
sometimes H2 antagonists precede ra HIMA and COC are now actively solic Missouri Epidemiologist was not is
diography with contrast media. This iting health care facilities and organiza sued for November-December.
tions for participation in this study.
January-February 1994 9
Update: Hantavirus Pulmonary Syndrome -
United States, 1993
Reprinted in part from MMWR, Vol. 42/No. 42, October 29, 1993, and MMWR Vol. 43/No. 3, January 28, 1994
In June 1993, a newly recognized han virus were unlike those of any known cardiogenic pulmonary edema or adult
tavirus was identified as the etiologic hantavirus; the new hantavirus is most respiratory distress syndrome. Onset of
agent of an outbreak of severe respira closely related to the Prospect Hill strain illness has been characterized by a
tory illness (hantavirus pulmonary syn of hantavirus. prodrome consisting of fever, myalgia,
drome [HPS]) in the southwestern United and variable respiratory symptoms (e.g.,
States. Since this problem was recog In November 1993, the etiologic han cough) followed by the abrupt onset of
nized, sporadic cases have been identi tavirus associated with HPS was iso acute respiratory distress. Other symp
fied from a wide geographic area in the lated from tissues of a deer mouse toms reported during the early phase of
western United States. (Peromyscus maniculatus) trapped in illness have included headache and gas
New Mexico in June 1993 near the resi trointestinal complaints. Other findings
Through December 31, 1993, 53 per dence of a person with confirmed HPS. include thrombocytopenia, hemocon
sons with illnesses meeting the surveil Lung material from this animal was twice centration, leukocytosis, increased band
lance case definition of HPS have been passed in uninfected laboratory deer mice forms on differential, hypoalbuminemia,
reported to the Centers for Disease Con and then adapted to Vero E6 cell cul and lactic acidosis. In all case-patients
trol and Prevention. Patients' ages have tures. The genetic sequence of the 139- reviewed, bilateral pulmonary infiltrates
ranged from 12 years to 69 years (me nucleotide PCR product from the iso developed within 2 days of hospitaliza
dian age: 31 years), and 32 (60%) were lated virus was identical to PCR prod tion. The hospital course was character -
aged 20-39 years; 30 (57%) were male. ucts amplified from this rodent in June ized by fever, hypoxia, and hypoten
Twenty-six (4 9%) were American Indi 1993 and from lung tissue of the associ sion; recovery in survivors has been
ans; 22 (42%), non-Hispanic whites; ated patient. At the same time, the U.S. without sequelae.
four (8% ), Hispanic; and one (2%) , non Army Medical Research Institute of In
Hispanic black. Thirty-two (60%) pa fectious Diseases isolated the virus from Previously isolated hantaviruses have
tients died; persons with fatal cases and specimens from a person in New Mexico demonstrated in vitro sensitivity to the
persons with nonfatal cases were similar and from a rodent in California. Muerto investigational antiviral drug ribavirin.
in age, sex, and race. Canyon virus has been proposed as the Based on this finding and evidence of
name for this virus, following standard activity of intravenous ribavirin therapy
Cases have occurred in residents of 14 conventionsfornamingzoonoticviruses againstHantaan virus infection, intrave
states including New Mexico (18), Ari after a nearby geographic feature. nous ribavirin has been made available
zona (11), Colorado (5), California (3), as an investigational agent though a
Nevada (3), Idaho (3), Montana (2), The prognosis is poorest in case-pa CDC-sponsored open label protocol for
South Dakota (2) and Oregon, North tients with shock and with severe lactic patients with HPS. Whether treatment
Dakota, Minnesota, Texas, Kansas, and acidosis. Anecdotal reports suggest that with ribavirin has had any beneficial
Louisiana with one each. Of the 34 periods of severe hypoxia or hypoten effect on-the course ofHPS is unknown.
(64%) persons who were residents of sion before stabilization in the inten Further plans for study of ribavirin are
Arizona, Colorado, or New Mexico, ill sive-care setting adversely affect sur under consideration by a collaborative
ness occurred in 25 (74%) during April vival. Supportive measures are the basis working group sponsored by the Na
-July 1993 and in one before 1993. In for therapy; severe hypoxia and tional Institute for Allergy and Infec
comparison, of 19 cases reported from overhydration should be avoided or pre tious Diseases, National Institutes of
other states, five (26%) had onset of vented. Pressors or cardiotonic drugs Health. Physicians who want to enroll
illness during April - July 1993, and should be employed to maintain perfu patients should contact the CDC
seven (37%) had onset before 1993. All sion without excessive fluid administra Ribavirin Officer of the Day at (404)
patients either lived in rural areas or had tion. Testing for alternative diagnoses 639-1510 weekdays or [phone]
visited rural areas during the 6 weeks should be done, and appropriate treat evenings and weekends. Physicians must
before onset of illness. ment to cover infections mimicking HPS report patients meeting the screening
should be administered early. Serologic criteria for HPS and submit appropriate
The etiology of HPS was initially iden tests in combination with PCR and IHC clinical samples to state health depart
tified by serology, polymerase chain re should be used in confirming the diag ments to confirm the diagnosis.
action (PCR), and immunohistochemis nosis of acute hantavirus infection.
try. Additional cloning and sequencing New clinical syndromes and infections
of virus ribonucleic acid (RNA) from No defined set of symptoms and signs associated with previously unknown
human autopsy tissues indicated that all reliably distinguishes HPS at the time of pathogens often are recognized only af
three of the RNA segments of this new presentation from other forms of non- ter clinicians and public health officials
10 Missouri Epidemiologist