Missouri Department of Health & Senior Services Health Alerts 2011

2011·0.3 MB·English

by  Missouri Department of Health and Senior Services

Missouri Department of Health & Senior Services

Health Alert: Health Alert
October 21, 2011
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FROM: MARGARET T. DONNELLY

DIRECTOR

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SUBJECT: Potential Contamination of Plak-Vac Oral Care System

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The Department of Health and Senior Services advises health care facilities to temporarily
suspend the use of Plak-Vac Oral Care System. The product has been used by health care
facilities for oral hygiene of patients on ventilators. One lot of this product was analyzed
and found to be contaminated with Burkholderia cepacia. In addition to patients on
October 21, 2011 ventilators, this organism is hazardous to those with chronic respiratory disease, cystic
fibrosis or are otherwise immune compromised. The department is working with the Food
This document will be updated as new
and Drug Administration on the investigation and further details will be provided as they
information becomes available. The
become available.
current version can always be viewed
at http://www.health.mo.gov
The product label is pictured below.
The Missouri Department of Health &

Senior Services (DHSS) is now using
4 types of documents to provide
important information to medical and
public health professionals, and to
other interested persons:

Health Alerts convey information
of the highest level of importance
which warrants immediate action or
attention from Missouri health
Plak-Vac-
providers, emergency responders,
public health agencies, and/or the
public.

Health Advisories provide
important information for a specific
incident or situation, including that
impacting neighboring states; may not
require immediate action.
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Health Guidances contain
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comprehensive information pertaining
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Health Updates provide new or , Apply rnouUl fflOG1u,1Ze<10 ·lll5--!!s-!II•
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updated information on an incident or MJl)blor
situation; can also provide informa- NfitOOfllOD
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tion to update a previously sent
Health Alert, Health Advisory, or
Health Guidance; unlikely to require
immediate action.
__________________________________

Office of the Director
912 Wildwood
P.O. Box 570
Jefferson City, MO 65102
Telephone: [phone]
Fax: [phone]
Web site: http://www.health.mo.gov
Missouri Department of Health & Senior Services

Health Alert: Health Alert
FROM: MARGARET T. DONNELLY October 26, 2011

DIRECTOR

SShh iiggaa ttooxxiinn-- SUBJECT: Increase in reported Shiga toxin-producing Escherichia coli
pprroodduucciinngg (STEC) Illnesses in St. Louis Area

EEsscchheerriicchhiiaa ccoollii
Situational Update

The St. Louis County Health Department has reported a marked increase in cases of Shiga toxin-producing Escherichia coli
(STEC). The cases are being investigated by the St. Louis County Health Department and the Missouri Department of Health
and Senior Services (DHSS). At this time the cause of the illnesses is unknown.

CDC has recommended that any person who has signs or symptoms of STEC infection should seek medical care and let the
October 26, 2011 medical provider know about the increase of STEC infections in St. Louis region and the importance of being tested for
STEC infection.

This document will be updated as new
Symptoms of STEC infection include severe stomach cramps, diarrhea (which is often bloody) and vomiting. If there is fever,
information becomes available. The it usually is not very high. Most people get better within 5–7 days, but some patients go on to develop HUS (hemolytic
current version can always be viewed uremic syndrome), usually about a week after the diarrhea starts. The classic triad of findings in HUS is acute renal damage,

at http://www.health.mo.gov microangiopathic hemolytic anemia (evidence of schistocytes and helmet cells on peripheral blood smear), and
thrombocytopenia.
The Missouri Department of Health &
Senior Services (DHSS) is now using It is not recommended to give antibiotics to patients with suspected STEC infections until complete diagnostic testing can be
4 types of documents to provide performed and STEC infection is ruled out. Some studies have shown that administering antibiotics in patients with STEC
important information to medical and infections might increase their risk of developing HUS. However, clinical decision making must be tailored to each individual
public health professionals, and to patient. There may be indications for antibiotics in patients with severe intestinal inflammation if perforation is of concern.

other interested persons:
Guidelines to ensure as complete as possible detection and characterization of STEC infections include the following:

Health Alerts convey information
• All stools submitted for testing from patients with acute community-acquired diarrhea should be cultured for
of the highest level of importance
STEC O157:H7. These stools should be simultaneously assayed for non-O157 STEC with a test that detects the
which warrants immediate action or
Shiga toxins or the genes encoding these toxins.
attention from Missouri health
• Clinical laboratories should report and send E. coli O157:H7 isolates and Shiga toxin-positive samples to the state
providers, emergency responders, public health laboratory as soon as possible for additional characterization.
public health agencies, and/or the • Specimens or enrichment broths in which Shiga toxin or STEC are detected, but from which O157:H7 STEC
public. isolates are not recovered should be forwarded as soon as possible to the state public health laboratory so that non-
O157:H7 STEC can be isolated.
Health Advisories provide • It is often difficult to isolate STEC in stool by the time a patient presents with HUS. Immunomagnetic separation
important information for a specific (IMS) has been shown to increase recovery of STEC from HUS patients. For any patient with HUS without a
incident or situation, including that culture-confirmed STEC infection, stool can be sent to the CDC (through the state public health laboratory). In
impacting neighboring states; may not addition, serum can be sent to CDC (through the state public health laboratory) for serologic testing of common
require immediate action. STEC serogroups.

Health Guidances contain The benefits of adhering to the recommended testing strategy include early diagnosis, improved patient outcome, and
comprehensive information pertaining detection of all STEC serotypes.
to a particular disease or condition,
E. coli is a Category I reportable disease. All patients with Shiga toxin-positive diarrheal illness or HUS either known or
and include recommendations,
suspected cases should be reported to your local public health agency, or to the Missouri Department of Health and Senior
guidelines, etc. endorsed by DHSS.
Services (DHSS) at 800/392-0272 (24/7).

Health Updates provide new or
Laboratory consultation is available from the Missouri State Public Health Laboratory (MSPHL) by calling 573/751-3334, or
updated information on an incident or
800/392-0272 (24/7).
situation; can also provide informa-
tion to update a previously sent Questions should be directed to DHSS’ Bureau of Communicable Disease Control and Prevention at 573/751-6113 or
Health Alert, Health Advisory, or 800/392-0272 (24/7).
Health Guidance; unlikely to require
immediate action.

Office of the Director
912 Wildwood
P.O. Box 570
Jefferson City, MO 65102
Telephone: [phone]
Fax: [phone]
Web site: http://www.health.mo.gov
Missouri Department of Health & Senior Services

Health Alert: Health Alert
October 28, 2011
FROM: MARGARET T. DONNELLY

DIRECTOR

SShhiiggaa ttooxxiinn--
SUBJECT: Increase in reported Shiga toxin-producing Escherichia coli
pprroodduucciinngg (STEC) Illnesses in St. Louis Area
EEsscchh eerriicchhiiaa ccoollii
Situational Update 10/28/11
All stools submitted to clinical laboratories for testing from patients with suspected E coli infection should be
cultured for O157 STEC on selective and differential agar. These stools should be simultaneously assayed for
non-O157 STEC with a test that detects the Shiga toxins or the genes encoding these toxins. Specimens or
enrichment broths in which Shiga toxin or STEC are detected but from which O157 STEC are not recovered
October 28, 2011
should be forwarded as soon as possible to the Missouri State Public Health Laboratory.

This document will be updated as new
information becomes available. The Situational Update 10/26/11
current version can always be viewed
at http://www.health.mo.gov The St. Louis County Health Department has reported a marked increase in cases of Shiga toxin-producing
Escherichia coli (STEC). The cases are being investigated by the St. Louis County Health Department and the

The Missouri Department of Health & Missouri Department of Health and Senior Services (DHSS). At this time the cause of the illnesses is unknown.
Senior Services (DHSS) is now using
4 types of documents to provide CDC has recommended that any person who has signs or symptoms of STEC infection should seek medical
important information to medical and care and let the medical provider know about the increase of STEC infections in St. Louis region and the
public health professionals, and to importance of being tested for STEC infection.
other interested persons:
Symptoms of STEC infection include severe stomach cramps, diarrhea (which is often bloody) and vomiting. If
Health Alerts convey information
there is fever, it usually is not very high. Most people get better within 5–7 days, but some patients go on to
of the highest level of importance
develop HUS (hemolytic uremic syndrome), usually about a week after the diarrhea starts. The classic triad of
which warrants immediate action or
findings in HUS is acute renal damage, microangiopathic hemolytic anemia (evidence of schistocytes and
attention from Missouri health
helmet cells on peripheral blood smear), and thrombocytopenia.
providers, emergency responders,

public health agencies, and/or the
It is not recommended to give antibiotics to patients with suspected STEC infections until complete diagnostic
public.
testing can be performed and STEC infection is ruled out. Some studies have shown that administering

Health Advisories provide antibiotics in patients with STEC infections might increase their risk of developing HUS. However, clinical
decision making must be tailored to each individual patient. There may be indications for antibiotics in patients
important information for a specific
with severe intestinal inflammation if perforation is of concern.
incident or situation, including that

impacting neighboring states; may not
Guidelines to ensure as complete as possible detection and characterization of STEC infections include the
require immediate action.
following:

Health Guidances contain
comprehensive information pertaining • All stools submitted for testing from patients with acute community-acquired diarrhea should be
to a particular disease or condition, cultured for STEC O157:H7. These stools should be simultaneously assayed for non-O157 STEC
and include recommendations, with a test that detects the Shiga toxins or the genes encoding these toxins.
guidelines, etc. endorsed by DHSS. • Clinical laboratories should report and send E. coli O157:H7 isolates and Shiga toxin-positive
samples to the state public health laboratory as soon as possible for additional characterization.
Health Updates provide new or
• Specimens or enrichment broths in which Shiga toxin or STEC are detected, but from which O157:H7
updated information on an incident or
STEC isolates are not recovered should be forwarded as soon as possible to the state public health
situation; can also provide informa-
laboratory so that non-O157:H7 STEC can be isolated.
tion to update a previously sent
• It is often difficult to isolate STEC in stool by the time a patient presents with HUS. Immunomagnetic
Health Alert, Health Advisory, or
separation (IMS) has been shown to increase recovery of STEC from HUS patients. For any patient
Health Guidance; unlikely to require
with HUS without a culture-confirmed STEC infection, stool can be sent to the CDC (through the
immediate action.
state public health laboratory). In addition, serum can be sent to CDC (through the state public health
__________________________________
laboratory) for serologic testing of common STEC serogroups.

Office of the Director
The benefits of adhering to the recommended testing strategy include early diagnosis, improved patient
912 Wildwood
outcome, and detection of all STEC serotypes.
P.O. Box 570
Jefferson City, MO 65102 E. coli is a Category I reportable disease. All patients with Shiga toxin-positive diarrheal illness or HUS either
Telephone: [phone] known or suspected cases should be reported to your local public health agency, or to the Missouri Department
Fax: [phone] of Health and Senior Services (DHSS) at 800/392-0272 (24/7).
Web site: http://www.health.mo.gov
Laboratory consultation is available from the Missouri State Public Health Laboratory (MSPHL) by calling

573/751-3334, or 800/392-0272 (24/7).

Questions should be directed to DHSS’ Bureau of Communicable Disease Control and Prevention at 573/751-
6113 or 800/392-0272 (24/7).
Missouri Department of Health & Senior Services

Healt h Health Alert

October 31, 2011
Alert:

FROM: MARGARET T. DONNELLY

SShhiiggaa TTooxxiinn-- DIRECTOR
pprroodduucciinngg
SUBJECT: Outbreak of Shiga Toxin-producing E. coli Infection in St. Louis
EEsscchheerriicchhiiaa ccoollii
Metropolitan Area

The Missouri Department of Health and Senior Services (MODHSS) together with the local public
health agencies and the Centers for Disease Control and Prevention (CDC) is investigating an
outbreak of Shiga toxin-producing Escherichia coli infection in St Louis metropolitan area. As of
October 31, 2011 October 31, 2011, 35 specimens have been submitted to the State Public Health Lab. Thus far, 28 of
those specimens are positive for E. coli O157:H7, representing 26 cases (more than one specimen
This document will be updated as new was submitted for some cases). In total, there are 32 suspected, probable and confirmed cases of
information becomes available. The
Shiga Toxin-producing E. coli (STEC) infection. Cases of infection have been detected in St Louis
current version can always be viewed
County, St Louis City, and St Charles, Jefferson, and Franklin counties in Missouri. Preliminary
at http://www.health.mo.gov
findings from case interviews indicate that food from the salad bar at a local supermarket chain

The Missouri Department of Health & could be a source. Additional investigation and testing of food items is in progress.
Senior Services (DHSS) is now using The MODHSS asks providers to consider E. coli O157:H7 infection when evaluating patients with
4 types of documents to provide diarrhea, particularly bloody diarrhea. Testing for E. coli O157:H7 should be specifically requested
important information to medical and
on stools collected from suspect cases. Laboratories should attempt to isolate E. coli O157:H7 on
public health professionals, and to
sorbitol-MacConkey (SMAC) agar in addition to standard testing for detection of Shiga-toxin
other interested persons:
producing bacteria. Suspect or confirmed cases should be reported promptly to the local health

Health Alerts convey information department.
of the highest level of importance
which warrants immediate action or Disease due to E. coli O157:H7
attention from Missouri health
E. coli O157:H7, or STEC O157:H7, which is a Shiga toxin-producing E. coli is an important cause
providers, emergency responders,
of bloody diarrhea and hemolytic uremic syndrome (HUS). Infection commonly occurs through
public health agencies, and/or the
ingestion of the bacteria, usually through contaminated food products of bovine origin such as
public.
undercooked ground beef. Outbreaks have also been associated with consumption of such foods as
Health Advisories provide lettuce, alfalfa sprouts, unpasteurized juices, and fresh spinach. Any food that can be contaminated
important information for a specific by beef, cow manure, contaminated water, or an infected food handler may be a potential source of
incident or situation, including that
infection. The infectious dose is low, and person-to-person transmission can be quite common.
impacting neighboring states; may not
When disease develops, the fever is not usually high, or could be absent. Infection can be entirely
require immediate action.
asymptomatic or can present with a wide range of clinical features, including watery diarrhea,

Health Guidances contain bloody diarrhea, HUS or thrombocytopenic purpura (TTP). The classic triad of findings in HUS is
comprehensive information pertaining acute renal damage, microangiopathic hemolytic anemia, and thrombocytopenia. Illness typically
to a particular disease or condition, begins 3-4 days (ranges from 1-9 days) after exposure. Patients usually
and include recommendations,
develop watery diarrhea; in most patients, the diarrhea resolves without progression and the
guidelines, etc. endorsed by DHSS.
illness is mild. In those with progressive illness, bloody diarrhea usually begins on the second or

Health Updates provide new or third day, with stool content ranging from blood streaks to all blood. Most people get better within
updated information on an incident or 5–7 days, but some patients go on to develop HUS, usually about a week after the diarrhea starts.
situation; can also provide informa- Physicians evaluating patients presenting with gastrointestinal illness, particular bloody diarrhea,
tion to update a previously sent should include E. coli O157:H7 in their differential diagnosis.
Health Alert, Health Advisory, or

Health Guidance; unlikely to require

immediate action.
TESTING
__________________________________
It is required that physician specifically request testing stool for E. coli O157:H7 when infection is
suspected, especially for patients with bloody diarrhea or HUS. E. coli O157:H7 is not detected by
Office of the Director
standard methods; the recommended medium for isolation is sorbitol-MacConkey (SMAC) agar.
912 Wildwood
Any isolates positive for E. coli O157:H7 should be forwarded to the MODHSS for further analysis.
P.O. Box 570
If a patient specimen tests negative for E. coli O157:H7 but the submitting provider has a high
Jefferson City, MO 65102
clinical suspicion for E. coli O157:H7 disease, the original stool specimens could be forwarded to
Telephone: [phone]
the State Public Health Laboratory (SPHL) for organism isolation. Laboratories that perform a Shiga
Fax: [phone]
toxin detecting assay should forward the enrichment broth from the original stool specimens to the
Web site: http://www.health.mo.gov SPHL for organism isolation. Specimen broths positive for Shiga toxin should be subcultured to
SMAC for E. coli O157:H7 isolation or forwarded to the SPHL. It is often difficult to isolate STEC
in stool by the time a patient presents with HUS. Immunomagnetic separation (IMS) has been shown
to increase recovery of STEC from HUS patients. For any patient with HUS without a culture-
confirmed STEC infection, stool can be sent to a public health laboratory that performs IMS or to
2

SMAC for E. coli O157:H7 isolation or forwarded to the SPHL. It is often difficult to isolate STEC in stool by the time a
patient presents with HUS. Immunomagnetic separation (IMS) has been shown to increase recovery of STEC from HUS
patients. For any patient with HUS without a culture-confirmed STEC infection, stool can be sent to a public health
laboratory that performs IMS or to the CDC (through the SPHL). In addition, serum can be sent to CDC (through the
SPHL) for serologic testing of common STEC serogroups.

TREATMENT
Treatment for E. coli O157:H7 diarrhea includes standard rehydration. Patients should be
advised to not use over-the-counter antidiarrheal medications, and should not be prescribed
antibiotics. Both treatments have been reported to worsen symptoms and may lead to adverse
outcomes. Patients who are showing signs of anemia or kidney dysfunction should be referred
for care immediately. It is not recommended to give antibiotics to patients with suspected STEC infections until complete
diagnostic testing can be performed and STEC infection is ruled out. Some studies have shown that administering
antibiotics in patients with STEC infections might increase their risk of developing HUS. However, clinical decision
making must be tailored to each individual patient.

INFECTION CONTROL RECOMMENDATIONS

• Always wash hands after using the toilet, changing diapers, or coming in contact with fecal matter
• Persons involved in patient care, food service, or day care, and experiencing gastrointestinal illness should notify their
employer and be excluded until symptoms resolve, unless the cause of illness is determined to be non-infectious. Those
positive for E. coli O157 may not return until two successive stool samples collected 24 hours apart and obtained no
sooner than 48 hours after the last dose of antibiotics (if given) have tested negative.
• Children with diarrhea in day care centers must be sent home and advised to seek medical attention. Children who have
been diagnosed with E. coli O157 must be excluded until two successive stool samples collected 24 hours apart and
obtained no sooner than 48 hours after the last dose of antibiotics (if given) have tested negative.

Laboratory consultation is available from the Missouri State Public Health Laboratory (SPHL) by calling 573/751-3334,
or 800/392-0272 (24/7).]
In Missouri, report all known or suspected cases to your local public health agency, or to the Missouri Department of
Health and Senior Services (DHSS) at 800/392-0272 (24/7).

FURTHER INFORMATION
Further information is available at the following websites:
MODHSS website –
http://health.mo.gov/living/healthcondiseases/communicable/communicabledisease/cdmanual/pdf/stec.pdf
CDC website –
http://www.cdc.gov/ecoli

___________________________________________________________________________
Missouri Department of Health & Senior Services

Health A lert: Health Alert

December 19, 2011
TTwwoo ccaasseess ooff
FROM: MARGARET T. DONNELLY
iinnvvaassiivvee DIRECTOR
EEnntteerroobbaacctteerr
ssaakkaazzaakkiiii iinnffeeccttiioonn SUBJECT: Two cases of invasive Enterobacter sakazakii infection
in infants treated in Missouri hospitals
iinn iinnffaannttss ttrreeaatteedd iinn
MMiissssoouurrii hhoossppiittaallss
The Missouri Department of Health and Senior Services (DHSS) has been notified of
two cases of invasive Enterobacter sakazakii infection in newborns treated in Missouri
December 19, 2011 hospitals within the last month. The most recent case notification occurred yesterday.

Of these two cases, one was an out-of-state resident who recovered, and the most recent
This document will be updated as new case was a Missouri resident who has died. Both infants were fed powdered infant
information becomes available. The
formula. Clusters of E. sakazakii infections have previously been reported around the
current version can always be viewed
world among infants fed milk-based powdered formula from various manufacturers.
at http://www.health.mo.gov
Testing of all baby formulas involved, as well as all other products given to the babies
The Missouri Department of Health &
reported in Missouri is on-going.
Senior Services (DHSS) is now using
4 types of documents to provide
important information to medical and Enterobacter sakazakii is a gram-negative rod-shaped bacterium within the family
public health professionals, and to
Enterobacteriaceae. Recently, E. sakazakii has been reclassified as a Cronobacter
other interested persons:
sakazakii; the genus Cronobacter is synonymous with Enterobacter sakazakii. The
Health Alerts convey information
natural habitat of E. sakazakii is not well understood. The bacterium can be detected in
of the highest level of importance
the gut of healthy humans, most probably as an intermittent guest. It can also be found
which warrants immediate action or
attention from Missouri health in the gut of animals, as well as in the environment.
providers, emergency responders,
public health agencies, and/or the
The majority of cases of E. sakazakii infection reported in the literature have been
public.
described in newborns with sepsis, meningitis, or necrotizing enterocolitis as a
Health Advisories provide
consequence of the infection, and the case-fatality rate among infected neonates has
important information for a specific
been reported to be as high as 33% - 80%. The pathogen is also a rare cause of
incident or situation, including that
impacting neighboring states; may not bacteremia and osteomyelitis in adults, but the outcomes related to adult disease seem
require immediate action. to be significantly milder.

Health Guidances contain
comprehensive information pertaining The scientific literature suggests that premature infants and those with underlying
to a particular disease or condition,
medical conditions are at highest risk for developing E. sakazakii infection. Several
and include recommendations,
outbreaks have occurred in neonatal intensive care units worldwide. However, an
guidelines, etc. endorsed by DHSS.
apparently healthy full-term newborn infant who suffered permanent neurological
Health Updates provide new or
sequelae has also been previously reported.
updated information on an incident or
situation; can also provide informa-
tion to update a previously sent Although the reservoir of the organism is unknown, a growing number of outbreaks of
Health Alert, Health Advisory, or
infection among newborns has provided compelling evidence that milk-based
Health Guidance; unlikely to require
powdered infant formulas have served as the source of infection. One study tested
immediate action.
__________________________________ milk-based powdered infant formula products obtained from a number of different
countries and found that E. sakazakii could be recovered from 14% of samples. The
Office of the Director results of another investigation suggest that even low levels of E. sakazakii in milk-
912 Wildwood
based powdered infant formula can lead to development of infection. E. sakazakii has
P.O. Box 570
been detected in other types of food, but only powdered infant formula has been linked
Jefferson City, MO 65102
to outbreaks of disease. No exclusively breastfed infants have been reported to have E.
Telephone: [phone]
Fax: [phone] sakazakii infections.
Web site: http://www.health.mo.gov
2

There are at least three routes by which E. sakazakii can enter infant formula:
a) through the raw material used for producing the formula;
b) through contamination of the formula or other dry ingredients after pasteurization; and
c) through contamination of the formula as it is being reconstituted by the caregiver just prior to
feeding.
It is important to remember that powdered infant formulas are not commercially sterile products.
Powdered milk-based infant formulas are heat-treated during processing, but unlike liquid formula
products they are not subjected to high temperatures for sufficient time to make the final packaged
product commercially sterile. FDA has noted that infant formulas nutritionally designed for consumption
by premature or low birth weight infants are available only in commercially sterile liquid form. However,
so-called "transition" infant formulas that are generally used for premature or low birth weight infants
after hospital discharge are available in both non-commercially available sterile powder form and
commercially sterile liquid form. Some other specialty infant formulas are only available in non-sterile
powder form.
Recommendations
In light of the epidemiological findings and the fact that powdered infant formulas are not commercially
sterile products, FDA recommends that powdered infant formulas not be used in neonatal intensive care
settings unless there is no alternative available. If the only option available to address the nutritional needs
of a particular infant is a powdered formula, risks of infection in healthy and sick newborn babies can be
reduced by:
Preparing only a small amount of reconstituted formula for each feeding to reduce the quantity
and time that formula is held at room temperature for consumption. Do not hold reconstituted
formula for longer than two hours without refrigeration. Recognizing differences in infant
formula preparation among hospitals, individual facilities should identify and follow procedures
appropriate for that institution to minimize microbial growth in infant formulas;
Minimizing the holding time, while under refrigeration, before a reconstituted formula is fed; and
Minimizing the "hang-time" (i.e., the amount of time a formula is at room temperature in the
feeding bag and accompanying lines during enteral tube feeding), with no "hang-time" exceeding
4 hours. Longer times should be avoided because of the potential for significant microbial growth
in reconstituted infant formula.
The World Health Organization guidelines on safe preparation of powdered infant formula are available
at: http://www.fao.org/ag/agn/agns/files/pif_guidelines.pdf.

DHSS urges health care providers to report cases of E. sakazakii infections in infants to your local
public health agency, or to DHSS at 800/392-0272 (24/7).