MMWR  June 12, 2009 / 58(22);622

QuickStats: Average Number of Illness or Injury Bed Days* During the Preceding 12 Months Among Adults Aged ≥18 Years, by Age Group — National Health Interview Survey, United States, 2007†

MMWR June 12, 2009 / 58(22);618-621

Brucella suis Infection Associated with Feral Swine Hunting — Three States, 2007–2008

Historically, brucellosis from Brucella suis infection occurred among workers in swine slaughterhouses. In 1972, the U.S. Department of Agriculture National Brucellosis Eradication Program was expanded to cover swine herds. Subsequent elimination of brucellosis in commercial swine resulted in a decrease in B. suis-associated illness in humans. Currently, swine-associated brucellosis in humans in the United States is predominantly associated with exposure to infected feral swine (i.e., wild boar or wild hogs).* In May and July 2008, CDC was contacted by the state health departments in South Carolina and Pennsylvania regarding two cases of brucellosis possibly linked to feral swine hunts. Both state health departments contacted the state health department in Florida, where the hunts took place. The subsequent investigation, conducted jointly by the three state health departments and CDC, determined that the two patients had confirmed brucellosis from B. suis infection and the brother of one patient had probable brucellosis.† All three exposures were associated with feral swine hunting, and at least two patients did not have symptoms until 4–6 months after exposure (Table). The findings from this investigation suggest that clinicians treating patients with unexplained febrile illness should consider brucellosis in the differential diagnosis and obtain a thorough history of travel (e.g., to enzootic areas), food consumption, occupation, and recreational activities, including feral swine hunting. Cross-agency collaboration by state health departments and agriculture agencies is needed on brucellosis investigations to reduce the risk for illness through contact with infected animals.

Case Reports

Patient A. On May 7, 2008, a man aged 67 years from South Carolina (patient A) was referred by his private physician to a local emergency department after 1 week of fever (cyclic daily range: 99.2°–102.5°F [37.3°C--39.2°C]), malaise, anorexia, painful swollen left knee, and headaches. Patient A had a left total knee arthroplasty in 2004 and uneventful treatment in 2005 for septic arthritis in the same knee. Before onset of symptoms for his acute illness, patient A reported that he felt well except for an unintended 13-pound weight loss over a 16-week period and night sweats that began the day before he sought treatment. In the emergency department, blood and synovial fluid were obtained for culture, and the patient was empirically treated with intravenous nafcillin for septic arthritis.

Two days later, on May 9, the man was referred to a hospital with chills, persistent fever, continuing left knee arthralgia, and edema. He was admitted with a diagnosis of left knee infection and sepsis and treated initially with vancomyin. Knee aspirate cell count results were 16,700 white blood cells/mm3 (normal: <150/mm3) and 1,322 red blood cells/mm3 (normal: <1/mm3). Specimens of blood and a knee aspirate were collected for culture. Initial microbiologic examination indicated Corynebacterium urealyticum. Upon infectious disease consultation, the patient was started on doxycycline and naprosyn; on May 11, he developed epididymo-orchitis and was changed to levofloxacin and daptomycin on May 12 for a 6-week course. Brucella spp. subsequently were identified from isolates from the blood and synovial specimens collected from patient A on May 7. Isolates were sent to the South Carolina state public health laboratory and CDC for confirmatory testing. On May 29, B. suis biovar 1 was identified.

The epidemiologic investigation revealed that patient A had hunted feral swine in southwestern and south central Florida with two companions during December 23–29, 2007. All three participated in field dressing and butchering eight or nine feral swine at two locations. While field dressing one of the swine, patient A cut his hand with a knife. No personal protective equipment was worn during the field dressing and butchering. The meat was brought back to South Carolina, stored in a freezer, and boiled before being consumed by patient A over several months. No one else prepared or ate the meat, and no meat was collected for testing. No other risk factors for brucellosis were identified.

Because patient A’s hunting companions were well, serologic testing for brucellosis was not performed. Patient A recovered with no permanent knee joint damage after antimicrobial therapy with levofloxacin and daptomycin for 6 weeks.

Patient B. On July 14, 2008, a previously healthy man aged 37 years from Pennsylvania (patient B) went to a local emergency department after 1 week of morning fevers, chills, myalgia, shortness of breath, and night sweats. He also reported an unintended 30-pound weight loss over a 1-month period, beginning 3 weeks before illness onset. A blood chemistry profile was within normal limits with the exception of glucose of 121 mg/dL (normal: 74–100 mg/dL). A complete blood cell count was within normal limits with the exception of mean platelet volume of 7.2 fL (normal: 7.4–10.4 fL); eosinophils on the differential were 0.2% (normal: 0.7%–5.2%). Urinalysis was positive for trace white blood cell esterase and for a white blood cell count of 1–4/mm3 (normal: 0–1/mm3). A chest radiograph was within normal limits, and a blood specimen for culture was obtained.

Clinical impression was acute viral syndrome; patient B was discharged with instructions to use an albuterol metered-dose inhaler three times daily for 1–2 days for his shortness of breath and to follow up with his private physician in 2–3 days. On July 23, the Pennsylvania state public health laboratory received patient B’s blood specimen from the local hospital and isolated and identified B. suis using Laboratory Response Network§ standardized biochemical tests and polymerase chain reaction.

Epidemiologic investigation revealed that, on December 29, 2007, patient B had hunted feral swine in Florida with his brother (patient C), a Florida resident. Both men participated in field dressing and butchering four feral swine. No personal protective equipment was worn during these procedures, and no other risk factors for brucellosis were identified. Patient B brought the meat back to Pennsylvania and stored it in a freezer. The meat was prepared and consumed by patient B and his family members over a 7-month period. According to patient B, the meat was cooked adequately (i.e., to an internal temperature of 160°F [71.1°C]).

CDC received three B. suis isolates for confirmation and further molecular characterization. One isolate was from the blood of patient B, and the other two were recovered from frozen sausage and tenderloin of a feral swine from the December 29 hunt. All three B. suis isolates were analyzed at CDC by molecular genotyping assay, using multiple-locus variable-number tandem repeat analysis. The assay indicated that the two meat isolates had identical signatures at all of the 15 genomic markers, and the patient B isolate matched the meat isolates at all but one of 15 markers, suggesting that the three isolates were linked.

Patient B reported that his wife and children were not ill; however, his brother (patient C) had experienced similar symptoms in April. Although asymptomatic, initial serologic testing for brucellosis was performed on all household family members, and no antibody elevation was noted. Patient B recovered after 6 weeks of treatment with rifampin and doxycycline.

Patient C. In August, the Pennsylvania state health department reported the association between patient B’s infection and feral swine hunting to the Florida state health department, which, on August 21, contacted patient C (patient B’s brother who had accompanied him on feral swine hunts). At the time, neither patient C nor his family members reported experiencing symptoms of brucellosis. However, patient C recalled feeling ill in April with night sweats and shortness of breath. He did not seek treatment because he attributed his symptoms to a recent scorpion sting.

Other than feral swine hunting, no other brucellosis risk factors were identified for patient C. He reported that all the meat he received from the December 2007 feral swine hunts was either smoked, roasted, or barbequed and was consumed at one family cookout. On September 12, a serum specimen from patient C was tested at CDC for anti-Brucella antibodies using the Brucella microagglutination test. The resulting immunoglobulin G titer of 1:640 met the case definition for probable brucellosis.

Because patient C’s family was well, serologic testing for brucellosis was not performed. Treatment was recommended for patient C, but he was lost to follow-up.

Reported by: D Giurgiutiu, MD, C Banis, South Carolina Dept of Health and Environmental Control. E Hunt, MPH, J Mincer, C Nicolardi, A Weltman, MD, Pennsylvania Dept of Health. D Stanek, DVM, S Matthews, MPH, C Siegenthaler, C Blackmore, DVM, Florida Dept of Health. R Tiller, MPH, B De, PhD, Div of Foodborne, Bacterial, and Mycotic Diseases, National Center for Zoonotic, Vector-Borne, and Enteric Diseases; K Stauffer, DVM, EIS Officer, CDC.

Editorial Note:

Brucellosis is a bacterial zoonotic infection usually caused by Brucella abortus, B. melitensis, B. suis, or rarely B. canis. Humans are infected through occupational or recreational exposure to infected animals, inhalation of infectious aerosols, laboratory exposure (1), consumption of contaminated unpasteurized dairy products, or consumption of inadequately cooked contaminated meat. The average incubation period for brucellosis is 2–10 weeks but, as seen in this report, can range to 6 months. Symptoms can be nonspecific and influenza-like: intermittent fever, chills, malaise, diaphoresis, arthralgia, myalgia, headache, anorexia, and fatigue (2,3). Because of its nonspecific clinical syndrome, B. suis infection likely is underreported. Clinicians should inquire about travel, food consumption, occupation, and recreational activities (including feral swine hunting) of patients with nonspecific influenza-like symptoms with intermittent fever.

Patient A likely was infected through the hand wound he acquired while field dressing feral swine. The investigations suggest that patient B and patient C also were infected during the field dressing or butchering process because family members consumed the meat and were not affected clinically. Clinicians should order brucellosis testing for persons who are symptomatic and have a history of feral swine hunting. Duration and type of therapy is dependent upon multiple factors such as health status or age of patient and the manifestation of disease. Untreated brucellosis can last from several weeks to several years. Chronic untreated brucellosis can lead to abscesses in the liver, spleen, heart valves, brain, or bone; osteoarticular complications; and, in rare cases, death (2,3).

Human brucellosis is a nationally notifiable disease in all 50 states, New York City, the District of Columbia, and all U.S. territories except Puerto Rico. In 2007, 131 brucellosis cases were reported in the United States (Figure). States with the highest numbers of reported cases were California (33), Texas (25), and Florida (10) (4).

Feral swine have been reported in 35 states (J. Corn, PhD, personal communication, Southeastern Cooperative Wildlife Disease Study, 2009). The national feral swine population is estimated at approximately 4–5 million, with the largest populations in Texas (1.5 million), California, Florida, and Hawaii. Serologic surveys have detected endemic feral swine infection with B. suis in 10 states (Arkansas, California, Florida, Georgia, Hawaii, Louisiana, Mississippi, Missouri, South Carolina, and Texas) (5–9). Feral swine hunting is allowed in most states with feral swine presence, and most states require some form of license to hunt feral swine. Out-of-state hunters, as in this report, often bring swine meat back to their home states.

Efforts to prevent B. suis infection should focus on education of hunters and partnerships between state and local public health, wildlife, and agricultural agencies, and sportsmen’s associations. Educational materials for feral swine hunters should include recommendations for safe field dressing, butchering, and cooking (9). All human brucellosis cases should be investigated jointly by state health departments and agriculture agencies to determine the sources of infection and prevent further illness in humans.

Acknowledgments

This report is based, in part, on contributions by D Donch, DVM, Veterinary Svcs, S Swafford, MS, Wildlife Svc, Animal and Plant Health Inspection Svc, US Dept of Agriculture; J Corn, PhD, Southeastern Cooperative Wildlife Disease Study; M Piergallini, MD, practitioner; and S Weber, MD, Susquehanna Health Medical Group.

References

1. CDC. Laboratory-acquired brucellosis—Indiana and Minnesota, 2006 MMWR 2008;57:39–42.
2. Glynn MK, Lynn TV. Brucellosis. J Am Vet Med Assoc 2008;233:900–8.
3. Mandell GL, Bennett JE, Dolin R. Brucella species [Chapter 223]. In: Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. 6th ed. Philadelphia, PA: Elsevier Inc.; 2005:2669–74.
4. CDC. Summary of notifiable diseases—United States, 2007. MMWR 2009;56(53). In press.
5. Gresham CS, Gresham CA, Duffy MJ, Faulkner CT, Patton S. Increased prevalence of Brucella suis and pseudorabies virus antibodies in adults of an isolated feral swine population in coastal South Carolina. J Wildl Dis 2002;38:653–6.
6. Stoffregen WC, Olsen SC, Wheeler CJ, et al. Diagnostic characterization of a feral swine herd enzootically infected with Brucella. J Vet Diagn Invest 2007;19:227–37.
7. van der Leek ML, Becker HN, Humphrey P, et al. Prevalence of Brucella sp. antibodies in feral swine in Florida. J Wildl Dis 1993;29:410–5.
8. Zygmont SM, Nettles VF, Shotts EB, et al. Brucellosis in wild swine: a serologic and bacteriologic survey in the southeastern United States and Hawaii. J Am Vet Med Assoc 1982;181:1285–7.
9. Animal and Plant Health Inspection Service, US Department of Agriculture. Feral/wild pigs: potential problems for farmers and hunters. Agriculture information bulletin no. 799. Washington, DC: US Department of Agriculture; 2005. Available at http://www.aphis.usda.gov/publications/wildlife_damage/content/printable_version/feral%20pigs.pdf.

MMWR  June 12, 2009 / 58(22);615-618

Outbreak of Cryptosporidiosis Associated with a Splash Park — Idaho, 2007

On August 6, 2007, Idaho’s Central District Health Department (CDHD) received a complaint of several ill persons with watery diarrhea consistent with cryptosporidiosis after attendance at a municipal splash park on July 26. Cryptosporidium spp. is a protozoan that causes diarrheal illness and has been implicated previously in recreational water illness outbreaks at splash parks (1–3). CDHD and the Idaho Department of Health and Welfare (IDHW) initiated an investigation of illness among municipal park visitors who attended reservation-only gatherings at an onsite pavilion July 23–August 10. The investigation revealed five immunofluorescence assay (IFA)-confirmed and 45 clinically compatible cases of cryptosporidiosis among 154 persons interviewed (32% attack rate). Patients were more likely than non-ill park visitors to have been exposed to water from a splash feature (relative risk [RR] = 4.7). Water samples collected from splash features and an adjacent drinking fountain tested positive for Cryptosporidium hominis. This report summarizes the investigation of the outbreak and highlights the importance of splash park design, operation, access to hygiene facilities, and public education in prevention of waterborne cryptosporidiosis and other infectious agents. Educational efforts and enactment of regulations requiring enhanced disinfection technology, exclusion of persons with diarrhea, adequate hygiene facilities, and preconstruction consultation with health departments might decrease the risk for recreational water illness at splash parks.

The exposures occurred at a recently constructed splash park located within a municipal park in a suburban community in Idaho with a surrounding population of 550,000. Splash parks are increasingly popular venues associated with recreational water illness (1–4) and are often easily accessible, unmonitored, and charge no admission (5). Splash parks have multiple, interactive water features that spray, splash, or pour water on visitors, without pools or standing water. Typically, a municipal system supplies the water, which flows from the features onto impermeable surfaces (e.g., concrete), through drains, and recirculates through high-flow sand filters back to the water features. In Idaho, splash park design, construction, and operation are not regulated by the Idaho pool code.

The initial investigation by CDHD and IDHW began on August 7 with interviews of 20 persons who attended a party at the splash park on July 26. Among those 20 persons, 12 reported gastrointestinal illness that began August 1–6 (6–11 days after exposure), including eight persons who reported watery diarrhea. All 12 ill persons reported exposure to splash-feature water, and six reported exposure to water from a nearby drinking fountain. No food items at the party were implicated as the source of the outbreak. Investigators hypothesized that swallowing contaminated splash park water was the source of illness.

To find additional cases, identify risk factors, and implement control measures, CDHD and IDHW initiated telephone interviews of municipal park visitors who attended reservation-only gatherings at an onsite pavilion July 23–August 10, the only dates for which reservation listings were available. Reservations for 12 separate groups encompassing approximately 600 persons were identified. Information about visitors without reservations was not recorded by the municipal park; consequently, the total number of visitors during the study period could not be determined. To enable prompt intervention, interviews were limited to the first 154 respondents contacted, representing nine (75%) of the 12 reservation parties. Respondents were contacted in order of their position on the reservation listings.

A clinical case was defined as the onset of diarrhea (three or more loose stools in 24 hours) or four or more symptoms consistent with gastroenteritis (i.e., abdominal cramps, nausea, vomiting, fever, or body aches) in a person within 1–12 days after visiting the municipal park. A confirmed case was defined as illness in a person with a positive IFA stool test result for Cryptosporidium. Non-ill park visitors were identified from attendees who did not meet either case definition. Study participants were administered a standardized questionnaire by telephone.

The 154 respondents represented 51 separate households and 12 different days of exposure. For respondents reporting multiple days of exposure to the municipal park, the latest day of exposure was used for the analysis. Fifty (32%) of 154 attendees had illness meeting the clinical (n = 45) or confirmed (n = 5) case definition; 26 (52%) were males (Table 1). The median age of patients was 7 years (range: 10 months–58 years). Illness onset ranged from July 28 to August 20 (Figure), and the median time from exposure to onset of illness was 6 days (range: 1–14 days). One patient with a confirmed case reported splash park exposure on August 1 and illness onset August 15. Among 29 patients whose illness was resolved at the time of interview, the median duration of illness was 3 days (range: 1–9 days). The most common symptoms reported were diarrhea (86%), vomiting (64%), abdominal cramps (62%), nausea (62%), fever (52%), headache (46%), and body aches (40%). No hospitalizations or deaths associated with illness were reported. Treatment information for patients was not available.

A retrospective cohort analysis was used to identify risk factors for illness, after combining confirmed and clinical cases. Patients were more likely to have been exposed to splash-feature water only than were non-ill persons (RR = 4.7; 95% confidence interval [CI] = 1.8–11.9) (Table 2). Patients also were more likely to report exposure to both splash-feature water and adjacent drinking fountain water than were non-ill persons (RR = 8.6; CI = 3.2–23.3). In a second analysis, to limit the possibility of including secondary cases in the risk factor analysis, household contacts who also had visited the municipal park were excluded if they reported exposure to the splash park after August 4 or illness onset >4 days after the household index case. The remaining household patients (n = 32) were more likely to have been exposed to the splash park (RR = 18.4; CI = 2.6–128.2) and to an adjacent drinking fountain (RR = 1.5; CI = 1.1–2.0) than were non-ill persons.

An environmental investigation was begun August 9. During an initial site inspection, young children were observed to be the predominant users of the splash park, and diapered children frequently sat on top of splash features. Soap was not available in nearby restrooms, nor were showers. Public health education signs were not posted at the park. The splash park did not have any standing water; investigators noted that water drained from a concrete deck, passed through a high-flow sand filter, and was chlorinated before recirculation through several splash features.

On August 9, CDHD collected water samples from the splash park, and those samples were analyzed for total coliforms and Escherichia coli using the 9223B substrate Colilert method. Water samples collected on August 20 from the high-flow sand filter backwash and adjacent drinking fountain were tested at the Environmental Protection Agency (EPA) Region 10 laboratory following EPA method 1623* (6). C. hominis was identified in the sample by polymerase chain reaction-restriction fragment length polymorphism analysis of the 18S rRNA gene in DNA extracted from microscopy-positive slides. Oocysts in both samples were further subtyped by DNA sequencing of the gp60 gene as IaA28R4 (7). Two Cryptosporidium isolates from patients also were genotyped and subtyped C. hominis IaA28R4.

The splash park was closed August 17, and the municipal park drinking fountains were turned off August 23. An engineering investigation determined no source of drinking water contamination; however, after the outbreak, two return backflow-prevention devices designed to prevent retrograde flow of splash park water into municipal water lines failed inspection and were replaced. Although the municipal water supply is maintained at a higher pressure than the splash park, a decrease in water pressure could have allowed a potential retrograde flow of contaminated water into the municipal water line. Repeat testing of the drinking-fountain water on August 29 and upstream municipal water on August 31 yielded no Cryptosporidium oocysts. The drinking fountains were turned back on September 11. The municipality reopened the splash park in 2008 after installation of an ultraviolet treatment system, improvement of hygiene facilities, hiring of attendants to monitor for nonhygienic behaviors by visitors, and posting of educational signs instructing visitors not to drink the splash-feature water.

Reported by: R Jue, T Schmalz, Central District Health Dept, Idaho. K Carter, DVM, Coordinating Office for Terrorism Preparedness and Emergency Response; RJ Nett, MD, EIS Officer, CDC.

Editorial Note:

Cryptosporidium, a chlorine-resistant parasite, can cause illness after ingestion of as few as 10 oocysts, and can remain infectious for up to 6 months in moist environments (8). In this outbreak investigation, detection of identical subtypes of C. hominis, a species primarily restricted to humans (9), in the stool specimens of patients and in water samples from the sand filters and drinking fountain implicated ingestion of fecally contaminated splash-feature and drinking fountain water as the cause of the illnesses. Because reported exposures occurred during July 23–August 10 and splash park water collected on August 20 tested positive for Cryptosporidium, initial contamination of splash park water by an ill visitor likely caused persistent contamination of the splash park system and resulted in ongoing transmission. Similar outbreaks have occurred at other splash parks that lacked ultraviolet or ozone treatment systems that can inactivate Cryptosporidium (1,3). Splash park operators cannot rely solely upon high-flow sand filtration and chlorine disinfection to protect patrons from Cryptosporidium.

The findings in this report are subject to at least four limitations. First, reservations at the on-site pavilion represented a small percentage of daily attendance at the splash park; the total number of visitors to the splash park during the study period could not be determined, nor could the total number of cryptosporidiosis cases associated with the splash park among nontallied visitors. Second, limited staff resources might have led to selection bias by restricting interviews to those persons able to be contacted most quickly, perhaps biasing the study toward persons more likely to be at home and ill. Third, a statewide cryptosporidiosis outbreak involving multiple recreational water venues was occurring at the same time as the municipal splash park outbreak, and ill persons might have been exposed to other contaminated sources of recreational water, potentially confounding the results. Finally, despite an engineering investigation, the specific source of drinking water contamination could not be determined. Although failed backflow prevention devices might have allowed contaminated splash park water to enter the municipal drinking water line supplying the drinking fountain, most ill person (27/40) did not have exposure to the drinking fountain.

The outbreak described in this report involved a recently constructed, unregulated splash park, with contributing factors related to design and operation that prior consultation with health department staff might have identified and corrected. State and local governments should consider including splash parks in the pool code and requiring preconstruction health department consultation, supplemental disinfection technology (e.g., ultraviolet light), appropriate hygiene facilities, and education of splash park operators and the public. Furthermore, research on splash park design and operation is needed to develop engineering and operational guidelines specific to these facilities.

Regulation without education is unlikely to reduce substantially the risk for recreational water illness outbreaks. Splash parks are relatively new, and operator knowledge of appropriate disinfection and maintenance requirements might be inadequate (10); public health officials and industry associations should make regular efforts to educate operators. Additionally, splash park operators and public health officials should work jointly to educate visitors about prevention of recreational water illness. Persons using splash park and other water park facilities are the primary source of contamination, and even water in well-maintained and treated recreational water venues can transmit Cryptosporidium. Posted signs should guide patrons to wash young children’s bottoms with soap in the shower before splash park entry, refrain from drinking the splash-feature water, discourage children from sitting on top of splash features, and change diapers only in designated areas. Persons with diarrhea should be prohibited from entering recreational water venues. Behavioral restrictions, however, might not be enforceable at splash parks that have unrestricted and unmonitored public access.

Acknowledgments

The findings in this report are based, in part, on contributions by H Ezell, D Irons, F Isenberg, B Tramontin, Central District Health Dept; E Huffe, City of Meridian; C Greenwalt, C Hahn, MD, S Mundt, S Radwin, T Shanahan, K Turner, K Vlcek, E Zager, Idaho Dept of Health and Welfare; D Lee, Idaho Dept of Environmental Quality; S Bailey, G Dodo, S Harris, DVM, J Parker, Environmental Protection Agency; M Beach, PhD, M Hlavsa, J Yoder, and L Xiao, DVM, PhD, National Center for Zoonotic, Vector-Borne and Enteric Diseases, and K Bisgard, DVM, Office of Workforce and Career Development, CDC.

References

1. CDC. Outbreak of gastroenteritis associated with an interactive water fountain at a beachside park—Florida, 1999. MMWR 2000;49:565–8.
2. Jones M, Boccia D, Kealy M, et al. Cryptosporidium outbreak linked to interactive water feature, UK: importance of guidelines. Euro Surveill. 2006;11:126–8.
3. Schaffzin JK, Keithly J, Johnson G, et al. Large outbreak of cryptosporidiosis associated with a recreational water spraypark—New York, 2005 [Abstract]. Proceedings of the 55th Annual Conference of the Epidemic Intelligence Service; 2006; Atlanta, GA: US Department of Health and Human Services, CDC; 2006.
4. CDC. Surveillance for waterborne-disease outbreaks—United States, 1997–1998. MMWR 2000;49(No. SS-4).
5. Kebabjian RS. Interactive water fountains: the potential for disaster. J Environ Health 2003;66:24, 29–30.
6. Environmental Protection Agency. Method 1623: Cryptosporidium and Giardia in water by filtration/IMS/FA. Washington, DC: Environmental Protection Agency, Office of Water; 2005. Available at http://www.epa.gov/nerlcwww/1623de05.pdf.
7. Xiao L, Ryan UM. Molecular epidemiology. In: Fayer R, Xiao L, eds. Cryptosporidium and cryptosporidiosis. 2nd ed. Boca Raton, FL: CRC Press and IWA Publishing; 2008:119–71.
8. Huang DB, White AC. An updated review on Cryptosporidium and Giardia. Gastroenterol Clin North Am 2006;35:291–314, viii.
9. Morgan-Ryan UM, Fall A, Ward LA, et al. Cryptosporidium hominis n. sp. (Apicomplexa: Cryptosporidiidae) from Homo sapiens. J Eukaryot Microbiol 2002;49:433–40.

MMWR June 26, 2009 / 58(24);675

QuickStats: Age-Adjusted Death Rates Per 100,000 Population* for the Three Leading Causes of Injury† Death — United States, 1979–2006

MMWR June 26, 2009 / 58(24);673-674

Updated Recommendations for Use of Haemophilus influenzae Type b (Hib) Vaccine: Reinstatement of the Booster Dose at Ages 12–15 Months

On December 13, 2007, certain lots of Haemophilus influenzae type b (Hib) vaccine marketed as PedvaxHIB (monovalent Hib vaccine) and Comvax (Hib-HepB vaccine), and manufactured by Merck & Co., Inc., were recalled voluntarily, and the company temporarily suspended production of these vaccines. To conserve the limited supply of Hib-containing vaccines, CDC, in consultation with the Advisory Committee on Immunization Practices (ACIP), the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics (AAP), on December 18, 2007, recommended that vaccination providers temporarily defer the routine Hib vaccine booster dose administered to most healthy children at age 12–15 months (1–5).

Production of Merck Hib vaccine products is still suspended. However, two other Hib-containing vaccines manufactured by Sanofi Pasteur have been available for use in the United States during this shortage: monovalent Hib vaccine (ActHIB) and DTaP-IPV/Hib (Pentacel). Beginning in July 2009, the manufacturer of these two vaccines will increase the number of doses of these two products available for use in the United States, which will result in the supply being sufficient to reinstate the Hib vaccine booster dose.

Reinstatement of Hib Booster Dose

Effective immediately, CDC, in consultation with ACIP, AAFP, and AAP, is recommending reinstatement of the booster dose of Hib vaccine for children aged 12–15 months who have completed the primary 3-dose series. Infants should continue to receive the primary Hib vaccine series at ages 2, 4, and 6 months. Children aged 12–15 months should receive the booster dose on time. Older children for whom the booster dose was deferred should receive their Hib booster dose at the next routinely scheduled visit or medical encounter. Although supply is sufficient to reinstate the booster dose and begin catch-up vaccination, supply is not yet ample enough to support a mass notification process to contact all children with deferred Hib booster doses.

Sufficient vaccine will be available to administer the primary series at ages 2, 4, and 6 months and a booster dose on time to children aged 12–15 months. As part of delivering the booster dose to those children for whom it was deferred at the next routinely scheduled appointment or medical encounter, practices should discuss with parents the reasons for the change in recommendation and might consider 1) reviewing electronic or paper medical records or immunization information system records to identify children in need of a booster dose before physician encounters, 2) evaluating children’s vaccination status during their scheduled visit, and 3) sharing immunization schedules with parents to make them aware of this plan.

Use of Combination Vaccines

During the Hib shortage, children received protection from certain vaccine preventable diseases in their primary vaccination series through various permutations of available combination vaccines (e.g., DTaP-IPV/Hib [Pentacel] and DTaP-IPV-HepB [Pediarix]) and monovalent vaccines (e.g., ActHib, HepB, and IPV). Therefore, a mismatch might exist between patient vaccination needs and the available stock of different vaccine formulations (e.g., combination products versus single-antigen vaccines) in local provider offices. This situation presents a challenge for providers to administer vaccines to ensure appropriate coverage while minimizing extra doses of unneeded vaccine. For example, if a provider is using DTaP-IPV/Hib (Pentacel) vaccine to protect infants against Hib disease, the provider should ensure that adequate stock of monovalent HepB vaccine is available to complete the HepB vaccine series.* Children who need the Hib booster and who already have received 4 doses of DTaP should receive monovalent Hib vaccine (ActHIB) as their Hib booster dose. However, if DTaP-IPV/Hib is the only Hib-containing vaccine available, this combination product can be used to complete the series of Hib vaccination, even if the child already has received all the necessary doses of DTaP and IPV.

Information Regarding ActHIB or Pentacel

Vaccination providers with questions about their supplies of monovalent Hib vaccine (ActHIB) or DTaP-IPV/Hib (Pentacel) purchased with nonpublic funds should contact Sanofi Pasteur’s customer service department (telephone, 800-822-2463). Sanofi Pasteur will work directly with physicians to increase allotments of Hib-containing vaccines on the basis of previous purchasing patterns or practice birth cohort and estimates of additional vaccine doses needed. For public vaccine supplies, including Vaccines for Children Program vaccine, providers should contact their state/local immunization program to obtain vaccine.

This recommendation reflects CDC’s assessment of the existing national Hib vaccine supply and will be updated if the supply changes. Updated information about the national Hib vaccine supply is available at http://www.cdc.gov/vaccines/vac-gen/shortages/default.htm.

Details about the routine Hib schedule are available at http://www.cdc.gov/vaccines/recs/schedules/default.htm#child. Adverse events following receipt of any vaccine should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://vaers.hhs.gov.

References

1. CDC. Interim recommendations for the use of Haemophilus influenzae type b (Hib) conjugate vaccines related to the recall of certain lots of Hib-containing vaccines (PedvaxHIB and Comvax). MMWR 2007;56:1318–20.
2. CDC. Continued shortage of Haemophilus influenzae type b (Hib) conjugate vaccines and potential implications for Hib surveillance—United States, 2008. MMWR 2008;57:1252–5.
3. American Academy of Pediatrics. Haemophilus influenzae infections. In: Pickering LK, Baker CJ, Kimberlin CW, Long SS, eds. Red book: 2009 report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:314–21.
4. CDC. Invasive Haemophilus influenzae type b disease in five young children—Minnesota, 2008. MMWR 2009;58:58–60.
5. CDC health advisory. Invasive Haemophilus influenzae type b disease in young children and importance for all young children to receive 3 dose primary series with available Hib-containing vaccine. Available at http://www2a.cdc.gov/han/archivesys/viewmsgv.asp?alertnum=00281.

I’m all alone.
I need a pet.
I can’t afford a dog and I can’t stand a cat.
So, I decided to get me a fish.
I went to the pet store and the owner sold me a singing fish.
I took my fish home and waited for him to sing.
He sang.
But he was so off-key that I decided to get a music maestro to help.
When I called the music maestro and told him my dilemma, he laughed.
“Why are you laughing, maestro?”
He said, “Everyone knows you can’t tuna fish!”

But I digress……..

Attached is a health department news release to health professionals about 2 new cases of H1N1.  One in Findlay and one in Hancock County.

While ingested foreign objects usually pass spontaneously out of the you-know-where, multiple magnets present another problem.  Here’s a picture to entice you to read this.
http://omniphysicians.com/2009/06/25/what-you-should-be-thinking-about-when-a-patient-has-consumed-multiple-magnets/

This NEJM abstract concludes that STEMI patients who received fibrinolysis should be moved out for angioplasty within 6 hours for best results.  In this study, those who got early PCI had fewer episodes of death, reinfarction, recurrent ischemia, new or worsening congestive heart failure, or cardiogenic shock within 30 days compared to controls
http://omniphysicians.com/2009/06/25/move-them-out-quick/

This is a press release on a new opioid coming on the market.  It’s called Nucynta.
http://omniphysicians.com/2009/06/25/nucynta/

Take care,

Paul R.

Source:  AP, 6/24/09, http://www.forbes.com/feeds/ap/2009/06/23/ap6576634.html

Johnson & Johnson said Tuesday its painkiller Nucynta is now on the market, following approval from the Food and Drug Administration and Drug Enforcement Agency.

The company said immediate-release Nucynta tablets are available with a prescription in 50 mg, 75 mg, and 100 mg strengths, and is approved to treat moderate to severe acute pain in patients 18 and older. The Food and Drug Administration approved the opioid drug in November, but Johnson & Johnson could not market it before the DEA gave it a controlled-substance classification.

The agency ruled that Nucynta, or tapentadol, is a schedule II drug, meaning it has a high potential for abuse, and users may become psychologically or physically dependent on the drug, but it has an accepted medical use.

ABSTRACT

Background Patients with a myocardial infarction with ST-segment elevation who present to hospitals that do not have the capability of performing percutaneous coronary intervention (PCI) often cannot undergo timely primary PCI and therefore receive fibrinolysis. The role and optimal timing of routine PCI after fibrinolysis have not been established.

Methods We randomly assigned 1059 high-risk patients who had a myocardial infarction with ST-segment elevation and who were receiving fibrinolytic therapy at centers that did not have the capability of performing PCI to either standard treatment (including rescue PCI, if required, or delayed angiography) or a strategy of immediate transfer to another hospital and PCI within 6 hours after fibrinolysis. All patients received aspirin, tenecteplase, and heparin or enoxaparin; concomitant clopidogrel was recommended. The primary end point was the composite of death, reinfarction, recurrent ischemia, new or worsening congestive heart failure, or cardiogenic shock within 30 days.

Results Cardiac catheterization was performed in 88.7% of the patients assigned to standard treatment a median of 32.5 hours after randomization and in 98.5% of the patients assigned to routine early PCI a median of 2.8 hours after randomization. At 30 days, the primary end point occurred in 11.0% of the patients who were assigned to routine early PCI and in 17.2% of the patients assigned to standard treatment (relative risk with early PCI, 0.64; 95% confidence interval, 0.47 to 0.87; P=0.004). There were no significant differences between the groups in the incidence of major bleeding.

Conclusions Among high-risk patients who had a myocardial infarction with ST-segment elevation and who were treated with fibrinolysis, transfer for PCI within 6 hours after fibrinolysis was associated with significantly fewer ischemic complications than was standard treatment.

Source:    NEJM, 6/25/09, http://content.nejm.org/cgi/content/short/360/26/2705

An 88-year-old man presented with diffuse, painless swelling of the lateral borders of his tongue (Panel A). The swelling had been slowly increasing during the previous 20 years. Yellowish tumors with a smooth, shiny surface were visible. There was no frank macroglossia, dysphagia, dysarthria, or sleep apnea. No other tumors were identified anywhere in the body, including the oral cavity and the gastrointestinal tract, which were evaluated endoscopically. There was no cervical lymphadenopathy. Serum glucose and lipid levels were normal. The patient had no atherosclerotic disease, he did not drink alcohol, and no family members were similarly affected. Examination of a specimen from an incisional biopsy showed lobules of mature adipose tissue that were consistent with lipomatosis (Panel B, arrows); there was no evidence of liposarcoma. He received no treatment. Lipomas are very common; however, isolated lipomatosis of the tongue is rare.  Source:  NEJM (http://content.nejm.org/cgi/content/full/360/26/e33?query=TOC)

A 9-year-old boy ingested 23 magnets (Panel A). Four days later, he had clinical and surgical evidence of intestinal perforation and peritonitis due to pressure necrosis of the bowel. In an unrelated incident, a developmentally delayed 13-year-old boy ingested 15 magnets. Ten days later, volvulus and intestinal occlusion developed (Panel B, arrows). Both patients were operated on without complications, and all magnets were removed. Although ingested nonmagnetic foreign bodies are likely to be passed spontaneously without consequence, ingested magnets may attract each other through the intestinal wall and cause severe damage, such as pressure necrosis, perforation, intestinal fistulas, volvulus, and obstruction. Thus, close observation and early intervention are warranted after ingestion of magnets.  Source:  NEJM (http://content.nejm.org/cgi/content/full/360/26/2770?query=TOC)