Bureau of Epidemiology
Bureau of Epidemiology February 1999 Utah Department of Health
   Methicillin-resistant Staphylocococcus aureus (MRSA)
   It’s In The News: Listeriosis
   Head Lice - Still A Problem
  Immune Globulin Update
  Monthly Morbidity Summary


Methicillin-resistant Staphylocococcus aureus (MRSA)

Since the emergence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin has been the first-line and only uniformly effective antimicrobial agent for treatment of serious infections with MRSA. Of great concern was whether or not S.aureus could acquire glycopeptide resistance and become non-responsive to vancomycin, resulting in staphylococcal infections with similar morbidity and mortality to that which characterized these types of infections in the pre-antibiotic era.

Since 1997, three patients infected with S. aureus with intermediate resistance to the glycopeptide vancomycin (GISA/VISA, MIC = 8 g/ml) have been reported in the United States. As such, there has been concern that the frequency of vancomycin resistant/intermediate S. aureus will increase rapidly over the next several years and become a major public health problem. Some reports suggest these pathogens may already be causing therapeutic difficulties, but they are not being detected with current laboratory methods. Laboratory evidence suggests that the same mechanism of resistance which caused these strains of S. aureus to develop vancomycin MICs of 8 g/ml is present in methicillin- or oxacillin-resistant isolates with vancomycin MICs of 4 g/ml. Therefore, these S. aureus strains with reduced susceptibility to vancomycin (MIC> 4 g/ml) should be considered a potential public health problem. Through information provided by collaboration with a proprietary surveillance system of 150 U.S. hospitals, it is estimated that 0.6% of MRSA isolates exhibit reduced susceptibility to vancomycin (MIC = 4 g/ml), and each hospital reports approximately 200-700 of these MRSA isolates/year. Therefore, each hospital has on average 103 MRSA isolates with a vancomycin MIC = 4 g/ml.

"... there has been concern that the frequency of vancomycin resistant /intermediate S. aureus will increase rapidly over the next several years and become a major public health problem."

In order to learn about the epidemiology of these S. aureus strains with reduced susceptibility to vancomycin, the Hospital Infections Program, Centers for Disease Control and Prevention (CDC) has developed a nationwide case-control study that is currently undergoing IRB review. This study will attempt to define risk factors for acquisition of these strains, determine the risk of transmission, and assess the adequacy of the CDC recommendations in preventing transmission of S. aureus with reduced susceptibility to vancomycin from patient-to-patient or patient-to-healthcare worker.

The CDC would like to collaborate with state and local health departments to enroll patients in the case-control study. States would not be required to use any resources for this project. The CDC would request cooperation with infection control staff affiliated with the infected patient to collect information on these patients. The state health departments would be kept informed of any patient enrollment into the study, and state health departments would be asked to refer any inquiries regarding these S. aureus strains. Reports from other surveillance efforts will also be welcomed.

For additional information concerning this nationwide epidemiologic study, you may contact the CDC Hospital Infections Program at (404) 639-4951 or email (search@cdc.gov).

Adapted from Department of Health & Human Services, Public Health Service letter to CSTE members.

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It’s In The News: Listeriosis

The recall. From August 1998 to February 5, 1999, approximately 70 cases of listeriosis caused by a rare strain of Listeria monocytogenes have been reported in the United States. A total of 16 deaths have been reported; 11 adults have died and 5 pregnant women have had miscarriages. (No cases or deaths have been reported to date in Utah residents.) Epidemiologic and laboratory investigations have identified hot dogs and possibly deli meats that were produced by one manufacturer as the likely means of transmission. On December 22, 1998, the manufacturer, Bil Mar Foods, voluntarily recalled specific lots of the hot dogs and deli meats that might be contaminated. Recalled products have the establishment numbers EST P261 or EST 6911 on the outer edge of the package. The affected products include hot dogs and deli meats with the brand names Ball Park, Bil Mar, Bryan Bunsize, Bryan 3-lb Club Pack, Grillmaster, Hygrade, Mr. Turkey, Sara Lee Deli Meat, and Sara Lee Home Roast brands. Packages for the above brand names that carry other establishment numbers are not affected by the recall. Other Sara Lee products that are not meat also are not affected. Consumers who have the affected products should not eat them, but should discard them or return them to the store where they were purchased.

Who could get listeriosis? Every year in the United States, roughly 1,100 persons become seriously ill with listeriosis. Of these, approximately 250 will die. Those most likely to become seriously ill or die include pregnant women, newborns, adults with weakened immune systems, and the elderly. Healthy adults and children may become infected with the bacteria, but they rarely become seriously ill as a result of it.

How do you get listeriosis? Listeriosis is believed to be caused primarily by eating food that is contaminated with L. monocytogenes. Food can become contaminated with L. monocytogenes in a variety of ways because these bacteria are commonly found in soil and water. Vegetables may become contaminated from the soil or from manure used as a fertilizer. Animals can carry these bacteria without appearing ill and may contaminate foods of animal origin such as meats and dairy products. L. monocytogenes has been found in raw foods, such as meat and vegetables, and in processed foods that were contaminated after processing, such as soft cheeses and cold cuts. Unpasteurized (raw) milk or foods made from unpasteurized milk may also contain these bacteria.

How do you know if you have listeriosis? The symptoms of listeriosis frequently include fever and muscle aches. People with listeriosis may develop nausea and diarrhea, and if the infection spreads to their nervous system, they may have a headache, a stiff neck, confusion, loss of balance, or convulsions. Pregnant women may have a mild illness; however, infection with L. monocytogenes during pregnancy may lead to premature delivery, an infection in the newborn, or stillbirth.

The symptoms of listeriosis can be similar to those of other diseases. To definitively confirm the diagnosis, a health care provider will need to obtain either a blood or cerebrospinal fluid sample and have it tested for the presence of L. monocytogenes.

Can listeriosis be treated? Antibiotics can be used to treat listeriosis, but for these to be most effective, they need to be given as soon as possible. When infection occurs during pregnancy, antibiotics given promptly to the pregnant woman can often prevent infection of the fetus or newborn. Serious infections in newborns, children or adults may result in death, however, even with prompt treatment with antibiotics. Death is more likely in the elderly and in persons with other serious medical problems.

How can listeriosis be prevented? The main steps to prevent listeriosis are the same as those you need to take to prevent any foodborne illness:

     - Cook thoroughly raw food from animal sources, such as beef, pork, or poultry.
     -  Wash raw vegetables thoroughly before eating.
     -  Keep uncooked meats separate from other foods that will not be cooked thoroughly before they                  are eaten.
     -  Avoid unpasteurized (raw) milk or foods made from unpasteurized milk.
     -  Wash hands, knives, and cutting boards after handling uncooked foods.

If you are pregnant or if you have a weakened immune system, you may want to consider taking the following precautions:

     -  Avoid soft cheeses such as feta, Brie, Camembert, blue-veined, and Mexican-style cheese. (Hard                  cheeses, processed cheeses, cream cheese, cottage cheese, or yogurt need not be                  avoided.)

     -  Cook until steaming hot any left-over foods or ready-to-eat foods, such as hot dogs, before eating.

While the risk of listeriosis associated with foods from deli counters is believed to be low, pregnant women and those with weakened immune systems may want to avoid these foods or thoroughly reheat cold cuts before eating them.

To learn more: We have a fact sheet on listeriosis at the Utah Department of Health’s web site (http://www.health.state.ut.us/els/epidemiology/epifacts/listerio.html). The CDC also has a fact sheet (http//www.cdc.gov/ncidod/diseases/foodborn/lister.htm). The latest information on the recall is also available from the CDC (http://www.cdc.gov/od/oc/media/pressrel/r990114.htm).

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Head Lice - Still A Problem

Head lice can be a frustrating problem. Here is some information we hope can be of help.

First, the good news! Head lice do not transmit disease. While a person with lice might develop a secondary bacterial infection from itching their scalp, the lice themselves do not transmit disease.

Facts about lice. Head lice live only on the human scalp. They need a blood meal every four to six hours, and die in 24 hours if not able to feed. Adult females lay eggs which are attached to hair shafts close to the scalp. The eggs hatch in seven to 12 days. In the course of a 30-day lifetime, each female louse produces approximately 110 to 140 eggs.

A few other facts. 1) Head lice are not rare. Every year in the United States, six to 12 million persons get them. 2) People do not get lice because they are not clean, and being obsessively clean will not prevent lice. Most of the time, people get head lice when they have direct, head-to-head contact with someone else who has head lice. 3) While lice can scurry, they do not fly or hop from one head to another. 4) Most people infested with head lice have very few (one or two) lice in their hair.

How do you know if someone has head lice? Many people have no symptoms. The best way to check for lice is to use a fine-toothed comb to separate the hair and a strong light for viewing. Lice will hide from light, so spend at least three to five minutes looking for them. Adult females are about as big as a sesame seed, and reddish brown to black in color. Eggs and nits (empty eggs) are attached to hair shafts and are often found behind the ears and at the nape of the neck.

What to do (and not to do) about head lice.  1) Don’t panic! Head lice are unpleasant but not a disease threat, and they can be treated. 2) Purchase a shampoo or cream rinse designed to kill head lice. Follow the enclosed directions exactly. 3) After the treatment, use a fine-toothed comb to remove lice eggs. This may be difficult, but it is crucial because eggs left behind may hatch and begin a new infestation. 4) Repeat the whole treatment in seven to 12 days. 5) While lice do not live long away from the scalp, it is wise to clean the infested person’s clothes, bedding, etc. Put washable clothing and bedding through 20 minutes of a high heat dryer cycle first, and then into the washing machine. Dry clean things that cannot be washed, or seal them in a plastic bag for two weeks. 6) Thoroughly vacuum all fabric surfaces that may have had contact with the person’s head ( i.e., furniture, car upholstery).

For more help. Contact your local health department or the Bureau of Epidemiology (801-538-6191) for additional advice.

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Immune Globulin Update

Due to some recent developments in the manufacture and distribution of immune globulin for intramuscular injection (IMIG), it appears that over the next 6-12 months, enough IMIG will be produced to adequately meet national requirements. In addition, CDC will no longer screen large orders. The following is a list of manufacturers and the distributors that IMIG can be purchased from:


        Manufacturer                               Distributors

1. Bayer Corporation                       FFF Enterprises. . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-843-7477

                                                           Health Coalition  . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-456-7283

                                                           Chapin Medical  . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-221-7180

                                                           NHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-800-344-6087

                                                           Nationwide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-997-8846

2. Massachusetts Public
        Health Biologic                          FFF Enterprises . . . . . . . . . . . . . . . . . . . . . . . . . .  1-800-843-7477

3. Bio Port Corporation
        (formally the Michigan              Alternative Site
        Biologics Products Institute)    Distributors (ASD)  . . . . . . . . . . . . . . . . . . . . . . . . .1-800-837-5403                       

                                                            Biocare Division
                                                            Blood Systems, Inc . . . . . . . . . . . . . . . . . . . . . . . . .1-800-304-3064

Although there is no limit on the size of IMIG orders, health departments and other institutions are requested to spread orders to replenish stock over a period of 6-12 months. For questions concerning the management of hepatitis A outbreaks and exposure situations, please contact the Bureau of Epidemiology at (801)538-6191.

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Utah Department of Health, Bureau of Epidemiology
Monthly Morbidity Summary - February 1999 - Provisional Data

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The Epidemiology Newsletter is published monthly by the Utah Department of Health, Division of Epidemiology and Laboratory Services, Bureau of Epidemiology, to disseminate epidemiologic information to the health care professional and the general public.

Send comments to: The Bureau of Epidemiology, Box 142104, Salt Lake City, UT 84114-2104, or call (801) 538-6191
Approval 8000008:Appropriation 3705
Rod Betit, Executive Director,Utah Department of Health
Charles Brokopp, Dr.P.H., Division of Epidemiology and Laboratory Services
Craig R Nichols, MPA, Editor, State Epidemiologist, Director Bureau of Epidemiology
Cristie Chesler, BA, Managing Editor

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