To get you started, here are the addresses of some useful sites:

The Utah Department of Health’s global Internet site is full of links to important services and organizations in Utah (health.utah.gov). The Salt Lake City/County Health Department also has a web page with lots of useful information and links (www.slvhealth.org/).

The MMWR is available for free the first thing Friday morning from the CDC (no more waiting for your copy to arrive in the mail!) at (www.cdc.gov/epo/mmwr/mmrw.html/). In addition, the CDC’s web site contains information from all its Divisions at (www.cdc.gov/).

MedLine searches can be done from your own computer (from several sites including the National Library of Medicine at www.nlm.nih.gov/). You can even order full copies of journal articles (for a fee).

The American Academy of Family Physicians (www.aafp.org/) and the American Academy of Pediatrics (www.aap.org/) have useful information about both public health and general medical topics.

For up-to-date immunization information, the CDC’s National Immunization Program has an excellent web page (www.cdc.gov/nip/home.htm). More information and great handouts for patients with questions about immunizations or vaccine-preventable diseases are available at the Immunization Action Coalition/Hepatitis B Coalition’s web page (www.immunize.org).

The Food and Drug Administration offers food and drug safety information from their web page (www.fda.gov/).

The options listed above are only a small sample of what is available. With a little time and effort on your part, you will undoubtedly find other locations of interest to you. Try search words such as Health, Medicine, or the name of a disease that may be of interest to you. When the search engine you are using brings up a list of choices, review them and go to those sites that you find interesting. Remember that different search engines will often find different sites even if you use the same search words. With trial and error on your part, you will find search engines you prefer to others. Set ‘bookmarks’ on those sites you have found to be useful so you don’t have to search for them again.

No! Your journey on the Internet must be taken carefully. You can’t believe everything on the Internet any more than you can believe everything that you read in the newspaper or see on television. The unique danger with the Internet is that, while putting something into cyberspace doesn’t necessarily make it true, it may make it seem more believable! There are some simple steps you can take to protect yourself. A good rule of thumb is to stay with sites affiliated with organizations you recognize and respect. If you are not familiar with the organization that is responsible for the site, look for several key bits of information. These include who authored the site, when the information on the site was last updated, and whether the site’s sponsors are also trying to sell you something. A site that is attempting to sell a product (for example, vitamins or books offering medical knowledge "that cannot be obtained anywhere else") may be trustworthy, but the viewer needs to be aware of the possible conflict of interest between providing unbiased medical information and, at the same time, trying to sell a product. The common sense rule that "If something sounds too good to be true, it probably is" definitely applies here.

So, do travel, but travel safely on the Internet. The world is yours for the searching (or is that surfing?).

In the February 13, 1998 Morbidity and Mortality Weekly Report (Volume 47, Number 5), there is an article describing one confirmed and one possible case of rat-bite fever. The report describes the illnesses of two adolescent males who lived in New Mexico and became ill in late July 1996. Both boys developed a relapsing febrile illness with other symptoms that included myalgia, chills, and backache. The first boy was treated in the hospital with intravenous antibiotics followed by a seven-day course of oral antibiotics and recovered completely. Blood cultures were obtained from this boy prior to the administration of antibiotics. A gram negative rod was isolated from an aerobic blood culture on the seventh day of incubation. This organism was confirmed as Streptobacillus moniliformis by the New Mexico Department of Health’s Scientific Laboratory Division. The second boy was treated empirically as an outpatient with oral antibiotics but discontinued the antibiotics after three days. His illness relapsed seven days later. He then received a second course of oral antibiotics and recovered completely. Blood cultures that were taken from this boy prior to his first course of antibiotics, were discarded after five days because they were negative. Active surveillance did not identify additional cases of a similar illness in the area. Case investigation revealed that both boys had been licked by the same domestic dog and both had consumed water from an open irrigation ditch. No other sources of possible exposure to either rodents or rodent feces were identified (1).

A case of rat-bite fever resulting in death was recently reported to the Utah Department of Health, Bureau of Epidemiology. The Bureau received a call from the Office of the Medical Examiner in January 1998 regarding a child who had died shortly after being taken to a Salt Lake City hospital’s emergency room. Blood cultures that had been taken from the child shortly before death were positive for S. moniliformis. No other plausible cause of death was identified. The only history known at the time of death was that the child had traveled to SLC on a bus, and had arrived in SLC gravely ill. Case investigation revealed that, immediately prior to traveling to SLC, the child had been staying with extended family members who owned two pet rats. There was a history of the rats escaping "for a couple of days," and when the rats were recaptured they had reportedly bitten three people, including this child. The Bureau then notified the health department of the state the child had been living in of this event so they could alert the family of the child’s diagnosis. The health department reported back to the Bureau that the child’s family was traveling across country with the rats to a second state where the child’s funeral was to be held. The health department of the second state was then notified. They were able to locate the family, and the rats were delivered to health officials for testing. Other family members who had been bitten by the rats were offered prophylactic antibiotics. The CDC was contacted and asked to further characterize the bacterial isolate.

Rat-bite fever (RBF) is a rare disease that is caused either by S. moniliformis or by Spirillum minus (the latter is extremely uncommon in the United States). RBF is transmitted to humans typically through the bite of an infected animal (e.g., a rat, squirrel, mouse, cat or weasel), although transmission can occur by ingestion of food or milk products that have been contaminated with rodent droppings, or by direct contact with an infected animal. The incubation period for S. moniliformis is usually 3-10 days but may be as long as three weeks; for S. minus it is 7-21 days (2). Disease onset is characterized by an acute onset of chills, relapsing fever, headache and muscle pain. A rash that is most marked on the extremities develops 1-3 days after the onset. The most common history is that of a rat bite within the past 10 days that healed unremarkably. The case-fatality rate is 7-10% (3). Human-to-human transmission has only been documented where an infected person gave blood for a transfusion. The attack rate of S. moniliformis after a rat bite is 10%, and some experts recommend that penicillin be given prophylactically to any person reporting a rat bite (2).

Several important messages can be gleaned from this unfortunate event. First, while RBF is not listed as a reportable disease in the Communicable Disease Rule, please notify your health department of the occurrence of any unusual illness. Such notification in this instance allowed the health departments of three states to find this child’s family and alert them of the possible health risk posed by the rat bites they had received. Second, all three of these cases highlight the importance of obtaining blood cultures prior to administering antibiotics. Had this step not been taken, culture results would have been impossible to interpret. (Also, if you suspect RBF, please notify the laboratory because S. moniliformis has unique growth requirements.) Finally, these cases highlight the importance of obtaining thorough histories from patients, particularly when no obvious cause of illness can be ascertained.

References:

1. CDC. Morbidity and Mortality Weekly Report 1998; 47 (5): 89-91.
2. American Academy of Pediatrics. Rat-Bite Fever. In: Peter G, ed. 1997 Red Book: Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997: 442-443.
3. American Public Health Association. Rat-Bite Fever. In: Benenson AS, ed. Control of Communicable Diseases Manual. 16th ed. Washington, DC: American Public Health Association; 1995: 391-392.

This listserver has been created to serve health care providers and public health workers, and to give them a timely forum for the discussion of issues such as:

     -antibiotic resistant bacteria
     -problem cases and/or unique or unusual pathogens
     -laboratory tests and results
     -unusual clusters of cases or outbreaks

What are the rules? The rules are quite simple! 1) Messages posted to the list must not violate patient confidentiality. In other words, don’t write something that would allow others to identify an individual patient. 2) Messages should not contain disparaging remarks about persons, including other health care providers, who are not involved in an ongoing discussion. In other words, if you don’t like something another health care provider has done (or has not done, as the case may be), contact them directly. 3) Finally, the listserver is not a mechanism for reporting diseases to the State of Utah. Please use normal reporting channels to let us know of a reportable disease.