Mississippi Morbidity Report
Annual Summary
Selected Reportable Diseases
Mississippi – 2013
Volume 32, Number 4 December 2016
MISSISSIPPI STATE DEPARTMENT OF HEALTH
Mississippi Morbidity Report
Annual Summary
Selected Reportable Diseases
Mississippi – 2013
Page Left Blank Intentionally
Table of Contents
Preface .................................................................................................................................. 5
Mississippi Public Health Districts & Health Officers ........................................................... 7
Reportable Disease List ........................................................................................................ 8
Arboviral Infections (mosquito-borne) ............................................................................. 12
• Eastern Equine Encephalitis (EEE) .......................................................................... 13
• LaCrosse Encephalitis ............................................................................................. 14
• St. Louis Encephalitis ............................................................................................... 15
• West Nile Virus ......................................................................................................... 16
Campylobacteriosis ........................................................................................................... 20
Chlamydia .......................................................................................................................... 23
Cryptosporidiosis ................................................................................................................ 27
E. coli O157:H7/ STEC / HUS ............................................................................................... 28
Gonorrhea .......................................................................................................................... 31
Haemophilus influenzae, type b ....................................................................................... 35
Hepatitis A ........................................................................................................................... 37
Hepatitis B, acute ............................................................................................................... 39
HIV Disease ......................................................................................................................... 43
Influenza – 2013 – 2014 Season ......................................................................................... 48
Legionellosis ....................................................................................................................... 52
Listeriosis ............................................................................................................................. 53
Lyme Disease ..................................................................................................................... 55
Measles ............................................................................................................................... 56
Meningococcal disease, invasive .................................................................................... 59
Mumps ................................................................................................................................ 62
Pertussis ............................................................................................................................... 63
Pneumococcal disease, invasive ..................................................................................... 66
Rabies .................................................................................................................................. 68
Rocky Mountain spotted fever .......................................................................................... 70
Rubella ................................................................................................................................ 73
Salmonellosis ...................................................................................................................... 74
Shigellosis ............................................................................................................................ 77
Syphilis ................................................................................................................................ 80
Tuberculosis ........................................................................................................................ 86
Varicella .............................................................................................................................. 90
Vibrio disease ..................................................................................................................... 91
Special Reports ................................................................................................................... 96
• Enhanced Surveillance of Adult Influenza Mortality, 2013-2014 Influenza Season
................................................................................................................................. 96
• Haff Disease Identified in Three Mississippi Residents, July 2013 ........................ 98
Reportable Disease Statistics ...........................................................................................100
List of Contacts, Editors and Contributors ........................................................................102
General References ..........................................................................................................103
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Preface
Public health surveillance involves the systematic collection, analysis and dissemination
of data regarding adverse health conditions. The data are used to monitor trends and
identify outbreaks in order to assess risk factors, target disease control activities,
establish resource allocation priorities and provide feedback to the medical community
and the public. These data support public health interventions for both naturally
occurring and intentionally spread disease.
Statistics incorporated into tables, graphs and maps reflect data reported from health
care providers who care for Mississippi residents. Cases counted have met the
surveillance case definitions of the CDC and the Council of State and Territorial
Epidemiologists (CSTE), available at https://wwwn.cdc.gov/nndss/conditions/search/
.
Unless otherwise noted all rates are per 100,000 population. Data are based on “event”
date of the case with the exception of TB in which the case confirmation date is used.
The “event” date is defined as the earliest known date concerning a case and is
hierarchical (onset, diagnosis, laboratory date or date of report to the health
department).
Mississippi law (Section 41-3-17, Mississippi Code of 1972 as amended) authorized the
Mississippi State Board of Health, under which MSDH operates, to establish a list of
diseases which are reportable. The reportable disease list and the Rules and
Regulations Governing Reportable Diseases and Conditions may be found online at
http://www.msdh.state.ms.us/msdhsite/_static/14,0,194.html
. Class 1A diseases,
reportable by telephone within 24 hours of first knowledge or suspicion, are those to
which the MSDH responds immediately to an individual case. Class 1B diseases are
those that require individual case investigation but do not require an immediate public
health response and can therefore be reported by telephone within one business day
of first knowledge or suspicion. Class 2 diseases are reportable within a week of
diagnosis, and Class 3 diseases are reportable only by laboratories and do not
necessitate an immediate response to an individual case.
To report a case of any reportable disease or any outbreak, please call 601-576-7725
during working hours in the Jackson area, or 1-800-556-0003 outside the Jackson area.
For reporting tuberculosis, you also may call 601-576-7700, and for reporting STD’s or
HIV/AIDS, you may call 601-576-7723. For emergency consultation or reporting Class 1A
diseases or outbreaks afterhours (nights, holidays and weekends) please call 601-576-
7400.
The data included in the following document have come from physicians, nurses,
clinical laboratory directors, office workers and other health care providers across the
state who called or sent in reports. Without these individuals, public health surveillance
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and response would be incapacitated. For your dedication to this important part of
public health information, we thank you.
Paul Byers, MD
State Epidemiologist
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Mississippi Public Health Districts & Health Officers
Public Health
Districts
Northwest Public Health
District I
Dr. Alfio Rausa
662.563.5603
Northeast Public Health
District II
Dr. Crystal Tate
662.841.9015
Delta/Hills Public Health
District III
Dr. Alfio Rausa
662.453.4563
Tombigbee Public Health
District IV
Dr. Robert Curry
662.323.7313
West Central Public Health
District V
Dr. Kathryn Taylor
601.978.7864
East Central Public Health
District VI
Dr. Christy Barnett
601.482.3171
Southwest Public Health
District VII
Dr. Leslie England
601.684.9411
Southeast Public Health
District VIII
Dr. Christy Barnett
601.271.6099
Coastal Plains Public Health
District IX
Dr. Christy Barnett
228.436.6770
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Reportable Disease List
Mississippi State Department of Health
List of Reportable Diseases and Conditions
Reporting Hotline: 1-800-556-0003
Monday - Friday, 8:00 am - 5:00 pm
To report inside Jackson telephone area or for consultative services
Monday - Friday, 8:00 am - 5:00 pm: (601) 576-7725
Phone
Fax
Epidemiology
(601) 576-7725
(601) 576-7497
STD/HIV
(601) 576-7723
TB
(601) 576-7700
Mail reports to: Office of Epidemiology, Mississippi State Department of Health, Post Office Box
1700, Jackson, Mississippi 39215-1700
Class 1A Conditions should be reported within 24 hours (nights, weekends and holidays by
calling: (601) 576-7400)
Class 1A: Diseases of major public health importance which shall be reported directly to the
Department of Health by telephone within 24 hours of first knowledge or suspicion.
Class 1A diseases and conditions are dictated by requiring an immediate public
health response. Laboratory directors have an obligation to report laboratory findings
for selected diseases (refer to Appendix B of the Rules and Regulations Governing
Reportable Diseases and Conditions).
Any Suspected Outbreak (including foodborne and waterborne outbreaks)
Anthrax
Hepatitis A
Rabies (human or animal)
Botulism (including foodborne,
Influenza-associated pediatric
Ricin intoxication (castor
infant or wound)
mortality (<18 years of age)
beans)
Brucellosis
Measles
Smallpox
Diphtheria
Melioidosis
Tuberculosis
Escherichia coli O157:H7 and any
Neisseria meningitidis Invasive
Tularemia
shiga toxin-producing E. coli
Disease
†‡
Typhus fever
(STEC)
Pertussis
Viral hemorrhagic fevers
Glanders
Plague
(filoviruses [e.g. Ebola,
Haemophilus influenzae Invasive
Poliomyelitis
Marburg] and
Disease
†‡
Psittacosis
arenaviruses [e.g.,Lassa,
Hemolytic uremic syndrome
Q fever
Machupo])
(HUS), post-diarrheal
Any unusual disease or manifestation of illness, including but not limited to the appearance of a novel
or previously controlled or eradicated infectious agent, or biological or chemical toxin.
†
Usually presents as meningitis or septicemia, or less commonly as cellulitis, epiglottitis, osteomyelitis,
pericarditis or septic arthritis.
‡
Specimen obtained from a normally sterile site.
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Class 1B Conditions should be reported within 24 hours (within one business day)
Class 1B: Diseases of major public health importance which shall be reported directly to the
Department of Health by telephone within one business day after first knowledge or
suspicion. Class 1B diseases and conditions require individual case investigation, but
not an immediate public health response. Laboratory directors have an obligation to
report laboratory findings for selected diseases (refer to Appendix B of the Rules and
Regulations Governing Reportable Diseases and Conditions).
Arboviral infections including but
Chancroid
Syphilis (including
not limited to:
Cholera
congenital)
California encephalitis virus
Encephalitis (human)
Typhoid fever
Chikungunya virus
HIV infection, including AIDS
Varicella infection,
Dengue
Legionellosis
primary, in patients >15
Eastern equine encephalitis
Non-cholera Vibrio disease
years of age
virus
Staphylococcus aureus,
Yellow fever
LaCrosse virus
vancomycin resistant (VRSA) or
Western equine encephalitis
vancomycin intermediate (VISA)
virus
St. Louis encephalitis virus
West Nile virus
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Class 2: Diseases or conditions of public health importance of which individual cases shall be
reported by mail, telephone, fax or electronically, within 1 week of diagnosis. In
outbreaks or other unusual circumstances they shall be reported the same as Class 1A.
Class 2 diseases and conditions are those for which an immediate public health
response is not needed for individual cases.
Chlamydia trachomatis, genital
HIV infection in pregnancy
Rocky Mountain spotted
infection
Listeriosis
fever
Creutzfeldt-Jakob Disease,
Lyme disease
Rubella (including
including new variant
Malaria
congenital)
Ehrlichiosis
Meningitis other than
Spinal cord injuries
Enterococcus, invasive infection
‡
,
Meningococcal or
Streptococcus
vancomycin resistant
Haemophilus influenzae
pneumoniae, invasive
Gonorrhea
Mumps
infection
‡
Hepatitis (acute, viral only) Note -
M. tuberculosis infection (positive
Tetanus
Hepatitis A requires Class 1A
TST or IGRA*)
Trichinosis
Report
Poisonings** (including elevated
Viral encephalitis in horses
Hepatitis B infection in pregnancy
blood lead levels***)
and ratites****
‡
Specimen obtained from a normally sterile site.
*TST- tuberculin skin test; IGRA- Interferon-Gamma Release Assay (to include size of TST in millimeters
and numerical results of IGRA testing).
**Reports for poisonings shall be made to Mississippi Poison Control Center, UMMC 1-800-222-1222.
***Elevated blood lead levels (as designated below) should be reported to the MSDH Lead Program
at (601) 576-7447.
Blood lead levels (venous) ≥5µg/dL in patients less than or equal to 6 years of age.
**** Except for rabies and equine encephalitis, diseases occurring in animals are not required to be
reported to the MSDH.
Class 3: Laboratory based surveillance. To be reported by laboratories only. Diseases or
conditions of public health importance of which individual laboratory findings shall be
reported by mail, telephone, fax or electronically within one week of completion of
laboratory tests (refer to Appendix B of the Rules and Regulations Governing
Reportable Diseases and Conditions).
All blood lead test results in
CD4 count and HIV viral load*
Hepatitis C infection
patients ≤6 years of age
Chagas Disease (American
Nontuberculous
Campylobacteriosis
trypanosomiasis)
mycobacterial disease
Carbepenam-resistant
Cryptosporidiosis
Salmonellosis
Enterobacteriaceae (CRE)
Hansen disease (Leprosy)
Shigellosis
Enterobacter species, E.coli or
Klebsiella species only
*HIV associated CD4 (T4) lymphocyte results of any value and HIV viral load results, both detectable
and undetectable.
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Class 4: Diseases of public health importance for which immediate reporting is not necessary for
surveillance or control efforts. Diseases and conditions in this category shall be
reported to the Mississippi Cancer Registry within six months of the date of first contact
for the reportable condition.
The National Program of Cancer Registries at the Centers for Disease Control and Prevention
requires the collection of certain diseases and conditions. A comprehensive reportable list
including ICD9CM/ICD10CM codes is available on the Mississippi Cancer Registry website,
https://www.umc.edu/Administration/Outreach_Services/Mississippi_Cancer_Registry/Reportabl
e_Diseases.aspx.
Each record shall provide a minimum set of data items which meets the uniform standards
required by the National Program of Cancer Registries and documented in the North American
Association of Central Cancer Registries (NAACCR).
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Arboviral Infections (mosquito-borne)
Background
Arthropod-borne viral (arboviral) diseases in Mississippi are limited to a few types
transmitted by mosquitoes. In this state, there are four main types of arboviral infections
that have been reported: West Nile virus (WNV), St. Louis encephalitis (SLE), eastern
equine encephalitis (EEE), and LaCrosse encephalitis (LAC). WNV and SLE are members
of the Flavivirus genus, while EEE is an Alphavirus, and LAC is in the California virus group
of Bunyaviruses.
Infections do not always result in clinical disease. When illness occurs, symptoms can
range from a mild febrile illness to more severe cases of neuroinvasive disease with
encephalitis and/or meningitis. Neuroinvasive disease can result in long term residual
neurological deficits or death. The proportion of infected persons who develop
symptoms depends largely on the age of the persons and the particular virus involved.
Mosquito borne arboviral infections are typically more common in the warmer months
when mosquitoes are most active, but WNV cases have been reported year round. All
are transmitted by the bite of an infected mosquito, but the mosquito vectors and their
habitats differ. Infections are not transmitted by contact with an infected animal or
other person; humans and horses are “dead end” or incidental hosts. Rare instances of
WNV transmission have occurred through transplanted organs, blood transfusions, and
transplacentally.
Methods of Control
The methods of controlling mosquito-borne infections are essentially the same for all the
individual diseases. The best preventive strategy is to avoid contact with mosquitoes.
Reduce time spent outdoors, particularly in early morning and early evening hours
when mosquitoes are most active; wear light-colored long pants and long-sleeved
shirts; and apply mosquito repellant to exposed skin areas. Reduce mosquito breeding
areas around the home and workplace by eliminating standing or stagnant water.
Larvacides are effective when water cannot be easily drained.
Mosquito Surveillance
Mosquitoes are collected throughout the state for West Nile and other arboviral testing
to provide information regarding the burden and geographic distribution of infected
vectors. Mosquitoes are collected by local mosquito programs and MSDH personnel
and submitted as pools of 5-50 mosquitoes for testing. In 2013, 1044 mosquito pools
were submitted to MSDH PHL for WNV testing.
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Arboviral Testing
The Public Health Laboratory (PHL) performs an arboviral panel consisting of IgM testing
for WNV and SLE, and, for patients less than 25 years of age, LAC IgM. Clinicians are
encouraged to call MSDH Epidemiology or the PHL for specifics and indications for
arboviral testing. In 2013, 1110 samples were submitted to the MSDH PHL for arboviral
testing.
Please refer to the individual disease summaries for information on and epidemiology of
each specific arbovirus.
Eastern Equine Encephalitis (EEE)
2013 Case Total 0 2013 rate/100,000 0.0
2012 Case Total
0
2012 rate/100,000
0.0
Clinical Features
Clinical illness is associated with symptoms that can range from a mild flu-like illness
(fever, headache, muscle aches) to seizures and encephalitis progressing to coma and
death. The case fatality rate is 30-50%. Fifty percent of those persons who recover from
severe illness will have permanent mild to severe neurological damage. Disease is more
common in young children and in persons over the age of 55.
Infectious Agent
Eastern equine encephalitis virus, a member of the genus Alphavirus.
Reservoir
Maintained in a bird-mosquito cycle. Humans and horses are incidental hosts.
Transmission
Through the bite of an infected mosquito, usually Coquilletidia perturbans. This
mosquito, known as the salt and pepper or freshwater marsh mosquito, breeds mainly in
marshy areas.
Incubation
3-10 days (generally within 7 days).
Reporting Classification
Class 1B.
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Epidemiology and Trends
Human cases are relatively infrequent largely because primary transmission takes place
in and around marshy areas where human populations are generally limited. There
were no reported cases of EEE in Mississippi in 2013. The last two reported cases of EEE
occurred in October 2002.
Horses also become ill with EEE and are dead end hosts. Infected horses can serve as
sentinels for the presence of EEE, and can indicate an increased risk to humans. The
Mississippi Board of Animal Health (MBAH) reports equine infections to MSDH, and in
2013, 12 horses tested positive for EEE, which is a drastic decline from 32 in 2012. In 2013,
the EEE positive horses were reported from the following counties: Clarke (2), George
(1), Harrison (1), Jasper (1), Lamar (1), Lawrence (1), Madison (1), Neshoba (1), Pearl
River (1), Perry (1), and Wayne (1). All twelve of the positive horses were located in the
lower half of the state, with 50% (6) located in Districts VIII and IX.
LaCrosse Encephalitis
2013 Case Total 3 2013 rate/100,000 0.1
2012 Case Total
1 2012 rate/100,000 0.0
Clinical Features
Clinical illness occurs in about 15% of infections. Initial symptoms of LaCrosse
encephalitis infection include fever, headache, nausea, vomiting and lethargy. More
severe symptoms usually occur in children under 16 and include seizures, coma, and
paralysis. The case fatality rate for clinical cases of LaCrosse encephalitis is about 1%.
Infectious Agent
LaCrosse encephalitis virus, in the California serogroup of Bunyaviruses.
Reservoir
Chipmunks and squirrels.
Transmission
Through the bite of an infected Ochlerotatus triseriatus mosquito (commonly known as
the tree-hole mosquito). This mosquito is commonly associated with tree holes and
most transmission tends to occur in rural wooded areas. However, this species will also
breed in standing water in containers or tires around the home.
Incubation
7-14 days.
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Reporting Classification
Class 1B.
Epidemiology and Trends
Reported LaCrosse encephalitis remains relatively rare in Mississippi, with 19 reported
cases since 1999. There were three reported cases of LaCrosse encephalitis in 2013; all
of the cases were 10 years old or younger.
Of the 19 total cases since 1999, 53% were in females. The ages ranged from 3 months
to 78 years of age, with 95% of the cases under the age of 15 and a median age of 6
years.
Another Bunyavirus in the California group, Jamestown Canyon encephalitis virus, has
also been seen in Mississippi, with one reported case in 1993, one in 2006, and one in
2008. There were no reported cases of Jamestown Canyon encephalitis virus in 2013.
St. Louis Encephalitis
2013 Case Total 0 2013 rate/100,000 0.0
2012 Case Total
0 2012 rate/100,000 0.0
Clinical Features
Less than 1% of infections result in clinical illness. Individuals with mild illness often have
only a headache and fever. The more severe illness, meningoencephalitis, is marked
by headache, high fever, neck stiffness, stupor, disorientation, coma, tremors,
occasional convulsions (especially in infants) and spastic (but rarely flaccid) paralysis.
The mortality rate from St. Louis encephalitis (SLE) ranges from 5 to 30%, with higher rates
among the elderly.
Infectious Agent
St. Louis encephalitis virus, a member of the genus Flavivirus.
Reservoir
Maintained in a bird-mosquito cycle. Infection does not cause a high mortality in birds.
Transmission
Through the bite of an infected mosquito generally belonging to genus Culex (Culex
quinquefasciatus, Culex pipiens), the southern house mosquito. This mosquito breeds in
standing water high in organic materials, such as containers and septic ditches near
homes.
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Incubation
5-15 days.
Reporting Classification
Class 1B.
Epidemiology and Trends
The number of reported SLE cases fluctuates annually. There were no cases reported in
2004, 2006, 2008 or 2010, but there were nine cases with one death reported in 2005,
and two reported cases in both 2007 and 2009. There were no deaths due to SLE in
2007 or 2009.
Mississippi had no reported cases of SLE in 2013.
West Nile Virus
2013 Case Total 45 2013 rate/100,000 1.5
2012 Case Total
247
2012 rate/100,000
8.3
Clinical Features
Clinical illness occurs in approximately 20% of infected individuals. Most with clinical
manifestations will develop the milder West Nile fever, which includes fever, headache,
fatigue, and sometimes a transient rash. About 1 in 150 infected persons develop more
severe West Nile neuroinvasive disease ranging from meningitis to encephalitis.
Encephalitis is the most common form of severe illness and is usually associated with
altered consciousness that may progress to coma. Focal neurological deficits and
movement disorders may also occur. West Nile poliomyelitis, a flaccid paralysis
syndrome, is seen less frequently. The elderly and immunocompromised are at highest
risk of severe disease.
Infectious Agent
West Nile virus, a member of the genus Flavivirus.
Reservoir
WNV is maintained in a bird-mosquito cycle; it has been detected in more than 317
species of birds, particularly crows and jays.
Transmission
Primarily through the bite of an infected southern house mosquito (Culex
quinquefasciatus). This mosquito breeds in standing water with heavy organic matter.
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Incubation
3-15 days.
Reporting Classification
Class 1B.
Epidemiology and Trends
In Mississippi, West Nile virus was first isolated in horses in 2001 followed by human
infections in 2002 with 192 cases reported. The years following saw a decrease in the
number of reported infections; however in 2006, there was a resurgence of 184 cases
(Figure 1). In 2013, there was a decrease in reported WNV cases from 247 cases in 2012
to 45 cases in 2013, leading to one of the lowest recorded rates in the past ten years.
There were five deaths associated with WNV in 2013. Of the 45 cases in 2013 of WNV,
58% were males and 42% were females.
Figure 1
WNV is now thought to be endemic in Mississippi, and the mosquito vector is present the
entire year. Human illness can occur year round, but is most prevalent from June to
October. July, August, and September are usually the peak months and 89% of the
cases over the past five years have occurred during these three months (Figure 2).
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Figure 2
Of the 45 cases reported in 2013, 18 (40%) were classified as WNV fever and 27 (60%)
were neuroinvasive. The cases ranged in age from 3 to 91 years, with a median age of
54 years (Figure 3). The five reported deaths occurred in individuals over the age of 65,
with a median age of 84 years.
Figure 3
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WNV infection can occur in any part of the state, and since 2001, activity (human
cases, positive mosquito pools, horses or birds) has been reported in every Mississippi
County except Issaquena. The cases in 2013 were spread throughout the state with the
most cases in any one county reported from Hinds County with 12 cases (Figure 4).
District VIII had the highest rate of WNV infection in 2013 with a rate of 5.2 cases per
100,000 residents (Figure 5).
A total of 43 mosquito pools tested positive for WNV in 2013. Horses may also become ill
with WNV and can act as sentinels for the presence of infected mosquitoes. The
Mississippi Board of Animal Health reports equine infections to MSDH. In 2013, 4 horses
tested positive for WNV throughout Mississippi.
Figure 4
West Nile Virus Cases by County, Mississippi, 2013
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Figure 5
Campylobacteriosis
2013 Case Total 99 2013 rate/100,000 3.3
2012 Case Total
99
2012 rate/100,000
3.3
Clinical Features
Campylobacteriosis is a zoonotic bacterial disease of variable severity ranging from
asymptomatic infections to clinical illness with fever, diarrhea (may be bloody),
abdominal pain, and nausea and vomiting. Symptoms typically resolve after one
week, but may persist for weeks if untreated. Rare post-infectious syndromes include
reactive arthritis and Guillain-Barré syndrome (GBS).
Infectious Agent
Campylobacter jejuni (C. jejuni) causes most cases of diarrheal illness in humans.
Reservoir
Commonly present in cattle and poultry.
West Nile Virus Case Rates by District, Mississippi, 2013
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Transmission
Transmission mainly occurs through ingestion of undercooked meat, usually poultry, but
occasionally contaminated food or water or raw milk. The number of organisms
required to cause infection is low.
Incubation
Average incubation is 2-5 days, with a range from 1-10 days.
Period of Communicability
Person to person transmission does not typically occur, though the infected individual
may shed organisms for up to 7 weeks without treatment.
Methods of Control
Disease prevention includes promotion of proper food handling, good hand washing,
particularly after handling raw meats, and after contact with feces of dogs and cats.
Pasteurizing milk and chlorinating water are also important. Symptomatic individuals
should be excluded from food handling or care of patients in hospitals or long term
care facilities.
Reporting Classification
Class 3.
Epidemiology and Trends
In 2013, there were 99 reported cases of campylobacteriosis in Mississippi; this was
comparable to the number of reported cases in 2012 and to the three-year average
(2010-2012) of 100 cases (Figure 6). The 2013 cases were not associated with any
reported outbreaks.
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Figure 6
Campylobacter infections are typically more common in the warmer months, as are
many enteric illnesses; however in 2013, the reported number of cases remained stable
throughout the year (Figure 7). Children less than five years of age and adults 65 years
of age and older accounted for 42% of the overall cases in 2013 (Figure 8).
Figure 7
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Figure 8
Chlamydia
2013 Case Total 17,355 2013 rate/100,000 580.2
2012 Case Total
22,992
2012 rate/100,000
770.3
Clinical Features
Chlamydia is a sexually transmitted bacterial infection causing urethritis in males and
cervicitis in females. Urethritis in males presents with scant to moderate mucopurulent
urethral discharge, urethral itching, and dysuria. Cervicitis presents as a mucopurulent
endocervical discharge, often with endocervical bleeding. The most significant
complications in women are pelvic inflammatory disease and chronic infections, both
of which increase the risk of ectopic pregnancy and infertility. Perinatal transmission of
chlamydia occurs when an infant is exposed to the infected cervix during birth resulting
in chlamydial pneumonia or conjunctivitis. Asymptomatic infections can occur in 1%-
25% of sexually active men and up to 70% of sexually active women.
Infectious Agent
Chlamydia trachomatis, an obligate intracellular bacteria. Immunotypes D through K
have been identified in 35-50% of nongonococcal urethritis.
Reservoir
Humans.
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Transmission
Transmitted primarily through sexual contact.
Incubation
Incubation period is poorly defined, ranging from 7 to 14 days or longer.
Period of Communicability
Unknown.
Methods of Control
Prevention and control of chlamydia are based on behavior change, effective
treatment, and mechanical barriers. Condoms and diaphragms provide some degree
of protection from transmission or acquisition of chlamydia. Effective treatment of the
infected patient and their partners, from 60 days prior to the onset of symptoms, is
recommended.
Reporting Classification
Class 2.
Epidemiology and Trends
Chlamydia is the most frequently reported bacterial sexually transmitted disease in the
United States and in Mississippi. In 2013, the number of chlamydia cases in Mississippi
decreased 25% (from 22,992 to 17,355 cases), resulting in a case rate of 580.2 per
100,000 population (Figure 9). The 2013 case count and rate of chlamydia was the
lowest in Mississippi since 2003. The Mississippi rate has been above the national rate for
several years. In 2013, Mississippi had the fifth highest case rate of chlamydia in the
United States.
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Figure 9
Chlamydia was reported in every public health district, with the highest incidence
noted in Public Health District III (Figure 10).
Figure 10
Chlamydia infections were reported over a range of age groups, but the largest
proportion was reported among 15-24 year olds, accounting for 74% of the reported
cases (Figure 11). African Americans accounted for 82% of the reported cases in which
Chlamydia Incidence by Public Health District, Mississippi, 2013
District
Cases
Rate*
I
1,999
617.7
II
1,606
436.2
III
2,256
1,069.5
IV
1,472
598.9
V
4,021
628.3
VI
1,592
656.5
VII
947
549.9
VIII
1,480
478.5
IX
1,982
414.0
Statewide
17,355
580.2
*per 100,000 population
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race was known (Figure 12). In 2013, the rate of chlamydia infections for African
Americans (1,029.5 per 100,000) was eight times the rate for whites (125.0 per 100,000).
Figure 11
Figure 12
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Cryptosporidiosis
2013 Case Total 48 2013 rate/100,000 1.6
2012 Case Total 40 2012 rate/100,000 1.3
Clinical Features
A parasitic infection characterized by profuse, watery diarrhea associated with
abdominal pain. Less frequent symptoms include anorexia, weight loss, fever, and
nausea and vomiting. Symptoms often wax and wane and but generally disappear in
30 days or less in healthy people. Asymptomatic infections do occur and can serve as
a source of infection to others. The disease may be prolonged and fulminant in
immunodeficient individuals unable to clear the parasite. Children under 2, animal
handlers, travelers, men who have sex with men, and close personal contacts of
infected individuals are more prone to infection.
Infectious Agent
Cryptosporidium parvum, a coccidian protozoan, is associated with human infection.
Reservoir
Humans, cattle and other domesticated animals.
Transmission
Transmission is fecal-oral, which includes person-to-person, animal-to-person,
waterborne (including recreational use of water) and foodborne transmission. Oocysts
are highly resistant to chemicals used to purify drinking water and recreational water
(swimming pools, water parks). The infectious dose can be as low as 10 organisms.
Incubation
1 to 12 days (average 7 days).
Period of Communicability
As long as oocysts are present in the stool. Oocysts may be shed in the stool from the
onset of symptoms to several weeks after symptoms resolve.
Methods of Control
Education of the public regarding appropriate personal hygiene, including
handwashing. Symptomatic individuals with a diagnosis of cryptosporidiosis should not
use public recreational water (e.g., swimming pools, lakes, ponds) while they have
diarrhea and for at least 2 weeks after symptoms resolve. It is recommended that
infected individuals be restricted from handling food, and symptomatic children be
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restricted from attending daycare until free of diarrhea. Prompt investigation of
common food or waterborne outbreaks is important for disease control and prevention.
Reporting Classification
Class 3.
Epidemiology and Trends
There were 48 reported cases of cryptosporidiosis in 2013 (Figure 13). This is comparable
to the 40 cases reported in 2012, but higher than the three year average of 38 cases
from 2010 to 2012. There were no common source outbreaks identified in 2013.
Figure 13
E. coli O157:H7/ STEC / HUS
2013 Case Total 30 2013 rate/100,000 1.0
2012 Case Total 31 2012 rate/100,000 1.0
Clinical Features
Escherichia coli (E. coli) O157:H7 is the most virulent serotype of the Shiga toxin-
producing E. coli (STEC), and is associated with diarrhea, hemorrhagic colitis, hemolytic-
uremic syndrome (HUS), and post-diarrheal thrombotic thrombocytopenic purpura
(TTP). Symptoms often begin as nonbloody diarrhea but can progress to diarrhea with
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occult or visible blood. Severe abdominal pain is typical, and fever is usually absent.
The very young and the elderly are more likely to develop severe illness and HUS,
defined as microangiopathic hemolytic anemia, thrombocytopenia, and acute renal
dysfunction. HUS is a complication in about 8% of E. coli O157:H7 infections. Supportive
care is recommended as antibiotic use may increase the risk of progression to HUS.
Other serotypes of E. coli are capable of producing Shiga toxins (STEC) that can lead to
illness and HUS.
Infectious Agent
E. coli are gram negative bacilli. E. coli O157:H7 is thought to cause more than 90% of
all diarrhea-associated HUS. Other non-O157 STEC serogroups include O26, O111, and
O103.
Reservoir
Cattle, to a lesser extent other animals, including sheep, deer, and other ruminants.
Humans may also serve as a reservoir for person-to-person transmission.
Transmission
Mainly through ingestion of food contaminated with ruminant feces, usually
inadequately cooked hamburgers; also contaminated produce or unpasteurized milk.
Direct person-to-person transmission can occur in group settings. Waterborne
transmission occurs both from contaminated drinking water and from recreational
waters.
Incubation
2-10 days, with a median of 3-4 days.
Period of Communicability
Duration of excretion is typically 1 week or less in adults but can be up to 3 weeks in
one-third of children. Prolonged carriage is uncommon.
Methods of Control
Education regarding proper food preparation and handling and good hand hygiene is
essential in prevention and control. Pasteurization of milk and juice is important.
MSDH investigates all reported cases of HUS and E. coli O157:H7 infections. All isolates
should be submitted to the Public Health Laboratory (PHL) for molecular subtyping, or
DNA “fingerprinting”, with pulsed-field gel electrophoresis (PFGE). Isolate information is
submitted to a national tracking system (PulseNet), a network of public health and food
regulatory agencies coordinated by the CDC. This system facilitates early detection of
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common source outbreaks, even if the affected persons are geographically far apart,
and assists in rapidly identifying the source of outbreaks.
Reporting Classification
Class1A (includes E. coli O157:H7, non O157:H7 STEC and post-diarrheal HUS).
Epidemiology and Trends
In Mississippi, all E. coli O157:H7 infections, non O157:H7 STEC infections (added to the
List of Reportable Diseases and conditions in late 2010) and cases of post-diarrheal HUS
are reportable. In 2013 there were 30 cases reported to MSDH; 11 E. coli O157:H7 and 19
non O157:H7 STEC. This was comparable to the 31 reported cases in 2012 (Figure 14).
The 19 non O157:H7 STEC cases were due to serogroups O103 (3), O26 (4), O111 (4),
and O121 (1). The serogroups of the remaining seven STEC cases were unknown. One of
the E. coli O157:H7 cases also developed HUS. There were no deaths reported in
Mississippi in 2013.
Figure 14
*U.S. rate includes E. coli O157:H7; shiga toxin positive, serogroup non-O157; and shiga toxin positive, not serogrouped.
**Mississippi rate includes E. coli O157:H7; shiga toxin positive, serogroup non-O157; shiga toxin positive, not serogrouped,
and post-diarrheal HUS.
The 2013 E. coli O157:H7/STEC/HUS cases ranged in age from 14 months to 73 years with
a median of 10.5 years of age. Of the 61 cases of E. coli O157:H7/STEC/HUS that were
reported to MSDH in 2012 and 2013, 46% occurred in children less than 10 years of age
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(Figure 15). Children and the elderly are at higher risk for the development of severe
illness and HUS as a result of infection.
Districts I, VIII, and IX experienced the highest rates of E. coli O157:H7 and non-O157:H7
STEC cases, with rates of 1.85, 2.26, and 1.46 cases per 100,000 residents, respectively.
Figure 15
There was one outbreak reported by the CDC in March 2013. This included 35 cases in
19 states, one case being in Mississippi. The STEC strain O121 was identified as the
infectious agent and frozen food products were found to be the source of infection.
There were two other outbreaks in Mississippi. In May 2013, an outbreak of E. coli O26
was identified with 23 cases across 11 states, with one in Mississippi. Another outbreak
occurred in June 2013, when a child was infected with E. coli O111 while at a camp in
Missouri.
Gonorrhea
2013 Case Total 5,090 2013 rate/100,000 170.2
2012 Case Total 6,860 2012 rate/100,000 229.8
Clinical Features
Gonnorhea is a sexually transmitted bacterial infection that primarily targets the
urogenital tract leading to urethritis in males and cervicitis in females. Other less
common sites of infection include the pharynx, rectum, conjunctiva, and blood.
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Urethritis presents with mucopurulent discharge and dysuria, while cervicitis often
presents with vaginal discharge and postcoital bleeding. Asymptomatic infections do
occur.
Complications associated with gonorrhea infection in males include epididymitis, penile
lymphangitis, penile edema, and urethral strictures. The primary complication
associated with gonorrhea infection in females is pelvic inflammatory disease, which
produces symptoms of lower abdominal pain, cervical discharge, and cervical motion
pain. Pregnant women infected with gonorrhea may transmit the infection to their
infants during a vaginal delivery. Infected infants can develop conjunctivitis leading to
blindness if not rapidly and adequately treated. Septicemia can also occur in infected
infants.
Infectious Agent
Neisseria gonorrhoeae, an intracellular gram-negative diplococcus.
Reservoir
Humans.
Transmission
Gonorrhea is transmitted primarily by sexual contact, but transmission to an infant
delivered through an infected cervical canal also occurs.
Incubation
In males the incubation period is primarily 2-5 days, but may be 10 days or longer. In
females it is more unpredictable, but most develop symptoms less than 10 days after
exposure.
Period of Communicability
In untreated individuals, communicability can last for months; but if an effective
treatment is provided communicability ends within hours.
Methods of Control
Prevention and control of gonorrhea are based on education, effective treatment, and
mechanical barriers. Condoms and diaphragms provide some degree of protection
from transmission or acquisition of gonorrhea. Effective treatment of the infected
patient and their partners from 60 days prior to the onset of symptoms is recommended.
Reporting Classification
Class 2.
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Epidemiology and Trends
Gonorrhea is the second most commonly reported notifiable disease in the United
States. From 2007 through 2011 there was a steady decline in the rate and number of
cases of gonorrhea in Mississippi. The number of cases during that time period
decreased from 8,163 cases in 2007 to 5,806 cases in 2011, representing a 29%
decrease. From 2011 to 2012, reported cases of gonorrhea increased 18% (from 5,806 to
6,860 cases); however in 2013, reported cases decreased 26% to 5,090 cases (Figure
16). In 2013, Mississippi had the third highest case rate of gonorrhea in the United States.
Figure 16
Gonorrhea was reported in every public health district, with the highest incidence
noted in Public Health District III (Figure 17).
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Figure 17
Although the disease impacted individuals across all age groups, 66% of reported cases
were among 15-24 year olds (Figure 18). African Americans accounted for 89% of the
reported cases in which race was known (Figure 19). In 2013, the rate of gonorrhea
infections for African Americans (343.1 per 100,000) was fifteen times the rate of whites
(23.0 per 100,000).
Figure 18
Gonorrhea Incidence by Public Health District, Mississippi, 2013
District
Cases
Rate*
I
498
153.9
II
380
103.2
III
573
271.6
IV
436
177.4
V
1523
238.0
VI
403
166.2
VII
229
133.0
VIII
480
155.2
IX
568
118.6
Statewide
5,090
170.2
*per 100,000 population
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Figure 19
Haemophilus influenzae, type b
2013 Case Total 1 2013 rate/100,000 0.0
2012 Case Total
0
2012 rate/100,000
0.0
Clinical Features
Haemophilus influenzae (H. influenzae) is an invasive bacterial disease, particularly
among infants, that can affect many organ systems. There are six identifiable types of
H. influenzae bacteria (a through f). Type b (Hib) is the most pathogenic and is
responsible for the majority of invasive infections. Meningitis is the most common
manifestation of invasive disease. Epiglottitis, pneumonia, septic arthritis, and
septicemia are other forms of invasive disease. Hib meningitis presents with fever,
decreased mental status and nuchal rigidity. Neurologic sequelae can occur in 15-30%
of survivors, with hearing impairment as the most common. Case fatality rate is 2-5%
even with antimicrobial therapy. Peak incidence is usually in infants 6-12 months of age;
Hib disease rarely occurs beyond 5 years of age. In the prevaccine era, meningitis
accounted for 50-60% of all cases of invasive disease. Since the late 1980’s, with the
licensure of Hib conjugate vaccines, Hib meningitis has essentially disappeared in the
U.S.
Infectious Agent
Haemophilus influenzae (H. influenzae), a gram-negative encapsulated bacterium.
Serotypes include a through f.
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Reservoir
Humans, asymptomatic carriers.
Transmission
Respiratory droplets and contact with nasopharyngeal secretions during the infectious
period.
Incubation
Uncertain; probably short, 2-4 days.
Period of Communicability
As long as organisms are present; up to 24-48 hours after starting antimicrobial therapy.
Methods of Control
Two Hib conjugate vaccines are licensed for routine childhood vaccination. The
number of doses in the primary series is dependent on the type of vaccine used. A
primary series of PRP-OMP (PedvaxHIB®) vaccine is two total doses, at 2 and 4 months
of age; the primary series with PRP-T (ActHIB®) requires three total doses, given at 2, 4
and 6 months of age. A booster dose at 12-15 months of age is recommended
regardless of which vaccine is used for the primary series. Vaccination with Hib
containing vaccines may decrease the carriage rate, decreasing the chances of
infection in unvaccinated in children. Immunization is not recommended for children
over 5 years of age.
The Mississippi State Department of Health (MSDH) investigates all reports of suspected
or confirmed invasive disease due to H. influenzae to determine serotype and the need
for prophylactic antibiotics for contacts. For Hib cases MSDH provides prophylactic
antibiotics (rifampin) for all household contacts with one or more children under one
year of age or in households with children 1-3 years old who are inadequately
immunized. Although the protection of contacts is only recommended after exposure
to cases of Hib disease, contacts are often treated before the isolate’s serotype is
known in order to facilitate rapid provision of post-exposure prophylaxis . MSDH requests
that all H. influenzae isolates be sent to the Public Health Laboratory (PHL) for
serotyping.
Reporting Classification
Class 1A.
Epidemiology and Trends
Prior to the development and widespread use of Hib conjugate vaccines in the late
1980’s and early 1990’s, Hib was the most common cause of bacterial meningitis in
children < 5 years of age. In Mississippi, conjugate vaccine was first offered to 18 month
olds in 1989, to 15 month olds in 1990, and as a primary series, starting at 2 months of
age, with a 12-15 month booster, in January 1991. With the institution of vaccination, the
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number of reported cases of invasive disease due to Hib dropped from 82 in 1989, to 5
by 1994. There have been fewer than 5 cases of Hib per year since 1995.
There were 31 cases of H. influenzae reported in 2013, with only one case confirmed as
type b. This case presented as septicemia in an 81 year old female. There were three
deaths associated with invasive H. influenzae infection, all of which were over the age
of 60. Districts I and V had the highest rates of H. influenzae infection of 1.85 and 1.72
per 100,000 residents, respectively. Of the overall cases, 26 presented as septicemia
(84%), three presented as meningitis (10%) and two presented as other invasive
infections (6%). Ages ranged from newborn to 88 years, with a median of 69 years. The
invasive H. influenzae cases were identified as being type b (3%), type f (3%), not type b
(71%), not typed (3%) and unknown (19%).
Hepatitis A
2013 Case Total 5 2013 rate/100,000 0.2
2012 Case Total
11
2012 rate/100,000
0.4
Clinical Features
Hepatitis A is a viral illness with an abrupt onset of fever, malaise, anorexia, nausea,
vomiting, and abdominal pain, followed by jaundice in a few days. The disease varies
in intensity from a mild illness of 1-2 weeks, to a severe disease lasting several months.
Most cases among children are asymptomatic and the severity of illness increases with
age; the case fatality rate is low—0.1%-0.3%. No chronic infection occurs.
Infectious Agent
Hepatitis A virus (HAV), an RNA virus.
Reservoir
Humans, rarely chimpanzees and other primates.
Transmission
Transmission occurs through the fecal-oral route either by person to person contact or
ingestion of contaminated food or water. Common source outbreaks may be related
to infected food handlers. Many younger children are asymptomatic, but shed virus
and are often sources of additional cases.
Incubation
Average 28-30 days, (range 15-50 days).
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Period of Communicability
Infected persons are most likely to transmit HAV 1-2 weeks before the onset of
symptoms and in the first few days after the onset of jaundice, when viral shedding in
the stool is at its highest. The risk of transmission then decreases and becomes minimal
after the first week of jaundice.
Methods of Control
In the prevaccine era, hygienic measures and post-exposure immune globulin were the
primary means of preventing infection. Vaccine was first introduced in 1995, and
following successful vaccination programs in high incidence areas, the Advisory
Committee on Immunization Practices (ACIP) recommended routine vaccination for all
children in 2005. Children aged 12-23 months of age should receive one dose of
hepatitis A vaccine followed by a booster 6-18 months later, with catch up vaccination
for children not vaccinated by 2 years of age.
Post-exposure prophylaxis is recommended within two weeks of exposure for all
susceptible individuals who are close personal contacts to the case or who attend
daycare with infected individuals, or are exposed to hepatitis A virus through common
source outbreaks. Hepatitis A vaccine (with completion of the series) is recommended
for post-exposure prophylaxis for all healthy persons aged 12 months to 40 years.
Immune globulin should be considered for children less than 12 months of age, adults
over 40 years of age, and those in whom vaccination is contraindicated. Use of both
simultaneously can be considered with higher risk exposures. Post-exposure prophylaxis
is not generally indicated for healthcare workers who care for patients infected with
hepatitis A unless epidemiological investigation indicates ongoing transmission in the
facility.
Reporting Classification
Class 1A.
Epidemiology and Trends
The rate of hepatitis A in Mississippi has been below the national average for more than
a decade. In 2013, there were only five cases of acute hepatitis A reported in
Mississippi; less than both the eleven cases reported in 2012 and the three year (2010-
2012) average of six annual cases (Figure 20). No common source exposures or
outbreaks of hepatitis A were reported in 2013.
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Figure 20
Hepatitis B, acute
2013 Case Total 54 2013 rate/100,000 1.8
2012 Case Total
78
2012 rate/100,000
2.6
Clinical Features
An acute viral illness characterized by the insidious onset of anorexia, abdominal
discomfort, nausea and vomiting. Clinical illness is often unrecognized because
jaundice occurs in only 30-50% of adults and less than 10% of children. Approximately
5% of all acute cases progress to chronic infection. Younger age at infection is a risk
factor for becoming a chronic carrier with 90% of perinatally infected infants becoming
chronic carriers. Chronic cases may have no evidence of liver disease, or may develop
clinical illness ranging from chronic hepatitis, to cirrhosis, liver failure or liver cancer.
Hepatitis B infections are the cause of up to 80% of hepatocellular carcinomas
worldwide.
Infectious Agent
Hepatitis B virus, a hepadnavirus.
Reservoir
Humans.
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Transmission
Transmission occurs through parenteral or mucosal exposure to body fluids of hepatitis B
surface antigen (HBsAg) positive persons, such as through perinatal exposure, contact
with contaminated needles, or sexual contact. Blood and blood products, saliva,
semen and vaginal secretions are known to be infectious. The three main groups at risk
for hepatitis B infection are heterosexuals with infected or multiple partners, injection-
drug users, and men who have sex with men.
Incubation
45-180 days, average 60-90 days.
Period of Communicability
As long as HBsAg is present in blood. In acute infections, surface Ag can be present 1-2
months after the onset of symptoms.
Methods of Control
Routine hepatitis B vaccination series is recommended for all children beginning at
birth, with catch-up at 11-12 years of age if not previously vaccinated. The usual three
dose schedule is 0, 1-2, and 6-18 months. Vaccination is also recommended for high
risk groups, including those with occupational exposure, household and sexual contacts
of HBsAg positive individuals (both acute and chronic infections), and injection drug
users.
Transmission of hepatitis B can be interrupted by identification of susceptible contacts
and HBsAg positive pregnancies, and the timely use of post-exposure prophylaxis with
vaccine and/or immune globulin.
Perinatal transmission is very efficient in the absence of post-exposure prophylaxis, with
an infection rate of 70-90% if the mother is both HBsAg and hepatitis B e antigen
(HBeAg) positive. The risk of perinatal transmission is about 10% if the mother is only
HBsAg positive. Post-exposure prophylaxis, consisting of hepatitis B immune globulin
and vaccine, is highly effective in preventing hepatitis B vertical transmission, therefore,
testing of all pregnant women for HBsAg is recommended with each pregnancy. MSDH,
through the Perinatal Hepatitis B Program, tracks HBsAg positive pregnant women,
provides prenatal HBsAg testing information to the delivery hospitals when available,
and monitors infants born to infected mothers to confirm completion of the vaccine
series by 6 months of age, and then tests for post-vaccine response and for possible
seroconversion at 9-12 months of age. As an addition to the existing reporting
requirement of acute hepatitis B infection, in 2011 hepatitis B infection in pregnancy
was added to the list of reportable diseases. This addition was made to facilitate
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identification of hepatitis B infected women and ensure the provision of appropriate
vaccination for the affected infant.
Reporting Classification
Class 2; any acute hepatitis B infection and any hepatitis B infection in pregnancy
Epidemiology and Trends
In 2013, 54 cases of acute hepatitis B were reported. This was lower than the 78
reported cases in 2012, but was comparable to the three year average (2010-2012) of
57 annual cases (Figure 21). Thirty-three (61%) of the 54 reported cases occurred in
individuals aged 20-39 years. Overall, the cases ranged in age from 21 years to 74
years old, with a median age of 37 years (Figure 22).
Figure 21
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Figure 22
A comprehensive strategy to eliminate hepatitis B virus transmission was recommended
in 1991. The strategy includes prenatal testing of pregnant women for Hepatitis B
surface antigen (HBsAg) to identify newborns that require immunoprophylaxis,
identification of household contacts who should be vaccinated, the routine
vaccination of infants, the vaccination of adolescents, and the vaccination of adults at
high risk for infection.
In 2013, 76 HBsAg positive pregnant women were reported to the Perinatal Hepatitis B
Prevention Program (Figure 23). This is lower than both the 100 reported in 2012 and the
three year average (2010 – 2012) of 100. There were no reported cases of HBsAg
positive infants born to HBsAg positive mothers in 2013. The last cases of perinatal
transmission occurred in 2007, when two cases were reported.
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Figure 23
HIV Disease
2013 Case Total 556 2013 rate/100,000 18.6
2012 Case Total
547
2012 rate/100,000
18.3
Clinical Features
The clinical spectrum of human immunodeficiency virus (HIV) infection varies from
asymptomatic infections to advanced immunodeficiency with opportunistic
complications. One half to two thirds of recently infected individuals have
manifestations of an infectious mononucleosis-like syndrome in the acute stage. Fever,
sweats, malaise, myalgia, anorexia, nausea, diarrhea, and non-exudative pharyngitis
are prominent symptoms in this stage. Constitutional symptoms of fatigue and wasting
may occur in the early months or years before opportunistic disease is diagnosed. Over
time, HIV can weaken the immune system, lowering the total CD4 count and leading to
opportunistic infections and the diagnosis of Acquired Immunodeficiency syndrome
(AIDS).
Infectious Agent
Human immunodeficiency virus is a retrovirus with two known types, HIV-1 and HIV-2.
These two types are serologically distinct and have a different geographical
distribution, with HIV-1 being primarily responsible for the global pandemic and the
more pathogenic of the two.
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Reservoir
Humans.
Transmission
HIV infection can be transmitted from person to person during sexual contact, by blood
product transfusion, sharing contaminated needles or infected tissue or organ
transplant. Breast feeding is also a known vehicle of mother to infant transmission of HIV.
Without appropriate prenatal treatment, 15-30% of infants born to HIV positive mothers
are infected through maternal fetal transmission. Transmission by contact with body
secretions like urine, saliva, tears or bronchial secretions has not been recorded.
Incubation
The time from infection to the detection of antibodies to HIV is usually less than one
month. The period from the time of infection to the development of AIDS ranges from 1
year up to 15 years or longer. The availability of effective anti-HIV therapy has greatly
reduced the development of AIDS in the U.S.
Period of Communicability
Individuals become infectious shortly after infection and remain infectious throughout
the course of their lives, however, successful therapy with antiretroviral drugs can lower
the viral load in blood, semen and vaginal secretions to undetectable levels,
substantially decreasing the transmission probability of HIV.
Methods of Control
Abstinence is the only sure way to avoid sexual HIV transmission; otherwise mutual
monogamy with partners known to be uninfected and the use of latex condoms are
known to reduce the risk of infection. Confidential HIV testing and counseling and
testing of contacts, prenatal prevention by counseling and testing all pregnant women,
and early diagnosis and treatment with appropriate anti-retroviral therapy can reduce
transmission. Post-exposure prophylaxis for health care workers exposed to blood or
body fluids suspected to contain HIV is an important worksite preventive measure. In
recent years, a number of biomedical interventions including male circumcision, pre-
exposure, and post-exposure prophylaxis have proven to be effective in decreasing the
rate of acquisition of HIV among high risk individuals. MSDH performs contact
investigation, counseling and testing for each reported case of HIV infection in addition
to facilitating linkage to care of infected individuals.
Pre-exposure prophylaxis, or PrEP, is a prevention option for those individuals at high risk
for HIV infection. Taken consistently, PrEP has been shown to substantially reduce the
risk of infection, especially if combined with condoms and other prevention methods.
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Reporting Classifications
Class 1B; HIV infection-including AIDS
Class 3; CD4 count and HIV viral load.
Epidemiology and Trends
Both HIV infection and AIDS are reportable at the time of diagnosis, so many patients
may be reported twice (once at first diagnosis of HIV infection, and again when
developing an AIDS defining illness). The epidemiologic data that follows is regarding
the initial report of HIV disease, whether first diagnosed as HIV infection or AIDS. Over
the past few years, there has been little change in HIV disease trends. There were 556
cases of HIV disease reported in 2013 (Figure 24).
Figure 24
Individuals from every Public Health District were impacted by this disease. Public
Health District V reported the highest case rate statewide, followed by District III (Figure
25).
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Figure 25
HIV disease was reported in all age groups, with 41% of the cases reported among 20-
29 year olds and 23% among 30 to 39 year olds (Figure 26). African Americans were
disproportionately impacted by HIV disease. In 2013, 78% of new cases were among
African Americans in which race was known (Figure 27).
Figure 26
HIV Disease Incidence by Public Health District, Mississippi, 2013
District
Cases
Rate*
I
57
17.6
II
41
11.1
III
51
24.2
IV
27
11.0
V
197
30.8
VI
35
14.4
VII
29
16.8
VIII
57
18.4
IX
62
13.0
Statewide
556
18.6
*per 100,000 population
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Figure 27
There are a number of identifiable risk factors associated with HIV infection, including
male-to-male sexual contact (MSM), heterosexual contact (hetero), and injection drug
use (IDU)(Figure 28). Cases in persons with no reported exposure to HIV through any
routes listed in the hierarchy of transmission categories are classified as “no risk factor
reported or identified” or NIR. For the last several years, the percentage of cases
among individuals identifying themselves as MSM has steadily increased, from 36% in
2008 to 54% in 2013.
Figure 28
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Additional References:
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the
use of antiretroviral agents in HIV-1-infected adults and adolescents. Department
of Health and Human Services. Available at
https://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf.
Centers for Disease Control and Prevention. Guidelines for Prevention and
Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents.
MMWR 2009;58 (No. RR-4) April 10, 2009
Centers for Disease Control and Prevention. Guidelines for the Prevention and
Treatment of Opportunistic Infections Among HIV-Exposed and HIV-Infected
Children. MMWR 2009; 58 (No. RR-11) September 4, 2009
Influenza – 2013 – 2014 Season
Clinical Features
An acute viral infection of the respiratory tract characterized by sudden onset of fever,
often with chills, headache, malaise, diffuse myalgia, and nonproductive cough. The
highest risks for complications from seasonal influenza are in persons aged 65 years and
older, young children, pregnant and postpartum women, and persons at any age with
chronic underlying illnesses. Pneumonia due to secondary bacterial infections is the
most common complication of influenza. Estimated influenza deaths range from a low
of 3,000 to a high of 49,000 per year in the United States.
Infectious Agent
Influenza is caused by an RNA virus. Each season both influenza A and B virus strains
circulate and cause illness but there is usually one predominant type or subtype of
influenza virus that causes the majority of infections.
Reservoir
Humans are the reservoir for seasonal influenza. Wild aquatic bird, domestic poultry and
domestic pigs can serve as reservoirs for emerging variant influenza strains.
Transmission
Transmission occurs person to person by direct or indirect contact with virus laden
droplets or respiratory secretions. Transmission of variant strains is usually the result of
direct contact with an infected animal, such as pigs or domestic poultry.
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Incubation
The incubation period usually is 1 to 4 days, with a mean of 2 days.
Period of Communicability
From 1 day before clinical onset through 3-5 days from clinical onset in adults; and up
to 7-10 days from clinical onset in young children.
Methods of Control
Routine annual influenza vaccination is recommended for all persons aged ≥6 months,
and is the single most effective method for the prevention of infection. Additionally,
basic personal hygiene, including handwashing, and respiratory etiquette should be
reinforced.
Antivirals can also be used to prevent and treat influenza. The neuraminidase inhibitors
(oseltamivir and zanamivir) are effective against all forms of influenza. Sporadic
resistance to oseltamivir has been identified in some influenza strains (influenza A H1N1),
however neuraminidase inhibitors are still recommended for the treatment of influenza
A (H1N1) and A (H3N2) and influenza B virus infections. Treatment with antivirals within
the first 48 hours of can be effective in reducing the duration of illness, and is
recommended for individuals who are hospitalized or at higher risk of severe
complications from influenza infections. Adamantanes (amantadine and rimantadine)
are not effective against influenza B viruses and are not recommended for influenza A
viruses due to high levels of resistance.
For the most current guidelines available at the date of this publication, please see the
Centers for Disease Control and Prevention (CDC) Recommendations and Reports,
“Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the
Advisory Committee on Immunization Practices—United States, 2016-2017”. MMWR
65(No. RR5); August 26, 2016, available online at
https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6505.pdf
For guidelines on the use of antivirals see the CDC website at:
http://www.cdc.gov/flu/professionals/antivirals/antiviral-use-influenza.htm
and the CDC
report “Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza”
available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6001a1.htm
Reporting Classification
Class 1A: Influenza-associated pediatric deaths (<18 years of age).
Epidemiology and Trends
A typical influenza season usually peaks anywhere from December through March but
influenza activity can occur earlier or later. The risk of complications depends on many
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factors, including age and underlying medical conditions. Vaccination status and the
match of vaccine to circulating viruses affect both the susceptibility to infection and
the possibility of complications. Outbreaks can occur in group settings, such as nursing
homes.
MSDH monitors seasonal influenza activity statewide through an active syndromic
surveillance program reported by sentinel providers. In the 2013 – 2014 influenza
season, 47 sentinel providers in 37 counties were enrolled in this system, representing
hospital emergency departments, urgent care and primary care clinics, and college
and university student health centers. These providers reported weekly numbers of non-
trauma patient visits consistent with an influenza-like illness (ILI), defined as fever >100ºF
and cough and/or sore throat in the absence of a known cause other than influenza.
MSDH uses this information to estimate the magnitude of the state’s weekly influenza
activity. These data are also used to estimate the geographic spread of influenza
within the state, ranging from no activity to widespread activity. This terminology
represents a geographic estimate rather than an indication of severity of the season. ILI
providers are also supplied with kits for PCR influenza testing at the Public Health
Laboratory (PHL).
Influenza activity peaked in late December in the US and influenza A (pH1N1) was the
predominant virus in the US, although influenza B activity increased later in the influenza
season. The 2013 – 2014 influenza season was the first pH1N1-predominant season since
the 2009 pH1N1 pandemic. Also of significance for the 2013 – 2014 was the higher than
expected hospitalization rates among those aged 50 to 64 years. This age group had
the second highest hospitalization rate, just behind those aged 65 years and older. The
CDC surmised that the increased hospitalization rates were likely due to several factors,
including lack of cross-protective immunity to pH1N1 and lower influenza vaccination
coverage in this age group.
In Mississippi, influenza activity also peaked in late December 2013 at 8.2%, which was
comparable to when the peak occurred during the previous season. The 2013 – 2014
season followed the same seasonal pattern as the two previous influenza seasons
(Figure 29). Early in the 2013 – 2014 season, the predominant virus identified in the PHL
was influenza A (pH1N1), although both influenza A (subtyped not performed) and
Influenza B isolates were identified later in the season (Figure 30). There was one
influenza-associated pediatric death reported in Mississippi in the 2013 – 2014 season.
The death occurred in a 17 month old.
During the 2013-2014 influenza season, MSDH began receiving reports of serious
complications associated with influenza infection, including deaths, in individuals less
than 65 years of age. In response to these reports, MSDH developed an enhanced
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surveillance system to identify influenza deaths in hospitalized adults. Please see the
Special Reports section for a discussion of this enhanced surveillance activity.
Figure 29
Figure 30
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Legionellosis
2013 Case Total 18 2013 rate/100,000 0.6
2012 Case Total 17 2012 rate/100,000 0.6
Clinical Features
Legionellosis is an acute bacterial infection that has two clinical syndromes;
Legionnaires’ disease and Pontiac fever. Both syndromes can present with fever,
headache, diarrhea and generalized myalgias. Those with Legionnaires’ disease
develop a non-productive cough and pneumonia that can be severe and progress to
respiratory failure. Even with improved diagnosis and treatment, the case fatality rate
for Legionnaires’ disease remains at approximately 15%. Pontiac fever is a self-limited
febrile illness that does not progress to pneumonia or death.
Infectious Agent
Legionella pneumophila (L. pneumophila), a gram negative bacillus with 18 serogroups.
L. pneumophila serogroup 1 is the most common serogroup associated with illness.
Reservoir
Legionellosis is a waterborne disease. The best conditions for growth of the bacteria are
warm water temperatures, stagnation, sediment and low levels of biocide.
Transmission
Airborne transmission occurs when water sources contaminated with L. pneumophila
are aerosolized. Common sources of outbreaks are potable water systems,
whirlpools/spas and cooling towers.
Incubation
Legionnaires’ disease — 2-10 days, most commonly 5-6 days.
Pontiac Fever — 5-72 hours, most commonly 24-48 hours.
Period of Communicability
Legionellosis is not transmitted person to person.
Reporting Classification
Class 1B.
Epidemiology and Trends
In 2013, there were 18 cases of legionellosis reported in Mississippi (Figure 31). The cases
ranged in age from 2 to 88 years, with a median age of 61. There were two deaths
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reported in 2013. These deaths occurred in individuals over the age of 80. On average,
15 cases have been reported annually over the past three years (2010-2012). The 2013
cases were not epidemiologically linked and no outbreaks were reported.
Figure 31
Listeriosis
2013 Case Total 4 2013 rate/100,000 0.1
2012 Case Total 4 2012 rate/100,000 0.1
Clinical Features
A bacterial illness that in immunocompetent adults may present as an acute, mild
febrile illness. In the elderly, immunocompromised persons, diabetics, alcoholics and in
newborns, illness may present as meningoencephalitis and/or septicemia. The onset of
meningoencephalitis can be sudden with fever, intense headache, nausea, vomiting
and signs of meningeal irritation. Infected pregnant women may be asymptomatic or
experience only a mild febrile illness; however, infection during pregnancy can lead to
miscarriage or stillbirth, premature delivery, or infection of the newborn. The case
fatality rate is as high as 30-50% in newborns.
Infectious Agent
Listeria monocytogenes, a gram-positive, rod-shaped bacterium.
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Reservoir
Mainly occurs in soil, forage, water, mud and silage. Animal reservoirs include domestic
and wild mammals, fowl and people. Asymptomatic fecal carriage is as high as 10% in
humans.
Transmission
Ingestion of unpasteurized or contaminated milk and soft cheeses, as well as
vegetables and ready-to-eat meats, such as deli meats or hot dogs. Unlike most other
foodborne pathogens, Listeria tends to multiply in contaminated foods that are
refrigerated. In neonates, infection can be transmitted in utero or by passage through
the infected birth canal.
Incubation
Variable, estimated median incubation is 3 weeks (range 3-70 days)
Period of Communicability
Mothers of infected newborns can shed the bacterium in vaginal discharges and urine
for 7-10 days post delivery. Infected individuals can shed the bacteria in their stools for
several months.
Methods of Control
Education for proper food handling and preparation. Avoid unpasteurized (raw) milk or
foods made from unpasteurized milk, such as soft cheeses, which can support the
growth of organisms during ripening. Consume perishable and ready-to-eat foods as
soon as possible after purchase, and cook hot dogs thoroughly before consumption.
These recommendations are especially important during pregnancy. MSDH
investigates all reported cases for rapid identification of common source outbreaks.
Reporting Classification
Class 2.
Epidemiology and Trends
There were four reported cases of listeriosis in Mississippi in 2013, which was comparable
to the number reported in 2012 and to the average number of four cases reported
annually from 2010 through 2012. The incidence in Mississippi has remained at or below
national rates since Listeria was added to the National Notifiable Disease List in 2000
(Figure 32).
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Figure 32
There were no neonatal infections reported in 2013. The four reported cases ranged in
age from 34 to 96 years, with a median age of 68 years. No deaths were reported in
2013. None of the infections were epidemiologically linked or associated with common
source outbreaks.
Lyme Disease
2013 Case Total 0 2013 rate/100,000 0.0
2012 Case Total
1 2012 rate/100,000 0.0
Clinical Features
A tick-borne bacterial disease characterized primarily by a distinct “bull’s-eye” rash
(erythema migrans) in the early stage of the infection. The rash is present in up to 60%-
80% of patients. Accompanying symptoms may include malaise, fever, headache, stiff
neck, myalgias, migratory arthralgias and/or lymphadenopathy. In untreated patients,
chronic or late manifestations may include musculoskeletal symptoms (joint swelling or
chronic arthritis), neurological manifestations (aseptic meningitis, cranial neuritis, facial
palsy, rarely encephalomyelitis), and cardiac abnormalities (specifically 2nd or 3rd
degree atrioventricular conduction defects).
Infectious Agent
Borrelia burgdorferi, a spirochete.
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Reservoir
Small mammals, mainly mice. Deer are efficient maintenance hosts and play an
important role in transporting ticks.
Transmission
Transmission occurs through the bite of an infected Ixodes scapularis tick (black-legged
tick). Nymphs are more likely to transmit disease, and they feed primarily on small
mammals. Studies indicate the tick usually must be attached 24 hours or longer to
efficiently transmit the bacteria. No person to person transmission or maternal fetal
transmission has been confirmed.
Incubation
2-30 days after tick exposure for erythema migrans, however, early infection may be
unapparent and patients may present weeks to months after exposure with late
manifestations.
Methods of Control
Avoid tick infested areas when possible. When unavoidable, use tick repellant and
measures to decrease tick exposure. After leaving tick prone areas examine body well
and remove any ticks. It is important to promptly remove any attached ticks; it is not
necessary to remove the head.
Reporting Classification
Class 2.
Epidemiology and Trends
Most cases of Lyme disease occur in late spring and summer. Lyme disease is not
considered endemic in Mississippi. Although the vector is present in the state, definitive
transmission within the state of Mississippi has not been clearly demonstrated.
There were no cases of Lyme disease reported in 2013, compared to one case in 2012.
Measles
2013 Case Total 0 2013 rate/100,000 0.0
2012 Case Total 0 2012 rate/100,000 0.0
Clinical Features
Measles is a highly contagious viral illness characterized
by cough, coryza, conjunctivitis
(3 C’s), fever, an erythematous maculopapular
rash, and a pathognomonic
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enanthema (Koplik spots). Complications are seen more frequently in children younger
than 5 years of age and in adults 20 years of age and older. Diarrhea, pneumonia and
encephalitis are the most common complications seen. The risk of death is higher in
these age groups as well; the most common cause of death is pneumonia in children,
and acute encephalitis in adults. Subacute sclerosing panencephalitis is a rare
degenerative central nervous system disease that is thought to be due to persistent
measles infection of the brain, and typically presents approximately 7 years after initial
infection.
Infectious Agent
Measles virus, in the paramyxovirus family.
Reservoir
Humans.
Transmission
Transmitted by direct contact with large infectious droplets or, less commonly, by
airborne spread. Measles is highly contagious, and all persons without previous disease
or vaccination are susceptible.
Incubation
Eight to ten days.
Period of Communicability
Three to five days before to four days after rash onset.
Methods of Control
Measles, mumps and rubella (MMR) vaccine is recommended for all children at 12 to15
months of age with a second dose at school entry (4 to 6 years of age). Appropriate
two dose vaccination induces immunity in 99% of individuals.
MSDH investigates all reported cases and provides prophylaxis for all contacts as
appropriate. Measles vaccine administered within 72 hours of exposure may provide
protection in some cases. Immunoglobulin, given within six days of exposure, can
prevent or modify measles in susceptible persons who are at high risk for complications.
Because measles remains endemic in much of the world, international travelers should
be up-to-date on vaccinations. Most international travelers should receive 1 to 2 doses
of measles containing vaccine, including infants aged 6 months through 11 months of
age who should receive a single dose of MMR when traveling internationally (still require
routine doses at 12 months and 4 to 6 years of age).
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Reporting Classification
Class 1A.
Epidemiology and Trends
There have been no reported cases of measles in Mississippi since 1992, when there
were 17 reported cases. Fifteen of those cases were associated with an outbreak at
the University of Mississippi and the index case’s infection in that outbreak was traced to
an exposure in Europe. Following this outbreak, a history of 2 doses of MMR was
required to attend public universities in Mississippi.
Measles occurs throughout the world with peak incidence usually in late winter and
spring. In 2000 widespread measles immunization led to the interruption of endemic
measles transmission in the United States. However, measles incidence has increased
worldwide, with outbreaks and increased transmission in several countries, particularly in
Europe, due in part to dropping immunization rates. Importation of measles to the U.S.
has resulted in a number of cases and outbreaks, particularly in unvaccinated
populations.
In 2013, a total of 187 cases were reported in the United States. There were 11 reported
outbreaks, three of which had more than 20 cases, including one with 58 cases. In a
CDC Morbidity and Mortality Weekly Report (MMWR) issued in September 2013, cases
of measles occurring from January 1 through August 24, 2013 were evaluated. Of the
159 cases reported during that time frame, 131 (82%) occurred in unvaccinated
persons, and 157 (99%) were import-associated cases.
Continued high vaccine rates in the U.S. and in Mississippi are important to provide
appropriate population immunity and decrease the risk to those who are too young to
receive vaccine or have medical contraindications to vaccination.
Additional References:
• CDC. Measles Cases and Outbreaks. Available online at
http://www.cdc.gov/measles/cases-outbreaks.html
.
• CDC. Measles—United States, January 1-August 24, 2013. MMWR. September 13,
2013/62(36); 741-743.
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Meningococcal disease, invasive
2013 Case Total 4 2013 rate/100,000 0.1
2012 Case Total 5 2012 rate/100,000 0.2
Clinical Features
Invasive meningococcal disease is an acute bacterial illness characterized by
meningitis and/or meningococcemia that may rapidly progress to purpura fulminans,
shock and death. Symptoms include rapid onset of fever, severe headache, stiff neck,
nausea and vomiting, and possibly a petechial rash. The case fatality rate, even with
the use of antibiotics and improved supportive measures, remains high at 8-15%. Long
term sequelae occur in 10-20% of survivors and include hearing loss, mental retardation
and the loss of the use of a limb.
Infectious Agent
Neisseria meningitidis (N. meningitidis), an aerobic gram negative diplococcus. The
most common serogroups in the United States are B, C, W-135, and Y. Licensed
vaccines are not protective against serogroup B.
Reservoir
Humans. Up to 5-10% of the population may be asymptomatic carriers.
Transmission
Transmission of N. meningitidis is person to person by direct contact with respiratory
droplets from the nose and throat of infected individuals or carriers. Less than 1% of
colonized individuals will progress to invasive disease.
Incubation
The incubation period is 2-10 days, commonly 3-4 days.
Period of Communicability
Individuals remain contagious until meningococci are no longer present in nasal or
throat secretions, usually 24 hours after antibiotic treatment has begun.
Methods of Control
Vaccination and post-exposure prophylaxis are effective in preventing invasive
meningococcal disease. Routine vaccination with the quadrivalent meningococcal
conjugate vaccine (MCV4) is recommended for all children aged 11-12 years (and
children aged 13-18 years not previously vaccinated) with a booster dose at 16 years of
age. Additionally, previously unvaccinated persons with persistent complement
component deficiency or anatomic/functional asplenia should receive two doses at
least eight weeks apart, with a booster dose every five years thereafter. MCV4 is also
recommended for persons who travel to countries in which N. meningitidis is
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hyperendemic or epidemic. Use of the meningococcal polysaccharide vaccine
(MPSV) should be limited to persons older than 55 years of age, or used when MCV4 is
not available. Both MCV4 and MPSV4 are recommended for use in the control of
meningococcal outbreaks caused by vaccine-preventable serogroups (A, C, Y and W-
135).
MSDH investigates each reported case and provides prophylactic antibiotics (rifampin)
for household contacts and other appropriate close contacts. Health care workers are
not usually at risk unless there is direct contact with nasopharyngeal secretions (mouth-
to-mouth resuscitation).
Reporting Classification
Class 1A.
Epidemiology and Trends
In 2013, there were four reported cases of invasive meningococcal disease. This was
comparable to the number of reported cases in 2012. The annual number of reported
cases has decreased over the last several years, from 24 cases in 2003, to four to five
cases per year since 2009 (Figure33). Nationally, infants less than 12 months of age have
the highest incidence of invasive disease. In the U.S., rates of disease decline in early
childhood, increase during adolescence and early adulthood, then decrease again in
older adults. The 2013 Mississippi cases ranged in age from 17 to 75 years, with a median
age of 36. From 2009 – 2013, 36% of the cases occurred in children less than five years
of age (Figure 34).
MSDH requests the submission of all isolates to the PHL for typing. Three of the confirmed
cases in 2013 were typed as serogroup Y and one case was not able to be subtyped.
There were no reported deaths in 2013.
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Figure 33
Figure 34
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Mumps
2013 Case Total 0 2013 rate/100,000 0.0
2012 Case Total 3 2012 rate/100,000 0.1
Clinical Features
Mumps is a vaccine preventable viral illness characterized by an acute onset of fever,
tenderness and swelling in one or more of the salivary glands. Parotitis is the most
common presentation, but asymptomatic infections do occur. Symptoms typically
resolve within 7-10 days. Orchitis in postpubertal males and oophoritis in postpubertal
females are the most frequent complications.
Infectious Agent
Mumps virus, in the paramyxovirus family.
Reservoir
Humans.
Transmission
Spread through airborne transmission or by direct contact with infected droplet nuclei
or saliva.
Incubation
About 16 – 18 days (range 14 – 25).
Period of Communicability
Three days before to four days after onset of symptomatic disease. Virus has been
isolated from saliva up to 7 days before and 9 days after onset of parotitis.
Methods of Control
Measles, mumps and rubella (MMR) vaccine routinely given at 12 – 15 months of age
with a second dose at 4 – 6 years. Immunization of susceptible contacts may be helpful
in prevention of infection.
Reporting Classification
Class 2.
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Epidemiology and Trends
Mumps is not common in Mississippi or in the US. There can be significant variability in
the number of cases reported in the US each year; there were 2612 cases reported in
2010 versus only 229 in 2012. In 2013, there were 584 cases reported nationally.
In Mississippi, there are typically fewer than 5 cases reported annually. In 2013, there
were no reported mumps cases, compared to three cases in 2012.
Pertussis
2013 Case Total 60 2013 rate/100,000 2.0
2012 Case Total
77
2012 rate/100,000
2.6
Clinical Features
Pertussis is an acute bacterial disease of the respiratory tract distinguished by prolonged
paroxysmal coughing with a characteristic inspiratory “whoop.” There are three clinical
stages: catarrhal stage, paroxysmal cough stage, and a convalescent stage. Post-
tussive vomiting is common in the paroxysmal stage. Infants under 6 months of age,
vaccinated children, adolescents and adults often do not have whoop or paroxysms.
Pneumonia is the most frequent complication; the majority of fatalities occur in children
under 6 months of age. Adults and adolescents may have a mild illness which often is
undiagnosed, but serve as a source of infection for unvaccinated or incompletely
vaccinated children.
Infectious Agent
Bordatella pertussis, an aerobic gram negative rod.
Reservoir
Humans. Adolescents and adults serve as reservoirs for B. pertussis and are often the
source of infection in infants.
Transmission
Direct contact with respiratory secretions by airborne route, probably via droplets.
Incubation
Average 9-10 days. (Range 6-20 days).
Period of Communicability
Most transmissible in the catarrhal stage (which lasts about 1 week) and then during the
first 2 weeks after onset of paroxysmal cough, or a total of 21 days after symptom onset.
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Communicability then gradually decreases and becomes negligible. Individuals are no
longer considered contagious after 5 days of appropriate antibiotic treatment.
Methods of Control
Vaccination and post-exposure prophylaxis are effective in preventing pertussis.
Pertussis vaccine is combined with diphtheria and tetanus toxoids (DTaP); the primary
series consists of four doses given between the ages of 2 months and 18 months, with a
booster at 4-6 years of age.
Pertussis immunity wanes 5-10 years after the booster vaccine, leaving adolescents and
adults more vulnerable to infection. ACIP recommends a single dose of Tdap (pertussis
containing vaccine for use in those >11 years of age) for all adolescents aged 11
through 18 years. Additionally, one dose of Tdap is recommended for all persons up to
age 64, and for adults 65 years of age and older who have close contact with infants
less than 12 months of age (for example, grandparents, child care providers and
healthcare workers).
MSDH investigates each reported case and provides prophylactic antibiotics
(azithromycin) for all household contacts where there is a child less than one year of
age or a pregnant woman in the last three weeks of her pregnancy in the home.
Reporting Classification
Class 1A.
Epidemiology and Trends
Among the diseases for which universal childhood vaccination is recommended,
pertussis is consistently the one that has the highest number of cases annually.
Susceptibility of unimmunized persons is universal. Infants less than 1 year of age, who
are at greatest risk for severe disease and death, continue to have the highest reported
rate of pertussis.
In 2013, there were 60 reported cases of pertussis infections. This was lower than the 77
cases which were reported in 2012 and the three year average of 77 cases from 2010-
2012 (Figure 35).
Twenty-seven (45%) of the cases in 2013 occurred among children less than 1 year of
age (Figure 36), with fifteen (56%) of these cases occurring in one- to two-month old
infants. No pertussis deaths were reported in 2013. The last reported death in Mississippi
was a two month old infant in 2012.
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Figure 35
Figure 36
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Pneumococcal disease, invasive
2013 Case Total (all ages) 239 2013 rate/100,000 8.0
2013 Case Total (under 5) 20 2013 rate/100,000 0.7
2012 Case Total (all ages) 189 2012 rate/100,000 6.3
2012 Case Total (under 5) 25 2012 rate/100,000 0.8
Clinical Features
An acute bacterial infection with two clinical invasive syndromes: septicemia and
meningitis. Septicemia is the most common clinical presentation, with a case fatality
rate as high as 60% among the elderly. Pneumococcal meningitis has a case-fatality
rate of 30%, but may be as high as 80% in elderly persons. Symptoms of meningitis
include abrupt onset of high fever, headache, lethargy, vomiting, irritability, and nuchal
rigidity. It is the leading cause of bacterial meningitis in children less than 5 years of
age. Neurologic sequelae are common among meningitis survivors.
Infectious Agent
Streptococcus pneumoniae (S. pneumoniae), a gram-positive diplococcus. Most
strains causing severe forms of disease are encapsulated; there are 90 known capsular
serotypes.
Reservoir
The nasopharynx of asymptomatic human carriers. Carriage is more common in
children than adults.
Transmission
Droplet spread and contact with respiratory secretions.
Incubation
Unknown; probably short, 1-4 days.
Period of Communicability
Period of communicability is unknown, but it is presumed that transmission can occur as
long as S. pneumoniae occurs in respiratory secretions.
Methods of Control
Conjugate and polysaccharide vaccines are available for the prevention of
pneumococcal disease. Pneumococcal conjugate vaccine is recommended for all
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children younger than two years of age, all adults 65 years or older, and persons two
through 64 years old with certain medical conditions. Pneumococcal polysaccharide
vaccine is recommended for all adults 65 years or older, persons two through 64 years
old who are at increased risk for disease due to certain medical conditions, and adults
19 through 64 years old who smoke cigarettes.
Reporting Classification
Class 2; invasive infection.
Epidemiology and Trends
In late 2010 the reporting criteria for invasive S. pneumoniae was expanded to include
all cases of invasive disease. The previous reporting criteria were limited to cases in
children less than 5 years of age and any cases that demonstrated antibacterial
resistance regardless of age. In 2013 there were a total of 239 reported cases of
invasive S. pneumoniae infections. The reported cases ranged in age from one month
to 96 years of age, with a median age of 60 years.
Twenty of the reported cases were in children less than 5 years of age; about the same
as the 25 cases reported in 2012. Of these 20 cases, 18 had septicemia and two had
meninigitis. Ages ranged from one month to four years of age. Over the past five years,
the majority (78%) of S. pneumoniae invasive infections in children less than 5 years of
age have presented as septicemia (Figure 37).
Figure 37
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Rabies
Clinical Features
Rabies is an acute fatally progressive disease that affects the central nervous system.
Early signs include anxiety, discomfort or paresthesia at the site of the bite of an
infected animal, primarily raccoons and bats in the U.S. Progression to symptoms of
cerebral dysfunction such as confusion, agitation, delirium, hallucinations, and insomnia
occurs within a few days of symptom onset. This is followed by generalized paralysis,
coma and death within 2 to 10 days.
Infectious Agent
Lyssavirus, family Rhabdoviridae; an RNA virus. Variants occur among animal species
and geographic location, but all of the members of the genus are antigenically
related.
Reservoir
Rabies has both an urban and a wild cycle. The urban cycle (maintained by rabid
dogs) has been reduced greatly in the U.S., but carnivores (primarily raccoons, wild
canids, and skunks) and several species of insectivorous bats maintain the wild cycle in
areas of the U.S. The only reservoir identified in Mississippi over the last several decades
is bats.
Transmission
The most common mode of rabies virus transmission is through the bite of an infected
host. All mammals are susceptible to varying degrees, but not all mammals efficiently
transmit infection. Since the 1990’s virtually 100% of human rabies cases in the US have
been due to exposure to infected bats. Transmission has also been documented
through organ transplantation, specifically corneal transplants, from a donor dying of
undiagnosed rabies.
Incubation
The incubation period can be up to six months or longer. The incubation period is longer
the farther away the bite is from the CNS.
Period of Communicability
Rabies is transmissible once it reaches the CNS and can be found in the salivary glands.
The animal is usually exhibiting abnormal behavior and other clinical signs by this time.
Methods of Control
The best method of control is prevention. Domestic animal rabies vaccination
programs, as well as pre- and post-exposure rabies vaccination in humans have
significantly decreased the human risk and deaths from rabies in the United States.
People who are bitten by animals that are known reservoirs of rabies exhibiting
abnormal behavior, such as unprovoked aggressiveness, increased drooling or paralysis
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should be considered at higher risk, and consideration should be given to the use of
post-exposure vaccination.
Recommendations for preventing and controlling rabies in animals can be found in the
Compendium of Animal Rabies Prevention and Control, at
http://avmajournals.avma.org/doi/pdf/10.2460/javma.248.5.505
Rabies can be prevented with the initiation of appropriate medical intervention
following high risk animal exposures (primarily bats in Mississippi, but wild animal species
such as raccoons, skunks, coyotes and foxes should also be considered higher risk
exposures). Prompt wound care and post-exposure prophylaxis consisting of rabies
immune globulin (RIG) and rabies vaccine are highly effective in preventing rabies
following high risk animal exposures. Recommendations for prevention of rabies in
humans can be found in the document by the Advisory Committee on Immunization
Practices (ACIP) entitled Human Rabies Prevention—United States, 2008, at
http://www.cdc.gov/mmwr/pdf/rr/rr57e507.pdf
. Updated vaccine dosing
recommendations are available at http://www.cdc.gov/mmwr/PDF/rr/rr5902.pdf .
Reporting Classification
Class 1A (human or animal).
Epidemiology and Trends
In the U.S. in the 1940s and 1950s, canines were the predominant reservoir and cause of
human rabies. By 2006, however, approximately 92% of animal rabies cases were in
wildlife, and only 8% were in domestic animals. This change is attributed to concerted,
targeted rabies vaccination campaigns and stray animal control that have reduced
the number of canine rabies cases from 6,947 in 1947 to 79 in 2006. Currently, most
human cases in the United States are caused by bat strains of rabies. In the U.S., bats
are now the second most reported rabid animal behind raccoons.
As of 2013, there has not been an indigenous terrestrial animal (land) rabies case
reported in Mississippi since 1961, however, rabid raccoons, skunks and foxes are
routinely identified in states contiguous to Mississippi. Mississippi reported a human case
of rabies due to a bat strain in a 10 year old boy in 2005. Prior to this 2005 human case,
the last reported human rabies case in Mississippi was in 1953 and this was transmitted
by a terrestrial animal.
The MSDH PHL is the only laboratory in Mississippi that tests for rabies in animals. Since
1962, bats are the only animals that have tested positive for rabies in Mississippi. Usually,
several bats test positive each year. There were five positive bats out of 70 tested in the
PHL in 2013. The positive bats were submitted from Grenada, Lowndes, Oktibbeha,
Rankin and Yazoo counties. In the past ten years, there has been a wide geographic
distribution of positive bats, with 47 reported positives in 22 counties (Figure 38).
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Figure 38
Rabies in Bats by County, Mississippi, 2004-2013
Rocky Mountain spotted fever
2013 Case Total 39 2013 rate/100,000 1.3
2012 Case Total 25 2012 rate/100,000 0.8
Clinical Features
Rocky Mountain spotted fever (RMSF) is a tickborne rickettsial illness with an acute onset
of fever, severe headache, malaise, myalgia, nausea, vomiting, and may include a
macular or maculopapular rash on the extremities, including the palms and soles, which
usually spreads over the entire body. A petechial rash often follows. Prompt recognition
and treatment are paramount; if RMSF is suspected based on clinical presentation
and/or a history of tick exposure, treatment with appropriate antibiotics (doxycycline)
should not be delayed for laboratory confirmation. Doxycycline is the treatment of
choice for any age. In untreated cases the case fatality is between 20 to 80%. Risk
factors associated with severe disease and death include delayed treatment and age
over 40. Early stages of RMSF are often confused with ehrlichiosis and
meningococcemia.
County with at least one
positive bat
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Infectious Agent
Rickettsia rickettsii, a gram-negative coccobacillus.
Reservoir
Small rodents (chipmunks, squirrels, white-footed mice).
Transmission
Through the bite of an infected Dermacentor variabilis tick (American dog tick). A 4-6
hour attachment is required for transmission.
Incubation
3-14 days (most occurring between 5-7 days).
Period of Communicability
No evidence of person to person transmission.
Methods of Control
Avoid tick infested areas when possible. When unavoidable, use tick repellant and
measures to decrease tick exposure. After leaving tick prone areas, examine body well
and remove any ticks; removing the embedded head of the tick is not necessary.
Reporting Classification
Class 2.
Epidemiology and Trends
In 2013, there were 39 cases of RMSF reported in Mississippi. This is higher than both the
three year (2010-2012) average of 25 cases (Figure 39) and the number of reported
cases in 2012 (25). The cases ranged in age from 5 to 80 years, with a median age of 51
years.
There were no reported deaths due to RMSF in Mississippi in 2013.
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Figure 39
Both in Mississippi and the U.S., the majority of Rocky Mountain spotted fever cases
occurred between April and September. In Mississippi over the past five years, 83% of
the reported cases have occurred during this time frame (Figure 40).
Figure 40
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Rubella
2013 Case Total 0 2013 rate/100,000 0.0
2012 Case Total 0 2012 rate/100,000 0.0
Clinical Features
A mild, febrile viral disease characterized by a 3 day maculopapular rash. Children
often have few signs or symptoms other than the rash. The rash, typically fainter than a
measles rash, appears on the face initially and progresses distally. Adults may have a
febrile prodrome and lymphadenopathy. Up to 50% of all rubella infections are
subclinical or asymptomatic. Complications occur most often in adults and include
arthritis and encephalitis. Infection during pregnancy, especially in the first trimester,
may result in congenital rubella syndrome (CRS), causing fetal death, prematurity or
birth defects.
Infectious Agent
Rubella virus is classified as a togavirus, genus Rubivirus.
Reservoir
Humans.
Transmission
Direct contact with nasopharyngeal secretions of infected persons or by droplet
spread. Rubella is moderately contagious. Maternal-fetal transmission causes CRS.
Incubation
Usually 14 days, with a range of 12-23 days.
Period of Communicability
The period of communicability is about 1 week before and up to 5-7 days after onset of
the rash. Infants with congenital rubella syndrome may shed the virus for months after
birth.
Methods of Control
Vaccination is the most effective method in preventing rubella. Rubella vaccine is
available combined with measles and mumps vaccines as MMR. The first dose of MMR
is recommended at 12-15 months, followed by a second dose at 4-6 years. All
susceptible adolescents and adults, especially women of child bearing age, should be
vaccinated with MMR vaccine.
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Reporting Classification
Class 2.
Epidemiology and Trends
In the last major rubella epidemic in the United States, during 1964–1965, an estimated
12.5 million rubella virus infections resulted in 11,250 therapeutic or spontaneous
abortions, 2,100 neonatal deaths, and 20,000 infants born with CRS. In 2004, after
implementation of a universal vaccination program, elimination of endemic rubella
virus transmission was documented in the United States. However, rubella virus
continues to circulate elsewhere in the world, especially in regions where rubella
vaccination programs have not been established (e.g., the African Region), placing
the United States at risk for imported cases of rubella and CRS.
During 2004–2012, 79 cases of rubella and six cases of CRS were reported in the United
States (see the CDC MMWR referenced below which highlights CRS in three states).In
2013, there were 9 cases of rubella and 1 case of CRS in the US. There were no reported
cases of rubella in Mississippi in 2013. The last reported case in the state was in a 4 year
old in 1986.
• CDC. Three cases of congenital rubella syndrome in the post elimination era-
Maryland, Alabama, Illinois, 2012.MMWR. March 29, 2013/62(12); 226-229.
Salmonellosis
2013 Case Total 919 2013 rate/100,000 30.7
2012 Case Total 1248 2012 rate/100,000 41.8
Clinical Features
Salmonellosis is a bacterial disease that commonly presents as acute enterocolitis, with
sudden onset of headache, abdominal pain, diarrhea, nausea and sometimes
vomiting. Fever is almost always present. Dehydration may occur in infants and the
elderly, and septicemia occasionally results from infection.
Infectious Agent
Salmonella organisms are gram negative bacilli. The genus Salmonella is divided into
two species: S. enterica (divided into six subspecies) and S. bongori. Subspecies are
further divided into multiple serotypes. Almost all of the serotypes pathogenic for
humans are in one subspecies of S. enterica. Currently, there are more than 2460
identified Salmonella serotypes. The predominant isolates in Mississippi are Salmonella
serotypes Javiana, Mississippi, Newport and Typhimurium.
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Reservoir
Domestic and wild animals, including poultry, swine, cattle, and rodents, and many
reptiles. Humans are also reservoirs, especially in mild and unrecognized cases.
Chronic carriers are prevalent in animals and birds.
Transmission
Salmonella is transmitted through ingestion of organisms in food derived from infected
animals or food or water contaminated by feces from an infected animal. Person to
person transmission by fecal oral route also occurs. Although S. serotype Enteritidis is not
commonly seen in Mississippi, this serotype can be passed trans-ovarially from infected
hens to their eggs and transmission can then occur when eggs are not fully cooked.
Incubation
From 6 to 72 hours, usually about 12-36 hours.
Period of Communicability
Throughout the course of infection; extremely variable, several days to several weeks.
A temporary carrier state occasionally continues for months, especially in infants.
Methods of Control
Transmission of Salmonella can be controlled with proper food preparation and sanitary
measures for food processing, proper hand hygiene, and clean water supplies. MSDH
investigates all possible common source food or waterborne outbreaks. The Public
Health Laboratory (PHL) requests isolate submission for molecular subtyping with pulsed-
field gel electrophoresis (PFGE). The DNA pattern, or “fingerprint”, is submitted to
PulseNet, a national tracking network coordinated by the CDC. This system facilitates
early detection of common source outbreaks, even if the affected persons are
geographically far apart, often allowing the source to be more rapidly identified.
Reporting Classification
Class 3.
Epidemiology and Trends
In Mississippi, 919 cases of salmonellosis were reported to MSDH in 2013 (Figure 41). Five
Salmonella serotypes accounted for 77% of the total serotyped isolates seen in
Mississippi: Mississippi (18%), Typhimurium (17%), Newport (16%), Javiana (15%), and
Enteritidis (11%).
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Figure 41
Infections occur in people of all ages, but there is higher incidence in infants and small
children. In 2013, 381 (42%) of the cases were in children less than 5 years of age (Figure
42) in which age was known.
Figure 42
In 2013, eight multistate outbreaks were reported through the CDC PulseNet system,
three of which affected Mississippi. In March 2013, two cases of Salmonella were
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reported in Mississippi that were associated with a May 2012 outbreak of Salmonella
Sandiego, Salmonella Pomona, and Salmonella Poona. This outbreak had a total of
473 cases from 43 states, with a total of four cases in Mississippi residents. This outbreak
was caused by exposure to turtles or their environments (e.g., water from a turtle
habitat). In April 2013, two outbreaks were reported that were both caused by contact
with live baby poultry. The first outbreak involved 356 cases from 39 states, including six
cases in Mississippi. It was caused by Salmonella Typhimurium. The second outbreak of
Salmonella Infantis, Salmonella Lille, Salmonella Newport, and Salmonella Mbandaka
involved 158 cases across 30 states. Both cases reported in Mississippi were Salmonella
Infantis.
Shigellosis
2013 Case Total 226 2013 rate/100,000 7.6
2012 Case Total
285 2012 rate/100,000 9.5
Clinical Features
Shigellosis is an acute bacterial illness characterized by loose, often bloody stools
(dysentery), fever, nausea and vomiting, abdominal cramping and tenesmus.
Asymptomatic infections do occur. The illness is usually self-limited, lasting an average
of 4-7 days; however infection with Shigella dysenteriae (S. dysenteriae) can lead to a
severe illness with a case fatality rate of 20% among hospitalized patients. All age
groups are susceptible, with the peak incidence in 1-4 year olds. Children in daycares,
persons in institutions, and in facilities where adequate hand washing is difficult to
maintain are at high risk for outbreaks of shigellosis.
Infectious Agent
Genus Shigella, a gram negative bacterium comprising four serogroups: Group A, S.
dysenteriae; Group B, S. flexneri; Group C, S. boydii; and Group D, S. sonnei. In
Mississippi, Group D, S. sonnei are the predominant isolates.
Reservoir
Humans are the primary reservoir.
Transmission
Primarily person to person by direct or indirect fecal oral contact. Infection may also
occur after ingestion of contaminated food or water. Shigella is highly infectious with
an infective dose as low as 100-200 organisms.
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Incubation
Ranges from 12 hours to 7 days, with an average of 2-4 days.
Period of Communicability
Until the agent is no longer present in feces. This is usually 4 weeks after cessation of
symptoms, but asymptomatic carriers may transmit infection for months or longer.
Methods of Control
Disease prevention includes promotion of good hand washing, exclusion from work for
food handlers or from school or daycare for children until symptom free for at least 24
hours. MSDH performs prompt investigation of common source food or waterborne
outbreaks, and investigates all reported infections in children less than 5 years of age.
Reporting Classification
Class 3.
Epidemiology and Trends
There were 226 cases of Shigellosis reported to MSDH during 2013 (Figure 43). There is
variability in the number of yearly reported cases, with a peak of 1,426 cases in 2007
associated with a large outbreak that occurred in the Jackson metropolitan area and
along the Gulf Coast. Although Shigellosis is usually a summer month illness, over half
(59%) of the 2013 cases occurred between August and December (Figure 44).
Figure 43
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Figure 44
Shigella typically impacts children disproportionately. In 2013, the reported cases
ranged in age from 1 month to 92 years, with 62% occurring in children less than 10
years of age (Figure 45).
Figure 45
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Syphilis
Primary and Secondary Syphilis
2013 Case Total 78 2013 rate/100,000 2.6
2012 Case Total
155
2012 rate/100,000
5.2
Early Latent Syphilis
2013 Case Total 185 2013 rate/100,000 6.2
2012 Case Total 259 2012 rate/100,000 8.7
Clinical Features
Syphilis is a bacterial infection that has three stages: primary, secondary, and tertiary.
The primary lesion (chancre) is a painless indurated ulcer that develops at the sight of
initial infection, usually on the external genitalia. Even without treatment, the primary
lesion resolves in 4-6 weeks. Secondary syphilis may then develop and is characterized
by a generalized symmetrical maculopapular rash that often involves the soles and
palms. It may be accompanied by generalized lymphadenopathy, fever, malaise, sore
throat, headache and arthalgia. Clinical manifestations of secondary syphilis usually
resolve without treatment in weeks to months. Tertiary syphilis will develop years later in
15-40% if untreated, primarily as cardiovascular or neurosyphilis, or as skin, bone, visceral
or mucosal surface gummas. Latent syphilis, a period of seroreactivity without clinical
disease, is classified as early (infection acquired within the preceding year) or late
(infection of more than a year’s duration).
Fetal transmission occurs through the placenta in untreated women with early syphilis,
resulting in congenital syphilis. Congenital syphilis can lead to abortions, stillbirths or
death shortly after birth. An infected infant may be asymptomatic for the first few
weeks of life; however, late manifestations may occur resulting in CNS involvement or
other conditions such as Hutchinson teeth, saddlenose, periostitis, interstitial keratitis or
deafness.
Infectious Agent
Treponema pallidum, a spirochete.
Reservoir
Humans.
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Transmission
Syphilis is transmitted primarily by sexual contact with an infected individual with early
syphilis (the first year of infection), especially during primary and secondary syphilis.
Transplacental infection of the fetus occurs during the pregnancy of an infected
woman, resulting in congenital syphilis. Transmission can also occur from a blood
transfusion if the donor is in the early stages of infection.
Incubation
The average incubation period for syphilis before clinical manifestations is 3 weeks but
ranges from 3 – 90 days.
Period of Communicability
In untreated individuals, communicability can last for up to two years. Syphilis is most
communicable during the primary and secondary stages. Maternal-fetal transmission is
more likely in early syphilis, but may occur at any stage.
Methods of Control
Mechanical barriers, early detection, and effective treatment of the patient and their
partners are effective methods in prevention and control of syphilis. MSDH performs
contact investigation and treatment for each reported case of syphilis.
Reporting Classification
Class 1B.
Epidemiology and Trends
Although Mississippi saw a nearly five-fold increase in primary and secondary (P&S)
syphilis cases from 2005-2010 (from 51 to 226 cases), there was a 65% decrease from
2010 to 2013 (from 226 to 78 cases) (Figure 46). In 2013, for the first time since 2006, the
rate of P&S syphilis cases in Mississippi was lower than the national average. In 2013, MS
ranked thirty-seventh nationally.
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Figure 46
District V had the highest incidence of P&S syphilis (Figure 47). Fifty-one percent of P&S
syphilis cases occurred among 20-29 year olds (Figure 48 ) and 96% of cases in which
race was known were among African Americans (Figure 49 ). In 2013, the rate of P& S
syphilis infections for African Americans (6.5 per 100,000) was fifty-nine times the rate of
whites (0.11 per 100,000).
Figure 47
Primary and Secondary Syphilis Incidence by Public Health District, Mississippi,
2013
District
Cases
Rate*
I
10
3.1
II
2
0.5
III
3
1.4
IV
9
3.7
V
32
5.0
VI
3
1.2
VII
4
2.3
VIII
6
1.9
IX
9
1.9
Statewide
78
2.6
*per 100,000 population
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Figure 48
Figure 49
Over the past ten years, Mississippi has had rates higher than national average for early
latent syphilis (acquired within the previous 12 months). Since 2010, there has been a
52% decrease in the number of cases (from 384 to 185 cases) (Figure 50).
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Figure 50
Early latent syphilis was reported in every district. District V had the highest case rates in
the state (Figure 51).
Figure 51
Nearly half (48%) of reported cases were among 20-29 year olds (Figure 52). African
Americans are disproportionately affected, accounting for 83% of cases for which race
Early Latent Syphilis Incidence by Public Health District, Mississippi, 2013
District
Cases
Rate*
I
23
7.1
II
30
8.1
III
14
6.6
IV
7
2.8
V
66
10.3
VI
8
3.3
VII
7
4.1
VIII
11
3.6
IX
19
4.0
Statewide
185
6.2
*per 100,000 population
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was known (Figure 53) and had rates that were almost nine times greater than the rate
among whites.
Figure 52
Figure 53
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Tuberculosis
2013 Case Total 65 2013 rate/100,000 2.2
2012 Case Total 81 2012 rate/100,000 2.7
Clinical Features
Pulmonary tuberculosis (TB) is the most common form of active TB disease; but, disease
can also be extrapulmonary and involve many organ systems. Symptoms are
dependent on the site of infection. Pulmonary TB generally presents with cough (dry
and later productive), pleuritic chest pains, hemoptysis, shortness of breath, fever,
malaise, weakness, night sweats, and anorexia and weight loss. Individuals with
Tuberculosis infection without disease (TBI) are asymptomatic and non-infectious.
Infectious Agent
Mycobacterium tuberculosis complex, an acid-fast bacillus
Reservoir
Primarily humans, rarely primates; in some areas, diseased cattle, badgers, swine and
other mammals are infected.
Transmission
Exposure to tubercle bacilli in airborne droplet nuclei, 1 to 5 microns in diameter. The risk
of infection with the tubercle bacillus is directly related to the degree of exposure.
Incubation
TB interferon gamma release assay (IGRA) or TB skin test conversion, indicating TBI,
occur 2-10 weeks after exposure to active TB disease, if infected. Ten percent of
persons with TBI will develop active disease, with the first 12-24 months after infection
constituting the most hazardous period. HIV infection increases the risk and shortens the
interval for development of active disease following infection with TB. In children, those
under 5 years of age have the highest risk of developing disease. Smokers, diabetics,
persons taking immunosuppressive drugs or TnF inhibitors, and persons with certain other
chronic diseases have a higher risk of progression to active TB disease.
Period of Communicability
The degree of communicability depends on the number of bacilli discharged, virulence
of the bacilli, adequacy of ventilation, exposure of bacilli to sun or UV light, and
opportunities for aerosolization. Antimicrobial chemotherapy usually eliminates
communicability within 2-4 weeks. Young children with primary tuberculosis are
generally not infectious. TBI is not infectious.
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Methods of Control
Prompt identification, diagnosis, follow-up, and treatment of potentially infectious
patients with TB disease are necessary to interrupt continued transmission. MSDH
performs contact investigations, targeted TB testing in high risk areas, and provides
treatment for all active TB disease and TB infections.
Reporting Classification
Class 1A; Tuberculosis
Class 2; M. tuberculosis infection (positive TST or Interferon-Gamma Release Assay)
Epidemiology and Trends
Since 2007 there has again been a gradual decline in active TB cases reported in
Mississippi, with only 65 cases in 2013. Since 2011, the Mississippi case rate has been
below the US case rate (Figure 54).
Figure 54
Geographically, TB was reported in every public health district, with the highest
incidence noted in Public Health Districts III, V and VII (Figure 55).
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Tuberculosis Incidence by Public Health District, Mississippi, 2013
Figure 55
Disease occurred across all age groups, with 75% of cases (49/65) occurring in
individuals ≥45 years (Figure 56).
Figure 56
The number of cases in all racial groups has steadily decreased over the last several
years, though the African American population is disproportionately affected. While the
total number of cases has been declining in the last several years, disease in the African
District
Cases
Rate*
I
7
2.2
II
6
1.6
III
7
3.5
IV
1
0.4
V
22
3.4
VI
1
0.4
VII
6
3.5
VIII
4
1.3
IX
11
2.5
Statewide
65
2.2
*per 100,000 population
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American population still routinely accounts for approximately 60% of the yearly
reported cases. In 2013, 57% (37/65) of the cases were in this group (Figure 57).
Figure 57
Following a peak in 2009, the percentage of TB cases among patients co-infected with
HIV showed moderate decreases from 2010 through 2012. However, in 2013, this
percentage rose to 12.3%, which is nearly twice the percentage of TB patients co-
infected in 2012 (6.2%), but less than 2009 (14.9%) (Figure 58).
Figure 58
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Varicella
2013 Case Total 5 2013 rate/100,000 0.2
2012 Case Total 11 2012 rate/100,000 0.4
Clinical Features
An acute viral disease with primary infection (chickenpox) characterized by a
generalized pruritic rash that progresses rapidly from macules to papules to vesicular
lesions before crusting. The rash will be seen in various stages of development at any
given time, usually appearing first on the head and more highly concentrated on the
trunk rather than extremities. Adults may have 1-2 days of fever and discomfort prior to
rash onset, but the rash is frequently the first sign of disease in children. Adults may have
more severe disease and have a higher incidence of complications (secondary
bacterial infections, pneumonia, aseptic meningitis and encephalitis). Herpes zoster is a
localized manifestation of latent varicella infection, with incidence increasing with age.
Lesions usually follow unilateral dermatomal patterns, but can be widespread or
disseminated. Postherpetic neuralgia occurs in up to 15% of zoster patients.
Infectious Agent
Varicella zoster virus, a member of the herpes virus group.
Reservoir
Humans.
Transmission
Person to person transmission by airborne droplet or direct contact with the lesions.
Indirect spread can occur through contact with articles freshly soiled by vesicular or
respiratory secretions. Maternal-fetal transmission also occurs. Susceptible contacts to
localized herpes zoster may develop chickenpox by direct contact with fluid from the
lesions, but respiratory transmission can occur in disseminated zoster.
Incubation
The incubation period is 14-16 days with a range of 10-21 days.
Period of Communicability
The period of communicability can be up to 5 days before onset of the rash (usually 2
days) and continues until all lesions are crusted (about 5 days).
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Methods of Control
The live attenuated varicella vaccine is effective in preventing chickenpox. Routine
vaccination is recommended at 12 months with a second dose at 4-6 years of age.
Two doses of vaccine are also recommended for all susceptible healthcare personnel.
In 2006, FDA approved herpes zoster vaccine for persons 60 years of age and older.
Clinical trials indicate the vaccine reduces the overall incidence of shingles by 51% in
adults ≥60 years (64% for adults 60-69 years and 38% for adults ≥70 years) and reduces
the incidence of postherpetic neuralgia by 67%.
MSDH investigates outbreaks of varicella, and vaccine is recommended after exposure
if there is no evidence of prior disease or vaccination. The vaccine is 70% - 100%
effective in preventing or attenuating disease if given within 72 hours of exposure.
Reporting Classification
Class 1B; varicella infection, primary, in patients >15 years of age.
Epidemiology and Trends
In 2013, there were five reported cases of varicella infection in patients >15 years of
age. The cases ranged in age from 16 to 61 years, with a median age of 28 years. No
deaths were reported in 2013. The three year average from 2010 to 2012 was 11 cases
of varicella per year. There were no reported outbreaks in 2013.
Vibrio disease
2013 Case Total 11 2013 rate/100,000 0.4
2012 Case Total 16 2012 rate/100,000 0.5
Clinical Features
There are several noncholera Vibrio species that can cause clinical illness in humans,
primarily through wound infections, septicemia or gastroenteritis. Vibrio vulnificus and
Vibrio parahaemolyticus are the two most frequently reported species leading to
human infections in Mississippi.
V. vulnificus infection leads to the rapid development of sepsis 12 hours to 3 days after
ingestion of contaminated seafood, usually raw oysters, or after exposure of a wound to
coastal waters where Vibrio bacteria thrive. Individuals with chronic liver disease,
alcoholism, or immunosuppression are at high risk for sepsis and death. V. vulnificus
sepsis is characterized by the rapid onset of fever, chills, blistering skin lesions, shock and
death. The case fatality rate is over 50% when septicemia occurs.
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V. parahaemolyticus infection typically causes gastroenteritis accompanied by watery
diarrhea with abdominal cramps, nausea, vomiting and fever, and less commonly,
wound infections. Infections with V. parahaemolyticus can also lead to sepsis and
death.
Infectious Agent
Anaerobic, gram-negative halophilic (salt requiring) bacteria found naturally in marine
and estuarine environments. V. vulnificus and V.parahaemolyticus are the two most
frequently reported species in Mississippi. Other species common to Mississippi are V.
mimicus, Grimontia hollisae (formerly V. hollisae), and V. fluvialis. Nontoxigenic Vibrio
cholerae serogroups (non-O1/non-O139) are also reported as non-cholera Vibrio
infections.
Reservoir
Found free living in warm coastal waters and in fish and shellfish, particularly oysters.
Transmission
Ingestion of the organisms in raw, undercooked, or contaminated fish and shellfish, or
any food or water contaminated with raw seafood. Wound infections with V. vulnificus
occur when wounds are exposed to estuarine waters.
Incubation
Median incubation period of 23 hours, with a range of 5-92 hours.
Period of Communicability
Not typically transmitted person to person.
Methods of Control
Seafood should be cooked adequately. Wounds exposed to seawater (either
occupational or accidental) should be rinsed with clean fresh water. All children and
immunocompromised individuals, especially alcoholics or individuals with liver disease,
should avoid eating raw seafood, especially oysters, and should avoid seawater
exposure to wounds. MSDH investigates all reported cases to determine the source of
infection and possible risk factors of the case.
Reporting Classification
Class 1B.
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Epidemiology and Trends
In 2013, there were eleven reported Vibrio infections. While lower than the reported
number of cases in 2012 (16), the number of reported cases in 2013 is comparable to
the three year average of 12 cases for 2010 – 2012 (Figure 59).
Figure 59
Of the eleven reported cases, four were due to V. vulnificus (all isolated from blood
cultures); three were due to non-O1, non-139 V. cholerae (two isolated from stool
cultures and one isolated from a wound culture); two were due to V. mimcus (both
isolated from stool cultures); one was due to G. hollisae (isolated from a stool culture);
and one was due to V. fluvialis (isolated from a stool culture) (Figure 60). There was one
reported death in 2012 due to V. vulnificus. The death occurred in an individual over
the age of 50 who had a history of alcoholism, and presented as septicemia.
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Figure 60
Over the past five years there have been a total of 59 cases of non-cholera Vibrio
infections reported in Mississippi. V. vulnificus (25) and V. parahaemolyticus (13) have
accounted for 64% of the total reported cases, followed by nontoxigenic V. cholerae
(10), V. mimicus (5), other Vibrio spp (5), and an unknown Vibrio spp (1) (Figure 61).
Figure 61
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From 2009 through 2013, 63% of the reported Vibrio cases occurred between May and
August (Figure 62).
Figure 62
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Special Reports
This section of the Annual Summary of Selected Reportable Diseases provides reports on
selected events of public health significance, including significant outbreak
investigations conducted by MSDH in 2013.
Enhanced Surveillance of Adult Influenza Mortality, 2013-2014 Influenza Season
Introduction: In December 2013, during the 2013-2014 influenza season, the Mississippi
State Department of Health (MSDH) began receiving reports of serious complications
associated with influenza infection, including deaths. It was recognized that the most
affected individuals were persons <65 years of age with underlying medical conditions;
a younger age cohort than expected for complications and deaths due to influenza.
The predominant subtype of influenza causing illness in Mississippi was the 2009 influenza
A H1N1, the influenza virus that led to the 2009 pandemic and known to lead to higher
complications and deaths in people younger than 65 years of age. As the season
progressed, the number, frequency and geographic range of the reports of deaths in
younger adults increased. Additional reports indicated some facilities had decreased
ICU bed capacity as a result of the severity of illness in younger individuals.
While influenza associated pediatric deaths (death in a child <18 years of age) are
reportable in Mississippi, there was no established surveillance system for confirmed
influenza associated deaths in adults. In order to better characterize the influenza
deaths in adults (≥18 years of age), and to provide guidance on risk factors and
treatment, MSDH developed an enhanced surveillance system to identify influenza
deaths in hospitalized adults.
Enhanced Surveillance: The enhanced surveillance extended from December 1, 2013
through February 24, 2014. A case definition and standardized worksheet were
developed for hospital staff to provide weekly updates of influenza associated deaths
among hospitalized adults. A case report was developed to capture complete
demographic information, influenza vaccination status, influenza laboratory results,
onset date/date of death, underlying co-morbidities and the use of antivirals
(oseltamavir and zanamavir) for each of the confirmed influenza associated deaths in
adults. Eighty-three percent (74/89) of the targeted hospitals participated in the
enhanced surveillance efforts.
Case Definition: For the purposes of the enhanced surveillance the following case
definition for influenza-associated mortality in adults (≥18 years of age) was used:
Death in a hospitalized adult resulting from a clinically compatible illness that is
laboratory confirmed (either rapid influenza diagnostic test, RT-PCR or other diagnostic
method) as influenza.
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Findings: At the close of the enhanced surveillance, 27 influenza associated deaths in
adults were reported by the participating hospitals. The dates of reported deaths
ranged from early December 2013 to early February 2014. The median age for the
deaths was 54 years (age range 19 to 80 years), much younger than the age groups
typically affected per national data. In those in whom vaccine status was known, 69%
had not been vaccinated against influenza.
A number of underlying medical conditions placing individuals at high risk for
complications from influenza infection were identified. The most frequently reported
condition was heart disease, noted in 48% of the deaths, followed by obesity in 41%
(BMI ≥30); metabolic disorders (30%), lung disease (30%) and diabetes (19%), among
other reported conditions (Figure 63).
Figure 63
Seventy-four percent of the reported deaths were treated with antivirals during the
course of their illness; however delays in starting antiviral treatment were noted. There
was an average of seven days between the onset of illness and the start date of
antivirals overall; the length of time lowered slightly to an average of five days when
calculated from hospital admission date to start date of antivirals.
Opportunities: The surveillance system highlights two areas that can potentially impact
the severity of illness due to influenza: influenza vaccination among persons <65 years,
especially with underlying health problems, and earlier use of antivirals in high risk
persons.
4%
4%
19%
30%
48%
26%
30%
11%
41%
4%
22%
0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00%
No known condition
Asthma
Diabetes
Metabolic disorder
Cardiovascular disease
Immunosuppression
Chronic lung disease
Neurological/Neurodevelopmental conditions
Obesity
Pregnancy
Renal Disease
Percentage
Medical Condition
Reported Influenza Deaths with Selected Underlying Medical
Conditions, Mississippi 2013-2014 Season*
*More than one medical condition may be present per patient
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Fewer than half of all adults in the US aged 18–64 are vaccinated each season despite
a recommendation for universal influenza vaccination for persons aged ≥6 months. In
the US during the 2013-2014 season, only 36.7% of this age group were vaccinated; by
comparison 58.9% of children aged 6 months to 17 years, and 65% of adults aged 65
years and older were vaccinated. Rates of hospitalization for adults aged 18-64 were
significantly higher than in previous seasons, with persons in this age group accounting
for 57% of all influenza- associated hospitalizations in the US, compared to 35-40% in
previous seasons.
Early antiviral treatment can reduce the risk of complications from influenza (e.g.,
pneumonia, respiratory failure, and death). When indicated, antiviral treatment should
be started as soon as possible after the onset of symptoms, ideally within 48 hours.
However, antiviral treatment after 48 hours may have some benefit to patients with who
are: hospitalized; have severe, complicated, or progressive illness; or are at higher risk
for influenza complications due to age, a history of underlying chronic medical
conditions or pregnancy. The initiation of treatment should not be delayed for
laboratory confirmation.
Haff Disease Identified in Three Mississippi Residents, July 2013
On the morning of July 3, 2013 two family members, a 56 year old female (patient A)
and her 26 year old nephew (patient B), presented to a central Mississippi Emergency
Department complaining of an acute onset of severe myalgia. Physical examinations
of the two were unremarkable but both had markedly elevated creatine
phosphokinase (CPK), 1390 U/L and 1189 U/L respectively. During the evaluation of
patients A and B, a third family member (patient C-the 57 year old husband of patient
A) developed similar symptoms with an elevated CPK of 494. All three were admitted
for additional evaluation and intravenous fluid replacement. In the course of the
hospitalizations patient A had a peak CPK of 9038, patient B 25,681 and patient C 992.
Elevated aspartate aminotransaminase (AST) and alanine aminotransaminase (ALT)
were also observed for patients A (AST 95 and ALT 61) and B (AST 582 and ALT 169). All
three were discharged after brief hospitalizations with the complete resolution of
symptoms and laboratory abnormalities.
The astute provider at the hospital diagnosed the three family members with Haff
disease rhabdomyolysis after obtaining a history of consumption of pan-fried buffalo fish
the evening prior to hospitalization. Haff Disease is a rare illness characterized by
rhabdomyolysis after the consumption of certain types of freshwater fish. The disease,
primarily associated with the consumption of buffalo fish, is caused by an as yet
unidentified toxin contained in the fish. Buffalo fish are a bottom feeding species found
in the Mississippi River and its tributaries.
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The first cases of Haff disease were identified in the Baltic Sea area in 1924 and since
that time have occurred both sporadically and in large seasonal outbreaks in Europe.
There have been approximately 30 cases reported in the US with the first reported in
1984. Most instances of reported Haff disease in the US since 2004 have been limited to
isolated cases or clusters of 2-3 cases. Nearly all US cases have been associated with
buffalo fish consumption and most occur in the summer months.
Haff disease presents with a rapid onset of symptoms within 12 hours after eating fish.
Initial symptoms may be nonspecific and include myalgia and muscle stiffness, chest
pain and painful breathing and nausea or vomiting. Over the course of the next several
hours, severe muscle weakness, dark urine and rhabdomyolysis may develop. The most
profound clinical feature is an elevation of CPK which has been reported as 10-1500
times normal. Liver function tests including serum transaminase levels are often
elevated. Complications have included renal failure and disseminated intra-vascular
coagulation. Treatment is supportive with intravenous fluid hydration to prevent
myoglobin toxicity to the renal tubules. Symptoms usually resolve within two to three
days. The case fatality rate has been reported as approximately 1.0%; no deaths have
been reported in the US.
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Reportable Disease Statistics
Mississippi Reportable Disease Statistics
2013
Public Health District
I
II
III
IV
V
VI
VII
VIII
IX
State Total*
Sexually Transmitted
Diseases
Primary & Secondary Syphilis
10
2
3
9
32
3
4
6
9
78
Early Latent Syphilis
23 30 14 7 66 8 7 11 19 185
Gonorrhea
498 380 573 436 1,523 403 229 480 568 5,090
Chlamydia
1,999
1,606
2,256 1,472
4,021 1,592
947 1,480 1,982
17,355
HIV Disease
57 41 51 27 197 35 29 57 62 556
Myco-
bacterial
Diseases
Pulmonary Tuberculosis (TB)
4 5 6 0 20 1 6 3 11 56
Extrapulmonary TB
3 1 1 1 2 0 0 1 0 9
Mycobacteria Other Than TB
24 43 22 27 138 40 30 25 69 418
Vaccine
Preventable
Diseases
Diphtheria
0 0 0 0 0 0 0 0 0 0
Pertussis
3 2 1 3 16 8 2 7 18 60
Tetanus
0 0 0 0 0 0 0 0 0 0
Poliomyelitis
0 0 0 0 0 0 0 0 0 0
Measles
0 0 0 0 0 0 0 0 0 0
Mumps
0 0 0 0 0 0 0 0 0 0
Hepatitis B (acute)
2 6 2 4 6 1 1 13 19 54
Invasive H. influenzae disease
6 5 1 3 11 1 0 2 2 31
Invasive Meningococcal
disease
0 0 0 0 1 1 1 0 1 4
Enteric
Diseases
Hepatitis A (acute)
1 0 0 1 1 1 0 0 1 5
Salmonellosis
90 144 35 77 251 78 51 83 100 919
Shigellosis
31 31 10 1 49 18 9 22 54 226
Campylobacteriosis
7 10 10 3 27 2 5 20 15 99
E. coli O157:H7/HUS/STEC
6 3 1 2 2 1 1 7 7 30
Zoonotic
Diseases
Animal Rabies (bats)
1 0 0 2 2 0 0 0 0 5
Lyme disease
0 0 0 0 0 0 0 0 0 0
Rocky Mountain spotted fever
2 6 1 12 6 0 3 5 4 39
West Nile virus
1 0 3 1 20 0 3 16 1 45
*Totals include reports from Department of Corrections and those not reported from a specific District.
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Mississippi
Provisional Reportable Disease Statistics
November 2016
Figures for the current month are provisional
Public Health District
State Totals*
I II III IV V VI VII VIII IX
Nov
2016
Nov
2015
YTD
2016
YTD
2015
Sexually
Transmitted
Diseases
Primary & Secondary Syphilis
2 0 2 0 6 0 0 2 3 15 17 290 198
Total Early Syphilis
3 0 3 0 5 2 0 1 2 16 38 431 377
Gonorrhea
41 37 57 40 122 32 20 33 67 449 498 5,966 5,098
Chlamydia
164 132 122 120 332 106 59 113 133 1,281 1,548 16,411 15,391
HIV Disease
1 2 1 0 16 3 1 3 3 30 24 404 501
Myco-
bacterial
Diseases
Pulmonary Tuberculosis (TB)
1 1 0 0 1 0 0 0 1 4 8 40 53
Extrapulmonary TB
1 0 0 0 0 0 0 0 0 1 1 10 8
Mycobacteria Other Than TB
4 5 1 2 19 0 0 6 2 39 35 369 398
Vaccine
Preventable
Diseases
Diphtheria
0 0 0 0 0 0 0 0 0 0 0 0 0
Pertussis
0 0 0 0 0 0 0 0 0 0 1 3 11
Tetanus
0 0 0 0 0 0 0 0 0 0 0 1 0
Poliomyelitis
0 0 0 0 0 0 0 0 0 0 0 0 0
Measles
0 0 0 0 0 0 0 0 0 0 0 0 0
Mumps
0 0 0 0 0 0 0 0 0 0 0 1 0
Hepatitis B (acute)
0 0 0 1 0 0 0 0 0 1 5 25 50
Invasive H. influenzae disease
1 0 0 0 2 0 0 2 1 6 6 54 41
Invasive Meningococcal
disease
0 0 0 0 0 0 0 0 0 0 0 0 0
Enteric
Diseases
Hepatitis A (acute)
0 0 0 0 0 0 0 0 0 0 0 3 1
Salmonellosis
4 13 2 3 20 4 3 6 15 73 66 1,142 1,018
Shigellosis
0 0 1 0 0 0 5 0 1 7 6 66 94
Campylobacteriosis
1 2 5 0 5 1 1 0 6 22 19 232 182
E. coli O157:H7/STEC/HUS
0 1 0 0 0 0 0 0 0 1 1 23 21
Zoonotic
Diseases
Animal Rabies (bats)
0 0 0 0 0 0 0 0 0 0 1 2 4
Lyme disease
0 0 0 0 1 0 0 0 0 1 0 1 3
Rocky Mountain spotted fever
0 0 0 0 1 0 0 0 0 1 5 90 97
West Nile virus
0 0 0 0 1 0 1 0 0 2 1 42 38
*Totals include reports from Department of Corrections and those not reported from a specific District.
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List of Contacts, Editors and Contributors
Office of the State Health Officer
601.576.7634
Mary Currier, MD, MPH
State Health Officer
Office of Communicable Diseases/Epidemiology
601.576.7725
Paul Byers, MD
State Epidemiologist
Joy Sennett, MHS
Director
Immunization Program
601.576.7751
Valorie Woods, R. Ph
Director
STD/HIV/AIDS Program
Nicholas Mosca, DDS, DrPH
601.576.7723
Director
Tuberculosis Program
601.576.7700
J.M. Holcombe, MPPA
Director
Editors
Theresa Kittle, MPH
Epidemiologist
Office of Communicable Diseases/Epidemiology
Kathryn Taylor, MD
Health Officer
District V
Paul Byers, MD
State Epidemiologist
Office of Communicable Diseases/Epidemiology
Contributors
Alisha Brinson, MS
Joel Henderson, MPH
Monique Drake
Michael Jacobson, MPH
Jesse Ellis, MBA
Kendra Johnson, MPH
Carl Haydel, MS
Wendy Varnado, PhD
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General References
• Heymann D, ed. Control of Communicable Diseases Manual. 20
th
ed.
Washington, D.C.: American Public Health Association; 2015.
• CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases, 2015. 13
th
ed.
• Kimberlin DW, ed. Red Book: 2015 Report of the Committee on Infectious
Diseases. 30
th
ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015.
• CDC. Sexually Transmitted Disease Surveillance 2013; December 2014.
• CDC. Diseases and Conditions A-Z Index. Available online at:
http://www.cdc.gov/az/a.html
• CDC. Case Definitions for Nationally Notifiable Infectious Diseases. Available
online at: https://wwwn.cdc.gov/nndss/case-definitions.html
• CDC. MMWR: Notice to Readers: Final 2013 Reports of Nationally Notifiable
Infectious Diseases, August 15, 2014 / 63(32); 702-715. Available online at:
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a6.htm
• CDC. MMWR: Summary of Notifiable Diseases, United States, 2000-2013. Available
online at: http://www.cdc.gov/mmwr/mmwr_su/mmwr_nd/
.
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