MINNESOTA
DEPARTMENT
OF HEALTH
D ISEASE C ONTROL N EWSLETTER
Volume 32, Number 1 (pages 1-8)
Jan/Feb 2004
Recommended Childhood and Adolescent
Immunization Schedule, Minnesota, 2004
The Minnesota Department of Health
(MDH) 2004 Recommended Childhood
and Adolescent Immunization
Schedule represents another step
toward a national recommendation for
universal influenza vaccination in
childhood. In October 2003, the
Advisory Committee on Immunization
Practices (ACIP) voted to recommend
that, starting in the fall of 2004, all
infants 6 to 23 months of age receive
influenza vaccination each fall as part
of their routinely recommended
vaccinations. The Centers for Disease
Control and Prevention likely will adopt
the ACIP recommendation, and both
the Committee on Infectious Diseases
of the American Academy of Pediatrics
(AAP) and the American Academy of
Family Physicians (AAFP) likely will
make the same recommendation.
(third or fourth dose) at >24 weeks of
age. The schedule provides additional
instruction on the use of combination
vaccines following a dose of hepatitis
B vaccine given at birth. Lastly, the
format of the catch-up algorithm has
been modified to enhance its usability.
MDH issues the childhood
immunization schedule annually to
incorporate changes as newly licensed
vaccines become available, products
change, and vaccine
recommendations are modified. The
schedule consolidates
recommendations of national advisory
bodies such as the ACIP, the AAP, and
the AAFP. The MDH Immunization
Practices Advisory Committee reviews
the schedule and, as necessary,
suggests modifications specific to
Minnesota.
The 2004 childhood and adolescent
immunization schedule includes other
changes and new information. The
updated schedule provides information
on the newly licensed live-attenuated
influenza vaccine (LAIV), which is an
acceptable alternative to the
intramuscular trivalent inactivated
influenza vaccine (TIV) for children 5
years of age or older. Other changes
include specifying minimum ages for
the final dose in vaccine series, as
follows: 1) diphtheria and tetanus
toxoids and acellular pertussis (DTaP)
at >4 years of age, 2) Haemophilus
influenzae type b (Hib) conjugate
vaccine at >12 months of age, 3)
pneumococcal conjugate vaccine at
>12 months of age, and 4) hepatitis B
The Minnesota schedule is available
on the MDH website at http://
www.health.state.mn.us/immunize;
scroll down to “Schedules and Recom­
mendations.” Color copies of the
childhood schedule are being printed;
MDH will distribute them to all clinics,
hospitals, local public health agencies,
and health plans when they become
available. Additional copies can be
ordered by calling the Minnesota
Immunization Hotline at 612-676-5100
or 800-657-3970, or by contacting
MDH at [email protected].
For more detailed information, consult
the complete ACIP statements at http://
www.cdc.gov/nip/acip/; click on
“Recommendations.”
Other resources regarding vaccine
recommendations include:
• American Academy of Pediatrics.
Pickering LK, ed. Red Book: 2003
Report of the Committee on
Infectious Diseases. 26th ed. Elk
Grove Village, IL: American
Academy of Pediatrics; 2003.
• Minnesota Immunization Hotline
(M-F, 9:00 a.m. – 12:00 p.m. and
1:00 p.m.– 4:00 p.m.) at 612-6765100 or 800-657-3970.
• Centers for Disease Control and
Prevention Immunization Hotline
at 800-232-0233 or http://
www.cdc.gov/nip/.
• Department of Health and Human
Services, Centers for Disease
Control and Prevention. Atkinson
WA, Wolfe C, eds. Epidemiology
and Prevention of VaccinePreventable Diseases. 7th ed.
Washington, DC: Public Health
Foundation; 2002.
• Vaccine manufacturers’ telephone
help-lines and package inserts.
continued...
Inside:
“1-3-6” Newborn Hearing Screen­
ing: A Standard of Care for
Newborns in Minnesota...............4
Outbreaks of Conjunctivitis Due to
Streptococcus pneumoniae....6
Third Annual Minnesota Colorectal
Cancer Consortium Summit........8
Recommended Childhood and Adolescent
Immunization Schedule, Minnesota, 2004
Range of recommended ages
Age
�
Vaccine
�
Birth
HepB-1
1
Hepatitis B
Catch-up vaccination
1
mo
2
mos
4
mos
6
mos
Haemophilus influenzae
type b3
Inactivated Poliovirus
DTaP
DTaP
DTaP
Hib
Hib
Hib3
IPV
IPV
18
mos
24
mos
4-6
yrs
11-12
yrs
13 -18
yrs
HepB series
DTaP2
DTaP
PCV
PCV
PCV
Vaccines below this line are for selected populations
IPV
IPV
MMR-1
MMR-2 4
PCV
Influenza (yearly) as of fall 2004
Hepatitis A8
Td2
Hib3
MMR-2 4
Varicella
Varicella
Varicella5
Influenza7
15
mos
HepB-3
Measles, Mumps,
Rubella4
Pneumococcal6
12
mos
only if mother is HBsAg(-)
HepB-2
Diphtheria, Tetanus,
Pertussis2
Preadolescent assessment
PCV
PPV
Influenza (yearly)
HepA series
Guidelines: This schedule is for children through age 18 yrs. It indicates the recommended ages for routine administration of childhood vaccines licensed as of January 1, 2004. Any dose not
Indicates age groups that warrant special effort to administer those vaccines not
given at the recommended age should be given at any subsequent visit when indicated and feasible.
previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and
the vaccine’s other components are not contraindicated. Consult the manufacturers’ package inserts for detailed recommendations.
1. Hepatitis B (hepB): All infants should receive hepB-1 soon after birth and before hospital
discharge; the 1st dose also may be given by age 2 mos if the infant’s mother is hepatitis B
surface antigen (HBsAg) negative. Only monovalent hepB vaccine can be used for the dose
given before age 6 wks. Monovalent or combination vaccine containing hepB may be used to
complete the series. Four doses of vaccine may be administered when a birth dose is given.
The 2 nd dose should be given at least 4 wks after the 1st dose, except for combination
vaccines that cannot be administered before age 6 wks. The 3rd dose should be given at least
16 wks after the 1st dose and at least 8 wks after the 2nd dose. The last dose in the
vaccination series (3rd or 4th dose) should not be administered before age 24 wks.
Infants born to HBsAg-positive mothers should receive hepB-1 and 0.5 mL hepatitis B
immune globulin (HBIG) at separate sites within 12 hrs of birth. The 2nd dose is recom­
mended at age 1-2 mos and the 3rd dose at age 6 mos (no sooner than age 24 wks). Test
these infants for HBsAg and antibody to HBsAg (anti-HBs) at age 9-15 mos.
Infants born to mothers whose HBsAg status is unknown should receive hepB-1 within
12 hrs of birth. Maternal blood should be drawn as soon as possible to determine the
mother’s HBsAg status. If the HBsAg test is positive, the infant should receive 0.5 mL of
HBIG as soon as possible (no later than age 1 wk). HepB-2 is recommended at age 1-2 mos.
The last dose of the series should not be given before age 24 wks.
2. Diphtheria, tetanus, and acellular pertussis (DTaP): DTaP-4 may be given as early as
age 12 mos if at least 6 mos have passed since DTaP-3 and the child is unlikely to return at
age 15-18 mos. The final dose should be given at age >4 yrs.
Td (tetanus and diphtheria toxoids, for persons age >7 yrs) is recommended at age 11-12 yrs
if at least 5 yrs have passed since the last dose of tetanus- and diphtheria-containing vaccine.
Subsequent routine Td boosters are recommended every 10 yrs.
3. Haemophilus influenzae type b (Hib) conjugate: Three Hib conjugate vaccines are
licensed for infant use. If PRP-OMP (PedvaxHIB or Comvax) is given at age 2 and 4 mos, a
dose at 6 mos is not required. Do not use DTaP/Hib combination products for the 1st, 2nd, or
3rd doses (primary series). Use any Hib conjugate vaccine as a booster. The final dose in the
series should be given at age >12 mos.
4. Measles, mumps, rubella (MMR): MMR-2 is recommended at age 4-6 yrs but may
be given during any visit, provided at least 4 wks have elapsed since MMR-1 and both
doses are given at age >12 mos. Those who have not received a 2nd dose should do so
by age 11-12 yrs.
5. Varicella: Varicella vaccine is recommended at any visit at age >12 mos for
susceptible children, those who lack a reliable history of chickenpox. Susceptible
persons age >13 yrs should receive 2 doses given at least 4 wks apart.
6. Pneumococcal: The 7-valent pneumococcal conjugate vaccine (PCV) is
recommended for all children age 2-23 mos and for certain children age 24-59 mos. The
final dose in the series should be given at age >12 mos. Pneumococcal polysaccha­
ride vaccine (PPV) is recommended in addition to PCV for certain high-risk groups age
>2 yrs. See MMWR 2000;49(RR-9):1-35.
7. Influenza: Beginning in the fall of 2004, influenza vaccine is recommended annually
for children age 6–23 mos because they are at substantially increased risk for influenzarelated hospitalizations. It also is recommended for children age >2 yrs with certain risk
factors including, but not limited to, asthma, cardiac disease, sickle cell disease, HIV,
and diabetes. See MMWR 2003;52[RR-8]:1-34. Children age >2 yrs who are household
contacts of at-risk persons, including infants age <6 mos, also should be vaccinated.
Other children wishing to obtain immunity may be vaccinated. For healthy persons age
5-49 yrs, the intranasally administered live-attenuated influenza vaccine (LAIV) is an
acceptable alternative to the intramuscular trivalent inactivated influenza vaccine (TIV).
See MMWR 2003;52(RR-13):1-8. Children receiving TIV should receive the ageappropriate dosage: 0.25 mL if age 6-35 mos or 0.5 mL if age >3 yrs. Children age <8
yrs who are receiving influenza vaccine for the first time should receive 2 doses
separated by > 4 wks following a dose of TIV or 6 wks following a dose of LAIV.
8. Hepatitis A (hepA): Give hepA vaccine to children and adolescents who are at
increased risk of infection, as defined by ACIP, and consider it for all others age >2 yrs
who wish to obtain immunity. Give a booster dose 6 mos after initial dose.
Based on recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy
of Family Physicians (AAFP), and endorsed by the Immunization Practices Advisory Committee of the Minnesota Department of Health (MDH).
2
For Children and Adolescents Who Start Late or Who Are >1 Month Behind
The tables below give catch-up schedules and minimum intervals between doses for children who have delayed immunizations. There is no need to
restart a vaccine series, regardless of the time that has elapsed between doses. Use the chart appropriate for the child’s age. Footnotes apply to
both charts.
Catch-up schedule for children age 4 months through 6 years
Vaccine
Minimum Interval Between Doses
(Minimum Age
for Dose 1)
Dose 1 to Dose 2
Dose 3 to Dose 4
Dose 2 to Dose 3
Dose 4 to Dose 5
6 mos1
DTaP (6 wks)
4 wks
4 wks
6 mos
IPV (6 wks)
4 wks
4 wks
4 wks2
HepB3 (birth)
4 wks
8 wks (and 16 wks after 1st dose)
MMR (12 mos)
4 wks4
Varicella (12 mos)
Not needed
Hib5 (6 wks)
4 wks: if 1st dose given at age <12
mos
8 wks (as final dose): if 1st dose
given at age 12-14 mos
No further doses needed: if 1st
dose given at age >15 mos
4 wks6: if current age <12 mos
8 wks (as final dose)6: if current
age >12 mos and 2nd dose given
at age <15 mos
No further doses needed: if
previous dose given at age
>15 mos
8 wks (as final dose): this
dose only necessary for
children age 12 mos to 5
yrs who received 3 doses
before age 12 mos
PCV 5 (6 wks)
4 wks: if 1st dose given at age <12
mos and current age <24 mos
8 wks (as final dose): if 1st dose
given at age >12 mos or current
age 24-59 mos
No further doses needed: for
healthy children if 1st dose given
at age >24 mos
4 wks: if current age <12 mos
8 wks (as final dose): if current
age >12 mos
No further doses needed: for
healthy children if previous dose
given at age >24 mos
8 wks (as final dose): this
dose only necessary for
children age 12 mos to 5
yrs who received 3 doses
before age 12 mos
Catch-up schedule for children age 7 through 18 years
Minimum Interval Between Doses
Vaccine
Dose 1 to Dose 2
Dose 2 to Dose 3
Td
4 wks
6 mos
IPV7
4 wks
4 wks
HepB
4 wks
8 wks (and 16 wks after 1st dose)
MMR
4 wks
Varicella8
4 wks
1.
2.
3.
4.
5.
6.
7.
8.
Dose 3 to Booster Dose
If age 7-10 yrs:
• 6 mos if 1st dose given before age 1 yr
• 5 yrs (no sooner than age 11 yrs) if 1st dose
given at age >1 yr
If age 11-18 yrs:
• 5 yrs if 3rd dose given before age 7 yrs
• 10 yrs if 3rd dose given at age >7 yrs
DTaP: The 5th dose is not necessary if the 4th dose was given after the 4th birthday.
IPV: The 4th dose is not necessary in an all-IPV or all-OPV schedule if the 3rd dose was given after the 4th birthday. If both OPV and IPV were given as part of a series, a total
of 4 doses should be given, regardless of the child’s current age.
HepB: All children and adolescents who have not been immunized against hepatitis B should begin the hepB immunization series during any visit. Providers should make
special efforts to immunize children who were born in, or whose parents were born in, areas of the world where hepatitis B virus infection is moderately or highly endemic.
MMR: The 2nd dose of MMR is recommended routinely at age 4-6 yrs but may be given earlier if desired.
Hib and/or PCV: Vaccine generally is not recommended for children age >5 yrs.
Hib: If current age <12 mos and 1st and 2nd doses were PRP-OMP (PedvaxHIB or ComVax [Merck]), the 3rd (and final) dose should be given at age 12-15 mos and at least 8
wks after the 2nd dose. If a 3rd dose of HbOC (HibTiter) or PRP-T (ActHib) is given at age >12 mos, a 4th dose is not needed.
IPV: Vaccine generally is not recommended for persons age >18 yrs.
Varicella: Give 2-dose series to all susceptible adolescents age >13 yrs.
Reporting Adverse Reactions
Report adverse reactions to vaccines through the federal Vaccine Adverse Event Reporting System. For
information on reporting reactions following vaccines administered by private clinics, call the 24-hour national
toll-free information line, 800-822-7967. Report reactions to vaccine administered in public clinics to the
Minnesota Department of Health, 612-676-5414 or toll-free 877-676-5414.
3
Disease Reporting
Report suspected cases of vaccine-preventable diseases to the local
health department or to the Minnesota Department of Health, P.O. Box
9441, Minneapolis, MN 55440-9441, 612-676-5414 or toll-free 877­
676-5414.
“1-3-6” Newborn Hearing Screening: A Standard
of Care for Newborns in Minnesota
Universal Newborn Hearing Screen­
ing in Minnesota
In accordance with recommendations
of the Joint Committee on Infant
Hearing (JCIH), the Minnesota Depart­
ment of Health (MDH) promotes the “13-6” universal newborn hearing
screening (UNHS) goal, which includes
the following objectives:
• screen all newborns for hearing
loss by 1 month of age;
• assess newborns who do not
pass the initial screening by 3
months of age; and
• offer early intervention(s) for
newborns with hearing loss by 6
months of age.
UNHS is mandated in 38 states and
the District of Columbia but is voluntary
in Minnesota. However, UNHS has
become a standard of care in Minne­
sota. Nearly 95% of newborns in 2003
were screened for hearing loss, which
represents a significant increase from
the 8% of newborns who were
screened in 1997. Among 111 birthing
hospitals in Minnesota, 105 (95%)
screen all of their newborns, either in
the hospital or as outpatients, before 1
month of age.
In 2002, through a partnership be­
tween its Newborn Hearing Screening
Program and Public Health Laboratory,
MDH began collecting data on new­
born hearing screening that are
recorded by hospital staff on the
newborns’ blood spot forms. These
data include: hearing screening
results for each ear, type of technology
used, date of screening, and reason
for not screening. When the blood
spot form arrives at the MDH Public
Health Laboratory, a UNHS form is
generated automatically and returned
to the birth hospital for any newborn
who did not pass or did not receive
hearing screening. Hospitals are
encouraged to share the UNHS form
with the newborn’s primary care
provider, who should refer the newborn
for an outpatient rescreening or a
diagnostic hearing test performed by
an audiologist trained to assess
newborns. The hospital or primary
care provider completes the rescreen­
ing information on the form and returns
it to MDH. If the newborn does not
pass the rescreening, MDH encour­
ages the hospital to refer the
newborn’s family to their local public
health agency for assistance in
connecting to the newborn’s medical
home.
When hearing loss is confirmed, it is
critical that health care professionals
collaborate to assist the affected
newborn’s family. Essential members
of the health care team may include
the family, physician/pediatrician/
primary care physician, nurse or nurse
practitioner, audiologist, otolaryngolo­
gist, ophthalmologist, speech-language pathologist, genetic counselor,
clinical geneticist, teacher of the deaf/
hard-of-hearing, and early intervention
specialist. Children who have risk
factors for congenital or acquired
hearing loss should be monitored
closely by their primary care providers,
which includes hearing tests every 6
months (Table 1).
Facts About Newborn Hearing Loss
Hearing loss is the most common birth
defect in the United States, affecting
approximately 12,000 children each
year. Hearing loss is 20 times more
prevalent than phenylketonuria (PKU).
Current data indicate that one of every
1,000 newborns is profoundly deaf,
and three to five are hard-of-hearing.
Based on these figures, four newborns
with congenital hearing loss are born
weekly, or about 200 babies per year,
in Minnesota.
Hearing loss is an “invisible” yet easily
identifiable disability. The average age
at which childhood hearing loss is
identified ranges from 18 months to 3
years, while the critical window for
optimal speech and language develop­
ment begins at 0 to 6 months of age.
Profound hearing loss typically is
identified earlier, whereas mild or
moderate hearing loss often remains
undetected until the child enters
school.
continued...
Table 1. Risk Factors for Late Onset/Progressive
Hearing Loss, by Age Group*
Birth to 28 Days
•
•
•
•
Illness or other condition requir­
ing admission to a neonatal
intensive care unit for 48 hours
or longer
Family history of congenital or
delayed-onset childhood
sensorineural hearing loss
Birth weight less than 1,500
grams or 3.3 pounds
Stigmata or other findings
associated with a syndrome
known to include sensorineural
hearing loss (e.g., Treacher
Collins Syndrome, Waardenburg
syndrome, Down syndrome)
•
Ear or other craniofacial anoma­
lies
•
In utero/gestational infections
(e.g., cytomegalovirus, rubella,
syphilis, herpes, toxoplasmosis)
29 Days to 2 Years
•
Any of the risk factors identified
for infants from birth to 28 days
•
Parental/caregiver concern about
hearing, speech, language, and/
or developmental delay
•
Recurrent or persistent (i.e., 3
months or longer) otitis media
with effusion
•
Head trauma or skull fractures
•
Childhood infectious diseases
associated with sensorineural
hearing loss (e.g., meningitis,
mumps, measles)
•
Neurodegenerative disorders
(e.g., Hunter syndrome) or
sensory motor neuropathies (e.g.,
Charcot-Marie Tooth Disease)
*Source: Joint Committee on Infant Hearing, 2000
4
UNHS programs screen all newborns
for hearing loss before hospital
discharge. Screening programs
targeted to high-risk newborns identify
only half of those with significant
congenital hearing loss. Physiologic
screening of children in their primary
care providers’ offices fails to achieve
the same extent of implementation,
coverage, or equal access to screen­
ing as UNHS. The average age at
which hearing loss is identified has
decreased markedly with the advent of
UNHS. In 2003, more than 40 infants
with hearing loss were identified at
birth in Minnesota.
Children whose hearing loss is
identified at birth and who are enrolled
in appropriate intervention services
before 6 months of age show signifi­
cantly greater language, speech,
social, and emotional development
than children whose hearing loss is
identified later. Children in the former
group demonstrate abilities that are
within the range of their normal hearing
peers. Identification of hearing loss at
birth also enables families and
professionals to connect the child to
early amplification and culturally
appropriate intervention services, as
needed; educational services then can
be focused on habilitation rather than
rehabilitation.
Hearing Screening Technologies
Currently acceptable physiological
methods for UNHS include otoacoustic
emissions and automated auditory
brainstem response (AABR), either
alone or in combination. Both tech­
nologies are rapid, non-invasive, and
easy to use. The cost and time
required for testing per newborn range
from $25 to $50 and from 5 to 15
minutes, respectively.
Early critics of UNHS questioned
excessive rates of referrals, which
were as high as 15-20% in some
settings. Today, with technological
advances and training, it is reasonable
to achieve a referral rate of 4% or
lower, as recommended by JCIH and
MDH. Such low rates of referral can
be achieved by rescreening newborns
who do not pass the initial test before
discharge or by adding a third outpa­
tient screening, thereby limiting the
number of infants who require a
diagnostic AABR test. The technology
used and the experience of the staff
significantly affect referral and failure
rates. Successful UNHS programs
have hospital staff who work closely
with a consulting audiologist and
medical staff to address quality
assurance and program effectiveness.
Tracking and Follow-Up
The American Academy of Pediatrics
encourages follow-up for all newborns
who are referred for audiologic
evaluation following screening or were
not screened initially at the birthing
hospital. MDH estimates that from 1 in
10 to 1 in 20 children referred from
screening have a hearing loss, which
demonstrates the importance of
following-up on children who do not
pass the screening. Although some
critics have questioned whether
newborn hearing screening results in
unnecessary anxiety caused by failed
screening tests, research suggests
that the benefits of early detection far
outweigh any stress due to a failed
initial screening.
MDH sends follow-up letters to the
newborn’s primary care provider when
information regarding hospital followup has not been returned to MDH. To
date, more than 500 physicians have
provided the needed information in
response to such follow-up. Primary
care providers are becoming increas­
ingly aware of newborn hearing
screening and the importance of a
tracking and follow-up program at the
state level. A statewide tracking and
surveillance system is critical to
ensuring that systems and families are
connected with diagnostic and early
intervention services.
Unfortunately, not all hospitals partici­
pate in Minnesota’s voluntary tracking
and follow-up system by obtaining
parental consent to share data with
MDH. Ninety-four hospitals report
some or all hearing screening data to
MDH on the blood spot form. Without
complete tracking and follow-up,
however, it is difficult to determine the
true incidence of hearing loss in
Minnesota, to assure that infants with
hearing loss receive adequate followup, and to serve the newborns and
their families who need services such
as early interventions.
Approximately 200 deaf or hard-ofhearing babies are born in Minnesota
per year. Yet, of the approximately 600
5
such children from birth to 3 years of
age, only 84 currently are receiving
services. According to the Minnesota
Department of Education (MDE),
however, the number of deaf and hardof-hearing children from birth to 3
years of age who receive early
intervention services increased
steadily from 2000 to 2002. With full
implementation of UNHS, tracking, and
follow-up, the number of children
enrolled in early intervention activities
is expected to increase significantly.
Cooperative efforts have been made
by MDH, MDE, and the Minnesota
Department of Human Services to
enhance Minnesota’s capacity to serve
infants with hearing loss and their
families. Sixteen regional Early
Hearing Detection and Intervention
teams have been formed. Each team
consists of an educational audiologist,
an early childhood educator, and a
teacher of the deaf/hard-of-hearing.
The teams have received intensive
training during the past 3 years, and
they will train local providers in their
respective areas.
What’s Next?
In 2004, MDH is developing a genetic
and medical protocol to assist primary
care providers in making decisions
regarding referral for hearing loss. In
2004, providers will receive results
from both blood spot testing and
hearing screening. Also, MDH is
developing a statewide tracking and
follow-up system to determine the
incidence of hearing loss and to
ensure achievement of the “1-3-6” goal
in Minnesota.
More information on newborn hearing
screening is available on the MDH
website at http://
www.health.state.mn.us/divs/fh/mch/
unhs. The site contains resources for
providers and families, including a
newborn hearing screening booklet for
hospitals and a checklist for parents,
which is available in English, Hmong,
Somali, and Spanish. Also, a regional
list of pediatric audiology diagnostic
and rehabilitation centers is available
at http://www.health.state.mn.us/divs/
fh/mch/unhs/provider.html. For further
information, contact either Pat Rice at
507-332-5481 or
[email protected], or Yaoli Li
at 651-281-9943 or
[email protected].
Outbreaks of Conjunctivitis Due to
Streptococcus pneumoniae
On November 21, 2003 the Mayo
Clinic notified their affiliated physicians
of the recent cases of pneumococcal
conjunctivitis. MDH then received
several reports of pneumococcal
conjunctivitis in patients seen at the
Mayo Clinic or Mayo-affiliated clinics in
communities near Rochester. MDH
staff interviewed case-patients and
queried schools and childcare centers
in Rochester, Zumbrota, and other
neighboring communities about cases
of conjunctivitis diagnosed in Novem­
ber. MDH provided schools and
childcare centers with information on
conjunctivitis infection control mea­
sures and asked them to report
pediatric cases of conjunctivitis
diagnosed since November.
Eye cultures were obtained from 115
Northfield area residents with conjunc­
tivitis; 59 (51%) were positive for S.
pneumoniae, and 24 (21%) were
positive for other bacterial species.
Thirty eye swabs were submitted for
viral culture; one (3%) was positive for
herpes simplex virus 1, one (3%) for
adenovirus, and 28 (93%) were
negative for viruses. Of 22 Northfield
area children with culture-confirmed
pneumococcal conjunctivitis, six (27%)
had clear eye discharge, 10 (45%) had
opaque eye discharge, and 15 (68%)
had crusting or mattering of the eyes.
Of the 508 case-patients without
culture-confirmed S. pneumoniae, 292
(57%) reported contact with a cultureconfirmed pneumococcal conjunctivitis
continued...
Figure 1. Conjunctivitis Cases Reported from Northfield, Fairbault,
and Rochester Areas, September 1, 2003 to December 13, 2003*
Northfield and Fairbault Areas
80
70
Culture-confirmed S. pneumoniae
conjunctivitis cases
Number of Cases
MDH staff reviewed the medical
records of conjunctivitis patients seen
since September 1, 2003 at two clinics
and one college health service in
Northfield. MDH asked local physi­
cians to report new conjunctivitis cases
and to obtain bacterial and viral
cultures. Local schools and childcare
centers were asked to report children
with conjunctivitis. MDH provided
schools, clinics, and childcare centers
with fact sheets regarding conjunctivitis
infection control measures. MDH
queried clinics and hospitals in
Lakeville, Farmington, Faribault,
Owatonna, Waterville, Cannon Falls,
Red Wing, Blooming Prairie, and Le
Sueur; only the hospital and clinics in
Faribault reported an increased
incidence of conjunctivitis. Conse­
quently, MDH expanded case-finding
and prevention efforts to Faribault.
Northfield and Faribault Areas
From September 1 to December 13,
2003, 567 cases of conjunctivitis were
reported in Northfield area residents;
269 of these cases diagnosed prior to
November 17 were identified retro­
spectively by two clinics in Northfield
(Figure 1). At those two clinics, 50
cases were seen in September, 157 in
October, and 62 in the first 17 days of
November. These numbers represent
a marked increase from the 36, 68,
and 60 cases, respectively, seen in a
similar time frame in 2002 by the same
clinics. Ten elementary/secondary
schools, 20 childcare centers, and two
colleges in the Northfield area also
reported cases of conjunctivitis.
60
Clinical conjunctivitis cases
50
40
30
20
10
0
01-06 07-13 14-20 21-27 28-04 05-11 12-18 19-25 26-01 02-08 09-15 16-22 23-29 30-06 07-13
Sep
Oct
Nov
Dec
Rochester Area
14
12
Number of Cases
Background
A Northfield physician contacted the
Minnesota Department of Health
(MDH) on November 12, 2003 to report
an increased number of cases of
conjunctivitis (approximately 100 cases
over several weeks). In the prior week,
bacterial eye cultures had been
obtained from 10 case-patients; all
yielded Streptococcus pneumoniae
(pneumococcus). In 2002, outbreaks
of pneumococcal conjunctivitis were
reported in university and school
settings in New England. Due to the
possibility of a similar outbreak in
Northfield, MDH initiated an investiga­
tion.
10
Culture -confirmed S. pneumoniae
conjunctivitis cases
Clinical conjunctivitis cases
8
6
4
2
0
01-06 07-13 14-20 21-27 28-04 05-11 12-18 19-25 26-01 02-08 09-15 16-22 23-29 30-06 07-13
Sep
Oct
Date of Onset or Clinic Visit
*Cases with reported date of onset/clinic visit
6
Nov
Dec
case at school, childcare, or home
(Table 1).
A total of 169 cases of conjunctivitis
were reported among Faribault area
residents (Figure 1). Bacterial eye
cultures were obtained from 24 casepatients; pneumococcus was isolated
in 12 (50%). Cases of conjunctivitis
were reported by nine schools and four
childcare centers; one school had
culture-confirmed pneumococcal
conjunctivitis cases. Of 157 Faribault
area conjunctivitis cases without
culture confirmation, 10 (6%) reported
contact at school or home to a cultureconfirmed pneumococcal conjunctivitis
case (Table 1). No other community
connections (e.g., health clubs, work
sites), were identified.
Rochester Area
A total of 66 conjunctivitis cases were
reported from Rochester and nearby
communities; 20 (30%) were cultureconfirmed as pneumococcal conjunc­
tivitis (Figure 1, Table 1). Of the 46
cases without culture confirmation, 41
(89%) were from the same classroom,
school, or household as a cultureconfirmed pneumococcal case.
Conjunctivitis cases were reported
from three schools and two childcare
centers in the area.
Pneumococcal Isolates
As part of these investigations, the
MDH Public Health Laboratory re­
ceived pneumococcal isolates from
eye cultures of 24 Northfield area
residents, six Faribault area residents,
and 14 Rochester area residents. To
date, antimicrobial susceptibility tests
have been completed for 18 isolates;
all were susceptible to erythromycin,
and 15 (83%) were susceptible to
tetracycline, penicillin, clindamycin,
and trimethoprim-sulfamethoxazole.
Serotyping of isolates using pooled
sera and Omnisera also was at­
tempted. For 42 (95%) of 44 isolates
tested, no Quellung reaction could be
elicited, which indicates the probable
lack of an exterior polysaccharide
capsule; these isolates were consid­
ered non-typeable.
Pulsed-field gel electrophoresis
(PFGE) subtyping was performed on
40 of 44 isolates received (including 38
of 42 non-typeable isolates). Prelimi­
nary results indicated that the 38 nontypeable isolates fell into four or five
clusters with indistinguishable or
similar PFGE patterns. One pattern
and several nearly indistinguishable
patterns (designated clonal group A)
represented 19 (50%) of the isolates
tested; this group comprised 18 of 23
isolates from Northfield area residents
and one of three isolates from
Faribault area residents. A second
group of six isolates had PFGE
patterns moderately similar to clonal
group A; this similar group included
one of 23 isolates from Northfield area
residents and five of 12 isolates from
Rochester area residents. Twelve
other isolates fell into two or three
groups with PFGE patterns distinctly
different from clonal group A; these 12
isolates included three of 23 isolates
from Northfield area residents, two of
three isolates from Faribault area
residents, and seven of 12 isolates
from Rochester area residents.
Further genetic testing is pending at
the Centers for Disease Control and
Prevention. Of interest, isolates in the
PFGE group with moderate similarity to
clonal group A had PFGE patterns
indistinguishable from or similar to
isolates associated with two prior
outbreaks of pneumococcal conjunc­
tivitis.
Summary
This outbreak of conjunctivitis contin­
ued for approximately 3 months and
involved more than 560 Northfield area
residents, including many without
documented connections to affected
schools or childcare centers. Labora­
tory tests performed late in the
outbreak indicated that many cases
were due to S. pneumoniae. Concur­
rently, other bacterial and viral patho­
gens also caused additional cases of
conjunctivitis. A simultaneous out­
break of conjunctivitis also affected
Faribault area residents. By the
second week in December, the
outbreaks had abated.
Cases from Rochester and nearby
communities were reported after local
physicians were alerted. Interviews
with case-patients indicated that
transmission had occurred in house­
hold, childcare, and school settings;
however, transmission apparently was
not as extensive as in Northfield.
Non-typeable pneumococci caused the
majority of cases of conjunctivitis for
which cultures were obtained. Nontypeable pneumococci lack the exterior
polysaccharide capsule, a structure
which enables pneumococci to evade
the human immune system. Paradoxi­
cally, unencapsulated pneumococci
have been recognized as causative
agents in conjunctivitis outbreaks in
the past. Initial PFGE testing indicated
that several strains of pneumococcal
conjunctivitis isolated from Northfield
area residents were genetically very
similar to each other and to strains
associated with prior pneumococcal
conjunctivitis outbreaks.
MDH issued recommendations for
several infection control practices in
response to these outbreaks. Patients
were encouraged to wash their hands
frequently and thoroughly using soap
and water or to use alcohol-based
hand sanitizer, especially after touch­
ing the eyes or face. Household
continued...
Table 1. Summary of Conjunctivitis Cases in Residents of Northfield,
Faribault, and Rochester Areas, September 1, 2003 to December 13, 2003
Northfield
Faribault
Rochester
Total number of reported
conjunctivitis cases
Culture-positive for S. pneumoniae
567
59
169
12
66
20
Cases with links* to culture-confirmed
S. pneumoniae conjunctivitis cases
Category
292
10
41
Schools with conjunctivitis cases
10
9
3
Schools with culture-confirmed S.
pneumoniae cases
7
1
2
20
4
2
9
0
2
Childcare centers with
conjunctivitis cases
Childcare centers with cultureconfirmed S. pneumoniae cases
*In the same classroom, school, childcare center, or household as a person with cultureconfirmed pneumococcal conjunctivitis
7
members and other contacts of casepatients also were encouraged to
practice proper hand hygiene and to
avoid sharing such items as towels,
contact lens solution, eye make-up,
eye drops, and eye medications.
Schools and childcare facilities with
children with conjunctivitis were
advised to thoroughly clean and
disinfect shared items (e.g., toys,
desks) and exclude children from
school/daycare for the recommended
time period. Conjunctivitis presenting
with pus and/or fever or eye pain
requires that children be evaluated by
a health care provider and excluded
from school or daycare until 24 hours
after antibiotic treatment begins or until
the health care provider has cleared
the child for readmission. The extent
to which these recommendations
mitigated the spread of pneumococcal
conjunctivitis is unknown, although
they likely contributed to halting these
outbreaks.
Dianne Mandernach, Commissioner of Health
Division of Infectious Disease Epidemiology, Prevention and Control
Harry F. Hull, M.D. ........................... Division Director & State Epidemiologist
Richard N. Danila, Ph.D., M.P.H. ................................ ADIC Section Manager
Kirk Smith, D.V.M., Ph.D. ......................................................................... Editor
Wendy Mills, M.P.H. ................................................................. Assistant Editor
Valerie Solovjovs ................................................................... Production Editor
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