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Biological Health Hazard – Elizabethkingia anophelis (fatal): Wisconsin

2016/03/04

ELIZABETHKINGIA ANOPHELIS – USA: (WISCONSIN) FATALITIES, COMMUNITY ACQUIRED, REQUEST FOR INFORMATION
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Published Date: 2016-03-03 19:57:24
Subject: PRO/EDR> Elizabethkingia anophelis – USA: (WI) fatalities, community acquired, RFI
Archive Number: 20160303.4067424

Date: Thu 3 Mar 2016
Source: Wisconsin State Journal [edited]

Health officials are testing water, skin care products and over-the-counter medications, and interviewing patients and families, to try to identify the source of an outbreak of an unusual bacteria that has sickened 44 people in southern Wisconsin and left 18 dead. Lab tests suggest a common source of the bacteria, called _Elizabethkingia_. But the investigation, which started in January 2016, has not revealed the source, health officials said.

Most of the patients are elderly, with serious underlying health conditions. No cases have been reported among children, and there is no evidence of transmission from one person to another, said Karen McKeown, state health officer. “We have not been able to identify the common theme between all of these that would point us to the source,” McKeown said. “We are pursuing every clue.”

Dr. Chris Braden, of the CDC, which is assisting in the probe, described the outbreak as a particularly challenging mystery. “We have collected a lot of data … and haven’t identified a source or even a strong hypothesis,” said Braden, deputy director of the CDC’s National Center for Emerging and Zoonotic Infectious Diseases. “This is a difficult one, even in the experience of doing these types of outbreaks in the past.”

The 44 cases are in the following counties: Columbia, Dane, Dodge, Fond du Lac, Jefferson, Milwaukee, Ozaukee, Racine, Sauk, Washington and Waukesha.

UW Hospital and Madison’s Veterans Hospital haven’t had any cases and Meriter Hospital has had 2 since 2014, spokespeople said. Kim Sveum, spokeswoman for St. Mary’s Hospital, wouldn’t say if St. Mary’s has had any cases. No cases linked to the Wisconsin outbreak have been reported in other states, McKeown and Braden said.

Nationwide about 250 to 500 cases are known to occur each year, with a few localized outbreaks in recent years, said CDC spokesman Tom Skinner. The Wisconsin outbreak is the largest, he said. Though 18 people have died, it’s not clear if their deaths were caused by the bacterial infection or their underlying health conditions, McKeown said. The conditions include cancer, diabetes, kidney disease and alcoholic cirrhosis.

_Elizabethkingia_ rarely cause illness in humans, the state health department said. Symptoms can include fever, shortness of breath, chills or cellulitis, a skin infection.

The 1st cases were reported in late December 2015, and the investigation started in early January 2016. The state Department of Health Services didn’t announce the outbreak until Wednesday, 2 Mar 2016. McKeown said doctors and “everybody who needed to know” were notified in early January. Health officials didn’t want to alarm the public, she said. “It’s a difficult balancing act to decide between creating concern among the public and being very transparent,” she said. “We decided that with 44 patients, it was important for the people of Wisconsin to know what was going on even if we don’t have all of the answers yet.”

5 disease investigators from the CDC joined state health investigators in interviewing affected patients and families, and gathering samples that might help pinpoint the source. The investigators have been visiting homes, nursing homes and other nursing facilities, Braden said. Samples are being collected for testing from water, drains, skin care and personal care products, over-the-counter medications and medicines distributed by pharmacies, he said.

The 44 patients are on different water systems, with some using wells, so the source doesn’t appear to be a water distribution system, Braden said. The Wisconsin State Laboratory of Hygiene, part of UW-Madison, has been testing patient samples and collecting environmental samples to ship to the CDC, said David Warshauer, the lab’s deputy director of communicable diseases.

_Elizabethkingia_ is resistant to some antimicrobials, but others are effective, McKoewn said. Some patients are being treated with a combination of antimicrobials, she said.

Previous outbreaks of _Elizabethkingia_ in the USA have been associated with hospitals, but the Wisconsin outbreak appears to be different, Braden said. “It looks like, for the most part, it’s being transmitted in the community somewhere,” he said. _Elizabethkingia_ has long been known to be in the environment, Braden said. “It can be in soil, it can be in water, it can be on surfaces,” he said.

It is named after Elizabeth King, who 1st reported on the bacteria in 1959 while at the CDC. The Wisconsin outbreak involves the species _anophelis_ of _Elizabethkingia_ 1st identified in 2011 in mosquitoes. It’s unclear if mosquitoes transmit the bacterium.
[Byline: David Wahlberg]

Communicated by:
David Wahlberg
Wisconsin State Journal
<dwahlberg@madison.com>

[This is a particularly curious outbreak for which ProMED would like more information. As stated above and below, this relatively newly characterized bacillus was 1st isolated from the midgut of an anopheline mosquito. Just as in the Lau report, it is not likely that mosquitoes had any role to play in transmission in this unique community-acquired outbreak as Anopheles mosquitos are not an upper USA area species and the time span is in the midst of winter so mosquitoes would not be circulating.

The following is extracted from:
Lau SK, Wu AK, Teng JL, et al: Evidence for Elizabethkingia anophelis transmission from mother to infant, Hong Kong. Emerg Infect Dis. 2015;21: 232-41.

“_Elizabethkingia anophelis_ is a recently discovered bacterium isolated from the midgut of the _Anopheles gambiae_ mosquito in 2011 (15). The genus Elizabethkingia also includes _E. meningoseptica_ (previously named _Chryseobacterium/Flavobacterium meningosepticum_) and _E. miricola_ (16). _E. meningoseptica_ causes neonatal sepsis and infections in immunocompromised persons. _E. anophelis_ has also recently been reported to cause neonatal meningitis in the Central African Republic, and a nosocomial outbreak was reported in an intensive care unit in Singapore (17-19). However, the role of mosquitoes or other sources in the transmission of _E. anophelis_ remains unclear.”

References:
15. Kämpfer P, Matthews H, Glaeser SP, et al. Elizabethkingia anophelis sp. nov., isolated from the midgut of the mosquito Anopheles gambiae. Int J Syst Evol Microbiol. 2011;61:2670-5.
16. Kim KK, Kim MK, Lim JH, Park HY, Lee ST: Transfer of Chryseobacterium meningosepticum and Chryseobacterium miricola to Elizabethkingia gen. nov. as Elizabethkingia meningoseptica comb. nov. and Elizabethkingia miricola comb. nov. Int J Syst Evol Microbiol. 2005;55:1287-93.
17. Frank T, Gody JC, Nguyen LB, et al: First case of Elizabethkingia anophelis meningitis in the Central African Republic. Lancet. 2013;381:1876.
18. Bobossi-Serengbe G, Gody JC, Beyam NE, Bercion R: First documented case of Chryseobacterium meningosepticum meningitis in Central African Republic. Med Trop (Mars). 2006;66:182-4 . [PubMed]
19. Teo J, Tan SY, Tay M, et al: First case of E anophelis outbreak in an intensive-care unit. Lancet. 2013;382:855-6.
– Mod.LL

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/250.]

………………………………………….sb/ll/je/dk

Source:
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