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Outbreaks, Alerts and Hot Topics

May, 2018

Updates on Ongoing Outbreaks 

Mary Anne Jackson, MD | Division Director, Infectious Diseases | Medical Editor, The Link Newsletter | Professor of Pediatrics

Measles Update 

  1. As of May 4, 2018, there have been a total of 35 cases of measles in our community that appear to be related to two separate outbreaks. 

  2. There are 22 measles cases reported in Kansas thus far; most attended the same daycare center or were linked to the daycare center located in Johnson County. Additional cases were in Linn and Miami counties. Genotype B3 was confirmed and consistent with importation from outside the U.S. Eight infants infected were not yet eligible for the MMR vaccine.

  3. There are 13 cases in Missouri thus far confirmed in five adults and eight children. The index case, an unimmunized young adult, likely acquired disease from outside the U.S. The genotype was confirmed to be D8. Most of the cases are from Clay County. All Missouri cases were vaccine-eligible; 10 (77 percent) individuals were unimmunized; in two, vaccine receipt was confirmed by history only. MMR vaccine receipt could be confirmed in one case. There are three distinct household clusters among the cases. Surveillance is ongoing and there are cases that are still awaiting laboratory confirmation. 

  4. In a review of 400 measles cases in California that included 165 outbreaks between Jan. 1, 2000 through Dec. 31, 2015, authors found that genotype B3 was significantly more transmissible than other genotypes.1 The authors also found that school age predicted transmissibility, likely associated with the number of contacts. 

  5. Community providers should:

  • Keep parents and their staff updated on the status of the community outbreak and provide MMR vaccine to all who are age eligible. 

  • Verify measles immunity in your staff. Any HCP born after 1956 should have documentation of two doses of MMR vaccine. Serologic confirmation of immunity is recommended for those who cannot provide documentation. 

  • If you see a patient with possible measles in any ambulatory care setting, or you have spoken to the parent of a child where measles is suspected, stop and ensure that appropriate communication with the referring facility occurs before sending the patient. This communication needs to happen before referral of the patient for additional outpatient or inpatient services, or referral for radiologic or laboratory services. This caveat applies, no matter how unlikely you believe the diagnosis of measles may be. Education of parents is also required so they understand that a child with suspected measles should not enter a health care environment without you calling ahead; and that they will need instructions as to how to enter the facility to ensure prompt use of airborne precautions. 

Salmonella Outbreaks


  1. There have been 23 cases in nine states linked to Rose Acre Farms shell eggs, that were produced at the Hyde County North Carolina facility. Most cases are located in states on the East coast, or in the mid-Atlantic region, in Florida and Colorado. Salmonella Braenderup has been the infecting strain and so far, six individuals have required hospitalization. 

  2. Since Sept. 22, 2017, there have been 13 cases of Salmonella Typhimurium infection from eight states associated with bulk packages of Go Smiles Dried Coconut Raw.

  3. A total of 132 cases of kratom associated Salmonella infection have been reported from 38 states with 38 hospitalizations, since early January 2017, including two cases in Missouri. Multiple outbreak strains including Salmonella Javiana, Salmonella Okatie, and Salmonella Thompson have been reported. Kratom is an unregulated herb that has opioid properties and is used recreationally; those infected consumed kratom products that were contaminated. Grown in Thailand, Malaysia, Indonesia and Papua New Guinea, kratom is sold in a variety of forms including powder, pills or in tea.

  4. And lastly, a recent MMWR report noted Salmonella Oranienburg infection linked to ingestion of rattlesnake pills. Rattlesnake pills are found in alternative medicine health food stores and some roadside markets and are marketed for a variety of conditions. 


E. Coli O157:H7 Linked to Romaine Lettuce Grown in Yuma, Ariz. 


  1. The first case was reported on March 13, 2018 and illnesses that started since April 7, 2018 may not yet be included in the reported cases.

  2. As of April 26, 2018, there have been 98 cases from 22 states, including one case from Missouri. So far, 46 patients have been hospitalized and 10 have developed hemolytic uremic syndrome.

  3. The median age is 31 years, but cases range from 1-88 years and 65 percent are women.

  4. Messaging for your patients includes: don’t eat or buy Romaine lettuce, even if the product does not indicate the lettuce was grown in Yuma, Ariz., since labeling does not reliably identify the place the product was grown. This recommendation applies to any lettuce mix that includes Romaine lettuce (if you can’t tell, tell your patients not to buy), organic Romaine, chopped or baby Romaine, and hearts of Romaine.

Lastly, It is Tick Season …

  1. Now that we are in tick season, broaden your differential to include tick-borne diseases in children with fever and flu-like symptoms (headache and myalgia). Patients with Rocky Mountain Spotted Fever or ehrlichiosis lack a tick bite history in about 10 percent of cases, but may be exposed in tick-infested outdoor play areas. For RMSF, the typical rash is seen in 90 percent, but does not present until day 2 or 3 of illness and may be absent entirely in as many as 10 percent. In ehrlichiosis, rash is nonspecific and only present in about one-half of patients.

  2. Laboratory studies that may be helpful include CBC, BMP and LFT. Look for cytopenias, hyponatremia or transaminitis (more common with ehrlichiosis).

  3. In patients with compatible history, examination and/or laboratory findings, doxycycline is the drug of choice in all age groups and initiation should never be delayed to wait for results from tick serology (invariably negative during the first week). 


1. Genotype-Specific Measles Transmissibility: A Branching Process Analysis, Ackley, et al. Clinical Infect Dis 2018:66 (15 April).