By Carol A. Kemper, MD, FACP

Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center

Dr. Kemper reports no financial relationships relevant to this field of study.

Jump in Cocci Cases, Winter 2017

SOURCE: Bezold CP, Khan MA, Adame G, et al. Notes from the field: Increase in coccidioidomycosis — Arizona, October 2017-March 2018. MMWR Morb Mortal Wkly Rep 2018;67:1246-1247.

The largest number of cases of coccidioidomycosis ever reported in the state of Arizona occurred in December 2017 (17.2 cases/100,000). Most of the reported cases of coccidioidomycosis within the United States occur in California and Arizona, with a remarkably seasonal distribution. Generally, an increasing trend in cases is observed in the late summer to fall, peaking approximately in December, and then falling off by spring, probably as the result of wind and weather patterns. Observations from Arizona in fall to winter 2017 suggested a larger than expected number of cases were occurring, with this dramatic peak in cases in December 2017.

Compared with October 2016 to March 2017, when 3,050 cases were reported in Arizona, the total number of reported cases during the same time period in 2017-2018 was 4,827 cases (a 58% increase). The median age of cases in 2017-2018 was 56 years, and there was no apparent difference between gender. Ninety percent of the 2017-2018 cases lived in Maricopa County (Phoenix), Pima County (Tucson), or Pinal County. For Maricopa County alone, a 70.5% increase in cases was reported for the month of December 2017 (87 cases/100,000) compared with December of the previous year.

Reported cases of cocci may be based on serologic data alone and/or molecular, microbiologic, or histopathology supporting the diagnosis. On the chance that this observed increase in cases occurred because of some laboratory anomaly, researchers examined the proportion of cases diagnosed solely on the basis of coccidioidomycosis IgM antibodies by EIA. From October 2017 to March 2018, the proportion of cases diagnosed based on IgM serology alone was similar to that of the same time period the previous year (13% vs. 10.6%). Thus, no apparent change in laboratory technique explained the dramatic increase in observed cases.

Many attribute this increase to an effect of global warming, with changes in wind and precipitation. A similar increase in cocci cases was observed in California last winter. Comparing the months of January 2017 and January 2018, a total of 249 cases vs. 636 cases were reported in the state, respectively (a 155% increase). The annual upward trend in cocci cases in California should raise alarm bells: The total number of cases for every year for the past three years has increased (from 5,706 in 2016 to 7,534 in 2017 to 8,187 cases in 2018).

Although weather patterns may play a role, it is important to note that the Census Bureau reported that Maricopa County was the country’s fastest growing county from 2016 to 2017 (with 73,650 new arrivals). Phoenix ranked second in population growth in the United States from 2016 to 2017, now ranking as the fifth largest U.S. city.

All of those new arrivals, many of whom are older and retiring to Arizona, probably lack protective immunity to coccidioidomycosis, making them vulnerable newcomers to the state. Further, to accommodate all of these individuals, all of the construction and new housing in Phoenix and Tucson could only be kicking up more dust.

Who Knew the Ink Was Not Sterile?

SOURCE: Griffin I, Schmitz A, Oliver C, et al. Outbreak of tattoo-associated nontuberculous mycobacterial skin infections. Clin Infect Dis 2018; Nov 17. doi: 10.1093/cid/ciy979. [Epub ahead of print].

A diagnosis of nontuberculous mycobacterial (NTM) infection complicating new tattoos in three individuals from the same tattoo parlor in February-March 2015 prompted investigation by the Miami-Dade County Department of Public Health. As with crime scene investigations, the first step was to collect evidence at the scene. An initial interview revealed that the three tattoo artists working at the facility chose to dilute gray ink, some with distilled water or with tap water. To create more variation in shading, prediluted gray ink, in various strengths, can be ordered from the manufacturer, but apparently further gradations in shading were desired. Further, one particular bottle of diluted gray ink had been open and in use for several months (ink A).

A survey was administered to clients of the parlor during the same time period: 246 of 356 clients could be located, although 20 declined to participate. Investigators identified eight confirmed cases of NTM infection plus 30 other individuals with a suspect rash occurring at least two weeks after getting tattooed. Of these, 27 cases were male (71%), and the median age was 28 years (19 to 54 years of age). The 38 individuals reported a variety of symptoms, including (in descending order) papules/pustules at the site of infection (100%), redness (76%), itching (58%), swelling (26%), pain (26%), and fever (8%). The incubation period ranged anywhere from one to 59 days, and the duration of rash extended from 15 days to five months. When contacted later, eight people (38%) remained symptomatic six months or more later.

Only a minority of patients had sought medical care, and only four individuals reported taking medication when prescribed. More cases were identified after the tattoo parlor had stopped using ink A in April 2016. Among the eight confirmed cases, six tested positive for Mycobacterium abscessus or M. abscessus-chelonae complex (by culture and/or PCR) and one case tested positive for Mycobacterium fortuitum (by both PCR and culture). Interestingly, by PGFE analysis, the isolates appeared to be the same species, differing only by one or two bands.

All skin biopsies underwent histopathologic review, with special stains and PCR testing, and isolates were identified and compared using pulsed-field gel electrophoresis. In addition, environmental samples collected from tap water, sink taps, and gray wash ink were submitted to FDA laboratories for microbiologic testing and genome analysis. The tap water yielded multiple mycobacterial species (M. abscessus, M. fortuitum, M. mucogenicum, and two others). The open bottle of ink A grew M. abscessus and M. fortuitum. The five unopened bottles of ink of varying dilution grew M. chelonae and several molds.

Investigators used shotgun whole-genome sequencing to compare isolates (five from skin biopsies, three from tap water, and nine from gray wash ink) to four isolates from an American culture collection. Phylogenetic analysis suggested similarity between the M. fortuitum isolates from both the clinical case and ink A, but none of the clinical isolates matched the isolates in the unopened ink bottles. This suggests that contamination of ink A, diluted on site, likely was the source for the clinical infections, and not contamination at the manufacturer (although the unopened ink was contaminated with other pathogens). Samples of gray wash ink from five other tattoo parlors in the area also yielded five unrelated M. chelonae organisms.

Even though it is applied intradermally, tattoo ink is classified by the FDA as a “cosmetic agent.” As such, it does not need to be sterile, although regulations specify it should be free of “pathogens.” Similar to nail salons and hair parlors, the responsibility for regulating tattoo parlors and suppliers falls to individual counties. However, many counties, including Miami-Dade, do not have specific regulations for the use of tattoo ink. The Miami-Dade County health code stipulates that tattoo parlors should follow manufacturers’ guidelines for ink. There are none.

Somehow, with all that signage about “sterile needles” and “sterile technique,” who would imagine that the ink was a problem?

Homeless Population Requires Hepatitis A Vaccination

SOURCE: Foster M, Ramachandran S, Myatt K, et al. Hepatitis A virus outbreaks associated with drug use and homelessness — California, Kentucky, Michigan, and Utah, 2017. MMWR Morb Mortal Wkly Rep 2018;67:1208-1210.

A multistate outbreak of hepatitis A virus (HAV) infection in the homeless and/or drug-using population has prompted the United States Advisory Committee on Immunization Practices (ACIP) to add “homelessness” as an indication for HAV vaccination, effective Oct. 24, 2018. This indication is in addition to existing indications for HAV vaccination of men who have sex with men (MSM) and illicit drug users (with the exception of marijuana use).

During 2017, a total of 1,521 outbreak cases of acute hepatitis A infection were reported from California, Kentucky, Michigan, and Utah, mostly in the homeless and/or drug-using population. An outbreak case was defined as acute HAV infection with a viral specimen matching the outbreak strain or if the case could be linked with another identified case. Although HAV generally is transmitted by close personal or sexual contact and unsanitary conditions, this was the first time an outbreak was fueled, in part, by parenteral transmission from contaminated needles and other shared paraphernalia. This shift in the epidemiology of hepatitis A infection raised alarms for health officials.

Forty-one (3%) of the outbreak cases died and 1,073 (71%) were hospitalized. Three percent had confirmed hepatitis B co-infection and 22% had confirmed or probable hepatitis C co-infection. More than half (57%) reported homelessness and/or drug use, and 5% were MSM.

Increasingly, molecular techniques are used to identify outbreaks of HAV infection. For this investigation, serum samples submitted to the CDC were used to extract and amplify a fragment of the VP1/P2B region of the virus for genetic characterization. A total of 1,054 specimens were tested, 96% of which were positive for genotype 1b virus, which generally is an uncommon strain. Most clinical cases of HAV infection in the United States before 2017 have been due to genotype 1a virus. The genotype 1b strain circulating in California, Utah, and Kentucky was different from that found in the Michigan cases.

In California, the outbreak started in San Diego County in November 2016 and quickly spread to Los Angeles, Santa Cruz, and Monterey counties. In October 2017, Gov. Jerry Brown declared a state of emergency in order to secure a large number of doses of vaccine. Three California counties mounted an offensive, deploying vans to homeless encampments and distributing alerts to local clinics and emergency rooms. Approximately 123,000 doses of HAV vaccine were dispensed, effectively quelling the outbreak in this state.

Although aggressive public health intervention in California stopped the outbreak there, it continues in Kentucky, Michigan, and Utah and may be spreading to other states. As of October 2018, more than 7,000 cases of acute HAV infection have been reported from 12 states.