Morbidity and Mortality Weekly Report www.cdc.gov/mmwr Weekly January 4, 2008 / Vol. 56 / No. 51 & 52 Public Health Response to a Rabid Kitten — Four States, 2007 On July 24, 2007, the South Carolina Department of On July 18, the mother of a softball player from North Carolina, after learning from the coach that the kitten had Health and Environmental Control (SCDHEC) was noti- become ill and was subsequently euthanized, contacted the fied by the North Carolina Division of Public Health emergency animal hospital and asked whether the kitten (NCDPH) of a stray, rabid kitten that had been handled had been tested for rabies. The mother had been bitten by players on several girls’ softball teams during a tourna- while trying to feed the kitten during the tournament. ment in Spartanburg County, South Carolina. This report Rabies testing had not been planned by the animal hospi- summarizes the public health response to exposure to the tal because the coach’s housemate had signed a routine rabid kitten and highlights the importance of multistate release form indicating the kitten had not bitten anyone collaboration in a rabid animal investigation. during the preceding 10 days. The mother went to the During July 13-15, 2007, the South Atlantic Summer clinic, requested the cat’s body, and took it in her private Showdown softball tournament was held at a recreational vehicle to her local health department. On July 20, the complex in Spartanburg County. Softball games were held local health department sent the body to the North at four recreational facilities. Approximately 60 teams of Carolina State Laboratory for Public Health for rabies test- approximately 12 players each from multiple states par- ing. On July 23, the kitten had rabies diagnosed by direct ticipated in this tournament. Spectators at the tournament fluorescent antibody testing. The rabies virus was identi- included families and friends of the softball players and fied as the eastern United States raccoon variant by rabies tournament coordinators and staff members. monoclonal antibody typing. On July 14, a softball coach from a North Carolina team The mother provided her travel history to NCDPH, which found an apparently healthy and alert kitten in a barrel- then contacted SCDHEC on July 23 to alert the depart- shaped garbage bin located near one of the playing fields at ment about the possible human rabies exposures in which the tournament was held. The kitten was placed in Spartanburg County. NCDPH and SCDHEC obtained a a box and later brought to at least six different games played roster of teams from the tournament organizer and discov- at two recreational facilities that same day. That evening, ered that Georgia, North Carolina, South Carolina, and the kitten was transported by the coach in her private Tennessee all had teams participating in the tournament. vehicle to her home in Buncombe County, North Caro- NCDPH and SCDHEC contacted CDC and state public lina. On July 15, the kitten began behaving abnormally health authorities in Georgia and Tennessee, and all four and became increasingly lethargic. The coach's housemate brought the kitten to an emergency animal hospital in Buncombe County for care. Although further investigation INSIDE would reveal that the housemate had been bitten by the 1340 Norovirus Outbreak in an Elementary School — kitten, she did not disclose this to the attending veterinar- District of Columbia, February 2007 ian at the time of the visit. After evaluation indicated that 1343 Acute Pesticide Poisoning Associated with Pyraclostrobin the kitten was severely ill, the kitten was euthanized and Fungicide — lowa, 2007 held for cremation, planned for July 18. Rabies was not 1345 Notices to Readers suspected by the attending veterinarian. 1347 QuickStats DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION MMWR January 4, 2008 states subsequently initiated contact investigations; these The MMWR series of publications is published by the Coordinating investigations sought to identify and locate potentially Center for Health Information and Service, Centers for Disease exposed persons and ensure that only persons with actual Control and Prevention (CDC), U.S. Department of Health and exposures (i.e., contact with saliva, either through a bite, a Human Services, Atlanta, GA 30333. lick on the oral or nasal mucosa, or a claw scratch) received Suggested Citation: Centers for Disease Control and Prevention. postexposure prophylaxis (PEP). SCDHEC coordinated the [Article title]. MMWR 2007;56:[inclusive page numbers]. interstate investigation and led its own intrastate investi- Centers for Disease Control and Prevention gation to locate persons, assess exposures, and prescribe PEP Julie L. Gerberding, MD, MPH as warranted; in South Carolina, PEP is provided by the Director state to exposed persons as determined by SCDHE(¢ Tanja Popovic, MD, PhD Chief Science Officer Io locate potentially exposed persons, each state issued James W. Stephens, PhD advisories (e ‘o5O rlh rough } daily e-mails) to local health Associate Director for Science departments; additionally, South Carolina, Georgia, and Steven L. Solomon, MD North Carolina used local news media to alert the public Director, Coordinating Center for Health Information and Service and solicit responses from potentially exposed persons. South Jay M. Bernhardt, PhD, MPH Director, National Center for Health Marketing Carolina also activated the state’s 2-1-1 telephone infor- Katherine L. Daniel, PhD mation system, which uses media channels to aadda vise Deputy Director, National Center for Health Marketing public to call a dedicated state telephone number (2-1 Editorial and Production Staff for information related to specific public health emergencies. Frederic E. Shaw, MD, JD The multistate contact investigations and interviews of Editor, MMWR Series persons who had potentially been exposed to the kitten Suzanne M. Hewitt, MPA revealed that at least two other stray kittens of similar ag Managing Editor, MMWR Series as the rabid kitten were found in the parking lot of a fast Douglas W. Weatherwax Lead Technical Writer-Editor food restaurant near the garbage bin where the rabid kit- Catherine H. Bricker, MS ten was found. These stray kittens, which were possibly Jude C. Rutledge from the same litter as the rabid kitten, were reported by Writers-Editors interviewees to also have been present throughout the length Beverly J. Holland of the softball tournament; several softball players ha Lead Visual Information Specialist be : handled them. These kittens were never located by public Lynda G. Cupell , : , Malbea A. LaPete health authorities Interviewees were questioned about the Visual Information Specialists handli~n~ g of all1] of th1 e kittens to assess potential expr osure to Quang M. Doan, MBA rabies. Erica R. Shaver Health department personnel relied on the point-of- Information Technology Specialists contact for each te the coach, to identify per- Editorial Board sons who might have been exposed to tUnhiee kitten. If players William L. Roper, MD, MPH, Chapel Hill, NC, Chairman reported exposure, they were interviewed by health depart- Virginia A. Caine, MD, Indianapolis, IN ment personnel. Anecdotal evidence indicated that no tour- David W. Fleming, MD, Seattle, WA William E. Halperin, MD, DrPH, MPH, Newark, NJ nament spectators had handled the kitten; investigators were Margaret A. Hamburg, MD, Washington, DC unable to contact spectators because neither documenta- King K. Holmes, MD, PhD, Seattle, WA tion nor recorded entry of persons to any of the recreational Deborah Holtzman, PhD, Atlanta, GA John K. Iglehart, Bethesda, MD facilities was available. Dennis G. Maki, MD, Madison, WI Of the approximately 60 teams participating in the tour- Sue Mallonee, MPH, Oklahoma City, OK nament, 38 had players and associated family and friends Stanley A. Plotkin, MD, Doylestown, PA Patricia Quinlisk, MD, MPH, Des Moines, [A who reported exposure to the rabid kitten. From these Patrick L. Remington, MD, MPH, Madison, WI teams, 27 persons were identified as having exposures that Barbara K. Rimer, DrPH, Chapel Hill, NC warranted PEP: one from South Carolina, 15 from Georgia, John V. Rullan, MD, MPH, San Juan, PR and 11 from North Carolina; Tennessee reported no Anne Schuchat, MD, Atlanta, GA Dixie E. Snider, MD, MPH, Atlanta, GA exposed persons. All recipients of PEP had reported actual John W. Ward, MD, Aclanta, GA exposure to a kitten’s saliva, either through a bite, a lick on Vol. 56 / No. 51 & 52 MMWR 1339 the oral or nasal mucosa, or a claw scratch. No reports of thorough washing with soap and water (7). An apparently human rabies or adverse reactions to PEP were reported. healthy dog, cat, or ferret that bites a person should be Reported by: 1M Bretous, MD, South Carolina Dept of Health and confined and observed daily for 10 days (7). If the animal Environmental Control. DA Cole, DVM, PhD, Georgia Div of Public becomes ill or dies during this observation period, its brain Health. JR Dunn, DVM, PhD, Tennessee Dept of Health. C Williams, should be examined by a state laboratory for evidence of DVM, M Salyers, MD, North Carolina Div of Public Health. CE Rupprecht, rabies virus infection (/). If rabies is detected, prompt VMD, PhD, Div of Viral and Rickettsial Diseases; WR Daley, DVM, administration of PEP is indicated (7). If the animal is Office of Workforce and Career Development; KA Christian, DVM, EIS unavailable for testing, public health officials should be Officer, CDC. consulted (7). Editorial Note: Animal rabies-control programs, includ- The rabid kitten in this investigation was infected with a ing extensive vaccination campaigns implemented during raccoon rabies—virus variant. Most rabid domesticated ani- the 1940s and 1950s, resulted in a substantial decline of mals are infected with the terrestrial rabies—virus variant rabies in domesticated animals in the United States (/). associated with the geographic location of the animal (8). Domesticated animals accounted for 7.9% of all rabid ani- In the southeastern United States, the region in which this mals reported in the United States in 2006 (/), compared incident occurred, the raccoon rabies—virus variant predomi- with 82.6% in 1950 (2). nates (8). Raccoons have been recognized as a major reser- Despite this decline, stray animals, including cats, con- voir for rabies in the southeastern United States since the tinue to pose a risk for transmission of rabies to humans. 1950s (J). During 2006, a total of 49 states and Puerto Rico reported This investigation highlights the need for rabies- to CDC a total of 6,940 cases of rabies in wild (e.g., rac- prevention measures, such as continued rabies vaccination coons, bats, skunks, and foxes) or domesticated (e.g., cats, among domesticated animals and wild animal populations. dogs, and cattle) animals and three cases in humans (/). The investigation also demonstrates the importance of Of these reported rabid animals, 318 were cats, represent- interstate collaboration during a rabies response. Exposed ing 4.6% of all cases. This represents an 18% increase from persons were identified through cooperation among the 2005, when 269 cases of rabid cats were reported (/). Of states and CDC, which included daily conference calls and the 24 human rabies cases reported to CDC in the United e-mail exchanges among investigators in the affected states; States since 2000, none have been associated with expo- CDC participated in conference calls to provide additional sure to a rabid cat. The last documented case of human expertise. In this investigation, rapid, open, interstate col- rabies from exposure to a rabid cat was in 1975 (/). Never- laboration enabled the expeditious identification and pro- theless, the risk for human rabies from rabid cats in the phylactic treatment of exposed persons while preventing United States should not be discounted. unnecessary administration of PEP. In addition to the risk for rabies, exposure to rabid cats carries substantial economic implications for exposed per- Acknowledgments sons, health insurance companies, and health departments. [his report is based, in part, on contributions by L Ard, T Burgess, For example, in Maryland, during 1983-1986, approxi- C Caruso, MSW, E Cook, D Drociuk, J Gault, ] Gibson, MD, mately 194 persons received PEP at a total cost of nearly D Goolsby, DVM, J] Mason, E Mays, M Parrott, MSEH, R Turner, $68,000 because of rabid cat exposures (3). In New Hamp- M Wyse, J Wright. Div of Acute Disease Epidemiology, South Caro- lina Dept of Health and Environmental Control; Georgia Public Health shire, in 1994, approximately 600 persons received PEP Districts 1-1, 1-2, 2-0, 3-1, 3-2, 3-4, 4-0, and 5-2; M Vello, MPH, after potential exposure to a single rabid cat, at a cost of Georgia Div of Public Health; North Carolina Amateur Softball Assoc; approximately $1 million for biologics alone (4). During Virology Section, North Carolina State Laboratory for Public Health; 1995-2000, cats accounted for 523 (24%) of 2,216 ani- M Buchanan, MD, Knox County Health Dept; M Zylstra, mal rabies exposures requiring PEP reported by four coun- Chattanooga-Hamilton County Health Dept; McLean County ties in upstate New York (5). Health Dept; C Austin, DVM, PhD, Communicable Disease Pro- Measures to reduce rabies exposures among humans by gram, Illinois Dept of Public Health; and J Blanton, MPH, R Franka, promotion of responsible pet ownership and routine vacci- DVM, PhD, L Orciari, MS, A Tumpey, MPH, P Yager, Div of Viral nation of cats remain public health priorities. Children and Rickettsial Diseases, CDC. should be taught to be cautious in their interactions with References animals, especially those that are unfamiliar, to avoid 1. Blanton JD, Hanlon CA, Rupprecht CE. Rabies surveillance in the potential exposures to rabies and other infectious diseases United States during 2006. ] Am Vet Med Assoc 2007;231:540—56. (6). First aid for animal bites and scratches should include 1340 MMWR January 4, 2008 Hourrigan JL. Reported incidence of rabies in the United States. classes outside their classroom each day (e.g., art or math), Animal Disease Eradication Division notice. Washington, DC: US they spent the majority of time in their own classrooms. Department of Agriculture; 1959:1-4. Fogelman V, Fischman HR, Horman JT, Grigor JK. Epidemiologic and No outbreaks of gastrointestinal illness in the community clinical characteristics of rabies in cats. ] Am Vet Med Assoc were reported to DCDOH during this period. 1993;202:1829-—33. A case of gastrointestinal illness was defined as illness in CDC. Mass treatment of humans exposed to rabies—New Hampshire, 1994. MMWR 1995;44:484-6. a student or staff member who reported nausea, vomiting, . Blanton JD, Bowden NY, Wyatt JD, et al. Rabies postexposure prophy or diarrhea and who was present at the school any time laxis, New York, 1995—2000. Emerg Infect Dis 2005;11:1921-7. during February 2-18. A questionnaire was developed to co D¢ a ompendium of measures to prevent disease associated with use in a cohort study of all staff members and students. animals in public settings, 2007. MMWR 2007;56(No. RR-5). CDC. Human rabies prevention—United States, 1999. Recommenda- Because no food was served at the school other than lunches tions of the advisory committee on immunization practices. MMWR that students brought from home and prepackaged snacks 1999:48(No. RR-1). served in prekindergarten classes, foodborne transmission McQuiston JH, Yager PA, Smith JS, et al. Epidemiologic characteris- tics of rabies virus variants in dogs and cats in the United States, 1999. was not suspected; questions focused on illness onset, symp- } Am Vet Med Assoc 2001;218:1939-—42 toms, school grade, classroom, special classes (e.g., art), ill contacts, and use of certain facilities or equipment (e.g., library computers) or participation in certain programs (e.g., after-school programs). Questionnaires were sent home by Norovirus Outbreak the school principal with all staff members and students in an Elementary School — the afternoon of February 9. The school nurse identified District of Columbia, February 2007 additional cases beginning February 9 by visiting each class- room daily; she interviewed persons who became ill during On February 8, 2007, the District of Columbia Depart- school and interviewed absent ill persons or a family mem- ment of Health (DCDOH) was notified of an outbreak of ber by telephone regarding grade, classes, illness onset, and acute gastroenteritis in an elementary school symptoms. Information regarding ill contacts, facility and (prekindergarten through sixth grade). The school nurse equipment use, and participation in programs was unavail- reported that 27 students and two staff members had able from the participants enrolled by the nurse. become ill during February 4-8 with nausea, vomiting, Of 314 students and 66 staff members at the school, and diarrhea; because symptoms lasted <48 hours, a viral 207 (66%) students and 59 (89%) staff members partici- etiology was suspected. DCDOH recommended two pated in the DCDOH investigation, for a total of 266 par- preinvestigation interventions, which were implemented ticipants (70%). A total of 225 (85%) were identified by the same evening (February 8): 1) more thorough using the questionnaire, and 41 (15%) were identified by handwashing and 2) bleach cleaning of all shared environ- the school nurse interview. Of 266 participants, 103 (39%) mental surfaces with a diluted (1:50 concentration) house- met the case definition. Among the 103 ill persons, 79 hold bleach solution. This report summarizes the subsequent (77%) were students and 24 (23%) were staff members. investigation of the outbreak, which suggested that The median age of students was 8 years (range: 3—12 years) noncleaned computer equipment (i.e., keyboards and mice) and of staff members was 41 years (range: 13-66 years). A and person-to-person contact resulted in illness. To decrease total of 42 of 77 (55%) students and 22 of 24 (92%) staff disease transmission during gastroenteritis outbreaks, public members were female. Illness onset occurred during health officials should emphasize good handwashing prac- February 4—17, with peak incidence on February 7 (Figure). tices, exclusion of ill persons, and thorough environmental Reported symptoms included vomiting (64%), nausea disinfection, including fomites that are shared but not (56%), and diarrhea (47%). Median illness duration was commonly cleaned. 36 hours (range: 0.2-96 hours). Median length of stay at home after onset of symptoms was | day (range: 0-4 days). Epidemiologic Investigation The attack rate (AR) among respondents was 39% over- On February 9, DCDOH conducted a site visit and all; ARs did not differ significantly between students and interviewed school personnel to determine the possible eti- staff members or between females and males (Table). Class- ology of and risk factors for illness and to recommend room ARs ranged from 18% (kindergarten classroom G) to additional control measures. The school had two to three 71% (first-grade classroom J). Illness was not significantly classes per grade, and one to three staff members were associated with grade, location (i.e., floor) of classroom, assigned to each class. Although students attended a few special classes, or certain facilities or programs. Two factors Vol. 56 / No. 51 & 52 MMWR 1341 FIGURE. Number of identified cases (N = 103) in a school gastroenteritis outbreak, were significantly associated with ill- by date of symptom onset — District of Columbia, February 2—18, 2007 ness in bivariate analyses (p<0.05, 20 Fisher's exact test): being in first-grade GB Staff members [—] Students Department of health notified classroom J (AR = 71%; relative risk Certain shared surfaces cleaned with bleach [RR] = 1.9; 95% confidence interval Site visit, environmental samples taken Weekend [Cl] = 1.3—2.8) and contact with an Stool specimens received ill person (AR = 38%; RR = 1.8; Norovirus identified Cl] = 1.2-2.7). Using a multivariable Snow day Computers model, being in classroom J and hav- oNcfoa. s es cleaned; ill persons ing an ill contact also were the only kept home 72 hours two independent and significant risk factors after backward elimination. First-grade classroom J was the only classroom in the school in which com- 10 puters were shared among students February and staff members. Students in all Date other classrooms either had their own TABLE. Attack rate and relative risk for illness among participants in a school gastroenteritis investigation (N = 266), by risk factor* — District of Columbia, February 2007 Persons with risk factor Persons without risk factor Attack Attack Relative Risk factor Total il rate (%) Total ll rate (%) risk (95% Clit) p value§ Being a student 207 79 38 59 24 41 0.94 (0.66—1.34) 0.76 Being female 159 64 40 104 37 36 1.13 (0.82—1.56) 0.52 Having an ill contact! 90 34 135 21 1.76 (1.16-2.67) 0.01 Ciassroom (grade) A (prekindergarten) 10 256 39 1.03 (0.48-2.24) 1.00 B (prekindergarten) 14 252 38 1.11 (0.60—2.08) 0.78 C (prekindergarten) 10 256 39 0.77 (0.29-2.00) 0.75 D (prekindergarten) 255 39 0.94 (0.42-2.08) 1.00 E (kindergarten) 258 0.97 (0.39-2.40) 1.00 F (kindergarten) 255 0.70 (0.26—1.85) 0.54 G (kindergarten) 255 0.46 (0.13—1.62) 0.21 H (kindergarten—first) 252 0.73 (0.31—1.69) 0.58 | (first) 256 1.31 (0.69-—2.47) 0.52 J (first) 252 1.94 (1.34-2.80) 0.02 K (second) 253 1.42 (0.84—2.40) 0.26 L (second) 253 0.99 (0.49-2.01) 1.00 M (third) 253 0.99 (0.49-2.01) 1.00 N (third) 27 251 0.68 (0.29—1.59) 0.42 O (fourth) 33 251 0.85 (0.41—1.78) 0.79 P (fourth) 50 250 1.32 (0.79-2.20) 0.43 Q (fifth) 33 257 0.86 (0.34—2.19) 1.00 R (fifth) 50 258 1.30 (0.64—2.65) 0.71 S (sixth) 29 259 0.73 (0.22-2.39) T (sixth) 12 OANAW4O2 WMAUTUN25O4 DTENWWHAWADS (0.54-2.15) Other Library use 60 16 27 165 (0.58—1.52) Library computer use 10 3 30 215 (0.41—2.84) * Certain rows do not add to total (N = 266) because of missing responses. 95% confidence interval of the calculated relative risk. «Fisher's exact test, two-tailed. ‘Data available only for respondents identified through the questionnaire, not for those identified through the school nurse interview. 1342 MMWR January 4, 2008 computer or shared library computers. Library computer Because of shared computer use in health-care facilities, use was not associated with illness, and no students in class- schools, and workplaces, certain researchers have suggested room J reported using library computers. that computer equipment might be a route of bacterial dis- ease transmission (5). A surrogate marker for norovirus, Laboratory Investigation feline calicivirus, has been shown to persist on computer mice and keyboards for 8—48 hours (6). Stool-specimen collection kits were provided during the This outbreak is the first report of norovirus detected on DCDONH site visit on February 9, and specimens were a computer mouse and keyboard, which highlights the received from two ill persons. Twenty-five swabs were used possible role of computer equipment in disease transmis- to sample environmental surfaces. Although February 9 was sion and the difficulty in identifying and properly disin- the day after the initial bleach cleaning, several surfaces fecting all possible environmental sources of norovirus had not been cleaned and were visibly soiled. Sampled sur- during outbreaks. The contaminated computer was located faces included toilets, faucets, water fountains, doorknobs, in first-grade classroom J, the only classroom that was mice and keyboards from three computers (each in a differnt independently associated with illness and the only class- room), school utensils, and toys. Samples were tested by room in which computers were shared by students and staff reverse transcription—polymerase chain reaction (RT-PCR) members. No other high-risk modes of transmission for norovirus and DNA sequencing; stool specimens also explain the increased attack rate in classroom J; for example, were cultured for bacteria. no food was served, water-fountain samples were negative Laboratory results were available February 13. One (4%) for norovirus, and no episodes of vomiting were reported. of the 25 environmental swabs, from a computer mouse These factors, together with previously documented hand- and keyboard in first-grade classroom J, was positive for to-fomite and fomite-to-hand norovirus transmission, sug- norovirus subtype GII. Norovirus subtype GII also was gest that computer contamination might have played a role identified in both stool specimens. Noroviruses from the in norovirus transmission in classroom J and possibly two stool specimens and a single environmental sample were elsewhere in the school. identical by DNA sequencing of region B, the gene com- Person-to-person contact also likely played a role in this monly used for genetic classification. Bacterial cultures of outbreak. Contact with an ill person was one of two signifi- stool specimens and environmental samples were negative. cant risk factors for illness in bivariate and multivariable On February 15, DCDOH recommended the following analyses. School children might be at increased risk for additional interventions: 1) clean computer equipment (e.g., person-to-person norovirus transmission because of close mice and keyboards) and other shared surfaces that were overlooked during the February 8 cleaning with a 1:50 con- quarters and poor hygiene (7). Because an ill person is infectious while symptomatic and possibly for 3-14 days centration household bleach solution, and 2) exclude ill or longer after recov ery because of continued fecal shed- persons from school for at least 72 hours after resolution of illness because of continued fecal shedding of infectious ding, the short exclusion time of ill persons from school virus (/). The last person reported with a case of illness had (median: 1 day after symptom onset) might have facili- symptom onset February 17 (Figure). tated person-to-person transmission in this outbreak. Stu- dent person-to-person contact during the weekend was Reported by: RD iggs, MPH, A Diallo, PhD, H Kan, PhD, C Glymph, reported anecdotally, and onset of new cases continued MPH, BW Furness, MD, District of Columbia Dept of Health. S] Chai, MD, EIS Officer, CDC. after the weekend. The findings in this report are subject to at least four Editorial Note: Norovirus (family Caliciviridae) causes the limitations. First, because data regarding ill contacts, majority of acute gastroenteritis outbreaks in the United facilities, and program participation were unavailable for States (2). Person-to-person spread through the fecal-oral nurse-interviewed participants, bivariate and multivariable route, contaminated food and water, and aerosolized vomi- analyses of these variables were limited to data from survey tus are known to transmit norovirus; contact with contami- respondents. Second, certain uninfected persons might have nated environmental surfaces also has been implicated in been misclassified as ill because of the broad case defini- transmission (3). Laboratory studies have demonstrated that tion and subjective reporting of symptoms, which might fingers contaminated with norovirus can transfer the virus have resulted in an overestimate of ARs. Third, data were to environmental surfaces, which can subsequently contami- not collected regarding which students in classroom J used nate clean fingers with detectable amounts of norovirus (4). computers; consequently, the risk associated with computer Vol. 56 / No. 51 & 52 MMWR 1343 contact could not be directly assessed. Finally, because . Rutala WA, White MS, Gergen MF, Weber DJ. Bacterial contamina- tion of keyboards: efficacy and functional impact of disinfectants. several fomites were cleaned before sampling and not all Infect Control Hosp Epidemiol 2006;27:372-7. fomites were sampled, the extent of environmental . Clay $, Maherchandani S, Malik YS, Goyal SM. Survival on uncom- contamination and the possible transmission role of fomites mon fomites of feline calicivirus, a surrogate of noroviruses. Am J Infect Control 2006;34:41-3. unrelated to computers could not be characterized. . Marks PJ, Vipond IB, Regan FM, Wedgwood K, Fey RE, Caul EO. A Proper washing with soap and water can eliminate school outbreak of Norwalk-like virus: evidence for airborne trans- norovirus from hands (4); alcohol-based sanitizers also mission. Epidemiol Infect 2003;131:727-36. reduce feline calicivirus on hands (8). Potentially (but . KampfG , Grotheer D, Steinmann J. Efficacy of three ethanol-based hand rubs against feline calicivirus, 2 surrogate virus for norovirus. nonvisibly) soiled surfaces are best disinfected with a solu- J] Hosp Infect 2005;60:144-9. tion of 1:50 to 1:10 concentration of household bleach in . CDC. “Norwalk-like viruses”: public health consequences and out water (1,000-—5,000 ppm chlorine) by vigorous wiping for break management. MMWR 2001;50(No. RR-9). . Duizer E, Bijkerk P, Rockx B, De Groot A, Twisk F, Koopmans M. >10 seconds (4,9). However, because a 1:10 household Inactivation of caliciviruses. Appl Environ Microbiol 2004;70:4538-43. bleach solution is caustic, only corrosion-resistant surfaces should be cleaned with this concentration. Laptop com- puter keyboards have been shown to withstand >300 dis- infections with 80 ppm bleach solution without visible Acute Pesticide Poisoning deterioration (5). When cleaning environmental surfaces Associated with Pyraclostrobin that are visibly soiled with feces or vomitus, masks and gloves Fungicide — lowa, 2007 should be worn, a disposable towel soaked in dilute deter- gent should be used to wipe the surface for >10 seconds, Pyraclostrobin is an agricultural pesticide product used and a 1:10 household bleach solution should then be to kill fungi (e.g., blights, mildews, molds, and rusts). applied for >1 minute (4,9). Disposable towels used to clean Hazards to humans from pyraclostrobin exposure include visibly soiled surfaces should be discarded appropriately eye injury and skin irritation (/). In July 2007, the lowa after use because they can transfer norovirus to fingers and Department of Public Health (IDPH) received reports of other surfaces (4). Although quaternary ammonium five events involving pyraclostrobin that sickened 33 per- toad compound-based cleaners typically are not recommended sons, including 27 migrant workers who were exposed in a for eliminating norovirus, certain newer formulations* are single incident during aerial application (i.e., crop dust- effective; alcohol-only cleaners are less effective (/0). ing). This report describes those five events and provides recommendations for preventing additional illnesses Acknowledgments associated with exposure to pyraclostrobin. [his report is based, in part, on contributions by J Davies-Cole, Event A. On July 23, 2007, IDPH received media PhD, District of Columbia Dept of Health; S$ Lyss, MD, and J Blair, reports that migrant workers in a field had been inadvert- PhD, Office of Workforce and Career Development, CDC. ently exposed to pyraclostrobin fungicide by a crop-duster References plane on July 22. An IDPH investigation identified 27 cases 1. CDC. Norovirus: technical fact sheet. Atlanta, GA: US Department of of acute illness among the potentially exposed workers; all Health and Human Services, CDC; 2006. Available at http:// illnesses were associated with off-target drift of the www.cdc.gov/ncidod/dvrd/revb/gastro/noro-factsheet.pdf. . Blanton LH, Adams SM, Beard RS, et al. Molecular and epidemio- pyraclostrobin to an adjacent field, owned by a different logic trends of caliciviruses associated with outbreaks of acute gastro- grower, where workers were detasseling field corn. IDPH enteritis in the United States, 2000-2004. J] Infect Dis learned that the pilot had seen the nearby workers yet pro- 2006;193:413-21. Wu HM, Fornek M, Schwab KJ, et al. A norovirus outbreak at a long ceeded to apply the fungicide. Some workers reported feel- term-care facility: the role of environmental surface contamination. ing wet droplets on their skin and seeing mist coming from Infect Control Hosp Epidemiol 2005;26:802-10. the aircraft. . Barker J, Vipond IB, Bloomfield SF. Effects of cleaning and disinfec- tion in reducing the spread of Norovirus contamination via environ- All 27 persons with acute illness were Hispanic and resi- mental surfaces. J Hosp Infect 2004;58:42-9. dents of Texas. Twenty were male, and seven were female; median age was 46 years (range: 15-74 years). All received skin decontamination on-site by a hazardous materials team *A list of cleaning products effective against norovirus approved by the before being transported to an emergency department for Environmental Protection Agency is available at http://www.epa.gov/oppad00 1/ list_g> norovirus. pdf. observation until their symptoms resolved. All cases were 1344 MMWR January 4, 2008 categorized as being of low severity.* The most common pain, headache, and dizziness after pyraclostrobin drifted symptom was upper respiratory tract pain or irritation into the yard of their home. On July 14, a man and woman (26 patients), followed by chest pain (20 patients). Three both aged 20 years reported eye pain and conjunctivitis patients had nausea, and one patient each had pruritis, skin after pyraclostrobin drifted into the yard of their home. In redness, eye pain, weakness, headache, dizziness, and chest all five of these cases, symptoms subsided after the exposed pain. persons moved indoors or away from the pyraclostrobin- The Iowa Department of Agriculture and Land Steward- treated fields. ship (IDALS) began an investigation on July 23 that Reported by: RM Gergely, MAg, BW Hokel, lowa Dept of Public Health. included collection of soil and vegetation samples from the GM Calvert, MD, Div of Surveillance, Hazard Evaluations, and Field cornfield where the detasselers had been working and Studies, National Institute for Occupational Safety and Health; SE samples of worker safety glasses and hats. All samples tested Luckhaupt, MD, EIS Officer, CDC. positive for pyraclostrobin, even though the samples were Editorial Note: The cases described in this report are the collected the day after pyraclostrobin application and after first published accounts of human illness caused by substantial evening rainfall. Before this incident, the field exposure to pyraclostrobin or any of the other strobilurin had not been treated with pesticide (i.e., herbicides con- chemical compounds used as agricultural fungicides. taining atrazine and topramezone) for 40 days. On August Pyraclostrobin has a toxicity category of II‘; the product 1, IDALS suspended the commercial pesticide applicator label warns that pyraclostrobin exposure can cause substan- license of the crop-dusting company that applied the fun- tial, although temporary, eye injury and skin irritation but gicide; an administrative law judge later revoked the license. can be fatal if swallowed (/). Contact with eyes, skin, or Event B. On July 20, a crop-duster pilot aged 55 years clothing should be avoided. After a cornfield has been treated visited an emergency department with first-degree chemi- with pyraclostrobin, workers should be prohibited from cal burns after skin and inhalational exposure to entering that field for 7 days to perform detasseling unless pyraclostrobin fungicide that occurred when his plane they are wearing appropriate personal protective equipment crashed during takeoff, spilling the liquid fungicide. Emer- (i.e. coveralls and chemical-resistant gloves) (/). Although gency department personnel consulted the Iowa Poison upper respiratory symptoms are not mentioned on the Center (IPC), and IDPH was notified of the case. The pilot product iabel warnings, 26 of the 27 workers exposed in was admitted to the hospital for observation for 2 days, event A experienced these symptoms, perhaps as a result of and the case was categorized as being of moderate severity. irritation of the upper respiratory mucosa by a mechanism Although inhalational exposure occurred, the pilot reported similar to that causing skin and eye irritation. no respiratory symptoms. The strobilurin fungicides, including pyraclostrobin, are Events C, D, and E. During July 2007, IPC notified relatively new to the U.S. agricultural market. Pyraclostrobin IDPH of three additional events involving five cases of acute was approved for sale in the United States in 2002 for use pesticide poisoning associated with pyraclostrobin expo- on a limited number of crops but was not approved for use sure that resulted from off-target drift of pyraclostrobin on corn until December 2004. During 2007, the first year from nearby aerial applications. All five illnesses were of of widespread use on field corn, pyraclostrobin was applied low severity; all persons who were exposed consulted IPC to an estimated 1.5 million acres of corn in lowa but did not otherwise seek medical care. On July 5, a man (C. Eckermann, IDALS, personal communication, 2007). aged 54 years experienced headache and eye pain after Increased use of pyraclostrobin on corn likely is attribut- pyraclostrobin exposure while riding a motorcycle near a able to several factors, including increased planting of corn field. On July 12, a woman aged 40 years reported eye in the same field in successive seasons, which is associated pain and headache, and a man aged 49 years reported eye with increased fungal disease risk to the corn plant; high demand for corn to produce corn-based ethanol; and * Severity was categorized by using the standard index of the National Institute for aggressive fungicide marketing by agricultural-chemical Occupational Safety and Health (available at http://www.cdc.gov/niosh/topics/ dealers (2,3). In addition, strobilurin fungicides, especially pesticides). Moderate-severity illness or injury consists of non-life threatening health effects that generally are systemic and require medical treatment. No residual disability is detected, and time lost from work or normal activities " The Environmental Protection Agency classifies pesticides into one of four toxicity usually does not exceed 5 days. Low-severity illness or injury includes illnesses categories based on established criteria (40 CFR § 156.62). Pesticides with the manifested by skin, eye, or upper respiratory irritation. These illnesses might greatest toxicity are in category I, and those with the least toxicity are in category also include fever, headache, fatigue, or dizziness. Typically, the illness or injury IV. Additional information is available at http://a257.g.akamaitech.net/7/257/ resolves without treatment, and time lost from work or normal activities is <3 2422/08aug20031600/edocket.access.gpo.gov /cfr_2003/ julqtr/pdf/ days. 40ctrl 56.60. pdf. Vol. 56 / No. 51 & 52 MMWR 1345 pyraclostrobin, might increase corn yield in the absence of pesticide label requirements. Pesticide applicators must disease by directly stimulating plant growth, although field avoid aerial applications of pesticides when workers are in trials to document this have produced inconsistent results nearby fields, application methods must minimize off- (4). No cases of illness related to exposure to trifloxystrobin target drift of pesticides, and farmers should consider the and azoxystrobin, the other two strobilurin fungicides potential adverse health effects on humans when weighing licensed in lowa, were reported to IDPH during 2006 or the risks and benefits of pesticide use. Greater use by crop- 2007. dusting pilots of educational programs offered by the The 27 workers sickened in event A were detasseling corn National Agricultural Aviation Association (e.g., Professional . : a , + ‘ (i.e., removing tassels from corn plants to prevent auto- Aerial Applicator Support System’) also might help reduce pollination and enable hybridization). Although the field the incidence of acute illnesses resulting from exposure to where these workers were detasseling had been treated pre- pesticide. viously with atrazine and topramezone, both of which can References produce mucosal irritation, 40 days had elapsed since that . BASF Corporation. Headline™ fungicide. Research Triangle Park, NC: treatment. Workers may return to a field 12 hours after BASF Corporation; 2004. Available at http://www.cdms.net/Idat/ 1d621030.pdf. such treatments. Therefore, these herbicides were unlikely . Bradley CA, Montgomery M. Prophylactic fungicide applications on to be responsible for the illnesses reported July 22. corn: a good practice? The bulletin: pest management and crop devel- In the United States, cases of pesticide-related illness and opment information for Illinois. No. 11 Article 6/June 8, 2007. Avail- able at http://www.ipm.uiuc.edu/bulletin. injury are identified through state-based surveillance sys- . Robertson A, Mueller D, Pilcher C, Schaefer K. Fungicide applications tems, several of which are supported by the National Insti- in corn may be increasing. Integrated crop management. June 25, 2007. tute for Occupational Safety and Health (NIOSH) through Available at http://www.ipm.iastate.edu/ipm/icm. 4. Nafziger E. Can foliar fungicide raise corn yield when there’s little the Sentinel Event Notification System for Occupational disease? The bulletin: pest management and crop development informa- Risk (SENSOR)-Pesticides program. Data from SENSOR- tion for Illinois. No. 14 Article 10/June 29, 2007. Available at http:// Pesticides and the California Department of Pesticide Regu- www.ipm.uiuc.edu/bulletin. lation were reviewed to identify cases associated with oa : ss pyraclostrobin exposure through 2005. A total of 12 cases Information available at http://www.agaviation.org/paass.htm. were identified; however, only one of these cases was asso- ciated with pyraclostrobin application to corn. The other Notice to Readers cases were associated with applications to grapes (five cases), Requirements for Use of a New other fruits (four), almonds (one), and tomatoes (one). One International Certificate of Vaccination case occurred in 2003 in Michigan, three cases occurred in 2004 in California, and eight cases occurred in 2005 in or Prophylaxis for Yellow Fever Vaccine California (six cases), Florida (one), and Washington (one). In response to the 2005 revision of the International All cases were work related; six occurred among pesticide Health Regulations (IHR 2005), as of December 15, 2007, handlers, five occurred during routine agricultural work (not a new International Certificate of Vaccination or Prophy- involving pesticide application), and one occurred in a laxis (ICVP) has replaced the old certificates (/). The new mosquito-control worker in a vineyard treated with certificate provides space for potential certification of addi- pyraclostrobin. Patients reported combinations of skin, eye, tional types of vaccination or prophylaxis to protect against respiratory, gastrointestinal, nervous system/sensory, and newly emerging or reemerging diseases or other events of systemic symptoms. Two cases were of moderate severity, public health importance. However, the only vaccination and 10 were of low severity. None of the patients were currently required to be indicated on the ICVP is for hospitalized. yellow fever. The events described in this report reinforce the impor- Yellow fever vaccine is required under IHR 2005 by cer- tance of compliance with existing pesticide regulations and tain countries for entry, and the new ICVP is required for any yellow fever vaccination administered beginning December 15, 2007. Persons vaccinated before that date » Through SENSOR-Pesticides, NIOSH provides funding and technical support to state health departments to conduct surveillance of acute, occupational, pesticide- may use the old certificate until it expires 10 years from related illness and injury. Health departments in 10 states (Arizona, California, the date of vaccination. Florida, Louisiana, Michigan, New Mexico, New York, Oregon, Texas, and The new certificates are available to health-care provid- Washington) participated through 2005. lowa joined the program in October 2006. Additional information is available at http://www.cdc.gov/niosh/topics/ ers through the U.S. Government Printing Office (GPO). pesticides. 1346 MMWR January 4, 2008 The new ICVPs are available for order from GPO online at symposia on innate immunity, cutaneous vaccination, ad- http://bookstore.gpo.gov/collections/vaccination.jsp, or by juvants, universal influenza vaccination, and recently licensed telephone (866-512-1800). Additional information regard- vaccines. Six oral sessions and posters will include presen- ing the new requirement is available from the CDC Travel- tations selected through peer review from submitted ab- ers’ Health Team by telephone (404-639-4500) or online stracts. Eligible abstracts will be considered for the Maurice via the Travelers’ Health website at http://wwwn.cdc.gov/ R. Hilleman Early-Stage Career Investigator Award, which travel/contentintcertofvaccination.aspx. provides $10,000 for research expenses and a travel stipend Reference and registration for the 2009 conference. 1. World Health Organization. International health regulations (2005). Deadline for submission of abstracts is February 15, 2008. Geneva, Switzerland: World Health Organization; 2005. Available at Information about the preliminary program, abstract hetp://www.who.int/csr/ihr. submission, registration, hotel accommodation, and exhi- bition space is available at http://www.nfid.org/conferences/ Notice to Readers vaccine08, and by e-mail ([email protected]), fax (301-907- 0878), telephone (301-656-0003, ext. 19), and mail 11th Annual Conference on Vaccine (NFID, Suite 750, 4733 Bethesda Avenue, Bethesda, MD Research 20814-5278). CDC and 11 other national and international agencies and organizations will collaborate with the National Foun- dation for Infectious Diseases in sponsoring the 11th Errata: Vol. 56, No. 49 Annual Conference on Vaccine Research: Basic Science, In Table III, “Deaths in 122 U.S. cities, week ending Product Development, and Clinical and Field Studies, to December 8, 2007 (49th Week),” on page 1304, incorrect be held May 5-7, 2008, at the Marriott Waterfront Hotel, pneumonia and influenza mortality data were listed for Baltimore, Maryland. The conference is the largest scien- certain reporting areas under the column heading, “P&I tific forum devoted exclusively to the research and dev el- Total.” The correct data are as follows: Jersey City, NJ, 2; opment of vaccines and related technologies for prevention Canton, OH, 2; St.Louis, MO, 3; Charlotte, NC, 10; and treatment of disease through immunization, bringing Knoxville, TN, 10; Mid. Atlantic, 103; E.N. Central, 136; together human and veterinary vaccinology researchers. W.N. Central, 47; S. Atlantic, 66; E.S. Central, 68; and [wenty-two invited speakers will appear at five special Total, 734.