CONTROL. Volume 31, Number 4 (pages 29-36) June West Nile Virus: An Update for Minnesota Medical Providers

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1 MINNESOTA DEPARTMENT OF HEALTH DISEASE CONTROL N EWSLETTER Volume, Number (pages 9-6) June 00 West Nile Virus: An Update for Minnesota Medical Providers West Nile virus (WNV) was documented in Minnesota for the first time in 00 as part of an intense national outbreak. The Minnesota Department of Health (MDH) is continuing surveillance for this virus in 00. This update describes the 00 outbreak, provides additional information about WNV, and provides instructions for submitting clinical specimens from suspected WNV and other arboviral encephalitis case-patients to the MDH Public Health Laboratory. History and Range of West Nile Virus WNV was first isolated from a febrile woman living in the West Nile province of Uganda in 97. The virus is in the family Flaviviridae and the Japanese Encephalitis Antigenic Complex (which also includes Alfuy, Japanese Encephalitis, Kokobera, Koutango, Murray Valley, Kunjin, St. Louis encephalitis, Stratford, and Usutu viruses). The first recorded outbreak occurred in Israel during the 90s, and WNV is now recognized as one of the most widespread flaviviruses. Along with its current range in North America, endemic transmission occurs in Africa, Southern Europe, and Western Asia. In late summer of 999, the first domestically acquired human cases of West Nile encephalitis in the United States were documented in the New York City area. Concurrently, WNV caused a large epizootic among wild birds (especially American Crows) in the same area. Since then, WNV has quickly spread to states and the District of Columbia in the United States, five Canadian provinces, two Mexican states, and the Cayman Islands. Exactly how WNV was introduced into the United States is not known. However, the most likely mechanism is that infected mosquitoes or birds were accidentally transported here. West Nile Virus Transmission Cycle WNV is maintained and circulated in a complex cycle involving several species of mosquitoes and wild birds. Infected mosquitoes feed on birds, some of which act as amplifying hosts for the virus. This cycle continues throughout the summer. By mid- to late summer, conditions for virus transmission to mammals have peaked with a large population of vector-competent infected mosquitoes. In addition, mosquitoes that feed on birds in the spring and early summer are believed to often switch to mammalian hosts for blood meals later in the summer. It has been hypothesized that mosquitoes make this switch because juvenile birds that provided an easy meal have matured, and birds have improved defensive behaviors (ruffling of feathers and twitching) that deter mosquitoes. It is not known how WNV survives northern winters, but it is believed the virus can be maintained in an area by over-wintering infected adult female mosquitoes or chronically infected resident birds, and/or be reintroduced in the spring by migratory birds. The West Nile Virus Outbreak in the United States and Minnesota, 00 The WNV outbreak that occurred in the United States in 00 was the largest outbreak of arboviral disease ever recorded in the Western Hemisphere. During 00,,6 human cases were confirmed in 9 states and the District of Columbia; this total included 8 fatalities. The median age of WNV cases was years (range, to 99 years). The median age of fatal WNV cases was 77 years (range, 9 to 99 years). By the end of 00, only Alaska, Hawaii, Oregon, Nevada, Utah, and Arizona had not reported WNV activity in humans, horses, birds, or mosquitoes (Figure ). In 00, WNV was detected in Minnesota in humans, horses, birds, and mosquitoes. There were 8 human cases reported from Minnesota counties (Figure ). Thirty-one (6%) of the 8 Minnesota cases were diagnosed with West Nile fever (WNF), the less severe end of the clinical spectrum, seven (%) of the cases had aseptic meningitis, and nine (9%) had encephalitis. Acute flaccid paralysis was observed in three (6%) of the cases (two of these three cases also had encephalitis). Twenty-seven (6%) cases were hospitalized; the median duration of hospitalization was 8 days (range, to 6 days). Two hospitalized casepatients were discharged to long-term care facilities. None of the cases was fatal. Thirty-two (67%) cases were male and 6 (%) were female. The median age for case-patients was 8 years continued... Inside: Blastomycosis Surveillance in Minnesota, Asthma Action Plan: A Tool for Medical Professionals...6

2 Figure. U.S. Counties Reporting Any West Nile Virus Activity, 00* * From the Centers for Disease Control and Prevention, through MMWR week (ending //00 -,80 counties). Reported and verified through ArboNet as of //00. for the majority of WNV transmission to birds and mammals. However, the exact species of mosquitoes and birds sustaining the virus likely varies by region in the United States. In eastern states and the eastern Midwest (e.g., Illinois, Michigan), especially in large urban areas, the Northern House Mosquito (Culex pipiens) has been implicated as the primary vector of WNV to humans. This mosquito reproduces in small pools of water with high levels of organic pollution, such as those that are often found in urban areas. In states further west, including Minnesota, Culex tarsalis is suspected as being the primary vector of WNV to humans. Culex tarsalis is a known vector of western equine encephalitis (WEE) virus. One of six WNVpositive mosquito samples in Minnesota during 00 was this species. (range, to 8 years). (Note: for both national and state case data, the median age was calculated using combined West Nile fever and West Nile meningoencephalitis cases). A majority of human cases occurred at the end of the summer. Onset dates ranged from August 7 to September 8; (9%) of the 8 cases had onset from August to September (Figure ). This distribution of onsets is consistent with national data. In addition to mosquito-borne transmission, five other routes of WNV infection were documented in the United States during the 00 outbreak. At least 0 cases of transfusion-associated WNV infection were reported. Four cases of WNV infection attributed to organ transplantation were reported. One case of transplacental WNV transmission was documented. There was one case of asymptomatic WNV infection in an infant in which the probable route of transmission was through breast milk. In addition, occupational infections in laboratory workers were reported. These additional routes of transmission accounted for a very small proportion of cases. Nationwide,,9 horses tested positive for WNV in 00; of these, 99 were from 8 of the 87 Minnesota counties (Figure ). As in other states, approximately one-third of symptomatic horses were euthanized or died from their WNV infection. WNV was first documented in Minnesota in a bird that was reported on July 9 in Mille Lacs County. Ultimately, of 790 birds tested (from 67 counties) in Minnesota were positive by polymerase chain reaction, immunohistochemistry, or virus isolation (Figure ). Fifty-nine percent of American Crows and % of Blue Jays (both in the Corvid family) tested by MDH were positive for WNV; these species are most useful in WNV surveillance. Fifty-nine percent of raptors (i.e., hawks and owls) tested by MDH were positive. In contrast, % of other bird species (e.g., finches, sparrows, blackbirds) tested were positive for WNV. A majority of positive birds were found within the seven-county Minneapolis-St. Paul metropolitan area; however, this was likely due to the large human population reporting birds and the logistic difficulty of transporting birds to the Minnesota Veterinary Diagnostic Laboratory (MVDL) for testing from greater Minnesota. Nationwide, 6,79 WNV-positive birds were reported in states plus the District of Columbia. WNV has been found in over 60 species of birds in the United States. Dead bird surveillance is still considered the most sensitive indicator of virus presence in an area. Twenty-nine species of mosquitoes in the United States have been found to be infected with WNV in field conditions; however, not all of these mosquito species are able to maintain and transmit the virus. It is believed that Culex genus mosquitoes are responsible 0 Clinical Presentation of West Nile Virus Disease Most human infections with WNV or other arboviruses are asymptomatic. Most clinically apparent WNV infections are febrile illnesses characterized by headache, stiff neck, myalgia, arthralgia, and fatigue. Severe symptomatic infections can result in various neurologic manifestations, ranging from aseptic meningitis to fulminant and fatal encephalitis. Signs and symptoms may include confusion or other changes in mental status, nausea, vomiting, meningismus, cranial nerve abnormalities, paresis or paralysis, sensory deficits, altered reflexes, abnormal movements, convulsions, and coma. West Nile meningitis or encephalitis cannot be distinguished clinically from some other central nervous system infections. Laboratory Testing and Surveillance The MDH Public Health Laboratory has an arbovirus testing panel available, and physicians who see suspected cases of arboviral encephalitis are encouraged to submit clinical specimens to MDH for testing. Several tests for human samples are available at MDH: Serum: WNV: IgM and IgG antibody capture EIA. LaCrosse encephalitis, eastern equine encephalitis (EEE), WEE, and St. Louis encephalitis: Igm IFA. continued on page

3 Figure. Minnesota Counties with West Nile Virus Positive Humans, Horses, or Birds, 00 Kittson Roseau Horses Humans 0 Horses of the Woods Horses Marshall 9 Horses Bird Koochiching Horses Polk Human Pennington Human Red Horses Bird Bird Clearwater Beltrami Bird St. Louis Horses 6 Birds Cook Horses Bird Itasca Horse Norman Humans Bird Clay Humans 0 Birds Mahnomen Becker Human 7 Horses Bird Hubbard Cass Horses Wilkin Human Horses Traverse Horses Big Stone Lac Qu i Parle Human Horses Lincoln Horses Grant Humans Bird Stevens Human Horses Otter Tail 9 Horses Swift Human Bird Yellow Medicine Lyon Horses Douglas Human Horses Pope Horses Chippewa Human Horses Bird Redwood Human 9 Horses Bird Wadena Horses Bird Todd 9 Horses Kandiyohi Human 0 Horses Renville Horses Bird Stearns Horses 0 Birds Meeker 0 Horses Brown Horses Bird Crow Wing Human 9 Horses Morrison Human Horses McLeod Humans 0 Horses Sibley Bird Nicollet Horses Benton Horses Bird Wright Human 67 Horses Sherburne Birds Carver Mille Lacs Bird Aitkin Horse Bird Kanabec Horses Bird Isanti Human Horses Chisago Anoka Humans Horses 0 Birds Humans Horses 87 Birds Humans Horses 6 Birds Scott Human 0 Horses 7 Birds Washington 9 Horses 8 Birds Dakota Humans Horses Carlton Horses Pine Horses Ramsey Human 7 Birds Le Sueur Rice Goodhue Humans Horses Wabasha Horses Counties with WNV- Positive Humans Confirmed Findings 8 Humans ( counties) 99 Horses (8 counties) (67 counties) - American Crow ( ) - Blue Jay ( 0) - Other/ Unknown ( 78) Pipestone Horses Murray 9 Horses Cottonwood Horses Watonwan Human 9 Horses Blue Earth Horses Bird Waseca Horses Steele Horses Birds Dodge Olmsted Winona 7 Horses Bird Rock Human Horse Nobles Humans 7 Horses 8 Birds Jackson Martin Faribault Freeborn Horses Horses 0 Horses Bird Mower Humans 7 Horses Bird Fillmore Houston 9 Horses Horses

4 Figure. Human West Nile Virus Cases by Illness Onset Date, Minnesota, 00 (n=8) E ncep hali tis/m en ing itis W e s t N ile Fe ve r Ac ute Flaccid P aralysis H os pita liz e d Number of Cases Aug us t On s e t D a te S e pte m be r Cerebrospinal fluid: WNV and other endemic arboviruses: EIA for IgM and IgG, TaqMan assay (PCR), Vero cell culture. To arrange testing or to report a suspected case, call MDH at or The MDH Public Health Laboratory is concentrating its WNV testing efforts and resources on patients who meet any of the following criteria: - presumptive viral encephalitis or aseptic meningitis; - fever and headache that warrant a lumbar puncture and/or hospitalization; or - presumed Guillain-Barre syndrome or acute flaccid paralysis. Collection of acute and convalescent (i.e., approximately - weeks after the acute sample) serum samples is strongly encouraged. Many asymptomatic or mildly ill patients may request arbovirus testing, especially if they were bitten by mosquitoes. The likelihood of WNV (or other arbovirus) infection in these patients is very small, and MDH does not encourage testing in these instances. MDH investigates all reported cases of arboviral illness to document the clinical details of the case and to determine where patients may have been exposed to virus-infected mosquitoes. MDH also works with the Metropolitan Mosquito Control District to test mosquitoes from locations where cases may have been exposed and from other high-risk areas. MDH is working with the Minnesota Board of Animal Health and the University of Minnesota College of Veterinary Medicine to test equine samples for WNV, WEE, and EEE. The most sensitive way to identify WNV in an area is through wild bird surveillance. Therefore, Minnesota residents are encouraged to report dead birds (especially American Crows and Blue Jays) to MDH via the internet by accessing the Dead Bird Reporting Form link on the quick links menu at If reporting via the internet is not feasible, dead birds also can be reported by calling (6) or (8:00 a.m.- :0 p.m.). The MDH Public Health Laboratory will be testing selected dead birds for WNV. For more information about WNV, visit the MDH website ( or call or References. Centers for Disease Control and Prevention. Public health dispatch: investigation of blood transfusion recipients with West Nile virus infections. MMWR 00;:8.. Centers for Disease Control and Prevention. Public health dispatch: West Nile virus infection in organ donor and transplant recipients Georgia and Florida, 00. MMWR 00;:790.. Centers for Disease Control and Prevention. Intrauterine West Nile virus infection New York, 00. MMWR 00;:-6.. Centers for Disease Control and Prevention. Possible West Nile virus transmission to an infant through breast-feeding - Michigan, 00. MMWR 00;: Centers for Disease Control and Prevention. Laboratory-acquired West Nile virus infections United States, 00. MMWR 00;:-. Blastomycosis Surveillance in Minnesota, Background Blastomycosis is a systemic mycosis caused by Blastomyces dermatitidis, a dimorphic fungus that exists as a mold in the environment and as a pathogenic yeast form in the body. Blastomycosis is endemic in the central and southeastern United States, particularly in the Mississippi and Ohio River valleys and the Great s states. The reservoir is rich, moist soil; transmission occurs through inhalation of aerosolized conidia from contaminated soil. The median incubation period, based on limited outbreak information, is days (range, to 06 days). Most infections are asymptomatic or self-limiting. In clinical cases, acute pulmonary symptoms ranging from mild to fulminant are the most common manifestation; however, the infection may disseminate to the skin, bones, genitourinary system, and central nervous system (CNS). The case fatality rate is approximately five percent nationwide. Epidemiology of Blastomycosis in Minnesota, From 999, when systematic surveillance for blastomycosis was instituted in Minnesota, through 00, 0 laboratory-confirmed cases of blastomycosis were reported to the Minnesota Department of Health (MDH). A confirmed case was defined as a Minnesota resident with B. dermatitidis cultured or visualized from tissue or body fluid. The 0 reported cases include 8 cases that occurred during an outbreak of blastomycosis in

5 Mountain Iron, Minnesota in 999. The median annual number of cases from 999 to 00 was 0. (range, 8 to 9 cases) (Figure ). The median annual incidence of blastomycosis statewide over the period was 0.6 cases per 00,000 population. St. Louis County residents accounted for cases reported to MDH from 999 to 00, followed by Itasca (), (), Ramsey (), Cass (seven), Anoka (five), and Beltrami (five) Counties (Figure ). The median annual incidence of blastomycosis in St. Louis County residents was.7 cases per 00,000 population (range,. [00] to.0 [999] per 00,000). The probable county of exposure to B. dermatitidis was identified for 89 cases; St. Louis, Itasca, Cass, and Beltrami Counties accounted for 66% of cases (Figure ). The median age of blastomycosis cases was years (range, to 8 years) (Figure ). Overall, 67% of cases were male. However, only five (8%) of the 999 outbreak-associated cases were male. If outbreak cases are excluded, the gender difference among sporadic cases from 999 to 00 is more remarkable; 88 (7%) of sporadic cases were male. The distribution of race among the cases was as follows: white, 8%; Native American/Alaskan Native, 8%; Asian/ Pacific Islander, %; black, %, and other %. Seventy-four percent of cases were diagnosed during June through December, with a peak in September (Figure ). Of cases with reported symptom information, 9 (80%) reported cough, including 7 (%) with hemopytsis; 8 (7%) reported fatigue; 8 (70%) reported fever, and 9 (%) reported Number of Cases skin sores. Sixty-eight (6%) of 0 cases reported weight loss; 6 (9%) reported night sweats and chills; 0 (8%) reported headache, and 0 (8%) reported chest pain. Eighty-eight (67%) of cases were hospitalized for a median of 7 days (range, to 6 days). There were fatal cases from 999 to 00, resulting in a case fatality rate of 8%. Cases with an underlying chronic illness were more likely to be fatal (five of [%] vs. one of 8 [%]; relative risk, 8.9; 9% confidence interval,.-.; p=0.00). The cases with Figure. Reported Human Cases of Blastomycosis in Minnesota by Year, (n=0) 8 Outbreak cases Sporadic cases Year Figure. Number of Human Blastomycosis Cases by County of Residence, (n=9)* Figure. Number of Human Blastomycosis Cases by Probable County of Exposure, (n=89)* Kittson Marshall Beltrami Pennington Polk Red Clear Itasca Water Norman Mahnomen Hubbard Cass Clay Becker Roseau of the Woods 7 Koochiching St. Louis Cook Kittson Roseau of the Woods Marshall Beltrami Pennington Polk Red Clear Itasca Water Norman Mahnomen Hubbard Cass Clay Becker Koochiching St. Louis 8 Cook Aitkin Aitkin Wilkin Traverse Big Stone Lac Qui Parle Yellow Medicine Lincoln Lyon Pipestone Rock Ottertail Grant Stevens Swift Murray Nobles Pope Chippewa Douglas Renville Wadena Todd Stearns Kandiyohi Meeker Morrison McLeod Crow Wing Benton Wright Sherburne Carver Mille Lacs Kanabec Isanti Anoka Carlton Chisago sey Scott Washing- Ramton Dakota Sibley Redwood Rice Goodhue Nicollet Le Sueur Wabasha Brown Waseca Watonwan Blue Earth Steele Cottonwood Dodge Olmsted Winona Jackson Martin Freeborn Faribault Fillmore Houston Mower Pine *The county of residence was unknown for one case. No. cases - 6- > Wilk in Traverse Big Stone Lac Qui Parle Yellow Medicine Lincoln Lyon Pipestone Rock Ottertail Grant Stevens Swift Murray Nobles Pope Chippewa Douglas Renville Redwood Cottonwood Jackson Wadena Todd Stearns Kandiyohi Brown Meeker Watonwan Martin Morrison McLeod Sibley Nicollet Crow Wing Benton Wright Blue Earth Sherburne Faribault Carver Le Sueur Mille Lacs Scott Waseca Kanabec Isanti Anoka Rice Steele Freeborn Chisago Washington Ra m- sey Dakota Carlton Pine Goodhue Dodge Mower Olmsted Wabasha Fillmore Winona No. cases - 6- > Houston *The probable county of exposure was not determined for of the 0 cases reported during

6 Number of Cases Figure. Human Blastomycosis Cases in Minnesota by Age, (n=0) Number of Cases <0 Median age, years ( range, -8 years) >70 Age Group (years) Figure. Human Blastomycosis Cases in Minnesota by Month of Diagnosis, * Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of Diagnosis *Based on cases for which information was available. chronic illness included nine with diabetes, three with leukemia, and ten with other neoplastic, degenerative, or inflammatory disorders. Seventy-nine (66%) of 9 blastomycosis cases with reported clinical information were limited to pulmonary infection, but in 0 (%) cases the infection had disseminated to skin or soft tissues (68%), bones or joints (6%), the CNS (%), the eye (%), or other tissues (8%). Ten (8%) cases were categorized as extra-pulmonary only; most of these were localized soft tissue infections following a traumatic injury such as a puncture wound. The diagnosis was confirmed in (90%) of cases by culture of bronchoalveolar lavage fluid (%), sputum (%), wound exudate (6%,) or lung aspirate (9%). In (%) cases, the organism was identified in a smear of sputum (%), bronchoalveolar lavage fluid (6%), lung aspirate (%), or wound exudate (%). Sixteen (%) cases were confirmed by histopathology of lymph nodes, lung nodules, or trans-bronchial biopsies. Serology was positive in nine cases. Eight (8%) of 0 blastomycosis cases from 999 to 00 had potential occupational exposures. Six cases were workers involved with excavation and outdoor construction, and two were forestry workers in endemic counties. Excavation has previously been identified as a risk factor for infection. From 999 to 00 in Minnesota, 6 (6%) sporadic blastomycosis cases reported excavation at or near their residence within months of onset of illness. This was the most commonly reported potential risk factor, followed by woodcutting (9%), hiking (%), fishing (8%), and owning or visiting a cabin (8%). 999 Mountain Iron Outbreak Prior to 999, the only blastomycosis outbreak identified in Minnesota occurred in 97 in Itasca County. In September 999, a cluster of blastomycosis cases was reported from the town of Mountain Iron in St. Louis County. The ensuing investigation involved active surveillance for human and veterinary cases, interviewing and serological screening of town residents, a case-control study to identify risk factors for infection, soil cultures, and a meteorologic review. A human case was defined as a Mountain Iron resident who had B. dermatitidis cultured or visualized from sputum or bronchial lavage fluid. Eighteen human cases were identified. All lived in a single neighborhood of approximately 00 households. The median age was 8 years (range, 7 to 70 years). Thirteen (7%) cases were female. Ten (6%) were hospitalized, for a range of to days. There were no fatalities. Cases were more likely to report other ill family members (odds ratio, 6.8; p<0.0) and lived closer to a recent new house excavation site than healthy neighborhood controls (p=0.0). Hunting, fishing, hiking on a neighborhood trail, gardening, or owning an ill dog were not associated with illness. A canine case was defined as a dog from Mountain Iron from which B. dermatitidis was cultured or visualized from sputum, skin, or bronchial lavage fluid; a suspect case had either a chronic cough or non-resolving skin lesion. Nineteen confirmed and four suspect canine cases lived in the same neighborhood as human cases. In this outbreak, dogs were not useful as sentinels because their onsets of illness were generally concurrent with or after human case illness onsets (Figure 6). Serologic testing of neighborhood volunteers by immunodiffusion and complement fixation did not identify additional cases. Only two of culture-confirmed cases and none of the other 7 residents tested developed a detectable antibody response. These findings illustrated the inadequacy of available serologic tests for screening or diagnostic purposes. All of the human isolates of B. dermatitidis

7 Figure 6. Illness Onset Dates for Human and Canine Blastomycosis Cases, 999 Mountain Iron Outbreak Number of Cases Confirmed Human Case Confirmed Canine Case Suspect Canine Case August September October Onset Date One human case had an approximate onset date of July. The onset date for three canine cases was unknown. Figure 7. Canine Blastomycosis Cases by Probable County of Exposure, (n=) Kittson Roseau of the Woods with a 6-month course of itraconazole. Blastomycosis cases presenting with Acute Respiratory Distress Syndrome (ARDS) or CNS involvement require immediate and aggressive therapy with amphotericin B. Marshall Polk Nor man Clay Wilkin Traverse Big Stone Yellow Medicine Lincoln Pipestone Rock Pennington Red Grant Stevens Lac Qui Parle Mahnomen Becker Ottertail Swift Lyon Chippewa Murray Washton ing- Ramsey Nobles Douglas Pope Beltrami Clear Water Renville Redwood Jackson Kandiyoh i Cottonwood Hubbard 7 Wadena Todd Stearns Brown 9 Morrison Watonwan Martin Cass Meeker Sibley Itasca McLeod Nicollet Koochich ing Crow Wing Benton Wright Blue Earth Faribault Sherburne Carver Le Sueur 7 Aitkin Mille Lacs Waseca Scott Kanabec Isanti Anoka Rice Freeborn Carlton Dakota Steele Chisago St. Louis Pine Mower G oodhue Dodge Olmsted Wabasha Fillmore Winona Houston Cook No. cases - 6- > Blastomycosis Prevention There are no known practical measures for the prevention of blastomycosis. Minimizing morbidity and mortality from blastomycosis depends primarily on early recognition and appropriate treatment of the disease. Currently, MDH and the Minnesota Board of Animal Health are studying the epidemiology of canine blastomycosis cases in Minnesota to better define endemic areas in the state. Canine cases are more numerous than human cases, and in many cases, the probable location of exposure to the organism can be more easily identified (Figure 7). Veterinary cases of blastomycosis are also reportable; during , a median of cases per year were reported (range, 6 to 98). were the same genotype by random amplified polymorphic DNA polymerase chain reaction and DNA sequencing, but different from 8 historical or reference isolates. All soil samples tested from the neighborhood were negative for B. dermatitidis by selective culture and mouse assay. B. dermatitidis is rarely isolated from the environment. In the months preceding the outbreak, Mountain Iron had above average precipitation (p=0.0), temperature (p<0.0), and dewpoint (p<0.0) than in the comparable timeframe in previous years. Weather conditions and recent disruption of soil at the excavation site probably contributed to this outbreak. Diagnosis and Treatment A high index of suspicion is important for timely diagnosis of blastomycosis, because the presenting symptoms frequently mimic acute bacterial pneumonia. Radiographic findings are variable but may include single or multiple segmental or lobar infiltrates, single or multiple nodules, or larger masses. All currently available serodiagnostic tests lack sensitivity; a negative result is not helpful in ruling out blastomycosis. The easiest and quickest method of diagnosis is examination by light microscopy of sputum or wound exudate for large, broad-based budding yeast cells. Most patients with blastomycosis can be successfully treated To report a human case of blastomycosis, or for further information on blastomycosis, call or References. Baumgardner DJ, Burdick JS. An outbreak of human and canine blastomycosis. Rev Inf Dis 99;: Tosh FE, Hammerman KJ, Weeks RJ, Sarosi GA. A common source epidemic of North American blastomycosis. Am Rev Respir Dis 97;09:-9.. Davies SF, Sarosi GA. Epidemiological and clinical features of pulmonary blastomycosis. Sem Resp Inf 997;:06-8.

8 Asthma Action Plan: A Tool for Medical Professionals The Asthma Action Plan (AAP) is a tool to individuals who should have a copy of an AAP based on the National Institutes help asthma patients and medical the AAP are: school nurse, other of Health/National Heart Lung and Blood professionals manage and prevent specialty medical providers, daycare Institute asthma guidelines asthma symptoms while providing providers, parents, coaches, grandpar- ( crucial information to those who contact ents, anyone who may be responsible for asthgdln.htm). This on-line AAP is on the or care for people with asthma. providing care for the patient in case of MDH asthma website an emergency, and the asthma patient. ( The action plan is meant to be shared cdee/asthma/). For more information, with any individual who may in some way MDH staff, with assistance from an contact Susan Ross at or be responsible for caring for or assisting advisory group and CIT (a computer susan.ross@health.state.mn.us. the asthma patient. Examples of company), created an on-line version of 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 CHANGING YOUR ADDRESS? Please correct the address below and send it to: DCN MAILING LIST Minnesota Department of Health 77 Delaware Street SE PO Box 9 Minneapolis, MN 0-9 The Disease Control Newsletter is available on the MDH Acute Disease Investigation and Control (ADIC) Section web site ( The Disease Control Newsletter toll-free telephone number is