Surveillance of Invasive Bacterial Disease in Alaska, 2009 

Arctic Investigations Program 

National Center for Emerging & Zoonotic Infectious Diseases 

Centers for Disease Control and Prevention 

4055 Tudor Centre Dr. 

Anchorage, AK 99508 

(907) 729-3400 

ncidaip@cdc.gov
Surveillance of Invasive Bacterial Disease in Alaska, 2009 2 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 3 

Alaska Statewide Invasive Bacterial Disease 

Table of Contents 

 Page 

Summary 4 

Introduction 5 

Invasive Pneumococcal Disease 6 

Invasive Haemophilus influenzae 16 

 

Invasive Neisseria meningitidis 21 

Invasive Group A Streptococcus 23 

Invasive Group B Streptococcus 27 

References 31 

Appendix 32 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 4 

Summary 

The Centers for Disease Control and Prevention's Arctic Investigations Program (AIP) in Anchorage, 

Alaska, maintains a statewide surveillance system for invasive diseases caused by Streptococcus 

pneumoniae, Haemophilus influenzae, Neisseria meningitidis, and groups A and B streptococci. 

Laboratories throughout the state are requested to send to AIP any isolates of these organisms recovered 

from a blood culture, CSF, or other normally sterile site in an Alaska resident. Isolate identification is 

confirmed and, when appropriate, serotyped and tested for antimicrobial susceptibility. The objectives 

of this system are to provide information on disease rates within the state, monitor the emergence of 

antimicrobial resistance, and to monitor the effectiveness of implemented vaccine programs, such as the 

23-valent pneumococcal polysaccharide vaccine, the pneumococcal conjugate vaccine and Haemophilus 

influenzae type b vaccines. 

Figure 1: Invasive Bacterial Disease Surveillance Regions – Alaska, 2009 

In 2009, the total numbers of cases of invasive disease caused by these organisms reported to AIP were

148 S. pneumoniae, 21 H. influenzae, 5 N. meningitidis, 35 group A Streptococci (GAS) and 31 group B 

Streptococci (GBS). Alaska Native people had higher rates of disease than non-Native people for all 

Arctic Slope

Interior

Kotzebue

Norton Sound

YK Delta

Bristol Bay

Anchorage

Southeast
Surveillance of Invasive Bacterial Disease in Alaska, 2009 5 

surveillance organisms. Rates of invasive pneumococcal disease were highest in Kotzebue. Rates for 

each organism by region are presented in the following table. 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 6 

Table 1: Surveillance Organisms Reported by Region – Alaska, 2009 

Region 

S. pneumoniae 

n (rate*) 

H. influenzae 

n (rate*) 

N. meningitidis 

n (rate*) 

GAS 

n (rate*) 

GBS 

n (rate*) 

Anchorage 98 (21.3) 9 (2) 3 (0.7) 17 (3.7) 21 (4.6)

Arctic Slope 1 (17.2) 0 (0) 0 (0) 0 (0) 0 (0) 

Bristol Bay 1 (14.4) 0 (0) 0 (0) 0 (0) 0 (0) 

Interior 30 (27.9) 2 (1.9) 0 (0) 9 (8.4) 4 (3.7) 

Kotzebue 3 (37.2) 1 (12.4) 0 (0) 1 (12.4) 0 (0) 

Norton Sound 0 (0) 0 (0) 0 (0) 0 (0) 2 (21.1) 

Southeast 9 (13) 2 (2.9) 1 (1.4) 3 (4.3) 3 (4.3) 

YK Delta 6 (24.1) 7 (28.1) 1 (4) 5 (20) 4 (1) 

Total 148 (21.4) 21 (3) 5 (0.7) 35 (5.1) 31 (4.5) 

*Cases per 100,000 population 

Introduction 

AIP conducts statewide surveillance of invasive Streptococcus pneumoniae, Haemophilus influenzae, 

Neisseria meningitidis, and groups A and B Streptococcus. This program is part of a passive, 

laboratory-based surveillance system in which laboratories from all hospitals throughout the state are

encouraged to participate. The population included in the AIP surveillance is the State of Alaska, which 

totaled 692,314 persons in 2009 [1]. Case detection occurs year-round as participating laboratories send 

isolates recovered from sterile sites to the AIP laboratory in Anchorage, accompanied by basic 

demographic and clinical information on the cases. Materials and forms for isolate shipment and data 

collection are provided to each laboratory by AIP. At year-end, AIP asks that each laboratory review 

their records and provide information on any cases that may have been overlooked. In 2009, 23 

laboratories in Alaska participated in the invasive disease surveillance system, either by sending isolates 

to the AIP laboratory throughout the year, conducting year-end record reviews, or both. Beginning in 

January, 2007, invasive S. pneumoniae, GAS and GBS became reportable conditions to the State of 

Alaska Division of Public Health (DPH). Reports of cases of disease caused by these organisms, along 

with cases of invasive H. influenzae and N. meningitidis which were previously reportable, are shared 

between AIP and DPH. 

AIP defines a case of invasive S. pneumoniae, H. influenzae, N. meningitidis, GAS or GBS as an isolate 

of the bacteria from a normally sterile site, including blood, cerebrospinal fluid, pleural fluid, peritoneal 

fluid or joint fluid that has been taken from a resident of Alaska. In addition, for GAS, isolates are 

requested from deep tissue infections such as might be collected from surgical debridement of cases of

necrotizing fasciitis.
Surveillance of Invasive Bacterial Disease in Alaska, 2009 7 

Invasive Pneumococcal Disease 

Overall Incidence

A total of 137 pneumococcal isolates were received at AIP in 2009. An additional 2 cases were detected 

through year-end follow up with participating laboratories and 9 cases through shared surveillance with 

the State DPH for a total of 148 cases of invasive pneumococcal disease. The overall rate for invasive 

pneumococcal disease in 2009 was 21.4 cases per 100,000 persons per year. Alaska rates for 2009 were 

higher than the Active Bacterial Core Surveillance (ABCs) 2009 national projected rate of 14.3/100,000

[2]. ABCs is a surveillance system operated in 10 states which covers a population of over 39 million

persons. 

Seasonality

Invasive Streptococcus pneumoniae cases were identified in each month of 2009. The largest number of 

cases was reported in October. 

Race 

In 2009, the state population was comprised of 20% Alaska Native people (Alaska Natives 138,429, 

non-Natives 553,885) [1]. Of all reported S. pneumoniae cases in 2009, 33% occurred among Alaska 

Native people for a total of 49 cases; the age-adjusted rate was 35.2/100,000 persons per year. Ninetynine cases occurred among the non-Native population for an age-adjusted rate of 16.5/100,000 persons 

per year. The rate ratio of age-adjusted rates of S. pneumoniae disease for the Alaska Native population 

compared with the non-Native population in 2009 was 2.1. 

0

5

10

15

20

25

30

Number of Cases

Figure 2: Invasive Pneumococcal Disease, by 

Month of Culture - Alaska, 2009
Surveillance of Invasive Bacterial Disease in Alaska, 2009 8 

Table 2: Invasive Streptococcus pneumoniae Cases by Race – Alaska, 2009 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 49 (33) 35.2 47 5 (10.2) 

Non-Native† 99 (67) 16.5 60 7 (7.2)‡ 

Total 148 56 12 (8.2) 

*Cases per 100,000 per percent distribution of Alaska 2000 population 

†Includes 4 cases for which race was unknown 

‡Outcome unknown in 2 cases 

Region 

The highest percentage (56%) of invasive pneumococcal disease cases occurred in the Anchorage area 

in 2009. Rates of disease, however, were highest in Kotzebue (37.2/100,000 persons per year). 

Age

Cases occurred in all age groups in 2009 ranging from 2 months to 97 years with a median age of 48 

years. Overall, the highest rates of disease occurred in adults 65 years and older. 

 

When stratified by age and race, the highest rates of disease in 2009 occurred in Alaska Native adults 65 

years and older (131.9/100,000 persons per year). 

0

20

40

0

20

40

60

80

100

120

Number of Cases

Rate per 100,000

Figure 3: Invasive Pneumococcal Disease, Cases 

& Rates by Region - Alaska, 2009

Cases

Rate
Surveillance of Invasive Bacterial Disease in Alaska, 2009 9 

Since the initiation of a pneumococcal conjugate vaccine program in 2001, overall rates of invasive 

disease have declined dramatically in children less than 2 years of age [3]. In 2000, overall yearly rates 

of pneumococcal disease in children less than 2 years were 191.2/100,000, dropping to a low of 

67.9/100,000 in 2002 and then increasing to 142.2/100,000 in 2006. In 2008, the rate of invasive 

pneumococcal disease in children less than 2 years declined to 65.6/100,000 which is the lowest rate 

observed in this age group since vaccine introduction; in 2009, the rate increased slightly to 

68.2/100,000. 

Although pneumococcal disease rates dropped initially in AK Native and non-Native children less than 

2 years of age after 2000, the rates of disease in AK Native children less than 2 years trended upward

from a low of 93.6/100,000 in 2001 to 335.9/100,000 in 2006. This increase in rates was due primarily

to disease caused by serotypes not contained in the pneumococcal conjugate vaccine [4,5]. In 2009, 

rates of disease in AK Native children less than 2 years declined to 87.1/100,000 which is the lowest rate 

since the introduction of the seven-valent pneumococcal vaccine. Rates of invasive disease in nonNative children less than 2 years declined during the same time period reaching 26.8/100,000 in 2005, 

0

20

40

60

80

100

120

140

0

10

20

30

40

50

60

<2 2-4 5-18 19-54 55-64 65+

Number of Cases

Rate per 100,000

Age (yrs)

Figure 4: Invasive Pneumococcal Disease, Cases 

& Rates by Age Group & Race - Alaska, 2009

AK Native

(# cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)

0

20

40

60

80

100

120

140

160

180

200

<2 2-4 5-18 19-54 55-64 65+

Rate per 100,000

Age (yrs)

Figure 5: Invasive Pneumococcal Disease by Age 

Group - Alaska, 2000-2009

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009
Surveillance of Invasive Bacterial Disease in Alaska, 2009 10 

and following an increase to 64.4/100,000 in 2007, declined in 2008 to 6.2/100,000. In 2009, the rate of 

disease in non-Native children less than 2 years has increased again to 60.3/100,000. 

Clinical Presentation

The primary clinical presentation was determined by a review of the discharge diagnoses in each 

patient’s individual medical record associated with the invasive bacterial illness. In cases with multiple 

discharge diagnoses, the most serious diagnosis related to the pneumococcal infection was recorded as 

the primary clinical presentation. Pneumonia with bacteremia was the most common primary clinical 

presentation in 2009 (72%) followed by bacteremia (13%). Eighteen cases had a secondary 

pneumococcal-related diagnosis in 2009 - 13 pneumonia, 2 cellulitis, 1 empyema, 1 osteomyelitis, and 1

unidentified other presentation. 

0

100

200

300

400

500

<2 2-4 5-18 19-54 55-64 65+

Rate per 100,000

Age (yrs)

Figure 6: Invasive Pneumococcal Disease in 

Alaska Natives, by Age Group - Alaska, 2000-2009

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

0

100

200

300

400

500

<2 2-4 5-18 19-54 55-64 65+

Rate per 100,000

Age (yrs)

Figure 7: Invasive Pneumococcal Disease in NonNatives, by Age Group - Alaska, 2000-2009

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009
Surveillance of Invasive Bacterial Disease in Alaska, 2009 11 

In 2009, blood was the most common source of a positive culture which was used to identify 137 (93%) 

of 147 cases. Pleural fluid was the positive site for 5 (3%) of cases; two cases were identified from

cerebrospinal fluid, 1 case from joint fluid, 1 case from a pericardial aspirate and 1 case from an 

unidentified non-sterile site.

Mortality 

In 2009, the overall case fatality ratio for S. pneumoniae in Alaska was 8.2% (12 deaths out of 146 cases 

for which outcomes were known). The case fatality ratio for AK Natives was higher than non-Natives; 

10.2% (5 deaths) and 7.2% (7 deaths), respectively. The majority of deaths and the highest case fatality 

ratio occurred in the 65+ age category (7 deaths) 18.9%. 

106

19 11 3 2 2 1 1 1 1

0

20

40

60

80

100

120

Number of Cases

Figure 8: Primary Clinical Presentations of 

Invasive Pneumococcal Disease - Alaska, 2009

*with bacteremia

0

5

10

15

20

0

1

2

3

4

5

6

7

8

<2 2-4 5-18 19-54 55-64 65+

Case Fatality Ratio (%)

Number of Deaths

Age (yrs)

Figure 9: Invasive Pneumococcal Deaths & Case 

Fatality Ratios by Age Group - Alaska, 2009

Deaths

CFR
Surveillance of Invasive Bacterial Disease in Alaska, 2009 12 

Serotype 

Serotyping of invasive pneumococcal isolates is performed at AIP using internationally standardized 

methods. Serotype identification is based on the organism’s polysaccharide capsule which is a principal 

virulence factor for pneumococci. This information provides a way to categorize organisms and to 

determine if the infection was due to a type that could be prevented by use of one of the available 

pneumococcal vaccines. Serotyping was performed on all of the S. pneumoniae cases for which an 

isolate was available. 

Table 3: Invasive Pneumococcal Serotype Distribution by Race and Age Group – Alaska, 2009 

 Alaska Native Non-Native Unknown 

Serotype Total n (%) <2 2-18 19-64 65+ <2 2-18 19-64 65+ All Ages 

01 1 (<1) - - - - 1 - - - - 

03 12 (9) - - 3 1 - - 6 2 - 

04 1 (<1) - - - - - - 1 - - 

06A 1 (<1) - - 1 - - - - - - 

06C 5 (4) - - - 2 - - 1 2 - 

07C 2 (1) - - - - - - 1 - 1 

07F 39 (28) 2 2 3 2 2 2 20 5 1 

08 4 (3) - - 2 - - - 2 - - 

09N 8 (6) - - 5 - - - 2 1 - 

10A 1 (<1) - - - - - - 1 - - 

11A 2 (1) - - 1 - - - - - 1 

12F 1 (<1) - - 1 - - - - - - 

14 1 (<1) - - - - - - - 1 - 

15A 5 (4) 1 - 1 - - - 3 - - 

15B 3 (2) 1 - - - - - 2 - - 

15C 1 (<1) 1 - - - - - - - - 

16F 5 (4) - - 2 - - - 2 1 - 

17F 1 (<1) - - 1 - - - - - - 

19A 29 (21) 1 1 3 2 4 1 8 8 1 

19F 1 (<1) - - - - - - - 1 - 

20 1 (<1) - - 1 - - - - - - 

22F 4 (3) - - 2 1 1 - - - - 

23A 2 (1) - - 1 1 - - - - - 

23B 1 (<1) - - - - - - 1 - - 

28 1 (<1) - - - - - - 1 - - 

31 2 (1) - - - - - - - 2 - 

33F 3 (2) - - - - 1 - 2 - - 

Total 137 6 3 27 9 9 3 53 23 4 

In 2009, the most common pneumococcal serotypes were 7F (39 isolates, 28%) and 19A (29 isolates, 

21%). From 1986 through 2001, serotype 14 was the most common invasive pneumococcal serotype 

ranging from 7.4% to 23.5% of isolates. Following introduction in 2001 of the pneumococcal conjugate 

vaccine which includes serotype 14, the proportion of serotype 14 isolates dropped to 1.5% of serotyped 

isolates in 2006, did not cause any invasive pneumococcal disease in 2007 or 2008, and only one case in 

2009. Disease caused by serotypes 7F and 19A, which are not included in the conjugate vaccine, has 

continually increased. Prior to 2005, yearly numbers of cases of serotype 7F disease and the proportion 

of total isolates ranged from 1 to 10 and 0.9% to 9.3%, respectively. Although the majority (62.5%) of 

serotype 7F disease occurred in AK Natives during 2005, the proportion of 7F disease occurring in nonNatives has gradually increased by 76% versus 24% in Alaska Natives in. The majority (74%) of 

serotype 7F cases and serotype 19A cases (55%) occurred in the Anchorage area in 2009. 

 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 13 

Table 4: Invasive Pneumococcal Serotype Distribution by Region – Alaska, 2009 

Serotype 

Anchorage 

Arctic 

Slope 

Interior 

Kotzebue 

Southeast 

YK Delta 

01 1 - - - - - 

03 8 - 3 - 1 - 

04 1 - - - - - 

06A - - 1 - - - 

06C 5 - - - - - 

07C 2 - - - - - 

07F 28 - 8 2 - 1 

08 2 - 2 - - - 

09N 6 - 2 - - - 

10A 1 - - - - - 

11A 1 - - - 1 - 

12F - - - - - 1 

14 1 - - - - - 

15A 3 - 2 - - - 

15B 2 - - 1 - - 

15C 1 - - - - - 

16F 4 - - - - 1 

17F 1 - - - - - 

19A 16 - 7 - 3 3 

19F - - 1 - - - 

20 - - 1 - - - 

22F 2 1 - - 1 - 

23A 2 - - - - - 

23B 1 - - - - - 

28 1 - - - - - 

31 1 - - - - - 

33F 3 - - - - - 

Total 94 1 27 3 6 6 

Vaccine Serotypes

Two vaccine types were licensed for prevention of pneumococcal disease in 2009. In 2001, the 

pneumococcal conjugate vaccine (PCV7) was included in the Alaska childhood vaccination schedule. 

This vaccine provides protection against the 7 most common pneumococcal serotypes causing invasive 

disease among children (types 4, 6B, 9V, 14, 18C, 19F, 23F). The table below shows the proportion of 

invasive infections from 2009 that were due to serotypes found in the PCV7 vaccine. There were no 

cases of pneumococcal disease caused by serotypes contained in the PCV7 vaccine in children less than 

5 years of age, the age group for which the vaccine is recommended. 

 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 14 

Table 5: Proportion of Invasive Isolates Contained in the PCV7 Vaccine by Age Group and Race 

– Alaska, 2009 

Age (yrs) Alaska Native (%) Non-Native (%) Total (%) 

<2 0 (0%) of 6 0 (0%) of 10 0 (0%) of 16 

2-4 0 (0%) of 1 0 (0%) of 2 0 (0%) of 3 

5+ 0 (0%) of 38 3 (4%) of 76 3 (3%) of 114 

Total 0 (0%) of 45 3 (3%) of 88 3 (2%) of 133 

For the year covered by this report, the 23-valent polysaccharide vaccine (Ps23V) was recommended in 

Alaska for all persons 65 years and older, and for persons over age 2 who are at higher risk for 

pneumococcal disease [5]. In 2009, for persons 65 years and older, 24 (75%) of 32 cases serotyped 

were potentially vaccine preventable invasive pneumococcal illnesses. 

Vaccine Failures 

A PCV7 vaccine failure is defined as invasive pneumococcal disease caused by a serotype contained in 

the PCV7 vaccine in a child less than five years old who has had at least two doses of vaccine. There

were no vaccine failures in 2009. 

Potentially Preventable Deaths

In 2009, pneumococcal vaccine status was known for 90 (61%) of the 148 cases; 59 cases (40%) did 

receive a pneumococcal vaccine prior to illness and 31 cases (21%) had no record of a pneumococcal 

vaccine. 

Table 6: Potentially Vaccine Preventable Invasive Pneumococcal Deaths – Alaska, 2009 

Serotypes < 2 years 2-4 5-18 19-54 55-64 65+ Total 

PCV7 0 0 0 0 0 1 (14%) 1 (8%) 

Ps23V 0 0 0 4 (80%) 0 2 (29%) 6 (50%) 

Non-Vaccine 0 0 0 0 0 2 (29%) 2 (17%) 

Unknown 0 0 0 1 (20%) 0 2 (29%) 3 (25%) 

Total 0 0 0 5 0 7 12 

Overall, 50% of all pneumococcal-related mortality in 2009 was potentially preventable with the use of

the 23-valent polysaccharide vaccine in persons over 2 years old; 25% of deaths were due to disease 

caused by serotypes not contained in the 23-valent vaccine. 

Six of the 12 deaths in 2009 from invasive S. pneumoniae occurred from serotypes contained within the 

Ps23V vaccine; 2 of the deaths were in individuals eligible for the vaccine. Of those two deaths, one

occurred in a vaccinated individual; time since vaccination was 12 years. 

 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 15 

Table 7: Invasive Pneumococcal Disease, Serotypes of Fatal Cases – Alaska, 2009 

Serotype 

Deaths 

n (%) 

Serotype 

Frequency (n) 

03* 1 (8%) 12 

07F* 1 (3%) 38 

09N* 1 (13%) 8 

16F 1 (20%) 5 

19A* 3 (10%) 29 

19F†* 1 (100%) 1 

23A 1 (50%) 2 

†Serotypes contained in the 7-valent conjugate vaccine 

*Serotypes contained in the 23-valent polysaccharide vaccine 

Associated Medical Conditions

The presence of one or more associated medical conditions was reported in 85% of invasive 

pneumococcal cases in 2009. Cigarette smoking was the most prevalent risk factor observed in adults 

followed by chronic lung disease and alcohol abuse.

Table 8: Associated Medical Conditions Identified in Invasive Pneumococcal Cases – Alaska, 

2009* 

Medical Condition/Risk 

Factor 

Adult Cases (≥ 18 years) 

n=123, Cases (%) 

Cigarette smoking 53 (43) 

Chronic lung disease 43 (35) 

Alcohol abuse 25 (20) 

Diabetes 21 (17) 

Immunosuppressive treatment 12 (10) 

Injection drug use 0 (0) 

Asplenia 0 (0) 

*More than one risk factor was identified in several cases 

Antibiotic Resistance

Susceptibility testing was performed on all isolates received in 2009. Results of the testing are 

presented in the following table. 

Table 9: Antibiotic Resistance in Invasive Streptococcus pneumoniae Isolates – Alaska, 2009 

Antibiotic Susceptible Intermediate Resistant I + R Total Tested 

Penicillin 112 (82%) 18 (13%) 7 (5%) 25 (18%) 137 

TMP-sulfa 104 (76%) 7 (5%) 26 (19%) 33 (24%) 137 

Erythromycin 113 (82%) 0 (0%) 24 (18%) 24 (18%) 137

Ceftriaxone 129 (94%) 3 (2%) 5 (4%) 8 (6%) 137 

Tetracycline 122 (90%) 1 (1%) 13 (10%) 14 (11%) 136

Chloramphenicol 136 (99%) 0 (0%) 1 (1%) 1 (1%) 137 

Rifampin 137 (100%) 0 (0%) 0 (0%) 0 (0%) 137 

Vancomycin 135 (99%) 0 (0%) 1 (1%) 1 (1%) 136 

Levofloxacin 125 (91%) 0 (0%) 12 (9%) 12 (9%) 137 

Clindamycin 136 (99%) 0 (0%) 1 (1%) 1 (1%) 137 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 16 

Cut points from the Minimum Inhibitory Concentration (MIC) Interpretive Standards were used to 

determine if an isolate was ‘susceptible’, ‘intermediate’, or ‘resistant’ to the antibiotic being tested [6]. 

The MIC Interpretive Standards definitions of ‘susceptible’, ‘intermediate’, and ‘resistant’ can be found 

in the Appendix. 

Serotypes found in the PCV7 vaccine are more likely to be non-susceptible to penicillin and 

erythromycin than non-vaccine serotypes. One potential benefit of the use of this vaccine was an 

anticipated decline in antibiotic resistance among circulating pneumococci. Following the initiation of 

the PCV7 vaccine in 2001, antibiotic resistance among invasive pneumococci dropped. During 2003, 

TMP-sulfa and penicillin resistance increased, however, both decreased in 2004 to levels of resistance

seen in 2002 and have remained fairly stable. After steadily declining from 2000 to a low of 4% in 

2004, erythromycin resistance has increased to 18% of tested isolates in 2009. Tetracycline resistance 

occurred in 11% of isolates in 2009; this is the highest level of resistance seen in pneumococcal isolates 

to date. 

 *Pen-FR = fully resistant, Pen-NS = non-susceptible 

0

5

10

15

20

25

30

35

Percent Resistant

Year

Figure 10: Trends in Antibiotic Resistance Among 

Invasive Pneumococcal Isolates - Alaska, 1989 - 2009

Pen-FR*

Pen-NS*

Erythro

TMP-Sulfa

Tet
Surveillance of Invasive Bacterial Disease in Alaska, 2009 17 

Invasive Haemophilus influenzae

Overall Incidence 

In 2009, there were 21 cases of invasive Haemophilus influenzae in Alaska, for a statewide rate of 

3/100,000 persons per year. This rate is higher than the national projected rate of 1.6/100,000 persons 

per year [8]. There was one death caused by H. influenzae in 2009 for a case fatality ratio of 5%. 

Seasonality 

Cases of invasive H. influenzae occurred throughout 2009; however, due to the small number of cases, 

trends in seasonality cannot be determined. 

Region 

The highest rates of disease caused by invasive H. influenzae cases in 2009 were in YK Delta, 

28.1/100,000 (7 cases), and Kotzebue, 12.4/100,000 (1 case). The largest number of cases occurred in 

the Anchorage area (9 cases), but the rate was much lower (2/100,000). 

0

1

2

3

4

5

Number of Cases

Month of Culture

Figure 11: Haemophilus influenzae Disease by 

Month of Culture - Alaska, 2009
Surveillance of Invasive Bacterial Disease in Alaska, 2009 18 

Race 

Table 10: Invasive Haemophilus influenzae Cases by Race – Alaska, 2009 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 12 (57%) 7.3 50 1 (8%) 

Non-Native 9 (43%) 1.6 22 0 (0%) 

Total 21 38 1 (5%) 

*Cases per 100,000 per percent distribution of Alaska 2000 population 

In 2009, 57% of the cases occurred in Alaska Natives. Age-adjusted rates were calculated for Alaska 

Natives and non-Natives. The age-adjusted rate ratio of H. influenzae disease for the Alaska Native 

population compared with the non-Native population in 2009 was 4.6. 

Age 

H. influenzae cases ranged in age from newborn to 80 years of age in 2009 (median 48.8 years). 

Overall, the highest rates of disease occurred in children less than 2 years old and adults 65 and older. 

Rates of disease in Alaska Native versus non-Native populations by age group were variable; overall 

numbers of cases and rates by race and age group are presented in Figure 14. The highest rates of 

disease occurred in Alaska Native children less than two years of age, 43.6/100,000 persons per year and 

Alaska Native adults 65 years and older, 36/100,000 persons per year. 

0

5

10

15

20

25

30

0

2

4

6

8

10

Number of Cases

Rate per 100,000

Figure 12: Invasive Haemophilus influenzae, 

Cases & Rates by Region - Alaska, 2009

Cases

Rate
Surveillance of Invasive Bacterial Disease in Alaska, 2009 19 

Clinical Presentation 

The primary clinical presentation was determined by a review of the discharge diagnoses in each 

patient’s individual medical record associated with the invasive bacterial illness. For cases with more 

than one diagnosis, the most serious H. influenzae-related diagnosis was recorded as the primary clinical 

presentation. In 2009, pneumonia with bacteremia was the most common presentation (48% of cases). 

All H. influenzae isolates were from blood samples in 2009. 

0

5

10

15

20

<2 2-4 5-18 19-54 55-64 65+

Rate per 100,000

Age (yrs)

Figure 13: Invasive Haemophilus influenzae by 

Age Group - Alaska, 2009

0

10

20

30

40

50

0

1

2

3

4

5

6

<2 2-4 5-18 19-54 55-64 65+

Number of Cases

Rate per 100,000

Age (yrs)

Figure 14: Invasive Haemophilus influenzae, Cases & 

Rates by Age Group & Race - Alaska, 2009

AK Native

(# cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)
Surveillance of Invasive Bacterial Disease in Alaska, 2009 20 

Table 11: Primary Clinical Presentation of Invasive Haemophilus influenzae - Alaska, 2009 

Primary Presentation n (%) 

Pneumonia* 10 (48%) 

Bacteremia 8 (38%) 

Cellulitis 2 (9%) 

Amnionitis 1 (5%) 

Total 21 

*with bacteremia 

Serotypes 

All isolates received at AIP are serotyped; 20 of the 21 cases in 2009 had isolates and were serotyped. 

The bacterial capsule is the basis for serotyping and is the primary virulence factor. Serotype b has been 

the most common serotype in the past, but its prevalence has decreased with use of the childhood Hib 

vaccine. Surveillance of serotypes is important for monitoring vaccine effectiveness and emergence of

non-vaccine serotypes. 

Table 12: Serotypes of Invasive Haemophilus influenzae Cases by Race – Alaska, 2009 

 Alaska Native Non-Native 

Serotype Total n (%) <2 2-18 19-64 65+ <2 2-18 19-64 65+ 

a 2 1 1 0 0 0 0 0 0 

b 4 2 2 0 0 0 0 0 0 

e 4 0 1 0 0 0 0 1 2 

f 2 0 0 0 0 0 0 2 0 

NT* 8 0 0 1 3 1 1 1 1 

Total 20 3 4 1 3 1 1 4 3 

*Non-typable 

Hib

In recent years, the prevalence of H. influenzae type b has declined due to increased use of a childhood 

vaccine against this serotype. Four cases of Hib occurred in 2009, all in vaccinated children. Two cases 

occurred in children under the age of 2 years; one received the Pentacel vaccine and one the PedVaxHib

vaccine. The other cases occurred in a seven and an eight year old and both had a history of an 

immunocompromised condition. 

Antibiotic Resistance 

Twenty Haemophilus influenzae isolates received at AIP were tested for susceptibility to 

chloramphenicol, ceftriaxone and TMP/sulfa. All 20 isolates were susceptible to chloramphenicol and 

ceftriaxone; seven isolates were fully resistant to TMP/sulfa, 6 had intermediate resistance and 7 were 

susceptible. 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 21 

Table 13: Summary of Invasive Haemophilus influenzae Case Characteristics, Alaska, 2009 

Sex Age (Yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) Serotype* 

Associated Medical 

Conditions Survived 

F Newborn Non-Native Anchorage Blood Bacteremia NT None Yes 

F 0.6 AK Native Other Blood Bacteremia b None Yes 

M 1 AK Native Other Blood Cellulitis a None Yes 

F 1.9 AK Native Other Blood Pneumonia b None Yes 

M 2.8 AK Native Other Blood Pneumonia e Chronic lung disease Yes 

M 7.9 AK Native Other Blood Pneumonia b Immunosuppressive 

treatment Yes 

M 8.3 AK Native Other Blood Bacteremia a None Yes 

F 8.4 AK Native Other Blood Cellulitis b None Yes 

M 8.6 Non-Native Anchorage Blood Cellulitis NT Diabetes Yes 

F 25 Non-Native Anchorage Blood Amnionitis, 

septic abortion NT Smoking Yes 

M 48.8 AK Native Other Blood Bacteremia Unknown Alcohol abuse Yes 

F 49.1 Non-Native Anchorage Blood Pneumonia e Chronic lung disease Yes 

F 50.9 Non-Native Anchorage Blood Pneumonia f Chronic lung disease Yes 

F 54.2 Non-Native Anchorage Blood Bacteremia f Chronic lung disease Unknown 

F 55.5 AK Native Other Blood Pneumonia NT Smoking, chronic lung 

disease Yes 

F 65.7 Non-Native Anchorage Blood Pneumonia e Smoking, chronic lung 

disease Yes 

M 68.4 Non-Native Other Blood Pneumonia NT Diabetes Yes 

F 68.5 AK Native Other Blood Pneumonia NT Chronic lung disease Yes 

F 69.7 AK Native Anchorage Blood Pneumonia NT 

Smoking, 

immunosuppressive 

treatment 

Yes 

M 74.8 AK Native Other Blood Bacteremia NT Immunosuppressive 

treatment No 

F 80.4 Non-Native Anchorage Blood Bacteremia e Immunosuppressive 

treatment No 

*NT = non-typeable 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 22 

Invasive Neisseria meningitidis

Overall Incidence

A total of 5 cases of invasive Neisseria meningitidis were reported to AIP in 2009 for an overall 

rate of 0.7/100,000. The Alaska rates are slightly higher than the ABCs 2009 national projected 

rate of 0.3/100,000 [9]. There were no invasive N. meningitidis-related deaths in Alaska in 2009. 

Seasonality

One N. meningitidis case occurred in each month of January, February, April, July and August; 

no clusters of related cases were reported. 

Race

In 2009, 60% of the cases occurred in non-Natives. Age-adjusted rates were calculated for 

Alaska Natives and non-Natives. The age-adjusted rate ratio of N. meningitidis disease for the 

Alaska Native population compared with the non-Native population in 2009 was 3.3. 

Table 14: Invasive Neisseria meningitidis Cases by Race – Alaska, 2009 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 2 (40%) 1.3 0 0 (0%) 

Non-Native† 3 (60%) 0.4 67 0 (0% 

Total 5 40 0 

*Cases per 100,000 per percent distribution of Alaska 2000 population 

†Includes 1 case for which race was unknown 

Region

Three cases of invasive N. meningitidis occurred in Anchorage and one case occurred in both the 

Southeast and the YK Delta. 

Age

Invasive N. meningitidis cases reported in 2009 ranged in age from 0.3 to 77.1 years old; the 

median age was 47.9 years. 

Clinical Presentation

The primary clinical presentation was determined by a review of the discharge diagnoses in each 

patient’s individual medical record associated with the invasive bacterial illness. In cases with 

multiple discharge diagnoses, the most serious diagnosis related to the N. meningitidis infection 

was recorded as the primary clinical presentation. Two cases presented with meningitis, two 

with bacteremia and one with pneumonia; one case had a secondary clinical presentation of 

cellulitis. 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 23 

N. meningitidis was isolated from blood in all five cases in 2009. 

Mortality

There were no N. meningitidis-related deaths reported in Alaska in 2009. 

Serogroup 

Five invasive N. meningitidis cases in 2009 were serogrouped; four were serogroup B and one 

was serogroup Y.

Table 15: Summary of Invasive Neisseria Meningitidis Cases Characteristics, Alaska, 2009 

Sex 

Age 

(yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) Serogroup 

Associated 

Medical 

Conditions Survived 

F 0.3 AK Native Other Blood Bacteremia B None Yes 

F 1.6 Non-Native Anchorage Blood Meningitis B None Yes 

F 47.9 AK Native Anchorage Blood Meningitis B 

Chronic 

lung disease, 

asplenia 

Yes 

M 58.5 Non-Native Other Blood Pneumonia, 

cellulitis B None Yes 

M 77.1 Non-Native Anchorage Blood Bacteremia Y None Yes 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 24 

Invasive group A Streptococcus

Overall Incidence

A total of 35 cases of invasive group A Streptococcus (GAS) were reported to AIP in 2009. The 

overall rate of invasive GAS disease in the state of Alaska was 5.1/100,000 persons per year. 

The Alaska rate is higher than the ABCs 2009 national projected rate of 3.6/100,000 [10]. In 

2009, there were 3 GAS-related deaths (all cases emm type 82) for a case fatality ratio of 8.8%. 

Seasonality 

Cases of group A Streptococcus occurred throughout the year in 2009 with no apparent trends in 

seasonality. 

Race

In 2009, 57% of invasive GAS cases in Alaska occurred in the Alaska Native population for an 

age-adjusted rate of 14.2/100,000 persons per year which was six times higher than the nonNative age-adjusted rate of 2.4/100,000 persons per year. 

Table 16: Invasive group A Streptococcus Cases by Race – Alaska, 2009 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 20 (57%) 14.2 50 2 (10.5%)† 

Non-Native 15 (43%) 2.4 73 1 (7%) 

Total 35 60 3 (8.6%) 

*Cases per 100,000 per percent distribution of Alaska 2000 population 

†Outcome unknown in one case 

Region 

0

1

2

3

4

5

6

Number of Cases

Month of Culture

Figure 15: Invasive group A Streptococcus, by 

Month of Culture - Alaska, 2009
Surveillance of Invasive Bacterial Disease in Alaska, 2009 25 

Seventeen (48.5%) of the 35 invasive group A Streptococcus cases in 2009 were reported in the 

Anchorage area, 9 cases in the Interior, 5 cases in the YK Delta, 3 cases in Southeast, and one 

case in Kotzebue. 

Age

Invasive group A Streptococcus cases reported in 2009 ranged in age from 6 months to 90.5 

years old; the median age was 48.3 years. Highest rates of disease occurred in children less than 

two years old (17/100,000). 

When stratified by race, the highest rates of invasive group A streptococcal disease occurred in 

Alaska Native children less than two years old (43.6/100,000 persons per year). The highest 

GAS disease rate in the non-Native population occurred in adults 65 and older (13.7/100,000 

persons per year). 

0

2

4

6

8

10

12

14

16

18

<2 2-4 5-18 19-54 55-64 65+

Rate per 100,000

Age (yrs)

Figure 16: Invasive group A Streptococcus by Age 

Group - Alaska, 2009

0

10

20

30

40

50

0

2

4

6

8

10

12

<2 2-4 5-18 19-54 55-64 65+

Number of Cases

Rate per 100,000

Age (yrs)

Figure 17: Invasive group A Streptococcus, Cases 

& Rates by Age Group & Race - Alaska, 2009

AK Native

(# cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)
Surveillance of Invasive Bacterial Disease in Alaska, 2009 26 

Clinical Presentation

The primary clinical presentation was determined by a review of the discharge diagnoses in each 

patient’s individual medical record associated with the invasive bacterial illness. In cases with 

multiple discharge diagnoses, the most serious diagnosis related to the GAS infection was 

recorded as the primary clinical presentation. Table 17 shows the primary clinical presentations 

of invasive group A Streptococcus in Alaska for 2009. Nine cases also presented with secondary 

diagnoses including streptococcal toxic shock syndrome, cellulitis, necrotizing fasciitis, bursitis 

and pneumonia. 

Group A Streptococcus was isolated from blood samples in 29 (83%) of 35 cases, four from joint 

fluid, and one each from bone and synovial fluid. 

 

Table 17: Primary Clinical Presentations of Invasive group A Streptococcus – Alaska, 2009 

Primary Presentation n (%) 

Cellulitis* 12 (34%) 

Bacteremia 8 (23%) 

Septic arthritis 5 (14%) 

Pneumonia* 3 (9%) 

Empyema 2 (6%) 

Endometritis 2 (6%) 

Osteomyelitis 2 (6%) 

Endocarditis 1 (3%) 

Total 35 

*with bacteremia
Surveillance of Invasive Bacterial Disease in Alaska, 2009 27 

Table 18: Summary of Invasive group A Streptococcus Case Characteristics, Alaska, 2009 

Sex 

Age 

(yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) 

emm

Type 

Associated Medical 

Conditions Survived 

F 0.5 AK Native Other Blood Bacteremia 108.10 None Yes 

M 0.5 AK Native Other Blood Bacteremia 82.00 None Yes 

M 1.5 AK Native Other Blood Bacteremia 82.00 None Yes 

M 1.5 Non-Native Anchorage Blood Bacteremia 101.00 Unknown Yes 

F 3.5 AK Native Other Blood Bacteremia None Yes 

M 5.5 AK Native Other Blood Pneumonia 1.00 None Yes

M 11.2 AK Native Other Joint fluid Septic arthritis, 

cellulitis 1.00 None Unknown 

M 15.8 Non-Native Anchorage Blood Empyema, pneumonia 5.14 None Yes 

M 21.3 Non-Native Other Joint fluid Cellulitis, bursitis 73.00 Smoking, diabetes Yes 

F 26 Non-Native Other Blood Endometritis 73.00 None Yes 

M 30.3 AK Native Other Bone Osteomyelitis Smoking Yes 

F 32.1 AK Native Other Blood Cellulitis 82.00 Alcohol abuse Yes 

F 33.1 AK Native Other Blood Endometritis 82.00 Smoking, chronic lung 

disease Yes 

M 34.2 AK Native Anchorage Blood Bacteremia 82.00 Alcohol abuse Yes 

M 36.4 Non-Native Other Blood Pneumonia 1.00 Smoking Yes 

F 37.1 AK Native Anchorage Blood Osteomyelitis 58.00 None Yes 

M 38.1 Non-Native Other Blood Empyema, pneumonia 1.00 None Yes 

M 48.3 AK Native Anchorage Joint fluid Septic arthritis, 

cellulitis 82.00 Smoking, alcohol abuse Yes 

M 49 AK Native Other Joint fluid Septic arthritis, 

necrotizing fasciitis 82.00 None Yes 

F 51.9 AK Native Anchorage Synovial 

fluid Septic arthritis 82.00 Smoking, alcohol abuse Yes 

M 52.2 Non-Native Anchorage Blood Septic arthritis 108.10 None Yes 

M 52.7 Non-Native Other Blood Cellulitis, strep toxic 

shock syndrome 82.00 Diabetes Yes 

M 53.7 AK Native Other Blood Bacteremia 82.00 Chronic lung disease, 

alcohol abuse, diabetes Yes 

F 54 AK Native Anchorage Blood Cellulitis 80.00 None Yes 

F 56.4 AK Native Anchorage Blood Cellulitis 92.00 Chronic lung disease Yes 

F 59 AK Native Anchorage Blood Pneumonia 82.00 None No 

F 62.8 Non-Native Anchorage Blood Cellulitis 82.00 None Yes 

F 65.7 Non-Native Other Blood 

Cellulitis, necrotizing 

fasciitis, strep toxic 

shock syndrome 

108.10 Diabetes Yes 

M 67.8 Non-Native Anchorage Blood Cellulitis 11.00 Diabetes Yes 

M 71 Non-Native Other Blood Cellulitis Alcohol abuse Yes 

F 78.1 Non-Native Anchorage Blood Bacteremia 118.00 None Yes 

M 78.5 AK Native Anchorage Blood Cellulitis 2.00 Smoking, chronic lung 

disease Yes 

F 80.3 AK Native Anchorage Blood Endocarditis, 

pneumonia 82.00 None No 

M 81.3 Non-Native Anchorage Blood Cellulitis 12.00 Immunosuppressive 

treatment Yes 

M 90.5 Non-Native Anchorage Blood Cellulitis 82.00 None No 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 28 

Invasive group B Streptococcus

Overall Incidence

A total of 31 cases of invasive group B Streptococcus (GBS) were reported to AIP in 2009. The 

overall rate of invasive GBS disease in the state of Alaska was 4.5/100,000 persons per year. 

The Alaska rate is lower than the ABCs 2009 national projected rate of 6.9/100,000 [11]. In 

2009, there were six GBS-related deaths for a case fatality ratio of 20% (outcome was unknown 

in 1 case). 

Seasonality

Cases of group B Streptococcus occurred throughout the year with no apparent trends in 

seasonality. 

Race

In 2009, 19% of invasive group B Streptococcus cases in Alaska occurred in the Alaska Native 

population; the age-adjusted rate was 4.2/100,000 persons per year which is slightly higher than 

the non-Native rate of 3.8/100,000 persons per year. 

Table 19: Invasive group B Streptococcus Cases by Race – Alaska, 2009 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 6 (19) 4.2 33 0 (0) 

Non-Native 25 (81)‡ 3.8 72 6 (24)† 

Total 31 65 6 (19)† 

*Cases per 100,000 per percent distribution of Alaska 2000 population 

‡Includes one case for which race was unknown 

†Outcome unknown in one case 

 

0

1

2

3

4

5

6

7

8

Number of Cases

Month of Culture

Figure 18: Invasive group B Streptococcus, by 

Month of Culture - Alaska, 2009
Surveillance of Invasive Bacterial Disease in Alaska, 2009 29 

Region 

In 2009, 21 (68%) of the 31 reported GBS cases occurred in Anchorage; four cases were 

reported in the Interior, three cases in Southeast Alaska, two cases in Norton Sound and one in 

the YK Delta. 

Age

Invasive group B Streptococcus cases reported in 2009 ranged in age from newborn to 88.1 years 

old; the median age was 55.7 years. Highest rates of disease occurred in children less than two 

years old (29.8/100,000 persons per year). 

When stratified by race, the highest rates of disease occurred in non-Native children less than 2 

years of age (36.2/100,000 persons per year). There were three cases of early-onset disease (less 

than 7 days old) for a rate of 0.3/1,000 births. 

0

5

10

15

20

25

30

35

<2 2-4 5-18 19-54 55-64 65+

Rate per 100,000

Age (yrs)

Figure 19: Invasive group B Streptococcus by Age 

Group - Alaska, 2009

0

5

10

15

20

25

30

35

40

0

1

2

3

4

5

6

7

8

9

10

<2 2-4 5-18 19-54 55-64 65+

Number of Cases

Rate per 100,000

Age (yrs)

Figure 20: Invasive group B Streptococcus, Cases & 

Rates by Age Group & Race - Alaska, 2009

AK Native (#

cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)
Surveillance of Invasive Bacterial Disease in Alaska, 2009 30 

Clinical Presentation

The primary clinical presentation was determined by a review of the discharge diagnoses in each 

patient’s individual medical record associated with the invasive bacterial illness. In cases with 

multiple discharge diagnoses, the most serious diagnosis related to the GBS infection was 

recorded as the primary clinical presentation. In 2009, the most common clinical presentation 

was bacteremia which occurred in 11 cases (35%). 

Group B Streptococcus was isolated from blood in 28 (90%) of 31 cases in 2009; two cases were 

isolated from cerebrospinal fluid and one case was isolated from an unspecified sterile site. 

Table 20: Primary Clinical Presentations of Invasive group B Streptococcus – Alaska, 2009 

*with bacteremia

Antibiotic Resistance

Susceptibility testing was performed on 28 GBS isolates received in 2009; one additional isolate 

was tested for tetracycline resistance. Results of the testing are presented in the following table. 

Table 21: Antibiotic Resistance in Invasive group B Streptococcus Isolates – Alaska, 2009 

Antibiotic Susceptible Intermediate Resistant I + R Total Tested 

Penicillin 28 (100%) 0 (0%) 0 (0%) 0 (0%) 28 

Ceftriaxone 28 (100%) 0 (0%) 0 (0%) 0 (0%) 28 

Erythromycin 13 (46%) 0 (0%) 15 (54%) 15 (54%) 28 

Tetracycline 5 (17%) 0 (0%) 24 (83%) 24 (83%) 29 

Levofloxacin 27 (100%) 0 (0%) 0 (0%) 0 (0%) 27 

Clindamycin 20 (71%) 0 (0%) 8 (29%) 8 (29%) 28 

Vancomycin 28 (100%) 0 (0%) 0 (0%) 0 (0%) 28 

All isolates tested were susceptible to penicillin, ceftriaxone, levofloxacin and vancomycin. 

Resistance to tetracycline, erythromycin and clindamycin was seen in 83%, 54% and 29%, 

respectively, of isolates tested. One isolates from one of the early onset cases was resistant to 

tetracycline and one was resistant to erythromycin; the isolate from the third case was susceptible 

to all antibiotics tested.

Primary Presentation n (%) 

Bacteremia 11 (35) 

Pneumonia* 6 (19) 

Cellulitis* 5 (16) 

Meningitis 2 (7) 

Osteomyelitis 2 (7) 

Endocarditis 2 (7) 

Septic arthritis 1 (3) 

Other 1 (3) 

No information 1 (3) 

Total 31 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 31 

Table 21: Summary of Invasive group B Streptococcus Case Characteristics, Alaska, 2009 

Sex Age (yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) 

Associated Medical 

Conditions Survived 

F Newborn Non-Native Anchorage Blood Bacteremia None Yes 

F Newborn AK Native Other Blood Bacteremia None Yes

M Newborn Non-Native Other Blood Pneumonia None Yes

M 11 days Non-Native Anchorage CSF Meningitis None Yes 

M 0.1 Non-Native Other Blood Cellulitis None Yes 

M 0.2 Non-Native Other Blood Pneumonia Chronic lung disease No 

F 0.3 Non-Native Anchorage CSF Meningitis None Yes 

M 20.6 AK Native Anchorage Blood Bacteremia Smoking, alcohol abuse Yes 

F 37.1 AK Native Anchorage Blood Osteomyelitis None Yes 

M 39.2 Non-Native Other Blood Cellulitis Diabetes Yes 

M 42.9 Non-Native Anchorage Blood Bacteremia Smoking Yes 

M 43.3 Non-Native Anchorage Blood Septic arthritis Smoking, alcohol abuse Yes 

F 46.7 Non-Native Anchorage Blood Endocarditis Smoking Yes 

F 53.9 Non-Native Anchorage Blood Cellulitis Smoking Yes 

M 55.3 Non-Native Anchorage Blood Pneumonia Smoking, alcohol abuse Yes 

F 55.7 AK Native Anchorage Blood Bacteremia Smoking, chronic lung 

disease Yes 

M 57.6 Non-Native Anchorage Blood Bacteremia None No 

M 60.1 Non-Native Anchorage Blood Endocarditis None No 

M 61.8 AK Native 

Anchorage Blood Bacteremia Smoking, chronic lung 

disease, immunosuppressive 

treatement 

Yes 

M 62.3 Non-Native Other Blood Bacteremia None Yes 

M 62.8 Unknown Other Other Unknown Unknown Unknown 

M 65.2 Non-Native Other Blood Bacteremia Diabetes Yes 

M 65.3 Non-Native Other Blood Bacteremia Diabetes No 

F 66.4 Non-Native Other Blood Osteomyelitis Immunosuppressive 

treatment No 

F 66.5 AK Native Anchorage Blood Bacteremia None Yes 

M 68.3 Non-Native Anchorage Blood Cellulitis, osteomyelitis Diabetes Yes 

M 79.3 Non-Native Anchorage Blood Pneumonia None No

F 81.7 Non-Native Anchorage Blood Pneumonia None Yes 

M 83 Non-Native Anchorage Blood Pneumonia None Yes 

F 85.1 Non-Native Anchorage Blood Other Diabetes Yes 

M 88.1 Non-Native Anchorage Blood Cellulitis Chronic lung disease, 

diabetes Yes 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 32 

References 

[1] State of Alaska, Department of Labor & Workforce Development. Retrieved 4/9/2010 from 

http://almis.labor.state.ak.us 

[2] Centers for Disease Control and Prevention. 2010. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Streptococcus pneumoniae, 2009.

[3] Hennessy TW, Singleton RJ, Bulkow LR, Bruden DL, Hurlburt DA, Parks, D, Moore M, 

Parkinson AJ, Schuchat A, Butler JC. Impact of heptavalent pneumococcal conjugate 

vaccine on invasive disease; antimicrobial resistance and colonization in Alaska Natives: 

progress towards elimination of a health disparity. Vaccine 2005;23:5464-73. 

[4] Singleton RJ, Hennessy TW, Bulkow LR, Hammitt LL, Zulz T, Hurlburt DA, Butler JC, 

Rudolph K, Parkinson A. Invasive pneumococcal disease caused by nonvaccine serotypes 

among Alaska Native children with high levels of 7-valent pneumococcal conjugate vaccine 

coverage. JAMA 2007;297(16):1784-92. 

[5] Wenger JD, Zulz T, Bruden D, Singleton R, Bruce MG, Bulkow L, Parks D, Rudolph K, 

Hurlburt D, Ritter T, Klejka J, Hennessy T. Invasive pneumococcal disease in Alaskan 

children: impact of the seven-valent pneumococcal conjugate vaccine and the role of water 

supply. Pediatr Infect Dis J 2010;29: 251-256. 

[6] State of Alaska, Department of Health & Human Services. Retrieved 3/17/11 from 

http://www.epi.hss.state.ak.us/bulletins/docs/b2009_24.pdf

[7] Clinical and Laboratory Standards Institute (CLSI). Performance Standards for 

Antimicrobial Susceptibility Testing; Nineteenth Informational Supplement. 2009; 29(3): 

M100-S19. p.21. 

[8] Centers for Disease Control and Prevention. 2010. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Haemophilus influenzae, 2009. 

[9] Centers for Disease Control and Prevention. 2010. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Neisseria meningitidis, 2009. 

[10]Centers for Disease Control and Prevention. 2010. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Group A Streptococcus, 2009. 

[11] Centers for Disease Control and Prevention. 2010. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Group B Streptococcus, 2009. 
Surveillance of Invasive Bacterial Disease in Alaska, 2009 33 

Appendix 

MIC Interpretive Standards Definitions: 

CLSI [5] provides recommended interpretive categories for various Minimum Inhibitory 

Concentration values (cut points) for each organism/antibiotic combination which are defined as 

follows: 

1. Susceptible (S): 

The “susceptible” category implies that isolates are inhibited by the usually achievable 

concentrations of antimicrobial agent when the recommended dosage is used for the site of 

infection. 

2. Intermediate (I): 

The “intermediate” category includes isolates with antimicrobial agent MICs that approach 

usually attainable blood and tissue levels and for which response rates may be lower than for 

susceptible isolates. The “intermediate” category implies clinical efficacy applicability in body 

sites where the drugs are physiologically concentrated (e.g., quinolones and β-lactams in urine) 

or when a higher dosage of a drug can be used (e.g., β-lactams). The “intermediate” category 

also includes a buffer zone which should prevent small, uncontrolled technical factors from 

causing major discrepancies in interpretations, especially for drugs with narrow 

pharmacotoxicity margins. 

3. Resistant (R): 

Resistant strains are not inhibited by the usually achievable concentrations of the agent with 

normal dosage schedules, and/or that demonstrate MICs or zone diameters that fall in the range 

where specific microbial resistance mechanisms are likely (e.g., β-lactamases) are likely, and 

clinical efficacy of the agent against the isolate has not been reliably shown in treatment studies.