Surveillance of Invasive Bacterial Disease in Alaska, 2008 

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, 2008 2 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 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, 2008 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, 2008 

In 2008, 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, 38 group A Streptococci (GAS) and 28 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, 2008 5 

surveillance organisms except Neisseria meningitidis. Rates of invasive pneumococcal disease were 

highest in the YK Delta. Rates for each organism by region are presented in the following table. 

Table 1: Surveillance Organisms Reported by Region – Alaska, 2008 

Region 

S. pneumoniae 

n (rate*) 

H. influenzae 

n (rate*) 

N. meningitidis 

n (rate*) 

GAS 

n (rate*) 

GBS 

n (rate*) 

Anchorage 74 (16.4) 9 (2) 4 (0.9) 25 (5.5) 20 (4.4)

Arctic Slope 3 (52.3) 1 (17.4) 0 (0) 0 (0) 0 (0) 

Bristol Bay 2 (28.6) 0 (0) 0 (0) 0 (0) 0 (0) 

Interior 23 (22.2) 3 (2.9) 1 (1) 1 (1) 4 (3.9) 

Kotzebue 3 (37.1) 0 (0) 0 (0) 3 (37.1) 0 (0) 

Norton Sound 3 (31.6) 1 (10.5) 0 (0) 0 (0) 0 (0) 

Southeast 16 (23.1) 2 (2.9) 0 (0) 3 (4.3) 3 (4.3) 

YK Delta 24 (96.4) 5 (20.1) 0 (0) 6 (24.1) 1 (4) 

Total 148 (21.8) 21 (3.1) 5 (0.7) 38 (5.6) 28 (4.1)

*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 679,720 persons in 2008 [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 2008, 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, 2008 6 

Invasive Pneumococcal Disease 

Overall Incidence

A total of 138 pneumococcal isolates were received at AIP in 2008. An additional 3 cases were detected 

through year-end follow up with participating laboratories, 6 cases through shared surveillance with the 

State DPH and one case through on-site personnel review of medical records for a total of 148 cases of

invasive pneumococcal disease. The overall rate for invasive pneumococcal disease in 2008 was 21.8 

cases per 100,000 persons per year. Alaska rates for 2008 were higher than the Active Bacterial Core 

Surveillance (ABCs) 2008 national projected rate of 14.5/100,000 [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 2008. The largest number of 

cases was reported in April. 

Race 

In 2008, the state population was comprised of 19.8% Alaska Native people (Alaska Natives 134,633, 

non-Natives 545,087) [1]. Of all reported S. pneumoniae cases in 2008, 51% occurred among Alaska 

Native people for a total of 76 cases; the age-adjusted rate was 54.4/100,000 persons per year. Seventytwo cases occurred among the non-Native population with an age-adjusted rate of 11.8/100,000 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 2008 was 4.6. 

0

5

10

15

20

Number of Cases

Figure 2: Invasive Pneumococcal Disease, by 

Month of Culture - Alaska, 2008
Surveillance of Invasive Bacterial Disease in Alaska, 2008 7 

Table 2: Invasive Streptococcus pneumoniae Cases by Race – Alaska, 2008 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 76 (51) 54.4 46 7 (9.2) 

Non-Native 72 (49) 11.8 54 6 (8.3) 

Total 148 50 13 (8.8) 

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

Region 

The highest percentage (50%) of invasive pneumococcal disease cases occurred in the Anchorage area 

in 2008. Rates of disease, however, were highest in the YK Delta (96.4/100,000 persons per year). 

Age

Cases occurred in all age groups in 2008 ranging from 4 months to 101 years with a median age of 46 

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

 

When stratified by age and race, the highest rates of disease in 2008 occurred in Alaska Native children 

less than 2 years old (210.7/100,000 persons per year). 

0

20

40

60

80

100

120

0

20

40

60

80

Number of Cases

Rate per 100,000

Figure 3: Invasive Pneumococcal Disease, Cases 

& Rates by Region - Alaska, 2008

Cases

Rate
Surveillance of Invasive Bacterial Disease in Alaska, 2008 8 

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. 

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 is due primarily to 

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

rate of invasive pneumococcal disease in AK Native children less than 2 years in 2008 was 

210.7/100,000, this is 34 times the rate of disease seen in non-Native children. Rates of invasive disease 

in non-Native children less than 2 years declined during the same time period reaching 26.8/100,000 in

2005, increasing to 64.4/100,000 in 2007 and declining in 2008 to 6.2/100,000. 

0

50

100

150

200

250

0

5

10

15

20

25

30

35

40

<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, 2008

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, 2000-2008

2000

2001

2002

2003

2004

2005

2006

2007

2008
Surveillance of Invasive Bacterial Disease in Alaska, 2008 9 

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 2008 (71%) followed by bacteremia (13%). Nineteen cases had a secondary 

pneumococcal-related diagnosis in 2008 – 13 pneumonia, 3 cellulitis, 1 endocarditis, 1 empyema and 1 

septic arthritis. 

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, 2000-2008

2000

2001

2002

2003

2004

2005

2006

2007

2008

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, 2000-2008

2000

2001

2002

2003

2004

2005

2006

2007

2008
Surveillance of Invasive Bacterial Disease in Alaska, 2008 10 

In 2008, blood was the most common source of a positive culture which was used to identify 138 (95%) 

of 146 cases. Cerebrospinal fluid was the positive site for 4 (3%) cases, 3 cases were identified from 

pleural fluid and 1 case from an abscess.

Mortality 

In 2008, the overall case fatality ratio for S. pneumoniae in Alaska was 8.8% (13 deaths out of 148 cases 

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

9.2% (7 deaths) and 8.3% (6 deaths), respectively. Although the majority of deaths occurred in the 19-

54 age category (6 deaths), the highest case fatality ratio occurred in the 55-64 age category; 15.8% (5 

deaths). 

103

19

8 7 2 2 2 2

0

20

40

60

80

100

120

Number of Cases

Figure 8: Primary Clinical Presentations of 

Invasive Pneumococcal Disease - Alaska, 2008

*with bacteremia

0

5

10

15

20

0

1

2

3

4

5

6

7

<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, 2008

Deaths

CFR
Surveillance of Invasive Bacterial Disease in Alaska, 2008 11 

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, 2008 

 Alaska Native Non-Native 

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

03 3 (2) 1 - - - - 1 1 - 

06A 2 (1) - - 1 - - - - 1 

06C 2 (1) - - 1 - - - 1 - 

07C 1 (<1) - - - - - - 1 - 

07F 29 (22) 2 3 4 - 1 3 13 3 

08 7 (5) - - 4 - - 1 2 - 

09N 1 (<1) - - - - - - - 1 

09V 1 (<1) - - - - - - 1 - 

10A 3 (2) - - 1 - - - - 2 

10F 2 (1) - - - - - - - 2 

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

12F 11 (8) - - 7 1 - - 3 - 

15A 4 (3) 1 - 1 - - - 2 - 

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

16F 4 (3) - - 1 1 - - - 2 

19A 28 (21) 7 4 4 2 - 1 8 2 

19F 2 (1) 1 - - 1 - - - - 

20 8 (6) - - 6 1 - - 1 - 

22F 11 (8) - 1 3 - - - 5 2 

23A 1 (<1) - - 1 - - - - - 

23B 4 (3) 1 - - - - 1 1 1 

31 1 (<1) - - 1 - - - - - 

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

35B 3 (2) 1 - 1 1 - - - - 

Total 135 14 9 38 7 1 7 41 18 

In 2008, the most common pneumococcal serotypes were 7F (29 isolates, 22%) and 19A (28 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 and did not cause any invasive pneumococcal disease in 2008. However, disease caused

by serotypes 7F and 19A, which are not included in the conjugate vaccine, has increased. Prior to 2005, 

yearly numbers of cases of serotype 7F disease and the proportion of total isolates have 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, it was more evenly distributed between AK Native people (48%) and nonNatives (52%) in 2006. In 2007, the proportion of serotype 7F disease increased in non-Natives (57%) 

versus AK Natives (43%) and reached 69% versus 31%, respectively, in 2008. The majority (66%) of 

serotype 7F cases occurred in the Anchorage area in 2008. 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 12 

Table 4: Invasive Pneumococcal Serotype Distribution by Region – Alaska, 2008 

Serotype 

Anchorage 

Arctic 

Slope 

Bristol 

Bay 

Interior 

Kotzebue 

Norton 

Sound 

Southeast 

YK Delta 

03 2 - - - - 1 - - 

06A 1 - - 1 - - - - 

06C 1 - - 1 - - - - 

07C 1 - - - - - - - 

07F 19 - - 5 - - 3 2 

08 3 - - - 1 1 2 - 

09N 1 - - - - - - - 

09V 1 - - - - - - - 

10A 1 - - - - - 1 1 

10F 2 - - - - - - - 

11A 1 - - 1 - - - - 

12F 5 - 1 - - - - 5 

15A 2 - - 1 - - - 1 

15B 1 - - - - - 1 - 

16F 2 - - - - - 2 - 

19A 8 2 1 8 - 1 2 6 

19F 1 - - - - - 1 - 

20 5 - - 3 - - - - 

22F 7 1 - - - - 1 2 

23A - - - - - - - 1 

23B 2 - - 1 - - - 1 

31 1 - - - - - - - 

33F 2 - - - - - - 1 

35B 1 - - - 1 - - 1 

Total 70 3 2 21 2 3 13 21 

Vaccine Serotypes

Two vaccine types were licensed for prevention of pneumococcal disease in 2008. 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 2008 that were due to serotypes found in the PCV7 vaccine. There was one 

case of pneumococcal disease caused by a serotype (19F) contained in the PCV7 vaccine in a child less 

than 5 years of age, the age group for which the vaccine is recommended, however, the child had not 

received any doses of vaccine. 

 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 13 

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

– Alaska, 2008 

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

<2 1 (7%) of 14 0 (0%) of 1 1 (7%) of 15 

2-4 0 (0%) of 4 0 (0%) of 4 0 (0%) of 8 

5+ 1 (2%) of 49 1 (2%) of 59 2 (2%) of 108 

Total 2 (3%) of 67 1 (2%) of 64 3 (2%) of 131 

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

Alaska for all persons 55 years and older, and for persons over age 2 who are at higher risk for 

pneumococcal disease. Revaccination was recommended after 6 years [6]. In 2008, for persons 55 

years and older, 31 (74%) of 42 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 2008. 

Potentially Preventable Deaths

In 2008, pneumococcal vaccine status was known for 96 (66%) of the 146 cases; 59 cases (40%) did 

receive a pneumococcal vaccine prior to illness and 37 cases (25%) had no record of a pneumococcal 

vaccine. 

Table 6: Potentially Vaccine Preventable Invasive Pneumococcal Deaths – Alaska, 2008 

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

PCV7 0 0 0 1 (17%) 0 0 1 (8%) 

Ps23V 0 0 1 (100%) 3 (50%) 2 (67%) 3 (100%) 9 (69%)

Non-Vaccine 0 0 0 1 (17%) 0 0 1 (8%) 

Unknown 0 0 0 1 (17%) 1 (33%) 0 2 (15%) 

Total 0 0 1 6 3 3 13 

Overall, 69% of all pneumococcal-related mortality in 2008 was potentially preventable with the use of

the 23-valent polysaccharide vaccine in persons over 2 years old; 16% of deaths were due to disease 

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

Nine of the 13 deaths in 2008 from invasive S. pneumoniae occurred from serotypes contained within 

the Ps23V vaccine; 5 of the deaths were in individuals eligible for the vaccine. Of those five deaths, two 

occurred in vaccinated individuals; time since vaccination for each was 3 years and 12 years. 

 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 14 

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

Serotype 

Deaths 

n (%) 

Serotype 

Frequency (n) 

03* 1 (33%) 3 

08* 1 (14%) 7 

09V†* 1 (100%) 1 

10A* 1 (33%) 3 

15A 1 (25%) 4 

20* 3 (38%) 8 

22F* 2 (18%) 11 

33F* 1 (33%) 3 

†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 86% of invasive 

pneumococcal cases in 2008. Cigarette smoking was the most prevalent risk factor observed in adults 

followed by alcohol abuse and chronic lung disease.

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

2008* 

Medical Condition/Risk 

Factor 

Adult Cases (≥ 18 years) 

n=112, Cases (%) 

Cigarette smoking 53 (47) 

Alcohol abuse 40 (36) 

Chronic lung disease 28 (25) 

Diabetes 17 (15) 

Immunosuppressive treatment 5 (5) 

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 2008. Results of the testing are 

presented in the following table. 

Table 9: Antibiotic Resistance in Invasive Streptococcus pneumoniae Isolates – Alaska, 2008 

Antibiotic Susceptible Intermediate Resistant I + R Total Tested 

Penicillin 106 (79%) 25 (19%) 4 (3%) 29 (22%) 135 

TMP-sulfa 100 (74%) 9 (7%) 26 (19%) 35 (26%) 135 

Erythromycin 114 (84%) 0 (0%) 21 (16%) 21 (16%) 135

Ceftriaxone 130 (96%) 3 (2%) 2 (2%) 5 (3%) 135 

Tetracycline 131 (97%) 0 (0%) 4 (3%) 4 (3%) 135 

Chloramphenicol 133 (98%) 0 (0%) 2 (1%) 2 (1%) 135 

Rifampin 135 (100%) 0 (0%) 0 (0%) 0 (0%) 135 

Vancomycin 133 (98%) 0 (0%) 2 (2%) 2 (2%) 135 

Levofloxacin 131 (97%) 0 (0%) 4 (3%) 4 (3%) 135 

Clindamycin 134 (99%) 0 (0%) 1 (1%) 1 (1%) 135 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 15 

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 [7]. 

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 similar levels of 

resistance seen in 2002 and remained at those levels until 2008 when both show an increase. After 

steadily declining from 2000 to a low of 4% in 2004, erythromycin resistance has increased to 16% of 

tested isolates in 2008. 

 *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 - 2008

Pen-FR*

Pen-NS*

Erythro

TMP-Sulfa

Tet
Surveillance of Invasive Bacterial Disease in Alaska, 2008 16 

Invasive Haemophilus influenzae

Overall Incidence 

In 2008, there were 21 cases of invasive Haemophilus influenzae in Alaska, for a statewide rate of 

3.1/100,000 persons per year. This rate is higher than the national projected rate of 1.55/100,000 

persons per year [7]. There were three deaths caused by H. influenzae in 2008 for a case fatality ratio of 

14%. 

Seasonality 

Cases of invasive H. influenzae occurred throughout 2008; 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 2008 were in YK Delta, 

20.1/100,000 (5 cases), and the Arctic Slope, 17.4/100,000 (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, 2008
Surveillance of Invasive Bacterial Disease in Alaska, 2008 17 

Race 

Table 10: Invasive Haemophilus influenzae Cases by Race – Alaska, 2008 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 10 (48%) 6.6 60 0 (0%) 

Non-Native 11 (52%) 1.6 64 3 (27%) 

Total 21 62 3 (14%) 

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

In 2008, 52% of the cases occurred in non-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 2008 was 4.1. 

Age 

H. influenzae cases ranged in age from newborn to 93 years of age in 2008 (median 54.4 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, 45.2/100,000 persons per year and 

Alaska Native adults 65 years and older, 25.1/100,000 persons per year. 

0

5

10

15

20

25

0

2

4

6

8

10

Number of Cases

Rate per 100,000

Figure 12: Invasive Haemophilus influenzae, 

Cases & Rates by Region - Alaska, 2008

Cases

Rate
Surveillance of Invasive Bacterial Disease in Alaska, 2008 18 

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 2008, pneumonia with bacteremia was the most common presentation (43% of cases). 

H. influenzae was isolated from 17 (81%) blood samples, 2 (10%) cerebrospinal fluid samples, 1 (5%) 

pleural fluid sample, and 1 (5%) joint fluid sample. 

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 13: Invasive Haemophilus influenzae by 

Age Group - Alaska, 2008

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, 2008

AK Native

(# cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)
Surveillance of Invasive Bacterial Disease in Alaska, 2008 19 

Table 11: Primary Clinical Presentation of Invasive Haemophilus influenzae - Alaska, 2008 

Primary Presentation n (%) 

Pneumonia* 9 (43%) 

Bacteremia 7 (33%) 

Meningitis 2 (10%) 

Septic Arthritis 2 (10%) 

Empyema 1 (5%) 

Total 21 

*with bacteremia 

Serotypes 

All isolates received at AIP are serotyped; 20 of the 21 cases in 2008 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, 2008 

 Alaska Native Non-Native 

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

a 2 0 1 0 0 1 0 0 0 

b 3 2 0 1 0 0 0 0 0 

e 1 0 0 1 0 0 0 0 0 

f 1 0 0 0 0 1 0 0 0 

NT* 13 1 0 2 2 2 0 2 4 

Total 20 3 1 4 2 4 0 2 4 

*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. Three cases of Hib occurred in 2008; two in unvaccinated children under 

the age of 2 and one in a 43 year old adult.

Antibiotic Resistance 

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

chloramphenicol, ceftriaxone and TMP/sulfa. All 19 isolates were susceptible to ceftriaxone; one isolate 

was fully resistant to chloramphenicol; 2 were fully resistant to TMP/sulfa 3 had intermediate resistance 

and 14 were susceptible. 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 20 

Table 13: Summary of Invasive Haemophilus influenzae Case Characteristics, Alaska, 2008 

Sex Age (Yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) Serotype* 

Associated Medical 

Conditions Survived 

M Newborn Non-Native Other Blood Bacteremia NT None Yes 

F Newborn AK Native Other Blood Bacteremia NT None Yes 

M 10 days Non-Native Anchorage Blood Bacteremia NT None Yes 

M 0.2 AK Native Other CSF Meningitis b None Yes 

M 0.5 Non-Native Other CSF Meningitis f None Yes 

M 0.6 Non-Native Anchorage Blood Septic arthritis a None Yes 

F 1.2 AK Native Other Blood Pneumonia b None Yes 

M 2.4 AK Native Other Blood Pneumonia a Chronic lung disease Yes 

M 43.5 AK Native Anchorage Blood Pneumonia b Smoking, alcohol abuse Yes 

M 45.5 AK Native Other Blood Pneumonia e 

Smoking, 

immunosuppressive 

treatment 

Yes 

M 54.4 AK Native Anchorage Blood Bacteremia NT Smoking Yes 

M 56.2 Non-Native Anchorage Joint fluid Septic arthritis Unknown Immunosuppressive 

treatment Yes 

F 62.3 AK Native Other Blood Pneumonia NT Chronic lung disease Yes 

M 63.5 Non-Native Anchorage Blood Pneumonia NT Diabetes No 

F 64.2 Non-Native Anchorage Pleural 

fluid 

Empyema, 

pneumonia NT Smoking, chronic lung disease, diabetes No 

M 75.7 AK Native Other Blood Pneumonia NT Chronic lung disease Yes 

F 77.4 Non-Native Anchorage Blood Bacteremia NT None Yes 

M 80.1 Non-Native Other Blood Pneumonia NT Diabetes Yes 

F 85.7 Non-Native Anchorage Blood Pneumonia NT None Yes 

F 92.4 Non-Native Other Blood Bacteremia NT None No

F 92.7 AK Native Other Blood Bacteremia NT None Yes

*NT = non-typeable 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 21 

Invasive Neisseria meningitidis

Overall Incidence

A total of 5 cases of invasive Neisseria meningitidis were reported to AIP in 2008 for an overall 

rate of 0.7/100,000. The Alaska rates are slightly higher than the ABCs 2008 national projected 

rate of 0.3/100,000 [9]. There were no invasive N. meningitidis-related deaths in Alaska in 2008. 

Seasonality

One N. meningitidis case occurred in each month of April, June, July, August and October; no 

clusters of related cases were reported. 

Race

In 2008, 80% 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 

non-Native population compared with the Alaska Native population in 2008 was 1.7. 

Table 14: Invasive Neisseria meningitidis Cases by Race – Alaska, 2008 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 1 (20%) 0.45 0 0 (0%) 

Non-Native 4 (80%) 0.75 75 0 (0%) 

Total 5 60 0 

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

Region

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

Interior. 

Age

Invasive N. meningitidis cases reported in 2008 ranged in age from 0.2 to 29.6 years old; the 

median age was 0.6 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. Four cases presented with meningitis and one 

with bacteremia; one case had a secondary clinical presentation of cellulitis. 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 22 

N. meningitidis was isolated from cerebrospinal fluid in four of five (80%) cases in 2008. One 

case was isolated from blood. 

Mortality

There were no N. meningitidis-related deaths reported in Alaska in 2008. 

Serogroup 

Five invasive N. meningitidis cases in 2008 were serogrouped; three were serogroup B and two 

were serogroup Y.

Table 15: Summary of Invasive Neisseria Meningitidis Cases Characteristics, Alaska, 2008 

Sex 

Age 

(yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) Serogroup 

Associated 

Medical 

Conditions Survived 

M 0.2 Non-Native Anchorage CSF Meningitis B None Yes 

F 0.2 AK Native Other Blood Bacteremia Y None Yes 

M 0.6 Non-Native Anchorage CSF Meningitis, 

cellulitis Y None Yes 

M 1.4 Non-Native Anchorage CSF Meningitis B None Yes 

F 20.6 Non-Native Anchorage CSF Meningitis B None Yes 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 23 

Invasive group A Streptococcus

Overall Incidence

A total of 38 cases of invasive group A Streptococcus (GAS) were reported to AIP in 2008. The 

overall rate of invasive GAS disease in the state of Alaska was 5.6/100,000 persons per year. 

The Alaska rate is higher than the ABCs 2008 national projected rate of 3.9/100,000 [10]. In 

2008, there were 5 GAS-related deaths (emm types 1 (2 cases), 73, 108.1 and one unknown) for a

case fatality ratio of 13.2%. 

Seasonality 

Cases of group A Streptococcus occurred throughout the year in 2008 with no apparent trends in 

seasonality. 

Race

In 2008, 47% of invasive GAS cases in Alaska occurred in the Alaska Native population for an 

age-adjusted rate of 12.3/100,000 persons per year which was three and a half times higher than 

the non-Native age-adjusted rate of 3.5/100,000 persons per year. 

Table 16: Invasive group A Streptococcus Cases by Race – Alaska, 2008 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 17 (45%) 12.3 65 1 (6%) 

Non-Native 21 (55%) 3.5 71 4 (19%) 

Total 38 68 5 (13%) 

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

0

1

2

3

4

5

6

7

Number of Cases

Month of Culture

Figure 15: Invasive group A Streptococcus, by 

Month of Culture - Alaska, 2008
Surveillance of Invasive Bacterial Disease in Alaska, 2008 24 

Region 

Twenty five (65.8%) of the 38 invasive group A Streptococcus cases in 2008 were reported in 

the Anchorage area, 6 cases in the YK Delta, 3 cases each in Southeast and Kotzebue, and one 

case in the Interior. 

Age

Invasive group A Streptococcus cases reported in 2008 ranged in age from 2.4 months to 87.2 

years old; the median age was 51.6 years. Highest rates of disease occurred in adults 65 and 

older (22.2/100,000). 

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

Alaska Native adults 65 and older (75.3/100,000 persons per year). The highest GAS disease 

rate in the non-Native population occurred in adults 65 and older (12.1/100,000 persons per 

year). 

0

5

10

15

20

25

<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, 2008

0

10

20

30

40

50

60

70

80

0

2

4

6

8

10

12

14

<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, 2008

AK Native

(# cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)
Surveillance of Invasive Bacterial Disease in Alaska, 2008 25 

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 2008. Nine cases also presented with secondary 

diagnoses including endocarditis, cellulitis, osteomyelitis and bursitis. 

Group A Streptococcus was isolated from blood samples in 32 (84%) of 38 cases, five from joint 

fluid and one from a surgical sample. 

 

Table 17: Primary Clinical Presentations of Invasive group A Streptococcus – Alaska, 2008 

Primary Presentation n (%) 

Cellulitis* 15 (39%) 

Pneumonia* 8 (21%) 

Bacteremia 7 (18%) 

Septic arthritis 2 (5%) 

Necrotizing fasciitis 2 (5%) 

Meningitis 1 (3%) 

Bursitis 1 (3%) 

Other 2 (5%) 

Total 38 

*with bacteremia
Surveillance of Invasive Bacterial Disease in Alaska, 2008 26 

Table 18: Summary of Invasive group A Streptococcus Case Characteristics, Alaska, 2008 

Sex 

Age 

(yrs) Race Residence 

Site of 

Isolation Clinical Presentation(s) 

emm

Type 

Associated Medical 

Conditions Survived 

M 0.2 Non-Native Anchorage Blood Bacteremia 9.00 None Yes 

M 0.6 AK Native Other Blood Cellulitis 82.00 None Yes 

M 1.2 AK Native Other Blood Bacteremia 82.00 None Yes 

F 6.1 AK Native Other Blood Cellulitis 12.00 None Yes 

M 18.5 AK Native Anchorage Blood Bacteremia 108.10 Chronic lung disease, 

diabetes Yes 

F 24 Non-Native Anchorage Blood Bacteremia, other 1.00 None No 

M 32.3 Non-Native Anchorage Blood Cellulitis Smoking, diabetes Yes 

M 33 AK Native Anchorage Blood Cellulitis 58.00 Smoking, alcohol abuse Yes 

F 33 Non-Native Anchorage Blood Other 108.10 Smoking Yes 

F 35.9 Non-Native Other Blood Other 44.00 Chronic lung disease Yes 

F 41.2 Non-Native Anchorage Blood Cellulitis 108.10 Diabetes Yes 

F 41.8 Non-Native Anchorage Blood Meningitis, endocarditis, 

pneumonia 73.00 

Smoking, chronic lung 

disease, alcohol abuse, 

diabetes 

No 

M 47 AK Native Anchorage Blood Cellulitis 108.10 Smoking, alcohol abuse Yes 

M 47.3 Non-Native Anchorage Blood Cellulitis 108.10 Smoking, alcohol abuse, 

diabetes Yes 

M 49 AK Native Other Joint fluid Septic arthritis, cellulitis 82.00 Smoking Yes 

F 49.1 Non-Native Anchorage Joint fluid Cellulitis, bursitis 9.20 Chronic lung disease, 

diabetes Yes 

M 49.5 Non-Native Anchorage Joint fluid Cellulitis, bursitis Smoking, chronic lung 

disease, alcohol abuse Yes 

M 49.7 Non-Native Anchorage Blood Pneumonia 1.00 Asplenia No 

M 51 Non-Native Anchorage Blood Pneumonia 82.00 Alcohol, immunosuppressive treatment Yes 

M 52.2 AK Native Anchorage Wound Necrotizing fasciitis Smoking, chronic lung 

disease, alcohol abuse Yes 

F 54.4 AK Native Other Blood Pneumonia, cellulitis 1.00 Smoking, alcohol abuse, 

injection drug use Yes 

M 54.5 Non-Native Anchorage Blood Necrotizing fasciitis 108.10 Alcohol abuse No 

M 57.3 Non-Native Anchorage Blood Bacteremia 92.00 Smoking Yes 

M 58.6 Non-Native Anchorage Blood Cellulitis Smoking, alcohol abuse, 

diabetes Yes 

F 59.8 AK Native Other Blood Bacteremia 44.00 Smoking Yes 

M 62 Non-Native Anchorage Blood Cellulitis 108.10 Diabetes Yes 

M 64.2 AK Native Anchorage Blood Cellulitis 92.00 Smoking, alcohol abuse Yes 

M 68 Non-Native Anchorage Blood Cellulitis None Yes 

M 69.4 Non-Native Anchorage Blood Cellulitis, other 1.00 Chronic lung disease, 

diabetes Yes 

M 70.7 AK Native Other Joint fluid Bursitis Unknown Yes 

M 71.7 AK Native Other Blood Pneumonia 1.00 None Yes 

M 72.6 Non-Native Anchorage Blood Bacteremia 1.00 None Yes 

F 74.2 AK Native Other Blood Cellulitis None Yes 

M 76.8 Non-Native Anchorage Blood Pneumonia 28.00 None Yes 

F 81 AK Native Other Blood Pneumonia, 

osteomyelitis Chronic lung disease No 

M 82.3 AK Native Other Joint fluid Septic arthritis, cellulitis Diabetes Yes 

M 83.2 Non-Native Anchorage Blood Pneumonia 82.00 Chronic lung disease, 

diabetes Yes 

F 87.2 AK Native Other Blood Pneumonia 49.00 None Yes 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 27 

Invasive group B Streptococcus

Overall Incidence

A total of 28 cases of invasive group B Streptococcus (GBS) were reported to AIP in 2008. The 

overall rate of invasive GBS disease in the state of Alaska was 4.1/100,000 persons per year. 

The Alaska rate is lower than the ABCs 2008 national projected rate of 6.5/100,000 [11]. In 

2008, there was one GBS-related death for a case fatality ratio of 3.7% (outcome was unknown 

in 1 case). 

Seasonality

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

seasonality. 

Race

In 2008, 37% of invasive group B Streptococcus cases in Alaska occurred in the Alaska Native 

population; the age-adjusted rate was 5.7/100,000 persons per year which is more than one and 

half times the non-Native age-adjusted rate of 3.1/100,000 persons per year. 

Table 19: Invasive group B Streptococcus Cases by Race – Alaska, 2008 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 8 (29) 5.7 87.5 0 (0) 

Non-Native 20 (71)‡ 3.1 60 1 (5.3) 

Total 28 68 1 (3.7) 

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

‡Includes one case for which race was unknown 

 

0

1

2

3

4

5

6

Number of Cases

Month of Culture

Figure 18: Invasive group B Streptococcus, by 

Month of Culture - Alaska, 2008
Surveillance of Invasive Bacterial Disease in Alaska, 2008 28 

Region 

In 2008, 20 (71%) of the 28 reported GBS cases occurred in Anchorage; four cases were 

reported in the Interior, three cases in Southeast Alaska, and one in the YK Delta. 

Age

Invasive group B Streptococcus cases reported in 2008 ranged in age from newborn to 104.6 

years old; the median age was 60.3 years. Highest rates of disease occurred in adults 65 years 

and older (24.3/100,000 persons per year). 

When stratified by race, the highest rates of disease occurred in AK Native adults 65 years of age 

and older (37.6/100,000 persons per year). There was one case of early-onset disease (less than 

7 days old) for a rate of 0.1/1,000 births. 

0

5

10

15

20

25

30

<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, 2008

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, 2008

AK Native

(# cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)
Surveillance of Invasive Bacterial Disease in Alaska, 2008 29 

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 2008, the most common clinical presentation 

was bacteremia which occurred in 14 cases (50%). 

Group B Streptococcus was isolated from blood in 22 (79%) of 28 cases in 2008; three cases 

were isolated from joint fluid and one case each was isolated from peritoneal fluid, a surgical 

specimen and an unspecified non-sterile site. 

Table 20: Primary Clinical Presentations of Invasive group B Streptococcus – Alaska, 2008 

*with bacteremia

Antibiotic Resistance

Susceptibility testing was performed on 25 GBS isolates received in 2008. Results of the testing 

are presented in the following table. 

Table 21: Antibiotic Resistance in Invasive group B Streptococcus Isolates – Alaska, 2008 

Antibiotic Susceptible Intermediate Resistant I + R Total Tested 

Penicillin 25 (100%) 0 (0%) 0 (0%) 0 (0%) 25 

Ceftriaxone 25 (100%) 0 (0%) 0 (0%) 0 (0%) 25 

Erythromycin 11 (44%) 0 (0%) 14 (54%) 14 (54%) 25 

Tetracycline 1 (4%) 0 (0%) 24 (96%) 24 (96%) 25 

Levofloxacin 25 (100%) 0 (0%) 0 (0%) 0 (0%) 25 

Clindamycin 19 (76%) 0 (0%) 6 (24%) 6 (24%) 25 

Vancomycin 25 (100%) 0 (0%) 0 (0%) 0 (0%) 25 

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

Resistance to tetracycline, erythromycin and clindamycin was seen in 96%, 54% and 24%, 

respectively, of isolates tested. An isolate from the one early onset case was susceptible to all 

antibiotics tested.

Primary Presentation n (%) 

Bacteremia 14 (50) 

Septic arthritis 5 (18) 

Cellulitis* 3 (11) 

Pneumonia* 2 (7) 

Osteomyelitis 1 (3.5) 

Meningitis 1 (3.5) 

Peritonitis 1 (3.5) 

Other 1 (3.5) 

Total 28 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 30 

Table 21: Summary of Invasive group B Streptococcus Case Characteristics, Alaska, 2008 

Sex Age (yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) 

Associated Medical 

Conditions Survived 

M Newborn AK Native Other Blood Bacteremia None Yes

M 11 days Unknown Other Blood Bacteremia None Yes 

M 0.1 Non-Native Other Blood Bacteremia None Yes 

M 0.2 AK Native Anchorage Blood Bacteremia None Yes

M 20.6 AK Native Other Blood Bacteremia Immunosuppressive 

treatment Yes 

F 25.3 Non-Native Anchorage Blood Osteomyelitis Diabetes No 

F 32.5 AK Native Anchorage Peritoneal 

fluid 

Peritonitis, 

endometritis Chronic lung disease Yes 

M 42.7 Non-Native Anchorage Blood Cellulitis Diabetes Yes 

M 48.1 AK Native Anchorage Blood Bacteremia None Yes 

M 50.1 Non-Native Anchorage Joint fluid Septic arthritis Smoking, alcohol abuse Yes 

F 50.6 Non-Native Anchorage Nonsterile Cellulitis None Yes 

F 52 Non-Native Anchorage Blood Cellulitis Diabetes Yes 

M 54.7 Non-Native Other Joint fluid Septic arthritis Diabetes Yes 

M 59 Non-Native Anchorage Blood Cellulitis None Yes

M 61.6 Non-Native Anchorage Joint fluid Septic arthritis Unknown Yes 

M 62.4 Non-Native Other Blood Bacteremia None Yes 

M 75.1 AK Native Anchorage Blood Bacteremia Chronic lung disease, 

alcohol abuse, diabetes Yes 

F 75.2 Non-Native Anchorage Blood Meningitis Diabetes Yes 

M 75.4 Non-Native Anchorage Blood Bacteremia None Yes 

M 75.7 Non-Native Anchorage Blood Bacteremia Diabetes Yes 

M 76.1 AK Native Other Blood Pneumonia Diabetes Yes

F 76.5 Non-Native Anchorage Blood Septic arthritis Immunosuppressive 

treatment Yes 

M 76.6 Non-Native Anchorage Blood Bacteremia Smoking, chronic lung 

disease Yes 

F 76.7 Non-Native Anchorage Blood Bacteremia Chronic lung disease Yes 

M 86.6 Non-Native Anchorage Blood Pneumonia, cellulitis Chronic lung disease Yes 

F 92.1 Non-Native Anchorage Blood Bacteremia None Yes 

F 95 Non-Native Anchorage Blood Septic arthritis None Yes 

M 104.6 AK Native Other Surgical 

specimen Other Chronic lung disease Yes 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 31 

References 

[1] State of Alaska, Department of Labor & Workforce Development. Retrieved 4/15/2009 from 

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

[2] Centers for Disease Control and Prevention. 2009. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Streptococcus pneumoniae, 2008.

[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 7/30/2007 from 

http://www.epi.hss.state.ak.us/id/iz/vaxpacket/vis/vis-PneumoPoly.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. 2009. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Haemophilus influenzae, 2008. 

[9] Centers for Disease Control and Prevention. 2009. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Neisseria meningitidis, 2008. 

[10 Centers for Disease Control and Prevention. 2009. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Group A Streptococcus, 2008. 

[11] Centers for Disease Control and Prevention. 2009. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Group B Streptococcus, 2008. 
Surveillance of Invasive Bacterial Disease in Alaska, 2008 32 

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.