Surveillance of Invasive Bacterial Disease in Alaska, 2015 

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, 2015 2
Surveillance of Invasive Bacterial Disease in Alaska, 2015 3

Alaska Statewide Invasive Bacterial Disease 

Table of Contents 

 Page 

Summary 4 

Introduction 5 

Invasive Pneumococcal Disease 6 

Invasive Haemophilus influenzae 19 

 

Invasive Neisseria meningitidis 24 

Invasive Group A Streptococcus 25 

Invasive Group B Streptococcus 31 

References 37 

Appendix 39 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 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, 2015 

In 2015, the total numbers of cases of invasive disease caused by these organisms reported to 

AIP were 100 S. pneumoniae, 22 H. influenzae, 4 N. meningitidis, 91 group A Streptococci 

Arctic Slope 

Interior 

Kotzebue 

Norton Sound 

YK Delta 

Bristol Bay 

Anchorage 

Southeast 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 5

(GAS) and 60 group B Streptococci (GBS). Alaska Native people had higher rates of disease 

overall than non-Native people for all surveillance organisms. Rates of invasive pneumococcal 

disease were highest in the YK Delta and Kotzebue regions. Rates for each organism by region 

are presented in the following table. 

Table 1: Surveillance Organisms Reported by Region – Alaska, 2015 

Region 

S. pneumoniae 

n (rate*) 

H. influenzae 

n (rate*) 

N. meningitidis 

n (rate*) 

GAS 

n (rate*) 

GBS 

n (rate*) 

Anchorage 59 (12) 10 (2) 2 (0.4) 60 (12.2) 37 (7.6) 

Arctic Slope 0 (0) 0 (0) 0 (0) 3 (33.9) 0 (0) 

Bristol Bay 1 (13.9) 0 (0) 0 (0) 1 (13.9) 1 (13.9) 

Interior 12 (10.7) 1 (0.9) 2 (1.8) 11 (9.8) 11 (9..8) 

Kotzebue 4 (46.8) 1 (11.7) 0 (0) 3 (35.1) 2 (23.4) 

Norton Sound 2 (19.9) 0 (0) 0 (0) 2 (19.9) 0 (0) 

Southeast 7 (9.4) 1 (1.3) 0 (0) 5 (6.7) 6 (8.1) 

YK Delta 15 (56.6) 9 (33.9) 0 (0) 6 (22.6) 2 (7.5) 

Total 100 (13.6) 22 (3) 4 (0.5) 91 (12.3) 59 (8) 

*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 737,625 persons in 2015 [1]. Case detection occurs year-round as 

participating laboratories send isolates recovered from sterile sites to the AIP laboratory in 

Anchorage; materials and forms for isolate shipment and data collection are provided to each 

laboratory by AIP. Demographic and clinical information on the cases are collected from a 

review of medical records. At year-end, AIP asks that each laboratory review their records and 

provide information on any cases that may have been overlooked. In 2015, 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, 2015 6

Invasive Pneumococcal Disease 

Overall Incidence

A total of 89 pneumococcal isolates were received at AIP in 2015. An additional 9 cases were 

detected through shared surveillance with the State DPH and 2 cases were reported by 

laboratories during the annual audit for a total of 100 cases of invasive pneumococcal disease. 

The overall rate for invasive pneumococcal disease in 2015 was 13.6 cases per 100,000 persons 

per year. Alaska rates for 2015 were higher than the Active Bacterial Core Surveillance (ABCs) 

2015 national projected rate of 9.2/100,000 [2]. ABCs is a surveillance system operated in 10 

states which covers a population of up to 42 million persons. 

Seasonality

Invasive Streptococcus pneumoniae cases were identified in each month of 2015. The largest 

number of cases (n=14) was reported in March. 

Race 

In 2015, the state population was comprised of 19% Alaska Native people (Alaska Natives alone 

or in combination 144,274 non-Natives 593,351) [1]. Of all reported S. pneumoniae cases in 

2015, 43% occurred among Alaska Native people for a total of 43 cases; the age-adjusted rate 

was 32/100,000 persons per year. Fifty-seven cases occurred among the non-Native population 

for an age-adjusted rate of 8.6/100,000 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 2015 was 3.7. 

0

5

10

15 Number of Cases

Figure 2: Invasive Pneumococcal Disease, by 

Month of Culture - Alaska, 2015
Surveillance of Invasive Bacterial Disease in Alaska, 2015 7

Table 2: Invasive Streptococcus pneumoniae Cases by Race – Alaska, 2015 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 43 (43) 32 61% 7 (16) 

Non-Native† 57 (57)† 8.6 67% 7 (13)‡ 

Total 100 64% 14 (14) 

*Cases per 100,000 per percent distribution of Alaska 2010 population 

†Includes 6 cases for which race was unknown 

‡Outcome unknown in 2 cases 

Region 

The highest percentage (59%) of invasive pneumococcal disease cases occurred in the 

Anchorage area in 2015. Rates of disease, however, were highest in the YK Delta (56.6/100,000 

persons per year) and the Kotzebue region (46.8/100,000 persons per year). 

Age

Cases occurred in all age groups in 2015 ranging from 6 months to 94.6 years with a median age 

of 58 years. Overall, the highest rates of disease occurred in children less than two years old and 

adults 65 years and older. 

 

When stratified by age and race, the highest rates of disease in 2015 occurred in Alaska Native 

adults 65 years and older (124.7/100,000 persons per year). 

0

20

40

60

0

20

40

60

80 Cases per 100,000 Number of Cases

Figure 3: Invasive Pneumococcal Disease, Cases 

& Rates by Region - Alaska, 2015

Cases

Rate
Surveillance of Invasive Bacterial Disease in Alaska, 2015 8

Since the initiation of a pneumococcal 7-valent conjugate vaccine program in 2001, overall rates 

of invasive disease declined dramatically in children less than 2 years of age [3]. In 2008, the 

rate of invasive pneumococcal disease in children less than 2 years declined to 65.6/100,000 

which was the lowest rate observed in this age group since introduction of the 7-valent vaccine. 

Following introduction of a 13-valent conjugate vaccine in 2010, rates of disease observed in 

children less than 2 years old declined to 18/100,000 in 2011. In 2012, however, disease rates in 

this age group increased to 60.3/100,000 due to disease caused by serotypes not included in the 

current vaccine. In 2015, rates have declined to 28.3/100,000. 

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

less than 2 years of age after introduction of the 7-valent vaccine, 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 was the lowest rate since the 

0

20

40

60

80

100

120

140

0

5

10

15

20

25

<2 2-4 5-18 19-54 55-64 65+ Cases per 100,000 Number of Cases

Age (yrs)

Figure 4: Invasive Pneumococcal Disease, Cases 

& Rates by Age Group & Race - Alaska, 2015

AK Native

(# cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)

0

20

40

60

80

100

120

140

160

<2 2-4 5-18 19-54 55-64 65+ Cases per 100,000

Age (yrs)

Figure 5: Invasive Pneumococcal Disease by Age 

Group - Alaska, 2006-2015

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015
Surveillance of Invasive Bacterial Disease in Alaska, 2015 9

introduction of the seven-valent pneumococcal vaccine. After introduction of the 13-valent 

vaccine in 2010, rates declined to 30.7/100,000 in 2011, however, increased to 177.5/100,000 in 

2012. Rates declined to 70.1/100,000 in 2014 and were similar in 2015 (71.9/100,000). One of 

the four cases that occurred in AK Native children less than 2 years old during 2015 was caused 

by a serotype contained in the 13-valent vaccine. 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, 

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 increased to 60.3/100,000, but declined to 

13/100,000 in 2012 with use of the 13-valent vaccine. Following an increase in 2013 

(26.3/100,000), rates in non-Native children less than 2 years were similar in 2014 

(25.9/100,000), but declined in 2015 to 12.8/100,000; one of two cases was caused by a nonvaccine serotype and the serotype for the second case was unknown. 

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 

0

100

200

300

400

<2 2-4 5-18 19-54 55-64 65+ Cases per 100,000

Age (yrs)

Figure 6: Invasive Pneumococcal Disease in 

Alaska Natives, by Age Group - Alaska, 2006-2015

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

0

100

200

300

400

<2 2-4 5-18 19-54 55-64 65+ Cases per 100,000

Age (yrs)

Figure 7: Invasive Pneumococcal Disease in NonNatives, by Age Group - Alaska, 2006-2015

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015
Surveillance of Invasive Bacterial Disease in Alaska, 2015 10

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 2015 (64%) followed by bacteremia (12%). Twelve 

cases had a secondary pneumococcal-related diagnosis in 2015; eight were pneumonia with 

bacteremia, one each were empyema, osteomyelitis and streptococcal toxic shock syndrome and 

one case had septic arthritis and necrotizing fasciitis. 

In 2015, blood was the most common source of a positive culture which was used to identify 93 

(93%) of 100 cases. Two cases were identified from peritoneal fluid, two from cerebrospinal 

fluid, two from pleural fluid and one from a surgical aspirate. 

Mortality 

In 2015, the overall case fatality ratio for S. pneumoniae in Alaska was 14% (14 deaths out of 98 

cases for which outcome was known). The case fatality ratio for AK Natives was slightly higher 

(16%, 7 deaths) than non-Natives (13%, 7 deaths). The largest number of deaths and highest 

case fatality ratio occurred in the 65 and older age category: 10 deaths, CFR 34.5%. 

64

12 9 5 3 2 2 1 1 1

0

20

40

60

80 Number of Cases

Figure 8: Primary Clinical Presentations of 

Invasive Pneumococcal Disease - Alaska, 2015

*with bacteremia

0

5

10

15

20

25

30

35

40

0

2

4

6

8

10

12

<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, 2015

Deaths

CFR
Surveillance of Invasive Bacterial Disease in Alaska, 2015 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, 2015 

 Alaska Native Non-Native 

Serotype Total n (%) <2 2-4 5-18 19-64 65+ <2 2-4 5-18 19-64 65+ 

03 12 (14) 1 - 1 3 2 - - 1 3 1 

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

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

07C 3 (3) - - 1 1 - - - - 1 - 

07F 3 (3) - - - 2 - - - - 1 - 

08 3 (3) - - - - 1 - - - 2 - 

09 1 (1) - - - 1 - - - - - - 

09N 6 (7) - - - 3 - - - - 3 - 

10A 4 (5) - - - 1 - - - - 3 - 

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

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

15A 1 (1) - - - - - - - - - 1 

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

15C 2 (2) - - - - - 1 - - 1 - 

16F 7 (8) - - - 2 2 - - - 3 - 

17F 2 (2) 1 - - - - - - - - 1 

19A 1 (1) - 1 - - - - - - 1 - 

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

20 5 (6) - - - 2 2 - - - - 1 

21 2 (2) - - - 1 1 - - - - - 

22F 8 (9) - - - 3 1 - - - 4 - 

23A 4 (5) - - - - 1 - - - 1 2 

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

28A 2 (2) - - - - - - - - - 2 

31 3 (4) - - - - 1 - - - - 2 

33F 5 (6) 1 - - - 1 1 - - 2 - 

34 1 (1) - - - 1 - - - - - - 

35 1 (1) - - - - - - - - - 1 

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

NT 1 (1) - - - 1 - - - - - - 

Total 89 4 1 2 22 13 2 0 1 30 14 

In 2015, the most common pneumococcal serotypes were 3, (12 isolates, 14%), 22F (8 isolates, 

9%), 16F (7 isolates, 8%) and 9N (6 isolates, 7%). 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 there 

were no serotype 14 cases in 2015. Disease caused by serotypes 7F and 19A, which are not 

included in the 7-valent conjugate vaccine, continually increased until the introduction of the 13-

valent vaccine in 2010 which does include these two serotypes. Although cases caused by 7F 

and 19A continue to occur, they are no longer the most common serotypes and it is anticipated 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 12

that the number of cases will continue to decline with the use of the vaccine. The majority (42%) 

of serotype 3 cases, serotype 16F cases (86%) and serotype 22F cases (88%) occurred in the 

Anchorage area in 2015. 

 

Table 4: Invasive Pneumococcal Serotype Distribution by Region – Alaska, 2015 

Serotype Anchorage Arctic Slope Bristol Bay Interior Kotzebue Norton Sound Southeast YK Delta 

03 5 - - 3 - - 1 3 

06A - - - 1 - - - - 

06C 1 - - - - 1 - - 

07C 2 - - - - - - 1 

07F 1 - - - - - 2 - 

08 2 - - - - - - 1 

09 - - - - - - - 1 

09N 3 - - 2 - - 1 - 

10A 3 - - - - - - 1 

11A - - - 1 - - - - 

12F 1 - - - - - - - 

15A 1 - - - - - - - 

15B 1 - - - 1 - - - 

15C 2 - - - - - - - 

16F 6 - - - - - - 1 

17F 1 - - - - - - 1 

19A 1 - - - - - - - 

19F 2 - - - - - - - 

20 2 - - 1 - - - 2 

21 - - - - 1 - - 1 

22F 7 - - 1 - - - - 

23A 3 - - - - - 1 - 

23B - - - 1 - - - - 

28A 2 - - - - - - - 

31 - - - 2 - - 1 - 

33F 2 - - - 1 - - 2 

34 1 - - - - - - - 

35 1 - - - - - - - 

35B 1 - - - - - - 1 

NT - - 1 - - - - - 

Unknown 9 - - - 1 1 1 - 

Total 59 0 1 12 4 2 7 15 

Vaccine Serotypes

In 2001, the pneumococcal conjugate vaccine (PCV7) was included in the Alaska childhood 

vaccination schedule. This vaccine provided protection against the 7 most common 

pneumococcal serotypes causing invasive disease among children (types 4, 6B, 9V, 14, 18C, 

19F, 23F). In early 2010, a new pneumococcal conjugate vaccine (PCV13) was introduced into 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 13

the Alaska childhood vaccination schedule. This vaccine provided protection against the 7 

pneumococcal serotypes contained in the PCV7 vaccine plus six additional serotypes (1, 3, 5, 

6A, 7F, 19A) that have caused invasive disease since the introduction of the PCV7 vaccine. The 

table below shows the proportion of invasive infections from 2015 that were due to serotypes 

found in the PCV13 vaccine. There were two cases of pneumococcal disease caused by 

serotypes contained in the PCV13 vaccine in children less than 5 years of age, the age group for 

which the vaccine is recommended. 

Table 5: Proportion of Invasive Isolates Contained in the PCV13 Vaccine by Age Group 

and Race – Alaska, 2015 

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

<2 1 (25%) of 4 0 (0%) of 2 1 (17%) of 6 

2-4 1 (100%) of 1 0 (0%) of 0 1 (100%) of 1 

5+ 8 (22%) of 37 9 (20%) of 45 17 (21%) of 82 

Total 10 (24%) of 42 9 (19%) of 47 19 (21%) of 89 

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 addition, one dose of PCV13 was also 

recommended for persons 65 years and older. In 2015, for persons 65 years and older, 11 (41%) 

of 27 cases serotyped were potentially vaccine preventable invasive pneumococcal illnesses. 

Vaccine Failures 

In 2015, pneumococcal vaccine status was known for 93 (93%) of the 100 cases; 42% (n=39) of 

cases with known vaccine status did receive a pneumococcal vaccine prior to illness and 54 cases 

(58%) had no record of a pneumococcal vaccine. 

A PCV13 vaccine failure is defined as invasive pneumococcal disease caused by a serotype 

contained in the PCV13 vaccine in a child less than five years old who has had at least two doses 

of vaccine. There were two vaccine failures in 2015; both had received 4 doses of PCV13. One 

case had possible underlying immunodeficiencies and the second case had no risk factors 

reported; case serotypes were 3 and 19F, respectively. 

Potentially Preventable Deaths

Overall, 43% of all pneumococcal-related mortality in 2015 was potentially preventable with the 

use of the 23-valent polysaccharide vaccine in persons over 5 years old; 43% of deaths were due 

to disease caused by serotypes not contained in pneumococcal vaccines. 

Table 6: Potentially Vaccine Preventable Invasive Pneumococcal Deaths – Alaska, 2015 

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

PCV13 0 0 0 1 (25%) 0 1 (10%) 2 (14%) 

Ps23V 0 0 0 1 (25%) 0 5* (50%) 6 (43%) 

Non-Vaccine 0 0 0 2 (50%) 0 4 (40%) 6 (43%) 

Unknown 0 0 0 0 0 0 0 

Total 0 0 0 4 0 10 14 

*Two cases were serotype 3 which is also contained in PCV13 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 14

Six of the 14 deaths in 2015 from invasive S. pneumoniae occurred from serotypes contained 

within the Ps23V vaccine; five of the deaths were in individuals eligible for the vaccine. Two 

deaths occurred in a vaccinated individual; time since vaccination was 7 years for one case and 

10 years for the second. 

Table 7: Invasive Pneumococcal Disease, Serotypes of Fatal Cases – Alaska, 2015 

Serotype 

Deaths 

n (%) 

Serotype 

Frequency (n) 

03†* 3 (25%) 12 

06A† 1 (100%) 1 

11A* 1 (100%) 1 

15B* 1 (50%) 2 

15C 1 (50%) 2 

16F 1 (14%) 7 

20* 1 (20%) 5 

21 1 (50%) 2 

22F* 1 (14%) 7 

23B 1 (100%) 1 

31 1 (33%) 3 

34 1 (100%) 1 

†Serotypes contained in the 13-valent conjugate vaccine 

*Serotypes contained in the 23-valent polysaccharide vaccine 

Associated Risk Factors

The presence of one or more associated risk factors was reported in 73% of invasive 

pneumococcal cases in 2015. Chronic lung disease was the most prevalent risk factor observed 

in adults followed by cigarette smoking, diabetes and alcohol abuse. 

Table 8: Associated Risk Factors Identified in Invasive Pneumococcal Cases – Alaska, 

2015* 

Risk Factor 

Adult Cases (≥ 18 years) 

n=90, Cases (%) 

Chronic lung disease 23 (26%) 

Cigarette smoking 22 (24%) 

Diabetes 19 (21%) 

Alcohol abuse 18 (20%) 

Immunosuppressive treatment 9 (10%) 

Injection drug use 2 (2%) 

Asplenia 0 (0%) 

*More than one risk factor was identified in several cases 

Antibiotic Resistance

Susceptibility testing was performed on 89 isolates received in 2015. Results of the testing are 

presented in the following table. 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 15

Table 9: Antibiotic Resistance in Invasive Streptococcus pneumoniae Isolates – Alaska, 2015 

Antibiotic Susceptible Intermediate Resistant I + R Total Tested 

Penicillin 76 (85%) 10 (11%) 3 (3%) 13 (14%) 89 

TMP-sulfa 84 (94%) 3 (3%) 2 (2%) 5 (5%) 89 

Erythromycin 70 (79%) 0 (0%) 19 (21%) 19 (21%) 89 

Ceftriaxone 88 (99%) 1 (1%) 0 (0%) 1 (1%) 89 

Tetracycline 82 (92%) 2 (2%) 5 (6%) 7 (8%) 89 

Chloramphenicol 87 (98%) 0 (0%) 2 (2%) 2 (2%) 89 

Vancomycin 89 (100%) 0 (0%) 0 (0%) 0 (0%) 89 

Levofloxacin 89 (100%) 0 (0%) 0 (0%) 0 (0%) 89 

Clindamycin 85 (96%) 1 (1%) 3 (3%) 4 (4%) 89 

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 and PCV13 vaccines are more likely to be non-susceptible to 

penicillin and erythromycin than non-vaccine serotypes. One potential benefit of the use of these 

vaccines 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, 

following an increase in disease caused by serotype 19A. This serotype is included in the 

PCV13 vaccine; decreasing proportions of isolates resistant to most antibiotics tested may be due 

to the introduction of the vaccine. However, the proportion of isolates resistant to erythromycin 

has increased which is a trend that was also seen after the introduction of PCV7 [8]. 

0

5

10

15

20

25

30

35 Percent Resistant

Year

Figure 10: Trends in Antibiotic Non-Susceptibility Among 

Invasive Pneumococcal Isolates - Alaska, 1995 - 2015

Penicillin

Erythro

TMP-Sulfa

Tet
Surveillance of Invasive Bacterial Disease in Alaska, 2015 16

Table 10: Summary of Invasive Streptococcus pneumoniae Case Characteristics, Alaska, 2015 

Sex 

Age 

(Yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) Serotype* Associated Risk Factors Survived 

M 0.6 AK Native Other Blood Septic arthritis 35B None Yes 

F 0.6 Unknown Other Blood Pneumonia 33F None Yes 

F 0.7 Non-Native Anchorage CSF Meningitis 15C None Yes 

F 0.9 AK Native Other Blood Bacteremia 17F None Yes 

M 1.8 AK Native Other Blood Pneumonia 33F None Yes 

F 1.9 AK Native Other Blood Pneumonia 3 None Yes 

M 4.7 AK Native Anchorage Blood Bacteremia 19F None Yes 

F 5.5 AK Native Other Pleural 

fluid 

Empyema, 

pneumonia 3 None Yes 

M 15.7 Non-Native Anchorage Blood Pneumonia 3 None Yes 

M 17.5 AK Native Other Blood Meningitis 7C None Yes 

M 22.8 AK Native Anchorage Blood Pneumonia 16F None Yes 

M 23.4 AK Native Other Blood Bacteremia 15B Alcohol abuse Yes 

M 30 AK Native Other Blood Bacteremia 9N Alcohol abuse Yes 

F 33.5 Non-Native Other Blood Bacteremia 6C Diabetes Yes 

M 33.7 Non-Native Anchorage Blood Pneumonia 8 Smoking Yes 

M 33.7 AK Native Other Blood Pneumonia NT Alcohol abuse Yes 

M 35.8 Non-Native Anchorage Blood Bacteremia 22F Smoking, chronic lung 

disease Yes 

M 36.8 Non-Native Other Blood Pneumonia ND Smoking Yes 

F 37.2 AK Native Other Blood Pneumonia 22F Smoking Yes 

M 42.7 Non-Native Anchorage Blood Pneumonia ND None Yes 

F 43.1 AK Native Anchorage Blood Pneumonia 22F Smoking, alcohol abuse, 

diabetes Yes 

M 43.7 Non-Native Anchorage Blood Pneumonia 12F Injection drug use Yes 

M 44.6 AK Native Anchorage Blood Meningitis, 

empyema 

3 Smoking, diabetes Yes 

M 44.7 AK Native Anchorage Blood Pneumonia 20 None Yes 

M 44.8 AK Native Anchorage Blood Endocarditis, 

pneumonia 9N Alcohol abuse Yes 

M 45 AK Native Other Blood Pneumonia 3 None Yes 

M 45.3 Non-Native Anchorage Blood Pneumonia 9N None Yes 

M 46.6 AK Native Other Blood Pneumonia 20 Smoking Yes 

F 46.7 Non-Native Anchorage Blood Endometritis 3 None Yes 

F 48.7 AK Native Other Blood Pneumonia 7F Smoking, chronic lung 

disease Yes 

F 49.2 AK Native Anchorage Blood Pneumonia 9N None Yes 

M 49.2 Non-Native Anchorage Blood Pneumonia 15B 

Smoking, chronic lung 

disease, immune 

suppressive therapy 

No 

M 49.5 AK Native Anchorage Blood Meningitis 34 Smoking, alcohol abuse No 

F 49.8 AK Native Other Blood Pneumonia 7F None Yes 

M 49.9 Non-Native Anchorage Blood Pneumonia 7C 

Smoking, chronic lung 

disease, alcohol abuse, 

immune suppressive 

therapy 

Yes 

M 49.9 Non-Native Anchorage Blood Pneumonia 8 None Yes 

M 50.8 Non-Native Anchorage Blood Pneumonia ND Smoking, immune 

suppressive therapy Yes 

F 51.1 Non-Native Anchorage Blood Septic arthritis, 

osteomyelitis 10A None Yes 

M 52.6 Non-Native Anchorage Blood Pneumonia 19F None Yes 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 17

Sex 

Age 

(Yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) Serotype* Associated Risk Factors Survived 

M 52.6 Non-Native Other Blood Bacteremia 9N None Yes 

M 52.9 Non-Native Anchorage Peritoneal 

fluid 

Peritonitis, 

pneumonia 7F Alcohol abuse Yes 

F 53 Non-Native Anchorage Blood Pneumonia 33F Smoking Yes 

F 54 Non-Native Anchorage Blood Pneumonia 3 None No 

F 54 Non-Native Anchorage Blood Meningitis 22F None Yes 

M 54.6 Non-Native Anchorage Peritoneal 

fluid Peritonitis 15C Diabetes No 

M 54.7 AK Native Other Blood Pneumonia 9 Smoking, alcohol abuse Yes 

M 54.9 AK Native Other Blood Pneumonia 16F None Yes 

M 54.9 Non-Native Anchorage Blood Pneumonia 16F Alcohol abuse Yes 

M 57.3 AK Native Anchorage Blood Endocarditis 22F Diabetes Yes 

F 57.8 Unknown Anchorage Blood Pneumonia ND Smoking Yes 

M 58.1 Non-Native Anchorage Blood Empyema, 

pneumonia 35B Smoking Yes 

F 58.5 AK Native Other Blood Pneumonia 21 Smoking, chronic lung 

disease Yes 

M 58.8 Non-Native Anchorage Blood Pneumonia 16F 

Chronic lung disease, 

immune suppressive 

therapy 

Yes 

M 59 Non-Native Anchorage Blood Pneumonia 22F Immune suppressive 

therapy Yes 

M 59 AK Native Other Blood Empyema, 

pneumonia 3 Alcohol abuse Yes 

M 59 Non-Native Anchorage Blood Pneumonia, strep 

toxic shock 23A Alcohol abuse Yes 

M 59.7 AK Native Anchorage Blood Pneumonia 7C Alcohol abuse Yes 

F 59.7 AK Native Other Blood Pneumonia 10A Chronic lung disease, 

alcohol abuse, diabetes Yes 

M 60.2 Non-Native Anchorage Blood Pneumonia 19A Alcohol abuse, injection 

drug use Yes 

F 60.2 Non-Native Anchorage Blood Pneumonia ND None Yes 

F 60.9 AK Native Other Surgical 

aspirate Other ND Alcohol abuse, diabetes Yes 

F 61 Non-Native Anchorage CSF Meningitis ND Diabetes Yes 

M 62 Non-Native Anchorage Blood Bacteremia 33F Smoking, alcohol abuse, 

diabetes Yes 

F 62.1 Non-Native Other Blood Pneumonia 9N Chronic lung disease Yes 

F 62.1 Non-Native Anchorage Blood Pneumonia 16F Chronic lung disease Yes 

F 62.2 Unknown Anchorage Blood Meningitis 22F Diabetes Yes 

M 62.4 Non-Native Anchorage Blood Pneumonia 10A Smoking, alcohol abuse Yes 

F 62.9 Non-Native Anchorage Blood 

Meningitis, septic 

arthritis, 

necrotizing fasciitis 

10A Diabetes Yes 

M 64.4 Unknown Anchorage Blood Bacteremia ND Unknown Unknown 

M 64.5 Non-Native Other Blood Pneumonia ND None Unknown 

F 64.7 Non-Native Other Blood Pneumonia 3 Chronic lung disease Yes 

M 65.5 Non-Native Anchorage Blood Pneumonia ND None Yes 

M 65.5 Unknown Anchorage Blood Pneumonia ND None Yes 

F 67.1 AK Native Other Blood Pneumonia 20 

Chronic lung disease, 

immune suppressive 

therapy, diabetes 

Yes 

M 67.6 AK Native Other Blood Pneumonia 20 None Yes 

M 69.8 Non-Native Anchorage Blood Pneumonia 15A None Yes 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 18

Sex 

Age 

(Yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) Serotype* Associated Risk Factors Survived 

M 70.2 Non-Native Anchorage Blood Bacteremia 20 Smoking No 

M 70.9 AK Native Other Blood Pneumonia 31 Smoking, diabetes Yes 

F 72.6 AK Native Other Blood Pneumonia 3 Diabetes No 

M 73.6 Non-Native Anchorage Blood Pneumonia 28A Chronic lung disease Yes 

M 73.7 Non-Native Other Blood Pneumonia 11A Chronic lung disease No 

F 74.2 Non-Native Anchorage Blood Endocarditis, 

pneumonia 23A None Yes 

M 74.8 Unknown Other Blood Pneumonia 31 None No 

M 74.9 Non-Native Anchorage Blood Meningitis 3 Smoking, chronic lung 

disease, diabetes Yes 

M 77.1 AK Native Other Blood Bacteremia 23A Chronic lung disease Yes 

F 80.9 AK Native Other Blood Pneumonia 33F None Yes 

M 81.4 Non-Native Other Blood Pneumonia 31 Chronic lung disease Yes 

M 81.8 Non-Native Other Blood Pneumonia 6A Diabetes No 

M 82.9 Non-Native Anchorage Blood Cellulitis 17F None Yes 

F 83.3 AK Native Other Blood Pneumonia 3 Chronic lung disease No 

M 83.3 Non-Native Anchorage Blood Pneumonia 6C 

Chronic lung disease, 

immune suppressive 

thereapy 

Yes 

F 84.4 Non-Native Anchorage Blood Pneumonia 35 Diabetes Yes 

F 84.7 AK Native Anchorage Pleural 

fluid Pneumonia 16F 

Chronic lung disease, 

immune suppressive 

therapy 

No 

F 84.7 AK Native Other Blood Bacteremia 23B Chronic lung disease, 

diabetes No 

M 86 AK Native Anchorage Blood Empyema, 

pneumonia 16F Chronic lung disease Yes 

F 86.1 Non-Native Anchorage Blood Pneumonia 28A Chronic lung disease Yes 

M 87.2 AK Native Other Blood Pneumonia 21 

Chronic lung disease, 

immune suppressive 

therapy, diabetes 

No 

M 94.1 AK Native Anchorage Blood Pneumonia 22F None No 

M 94.6 Non-Native Anchorage Blood Empyema, 

pneumonia 23A None Yes 

*ND = typing not done 

 NT = non-typeable 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 19 

Invasive Haemophilus influenzae

Overall Incidence 

In 2015, there were 22 cases of invasive Haemophilus influenzae in Alaska, for a statewide rate of 3/100,000 

persons per year. This rate is higher than the ABCs national projected rate of 1.9/100,000 persons per year [9]. 

There were no deaths associated with H. influenzae in 2015. 

Seasonality 

Cases of invasive H. influenzae occurred throughout 2015; however, due to the small number of cases, trends in 

seasonality cannot be determined. The largest number of cases (n=7) occurred in August. 

Region 

The highest rates of disease caused by invasive H. influenzae cases in 2015 were in the YK Delta region, 

33.9/100,000 (9 cases), and the Kotzebue region, 11.7/100,000 (1 case). Although a large number of cases 

occurred in the Anchorage area (10 cases), the rate was much lower (2/100,000). 

0

1

2

3

4

5

6

7

8 Number of Cases

Month of Culture

Figure 11: Haemophilus influenzae Disease by 

Month of Culture - Alaska, 2015
Surveillance of Invasive Bacterial Disease in Alaska, 2015 20 

Race 

Table 11: Invasive Haemophilus influenzae Cases by Race – Alaska, 2015 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 10 (45%) 6.2 70% 0 (0%) 

Non-Native 12 (55%) 1.7 25% 0 (0%) 

Total 22 45% 0 (0%) 

*Cases per 100,000 per percent distribution of Alaska 2010 population 

In 2015, 45% 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 2015 was 3.6. 

Age 

H. influenzae cases ranged in age from 4 months to 87 years of age in 2015 (median 40.7 years). Overall, the 

highest rates of disease occurred in children less than 2 years old (18.9/100,000). 

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 and 2-4 years of age, 71.9/100,000 persons per year and 

32.6/100,000 persons per year, respectively. 

0

10

20

30

40

0

2

4

6

8

10

12 Cases per 100,000 Number of Cases

Figure 12: Invasive Haemophilus influenzae, Cases & Rates by Region - Alaska, 2015

Cases

Rate
Surveillance of Invasive Bacterial Disease in Alaska, 2015 21 

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 2015, 

pneumonia with bacteremia was the most common presentation (55% of cases). 

Eighteen (82%) H. influenzae isolates were from blood samples in 2015, and one each was from cerebrospinal 

fluid, pleural fluid, peritoneal fluid and a surgical aspirate. 

0

10

20

<2 2-4 5-18 19-54 55-64 65+ Cases per 100,000

Age (yrs)

Figure 13: Invasive Haemophilus influenzae by 

Age Group - Alaska, 2015

0

20

40

60

80

0

1

2

3

4

5

6

7

<2 2-4 5-18 19-54 55-64 65+ Cases per 100,000 Number of Cases

Age (yrs)

Figure 14: Invasive Haemophilus influenzae, Cases & 

Rates by Age Group & Race - Alaska, 2015

AK Native

(# cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)
Surveillance of Invasive Bacterial Disease in Alaska, 2015 22 

Table 12: Primary Clinical Presentation of Invasive Haemophilus influenzae - Alaska, 2015 

Primary Presentation n (%) 

Pneumonia* 12 (55%) 

Bacteremia 2 (9%) 

Meningitis 2 (9%) 

Septic arthritis 2 (9%) 

Empyema 1 (5%) 

Peritonitis 1 (5%) 

Cellulitis* 1 (5%) 

Other 1 (5%) 

Total 22 

*with bacteremia 

Serotypes 

All isolates received at AIP are serotyped; 21 cases in 2015 had isolates and were serotyped. The bacterial 

capsule is the basis for serotyping and is the primary virulence factor. Serotype b was 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 13: Serotypes of Invasive Haemophilus influenzae Cases by Race – Alaska, 2015 

 Alaska Native Non-Native 

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

a 6 (29%) 3 2 1 - - - - - 

b 1 (4.5%) - 1 - - - - - - 

e 1 (4.5%) - - - - - - - 1 

NT* 13 (62%) 1 - 2 - - 1 4 5 

Total 21 4 3 3 0 0 1 4 6 

*Non-typeable 

Hib

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

against this serotype. There was one case of Hib in a child less than 5 years old in 2015; the child was fully 

vaccinated. 

Hia 

Prior to 2002, H. influenzae type a (Hia) had not been detected in Alaska. Following an outbreak in 2003 [10], 

cases have occurred sporadically until 2010 when an outbreak began in the YK Delta and continued through 

2011 [11]. Six cases of Hia were detected in 2015; all occurred in AK Native people. The rate of invasive 

disease caused by Hia in AK Native children less than 2 years old for 2015 was 53.9/100,000. 

Antibiotic Resistance 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 23 

Twenty-two H. influenzae isolates received at AIP were tested for susceptibility to ampicillin, chloramphenicol, 

ceftriaxone and TMP/sulfa. All isolates tested were susceptible to ceftriaxone, 4 isolates were resistant to 

ampicillin (1 intermediate, 3 fully resistant), 13 isolates were resistant to TMP/sulfa (4 intermediate and 9 fully 

resistant) and one isolate showed intermediate resistance to chloramphenicol. 

Table 14: Summary of Invasive Haemophilus influenzae Case Characteristics, Alaska, 2015 

Sex 

Age 

(Yrs) Race Residence Site of Isolation 

Clinical 

Presentation(s) Serotype* Associated Risk Factors Survived 

M 0.3 AK Native Other Blood Meningitis a None Yes 

M 0.5 AK Native Other CSF Meningitis a None Yes 

F 1.2 AK Native Other Blood Pneumonia NT None Yes 

M 1.8 AK Native Other Blood Septic arthritis a Chronic lung disease Yes 

M 2 AK Native Other Surgical aspirate Septic arthritis a None Yes 

M 3.5 AK Native Other Blood Pneumonia b None Yes 

F 3.5 AK Native Other Blood Cellulitis a None Yes 

F 7.2 Non-Native Anchorage Blood Pneumonia NT Chronic lung disease Yes 

F 22.8 Non-Native Anchorage Peritoneal fluid Peritonitis NT Chronic lung disease Yes 

M 34.2 AK Native Other Blood Pneumonia NT Smoking, alcohol abuse Yes 

F 34.7 Non-Native Anchorage Blood Pneumonia NT None Yes 

F 46.7 Non-Native Other Blood Other NT None Yes 

F 52.7 AK Native Other Blood Pneumonia NT Smoking, alcohol abuse Yes 

M 60 AK Native Other Blood Bacteremia a None Yes 

M 62 Non-Native Anchorage Pleural fluid Empyema, 

pneumonia ND Smoking, chronic lung disease Yes 

F 64.6 Non-Native Anchorage Blood Pneumonia NT Chronic lung disease Yes 

F 71.3 Non-Native Anchorage Blood Pneumonia NT Chronic lung disease Yes 

F 76 Non-Native Other Blood Pneumonia e Immune suppressive 

therapy, diabetes Yes 

F 78.8 Non-Native Anchorage Blood Pneumonia NT Immune suppressive 

therapy, diabetes Yes 

M 83.5 Non-Native Anchorage Blood Pneumonia NT Chronic lung disease Yes 

F 85.1 Non-Native Anchorage Blood Pneumonia NT None Yes 

M 86.9 Non-Native Anchorage Blood Pneumonia NT Immune suppressive 

therapy Yes 

*NT = non-typeable 

 ND = typing not done 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 24 

Invasive Neisseria meningitidis

Overall Incidence

Four cases of invasive Neisseria meningitidis were reported to AIP in 2015 for an overall rate of 

0.5/100,000. The Alaska rate is slightly higher than the ABCs 2015 national projected rate of 

0.11/100,000 [12]. There were no invasive N. meningitidis-related deaths in Alaska in 2015. 

 

Race 

Table 15: Invasive Neisseria meningitidis Cases by Race – Alaska, 2015 

Race 

Cases 

 n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 1 (25%) 0.8 100% 0 (0%) 

Non-Native 3 (75%) 0.5 0% 0 (0%) 

Total 4 67% 0 (0%) 

*Cases per 100,000 per percent distribution of Alaska 2010 population 

In 2015, 25% of the cases occurred in Alaska 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 2015 was 1.6. 

Table 16: Summary of Invasive Neisseria meningitidis Case Characteristics, Alaska, 2015 

Sex 

Age 

(Yrs) Race Residence 

Site of 

Isolation 

Clinical 

Presentation(s) Serogroup Associated Risk Factors Survived 

F 13.4 Non-Native Other Blood Meningitis C None Yes 

F 24.9 Non-Native Other CSF Meningitis C Smoking Yes 

F 27.3 AK Native Anchorage Blood Bacteremia C None Yes 

M 37.3 Non-Native Anchorage Blood Meningitis C Smoking, alcohol abuse Yes 

 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 25 

Invasive group A Streptococcus

Overall Incidence

A total of 91 cases of invasive group A Streptococcus (GAS) were reported to AIP in 2015. The overall 

rate of invasive GAS disease in the state of Alaska was 12.3/100,000 persons per year. The Alaska rate 

is higher than the ABCs 2015 national projected rate of 4.8/100,000 [13]. In 2015, there were 10 GASrelated deaths for a case fatality ratio of 11%. 

Seasonality 

Cases of group A Streptococcus occurred throughout the year in 2015 with no apparent trends in 

seasonality. The largest number of cases (n=12) occurred in April. 

Race

In 2015, 41% of invasive GAS cases in Alaska occurred in the Alaska Native population. The ageadjusted rate ratio of invasive GAS disease for the Alaska Native population compared with the nonNative population in 2015 was 3.3. 

Table 17: Invasive group A Streptococcus Cases by Race – Alaska, 2015 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 37 (41%) 28 54% 3 (8%) 

Non-Native 54† (59%) 8.5 63% 7 (13%) 

Total 91 59% 10 (11%) 

*Cases per 100,000 per percent distribution of Alaska 2010 population 

†Includes 5 cases for which race is unknown 

 

0

2

4

6

8

10

12

14 Number of Cases

Month of Culture

Figure 15: Invasive group A Streptococcus, by 

Month of Culture - Alaska, 2015
Surveillance of Invasive Bacterial Disease in Alaska, 2015 26 

Region 

Sixty (66%) of the 91 invasive group A Streptococcus cases in 2015 were reported in the Anchorage 

area, 11 cases in the Interior, 6 cases in the YK Delta, 5 cases in the Southeast, 3 cases each in the Arctic 

Slope and Kotzebue, 2 cases in Norton Sound and 1 case in Bristol Bay. The highest rates of disease 

occurred in the Kotzebue region (35.1/100,000) and the Arctic Slope (33.9/100,000). 

Age

Invasive group A Streptococcus cases reported in 2015 ranged in age from 11 days to 95.3 years old; the 

median age was 51.7 years. Highest rates of disease occurred in children less than 2 years old 

(28.3/100,000). 

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

Native adults 65 years and older (67.1/100,000 persons per year). The highest GAS disease rate in the 

non-Native population occurred in children less than two years old (19.2/100,000 persons per year). 

0

10

20

30

40

0

10

20

30

40

50

60

70 Number of Cases Cases per 100,00

Figure 16: Invasive GAS Disease, Cases & Rates 

by Region - Alaska, 2015

Cases

Rate

0

5

10

15

20

25

30

<2 2-4 5-18 19-54 55-64 65+ Cases per 100,000

Age (yrs)

Figure 17: Invasive group A Streptococcus by Age 

Group - Alaska, 2015
Surveillance of Invasive Bacterial Disease in Alaska, 2015 27 

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 15 shows the primary clinical presentations of invasive group A 

Streptococcus in Alaska for 2015. 

Group A Streptococcus was isolated from blood samples in 68 (75%) of 91 cases, 16 from tissue 

specimens, 2 each from joint fluid and aspirates, and one each from CSF, pleural fluid and bone. 

 

Table 18: Primary Clinical Presentations of Invasive group A Streptococcus – Alaska, 2015 

Primary Presentation n (%) 

Cellulitis* 32 (35%) 

Bacteremia 18 (20%) 

Pneumonia* 9 (10%) 

Necrotizing fasciitis 8 (9%) 

Osteomyelitis 7 (8%) 

Septic arthritis 6 (7%) 

Empyema 4 (4%) 

Strep toxic shock 3 (3%) 

Endocarditis 2 (2%) 

Meningitis 1 (1%) 

Other 1 (1%) 

Total 91 

*with bacteremia

Associated Risk Factors

The presence of one or more associated risk factors was reported in 80% of invasive GAS cases in 2015. 

Cigarette smoking was the most prevalent risk factor observed in adults followed by alcohol abuse and 

chronic lung disease. 

0

10

20

30

40

50

60

70

80

0

5

10

15

20

25

<2 2-4 5-18 19-54 55-64 65+ Cases per 100,000 Number of Cases

Age (yrs)

Figure 18: Invasive group A Streptococcus, Cases 

& Rates by Age Group & Race - Alaska, 2015

AK Native

(# cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)
Surveillance of Invasive Bacterial Disease in Alaska, 2015 28 

Table 19: Associated Risk Factors Identified in Invasive GAS Cases – Alaska, 2015* 

Medical Condition/Risk 

Factor 

Adult Cases (≥ 18 years) 

n=80, Cases (%) 

Cigarette smoking 27 (34%) 

Alcohol abuse 24 (30%) 

Chronic lung disease 23 (29%) 

Diabetes 19 (24%) 

Injection drug use 8 (10%) 

Immunosuppressive treatment 5 (6%) 

Asplenia 0 (0%) 

*More than one risk factor was identified in several cases 

Molecular Typing 

Strain characterization of GAS has traditionally been based on serological identification of the M protein 

which is a major surface protein and an important GAS virulence factor. In the mid-1990s, many 

reference labs started using a molecular approach based on sequencing of the N-terminal region of the M 

protein gene (emm gene). To date, more than 200 different emm types have been reported. While there 

are currently no vaccines available to protect against invasive GAS disease, baseline data on the burden 

of GAS disease to include emm typing are critical to evaluate the potential utility of any candidate 

vaccines.

In 2015, 75 invasive GAS isolates were emm typed at AIP. The most common emm types were emm 91 

(31%) and emm 11 (16%). The following graph shows emm typing trends over time. Strains that totaled 

≤ 10 over the time period were not included. 

Antibiotic Resistance 

Seventy-five GAS isolates received at AIP were tested for susceptibility to penicillin, ceftriaxone, 

erythromycin, vancomycin, levofloxacin and clindamycin. All isolates tested were susceptible to 

penicillin, ceftriaxone, and vancomycin. Thirteen isolates were resistant to erythromycin; 12 of those 

were emm type 11 and one was emm type 22 which was also resistant to clindamycin. One isolate was 

resistant to levofloxacin; it was emm type 108. 

0

10

20

30

40

50

60

70

80

90 Number of Cases

Figure 19: Invasive group A Streptococcus emm 

Typing Trends - Alaska, 2001-2015 Unknown

238

108

101

92

91

89

87

82

73

49

41

28

12

11

5

4

3

1
Surveillance of Invasive Bacterial Disease in Alaska, 2015 29 

Table 20: Summary of Invasive group A Streptococcus Case Characteristics, Alaska, 2015 

Sex 

Age 

(yrs) Race Residence 

Site of 

Isolation Clinical Presentation(s) 

emm

Type* Associated Risk Factors Survived 

F 11 days Non-Native Other Blood Bacteremia 12 None Yes 

M 1 month Non-Native Anchorage Blood Bacteremia 49 None Yes 

F 0.1 AK Native Anchorage Blood Bacteremia 49 None Yes 

F 0.2 AK Native Other Blood Cellulitis ND None Yes 

M 0.2 Unknown Anchorage Blood Bacteremia 4 None Yes 

M 1.3 AK Native Other Blood Bacteremia 34 None Yes 

F 2.2 AK Native Other Blood Pneumonia 87 None Yes 

M 5.2 Non-Native Anchorage Blood Bacteremia 28 None Yes 

F 6.2 AK Native Anchorage Tissue Other ND None Yes 

M 11 AK Native Anchorage Blood Cellulitis 1 None Yes 

M 15.6 Non-Native Anchorage Blood Endocarditis, pneumonia 1 None Yes 

M 18.1 Non-Native Anchorage Blood Cellulitis 4 None Yes 

F 18.8 Non-Native Other Blood Bacteremia 1 None Yes 

F 24.2 Non-Native Anchorage Blood Strep toxic shock 118 None Yes 

F 25.6 Non-Native Anchorage Pleural fluid Pneumonia 4 Smoking, injection drug use Yes 

M 30 AK Native Other Tissue Cellulitis ND Smoking Yes 

F 31 Unknown Other Blood Empyema, pneumonia 6 Smoking, injection drug use Yes 

F 31.1 Non-Native Anchorage Blood Bacteremia 28 None Yes 

M 31.3 Non-Native Anchorage Joint fluid Septic arthritis ND Injection drug use Yes 

M 34 Non-Native Anchorage Joint fluid Septic arthritis, cellulitis ND None Yes 

F 34.1 Non-Native Other Blood Endocarditis 75 Smoking, injection drug use Yes 

M 35 Non-Native Other Tissue Cellulitis ND None Yes 

F 36.9 Non-Native Other Blood Empyema 28 None Yes 

M 40.1 AK Native Anchorage Tissue Cellulitis ND Smoking Yes 

M 40.2 AK Native Anchorage Blood Pneumonia, cellulitis 81 Smoking, injection drug use Yes 

M 40.7 AK Native Anchorage Tissue Cellulitis 11 Smoking Yes 

F 41.3 Non-Native Anchorage Blood Bacteremia 89 Smoking, chronic lung disease Yes 

M 42.2 AK Native Other Tissue Cellulitis, necrotizing 

fasciitis 91 Smoking Yes 

F 42.3 AK Native Other Blood Cellulitis, necrotizing 

fasciitis 91 Alcohol abuse Yes 

M 43.7 AK Native Other Aspirate Cellulitis 91 Smoking, chronic lung disease, 

alcohol abuse, injection drug use Yes 

F 44.7 Non-Native Other Blood Necrotizing fasciitis 12 Immune suppressive treatment, 

diabetes Yes 

F 44.9 AK Native Other Blood Cellulitis 91 Immune suppressive treatment Yes 

M 45.2 AK Native Other Bone Osteomyelitis ND Smoking Yes 

M 45.5 AK Native Anchorage Tissue Cellulitis 91 Smoking, injection drug use Yes 

M 46.1 AK Native Anchorage Blood Cellulitis 11 Alcohol abuse Yes 

M 48.3 AK Native Other Blood Cellulitis 75 Alcohol abuse Yes 

M 48.4 Non-Native Anchorage Blood Cellulitis 11 Chronic lung disease, alcohol 

abuse Yes 

M 49.2 AK Native Other Blood Cellulitis 91 Smoking, chronic lung disease, 

alcohol abuse, diabetes Yes 

M 49.9 Non-Native Anchorage Blood Cellulitis, necrotizing 

fasciitis 22 Smoking, immune suppressive treatment, injection drug use Yes 

F 50.2 AK Native Anchorage Blood Cellulitis 11 Smoking, alcohol abuse Yes 

M 50.3 Non-Native Anchorage Blood Septic arthritis, cellulitis, 

osteomyelitis 108 Smoking, chronic lung disease, diabetes Yes 

M 50.6 Non-Native Anchorage Blood Osteomyelitis 108 Diabetes Yes 

M 51 Non-Native Anchorage Blood Pneumonia 91 Smoking, chronic lung disease, 

diabetes Yes 

M 51.4 Non-Native Anchorage Blood Cellulitis 1 None Yes 

M 51.6 AK Native Other Blood Bacteremia 108 None Yes 

M 51.7 Non-Native Anchorage Blood Bacteremia 91 None No 

M 52.3 AK Native Anchorage Blood Bacteremia 91 Alcohol abuse Yes 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 30 

Sex 

Age 

(yrs) Race Residence 

Site of 

Isolation Clinical Presentation(s) 

emm

Type* Associated Risk Factors Survived 

F 52.9 Non-Native Anchorage Tissue Pneumonia, cellulitis 11 Smoking, chronic lung disease, 

diabetes Yes 

M 53 Non-Native Anchorage Blood Cellulitis ND Smoking, diabetes Yes 

M 54 Non-Native Anchorage Blood Cellulitis, necrotizing 

fasciitis 11 Alcohol abuse No 

M 54.1 Unknown Anchorage Blood Pneumonia ND None No 

M 54.7 Non-Native Other Tissue Cellulitis, necrotizing 

fasciitis 91 Diabetes Yes 

M 55 AK Native Other Tissue Cellulitis, osteomyelitis 101 Smoking, diabetes Yes 

M 55.9 Non-Native Anchorage Blood Septic arthritis, cellulitis 91 Alcohol abuse Yes 

M 56.4 Unknown Anchorage Blood Cellulitis 1 None Yes 

M 58 Non-Native Anchorage Blood Septic arthritis 91 Chronic lung disease Yes 

M 58.2 AK Native Anchorage Blood Meningitis 11 Alcohol abuse, diabetes No 

F 58.9 Non-Native Anchorage Blood Pneumonia 91 Smoking, chronic lung disease, 

alcohol abuse, diabetes Yes 

M 58.9 AK Native Anchorage Blood Cellulitis, necrotizing 

fasciitis 11 Alcohol abuse Yes 

F 58.9 AK Native Other Blood Bacteremia 89 Alcohol abuse Yes 

F 59 Non-Native Anchorage Blood Septic arthritis, cellulitis 28 Chronic lung disease Yes 

F 59.1 AK Native Other Tissue Cellulitis, necrotizing 

fasciitis 11 Smoking, chronic lung disease, alcohol abuse Yes 

F 59.1 AK Native Anchorage Blood Cellulitis 11 Alcohol abuse Yes 

M 59.9 Non-Native Anchorage Blood Cellulitis 6 Smoking, diabetes Yes 

M 60.3 Non-Native Other Tissue Cellulitis, osteomyelitis ND Diabetes Yes 

F 60.7 Non-Native Anchorage Blood Bacteremia 95 Diabetes Yes 

M 61.4 AK Native Anchorage Blood Pneumonia, cellulitis, 

strep toxic shock 91 Smoking, chronic lung disease, alcohol abuse No 

F 62.5 Non-Native Anchorage CSF Empyema, pneumonia 1 Chronic lung disease Yes 

M 63 Non-Native Anchorage Blood Cellulitis 91 Diabetes Yes 

M 63.4 Non-Native Anchorage Blood Cellulitis ND None Yes 

F 63.9 AK Native Anchorage Tissue Cellulitis 89 Alcohol abuse Yes 

M 64.1 Non-Native Anchorage Blood Bacteremia 91 Diabetes Yes 

F 64.2 Non-Native Anchorage Blood Cellulitis 1 None Yes 

M 66.3 Non-Native Anchorage Blood Cellulitis, osteomyelitis ND Chronic lung disease, alcohol 

abuse Yes 

F 67 Non-Native Anchorage Blood Cellulitis ND Immune suppressive therapy Yes 

M 67.3 Non-Native Anchorage Blood Empyema, pneumonia, 

cellulitis 11 Smoking, chronic lung disease, alcohol abuse Yes 

M 68.2 Non-Native Anchorage Blood Cellulitis 53 Smoking, chronic lung disease Yes 

M 68.5 Non-Native Other Blood Cellulitis 11 Chronic lung disease, diabetes Yes 

F 69.2 AK Native Anchorage Tissue Cellulitis, osteomyelitis 91 Chronic lung disease, alcohol 

abuse Yes 

F 69.7 AK Native Other Tissue Cellulitis 91 Smoking, alcohol abuse Yes 

F 70.1 AK Native Other Blood Bacteremia 4 None Yes 

F 71 AK Native Other Tissue Septic arthritis, strep toxic 

shock, osteomyelitis 91 Alcohol abuse Yes 

M 71.3 Non-Native Anchorage Blood Cellulitis 87 Chronic lung disease, diabetes Yes 

F 72.8 Non-Native Anchorage Blood Bacteremia 91 Alcohol abuse No 

M 72.8 Non-Native Other Tissue Septic arthritis ND None Yes 

F 74.8 AK Native Anchorage Blood Cellulitis 91 Chronic lung disease, immune 

suppressive treatment Yes 

F 76.6 AK Native Anchorage Blood Pneumonia, cellulitis 91 Chronic lung disease Yes 

F 76.6 Unknown Anchorage Blood Cellulitis 111 Chronic lung disease No 

M 76.6 AK Native Other Blood Pneumonia 91 Chronic lung disease No 

M 92 Non-Native Other Blood Bacteremia ND Diabetes No 

F 95.3 Non-Native Anchorage Blood Cellulitis 1 None No 

*ND = typing not done
Surveillance of Invasive Bacterial Disease in Alaska, 2015 31 

Invasive group B Streptococcus

Overall Incidence

A total of 59 cases of invasive group B Streptococcus (GBS) were reported to AIP in 2015. The 

overall rate of invasive GBS disease in the state of Alaska was 8/100,000 persons per year. The 

Alaska rate is similar to the ABCs 2015 national projected rate of 8.9/100,000 [14]. In 2015, 

there were four GBS-related deaths for a case fatality ratio of 6.8%. 

Seasonality

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

seasonality. 

 

Race

In 2015, 25% of invasive group B Streptococcus cases in Alaska occurred in the Alaska Native 

population. The age-adjusted rate ratio of invasive GBS disease for the Alaska Native population 

compared with the non-Native population in 2015 was 1.7. 

Table 21: Invasive group B Streptococcus Cases by Race – Alaska, 2015 

Race 

Cases 

n (%) 

Age Adjusted 

Rate* % Male 

Deaths 

n (%) 

Alaska Native 15 (25) 11.1 73 0 (0) 

Non-Native 44 (75)‡ 6.5 57 4 (9.1) 

Total 59 61 4 (6.8) 

*Cases per 100,000 per percent distribution of Alaska 2010 population 

‡Includes 7 cases for which race was unknown 

 

0

2

4

6

8

10 Number of Cases

Month of Culture

Figure 20: Invasive group B Streptococcus, by 

Month of Culture - Alaska, 2015
Surveillance of Invasive Bacterial Disease in Alaska, 2015 32 

Region 

In 2015, 37 (63%) of the 59 reported GBS cases occurred in Anchorage; 11 cases were reported 

in the Interior, seven cases in Southeast, two in Kotzebue and one case each in Bristol Bay the 

YK Delta regions. The highest rates of disease occurred in the Kotzebue region (23.4/100,000) 

and Bristol Bay (13.9/100,000). 

Age

Invasive group B Streptococcus cases reported in 2015 ranged in age from newborn to 92 years 

old; the median age was 60.8 years. Highest rates of disease overall occurred in children less 

than two years old (42.4/100,000 persons per year). 

 

 When stratified by race, the highest rates of disease occurred in AK Native and non-Native 

children less than two years old, 53.9/100,000 persons per year and 32/100,000 persons per year, 

respectively. There was one case of early-onset disease (less than 7 days old) for a rate of 0.1 

cases per 1,000 live births. 

0

5

10

15

20

25

30

35

40

<2 2-4 5-18 19-54 55-64 65+ Cases per 100,000

Age (yrs)

Figure 21: Invasive group B Streptococcus by Age 

Group - Alaska, 2015

0

10

20

30

40

50

60

0

2

4

6

8

10

12

14

16

18

20

<2 2-4 5-18 19-54 55-64 65+ Cases per 100,000 Number of Cases

Age (yrs)

Figure 22: Invasive group B Streptococcus, Cases & 

Rates by Age Group & Race - Alaska, 2015

AK Native (#

cases)

Non-Native

(# cases)

AK Native

(rate)

Non-Native

(rate)
Surveillance of Invasive Bacterial Disease in Alaska, 2015 33 

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 2015, the most common clinical presentations 

were cellulitis and bacteremia which occurred in 18 (30%) and 17 (29%) cases, respectively. 

Group B Streptococcus was isolated from blood in 37 (63%) of 59 cases in 2015; 13 cases were 

isolated from tissue specimens, three each from bone and joint fluid, and one each from 

cerebrospinal fluid, peritoneal fluid, and amniotic fluid. 

Table 22: Primary Clinical Presentations of Invasive group B Streptococcus – Alaska, 2015 

*with bacteremia

Associated Risk Factors

The presence of one or more associated risk factors was reported in 83% of invasive GBS cases 

in 2015. Diabetes was the most prevalent risk factor observed in adults followed by cigarette 

smoking and chronic lung disease. 

Table 23: Associated Risk Factors Identified in Invasive GBS Cases – Alaska, 2015* 

Medical Condition/Risk 

Factor 

Adult Cases (≥ 18 years) 

n=51, Cases (%) 

Diabetes 28 (55%) 

Cigarette smoking 9 (18%) 

Chronic lung disease 6 (12%) 

Alcohol abuse 4 (8%) 

Injection drug use 1 (2%) 

Immunosuppressive treatment 1 (2%) 

Asplenia 0 (0%) 

*More than one risk factor was identified in several cases 

Primary Presentation n (%) 

Cellulitis* 18 (30) 

Bacteremia 17 (29) 

Osteomyelitis 7 (12) 

Septic arthritis 6 (10) 

Pneumonia* 4 (7) 

Endocarditis 2 (3) 

Meningitis 2 (3) 

Amnionitis 1 (2) 

Empyema 1 (2) 

Peritonitis 1 (2) 

Total 59 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 34 

Antibiotic Resistance

Susceptibility testing was performed on 42 GBS isolates received in 2015. Results of the testing 

are presented in the following table. 

Table 24: Antibiotic Resistance in Invasive group B Streptococcus Isolates – Alaska, 2015 

Antibiotic Susceptible Intermediate Resistant I + R Total Tested 

Penicillin 42 (100%) 0 (0%) 0 (0%) 0 (0%) 42 

Ceftriaxone 42 (100%) 0 (0%) 0 (0%) 0 (0%) 42 

Erythromycin 19 (45%) 0 (0%) 23 (55%) 23 (55%) 42 

Tetracycline 11 (26%) 0 (0%) 31 (74%) 31 (74%) 42 

Levofloxacin 42 (100%) 0 (0%) 0 (0%) 0 (0%) 42 

Clindamycin 30 (71%) 0 (0%) 12 (29%) 12 (29%) 42 

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

tetracycline, erythromycin, and clindamycin was seen in 74%, 55%, and 29%, respectively, of 

isolates tested. Of the two early onset cases, one isolate was available for susceptibility testing; 

the isolate was resistant to erythromycin and tetracycline.
Surveillance of Invasive Bacterial Disease in Alaska, 2015 35 

Table 25: Summary of Invasive group B Streptococcus Case Characteristics, Alaska, 2015 

Sex 

Age 

(yrs) Race Residence 

Site of 

Isolation Clinical Presentation(s) Associated Risk Factors Survived 

F Newborn Non-Native Anchorage Blood Bacteremia None Yes 

F 14 days AK Native Other Blood Meningitis None Yes 

F 0.1 Unknown Anchorage Blood Bacteremia None Yes 

M 0.1 Non-Native Anchorage Blood Septic arthritis None Yes 

F 0.2 Non-Native Anchorage Blood Bacteremia None Yes 

M 0.2 AK Native Anchorage CSF Meningitis None Yes 

M 0.5 Unknown Other Blood Bacteremia None Yes 

F 24.4 Unknown Anchorage Amniotic 

fluid Amnionitis None Yes 

M 32 Non-Native Other Tissue Septic arthritis None Yes 

M 34.4 AK Native Other Tissue Osteomyelitis Smoking Yes 

M 36 Non-Native Anchorage Tissue Cellulitis Diabetes Yes 

F 40.7 AK Native Anchorage Bone Cellulitis Smoking, diabetes, injection drug use Yes 

F 44.2 Non-Native Other Blood Endocarditis, pneumonia Smoking, alcohol abuse No 

M 44.4 AK Native Other Blood Bacteremia Chronic lung disease, diabetes Yes 

F 45.9 Non-Native Other Blood Pneumonia None Yes 

M 48 AK Native Other Tissue Cellulitis Smoking Yes 

F 50.3 AK Native Anchorage Blood Bacteremia Chronic lung disease, diabetes Yes 

F 50.5 Non-Native Anchorage Blood Bacteremia None Yes 

M 50.5 Unknown Anchorage Tissue Cellulitis, osteomyelitis Diabetes Yes 

M 51.2 Non-Native Other Tissue Cellulitis Diabetes Yes 

M 52.5 AK Native Anchorage Blood Cellulitis, osteomyelitis Diabetes Yes 

M 54.1 Non-Native Other Tissue Cellulitis, osteomyelitis Diabetes Yes 

M 54.5 Non-Native Anchorage Blood Septic arthritis Diabetes Yes 

F 55.5 Non-Native Other Tissue Cellulitis Diabetes Yes 

M 56.6 Non-Native Anchorage Blood Bacteremia Diabetes Yes 

M 59.5 Non-Native Anchorage Peritoneal 

fluid Peritonitis Diabetes Yes 

M 59.7 Non-Native Anchorage Blood Septic arthritis Diabetes Yes 

M 60.8 Non-Native Anchorage Blood Cellulitis Diabetes Yes 

M 61.2 Non-Native Anchorage Blood Bacteremia None Yes 

F 61.4 Non-Native Anchorage Blood Cellulitis Immune suppressive therapy Yes 

M 62.5 Non-Native Anchorage Blood Cellulitis None Yes 

M 62.5 Non-Native Anchorage Blood Cellulitis Diabetes Yes 

M 62.8 AK Native Other Tissue Osteomyelitis Smoking, alcohol abuse Yes 

F 62.9 Unknown Anchorage Bone Cellulitis Diabetes Yes 

M 63.9 Non-Native Other Tissue Empyema, cellulitis Chronic lung disease, diabetes Yes 

M 64.2 AK Native Anchorage Bone Osteomyelitis Diabetes Yes 

M 65.1 Non-Native Anchorage Blood Cellulitis None Yes 

F 66.6 Non-Native Other Blood Cellulitis Diabetes Yes 

F 66.6 Non-Native Other Tissue Cellulitis, osteomyelitis Diabetes Yes 

M 66.9 Non-Native Anchorage Joint fluid Septic arthritis, cellulitis Diabetes Yes 

M 67.5 AK Native Anchorage Blood Cellulitis Smoking Yes 

M 68.6 AK Native Anchorage Blood Bacteremia Smoking Yes 

M 69 Non-Native Anchorage Blood Cellulitis None Yes 

M 70.8 AK Native Other Blood Bacteremia Diabetes Yes 

M 71.6 Non-Native Anchorage Blood Bacteremia Alcohol abuse Yes 

M 72.8 Non-Native Anchorage Blood Bacteremia Diabetes Yes 

M 73.7 Non-Native Other Blood Pneumonia Chronic lung disease No 

F 74.5 Non-Native Other Tissue Pneumonia, septic arthritis None Yes 

F 75.7 Unknown Anchorage Tissue Cellulitis, osteomyelitis Diabetes Yes 

M 77.4 Non-Native Anchorage Blood Cellulitis None Yes 

F 78 Non-Native Anchorage Blood Pneumonia Smoking Yes 

F 78.2 Unknown Other Blood Bacteremia Chronic lung disease, diabetes Yes 

M 81 AK Native Other Blood Bacteremia Chronic lung disease Yes 

F 82.4 Non-Native Anchorage Blood Endocarditis None Yes 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 36 

Sex 

Age 

(yrs) Race Residence 

Site of 

Isolation Clinical Presentation(s) Associated Risk Factors Survived 

M 82.8 Non-Native Anchorage Joint fluid Septic arthritis Diabetes Yes 

M 84.8 Non-Native Anchorage Blood Cellulitis Diabetes Yes 

F 87.4 Non-Native Other Blood Bacteremia Smoking, alcohol abuse No 

F 92 Non-Native Anchorage Blood Bacteremia Diabetes No 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 37 

References 

1. State of Alaska, Department of Labor & Workforce Development. From 

http://laborstats.alaska.gov/pop/popest.htm

2. Centers for Disease Control and Prevention. 2015. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Streptococcus pneumoniae, 2015.

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 5/2/16 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. Rudolph K, Bulkow L, Bruce M, Zulz T, Reasonover A, Harker-Jones M, Hurlburt D, 

Hennessy T. Molecular resistance mechanisms of macrolide-resistant invasive Streptococcus 

pneumoniae isolates from Alaska, 1986 to 2010. Antimicrobial Agents and Chemotherapy

2013;57 (11): 5415-22. 

9. Centers for Disease Control and Prevention. 2015. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Haemophilus influenzae, 2015. 

10. Hammitt LL, Block S, Hennessy TW, DeByle C, Peters H, Parkinson A, Singleton R, Butler 

JC. Outbreak of invasive Haemophilus influenzae serotype a disease. Pediatr Infect Dis J

2005;24(5): 453-6. 

11. Bruce MG, Zulz T, DeByle C, Singleton R, Hurlburt D, Bruden D, Rudolph K, Hennessy T, 

Klejka J, Wenger JD. Haemophilus influenzae serotype a invasive disease, Alaska, USA, 

1983-2011. Emerg Infect Dis 2013;19(6): 932-7. 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 38 

12. Centers for Disease Control and Prevention. 2015. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Neisseria meningitidis, 2015. 

13. Centers for Disease Control and Prevention. 2015. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Group A Streptococcus, 2015. 

14. Centers for Disease Control and Prevention. 2015. Active Bacterial Core Surveillance 

Report, Emerging Infections Program Network, Group B Streptococcus, 2015. 
Surveillance of Invasive Bacterial Disease in Alaska, 2015 39 

Appendix 

MIC Interpretive Standards Definitions: 

CLSI [7] 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 -lactams in urine) 

or when a higher dosage of a drug can be used (e.g., -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., -lactamases) are likely, and 

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