June 10, 2005

Epi Update Managing Staff:

John A. Agwunobi, MD, MBA, MPH, Secretary, Florida Department of Health
Landis Crockett, MD, MPH, Director, Division of Disease Control
Dian K. Sharma, MS, PhD, Bureau Chief, Bureau of Epidemiology, Editor-in-Chief
Jaime Forth, Managing Editor, Bureau of Epidemiology

"The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow."

Foege WH., International Journal of Epidemiology 1976; 5:29-37




Selected Five-year Florida Injury Morbidity and
Mortality Trends from the Florida Injury
Surveillance Data System, 1999-2003
by Michael Lo, MSPH

Background
According to the Florida Vital Statistics Annual Report for 2003, unintentional injury was the 5^th leading cause of death to Florida residents, and suicide and homicide were the 9^th and 15^th leading causes, respectively. The Florida Department of Health, Office of Injury Prevention conducts injury surveillance through the Florida Injury Surveillance Data System to monitor the incidence of unintentional and violence-related injuries over time. This surveillance system is modeled after recommendations of the State and Territorial Injury Prevention Directors’ Association and uses a variety of data sources for injury surveillance, including death certificate and hospital discharge data.   

Methods 
Hospital discharge data were searched by ICD-9-CM diagnosis codes and death certificate data were searched by ICD-10 diagnosis codes according to case definitions and search algorithms defined by the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control for the following injury indicators: traumatic brain injury, drowning/near drowning, fire, firearm, homicide, suicide, motor vehicle, and poisoning. Counts of hospitalizations and deaths for each injury indicator were obtained by year and sex. Yearly age-specific hospitalization and death rates were then calculated by sex for each injury indicator by dividing the yearly counts by yearly Florida resident population estimates and age-adjusting to the 2000 U.S. standard population. Finally, overall age-adjusted hospitalization and death rates with both sexes included were calculated for each injury indicator by year.   

Results
Five-year trends in age-adjusted hospitalization and death rates in Florida for each injury indicator for 1999–2003 are displayed graphically and show fluctuations in rates over time. In addition to clearly apparent disparities in injury morbidity and mortality rates by sex, trends are shown for other population subgroups disproportionately affected by drowning/near drowning (residents ages 1–4) and homicide (black males).   

Conclusion
Injury surveillance is the epidemiologic foundation of injury prevention. Data from the Florida Injury Surveillance Data System are useful in planning injury prevention interventions at the state, county, or municipal levels targeted to at-risk populations in the community. Injury surveillance data may also be used to evaluate the impact of these interventions over time.

Michael Lo is an injury epidemiologist at the Health Access and Tobacco Bureau in the Office of Injury Prevention at Florida Department of Health. Michael can be reached at 850.245.4444, ext. 2729.
 

Access to Medical Care Among Adults
With Diabetes in Florida, 2002
by Regan Glover, MS
 

Diabetes is an ongoing and lifelong disease that can be self-managed with the assistance of a health care provider. The American Diabetes Association (ADA) has developed the Standards of Medical Care for Patients with Diabetes, which guides health care providers and patients through the complex process of managing diabetes¹. To control blood glucose levels, a person with diabetes may need access to supplies like blood glucose test strips and insulin. Usually, people with diabetes are able to get these medications and supplies covered through their health insurance policies. Unfortunately, many people with diabetes do not have health insurance coverage. In addition to a lack of health care coverage, many diabetes patients are unable to get medical care due to long distances to medical facilities, lack of knowledge of diabetes care, and long wait times for appointments.

The focus of this report is the inability to get needed medical care² in the past 12 months among adults with diagnosed diabetes³ in Florida. Data from the 2002 Florida County Behavioral Risk Factor Surveillance System  survey were used for this analysis and are based on a sample size of 34,551 respondents, of whom 3,582 reported being told by their doctors that they have diabetes, which is the definition of “diabetes” used for this report.

Among people with diagnosed diabetes, differences in the prevalence of inaccessible medical care were found by age group, racial/ethnic group, educational attainment and income.   

• A greater proportion of adults with diabetes between the ages 18 and 44 years (20.4 percent) and adults 45 to 64 years of age (16.0 percent) were not able to receive medical care compared to adults ages 65 years and older (3.9 percent). (See Figure 1.)  

• Among racial/ethnic groups, Hispanics with diabetes (38.0 percent) are more likely not to receive needed medical care than non-Hispanic whites (7.6 percent). Specifically, non-Hispanic white men are significantly less likely not to have received care (6.5 percent) than Hispanic men (47.2 percent).

• There is no statistically significant difference in the prevalence of inability to receive medical care between adults with diagnosed diabetes (11.1 percent) and adults without diagnosed diabetes (8.4 percent). (See Table 1.) 

• Adults with diabetes who have less than a high school education (24.3 percent) are significantly more likely to be unable to receive medical care than diabetes patients with a high school diploma/GED (8.7 percent) and adults with 1 or more years of college (8.0 percent). (See Figure 2.)

• Among adults with diabetes who have an annual household income of more than $50,000, the prevalence of not receiving needed medical care (2.4 percent) is significantly less than among adults who have annual household incomes less than $25,000 (17.7 percent). (See Figure 2.).

• The inability to get medical care in the past year is not significantly different for adults without diabetes than for adults with diabetes.  Among adults with diabetes, Hispanic men, young and middle-aged adults, those with less than a high school education, and those with annual incomes less than $25,000 are less likely to be able to get medical care than are non-Hispanic white men, adults aged 65-years and older, adults with a high school diploma/GED or beyond, and those with annual incomes exceeding $50,000.

• Finally, the prevalence of being unable to access medical care among adults with diabetes does not differ significantly by gender or marital status. Among adults with diabetes who did not receive needed care (n=347), the main reason given was cost, which includes no insurance (51.4 percent).

¹To access the Diabetes Standards of Care, visit http://www0.sw.org/dnet/manage/adastand2.htm.
² Inability to get medical care is measured by the following question, “Was there a time in the past 12 months when you needed medical care, but could not get it?”
³Diabetes is assessed by the following question, “Have you ever been told by a doctor that you have diabetes?”

*Confidence intervals for Table 1 are constructed utilizing the SAS 9.1 version.

                 
Regan Glover works in the Bureau of Epidemiology Chronic Disease Surveillance and Epidemiology Section as an intern and can be reached at 850.245.4444, ext. 2424.

Bureau Hires Two Epidemiologists
by Jaime Forth

The Bureau of Epidemiology has expanded by two, and both new staff members have already begun the tasks set before them. 

Janet Hamilton was an EIS fellow in Escambia County and is a recent graduate of that program. She comes to the bureau as an epidemiologist in the Surveillance and Reporting Section working on projects such as revision of the reportable disease list, Focus Area B Cooperative Agreement and case definitions. She recently presented one of the most popular Grand Rounds ever, based on the topic of MRSA. Janet graduated from Guilford College as an honor student with a BS in biology, and went on to the University of Georgia to study microbiology before graduating from the University of Michigan with a Master of Public Health degree.

As an EIS fellow she was deployed to affected areas throughout the state during Hurricanes Charley, Frances and Ivan; designed and managed a study to review the increase of MRSA in a Panhandle hospital; evaluated active ILI surveillance programs for hospital laboratories; and formed a county Epidemiology, Laboratory and Infection Control Task Force in Escambia County. To reach Janet, contact her via email at Janet_J_Hamilton@doh.state.fl.us. or telephone her at 850.245.4444, ext. 4409.

Robyn Kay was an EIS fellow in Duval County before the Bureau of Epidemiology hired her as an epidemiologist headquartered at the state laboratory in Jacksonville. Robyn works in the Investigations Section under the direction of Dr. Joann Schulte. She attended the University of Florida in Gainesville, earning a Bachelor of Science degree in microbiology and cell science before going on to the Rollins School of Public Health at Emory University to earn a Master of Public Health degree in epidemiology. 

During her EIS fellowship, Robyn worked with FBI agents investigating a suspicious white powder incident at a local postal facility; conducted disease and injury surveillance at a hospital during the hurricanes of 2004; participated in Superbowl 2005 bioterrorism preparedness and response surveillance evaluations; and investigated Norovirus G2, Hepatitis B and other outbreaks. Robyn, who says she knew she wanted to major in epidemiology after taking a class at USF called "Bacterial and Viral Pathogens," can be contacted at Robyn_Kay@doh.state.fl.us.

We're delighted these two professionals have agreed to join our bureau and we invite you to contact them and wish them well.

Jaime Forth is managing editor of Epi Update and can be reached at 850.245.4444, ext. 2440.

EpiCom Becomes More User Friendly
by Christie Luce

On June 3, 2005, a new version of EpiCom went into production giving registered EpiCom users more control over the type and frequency of information they receive. Users can now activate or de-activate the email notification function via their profile screen. Persons who activate this function will receive an email notification each time a message is posted to an EpiCom forum. With these changes, a moderator can now choose to send the entire message or only the message title. Registered users can also opt to receive a daily recap of all messages posted to EpiCom in the last 24 hours via their profile screen.   

This once-daily email will give the title of each message posted, and the date and time of the post. Future enhancements to the EpiCom system include organizing EpiCom forums and topics into classifications based on similar attributes, which would allow users to receive and view only information of interest to them. Proposed classifications include Environmental Health, Infectious Diseases, and Possible Bioterrorism Agents.

The Bureau of Epidemiology will also begin testing the emergency alerting function of the EpiCom system soon. Be on the lookout for emails explaining what to do if you’re contacted by the emergency alert system.  

If you have questions or comments about future or current EpiCom enhancements, please contact Christie Luce, marketing specialist in the Bureau of Epidemiology at 850.245.4444 ext. 2450. To become a registered EpiCom user, point your Internet browser to https://www.epicomfl.net. 

Christie Luce is the EpiCom consultant in the Bureau of Epidemiology Surveillance Systems Section. To contact her, call 850.245.4444, ext. 2450.

Bi-weekly CHD Conference Call
by Jaime Forth
 

The Bi-weekly conference call among Bureau of Epidemiology staff and members of county health departments around the state was held at 10:00 a.m. on Friday, June 3, 2005. A brief synopsis of the call is recounted here for those who were unable to participate.

Vaccinia Immunization Program. Dr. Landis Crockett announced a new program to produce immune globulin at four Life Sera Plasma Centers in the U.S., one of which is located in Pensacola. The globulin will be used as stockpile in response to a bioterrorism event. All centers are FDA-licensed. The operation began in May and will last 13 weeks, and the new vaccine is called Dryvax. Adverse events from smallpox vaccines a few years ago forced many entities such as the military to give up their immunization programs. If there are questions concerning activities of the Life Sera Centers, call 850.476.7999.

Dr. Crockett advised CHD clinical staff to become familiar with rashes and to make photos of unusual rashes they encounter to aid epidemiologists in Tallahassee in identifying them.

Cyclospora Investigation. Dr. Roberta Hammond stated there were 300 lab confirmed cases of cyclospora, with 23 out-of-state cases. She reminded listeners that approximately 70 records have no disposition listed in Merlin and the records need to be updated. She also advised that the FDA wants to perform a traceback on fresh basil.

Bioterrorism Grant Guidance. Dr. Richard Hopkins updated participants on the status of the 2005-06 grant cooperative agreement. He stated that focus areas are no longer the term of reference, that the CDC instead uses goals as the new measurement standard. The Florida Department of Health has requested status quo funding for EIS and CHD bioterrorism-funded positions, with the approval of the state's regional co-chairs. Additional funding has also been requested to support Dolphin and EpiCom projects.

Merlin Data Field Changes. Dr. Hopkins emphasized that among the new CDC requirements in this year's bioterrorism grant funding package, one measurement will be timeliness in surveillance. He explained that this affects Merlin reporting, specifically the intervals between date of lab confirmation to date of first notification to a public health agency. This new requirement will be reviewed carefully by Bureau of Epi staff as they calculate the Secretary of Health's quarterly performance measures, where responsiveness is a primary objective.

GI Outbreak in Escambia County. Samantha Rivers described an outbreak at an elementary school where on a Monday, 11 of 17 teachers became ill from deli food with symptoms of diarrhea, nausea and vomiting for two days. Upon investigation, the CHD team learned a deli employee had been sent home ill. On Tuesday, three other individuals with no ties to the school reported illness after having eaten food from the same deli.  Following Tuesday's report, another person became ill. Labs were taken and O&Ps were sent to the Jacksonville lab. Virals were sent to the Tampa lab.  All samples tested positive for Norovirus G2.  Better handwashing methods were recommended to restaurant workers, as the investigators felt the cause of the outbreak was a sick employee.

Neisseria Meningitis in Escambia County. Samantha Rivers reviewed the case of a 16 year old male with signs of rash followed by strong headache. The following day he died. He had experienced only a sore throat prior to the appearance of the rash. The boy attended a private religious school, which administration furnished the names of classmates to county health department investigators. The local media published extensive coverage about the incident and parents of all the victim's classmates requested prophylaxis which was subsequently administered, although as a rule it is given only to close contacts.

The following day an inmate at the local jail became ill with meningitis for the third time. Detention staff prophylaxed inmates who had had close contact with him as well as 48 other inmates who had had close contact but had been released. A POD plan was used for the response effort and it worked very well.

Training Announcements. Melanie Black announced the next Grand Rounds will be a presentation on June 28th on management of a pertussis outbreak during Hurricane Ivan. She also stated that the statewide epidemiology seminar held in May hosted a record 237 persons, and a review of the surveys is still ongoing but results will be extrapolated and released soon.

The next conference call is scheduled for Friday, June 17 at 10:00. Contact Melanie Black, MSW at 850.245.4444, ext. 2448 if you'd like to make a presentation or suggest an item for the agenda. 

Jaime Forth is managing editor of Epi Update and also a published freelance writer. Contact her at jaime_forth@doh.state.fl.us.

Timeliness in the Reporting of
Immediately Notifiable Diseases
by Angela Fix, MPH
 

The Bureau of Epidemiology Surveillance and Reporting Section conducted an analysis of the timeliness of reporting immediately notifiable diseases (as defined by Rule 64D-3, Florida Administrative Code) for the 2004 reporting year.  The times between reporting dates were examined each quarter of the year as well as the entire reporting year. The median number of days was calculated for the three time variables for each disease. The three time variables examined were, time from: 

1.  Lab result date to CHD notification date

2.  CHD notification date to Bureau of Epi notification date

3.  Lab result date to Bureau of Epi notification date

Of the 613 cases of immediately notifiable diseases reported in 2004, the median time between Lab Result Date and CHD Notification Date was one day (Table 1). The median reporting time varied between the four quarters of the year, with second and third quarters having a median of two days between report dates and the first and forth quarter having one day between report dates. The reporting time between the Lab Results Date and CHD Notification Date ranged from zero to 81 days, with 25% of the cases being reported within less than one day and 75% of the cases within four days. The median time between CHD Notification Date and the Bureau of Epi Notification Date was five days, with 25% of the cases being reported within two days and 75% of the cases within 11 days. The total time between Lab Result Date and the Bureau of Epi Notification Date averaged eight days, with 25% of the cases being reported within four days and 75% being reported within 15 days. 

Not all cases were included in this analysis due to missing report dates. Of the 613 cases reported, 232 were missing a Lab Result Date and 49 were missing a CHD Notification Date. None of the cases were missing the Bureau of Epi Notification Date, since this field is automatically populated when the case is saved in Merlin. 

The Bureau of Epidemiology will be working with county health departments to determine possible changes to the Merlin System regarding these reporting dates. The first change is to make the CHD Notification Date a required field. The field could be set to automatically populate when a case is initiated in Merlin. A CHD user could then edit the field in such cases where there had been lag between the CHD being notified and the case being entered into Merlin. Another change is to require that one of following dates also be required along with the CHD Notification Date: Date of Onset, Date of Diagnosis or Lab Result Date. 

If you have any questions, comments or concerns about the timeliness of reporting or changes to Merlin, please contact the Bureau of Epidemiology, Surveillance and Reporting Section.

Angela Fix is a respiratory disease epidemiologist in the Bureau of Epidemiology Surveillance and Reporting Section and can be contacted via email at Angela_Fix@doh.state.fl.us

Mosquito-borne Disease Update   May 29 - June 4, 2005
Rebecca Schultz, MPH, Caroline Collins, Tasharra Kenion, Calvin DeSouza, Carina Blackmore, Ph.D.

Weekly Update: During the period May 29-June 4, 2005, the following arboviral activity (St. Louis encephalitis [SLE] virus, eastern equine encephalomyelitis [EEE] virus, Highlands J [HJ] virus, West Nile [WN] virus and dengue virus) was recorded for Florida: 

West Nile (WN) virus activity: One seroconversion to WN virus was confirmed in a sentinel chicken from N. Walton County.

Eastern Equine Encephalomyelitis (EEE) virus activity: Seven seroconversions to EEE virus were confirmed in sentinel chickens from Alachua (3), Putnam (1), St. Johns (2), and Volusia (1) Counties. Six horses from Brevard, Clay , Lake (3) and Marion Counties were confirmed with EEE virus this week. .

St. Louis Encephalitis (SLE) virus activity: None yet this year. 

Highlands J (HJ) Virus activity: None this week.

There are no counties currently under medical alert for mosquito-borne disease. Where mosquitoes are present, people are urged to take precautions against getting bitten.   

Dead birds should be reported to www.wildflorida.org/bird/. See the web page for more information at http://www.myfloridaeh.com/. The Disease Outbreak Information Hotline offers recorded updates on medical alerts status and surveillance at 888-880-5782.

Rebecca Schultz is an arbovirus surveillance coordinator at the Bureau of Community Environmental Health and can be reached at Rebecca_Schultz@doh.state.fl.us.or by calling 850.245.4444, ext. 2437.

This Week on EpiCom
   by Christie Luce

• Bacterial meningitis reported in St. Lucie County
• Bacterial meningitis in St. Johns County
• Log on to EpiCom to see latest press release on the Cyclospora traceback

Christie Luce is an EpiCom consultant in the Bureau of Epidemiology Surveillance Systems Section. She can be reached at Christie_Luce@doh.state.fl.us or by calling 850.245.4444, ext. 2450.

                         Weekly Disease Table
                                                          by D'Juan Harris, MSP

Click here to review the most recent disease figures provided by the Florida Department of Health Bureau of Epidemiology.

D'Juan Harris is a GIS specialist in the Surveillance Systems Section of the Bureau of Epidemiology.
He can be reached at 850.245.4444, ext. 2435.

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