Division of Disease Control and Health Protection

The State of Florida operates a mosquito-borne encephalitis surveillance program as a collaboration of state and county agencies, including the following:

• Florida Department of Health (DOH): State Health Office (SHO), county health departments (CHDs), and Bureau of Laboratories
• Florida Department of Agriculture and Consumer Services (DACS): Bureau of Entomology and Pest Control, mosquito control districts (MCD), and Division of Animal Industry (DAI)
• Florida universities

Coordination is conducted via meetings, audioconferencing (in 1998, interagency Arbovirus Conference Calls were conducted from October 2 through December 18), telephone contact, newsletters, email, Bureau of Epidemiology Hotline and fax. During 1998, the DOH elicited interagency assistance for updating the manual, Surveillance and Control of Selected Arthropod-borne Diseases in Florida.

The SLE and EEE surveillance program and response involves the following activities:

DOH County Health Departments receives case reports of encephalitis from physicians or reference laboratories. The Bureau of Epidemiology and the county health departments assure laboratory confirmation of arboviral disease and conducts epidemiologic investigation. Sentinel chicken sera are tested at DOH Tampa Laboratory for antibodies to either SLE or EEE viruses using a hemagglutination inhibition (HI) test. Confirmed seroconverters require paired sera to be positive. When trigger events occur (e.g., increases in sentinel seroconversions), a health advisory or health alert is called, including press releases, "Dear Dr." letters and hotline information.

MCDs identify increases in Culex nigripalpus and Culiseta mellinura populations. DAI provides EEE diagnostics for veterinarians and forwards positive reports to DOH. When trigger events occur, adulticide and larvacide are applied to the environment.

In cooperation with CDC Ft. Collins, selected Panhandle MCDs have collected wild birds for EEE surveillance. Selected sites are conducting PCR testing of pooled mosquito populations.

FEMA-Funded ACTIVITIES

Florida's major disaster declaration, FEMA-1195-DR, was as a result of ongoing, slow flooding associated with a recent El Niño weather event. Beginning with a 1997 Christmas Day storm that flooded west-central Florida, South Florida was then barraged with severe precipitation on Groundhog Day, 1998. Later, on President's Day, parts of north central Florida were flooded. Yet more storms and tornadoes hit central Florida, including Kissimmee, causing widespread damage and loss of life in late February. Finally, in early March, still more storms hit Florida's panhandle, causing serious flooding. Fifty-five of the state's 67 counties were declared eligible for some type of assistance for losses resulting from the major disaster declared January 6 and expanded February 23.

The declared incident resulted in conditions that were ideal for a dramatic increase in mosquito populations that can vector human arboviruses including St. Louis encephalitis and eastern equine encephalitis. Planned FEMA activities were to expand arbovirus surveillance, support public health laboratory capacity and provide DOH with GIS capability for arbovirus surveillance.

Project Goals:

1. Expand arbovirus surveillance:

Six counties (accounting for 32 additional sentinel sites) were able to implement sentinel serosurveillance programs in addition to 22 existing programs. These new sites were in key SLE areas as evidenced by historic data.
An arthropod-borne disease surveillance manual was updated and presented to new and existing sites in efforts to standardize surveillance activities.
The State Public Health Veterinarian spoke at several in-state veterinary meetings about the arboviral surveillance program and the role of the veterinarian, encouraging veterinarians to contact local county health departments when they diagnosed eastern equine encephalitis.
 
2. Increase laboratory capacity:

The Tampa Laboratory tested 22,265 sera during 1998, an approximate 11% increase over 1997 figures. Resources also provided for replacing 30 year-old equipment that was in danger of failing.
 
3. Provide Bureau of Epidemiology GIS capability:

GIS training was completed for two staff and inservices were provided for others. Geographic data were discussed during weekly interagency conference calls. The Bureau of Epidemiology website will soon be accessible and arbovirus data will be included. Bureau of Epidemiology staff will be reviewing the National Electronic Arbovirus Reporting Software that includes GIS linkages.

1998 SURVEILLANCE SUMMARY

1. On October 16, the DOH Secretary called an SLE Health Alert for the four county area including Palm Beach, Martin, Hendry and Glades counties. The Alert was extended to Dade and Broward counties on November 4. The Alert status was terminated on December 18. With heightened awareness in the medical community, two human SLE cases (Dade County and Palm Beach County) were reported, both individuals survived. From November 20 through December 18, an EEE Health Advisory was called for Leon, Gadsden and Wakulla counties. No human EEE cases were reported during 1998.
2. DAI forwarded reports of 41 EEE cases in horses. These horse cases became trigger events in calling the EEE Health Advisory. Large animal veterinarians in the area were contacted weekly by DOH and Leon MCD staff for updated information regarding horses with clinical signs consistent with EEE.
3. Summary of surveillance in sentinel chickens for SLE virus activity:

Source: DOH Tampa Laboratory

Malaysia struggled on Monday to determine the origin of a newly detected virus that, along with another discovered six months ago, has killed 63 people in the central pig-breeding region. Health authorities said they knew little about the new virus except that it was similar to Hendra virus, a member of the Paramyxo [Paramyxoviridae] family, which caused the deaths of two people and 15 horses in Australia in 1994-95.

The new virus causes symptoms similar to those caused by JE virus, which was first detected in Malaysia in October and was also harbored in pigs, officials said. [Pigs were not found dying of JE virus last October.] Japanese encephalitis virus is transmitted by mosquitoes and is marked by high fever, headaches, dizziness, convulsions and loss of consciousness leading to death if untreated [and sometime even if treated]. But the new virus is different in that it was believed to be spread by direct contact. It can, however, be killed by soap, detergent and disinfectant.

Authorities said they had no idea where the new strain came from or how to wipe it out. The Malaysian Minister of Health indicated that the Government is trying to answer questions regarding origin of the virus, route of transmission, and pathogenicity for animals other than pigs. In that way, he suggested, it might be possible to improve control efforts. The discovery of the new strain 10 days ago has complicated efforts to battle the viral epidemic, which has prompted a health scare in two central regions. Authorities initially blamed the deaths on Japanese encephalitis, which is endemic in Malaysia and many other Asian countries.

In an effort to contain the outbreak, authorities have killed 139,000 pigs of a target population of about a million. Other efforts have focused on vaccinating residents and pigs against [JE], and spraying the two regions where the outbreaks occurred to kill Culex mosquitoes, which transmit [JE] from pigs to humans. But the presence of the Hendra-like virus required a fresh strategy as it is believed to be transmitted by direct contact with live, sick pigs. Fewer than one third of the 63 deaths have been confirmed as encephalitis cases and authorities have blamed the new virus for at least some of the deaths.

The epidemic has harmed the country's lucrative pig business and posed political headaches to the government. Sales of pork have dropped 70% while a ban of Malaysian pork imports by Thailand, Singapore and the Philippines has badly hit the 1.5 billion ringgit ($395 million) industry. Live pig exports are valued at 400 million ringgit a year. Almost all pig farmers and consumers belong to the ethnic Chinese minority, who eat pork, but the majority Muslim Malays, who make up more than half the 22 million population, revile the animal, which Islam considers unclean. Authorities have said that the best weapon against the [Hendra-like] virus so far seemed to be found in simple cleansing solutions, such as soaps and disinfectants.

A team of eight experts from Atlanta's Centers for Disease Control and Prevention is now on site. They are working with experts from [Malaysia], Australia and Taiwan to help find ways to fight the epidemic. The U.S. experts brought sophisticated equipment and have set up a makeshift laboratory at a government hospital to study the new virus. Authorities hope that ribavirin would be (as) effective in battling the new virus. The minister urged those with symptoms of high fever and dizziness to get vaccinated at once. The government has prepared to(vaccinate) 250,000 people but only about 65,000 had come forward until Friday.

The Health Ministry issued a list of precautionary measures to those working in the pig-breeding industry, asking them to be covered head to toe and to use soap liberally; and released a statement on Monday listing precautionary measures for the nation's estimated 300,000 pig farmers as well as thousands of farm helpers, truck drivers and slaughterhouse workers. It advised the use of eye goggles, face masks, boots, plastic aprons, and waterproof gloves when handling pigs. It also recommended refraining from treating or touching sick animals, and suggested spraying disinfectant on dead pigs.

Because of shared routes of transmission, co-infection with HIV and Hepatitis C (HCV) is common. However, finding information on this topic is somewhat difficult. ATIS frequently receives requests for information about how co-infection with HCV affects the progression of HIV disease, the current treatment options, and experimental therapies being conducted in clinical trials.

To assist you in locating information on this important topic, we have put together a new feature on our web site that provides a variety of links from various government agencies and other organizations dealing with this topic.

Please take a moment to review the site: http://www.hivatis.org/hepatitisC.html. We hope you find this information helpful.

ATIS provides information about federally approved treatment guidelines for HIV and AIDS. Visit the ATIS website at http://www.hivatis.org.

The Association for Professionals in Infection Control and Epidemiology (APIC) has produced an influenza prevention package designed for health care and infection control professionals to

use for community and health care worker education. "Influenza Prevention: A Program for Community and Healthcare Worker Education" contains everything necessary for implementing a successful influenza prevention program, including an instructor guide and lesson plan, handouts, transparency masters, promotional flyers, news release, staff bulletin, and PowerPoint slide presentation (all on disk except instructor guide).

The package costs $28 ($22 for APIC members), and can be ordered by contacting APIC at 202-789-1890 (phone) or 202-789-1899 (fax).

Few of us hold a warm place in our hearts for mosquitoes. They inflict itchy bites, buzz menacingly in our ears, and infringe on our warm-weather outdoor activities. But these pests are much more than annoying — they can pose serious health hazards. Insects that feed on blood have the potential to transmit disease between animals and humans. Mosquitoes, the most highly developed insect bloodsuckers, play a major role worldwide in the transmission of diseases like malaria, dengue and yellow fever. In the United States, the most common mosquito-borne disease is viral encephalitis.

Encephalitis is a disease that causes inflammation of the brain. While most people infected with viral encephalitis have only mild or no symptoms, serious cases can cause headaches, high fevers, lethargy, convulsions, delirium, coma, and even death.

More information on mosquito-borne encephalitis, preventing infection, eastern equine encephalitis, western equine encephalitis, St. Louis encephalitis and LaCrosse encephalitis can be found at the Mayo Clinic's HealthOasis site: http://www.mayohealth.org/

The last reported case of human plague in Florida occurred in 1920 during an outbreak in Pensacola [1]. Still the disease continues to be a threat because of enzootic foci in the wild rodent populations of several western states [2]. Even though plague is not currently found in Florida, there is always the possibility that animals infected with Y. pestis may be imported into areas of the state that have suitable flea vectors (including Xenopsylla cheopis) [3].

Plague is an acute, bacterial disease caused by Yersinia pestis, a Gram-negative coccobacillus that is transmitted from rodent to rodent by infected fleas. The most common mode of transmission of Y. pestis to humans is by the bite of infectious fleas, especially the Oriental rat flea (X. cheopis) [2, 4]. Less frequently, infection is caused by 1) direct contact with infectious body fluids or tissues while handling an infected animal or 2) inhaling infectious respiratory droplets. Signs and symptoms include fever, headache, myalgia, malaise, shaking chills, prostration, and gastrointestinal symptoms. Several antibiotics may be used for prophylactic therapy in persons exposed to Y. pestis, although streptomycin is the drug of choice [2, 4]. An inactivated vaccine is also available in the United States [4].

The three principal clinical presentations of plague are bubonic, septicemic, and pneumonic [4]. Bubonic, the most common, with an incubation period from 2-6 days is characterized by the development of an acute regional lymphadenopathy, or bubo. The case-fatality rate for untreated individuals is 50-60%. A septicemic form of the disease occurs when Y. pestis invades and multiplies in the bloodstream. This can occur secondarily to the bubonic form or develop without detectable lymphadenopathy. Pneumonic plague is the least common, but most fatal form of the disease. It can develop either as a secondary complication of septicemia or result from inhalation of infectious respiratory droplets expelled from a human or animal that has the pneumonic form. The incubation period for primary pneumonic plague is 1-3 days.

Outbreaks of plague in humans usually involve exposure to house rats and their fleas. Risk for plague in humans is greatest when epizootics cause high mortality in rat populations, thereby forcing hungry, infected rat fleas to seek alternative hosts such as humans [4]. The last rat-borne epidemic in the United States occurred in Los Angeles in 1924-25 [5]. Since then, all human plague cases in the U.S. have been sporadic cases acquired from wild rodents or their fleas or from direct contact with plague-infected animals. Rock squirrels, ground squirrels, prairie dogs, wood rats, and chipmunks have served as sources of human infection [5]. Domestic cats have recently been sources of infection for humans [6, 7].

In the United States, the majority of human cases are reported from Arizona, California, Colorado, and New Mexico [6, 7]. During the period 1970-1995, 341 cases of plague in humans were reported to the Centers for Disease Control and Prevention (average: 13 cases per year). Of these cases, 80% occurred in the southwestern states of Arizona, Colorado, and New Mexico [4].

1. Bigler WJ and Janowski DD. Bubonic plague in Florida??! Epi Update (Florida Department of Health, Bureau of Epidemiology).
2. Benenson AS (ed.). Control of Communicable Diseases Manual, Sixteenth Edition. United Book Press, Baltimore. 1995: 353-358.
3. Layne JN. Fleas (Siphonaptera) of Florida. Florida Entomologist. 1971; 54(1):35-51. March 6, 1997:1-2.
4. CDC. Prevention of Plague: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report. December 13, 1996; 45(no. RR-14).
5. CDC. Information on Plague. Internet address (accessed March 1999): http://www.cdc.gov/ncidod/dvbid/plague/info.htm
6. CDC. Human plague—United States, 1993-1994. Morbidity and Mortality Weekly Report. April 8, 1994; 43(13):242-246.
7. CDC. Fatal human plague – Arizona and Colorado, 1996. Morbidity and Mortality Weekly Report. July 11, 1997; 46(27):617-620.

The Florida State Dental Society was instrumental in establishing a Bureau of Dental Health within the State Board of Health in 1936. Initial funding for the program came from the Social Security Act, but alliances with local dental societies, county governments, community organizations and the school system enabled growth of this essential program. A broad based agenda included 1) providing corrective dental services for preschool and elementary school children, and prenatal and postnatal maternity patients, 2) conducting refresher courses for dentists in children’s dentistry and 3) aggressive community educational campaigns. Dr. Lloyd Harlow, Director of the Bureau, in the 1939 Annual Report, discusses events leading to formation of the bureau, the necessity for a community education campaign and the unique arrangements made by various counties to provide clinic services for indigent children. Selected excerpts follow: