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State of Florida
Department of Health, Bureau of Epidemiology
EPI UPDATE
April 8, 1999
Richard S. Hopkins, M.D., M.S.P.H., Bureau Chief, State Epidemiologist
Don Ward, Surveillance Section Administrator, Epi Update Managing Editor
Natalie E. Tackett, Epi Update Editor
Bureau of Epidemiology Frequent Contributors:
Steven Wiersma, M.D., M.P.H., Deputy State Epidemiologist |
William J. Bigler, Ph.D., M.S. Senior Epidemiologist |
Jodi Baldy, M.P.H., Biological Scientist IV |
Ursula E. Bauer, Ph.D.,
Chronic Disease Epidemiologist |
John Werth, M.A.
Bureau Education Coordinator |
Lisa Conti, D.V.M., M.P.H., State Public Health Veterinarian |
| |
Regional
Epidemiologists |
Dolly
Katz, Ph.D., M.P.H.,
SE Florida |
Roger Sanderson, R.N., M.A.,
SW Florida |
Carina
Blackmore, M.S. Vet. Med., Ph.D., NE Florida |
Zuber Mulla, M.S.P.H.,
Central Florida |
Gérard
Krause, M.D., D.T.M.H.,
NW Florida |
Please print out this material and share with epidemiology staff, county
health department directors, administrators, medical directors, nursing directors,
environmental health directors and others with an interest in information of this type.
Thank you.
The Bureau of Epidemiology is available 24 hours a day,
7 days a week for consultation at our main number (850/245-4401) PLEASE NOTE:
Consultation after 5 p.m. & on weekends is intended for emergencies.
Epi Update has a home on the World Wide Web at ---
http://www.doh.state.fl.us
The Florida Clean Indoor Air Act regulates smoking in indoor public
places.
To file a complaint call 1-800-337-3742
In this issue:
1. Epidemiology "Grand Rounds:" Round One!
2. Influenza Summary Report
3. Link of the Week
4. Florida Past: Cerebro-Spinal Fever
5. Weekly Disease Table Week 13
Epidemiology" Grand Rounds": Round One
Don Ward, Surveillance Section Administrator
The first Epidemiology Grand Rounds conference call, held on March 30 was an (almost)
unqualified success. A couple of techno-glitches prevented the session from being
flawless; a telephone rang through the first fifteen minutes of the call, there was a
high-pitched whine at the end, and some listeners had difficulty in gaining access to the
slide presentation. These annoyances were greatly diminished by the quality of the
presentation by Dr. Ursula Bauer who delivered a superb discussion of new and encouraging
data from the most recent Florida Youth Tobacco Survey. Some of the 1999 survey’s
most promising results include the following;
- There was a decline (from 1998 to 1999) in current tobacco use among both middle school
students (18.5% to 15%) and in high school students (from 27.4% to 25.2%). Note: the
largest decreases occurred in Non-Hispanic White students.
- Confirmed non-smokers (those who have never tried a cigarette and are not considering
trying a cigarette in the future) for middle school and high school students (combined)
rose from 31.1% in 1998 to 36% in 1999.
Dr. Bauer confirmed that she and other public health experts consider these results to
be encouraging; they may be early indicators that tobacco-use behaviors are changing, and
may also provide useful information about the success of the Florida Pilot Program on
Tobacco Control. Audience reaction to Dr. Bauer’s presentation was enthusiastic and
insightful. Some listeners still had questions to be asked when the session was closed due
to the call’s time limit. Dr. Bauer received more questions and discussion following
the call.
We offer the following tips for making the Grand Rounds call more useful and enjoyable:
- During the call (except when asking questions) leave your telephone mute button
"on."
- Do not put your phone on "hold" and leave the call.
- Please dial in on time.
- The computer route to the slide presentation is as follows:
- Access the DOH Intranet site
- Click on Division (Disease Control)
- Click on Bureau of Epidemiology
- Click on Grand Rounds
- Click on Slideshow Presentation
- You may need to use the options for "full screen" that can be found either
through the default screen (at the top of the page) or through the "view" menu.
In order to see the whole of each slide, it may also help to use the "control"
window to set your display at 1024 x 768 pixels. Do this ahead of time.
We thank and congratulate Dr. Bauer on her fine presentation and look forward to having
YOU as a member of the audience on April 27, when Dr. Russ Mardon will present the results
of a study of a cluster of brain cancer cases among children in St. Lucie County. Dial
(850) 921-5230 or Suncom 291-5230 at 11:00 a.m. sharp!
2. Influenza Summary Report - Week 10 (week ending March 13 1999)
Carina Blackmore, M.S. Vet. Med., Ph.D., NE Florida
National: Influenza activity levels remained high during week 10
but are declining. Thirty-four states, as reported by state and territorial
epidemiologists, reported regional or widespread activity compared to 44 states during
week 5. The WHO laboratories reported that 14% (8,798 of 60,981) of the specimens tested
since October 4 have been positive for influenza. Seventy eight percent (6,833) of these
were influenza A. Among the type A viruses, 26% have been subtyped. Subtype A(H3N2) has
predominated (99% of 1,795). Thirteen isolates have been subtyped as A(H1N1). So far this
season, influenza A has been the most common subtype in the U.S. overall and in all of the
nine regions; however, the percentage of influenza type a viruses has varied by region,
ranging from 58% in the East North Central region to 92% in the Mid-Atlantic region.
Influenza B has predominated in some regions during specific time periods. Of the total
patient visits to sentinel physicians, 3% were due to ILI (influenza-like-illness) in the
U.S. overall. The percentage of patient visits was within baseline values of 0%-3% in six
of the nine regions. In the South Atlantic and East South Central and West South Central
regions the percentages were 4%, 7% and 8% respectively. The percentage of pneumonia and
influenza deaths reported from the 122 cities during Week 10 was 8.7 %, above the epidemic
threshold of 7.5%. This is the fifth consecutive week in which the percentage of pneumonia
and influenza deaths has exceeded the epidemic threshold.
Florida: During week 10 (7-13 March 1999) there were 7 laboratory-confirmed
isolates of influenza reported: Influenza A cases were reported from Broward (AH1N1,
AH3N2), Hillsborough, Orange, Osceola (AH3N2) and Palm Beach counties. Since September 23
and to date, there have been 199 isolates reported; 64 (32%) of these were type B, 57
(29%) were type A(H3N2), 5 (3%) were type A(H1N1). Isolates have been reported from:
Alachua (1), Brevard (5), Broward (25), Dade (5), Desoto (1), Duval (14), Hillsborough
(46), Indian River (5), Leon (18), Martin (1) Okaloosa (2), Orange (20), Palm Beach (16),
Pinellas (12), Polk (4), Sarasota (19), Seminole (2), St. John’s (1) and Volusia (2)
counties.
Of the total patient visits to sentinel physicians during Week 10, 2% were due to ILI.
This is within the baseline levels of 0-3%. Since October 4 the percentage has ranged
between 1 and 4%. Influenza-like illness has been reported from health care providers in
20 of the 21 Florida counties in the sentinel physician surveillance network.
3. Links of the Week
Submitted by Zuber Mulla, M.S.P.H.
Epidemic! The World of Infectious Disease
The following site review may be of interest to you. The review was published by The
Scout Report, Volume 5, Number 46, March 26, 1999. Try to "name that creature"
in the "Epidemic -- On the Trail of Killer Diseases" section of the site.
Epidemic! The World of Infectious Disease -- AMNH [.pdf]
http://www.amnh.org/exhibitions/epidemic/index.html - This new online exhibition from the American Museum of Natural History offers a
captivating account of the physical and social environments that allow disease-causing
microbes to emerge and spread. Throughout the exhibit, which references both historical
and contemporary outbreaks, epidemics, and pandemics, users learn about the human and
environmental changes that contribute to the rise and decline of certain diseases, the
microbes that carry these diseases, and how they infect us. Essentially a collection of
short, illustrated passages, the exhibit is best viewed in the order presented, although
users may jump to specific sections. The text of the exhibit is frequently hyperlinked to
glossary terms and short sections offering further information on selected topics.
Additional features at the site include a collection of high-quality online resources,
teacher's guides (in .pdf format), a Kids Magazine, and a link to a partner site at
Discovery Online (reviewed in the December 10, 1997 Scout Report for Science and
Engineering). [MD]
4. Florida Past: Cerebro-Spinal Fever: The Epidemic at Madison
William J. Bigler, PhD
During the past century, we have seen amazing medical and scientific advances in the
prevention and control of many communicable diseases. Still, despite our best efforts, a
few of the more common diseases continue to exist and occasionally cause outbreaks,. What
was once known as cerebro-spinal fever caused by Diplococcus intracellularis is now
meningococcal disease and the causative agent has been renamed Neisseria meningitidis.
Dr. Hiram Byrd, one of the more articulate and prolific contributors to the written
records of the State Board of Health, was serving as a Special Agent for the Board out of
Jacksonville when he was called to investigate an unusual out break of Cerebral-spinal
Fever that devastated a small community near the Georgia border during February and March
in 1904. His account of the events is fascinating both in the descriptive detail of the
signs and symptoms of the disease and the conclusions drawn about the origin and
distribution of the agent. A few of his most interesting comments and insightful
observations follow. The entire 12 page report can be found in the 1905 Annual Report of
the State Board of Health.
"I have endeavored to give an accurate report of the outbreak, unbiased by any
erratic notions previously acquired. I am free to confess that in many instances it came
far short of my conception of cerebro-spinal, but I am forced to think that it was the
conception at fault and not the disease. I have interpreted freely the phenomena observed
without antagonism to any one. My conclusions are my own only so far as they are different
from others….
Cerebro-spinal fever, as encountered at Madison, usually began with a rise of
temperature, accompanied in about half of the cases by a chill. In some…(it) was
severe and repeated. In some.. severe, but not repeated. In others…less severe. And
in still others…(only) a chilly sensation…there was febrile temperature in every
instance. But it did not conform to any special type. Nor was its height any index to the
patient’s condition…. But as a rule the temperature was not very high. Perhaps
100 to 102 was the most common…
Headache, like fever, was a certain symptom. In the worst cases it was severe and
accompanied by retraction of the head and rigidity of the cervical muscles. In such cases,
delirium soon supervened, lasting a variable time and giving place to coma on the one hand
and stupor on the other. In milder cases headache was correspondingly mild. In some well
defined cases it was hardly complained of at all…Backache was noted in the worst
cases. Opisthotonos was reported in some of the fatal ones. From that degree of severity,
it too could be traced through cases less severe till it finally faded out and was not
present at all in some of the endoubted (sic) cases. Arthritis was noted as an occasional
symptom. The wrists, ankles and knees were most affected…Constipation was the
rule…Catarrhal symptoms were present in a few cases but so seldom that I feel
inclined to regard it as coincidental.
The eruption was present in about seventy-five percent of the cases. It was two
distinct types: petechial and herpetic. The petechial eruption appeared usually in twelve
to thirty-six hours after the onset of disease…As ordinarily encountered, it
resembled flea-bites, consisting of red splotches, varying in size from a pinhead to a
dime, the edges not well defined and shading off into the color of the skin….The
eruption was usually confined to the forearms and legs, but the distribution was by no
means constant. In some cases it was not only abundant in these place, but well sprinkled
over the body and face, while in others it was either sparsely localized or altogether
wanting…The herpetic eruption was about as constant as the petechial. It had a
prediliction for the face – especially the lips and chin.
The mental state of those suffering from cerebro-spinal fever is worth noting. In some
cases delirium came on shortly after onset and lasted from a few to several
hours…Finally after varying intervals the patient would pass into a coma or stuper
(sic) according as the symptoms were growing worse or better….Eye symptoms were noted
in eight cases. In seven of these it was strabismus and in the eighth ptosis… Only
one of the eight recovered, and he is still slightly affected with strabismus.
The duration, like other phases of the disease was variable. Ten of the fatal cases
only lived thirty hours to one week. The fifteen mildest cases recovered in the same time.
But between these there was (sic) two that died after several weeks, and three in which
convalescence was long and draw out, lasting three weeks to more than a month….
The exact mortality rate is difficult if not impossible to determine. Just how many
cases there were is not known, for the reason that there were many that were so mild that
it was impossible to make a diagnosis…Such doubtful cases are not included in this
report… (it includes) only those cases which were seen by a physician and in which a
diagnosis was established with a reasonable degree of certainty.
The first case reported developed on February 3rd and from that time till
the 17th, the disease was at its height. During these two weeks, fifteen of the
thirty cases (50%) developed, and seven of the twelve deaths (58%) occurred. During the
next two weeks, from February 17 to March 2nd, nine cases developed and one
death. During the three weeks, dating from March 2nd, four cases were reported,
and two deaths. Two that were reported convalescing subsequently died. This makes a total
of thirty cases and twelve deaths, or forty percent mortality.
It is the consensus of medical opinion that cerebro-spinal fever is, if contagious at
all, very mildly so; in any event not exceeding tuberculosis. I see nothing against that
opinion. Certain features of it did at first look as if it might be contracted one from
another…But on the other hand…of the eighteen families that it invaded, there
was twelve in which it originated without any traceable history of exposure. And fourteen
of the eighteen had only a single case, while only four had multiple cases.
…. this is a systemic infection….the specific cause (Diplococcus
intracellularis) has been recovered not only from the cerebro-spinal fluid, but from
the blood, the spleen, effusion into the joints, pneumonic areas of the lungs and from
catarrhal mucous membrane of the nose and throat… This organism is evidently widely
distributed in nature, for the disease has appeared from time to time all over the
world….it is not uncommon to find the pneumococcus in the sputa of a healthy
individual…Upon such grounds as these there is nothing preposterous in assuming
universal distribution of the Diplococcus intracellularis …
Now whether it is distributed through man’s environment, or is harbored by his
economy, is not quite clear. The preponderance of evidence is that it is in his
environment. That the disease is of such a local nature, bears strong testimony to this.
But on the other hand it has been sought for (by culture and isolation) in fifty healthy
individuals and found…one…It is a striking coincidence also that the number of
cases in the vicinity of Madison was to the whole population as one to fifty, there being
a population of about 1,500.
….The next question to answer is that if we accept universal distribution of the
organism why don’t we encounter these more frequently? The answer is to be found in
the laboratory….it is the attenuated state of the Diplococcus intracellularis
and not its absence that accounts for the rarety of the disease….attenuated organisms
may be grown in successive cultures under optimus (sic) conditions, and their virulence
increases. And that is why we so frequently encounter sporadic cases of diphtheria. The
organism exists in the healthy throat which is not a good environment for it. But let the
individual become weakened from exhaustion, cold, bronchitis, and he at once becomes a
good culture medium for the germ....Why may it not be true of cerebro-spinal fever?
Conclusions
- ….that cerebro-spinal meningitis is caused by the Diplococcus intracellularis
and that only.
- That this organism has a preference for the cerebral membranes, but does not necessarily
attack them.
- That the organism is widely distributed in nature but in an attenuated state.
- That under certain combinations of environments, its virulence (increases) till it is
capable of causing a sporadic case of cerebro-spinal fever.
- That as this combination of events extend to a whole community, the result is an
epidemic which may be regarded as so many sporadic cases.
- That it is not contagious, and when several cases occur in the same family or community,
they all come from the same cause and not from one another.
- That in our present state of knowledge we have no effective means of preventing it, but
there is no doubt that wholesome hygienic living will increase our vital resistence (sic)
and render us less easy prey to this fell disease.
Editorial note by Dr. Steven Wiersma
Dr. Bigler has again provided us with a superb historic reference to a contemporary
health menace—meningococcal disease. No matter if your perspective comes from Palatka
or Madison, the observations of Dr. Byrd are very revealing and highlight some important
issues. Mortality from this disease was often in excess of the 40% observed by Dr. Byrd
prior to the advent of modern therapy and supportive measures. The view that meningococcal
disease, "if contagious at all, very mildly so" is an accurate description of
the relatively low rate of secondary cases seen even during a community-wide outbreak, a
concept that is always difficult to communicate to our concerned public after a case(s)
are reported. Also, while we now know household contacts are at 500-800 times the
increased risk of the general population, with only 200+ cases of meningococcal disease in
Florida each year, the overall number of secondary household cases continues to be low. As
with many infectious diseases, host factors play an important but poorly understood role
in development of illness. Fortunately, preventive measures now exist in the form of
chemoprophylaxis and vaccination for high-risk populations and have been used effectively.
No matter if the year is 1904 or 1999, the place Palatka or Madison—meningococcal
disease is a problem that requires our continuing vigilance. We have come a long way but
we have a long way to go.
5. Weekly Disease Table - Week 13
County-Confirmed Cases, Sorted Alphabetically by Disease
NR represents years that the disease lacked status as a reportable condition
DISEASE |
1996 TO DATE |
1997 TO DATE |
1998 TO DATE |
3 YEAR AVERAGE
TO DATE |
1998 TOTAL CASES |
1999 TO DATE |
| Amebiasis |
14 |
8 |
7 |
9.7 |
90 |
2 |
| Anthrax |
0 |
0 |
0 |
0 |
0 |
0 |
| Botulism |
0 |
0 |
0 |
0 |
0 |
0 |
| Brucellosis |
3 |
0 |
1 |
1.3 |
3 |
0 |
| Campylobacteriosis |
208 |
166 |
120 |
164.7 |
974 |
156 |
| Ciguatera |
7 |
2 |
0 |
3 |
7 |
0 |
| Cryptosporidiosis |
26 |
15 |
23 |
21.3 |
203 |
8 |
| Cyclosporiasis |
0 |
0 |
2 |
0.7 |
7 |
0 |
| Dengue |
0 |
0 |
1 |
0.3 |
7 |
1 |
| Diphtheria |
0 |
0 |
0 |
0 |
0 |
0 |
| E. coli O157:H7 |
3 |
12 |
3 |
6 |
56 |
8 |
| E. coli, other (known serotype) |
2 |
2 |
2 |
2 |
12 |
5 |
| Ehrlichiosis, Human |
0 |
0 |
0 |
0 |
1 |
0 |
| Encephalitis, Eastern Equine |
0 |
0 |
0 |
0 |
0 |
0 |
| Encephalitis, St. Louis |
0 |
0 |
0 |
0 |
1 |
0 |
| Encephalitis, other (known organism) |
0 |
4 |
3 |
2.3 |
7 |
2 |
| Encephalitis, post-infectious* |
3 |
2 |
0 |
1.7 |
21 |
1 |
| Giardiasis (acute) |
310 |
274 |
231 |
271.7 |
1623 |
164 |
| Haemophilus influenzae*, invasive |
2 |
4 |
12 |
6 |
43 |
10 |
| Hansen’s Disease (Leprosy) |
0 |
0 |
2 |
0.7 |
4 |
0 |
| Hantavirus Infection |
0 |
0 |
0 |
0 |
0 |
0 |
| Hemolytic Uremic Syndrome |
0 |
2 |
0 |
0.7 |
12 |
0 |
| Hemorrhagic Fever |
0 |
0 |
0 |
0 |
0 |
0 |
| Hepatitis A |
73 |
107 |
131 |
103.7 |
549 |
139 |
| Hepatitis B |
73 |
68 |
69 |
70 |
508 |
66 |
| Hepatitis Non-A, Non-B |
15 |
14 |
19 |
16 |
102 |
4 |
| Hepatitis, unspecified |
1 |
0 |
0 |
0.3 |
25 |
2 |
| Histoplasmosis |
2 |
0 |
2 |
1.3 |
17 |
0 |
| Kawasaki |
4 |
5 |
13 |
7.3 |
47 |
1 |
| Lead Poisoning |
317 |
268 |
346 |
310.3 |
1813 |
98 |
| Legionellosis |
4 |
4 |
12 |
6.7 |
47 |
7 |
| Leptospirosis |
0 |
0 |
0 |
0 |
2 |
0 |
| Lyme Disease |
1 |
3 |
3 |
2.3 |
72 |
3 |
| Malaria |
12 |
18 |
14 |
14.7 |
95 |
19 |
| Measles |
1 |
0 |
1 |
0.7 |
2 |
0 |
| Meningococcal Disease (N. meningitidis) |
67 |
54 |
41 |
54 |
131 |
29 |
| Meningitis, Group B Streptococci |
6 |
2 |
2 |
3.3 |
20 |
4 |
| Meningitis, Haemophilus influenzae |
1 |
3 |
3 |
2.3 |
11 |
3 |
| Meningitis, Streptococcus pneumoniae |
27 |
27 |
36 |
30 |
91 |
28 |
| Meningitis, Listeria monocytogenes |
2 |
0 |
1 |
1 |
8 |
4 |
| Meningitis, other bacterial (including
unspecified) |
24 |
11 |
10 |
15 |
76 |
18 |
| Mercury Poisoning |
1 |
0 |
0 |
0.3 |
3 |
1 |
| Mumps |
1 |
7 |
2 |
3.3 |
11 |
0 |
| Paralytic Shellfish Poisoning |
0 |
0 |
0 |
0 |
0 |
0 |
| Pertussis |
12 |
18 |
11 |
13.7 |
39 |
4 |
| Pesticide Poisoning |
0 |
0 |
1 |
0.3 |
1 |
0 |
| Plague |
0 |
0 |
0 |
0 |
0 |
0 |
| Poliomyelitis |
0 |
0 |
0 |
0 |
0 |
0 |
| Psittacosis |
0 |
0 |
0 |
0 |
2 |
0 |
| Rabies, Animal |
53 |
73 |
57 |
61 |
215 |
38 |
| Reye Syndrome |
0 |
0 |
1 |
0.3 |
1 |
0 |
| Rocky Mountain Spotted Fever |
0 |
1 |
1 |
0.7 |
3 |
1 |
| Rubella, including congenital |
0 |
0 |
0 |
0 |
4 |
0 |
| Salmonellosis |
325 |
280 |
297 |
300.7 |
3004 |
309 |
| Shigellosis |
146 |
224 |
257 |
209 |
2293 |
293 |
| Streptococcal Disease, invasive Group A |
0 |
6 |
11 |
5.7 |
53 |
12 |
| Streptococcus pneumoniae, Drug
Resistant |
0 |
56 |
145 |
67 |
481 |
122 |
| Tetanus |
0 |
0 |
1 |
0.3 |
3 |
1 |
| Toxic Shock Syndrome |
0 |
0 |
2 |
0.7 |
4 |
2 |
| Toxoplasmosis |
3 |
1 |
4 |
2.7 |
13 |
1 |
| Typhoid Fever |
2 |
3 |
4 |
3 |
16 |
15 |
| Typhus (Louse & Murine) |
0 |
0 |
0 |
0 |
1 |
0 |
| Vibrio cholerae (serogrp O1) |
0 |
0 |
0 |
0 |
0 |
0 |
| Vibrio cholerae (serogrp Non-O1) |
1 |
2 |
1 |
1.3 |
12 |
2 |
| Vibrio vulnificus |
0 |
1 |
0 |
0.3 |
35 |
2 |
| Vibrio other (including unspecified) |
3 |
7 |
2 |
4 |
72 |
5 |
| Yellow Fever |
0 |
0 |
0 |
0 |
0 |
0 |
|
