Division of Disease Control and Health Protection

TALLAHASSEE—State health and environmental officials have issued an advisory as a result of the recent wildfires. The forest fires are causing an increase in the air pollution in the areas of the fires and surrounding areas. The pollution resulting from the fires combined with emissions from cars and trucks, hot temperatures and low winds push air quality into the unhealthy range for sensitive individuals. This degraded air quality can adversely affect the respiratory system and may aggravate heart and lung problems such as asthma and emphysema.

Persons in the areas affected by the fires with respiratory conditions or heart disease should avoid physical exertion and outdoor activity. This caution also extends to young children and the elderly.

Individuals who have respiratory conditions and do not have access to air conditioning should consider spending time in areas such as shopping malls, public libraries or museums.

If you feel you are experiencing adverse health affects, contact a physician for an evaluation or advice. This cautionary advisory will remain in effect as long as the state is suffering from wildfires and the weather conditions remain hot with low winds. Citizens are urged to exercise caution in accordance with local area conditions.

Several large wildfires occurred in Florida during June-July 1998, many involving both rural and urban areas in Brevard, Flagler, Orange, Putnam, Seminole, and Volusia counties (1,2). By July 22, a total of 2277 fires had burned 499,477 acres throughout the state (Florida Department of Community Affairs, unpublished data, 1998). On June 22, after receiving numerous phone calls from persons complaining of respiratory problems attributable to smoke, the Volusia County Health Department issued a public health alert (2) advising persons with pre-existing pulmonary or cardiovascular conditions to avoid outdoor air in the vicinity of the fires. To determine whether certain medical conditions increased in frequency during the wildfires, the Volusia County Health Department and the Florida Department of Health initiated surveillance of selected conditions. This report summarizes the results of this investigation.

The surveillance system monitored the frequency of patient visits associated with selected conditions at seven hospitals in Volusia County and one hospital in Flagler County. The medical records departments of these eight hospitals furnished data about persons seen in the emergency departments (EDs) and/or admitted for the selected conditions during June 1-July 6, 1998. For comparison, the hospitals also provided the same information for June 1-July 6, 1997. Data from the eight hospitals were combined for analysis.

From 1997 to 1998, ED visits increased substantially for asthma (91%), bronchitis with acute exacerbation (132%), and chest pain (37%). ED visits for painful respiration decreased (27%). Changes in the number of admissions were minimal.

Reported by: B Sorensen, MD, M Fuss, Volusia County Health Dept; Z Mulla, MSPH, W Bigler, PhD, S Wiersma, MD, R Hopkins, MD, State Epidemiologist, Florida Dept of Health.

Editorial Note

Editorial Note: In response to the wildfires in Florida, infection-control practitioners and public relations professionals at these local hospitals were used as liaisons between the medical records staff at their respective hospitals and the health department. The data were used to quantify the extent of morbidity possibly related to the wildfires.

The findings in this report are subject to at least two limitations. First, the increase in the frequency of the conditions observed for this report did not necessarily result from the wildfires. Certain persons who suffered from these conditions may have never presented at a hospital because they chose not to seek medical care or were seen by their private physician. Second, coding practices differ slightly between hospitals and may change over time within the same hospital.

This report illustrates that rapid surveillance of non-reportable diseases and conditions is possible during a public health disaster. The surveillance strategy included 1) identifying key staff in local hospitals well in advance of a disaster, 2) developing connections with these persons to ensure rapid access to critical information, and 3) providing simple data collection instruments that minimize confusion.

References

The table originally included in the MMWR article did not reproduce well for inclusion in the Epi Update.  If you wish to view the table, please do so at the following address: http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00056377.htm. For those of you who would prefer a hard copy, please send your e-mail requests to natalie_tackett@doh.state.fl.us.  Include your fax number and/or address. --Eds.

During the summer of 1998, concern about the possible adverse health effects of the wildfires led the Volusia County Health Department and the Bureau of Epidemiology to conduct hospital-based surveillance of 13 conditions including asthma, acute bronchitis, and conjunctivitis (see previous article).

The 1999 wildfire season has started in Florida. If our past experience is any indication, county health departments may be asked by politicians, physicians, and the general public to determine if the fires are causing an increase in the frequency of certain conditions. Since asthma, acute bronchitis, and conjunctivitis, are not reportable to the Department of Health and county health departments (CHDs) by law, data on these conditions must be specially requested from the local health care providers.

Last year when gearing up for this project we learned a few lessons that might be helpful for others contemplating active surveillance for fire and smoke related morbidity

First - We found that collaborating with both the hospital infection control practitioners (ICPs) as well as staff from the medical records department was beneficial. The ICPs, at times, acted as liaisons between the medical records staff at their respective hospitals and the Volusia CHD. This strategy seemed to facilitate the rapid transfer of data.

Second - Our overall approach to data collection was to keep it simple. We chose a series of 13 conditions that were easy for the hospital staff to identify and collect information on. Next time, perhaps we would choose fewer. Our request did not ask for the number of cases of a particular condition by ICD-9 code. We also found that coding practices varied somewhat from hospital to hospital. For example, asthma is represented by several codes. A particular hospital may never use all of these codes when coding an asthma case. In order to avoid missing cases, we furnished the hospitals with plain English text and avoided the used of codes.

Third – We chose a particular time frame for the current fire event and the same period for the previous year for comparison and used the same parameters for all hospitals surveyed.

Fourth – We used a simple data collection instrument and took the time to explain it to staff involved in its completion. This time on the front end paid dividends by promoting cooperation, avoiding delays and encouraged completion by a certain date. Whenever possible the form was hand delivered to the hospital so staff participating collection of the information requested had an opportunity to meet us and ask questions they might have. If this was not possible we faxed the form and followed up with a personal phone call. A sample table is shown below.

Frequency of Emergency Room Visits for Selected Conditions, and Percentage Change during May 1998 and 1999, X County

Fifth – In hindsight, we now believe it is only necessary to ask for data on emergency room (ER) visits. Last year we also asked the hospitals to furnish the numbers of admissions for the same 13 conditions. This no doubt delayed our data request, and, furthermore, the number of hospital admissions did not convey much information. The numbers were small and the overall change between 1997 and 1998 was small.

Sixth – We also learned to recognize and appreciate that coding practices may vary within one hospital over time. For instance, a large increase or decrease between 1998 and 1999 for a particular condition for a particular hospital may mean that in 1998, ER staff coded ER visits, but this year medical records staff coded ER visits.

Finally – One must always keep in mind that these are surveillance data – nothing more. Any increase in the frequency of the conditions over time is not necessarily due to the fires. Also, certain persons who suffered from these conditions may have never presented at a hospital because they chose not to seek medical care or were seen by their private physician.

Those with any additional questions regarding the institution of an active surveillance at hospital ER’s in their area may direct them to Mr. at hospital ER’s in their area may direct them to Mr. Zuber Mulla at (407) 623-1212 or SC 334-1212 ext. 178. Mr. Mulla is also on the departmental Intranet via cc-mail.

As a matter of interest, the Florida Department of Community Affairs has compiled 1998 wildfire statistics (number of acres burned, value of destroyed property, etc.) They can be contacted at (850) 413-9969 or Suncom 293-9969. Current health alerts may be found at the Website of the Department of Health (www.doh.state.fl.us). This site also has information on emergency operations

11:00 AM – 12:00 PM EST

On April 27, the Epidemiology Grand Rounds will feature Dr. Russell E. Mardon, Senior Management Analyst, with the Florida Department of Health’s Bureau of Environmental Epidemiology. Dr. Mardon will present "Cancer Risks and Environmental Exposures in St. Lucie County Florida: Report to the Community." This presentation will describe the recent investigation into the association between environmental chemicals and childhood cancer in St. Lucie County and will include epidemiologic methods and results, and strategies for communicating with the public.
 

April 27 June 29 August 31 October 26

• Never call in using a cellular telephone or cordless headset.
• Leave your telephone "mute button" on during the call (except when asking questions).
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• Dial-in on time.

DATE: February 18,1999

TO: County Health Directors/Administrators

THROUGH: Richard C. Hunter,.Ph.D.

Deputy State Health Officer

FROM: Steven Wiersma, M.D., M.P.H.

Deputy State Epidemiologist

SUBJECT: Hepatitis C—Department of Health Guidelines for Prevention and Control

Hepatitis C reports are increasing dramatically as new testing technology gains acceptance. The hepatitis C situation is often referred to as "the silent epidemic" because so few of those who carry the virus are aware of their infection. It is believed that as many as 4 million Americans are infected with hepatitis C, four times the number of HIV infections nationally. This translates to more than 200,000 hepatitis C infections in Florida.

Hepatitis C infections cause significant human suffering and death. Hepatitis C is the most common blood-borne infection, the most common cause of chronic hepatitis and the most common cause of liver transplants. Deaths from chronic hepatitis C may soon overtake the number of AIDS-related deaths. In addition to significant losses of productive life years, medical treatment costs are estimated to be hundreds of millions of dollars annually in the United states.

Prevention efforts for hepatitis C focus on primary prevention, to prevent new cases, and secondary prevention, to reduce the burden of hepatitis C virus-related disease in those already infected. Attention to hepatitis C virus prevention has been made possible by a better knowledge of hepatitis C virus epidemiology as well as new treatments for those chronically infected with the hepatitis C virus. As with HIV treatments, these hepatitis treatments are expensive but are continually improving.

County Health Departments can expect a steady increase in requests for information about the hepatitis C virus or HCV, requests for testing, explanations of test results and requests for referral to a source of care for biopsy and treatment. This increased demand for services will accelerate as various national and statewide bodies begin planned media campaigns.

There are currently no additional state funds available to support these activities, although proposals for funding may be considered during the current legislative session.

At this point, the Department of Health is still only maintaining surveillance for acute infection with the hepatitis A, B and C viruses at the state level, not for newly detected persons with chronic infection, even if symptoms have developed only recently. If additional funding is appropriated, we intend to add surveillance for newly detected chronic infection as well, including both symptomatic and asymptomatic chronic infection. This will involve the development of a hepatitis registry.

The state laboratory is offering the basic screening test for hepatitis C enzyme immunoassay or EIA. The state lab will charge county health departments for enzyme immunoassay for anti-hepatitis C virus tests done in support of screening activities. The confirmatory tests, recombinant immunoblot assay—RIBAÔ or reverse transcriptase polymerase chain reaction—RT-PCR and the follow-up test, alanine aminotransferase or ALT,will have to be ordered from a commercial laboratory.

The following list of recommendations is offered to prepare for anticipated inquiries about the hepatitis C virus:

• County health departments should assemble a list of local physicians who will take referrals for hepatitis C screening and for follow-up care after a positive test.
• If county health departments choose to offer screening:
• Screening should be offered in accordance with published Centers for Disease Control and Prevention recommendations. (Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease, MMWR,

• Adequate pre- and post-test counseling should be provided to those screened using the model of HIV-test counseling.
• County Health Departments should have a plan for medical referral of screened persons for follow-up care, regardless of health insurance status.

Because misinformation on hepatitis C virus is widespread, use care when recommending sources of information to clients. The Bureau of Epidemiology can provide current public health recommendations and sources for accurate information.

National: Influenza morbidity peaked during February and has been declining during March and early April. During week 14, five states (Alaska, Arizona, Maryland, Louisiana and Tenneessee) reported either regional or widespread activity, compared to 10 states the previous week. The WHO laboratories reported that 15% (11,998 of 77,649) of the specimens tested since October 4 have been positive for influenza. Seventy seven percent (9,217) of these were influenza A. Among the type A viruses, 25% have been subtyped. Subtype A(H3N2) has predominated (99% of 2,322)). Twenty isolates have been subtyped as A(H1N1) So far this season, influenza A have 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 have varied by region, ranging from 61% in the East North Central region to 91% in the New England region. Of the total patient visits to sentinel physicians, 1% were due to ILI (influenza-like-illness) in the U.S. overall. The percentage of patient visits was within baseline values of 0%-3% nationally and in all nine regions. The percentage of pneumonia and influenza deaths reported from the 122 cities during Week 14 was 8.3 %, above the epidemic threshold of 7.3%. The percentage of deaths from pneumonia and influenza continue to decline. However the percentage of pneumonia and influenza deaths remained above the epidemic threshold for the eleventh consecutive week.

Florida: During week 14 (4-10 April 1999) there were 6 laboratory-confirmed isolates of influenza reported: Influenza A was reported from Orange, Palm Beach and Sarasota (AH3N2) counties. Influenza B was reported from Broward and Orange counties. Since September 23 and to date, there have been 222 isolates reported; 67 (30%) of these were type B, and 155 type A. Of the influenza A isolates 65 (30 %) were typed; 59 (91%) were type A(H3N2), 6 (9%) were type A(H1N1). Isolates have been reported from: Alachua (1), Brevard (5), Broward (24), Dade (5), Desoto (1), Duval (13), Hillsborough (47), Indian River (5), Leon (19), Martin (2) Okaloosa (2), Orange (21), Osceola (1), Palm Beach (17), Pinellas (12), Polk (3), Sarasota (20), Seminole (2), St. John’s (1) and Volusia (2) counties.

Of the total patient visits to sentinel physicians during Week 14,1 % 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.

…"Health Departments in Florida participated in the earliest trials of the Salk Vaccine. There was even more interest in the Sabin oral vaccine. The new vaccine appeared to be a preparation, which would be readily accepted by the public… The effort is commendable because of the…cooperation between these organizations (the CHD and County Medical Association) and the various voluntary agencies, industrial groups, and the citizens of Hillsborough County…Particular attention was directed to population groups considered "hard to reach."…(and) a high percentage of these…took the vaccine…This monograph gives the findings of that… productive research and a successful…program. Of broader importance, it may be a move toward the eradication of poliomyelitis from Hillsborough County, from Florida, from the United States, and hopefully, eventually from the world…" --Albert V. Hardy, MD, DrPH

"This monograph summarizes the methods and results of the first large United States field trial of a trivalent oral polio vaccine prepared from the Sabin Strains of attenuated polio virus. (387,000 doses administered during a three-month period). The objectives…included (1) an evaluation of the immunogenicity of the vaccine in susceptible children; (2) measurement of the ability of the vaccine to reduce the transmission of polio…in the community, and (3) the elimination of clinical paralytic poliomyelitis as a public health problem in Hillsborough County. The program …also…measure(d)…those factors that were significant in either personal or community acceptance of the program.

The oral trivalent vaccine was found effective by…clinical, virological and serologic measurements. In the serologic study, 422 children (who)…had no demonstrable antibodies…against all three types of polio virus (had) 90.4 per cent conversion to Type I, 99.7 per cent to Type II, and 98.0 per cent to Type III…

Oral polio vaccine virus…circulating in the community was recovered from…sewage and rectal swabs (from healthy preschool…children) during the period of administration of vaccine. …(afterward) there was a gradual decline in the percentage of recoveries. Sewage specimens dropped from 39…to six percent (and)… rectal swab(s) dropped from 16 per cent… to zero…

Careful…surveillance for (CNS) viral infections…initiated in October…196I …(and) continued throughout the field trial and for 18 months thereafter…. (revealed) four cases of clinical paralytic disease… (only one), an 18 month old ,…(had) Type I poliovirus.. (in) the stools.. (with) clinical…asymetric flaccid paralysis. This child had received two doses of the trivalent vaccine in February and April of 1962, however, there was no evidence of Polio CF antibodies in either the acute or convalescent sera…

During the field trial it became readily apparent that the Hillsborough County community is a heterogenous social group, and public health programs must be tailored to fit the individual needs of each subculture…The program became a truly multidisciplinary effort, in which nurses, sanitarians, clerks, psychologists, physicians, social workers and the entire (CHD) staff joined forces to mobilize…the community… The necessity of maintaining protection in the community by immunization of all newborns or new arrivals…with emphasis on education and an appreciation of the importance of immunization (requires).. a follow-up program (that) has been organized… and is being effectively carried out." --James O. Bond MD, MPH and John S. Neill, MD, MPH