Division of Disease Control and Health Protection

For June 24, 1999

A team from the Palm Beach County Health Department, the Bureau of Environmental Epidemiology and the CDC are investigating an outbreak associated with more than 250 attendees at an insurance company conference held in a hotel in Palm Beach County,

May 12 - 16. Several of the attendees of the conference are from California. It was those attendees who alerted the Los Angeles County Health Department that advised us of the outbreak. Cases from California and Wisconsin have been confirmed positive for cyclospora by CDC. There were more than 28 states represented at this conference.

There is no clear picture of how many people are ill at this time and no related cases of cyclospora from the same time period or place have been reported from any other state. So far, illnesses appear to be confined to attendees of the conference. There is no clear picture about food consumed by attendees or whether any one food can be implicated at this time. Menus for the conference were obtained and included multiple buffet items. The hotel is very concerned about the outbreak and is being very helpful and cooperative.

Because of the emerging nature of this pathogen, multiple state involvement, potential traceback implications and the workload involved an EpiAid was requested. A questionnaire has been developed and is being administered as part of a cohort study by an EIS officer along with another epidemiologist from CDC, staff from the Bureau of Environmental Epidemiology and staff from the Palm Beach County Health Department. In addition, a letter was sent to State and Territorial Epidemiologists and State Public Health Laboratory Officials by CDC's Division of Parasitic Diseases (see below with links to cyclospora fact sheets). Considerable interest is being expressed by FDA in the outcome of this investigation because of their role in previous tracebacks of foods implicated in cyclospora outbreaks.

No other information is available at this time. It will take several days to administer the questionnaire to conference attendees, enter the resulting data and analyze it. Further information will be provided in the next EpiUpdate.

"Date: June 21, 1999

To: State and Territorial Epidemiologists and

State Public Health Laboratory Directors

Through: Director, NCID

From: Division of Parasitic Diseases (DPD), NCID, CDC

Subject: Outbreak of cyclosporiasis in Florida in mid May

This memo is being sent to inform you of an outbreak of cyclosporiasis associated with an insurance convention held at a hotel in West Palm Beach, Florida, from May 12-16. The convention was attended by over 250 persons from about 28 states. If your state has residents who attended the convention, you or an epidemiologist on your staff has already been contacted.

On June 14, CDC and the Florida Department of Health were notified of the outbreak by the Los Angeles County Department of Health Services, which had become aware of multiple ill persons who had attended the convention. The Los Angeles health department and the Wisconsin Department of Health and Family Services subsequently found multiple stool specimens from ill residents positive for Cyclospora cayetanensis. CDC has confirmed the results. The Palm Beach County Health Department, the Florida Department of Health, and CDC have initiated an investigation of the outbreak.

If you know of any additional outbreaks or cases that are suggestive of cyclosporiasis, please notify Dr. Barbara Herwaldt of the Division of Parasitic Diseases of CDC. Please note additional DPD contacts and information sources on the next page."

Cyclospora fact sheets written for the public and for health care providers can be ordered via the CDC Voice Information System: (888) 232-3299. The document number for the fact sheet for health care practitioners is 380105, and the document number for the fact sheet for the general public is 380106.

General Inquiries (Fax: 770-488-7761)

Sue Partridge General inquiries (770) 488-7775

Epidemiology (Fax: 770-488-7761)

Barbara Herwaldt Coordinator, Cyclospora activities (770) 488-7772

Adriana Lopez, Surveillance and traceback activities (770) 488-3602

Laboratory (clinical specimens, sporulation, environmental samples) (Fax: 770-488-4253)

Susanne Wahlquist (770) 488-4474

Henry Bishop (770) 488-4474

Mike Arrowood (770) 488-4421

Mark Eberhard (770) 488-4419

Hepatitis A is an acute viral infection of the liver that is transmitted predominantly by the fecal-oral route. The disease is asymptomatic in 70% of children less than 6 years old and symptomatic in 70% of older children and adults. Symptoms, which include fever, anorexia, nausea, abdominal discomfort, dark urine, and jaundice, begin an average of 28-30 days after exposure (range, 15-50 days) and usually resolve within 2 to 4 weeks. The rare fatalities (<1/1,000 cases) usually are due to acute liver failure. The infection does not produce chronic liver disease or chronic infection, and infection confers lifelong immunity. Hepatitis A cannot be distinguished from other types of viral hepatitis by symptoms; diagnosis is by detection of IgM antibody in serum.

Hepatitis A is the most common form of acute viral hepatitis in the United States, and one of the 10 most commonly reported infectious diseases. An estimated 80,000 clinical cases and 134,000 infections occur annually. While mortality is low, morbidity is relatively high: approximately 11% of cases are hospitalized, and an ill adult loses an average of 12 to 27 days of work. In Florida, an average of 650 cases have been reported annually from 1993 to 1998, with the highest rates in children 5-9 years old and adults age 25 to 39.

The virus is shed in stool. Peak shedding, and peak infectivity, occur two weeks before the onset of jaundice or elevated liver enzymes and decline rapidly after symptom onset; most persons probably are noninfectious within a week after jaundice appears. Infection is acquired primarily by person-to-person contact, including sexual contact, or by ingestion of contaminated food or water. The most frequently reported source of infection (22%-26%) is either household or sexual contact with a case. In Florida, males who have sex with males have become an increasingly important risk group for hepatitis A. The proportion of reported hepatitis A cases occurring in males age 18-49 rose from 32.9% in 1988 to 52.6% in 1998; within that age group, the ratio of males to females increased from 1.3 to 1 in 1988 to 4.6 to 1 in 1998.

Young children also play a key role in transmission because they are usually asymptomatic, have poorer hygiene, and may shed the virus for longer periods than adults. Restaurant associated outbreaks, although relatively uncommon, can be responsible for large numbers of cases. Florida's largest hepatitis A outbreak (103 cases) occurred in 1986 among patrons of a floating restaurant and was traced to an infected employee who had been fired for poor hygiene. Transmission by transfusion is very rare because of the relatively short viremic phase.

Prevention of hepatitis A is based on proper handwashing, prophylaxis of close contacts to a case, and vaccination of high risk groups. Careful handwashing, with particular attention to fingernails and fingertips, should be done after using the toilet, changing a diaper, or handling an animal, and before eating or preparing food. Prophylaxis with immune globulin is recommended for household and sexual contacts of cases; for classroom contacts of children in day care centers; for all staff and attendees of day care centers that care for children in diapers; and for other food handlers in a facility where a case occurs in a food handler. Prophylaxis should be given as soon as possible after exposure (defined as the last contact with the case during the time of peak infectivity); it is ineffective if given more than two weeks after exposure. Vaccination is recommended for travelers to certain foreign countries, for children of migrant farm workers, for males who have sex with males, and for certain other high risk groups (1,2).

1. Centers for Disease Control and Prevention. 1998 guidelines for treatment of sexually transmitted disease. MMWR 1997;47 (RR-1):98-100.

2. Centers for Disease Control and Prevention. Prevention of hepatitis A through active or passive immunization. MMWR 1996;45 (RR-15).

3. Koff RS. Hepatitis A. Lancet 1998;241:1643-9.

4. Noskin GA. Prevention, diagnosis, and management of viral hepatitis: a guide for primary care physicians. Arch Fam Med 1995;4:923-34.

5. American Academy of Pediatrics. Prevention of hepatitis A infections. Pediatrics 1996;98:1207-15

6. American Academy of Pediatrics. Hepatitis A. In: Peter G, ed. 1997 Red Book: report of the Committee on Infectious Diseases. 24th ed.

Elk Grove Village, Il: American Academy of Pediatrics; 1997:237-46.

June 29, 1999 - Audioconference

11:00 AM – 12:00 PM EST

The Bureau of Epidemiology Grand Rounds for June will feature Elizabeth Rainhart, MSPH, Orange County Health Department; and Zuber Mulla, MSPH, RTT, Florida Department of Health. Ms. Rainhart will present "A Study of the Reported Malaria Cases in Florida from 1992 to 1998." This presentation will detail a study undertaken to improve statewide malaria prevention practices.

Mr. Mulla’s presentation will be in two parts: "International Travel History of Reported Hepatitis A Cases," discussing the demographics (age, race, ethnicity, gender), travel destination, and length of travel of Hepatitis A cases reported to our State Health Office (SHO) in 1998 and "Travel Medicine Survey" discussing the results of a survey recently administered to all Florida county health departments by the SHO.

Further details regarding the audioconference call and PowerPoint files are posted on the DOH network. Upcoming topics and presenters will also be posted in future Epi Updates.

Bureau of Epidemiology Grand Rounds

The Epidemiology Grand Rounds, a monthly, one-hour audioconference conducted by the Bureau of Epidemiology, focuses on issues of epidemiologic interest to Florida public health providers, including county health department directors and administrators, nursing directors and nurse epidemiologists, laboratorians, and other interested parties. Each session features a formal PowerPoint presentation followed by an opportunity for audience interaction. Presenters include representatives of the State Department of Health, county health departments, schools of public health and other experts in epidemiology and associated specialties. Richard Hopkins, M.D., MSPH, Florida’s State Epidemiologist, will coordinate the presentations. Assistance with PowerPoint can be provided.

1999 Audioconference Dates:

June 29, July 27, August 31, September 28, October 26, November 30, and December 28

• Never call in using a cellular telephone or cordless headset.
• Leave your telephone mute button "on" during the call except when asking questions.
• Do not put your phone on "hold."
• Dial-in on time.

The Office of Epidemiology at the Orange County Health Department received a referral on May 26, 1999, from the regional food and water borne disease epidemiologist in Orlando, of two people who had been reported as having a possible reaction to ingestion of a toxic substance. The origin of the report was from the Florida Poison Information Center Network. The complainants (2) were seen for immediate burning pain in their mouth and throat upon eating foods in a restaurant. They were seen at a clinic on May 25, 1999 and released by 1:30 PM the same day. Several unsuccessful attempts have been made to contact the named individuals.

Contact was made with the chief of Environmental Health at the agency where the incident occurred. The facility involved is one of many restaurants within their purview at a theme park in central Florida.

The complainants interviewed were among the earliest guests at the restaurant that day. Case 1 sat at a table and sprinkled what he thought was table salt on his noon meal. He experienced an immediate burning in his mouth and throat upon ingesting flank steak. He also noticed that the area on the steak where the ‘salt’ was sprinkled had been discolored. As he commented about the color change and burning sensation the female party member, case 2, wetted her finger, touched the top of the salt shaker and tasted the powder. Her reaction was immediate and identical to the man’s complaint. The chief chef of the restaurant, case 3, who was seated at the adjacent table, overheard their complaint. He visually inspected the meat and powder and then tasted the powder. He had the same immediate reaction of a burning mouth and throat as the guests. The onset of symptoms for all those exposed was one to three minutes after exposure.

The chef immediately notified management of the incident and those stricken were directed to a first aid office near the restaurant. The first aid office referred them to the clinic for observation and treatment, if necessary. Clinicians at first aid reported that the guests wished to resume their visit to the park. The guests reported to a clinic site later.

The salt shaker from the table was removed and held for further disposition. Upon closer visual inspection, it was determined that the powder did not appear to have the same visual qualities as the cuboid crystalline structure of sodium chloride, but did resemble a cleansing powder. The chef used the same shaker to test the color change on another cut of flank steak. The steak was discolored in the same manner, as was that of the served meal. All other salt shakers were removed from the tables and immediately emptied and cleaned in a commercial dishwasher. No other guests were stricken.

Table salt (NaCl) is purchased in bulk and decanted into a wine carafe at that facility for refilling table salt shakers. Often, cups are utilized to form a spout-like pouring device to ease the filling process. The company environmental health staff determined that a box of tea/coffee cleaner had gotten wet with most of the contents clumped. Some of the salvageable cleaning powder was poured off into a cup for later use and the box was discarded. The cup, without a content label, was placed near the table salt filling station for storage. Apparently a staff member picked up the cup of cleaner and filled the salt shakers, thinking the alkaline cleaning powder was salt. The shakers were then placed on patron tables for use.

A product packaged under the commercial name of Dip-it™ is commonly used throughout the property to remove stains and clean coffee and tea urns. This product looked just like the salt shaker contents and was assumed to be the contents of the shaker. Active ingredients listed on an intact box of the product are sodium carbonate, sodium perborate, sodium tripolyphosphate, sodium metasilicate and sodium sulfate. The MSDS information sheet on the product lists the pH as 11-12 at a 1% solution.

Instruction and training was given to kitchen staff on the filling procedures and especially the hazards of saving potentially toxic materials in an unlabeled food service container. The practice of attempting to salvage cleaning agents, or other potentially toxic agents, is now forbidden. Staff have been instructed to discard the entire container should a similar incident occur in the future.

"Healthy Animals" is a new online compilation of Agricultural Research Service [ARS] news and expert resources on the health and well-being of agricultural animals and fish.

"Updated quarterly, the new web site provides links to recent ARS research accomplishments involving the health of cattle, chickens, turkeys, swine, sheep, goats, horses, catfish and other aquaculture fish species as well as related research on deer and other wildlife."

"A distinguished public health official recently recounted his treatment at the hands of a group of frightened and angry citizens. The incident took place at a meeting held to inform the community about the suspected presence of a toxic chemical dump near their homes and to answer their questions…the audience, in the words of the writer:

In some quarters at least, when it comes to environmental issues, the health department appears to be viewed as the enemy of the people…Public health officials are no strangers to controversy. Progress in public health has never come easily and has often been marked by prolonged and bitter struggle. Health departments have faced many adversaries, ignorance and apathy, businessmen who put their profits above the general welfare, uncaring or corrupt politicians, even organized medicine itself. However, in their battles for better sanitation, decent housing, milk pasteurization, and maternal and child health services, health departments have generally enjoyed the support of citizen reform groups. To find themselves now labeled by environmental activists of the 1980’s as the enemy is a stunning reversal of history and a shattering blow to their self-perception as the champions of the public interest…

Why? Are environmental groups unfair? Have health departments betrayed their public trust? How can natural allies be at such odds? There is no simple answer. Blame cannot be laid solely on one side or the other. Underlying much of the problem is the public’s intolerance of ambiguity, their yearning for simple declarations. Unfortunately, complex environmental issues rarely admit of such certainty…

To a frightened and impatient public, health official’s punctilious concern about the thinness of scientific evidence and their disinclination to draw conclusions from insufficient data are easily mistaken for lack of resolve or abdication of the responsibility to act…

Sometimes we are our own worst enemies. Environmental problems are usually multi-agency problems, involving health, environmental, planning, and other regulatory agencies at local, state and federal levels. All too often, the public is treated to the unedifying spectacle of experts in conflict over different and contradictory standards, risk assessments, and risk management plans. These… may be explicable, even reasonable…but to the general public they look more like governmental ineptitude at best, or a plot to mislead and cover up the truth at worst…

The clamor over environmental issues is testing the public health official as never before. As a public servant, he must respond to the needs of the people and be sensitive to the political world with which he deals, and in which he must survive if he is to do any good, as physicians, engineer or scientist….To the virtues of patience, openness and humility recommended by Freudenberg, public health workers must also bring fortitude and an unwavering allegiance to the pursuit of truth and the rigorous application of the scientific method. They must somehow arise above the clamor, and demand the solid evidence on which sound public policy must be founded. They must somehow find the strength in the face of criticism and false accusations to continue to be the voices of reason and to help keep our health priorities straight."