Division of Disease Control and Health Protection

For July 1, 1999

After publishing the new case definitions and related materials in the last Epi Update, we received several questions and requests for clarification. The following should resolve some of the inconsistencies, errors and lack of clarity:

Case Definitions.

1. Attached is a replacement (pestrev99.doc) for pages 28 and 29, the Pesticide-Related Illness definition. Changes made were in the matrix, "probable case" category, 2^nd column – exposure should be 2, health effects, 1 and causal relationship, 1. The "Comment" section was amended, deleting references to the national centers and telephone numbers.
2. Attached is a replacement for page 39 (replc39.doc). The ICD Code for Trichinosis is 12400, not 13090 as originally printed in the document.

Listeria. Cases of listeriosis are to be reported on the National Bacterial Meningitis and Bacteremia Case Report form (CDC 52.15). Listeria meningitis will continue to be reported as ICD Code 32070 and other forms of listeriosis will be reported as ICD Code 02700.

Disease List. Attached (List99.doc and List2-99.doc) are two lists of the notifiable diseases that may be reproduced and sent to providers. Please note that certain diseases are annotated with a (T) to indicate the need for telephone reporting. The "new Ts" are: hepatitis A; listeriosis; meningococcal meningitis; smallpox, tularemia, and "outbreaks."

Lab Findings List. Recent rule revisions included considerable changes for laboratory reporting responsibilities. The DOH has the responsibility of furnishing a list of "reportable laboratory findings" to be used by laboratories in determining which results are diagnostic for the notifiable diseases and conditions. This list (rptblablist.doc ) is as comprehensive as possible, but may not include all tests indicative of notifiables; it will be updated periodically, as changes in technology and reporting criteria warrant.

Congenital Anomalies (Birth Defects). Congenital anomalies diagnosed by one year of age during an inpatient hospitalization may be reported by hospitals to the Agency for Health Care Administration (ACHA) as part of the hospital discharge data submission. No additional reporting is required. Diagnoses during an inpatient hospitalization that are not reported to ACHA must be reported by the hospital directly to the Birth Defects Registry. This may include stillbirths that occur to inpatients, and any other eligible diagnosis that is not reported to ACHA, who only accepts the top ten diagnoses for any patient.

In addition, physicians are responsible for reporting eligible cases when the diagnosis is made in an outpatient or ambulatory setting. These reports go directly to the Birth Defects Registry using the same form as hospitals. If the patient was ever hospitalized for the condition or the condition was reported at birth, then the physician does not have to make a new report. However, reporting is mandatory for a new diagnosis, a condition not diagnosed at birth, or a stillbirth in an outpatient or ambulatory setting. The reporting requirement applies to births and fetal deaths in Florida (starting July 4, 1999). Detailed instructions and forms will be mailed to hospitals, selected physicians, and county health departments in July through the Births Defects Surveillance section. For questions concerning the Birth Defects Registry or reporting of congenital anomalies, contact Russ Mardon, PhD, Bureau of Environmental Epidemiology at (850) 488-3370.

Rule Revisions. Attached are the rule revisions (rul98finadop.doc) as submitted for final adoption. The Bureau of Administrative Code’s revisions will not be available for some time so this document will give you access to the important changes.

Date: Wed, 30 Jun 1999 11:23:31 +0200

"One month after a crisis broke out over dioxin contamination in Belgian food and livestock feed, it is still not known exactly what toxins were present, how much was there, how much food was contaminated, and where it went. A government has fallen over the issue, but little science is being done, and government regulators in countries that have banned Belgian food imports are wondering if and when they can lift the bans. This is an update on the event. I am writing in a personal capacity. My views do not necessarily express those of the publications for which I work.

"To recap what we know: about 8 litres of used PCB, probably from a transformer, ended up in an 80 tonne batch of recycled fats subsequently used to make animal feed, mainly for chickens, in mid-January 1999. It was sold as recycled animal fat, but contained vegetable oil too. There has been talk of motor oil but that is probably a confusion.

"One theory of how this happened involves public recycling depots for used frying fat, which also have containers for used motor oil. PCBs shouldn't have been in either. But it is possible that someone heading for the motor oil bin trying to quietly dispose of transformer oil instead dumped it in the used food oil. Other theories are that the PCBs were dumped deliberately or accidentally by a waste dealer; or that a heat transfer pipe using PCBs as the circulating fluid leaked, as in the Yusho incident in Japan [1968] and the Yu Cheng incident in Taiwan.

"Belgium is currently investigating several recycling companies other than their initial suspects. In February 1999 chicken farmers noticed that some laying hens were sick and dead, some chicks were failing to hatch, and some that did hatch had "neurological symptoms", probably impaired movement. One of the PCDFs in the mix was one for which the toxicity in birds is very high, as per the re-evaluation of relative congener toxicity done in 1998 by Martin Van den Berg et al, Env Health Perspectives, v106 pp 775-790, Dec 1998.

"It is possible that we would never have found out about this incident were that not the case. If the fat had been fed to cows, there would probably have been no symptoms, and in any EU country but Germany, which actively monitors milk for dioxins, the event might not have been detected for months. The Belgian farmers went to their feed companies, the feed companies called their insurance people, they called in a veterinary inspector, and he looked for everything, mainly nutrient deficiencies. Then in April 1999 he wondered if it might be dioxins -- a lucky stroke of insight as dioxins are usually suspected only in grazing animals exposed to incinerator deposits. He sent a sample of feed, and a dead laying hen, to RIKILT-DLO, the Dutch national lab for food quality in Wageningen, the Netherlands, choosing them partly because VITO in Mol, the only lab in Belgium accredited for dioxin analysis, specialises in milk.

"Toxicity for mixtures of dioxins and dioxin-like compounds, is expressed as toxic equivalency, or TEQ, a figure arrived at by multiplying the concentration of each congener present by its

known relative toxicity. RIKILT found 958 TEQ pg/g fat PCDDs and PCDFs (mostly the latter) in the chicken, and 781 ng TEQ per g of feed. The pattern of congeners resembled the Yusho incident in 1968 in Japan, especially the PCDFs, so RIKILT concluded that the origin was PCB contamination, and calculated the ratio of PCB to fat on this basis. PCBs have now been confirmed by direct measurement. These are the only numbers available for feed contamination, apart from the PCBs noted below. The feed companies told the government in late April 1999. It asked for another analysis. RIKILT tested 2 eggs, intended for hatching, and a laying hen. The eggs tested at 713 and 266 pg/g fat TEQ, the chicken 741 pg/g fat TEQ. Another 10 chicks were also tested and were contaminated -- levels have not been released.

They were probably collected in April 1999, but the scientists who tested them aren't sure.

"On 26 May 1999 Belgium informed its neighbours and the European Commission as required by law. The Commission is launching court action over the delay. Belgium pulled chickens and eggs off the market, then products made with eggs. Then they found cows and pigs had got the feed so they pulled beef and pork, and stopped exporting milk on order of the Commission though it was still sold in Belgium. They took Belgian butter off the market, though some report finding it in supermarkets. Indeed much depended on the cooperation of retailers -- I saw egg waffles on snack shelves in small shops which certainly were not removed during the crisis. Bins were set up for people to dump banned food, but many people did not use them, and at least some of what was dumped was spirited away.

"The government tried to determine what feed companies bought the fat, what farms bought their feed, and what farms didn't and could therefore be exonerated so as to get food back on the market. This was in the middle of a federal election campaign. The government defeat on 13 June 1999 was widely attributed to anger over the delay in informing the public about the dioxin contamination.

"The numbers cited above are the only measurements of dioxins in chickens from the period of probable maximum contamination of which I or anyone I have talked to is aware. Analyses now being done intensively at laboratories throughout Belgium and the region are aimed at making sure food available now is clean. RIKILT has found no evidence of contamination in any recent Dutch or Belgian food. No other data has been released.

"As PCBs cost less to analyse than dioxins, and this can be done by many laboratories in Belgium, the Belgian government has commissioned extensive PCB analyses on recent food. It is not being analysed quantitatively for total PCBs, but for a standard set of seven congeners being used as a marker for this incident. We don't know how much toxicity in food contaminated by the incident can be attributed to PCBs as no one has yet done a full congener analysis -- and the 7 standard congeners are not the co-planardioxin-like types for which we have toxic equivalency factors from which TEQ is calculated.

"The 80 tonnes of fat thought to be behind all this was enough to make 1600 tonnes, or 10 million chicken-days, of feed. It is not clear whether the authorities have been attempting to account for all 80 tonnes of the fat in the records of the feed companies, or all 1600 tonnes of feed that could have been made from it. Sales records are not enough to trace the contamination, because of a widespread practice of making sales without paperwork.

"Is this incident over? Everyone I have talked to says this was a one-off, that one 80 tonne contaminated batch of fats was the problem, and it has probably been eaten. Probably the contamination has already gone through the food chain insofar as it affected chickens, which have a fast turnover rate.

"But some of the contamination fed to cows and hogs may still be there and may not have gone through humans yet. No data have been released as to whether there have been any elevated levels of PCBs or dioxins found in meat, apart from general statements that meat produced recently is clean. There have been no elevated levels in recent milk, beyond Europe's usual background, which could be due to batch dilution.

"Meanwhile Austria, moved to do some analyses by this incident, found dioxin in some domestically produced pig feed. Levels were much lower than in Belgium, and the feed has been impounded.

Dioxins are given as 2 - 6 pg TEQ per g of feed, much less than the few values reported for Belgium. I do not know if the Austrians have done any pork analyses.

"There are plans for health surveys in Belgium to follow up this incident, but these will be of little use without data on the extent and nature of the contamination. A breast milk survey might be informative, but there would be 'noise' problems -- levels in western Europe are already high -- and unless the high levels of some PCDFs can be taken as a signature, it would be impossible to say whether any observed increases in dioxins or PCBs were caused by this incident. This is especially true as this is not the first time Europe has been affected by dioxins in feed. Dioxin-laced citrus pulp was discovered in 1997 to be affecting milk cattle. As in the US episode concentrations were lower than the few we know about from Belgium, but affected a larger area for a longer time. Some details of this are in the New Scientist article cited above. "

Debora MacKenzie, Europe correspondent

Florida counties currently address the problem of epizootic raccoon rabies through prevention measures including public education, enforcement of pet vaccination ordinances and animal control. In general, any unusual increase in the number of rabid animals elicits the declaration of a rabies alert by the county health director. Rabies alerts serve to inform the community to reduce their risk of exposure to potentially rabid animals. Alerts should be evaluated and removed after rabies activity has decreased. A sixty-day period is a general guideline for this in practice. An updated "Rabies Alert Map" will be maintained on the Department of Health website at http://www.doh.state.fl.us (click on "Epidemiology" and "Vector-Borne Diseases").

Date: June 25, 1999

From: Foodborne and Diarrheal Diseases Branch

Subject: Salmonella Muenchen infections associated with consumption of orange juice

To: State and Territorial Epidemiologists

"This message is being sent by e-mail and FAX to inform you about a recent cluster of cases of Salmonella Muenchen infections in Washington State and Oregon linked to the consumption of drinks containing "fresh-squeezed," unpasteurized orange juice traced to a single distributor, which distributes orange juice widely in the United States.

"On June 19, 1999, the Washington Department of Health received notice of three cases of Salmonella group C-2 infection. An ongoing investigation has determined that nine unrelated persons in the Seattle area became ill with Salmonella group C-2 infection in June; three isolates have been serotyped as Muenchen. The ill persons range in age from 2 to 85 years. Complete food histories were obtained from seven persons; all consumed a fruit smoothie drink from an outlet of Chain A between June 12 and June 16. Ill persons patronized four different Chain A outlets, which has around 10-12 outlets in Washington and several in the San Francisco Bay area. All but one of the smoothies contained "fresh squeezed," unpasteurized orange juice, which is usually delivered twice a week from Company B in Arizona; the other smoothie was mixed in the same machine used to make the orange-juice-containing smoothies. Company B is thought to distribute orange juice to many states mostly in the western United States. A label from one of the orange juice containers lists Arizona, California, Florida and Mexico as the source of the oranges.

"On June 23, the Oregon Health Division identified a cluster of diarrheal illness among persons who consumed a restaurant buffet-style meal on June13. A stool culture from one person yielded S. Muenchen. Ten of the 13 participants were interviewed; all four ill persons, but none of the six well persons, consumed orange juice (p=0.005). The orange juice came from Company B. Orange juice from Company B is available in at least one retail store in the Portland, Oregon, area.

"S. Muenchen is an uncommonly isolated serotype; Washington typically isolates 10 or fewer per year and Oregon 6 or fewer per year. State health departments who identify persons with S. Muenchen or serogroup C-2 infections beginning June 1, 1999 might wish to interview patients about consumption of orange juice. Attached is a standard questionnaire to assure that information from many sites is collected in a similar manner. Please continue to update your PHLIS Salmonella reporting weekly so that the extent of the increase in S. Muenchen can be monitored in your state and at the national level. Although any S. Muenchen isolated in June, especially from a person in a western state, should be considered suspect as being part of this outbreak, states might wish to refer some suspect isolates for PFGE with the standardized PulseNet protocol by an area laboratory or to CDC."

"It is universal custom in every household to thoroughly wash and dry dishes and ware after meals; only cleaned dry dishes are tolerated on the table. This washing process most always consists of a SOAP AND HOT WATER washing, a scalding and finally a cloth drying. Some homes may not follow this schedule exactly, but generally speaking it represents pretty much the average practice. HOW MANY PEOPLE ACCUSTOMED TO THIS USUAL HOME PROCEDURE WOULD TOLERATE A CHANGE TO THE SLOVENLY, FILTHY METHODS USED AT NINE TENTHS OF THE DRINK STANDS AND FOUNTAINS – THE MERE DIPPING OR RINSING OF THE GLASS OR DISH IN COLD - NONE TOO CLEAN WATER?…