Division of Disease Control and Health Protection

For July 23, 1999

Influenza season appears to have started already in Florida. The Bureau of Epidemiology has received reports of recent cases of influenza-like illness (ILI) in several Florida correctional facilities. Influenza A has also been isolated from two individuals: a 75-year old Clay County resident and a 37-year-old Alachua County resident with a history of recent travel to Alaska.

For the past two years, the Florida Department of Health has coordinated a voluntary influenza sentinel physicians surveillance network and is now recruiting volunteers for the 1999-2000 influenza surveillance season. The surveillance network is an integral part of our efforts to monitor and control the spread of influenza-like illnesses. The information collected will enable us to provide Floridians with accurate information regarding the occurrence of disease and circulating influenza strains. The CDC also uses the collected influenza virus isolates to determine what strains to include in future influenza vaccines. An effective surveillance program will monitor and help prevent the spread of more virulent epidemic or pandemic strains of influenza in Florida.

How can you assist? We are actively recruiting pediatricians and primary care physicians who, along with colleagues from other states, are willing to report clinical cases of ILI weekly to the CDC and to submit laboratory specimens to the state laboratories for virus isolation. The Department of Health regional epidemiologists will be contacting county health department directors and administrators soon to provide additional information about the program. Thank you in advance for your assistance with this important effort.

On July 4, 1999, all invasive Streptococcus pneumoniae infections became reportable. Infections caused by Streptococcus pneumoniae are among the leading causes of illness and death for young children. Annually, in the United States, pneumonococcal disease results in 50,000 cases of bacteremia and 3,000 cases of meningitis. By extrapolation, Florida should expect about 3750 cases of pneumococcal bacteremia and 225 cases of meningitis (121 cases were reported in 1996).

A critical issue in the management of infections caused by S. pneumoniae is the increasing drug resistance of the organism. Research in parts of the U.S. has demonstrated a growing resistance to penicillin and other commonly prescribed drugs. This drug resistance may have developed as a result of indiscriminate or inappropriate prescription or by natural mutation of the organism. Regardless, the extent (and type) of drug resistance to S. pneumoniae in a community offers critical information to physicians treating the disease. In addition to local surveillance, state data are summarized at the national level to provide valuable insights into drug resistance patterns for the country. The important surveillance issue for invasive Streptococcus pneumoniae is to monitor the percent of drug resistant organisms among all invasive S. pneumoniae organisms. In order to do so, it is necessary to collect reports of all invasive S. pneumoniae.

County health departments will report Streptococcus pneumoniae according to the following procedure:

Next week, the Bureau of Epidemiology will be mailing rule change information to 1200 clinical laboratories that provide testing services in Florida for notifiable diseases and conditions. Our goal is to improve adherence to the laboratory reporting requirements and to improve the quality of our collected data. We have included the laboratory letter and the accompanying enclosures (rule excerpt, Reportable Lab Findings document, and updated list of notifiable diseases and conditions) in this Epi Update. We would like to thank Jodi Baldy for the time she spent developing the Reportable Lab Findings document and for her assistance with the rule revision process.

"The Florida Department of Health clearly recognizes the key role of the state’s clinical laboratories in disease prevention. Virtually all reports of communicable and infectious disease result from the follow-up of positive laboratory results. With growing threats to the public’s health such as emerging infections, antibiotic resistance and bio-terrorism, the complete and timely reporting of laboratory information is critical.

Over the past year, The Department of Health has managed the formal process for the revision of Chapter 64D-3, Florida Administrative Code, Control of Communicable Diseases and Conditions Which May Significantly Affect Public Health. That process offered several opportunities for comment and input from both public health and private sectors. The revisions became effective on July 5, 1999. Revisions to Section 64D-3.003 "Notification by Laboratories," are outlined in the enclosed documents: (1) 64D-3.003, Notification by Laboratories, and (2) Reportable Laboratory Findings (July 1, 1999). Please note the additions and deletions to the reportable disease list. For easy reference, a summary of the new requirements is listed below:

• The state health office shall publish, at least annually, a list of laboratory results that are reportable (Reportable Laboratory Findings).
• Laboratories are now required to provide the following information on reports sent to the state:

• Name, address, and telephone number of processing laboratory, and
• Diagnostic test performed, specimen type, and result

• Address, telephone number, race, sex and ethnicity of the patient, or
• Name, address, and telephone number of the submitting physician or health care provider

• Special Requirements

Special Note: During the coming months, the Surveillance Section in the Bureau of Epidemiology will be initiating a project to examine the feasibility and methods for the electronic reporting (to the Department of Health) of laboratory information. Laboratories interested in working with the Surveillance Section on electronic reporting or for answers to questions regarding requirements of the revised rule.

Laboratories are an important component of our state disease surveillance system. We continue to appreciate your efforts on behalf of disease control. "

The following information was excerpted from a memorandum sent to arbovirus surveillance participants on July 2, 1999:

There were a total of 5 seroconversions to Eastern Equine Encephalitis virus (EEE) during June in Bay, Flagler, Orange and Osceola counties. This is well below the average for June, but is similar to the level seen in 1998 and 1988-1990.

There were no seroconversions to St Louis Encephalitis virus (SLE) during June."

This is the time of year in Florida when many of us feel like we will die from the heat. Unfortunately, a few people each year do die from heat related causes. The table below was compiled from Vital Statistics death records and shows the number of heat related deaths by month and year for the years 1993 through 1998. In this table, heat related deaths are those with a cause of death code (ICD-9-CM code) of E900.0 through E900.9. The title for code E900 is "Excessive Heat" and includes excessive heat due to weather conditions, excessive heat from man made origins (e.g. a boiler room), and unspecified origin.

Careful analysis of this table reveals that most heat related deaths occur in the summer months. For the entire 6-year period, the month with the most deaths is June with 21 followed by July with 17. May and August both have 7 across the 6 years. It is worth noting that in some years June is the worst month and in other years July has the most deaths. In 1993 August was the month with the most heat-related deaths.

In addition to the heat-related deaths, there are a few deaths each year where the cause of death is not directly related to heat but there are contributing causes that are heat related. The second table below summarizes these deaths by year and month. These deaths have a wide variety of causes but there are only 2 causes that occur in more than 2 deaths. These are Acute Myocardial Infarction with 3 deaths and overexertion and strenuous movements with 4 deaths.

In the last table, the deaths are summarized by age and sex. Males tend to die of heat-related causes more than females and these deaths occur across all ages. This is about all that can be said in this regard because the numbers are too small to compute and statistically analyze rates by sex and age.

* Deaths with the underlying cause of death coded as ICD-9 E900.0 through E900.9

* Deaths where the underlying cause is not ICD9 code E900.0 through E900.9 but these codes are listed as a contributing cause, or ICD9 code 992.0 through 992.9 are listed as a contributing cause.

Data Source: Florida vital Statistics

Table made by: Bureau of Epidemiology 6/23/99

Session 5 - "Hepatitis A in Orange County - A Florida Embedded Food-borne Outbreak"

July 27, 1999 - Audio-conference

11:00 AM – 12:00 PM EST

Bill L. Toth, MPH, Health Services Manager, Orange County Health Department, will present "Hepatitis A in Orange County - A Florida Embedded Food-borne Outbreak." This presentation will describe the emergence of Hepatitis A in Orange County Florida, especially in men who have sex with men (MSM). A food-borne outbreak among cruise line booking employees will also be described. Follow-up intervention strategies and outreach methods are discussed, including passive immunizations with globulin and permanent immunizations with a vaccine.

The Childhood Lead Poisoning Surveillance Program (Bureau of Environmental Epidemiology), with funding from the Centers for Disease Control and Prevention, is offering a teleconference on September 17, 1999, entitled "Childhood Lead Poisoning: Research Practice and Prevention." The teleconference agenda is attached. Additional information can be obtained on the internet at: http://www.doh.state.fl.us/.

For local participants, the event will be aired at the Winewood complex, building 6, room 407. We anticipate that most county health departments will participate as sites. Those county health department employees and other interested parties outside the department are encouraged to contact the satellite site coordinators at their local or nearest county health department for availability. Three continuing education credits will be offered through the Department of Health for environmental health professionals. Pending approval, continuing education credits will be offered for nurses.

Notice of Error:

• In last week's issue (July 15, 1999), there was an error in the first article entitled Dade County Influenza-like Illness Outbreak in a Correctional Facility. The article incorrectly cited the influenza strain as H2N2. The correct strain is H3N2.

Epi Update Editor Change:

• Natalie Tackett has done a wonderful job editing the Epi Update. We wish her well as she transitions to her new position within the Bureau of Epidemiology! Please send future Epi Update submissions to Jill Parker, who will assume Epi Update editing responsibilities.

"This is just a message from a 'misplaced' county health officer who no longer has the joy of heading an intensive program in one of Florida’s choice counties, but one who has bit off a huge 'bite' which may choke him to death. Let’s hope not!"

"You can do as much or more to prevent my choking by continuing to carry on your fine intensive county programs if you stay put until you and your programs are sold. And ‘selling your program’ also means that at the same time you must sell yourself. You and your program are one entity."

"You are pioneering in your county’s health work and because of the need as well as increasing public demand you will experience a very great expansion in the establishment of correct county health programs in Florida in a very few years. Threatening war or even war itself does not lessen the necessity for health programs at home. On the contrary, war, or the preparation for war will greatly increase the demands on our health programs."

"The county you are now serving has shown, by appropriating the hard cash, that they need and appreciate you and your staff. The State Board of Health and allied agencies, state and federal, need and want you and your program to get results but please do not become discouraged if you cannot show great results after one or even two years of diligent effort and hard work. By the end of the third year the results will begin to show for themselves in the form of lower morbidity and mortality rates."

"It is a mistake for any health officer to leave any county until he has successfully served a minimum of three years in his original county. A change of directors or other personnel, who are doing good work where located, may upset the "apple cart" before the benefits of the programs have a chance to become self evident."

"There is no reason why promotion cannot take place as a result of work in one county as well as in any other. After all, we first of all want to render the greatest service possible where it is needed most and certainly many of our more or less rural counties fill this order exactly."

"Haemophilus influenzae, invasive" and under "Encephalitis, post infectious." Cases of Haemophilus influenzae meningitis are reported under "Meningitis, H. influenzae."