|
 EPI UPDATE
A weekly publication by the Bureau of Epidemiology
For September 27, 1999
"The reason for collecting, analyzing and disseminating information
on a disease is to control that disease. Collection and analysis should not be allowed to
consume resources if action does not follow."
--Foege WH et al. Int. J of Epidemiology 1976; 5:29-37.
Richard S. Hopkins, MD, MSPH, Bureau Chief, State Epidemiologist
Don Ward, Surveillance Section Administrator, Epi Update Managing Editor
Jill H. Parker, MSP, Epi Update Editor
Bureau of Epidemiology Frequent Contributors:
Steven
Wiersma, MD, MPH,
Deputy State Epidemiologist |
William
J. Bigler, PhD, MS,
Senior Epidemiologist |
Jodi
Baldy, MPH,
Biological Scientist IV |
Ursula
E. Bauer, PhD,
Chronic Disease Epidemiologist |
John
Werth, MA,
Bureau Education Coordinator |
Lisa
Conti, DVM, MPH,
State Public Health Veterinarian |
Regional Epidemiologists:
Dolly Katz,
PhD, MPH,
SE Florida |
Roger
Sanderson, RN, MA,
SW Florida |
Carina Blackmore, MS Vet. Med.,
PhD, NE Florida Carina Blackmore, MS Vet. Med., PhD, |
Zuber Mulla, MSPH, Central
Florida Carina Blackmore, MS Vet. Med., PhD, |
Gérard Krause,
MD, DTMH,
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.
The Department of Health has a home on the World Wide Web at http://www.doh.state.fl.us
In this issue:
1. More than $1 Million Awarded to Florida Department of Health for
Bioterrorism Preparedness and Response
2. Eastern Equine Encephalitis (EEE) Update
3. New Antibiotic Approved by the FDA
4. CDC Guidance Letter for Use of Hepatitis B Vaccine that Does Not
Contain Thimerosal as a Preservative
5. Educational Opportunities
6. Internet Resources for Public Health Professionals
7. Editor's Corner
8. Weekly Disease Table: Week 37
1. More than $1 Million Awarded to Florida Department of Health for
Bioterrorism Preparedness and Response
Don Ward, Surveillance Section Administrator
On September 15, the Centers for Disease Control and Prevention announced awards
totaling $40 million to assist states and major cities in the development of bioterrorism
prevention programs. Florida received $1,063,621 of those funds. In describing the
bioterrorism grants program, CDC’s director, Dr. Jeffery Koplan stated," Every
dollar we spend on preparing public health locally for even the possibility of a
biological or chemical release among their civilian population is also a dollar that helps
reinvigorate our public health infrastructure. The medical expertise, laboratories, and
communication network needed to counter bioterrorism are the same resources that are
needed to detect disease in the community from any source, whether natural or
deliberate."
Florida competed successfully in three major categories:
- Epidemiology and Surveillance—Resources will be used to both enhance the existing
communicable diseases surveillance and information dissemination systems and develop
innovative surveillance systems that would assure the early identify possible bioterrorist
events.
- Laboratory Capacity for Biologic Agents—Funds for laboratory support will be
directed to enhancing the state laboratories’ capacity to rapidly identify biologic
agents which may be used by bioterrorists, including anthrax, botulism, plague, smallpox
and others.
- Health Alert Network—One of the critical elements in the prevention or control of a
bioterrorist event is the ability for public health officials and their colleagues to
communicate in real time over a secure network. The development of this network is a high
priority for both the CDC and the Florida DOH. More than 90% of the resources dedicated to
this strategy are earmarked to ensure that county health departments are included in the
health alert network.
Florida’s receipt of this award reflects the considerable efforts of a large
number of dedicated staff members from throughout the department. The competition for the
grant award may well mark the easiest part of the challenge which is to develop and
implement a comprehensive, coordinated bioterrorism preparedness and response plan
involving the 67 county health departments, numerous other local, state and federal
agencies, and the private medical and laboratory communities. We wish us well.
2. Eastern Equine Encephalitis (EEE) Update
Lisa Conti, DVM, MPH, State Public Health Veterinarian
Florida reports a second confirmed Eastern Equine Encephalitis (EEE) case for 1999.
This person is a Santa Rosa County resident. Walton County reported the first case of EEE
earlier this month.
An updated map entitled "EEE in Horses by Owner's County of Residence and Month of
Report, January through September 21, 1999 is attached. The map will also be posted to the
Bureau of Epidemiology web page at the DOH internet web site (http://www.doh.state.fl.us).
Note: One horse in Liberty County was reported by the Department of Agriculture and
Consumer Services to have antibodies to EEE. This is the first such horse in that county.
EEE
in Horses by Owner's County of Residence and Month of Report
3. New Antibiotic Approved by the FDA
(The following article appeared in a ProMed posting (serial online), September 21,1999)
FDA today approved Synercid, the first antibacterial drug to treat infections
associated with vancomycin-resistant _Enterococcus faecium_ bacteremia (VREF) when no
alternative treatment is available. Synercid also received approval for complicated skin
and skin structure infections. The following may be used to respond to questions.
Infections due to _E. faecium_ are particularly known to occur in hospitalized or
immunocompromised individuals. This organism is often resistant to multiple antibiotics.
Vancomycin has, for many years, served as the last resort for treatment of these
infections. In 1989 the first case of vancomycin-resistant _E. faecium_ (VREF) was
reported in this country. Since then, there has been a rapid increase in the incidence of
VREF.
Synercid, a combination of quinupristin and dalfopristin, is the first drug in the
streptogramin class approved for use in humans in the United States. The drug has been
granted accelerated approval, a regulatory mechanism that allows early approval for
products intended to treat serious or life- threatening conditions when they provide
meaningful therapeutic benefit over existing treatments. Accelerated approval is based on
surrogate markers of effectiveness, in this case, the drugs' ability to clear VREF
infection from the bloodstream. A study to verify the clinical benefit (e.g., resolution
of the specific site of infection) of therapy with Synercid is underway.
Synercid's approval was supported by clinical trials of more than 2000 patients; 1222
patients were treated with Synercid in four non-comparative studies for treatment of VREF
infections. In general, these patients were severely ill, making many of them unable to be
fully evaluated for purposes of the clinical trials. For those who were able to be
evaluated, based on strict study criteria, the overall effectiveness rate of Synercid was
52 percent. Sources of VREF infection included intra-abdominal sites, skin, soft tissue
and the urinary tract. Additionally 330 of the enrolled VREF patients (out of the original
1222) had VREF bacteremia of unknown origin. For this subgroup, 90 percent had clearance
of VREF in the first 48 to 72 hours of starting therapy.
Synercid was also found to be safe and effective for treatment of skin and soft tissue
infections caused by methicillin-susceptible _Staphylcoccus aureus_ (MSSA) and by
_Streptococcus pyogenes_ in two controlled clinical trials. In these studies 450 patients
enrolled in the Synercid arms were compared with 443 patients treated with antibacterial
drugs oxacillin or cefazolin.
The most frequently reported side effects attributed to Synercid in the clinical
studies were muscle and joint pain, nausea, diarrhea, vomiting and rash. In studies in
which the drug was administered through a peripheral vein (e.g., in the arm) many patients
experienced local reactions to the injection, including pain and inflammation at the
catheter injection site.
FDA's approval follows the recommendations of the Anti-Infective Drugs Advisory
Committee. Their recommendation for the approval of the VREF indication was based, in
addition to the results of the clinical studies, on the lack of availability of approved
drugs for the treatment of this resistant infection which may be serious and
life-threatening.
Rhone-Poulenc Rorer, a French company with US headquarters in Collegeville, Pa., will
market Synercid in the United States.
4. CDC Guidance Letter for Use of Hepatitis B Vaccine that Does Not
Contain Thimerosal as a Preservative
(The following information appeared in IAC Express #112 (serial online), September 21,
1999, published by the Immunization Action Coalition.)
The letter provides updated guidance and recommendations regarding hepatitis B
vaccination policies in response to the recent approval by the Food and Drug
Administration (FDA) of a hepatitis B vaccine that does not contain thimerosal as a
preservative.
Dear Colleague:
The purpose of this letter is to inform you about the recent approval by the Food and
Drug Administration (FDA) of a hepatitis B vaccine that does not contain thimerosal as a
preservative, and to provide updated guidance and recommendations regarding hepatitis B
vaccination. As public health professionals and health care providers, you continue to
play a critical role in assuring that the transition to vaccines that do not contain
thimerosal as a preservative takes place as expeditiously as possible, while at the same
time ensuring maintenance of high vaccination coverage levels and prevention of disease.
On July 8, 1999, the American Academy of Pediatrics (AAP) and the U.S. Public Health
Service (PHS) released a joint statement regarding thimerosal in vaccines and a comparable
statement was released by the American Academy of Family Physicians (AAFP). Both
statements provided specific recommendations related to hepatitis B vaccination,
encouraging continued administration of a birth dose of the currently available thimerosal
preservative-containing vaccine to infants at high risk for perinatal and early childhood
hepatitis B virus (HBV) transmission, with flexibility to delay the first dose of vaccine
until 2-6 months of age for infants born to hepatitis B surface antigen (HBsAg) negative
mothers. Results of a recent survey conducted by state and territorial health department
hepatitis coordinators, however, indicated that a large number of hospitals discontinued
routine vaccination of infants at birth, regardless of the HBsAg status of the mother.
Anecdotal reports were received by the Centers for Disease Control and Prevention (CDC)
that some infants were not vaccinated at birth even when their mother's status was
documented as HBsAg positive.
On August 27, 1999, Merck Vaccine Division received approval of a supplement to its
license from the FDA to include manufacture of a single-antigen hepatitis B vaccine that
does not contain thimerosal as a preservative (Recombivax HB, Pediatric). This vaccine is
expected to be available for purchase on the private retail market beginning September 13,
1999. A federal contract for purchase of this vaccine with public funds provided through
the Vaccines for Children (VFC) 317 grant, and State/local programs is expected in late
September, 1999. In both the public and private health care sectors, the initial supply of
this product will be limited.
Appropriate vaccine management will require prioritization for usage and close
monitoring of vaccine orders and distribution. Distribution of hepatitis B vaccine that
does not contain thimerosal as a preservative to birthing hospitals, or other settings
where babies are delivered, should be of highest priority.
Increased supplies are expected as similar products from other vaccine manufacturers
are licensed. An application for a single-antigen hepatitis B vaccine that does not
contain thimerosal as a preservative (Engerix-B Pediatric) has been submitted by
SmithKline Beecham Biologicals (SKB) and is currently under review by the FDA.
During this transition period when both thimerosal preservative-containing hepatitis B
vaccines and hepatitis B vaccines that do not contain thimerosal as a preservative remain
available, the following guidelines should be used to assure prevention of perinatal and
early childhood HBV transmission and to prevent shortages of single-antigen hepatitis B
vaccines that do not contain thimerosal as a preservative.
1. Newborn infants.
Priority must be given to using single-antigen hepatitis B vaccine that does not
contain thimerosal as a preservative for the routine vaccination of newborns, especially
in the hospital setting. Routine hepatitis B vaccination policies for all newborns should
be reintroduced immediately in hospitals in which these policies and practices were
discontinued. In addition, opportunities to initiate hepatitis B vaccination at birth in
all other hospitals should be considered.
2. Infants aged less than 6 months.
When available, hepatitis B vaccines that do not contain thimerosal as a preservative
should be used for vaccination of infants less than 6 months of age (single-antigen
hepatitis B vaccine for infants aged less than 6 weeks and either single antigen or
combination products for infants aged greater than or equal to 6 weeks). Infants in groups
at high risk for perinatal and early childhood HBV infections should complete the
three-dose hepatitis B vaccine series by age 6 months. When vaccines that do not contain
thimerosal as a preservative are not available for vaccination of infants at high risk of
perinatal and early childhood infection, these infants should be vaccinated with
thimerosal preservative-containing hepatitis B vaccines. For infants born to
HBsAg-negative mothers and who are not in high-risk groups, existing recommendations
should be used for administering thimerosal preservative-containing hepatitis B vaccines
if vaccine that does not contain thimerosal as a preservative is not available (see
Internet links to the MMWR "Notice to Readers" that follow this letter). These
groups should complete the three-dose hepatitis B vaccine series by age 18 months.
3. Children aged greater than or equal to 6 months.
Thimerosal preservative-containing hepatitis B vaccines should continue to be used for
vaccination of older children (greater than or equal to 6 months of age), adolescents and
adults as is currently recommended.
State and local immunization program staff should alert medical facilities to review
their policies to assure the vaccination of newborns as recommended by the Advisory
Committee on Immunization Practices, AAFP, and AAP.
Strategies to prioritize distribution of the hepatitis B vaccine that does not contain
thimerosal as a preservative to birthing hospitals and then to providers for
administration to infants less than 6 months of age should be communicated to birthing
hospitals or other settings where babies are delivered and all public and private
VFC-enrolled providers. Systems to closely monitor orders and target distribution of this
vaccine should be established and enforced by the State or project area.
For more information, please reference the "Notice to Readers" in the
Morbidity and Mortality Weekly Report, September 10, 1999, Vol. 48/No. 35 (see Internet
links that follow this letter below).
We appreciate your efforts to communicate this information to hospitals and providers
and prioritize and place limitations on the initial supplies of the hepatitis B
(Pediatric) vaccine that does not contain thimerosal as a preservative and your
recognition that other products are fully acceptable depending on the age of the vaccinee.
Please direct any questions regarding this matter to the Hepatitis Branch, National
Center for Infectious Diseases, (404) 639-3048, VFC Program Consultant at (404) 639-8222
or Immunization Program Consultant at (404) 639-8215.
Sincerely,
Walter A. Orenstein, M.D.
Director
Assistant Surgeon General
National Immunization Program
For more information on hepatitis B vaccine that does not contain thimerosal as a
preservative, please refer to the phone numbers provided in the last paragraph of the
letter above.
To read the text version of the "Notice to Readers" entitled
"Availability of Hepatitis B Vaccine That Does Not Contain Thimerosal as a
Preservative" which appeared in the September 10, 1999, issue of the MMWR.
5. Educational Opportunities
Epidemiology Grand Rounds for September 28, 1999
Topic: Florida Prostate Cancer Incidence and Mortality Analyzed by
Race and Age
Presenter: Daniel R. Thompson, MPH, Bureau of Epidemiology,
Florida Department of Health
Time: 11:00 AM - 12:00 PM EST
- Teleconference Announcement: "Communicating with Parents: Best Practices in
Childhood Immunization"
(The following information appeared in IAC Express #111 (serial online), September
17, 1999, published by the Immunization Action Coalition.)
This live teleconference entitled "Communicating with Parents: Best Practices in
Childhood Immunization" will provide information about changes made to the 1999
Recommended Childhood Immunization Schedule and ways to effectively communicate this
information to parents. The teleconference is scheduled at various times and dates
throughout the end of September and the month of October.
Sponsored by Montefiore Medical Center's CME teleconference series, the teleconference
is a 30-minute live forum presented by William L. Atkinson, MD, MPH, and Sharon G.
Humiston, MD, MPH, medical epidemiologists at the National Immunization Program, Centers
for Disease Control and Prevention (CDC). A 15-minute interactive question-and-answer
session will follow each teleconference. CME credit is available through Albert Einstein
College of Medicine. CEU credit is offered though the New York State Nurses Association
Council on Continuing Education.
To obtain a schedule of teleconference dates and times, and/or to
register, call (888) 375-9573 between 9:00am and 5:30pm ET.
Editor's Note:
This article is provided for information purposes only. Please note that registration
should be made between 9:00 a.m. and 5:30 p.m. ET, as directed
in the article. The Florida Department of Health will not be coordinating this
teleconference.
6. Internet Resources for Public Health Professionals:
(The following information appeared in a ProMed posting (serial online), September 7,
1999).
- Teaching Tool: Emerging Infections of International Public Health
A new teaching tool to learn about Emerging Infections of International Public Health
Importance is now available on the Internet from the APEC EINET project. The content was
derived from a series of transcribed lectures given at the University of Washington,
School of Public Health. The information may be accessed at: http://depts.washington.edu/eminf/
- WHO Report on Infectious Diseases
The World Health Organization (WHO) recently published the "WHO Report on
Infectious Diseases: Removing Obstacles to Healthy Development".
7. Editor's Corner: No Epi Update Next Friday (October 1, 1999)
The editorial staff for Epi Update will be attending the Annual Statewide Epidemiology
Seminar (ASES) September 29th through October 1st, so there will be
no Epi Update next week.
8. Weekly Disease Table: Week 37
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 |
55 |
39 |
48 |
47.3 |
91 |
35 |
| Anthrax |
0 |
0 |
0 |
0 |
0 |
0 |
| Botulism |
0 |
0 |
0 |
0 |
0 |
0 |
| Brucellosis |
5 |
0 |
3 |
2.7 |
3 |
1 |
| Campylobacteriosis |
828 |
703 |
538 |
689.7 |
975 |
644 |
| Ciguatera |
12 |
6 |
7 |
8.3 |
7 |
2 |
| Cryptosporidiosis |
152 |
89 |
104 |
115 |
203 |
96 |
| Cyclosporiasis |
181 |
64 |
6 |
83.7 |
6 |
5 |
| Dengue |
0 |
3 |
2 |
1.7 |
5 |
4 |
| Diphtheria |
0 |
0 |
0 |
0 |
0 |
0 |
| E. coli O157:H7 |
24 |
39 |
30 |
31 |
57 |
40 |
| E. coli, other (known serotype) |
4 |
5 |
3 |
4 |
12 |
13 |
| Ehrlichiosis, Human |
4 |
2 |
0 |
2 |
1 |
1 |
| Encephalitis, Eastern Equine |
0 |
2 |
0 |
0.7 |
0 |
1 |
| Encephalitis, St. Louis |
0 |
0 |
0 |
0 |
2 |
0 |
| Encephalitis, other (known organism) |
5 |
9 |
4 |
6 |
7 |
3 |
| Encephalitis, post-infectious1 |
13 |
6 |
8 |
9 |
21 |
6 |
| Giardiasis (acute) |
1272 |
1065 |
960 |
1099 |
1636 |
755 |
| Haemophilus influenzae, invasive1 |
15 |
17 |
32 |
21.3 |
45 |
32 |
| Hansen’s Disease (Leprosy) |
1 |
0 |
3 |
1.3 |
4 |
2 |
| Hantavirus Infection |
0 |
0 |
0 |
0 |
0 |
0 |
| Hemolytic Uremic Syndrome |
0 |
3 |
8 |
3.7 |
12 |
7 |
| Hemorrhagic Fever |
0 |
0 |
0 |
0 |
0 |
0 |
| Hepatitis A |
313 |
353 |
351 |
339 |
539 |
468 |
| Hepatitis B |
357 |
266 |
280 |
301 |
466 |
287 |
| Hepatitis C2 |
NR |
NR |
NR |
NR |
NR |
40 |
| Hepatitis Non-A, Non-B |
58 |
65 |
63 |
62 |
95 |
5 |
| Hepatitis, perinatal B2 |
NR |
NR |
NR |
NR |
NR |
1 |
| Hepatitis, unspecified |
3 |
6 |
11 |
6.7 |
26 |
10 |
| Hepatitis, +HBsAg, pregnant woman2 |
NR |
NR |
NR |
NR |
NR |
22 |
| Lead Poisoning |
1363 |
971 |
1258 |
1197.3 |
1805 |
503 |
| Legionellosis |
28 |
18 |
24 |
23.3 |
48 |
19 |
| Leptospirosis |
0 |
0 |
1 |
0.3 |
2 |
0 |
| Listeriosis2 |
NR |
NR |
NR |
NR |
NR |
19 |
| Lyme Disease |
14 |
22 |
30 |
22 |
71 |
31 |
| Malaria |
58 |
58 |
42 |
52.7 |
96 |
60 |
| Measles |
1 |
3 |
2 |
2 |
2 |
2 |
| Meningococcal Disease (N. meningitidis) |
139 |
112 |
96 |
115.7 |
133 |
84 |
| Meningitis, Group B Streptococci |
20 |
11 |
13 |
14.7 |
22 |
11 |
| Meningitis, Haemophilus influenzae1 |
5 |
6 |
11 |
7.3 |
12 |
11 |
| Meningitis, Streptococcus pneumoniae |
79 |
57 |
63 |
66.3 |
96 |
74 |
| Meningitis, Listeria monocytogenes |
4 |
2 |
4 |
3.3 |
13 |
6 |
| Meningitis, other bacterial (including
unspecified) |
76 |
43 |
41 |
53.3 |
75 |
49 |
| Mercury Poisoning |
5 |
2 |
0 |
2.3 |
4 |
2 |
| Mumps |
7 |
8 |
10 |
8.3 |
11 |
4 |
| Neurotoxic Shellfish Poisoning2 |
3 |
0 |
0 |
1 |
0 |
0 |
| Pertussis |
73 |
53 |
33 |
53 |
39 |
65 |
| Pesticide Poisoning |
1 |
0 |
1 |
0.7 |
1 |
1 |
| Plague |
0 |
0 |
0 |
0 |
0 |
0 |
| Poliomyelitis |
0 |
0 |
0 |
0 |
0 |
0 |
| Psittacosis |
0 |
0 |
1 |
0.3 |
2 |
0 |
| Rabies, Animal |
170 |
205 |
152 |
175.7 |
215 |
142 |
| Rocky Mountain Spotted Fever |
1 |
2 |
1 |
1.3 |
2 |
1 |
| Rubella, including congenital |
10 |
2 |
3 |
5 |
4 |
0 |
| Salmonellosis |
1587 |
1353 |
1635 |
1525 |
3038 |
1652 |
| Shigellosis |
1020 |
921 |
1500 |
1147 |
2343 |
973 |
| Smallpox2 |
NR |
NR |
NR |
NR |
NR |
0 |
| Staphlococcus aureus, (GISA/VISA)2 |
NR |
NR |
NR |
NR |
NR |
0 |
| Staphlococcus aureus, (GRSA/VRSA)2 |
NR |
NR |
NR |
NR |
NR |
0 |
| Streptococcal Disease, invasive Group A |
2 |
26 |
32 |
20 |
57 |
55 |
| Streptococcus pneumoniae, invasive
disease |
7 |
142 |
306 |
151.7 |
493 |
434 |
| Tetanus |
2 |
1 |
2 |
1.7 |
3 |
2 |
| Toxic Shock Syndrome |
0 |
1 |
4 |
1.7 |
4 |
4 |
| Toxoplasmosis |
6 |
4 |
7 |
5.7 |
15 |
10 |
| Typhoid Fever |
19 |
8 |
11 |
12.7 |
16 |
22 |
| Vibrio cholerae (serogrp O1) |
0 |
0 |
0 |
0 |
0 |
1 |
| Vibrio cholerae (serogrp Non-O1) |
2 |
6 |
6 |
4.7 |
11 |
8 |
| Vibrio vulnificus |
7 |
11 |
20 |
12.7 |
35 |
13 |
| Vibrio other (including unspecified) |
17 |
21 |
54 |
30.7 |
73 |
31 |
| Yellow Fever |
0 |
0 |
0 |
0 |
0 |
0 |
1 Haemophilus influenzae can be the agent responsible for disease under
three of the reportable conditions listed-: "Haemophilus influenzae,
invasive" and under "Encephalitis, post infectious." Cases of Haemophilus
influenzae meningitis are reported under "Meningitis, H. influenzae."
2 The reportable disease rule was revised in July, 1999. Kawasaki Disease,
Histoplasmosis, Reye Syndrome, and Typhus were deleted from the weekly disease table since
cases are no longer reportable as of July 4, 1999. Hepatitis C; perinatal hepatitis B;
hepatitis B +HbsAg, pregnant woman; listeriosis; smallpox, S. aureus (GISA/VISA)
and S. aureus (GRSA/VRSA) were added to the reporting requirements as of July 4,
1999. Paralytic shellfish poisoning is now referred to as neurotoxic shellfish poisoning.
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