Division of Disease Control and Health Protection

"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.

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.

In this issue:

John F. Werth, M.A.

11:00 AM – 12:00 PM EST

Session 9 will be presented by Dr. Gérard Krause, MD, DrMed, DTMH, CDC Epidemic Intelligence Service Officer, Bureau of Epidemiology, Florida Department of Health.

This presentation will provide an introduction to the four strategies of the global eradication of polio conducted by the World Health Organization (WHO). The focus will be the surveillance of acute flaccid paralysis, which is one of the four strategies for polio eradication. Based upon his experience as a WHO consultant in Niger, West Africa, Dr. Krause will demonstrate how a surveillance system for acute flaccid paralysis was implemented in one of the poorest countries in Africa.

Additional information and tips about accessing information about the Grand Rounds may be found on the Bureau of Epidemiology intranet website.

Bill Toth, County Epidemiologist, MPH, Orange County Health Department:

The Orange County Health Department received a report from Florida Hospital South on Saturday November 20, 1999 regarding three (3) patients they had seen in their emergency department with nausea, vomiting, diarrhea, bradycardia, depressed blood pressures, tingling and numbness around their mouths, and numbing and tingling in their hands and feet. One individual described a hot and cold sensation reversal. The RN in the department told the epidemiology section of another man who was hospitalized at Winter Park Hospital with similar condition; his hospitalization was confirmed by telephone.

These individuals were from five parties and two employees of the restaurant. All had eaten mahi-mahi or amberjack fish on Friday November 19 at Houston’s, on 215 S. Orlando Ave, Winter Park. Their onsets of illness were from 3-12 hours after ingesting fish at the restaurant. The onset window, signs and symptoms were compatible with ciguatoxin exposure (the incubation for scombroid poisoning is a few minutes to one hour). Exposure was on Thursday, November 18 and Friday, November 19.

A call was made immediately to Houston’s for the purpose of determining if additional cases existed and to have them hold, in the freezer, those mahi and amberjack fillets remaining. They were asked to reveal their supplier for those fish. The fillets are being held for investigators from FDA as are the invoices for fish received on November 16-20 from Supreme Seafood, Inc.(mahi-mahi) and Gary’s Seafood Specialties, Inc. (amberjack). FDA is in the process of checking the distribution of the fish as well as sending it to be tested for ciguatoxin. Fish received are mostly used the same day (approximately 30 lbs. used per type of fish per day), those stores left over are kept at proper holding temperatures and used first the following day. Restaurant managers adamantly deny substituting one type of fish for another (the question being whether 2 types of fish are actually involved).

The Orange county epidemiologist made a site visit to Houston’s, on Monday November 22, concurrent with Department of Business and Professional Regulation (DBPR). A copy of the invoices was made for both parties. A regulatory inspection was conducted by DBPR, which revealed no major infractions. Additional names of complainants were turned over to the epidemiologist for follow up. A party of 13 reported as many as 4 ill with compatible illness and onset times and exposures. As of this report, 16 are ill (including two restaurant employees) with one hospitalization (discharged on November 20). This is a dynamic number and may change as more is learned.

Don Ward, Surveillance Section Administrator, and

Beverly Keith, BSN, RN, Nursing Program Specialist, Orange County Health Department

Occasionally, most often when information on laboratory reports is incomplete, the Bureau of Epidemiology sends laboratory results to a county health department that is different from that of the patient’s residence. After the "wrong" county receives the laboratory report and determines that the patient lives in another county, they forward the report to the correct county. If appropriate information is missing, further (and often redundant) action will be required of the recipient county. To avoid this often involved and redundant effort, we suggest the following procedure.

When a county health department receives a laboratory report which requires a call to a physician's office for diagnostic, demographic and/or epidemiologic data (and the patient is discovered through the call to be the resident of another county) CHD staff should obtain the same information as for a resident of the CHD calling the physician. That information should then be transmitted to the appropriate county for morbidity reporting and any necessary follow-up. This practice will keep the recipient county from making additional phone calls to the physician's office, which is not only annoying to the physician's office but also many times is a long distance call from the recipient county health department. Information that is important to obtain includes:

1. Data necessary to complete the Communicable Disease Morbidity Surveillance Reporting Form (HRS-H Form 2016)

name, date of birth, sex, race, hispanic (yes or no), zip code, onset date (to compute the event date) imported status, outbreak status, occupation and daycare status.

2. Other information that is appropriate for determining morbidity according to the current case definition

3. Parent's name (if a child)

4. Was the patient symptomatic? If yes, what were their symptoms?

5. Treatment, if any

6. Is disease acute or chronic ( e.g., in the case of hepatitis B or C)?

7. Permission to contact the patient or family
8. Request that lab work be faxed from the physician's office to the recipient county, for cases which the state e-pi office requires a copy of the lab data
9. Other information that the physician feels may be useful in follow-up

Epidemiologic needs may necessitate further follow-up by the county of the patient’s residence, but a little extra effort by the county conducting the initial investigation may save time, prevent unnecessary effort and contribute greatly to case prevention.

Carina Blackmore, MS Vet Med. PhD

National: Since October 3, 1999, laboratory confirmed influenza A virus infections were reported from 35 states. Influenza B has been reported from 3 states. Both influenza A and B were isolated in Florida during this time period. Minnesota and Wisconsin reported regional influenza activity as assessed by state and territorial epidemiologists, and thirty-six other states reported sporadic influenza activity.

Florida During week 45 (7-13 November 1999) laboratory confirmed isolates of influenza A H3N2/Sydney-like were reported from Hillsborough, Indian River, Leon and Volusia counties. Since October 1, 1999, influenza A has also been isolated from specimens received from Alachua, Brevard, Broward, Collier (A H3N2), Duval, Miami-Dade, Orange and Palm Beach counties. Influenza B/Yamanashi-like has been isolated from Indian River county. Antigens from both influenza A/Sydney and influenza B/Yamanashi are included in the 1999-2000 influenza vaccine. Of the total patient visits to sentinel physicians for Week 45, 2% were due to ILI, the same level of influenza activity reported for the 5 previous weeks. and within the expected range of 0-3%. This week influenza-like illness was reported from providers in 17 (Alachua, Broward, Collier, Duval, Hillsborough, Indian River, Leon, Marion, Miami-Dade, Monroe, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk and Seminole) of the 29 Florida counties participating in the National Sentinel Physicians Surveillance Network.

William J. Bigler, PhD