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.

1. Press Release: Hepatitis A in Truckstop Restaurant Employees in Alamance County, North Carolina

2. Florida Influeza Program Summary Update: Week 47 (Week Ending November 27,1999)

3. Update: Ciguatera Outbreak at a Restaurant with Two Species of Fish over A Two-Day Interval

4. Selected Features of County Health Department Rabies Control Programs

5. Information Resources

6. Epidemiology Employment Opportunities

7. Florida Past - Public Health Renaissance Growing Pains

8. Weekly Disease Table: Week 48

Carina Blackmore, MS Vet Med., PhD

National:

Since October 3, 1999, laboratory confirmed influenza A virus infections have been reported from 44 states. All 209 (44%) of the 478 influenza A isolates subtyped by the WHO or the National Respiratory and Enteric Virus Surveillance System (NREVSS) laboratories were influenza A (H3N2). Influenza B has been reported from 2 states. Both influenza A and B were isolated in Florida during this time period. Arizona, Colorado, Hawaii, Minnesota, Montana, Wisconsin and Wyoming reported regional influenza activity as assessed by state and territorial epidemiologists, and 37 other states (including Florida) reported sporadic influenza activity. No influenza activity was reported from Alabama, Delaware, Mississippi, New Jersey and Virginia. Of the total patient visits to sentinel physicians, 2% were due to ILI (influenza-like-illness) in the U.S. overall. The percentages ranged from 1-3% in all 9 surveillance regions. The percentage of pneumonia and influenza deaths reported from the 122 cities participating in the Cities Mortality Reporting System was 7.0 %. This is above the epidemic threshold of 6.8% for week 47. The percentage of pneumonia and influenza deaths exceeded threshold values for this time of year for 9 of the past 10 weeks. The increase in influenza related mortality seen this year should be interpreted with caution. It is unclear whether it is due to early influenza activity, respiratory illness due to some other pathogen, or reporting changes under way in the 122 Cities Mortality Reporting System.

During week 47 (21-27 November 1999) laboratory confirmed isolates of influenza A H3N2/Sydney-like were reported from Duval, Hillsborough and Volusia Counties. Influenza A has also been isolated from Alachua, Brevard, Broward (A H3N2), Collier (A H3N2), Indian River (A H3N2), Lake (A H3N2), Leon (A H3N2), Miami-Dade (A H3N2), Orange, Palm Beach (A H3N2), Pinellas and Sarasota Counties since October 1 1999. 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 47, 3% were due to ILI, higher than the influenza activity reported for the 7 previous weeks but within the expected range of 0-3%. This week influenza-like illness was reported from providers in 16 (Brevard, Broward, Collier, Duval, Hillsborough, Indian River, Leon, Marion, Miami-Dade, Monroe, Orange, Palm Beach, Pinellas, Polk, Seminole and Volusia) of the 29 Florida counties participating in the National Sentinel Physicians Surveillance Network.

Bill l. Toth, MPH, Orange County Health Department

Roberta M. Hammond, Ph.D., Bureau of Environmental Epidemiology

(The following italicized information appeared in the November 24, 1999 issue of Epi Update.)

Additional names of complainants were turned over to the epidemiologist for follow up.

A total of 15 individuals who were symptomatic were contacted. The symptoms were nausea (100%), vomiting (80%), diarrhea (93%), perioral numbness and tingling (93%), an tingling sensation in their hands (100%), arms (80%), feet (100%), and legs (20%). Forty percent complained of headache, hot/cold sensation reversal (93%), dizziness (67%), itching (53%), and exhaustion (100%). Of those who were screened, 40% had bradycardia (mean 35.3 bpm) and hypotension (20%) was also noted. One individual complained of photophobia. The mean onset period for those ill was 5.13 hours (range 2-12 hours). Several individuals complained of lingering, but improving signs and symptoms for over one week. Those party members who ate at the restaurant at the same time as those ill and did not consume amberjack or mahi mahi were not ill.

Eleven of those who were ill consumed amberjack at the restaurant. Four separate individuals who were ill consumed mahi mahi at a different serving time at the same restaurant. Serving times are aggregated into lunch and dinner service on two dates (November 18 and 19, 1999). The signs and symptoms of the infected patients are consistent with their exposure to ciguatoxin through their meals of amberjack or mahi mahi. Duration of illness, although less severe, is also consistent with the toxin.

Meals Consumed by Ill People in Orange County Ciguatera Outbreak

** one suspect case pending interview alleged to have mahi mahi at dinner

Amberjack and mahi mahi were supplied to the restaurant on a daily basis from separate local distributors. Mahi mahi has been rarely documented in ciguatera intoxication with the jack family of fishes being more commonly implicated. Since the chances of two species of fish causing the same illness in a single restaurant over two-day interval appeared remote, a question of cross contamination of toxin from amberjack to mahi mahi was raised. The distribution of fish exposure linked to illness would, likely, be relatively random over the two day interval, i.e., the exposure to mahi mahi would be expected to be mixed well with amberjack exposure. The array of exposure outlined in the table above clearly shows a separation of exposures to the two species. Researchers at FDA in Dauphin Island and at the Dade County Ciguatera Network agree that the spread of ciguatoxin through cross contamination of fish is highly unlikely. Samples of both types of fish have been sent by FDA to their laboratory in Seattle for testing for histamines and ciguatoxin as well as for speciation. No results are available at this time.

Matthew Robertson, FAMU MPH Intern; Dr. Lisa Conti, Adviser

Florida county health officers have primary responsibility for the management of human exposures to rabid or suspected rabid animals. County health departments (CHDs) may elect to engage in agreements with other agencies to transfer certain responsibilities and activities for rabies control. These agencies may include animal control, the local veterinary community, and/or sheriffs' offices.

The purpose of this telephone-administered questionnaire was to assess selected current trends and inter-agency relationships of rabies control programs in each of Florida’s 67 counties.

Rabies is caused by a neurotropic virus of the genus Lyssavirus in the family Rhabdoviridae that occurs in most countries throughout the world. The bullet-shaped rabies virion consists of a helical ribonucleoprotein capsid enclosed within a lipoprotein envelope covered with glycoprotein projections.

Most exposures to rabies involve the bite of a suspected rabid animal, and the majority of human exposures to rabies occur in children <19 years of age (1999 Rabies Prevention and Control in Florida, Florida Bureau of Epidemiology). It is estimated that at least 40,000 Florida residents and visitors are bitten each year by some type of domestic or wild animal. Dogs are the major source of animal bites in Florida, followed by cats, rodents, raccoons, bats, and other species (1999 Rabies Prevention and Control in Florida, Florida Bureau of Epidemiology). The threat of rabies transmission from animals to humans warrants the maintenance of a surveillance system with thorough investigation and follow-up of all humans exposed to a suspected rabid animal.

There are over 20 parenteral animal rabies vaccines licensed by the U.S. Department of Agriculture (USDA) for use in dogs, cats, ferrets, sheep, cattle and/or horses. Revaccinations should occur at one-year or (for selected vaccines for dogs and cats) three-year intervals, depending upon whether the vaccine is licensed for annual or triennial boosters. Local rabies ordinances have mandated the vaccination of dogs and cats at intervals of one, two or three years.

The environmental health directors of each of the 67 county health departments were called and surveyed during a two-week period during August 1999. Environmental health personnel were asked three questions regarding inter-agency agreements, local ordinances regulating domestic animal vaccination, and pre-exposure prophylaxis. Employees targeted for the questionnaire were pre-identified as rabies control resource persons by the Bureau of Epidemiology. Employees who could not be contacted by telephone were emailed the questionnaire along with an explanation of the purpose for this follow-up effort.

Of the sixty-four (96%) counties that were successfully contacted during this phone-administered questionnaire, 39 (61%) counties have some type of local ordinance requiring domestic animals to be vaccinated against rabies. Of these thirty-nine, seven counties have local ordinances at the city-level only. Twenty-two (34%) counties do not have any local statue pertaining to rabies vaccination (although 4 counties indicated that they were in the process of establishing such a law). In this instance, CHD representatives indicated that they simply abide by Florida Statutes, which state that all dogs, cats, and ferrets must be vaccinated by a licensed veterinarian; the vaccine selection is the veterinarian's choice. Three CHDs (5%) were uncertain as to whether or not local rabies vaccination ordinances exist in their counties.

Currently, 33 (87%) of the 38 counties with local ordinances require that animals be vaccinated on a yearly basis. Five counties (13%) have local ordinances that allow for 3-year vaccines for dogs and cats.

Twenty-one (32%) counties have delegated the responsibility of decapitating the head of a potentially rabid animal exclusively to animal control. Seventeen (27%) counties retain the responsibility within the Environmental Health section of the County Health Department. An additional 19 counties have contracts with veterinarians exclusively, and five counties use veterinarians in collaboration with animal control and/or the local humane society. Two counties stated that potentially rabid animals are brought to the Department of Agriculture and Consumer Services, Diagnostic Laboratory for decapitations.

While all of the 63 CHDs recognize the potential benefits of pre-exposure prophylaxis vaccinations, only 58 of the CHDs surveyed either recommend or provide pre-exposure prophylaxis to the people hired or contracted to handle rabid animals.

Methods currently used in Florida to control rabies in domestic animals include vaccination and the institution of ordinances that require animal owners to adhere to rabies control laws. Over a third of the counties did not have a local ordinance at the city or county level that requires domestic animals to be vaccinated against rabies. Since rabies is endemic in wildlife populations (especially raccoons) in Florida, it is essential that rabies vaccination ordinances be developed and continually enforced to provide a barrier from rabid wildlife.

The state animal rabies vaccination statute does not require use of a particular vaccine based on its duration of immunity. Among the counties with local ordinances, 52% mandate 1-year vaccinations and subsequent boosters. Several counties are in the process of amending their ordinances to recognize the vaccines with three-year duration of immunity for dogs and cats.

Although a sizable portion of counties still rely upon their county health departments to decapitate the heads of potentially rabid animals, many counties are transferring the responsibility to outside agencies. Animal control workers and local veterinarians are most frequently used for this procedure. Counties that still rely upon environmental health personnel for this procedure tend to be more rural.

Counties that do not recommend pre-exposure prophylaxis to the people handling potentially rabid animals have all transferred that responsibility to an outside agency.

Attached is a document with Year 2000 week numbers and week ending dates for HSDE disease reporting.

cdcwk00.pdf

This document is fifth in a series of FYTS reports from the Bureau of Epidemiology Survey Research Unit. The document will be shared with school principals in each county, county health departments and Tobacco Coordinators. Anyone who is interested in obtaining a hard copy of the most current report or any past editions, can e-mail their request to Ms. Natalie Tackett.

The Bureau of Epidemiology would like to announce an anticipated opening in the Florida Hepatitis and Liver Failure Prevention and Control Program. The position title is Program Administrator. The incumbent will serve as program administrator and will report directly to the Deputy State Epidemiologist in the Investigations Section of the Bureau of Epidemiology. Duties include supervision of other program staff, planning, epidemiologic analysis of hepatitis data, administration, monitoring, and evaluation of the Florida Hepatitis and Liver Failure Prevention and Control Program. The pay grade is 25 with a minimum annual salary of $41,877.55.

Strong candidates for this position are persons with experience in the development, implementation and evaluation of disease prevention and control programs. Candidates will be familiar with public health practice models and have experience with health policy and administration. Also, the candidate should have the ability to formulate budgets, prepare budget requests, develop and manage grants, analyze proposed legislation, and effectively supervise staff. An advanced degree in public heath or related field is desirable.

The Bureau of Epidemiology announces an anticipated opening for a Database Analyst in the Florida Hepatitis and Liver Failure Prevention and Control Program. The pay grade for this position is 25; the minimum annual salary is $38,070.50.

Specific duties and responsibilities include:

We currently have an anticipated opening in the Chronic Disease Section of the Bureau of Epidemiology. The position class title is Health Services and Facilities Consultant, and most of the work involves perinatal epidemiology. The pay grade is 24 with a minimum annual salary of $35,831.

Good candidates for this position are persons with experience working with large data sets and programming in SPSS, SAS or similar software, and experience in perinatal epidemiology and statistics. Also important is the inclination and ability to write up the results of the work.

A new BSIV position is being advertised in the Bureau of Environmental Epidemiology, closing date: 12/22/99. The position will function as the bureau's bioterrorism coordinator and waterborne disease surveillance coordinator. Experience in working at county health departments and experience in epidemiology preferred. The position will involve training county health departments statewide in bioterrorism prevention and investigation activities. In addition, this position will further expand statewide waterborne disease surveillance activities along with training County Health Department staff in how to investigate waterborne disease outbreaks. The position will coordinate closely with the bureau's regional food and waterborne disease epidemiologists and with similar bioterrorism positions in the Bureau of Epidemiology. Applicants should be experienced in training development and implementation, public speaking, commonly used computer applications (Microsoft Word, EpiInfo, Excel, PowerPoint and Access).

William J. Bigler, PhD