Division of Disease Control and Health Protection

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.

1. Second Annual Hepatitis & Liver Disease Summit

2. Tetanus in an Unvaccinated Child

3. Florida Escapes Widespread or Regional Flu Activity for Another Week

4. The Health and Economic Impact of Tobacco Use in Florida

5. Amebiasis (Amoebiasis) - A Primer

6. Influenza and Pneumococcal Immunization of Older Adults

7. Florida Past: Spanish Military Medicine - Florida Style

8. Weekly Disease Table: Week 52

The Bureau of Epidemiology's Second Annual Hepatitis & Liver Disease Summit is scheduled for January 27, 2000, between 9:00 a.m. and 4:00 p.m. The summit will be held at the Sheraton Studio City Hotel, 5905 International Drive, Orlando, FL, 32819. On-line information and free registration is available on the Department's Intranet and Internet web sites. This year's meeting will launch the Florida Department of Health's Hepatitis and Liver Failure Prevention and Control Program and allow interested parties, from public and private sectors, to share information about how the appropriation is planned to be used, and allow those active in this area to network.

Tetanus is an acute, often fatal, disease caused by a toxin produced by the tetanus bacillus, Clostridium tetani [1, 2]. The disease is characterized by generalized increased rigidity and convulsive spasms of skeletal muscles. Tetanus spores are found in soil, dust, and animal feces, and may persist for years. One case of tetanus was reported to the Bureau of Epidemiology, Florida Department of Health, in 1997, and three cases were reported in 1998 [3].

On 12/20/99 a case of tetanus was reported to the Epidemiology Office of the Volusia County Health Department. The patient was a five-year old male who had not been immunized against tetanus. The patient stepped on a thorn on or about 12/09/99 and did not tell his parents. On 12/11/99 he complained of abdominal cramping, a backache, and muscle spasms. On 12/12/99 he was seen in an emergency room, given 1500 units of tetanus immune globulin (TIG), and hospitalized for 10 days. He was immunized with diphtheria toxoid, tetanus toxoid, and pertussis vaccine (DTP) while in the hospital.

The mother of the patient had decided not to have her child vaccinated because she had received negative information about vaccinations from various individuals. The mother also stated that her religious views were another reason why several of her children had not received their childhood vaccinations. The patient is home schooled. (Children who are home schooled are exempt from state immunization laws.) The mother is currently in the process of having her children immunized with the routine childhood vaccines.

Immunization with tetanus toxoid is recommended for all individuals. After a primary series of three properly spaced doses, essentially all recipients achieve antitoxin levels that are considerably higher than the minimal protective level [1]. The Pink Book states [1], "It can be inferred from protective antitoxin levels that a complete tetanus toxoid series has a clinical efficacy of virtually 100%; cases of tetanus occurring in fully immunized persons whose last dose was within the last 10 years are extremely rare."

1. Centers for Disease Control and Prevention. Epidemiology & Prevention of Vaccine-Preventable Diseases: The Pink Book, 4^th edition. Department of Health and Human Services, Atlanta, 55-64; 1997.
2. Benenson AS (ed.). Control of Communicable Diseases Manual, 16^th Edition. United Book Press, Baltimore, 459; 1995.
3. Florida Department of Health, Bureau of Epidemiology, Surveillance Section. Tallahassee, FL.

Since October 3, 1999, the World Health Organization (WHO) and the National Respiratory and Enteric Virus Surveillance System (NREVSS) laboratories have tested 18,624 respiratory specimens for influenza, from which 1,903 (10%) influenza isolates have been recovered. Influenza A accounted for 1,896 of the 1,903 (99.6%) isolates with 7 isolates being influenza B (0.4%). Of the 596 influenza A viruses subtyped 595 (99.8%) were A(H3N2) and 1 (0.2%) was A(H1N1). Both influenza A and B were isolated in Florida during this time period. During week 50, influenza activity was reported as widespread in 3 states (Montana, Utah and Washington). Arizona, Colorado, Hawaii, Illinois, Minnesota, Missouri, Nebraska, New Jersey, New Mexico, New York, Ohio, Pennsylvania, South Dakota, Tennessee, Virginia and Wisconsin reported regional influenza activity as assessed by state and territorial epidemiologists, 36 other states (including Florida) reported sporadic influenza activity, and 1 state did not report.

Of the total patient visits to sentinel physicians, 3% were due to ILI (influenza-like-illness) in the U.S. overall. The percentages ranged from 1-3% in 6 of the 9 surveillance regions. In the West North Central region 5% of patient visits were due to ILI. In the Pacific and West South Central regions 6% of patient visits were due to ILI. The percentage of pneumonia and influenza deaths (of all deaths) reported from the 122 cities participating in the City Mortality Reporting System was 7.8%. For week 50, this is above the epidemic threshold of 7.1%. The percentage of pneumonia and influenza deaths exceeded threshold values for this time of year for 11 of the past 13 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.

Since the beginning of week 50 (December 12, 1999) laboratory confirmed isolates of influenza A H3N2/Sydney-like were reported from Broward, Clay, Duval, Hillsborough, and Leon Counties. Influenza A H3N2 has also been isolated from Alachua, Collier, Indian River, Lake, Miami-Dade, Orange, Palm Beach, Pinellas, Sarasota and Volusia counties since October 1, 1999. Influenza B/Yamanashi-like has been isolated from Indian River county. An untyped isolate of influenza A has been reported from Brevard 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 50, 3% were due to ILI, the same level of activity was reported for 3 of the last 4 weeks and within the expected range of 0-3%. This week influenza-like illness was reported from providers in 16 (Brevard, Broward, Dade, Duval, Escambia, Indian River, Lake, Leon, Monroe, Palm Beach, Pasco, Pinellas, Polk, Sarasota, St. Johns, and St. Lucie) of the 29 Florida counties participating in the National Sentinel Physicians Surveillance Network.

Note: Reporting is incomplete for week 50, so numbers and percentages may change as more reports are received. Data for weeks 51 and 52 will be available in the next Epi Update.

Among adults, cigarette use was as high as 29% in 1986, and has fallen to 22.6 in 1998. Most of the decrease occurred from 1986 to 1991, however, and the proportion of Florida adults who smoke cigarettes has remained between 22% and 23% since 1991. Tobacco use among young adults aged 18 to 24 years has fluctuated during the 1990s, reaching a high of nearly 28% in 1997. Current cigar use among Florida adults was 6.3% in 1998.¹

Tobacco use data for teenagers show a decline in current cigarette use from 1998 to 1999, the two years for which data are available from the Florida Youth Tobacco Survey². The decline was larger in absolute terms for middle school students than for high school students (3.5 percentage points versus 2.2 percentage points) and also in percentage terms (18.9% vs. 8.0%). In 1998, 19.5 % of Florida high-school students reported use of cigars in the past 30 days, and 6.4 % reported use of spit tobacco. In 1998, 5.1% of 4^th and 5^th graders reported use of any type of tobacco in the preceding 30 days, as did 11.7% of 6^th graders. 14.4% of 5^th graders reported they had ever tried tobacco.

In 1998, there were 157,160 deaths in Florida residents from all causes.³ Of these, 29,450 were attributable to smoking, or 18.74 percent of the total. Men accounted for 18,372 (62.4%) of these deaths and women for 11,078 (37.6%). Tobacco use accounted for 22.8% of mortality in men and 14.48% of mortality in women.

There were 350.4 smoking-attributable deaths in 1998 per 100,000 people living in Florida. Among these smoking-attributable deaths, 10,342 were from cardiovascular disease (including 6,868 from heart attack), 11,849 from cancer (including 9,250 from lung cancer), and 7,259 from respiratory diseases (including 4,967 from chronic obstructive lung disease).

In 1998, there were 389,626 years of potential life lost among Florida residents as a result of premature death attributable to smoking, based on life expectancy. Of these, 231,746 were in men and 157,880 in women.

In 1998, there were 127,579 hospitalizations attributable to smoking, assuming that hospitalizations are related to smoking in the same way that mortality is. These constitute 712,515 hospital days and a total of $2.6 billion in hospitalization charges attributable to smoking.

During 1993, according to work done by Dr. Leonard Miller and colleagues at the University of California, total direct health care expenditures in Florida that were attributable to tobacco use were $4.6 billion. Of this total, $1.3 billion was for ambulatory care, $495 million for prescription drugs, $2.1 billion for hospital care, $198 million for home health services, and $512 million for nursing home care. They also estimated that the Medicaid program in Florida spent $517 million in 1993 on care for smoking-attributable illnesses, and that the federal Medicare program in 1993 spent $1.1 billion on care for smoking-attributable illnesses in Florida residents.^4-6

In addition to the expenditures estimated by Miller et al., Hopkins and Lynch estimated the smoking-attributable Medicaid expenditures that occurred in children or during pregnancy to be $53,933,279⁷. This estimate is not included in the models published by Miller et al. It includes expenditures for care for low birthweight and premature infants, care for women with complications of pregnancy, and care for children with asthma, ear infections, and other respiratory diseases.

Fourteen percent of Florida infants born in 1996 and 1997 had mothers who smoked cigarettes during pregnancy. Ten percent of all infants aged 3 to 6 months are exposed to tobacco smoke for at least one hour each day.⁸ Among women who smoked before pregnancy, 45.7% quit during pregnancy and 37.3% reduced their cigarette consumption.

Infants born to mothers who smoked during pregnancy have an almost two-fold greater risk of low birth weight. After adjusting for differences in mother’s education, race and marital status, which also are associated with low birth weight, the odds of a birth weight below 2000 grams are 64% higher for mothers who smoke (odds ratio 1.64). Smoking accounted for 6.9% of low birth weight in Florida in 1998.

If women did not smoke during pregnancy, an estimated 75 fewer infant deaths would have occurred among Florida infants born in 1996. In that year, if pregnant women did not smoke, the infant death rate would have been 7.0 instead of 7.4 deaths per 1,000 live births. Of this reduction, 39 preventable deaths would result from the effect of smoking on low birth weight, 24 would result from other effects of smoking during pregnancy, and 12 would be due to the combined effect. This calculation takes into account the fact that the women who are smokers tend to have other characteristics that are known to increase the risk of low birth weight and infant mortality.⁹

1. Florida Department of Health, Bureau of Epidemiology, Behavioral Risk Factor Surveillance System, 1986-1998.

2. Florida Department of Health, Bureau of Epidemiology, Survey Research Unit, Florida Youth Tobacco Survey, FYTS Report Volume 2, Number 1, April 15, 1999.

3. Florida Department of Health, Bureau of Epidemiology, 1997-1998 Smoking Attributable Mortality Report, Report Number 99-1124.

4. Miller et al., Public Health Reports, 113:141-151, 1998.

5. Miller et al., Public Health Reports, 113:447-458, 1998.

6. Miller et al., Health Care Financing Review, 20:1-19, 1999.

7. Hopkins, RS and Lynch, T, Smoking-Attributable Medicaid Expenditures in Florida, 1994-96, April 15, 1997.

8. Florida Department of Health, 1996 and 1997 Pregnancy Risk Assessment Monitoring System, PRAMS Report Number 3, January 25, 1999.

9. Florida Department of Health, Bureau of Epidemiology, Chronic Disease Epidemiology Section, Report Number 99-1104, November 1999.

Amebiasis is an infection caused by the protozoan parasite Entamoeba histolytica [1]. Entamoeba histolytica is an ameba. It should not be confused with Entamoeba dispar, which is morphologically identical to Entamoeba histolytica, but is nonpathogenic. Entamoeba coli and Entamoeba hartmanni are also nonpathogenic but these species can be differentiated from E. histolytica by morphology [2]. E. histolytica, E. dispar, E. coli, and E. hartmanni occur only in humans [3].

E. histolytica exists in two forms: the hardy, infective cyst, and the more fragile, potentially pathogenic trophozoite [1]. Transmission occurs when fecally contaminated food or water containing cysts is ingested. The trophozoite, or active form, principally inhabits the large intestine [3]. Intestinal amebiasis may be asymptomatic or have nonspecific or mild signs and symptoms such as flatulence, constipation, and loose stools [2]. Some may develop dysentery, which is characterized by abdominal cramps, tenesmus, and blood and mucus in the stool [2, 3]. An ameboma (a chronic granulomatous lesion) develops most frequently in the cecal or rectosigmoid region, and may be mistaken for a colonic carcinoma [2, 3].

Extraintestinal amebiasis occurs in a small percentage of patients and may involve various organs including the liver, lungs, and brain [2]. The most common extraintestinal manifestation is a hepatic abscess [4]. Signs and symptoms of a liver abscess include fever, abdominal pain, and weight loss [2]. A rupture of an abscess may lead to death.

An acute case of amebic dysentery does not play a major role in transmission since trophozoites cannot survive long outside the body of the host; however, asymptomatic patients generally produce only cysts and therefore are important sources of infection [3]. The incubation period of amebiasis is variable, ranging from a few days to months or years, but is usually one to four weeks. A diagnosis may be made by examining stool. Other diagnostic tests include antigen detection in stool, polymerase chain reaction, and various serologic assays [3]. The antibody tests are most helpful in the diagnosis of extraintestinal amebiasis with liver involvement [2]. Cases may be treated with various drugs [1, 2, 3].

At one time, E. histolytica was considered to infect approximately 10% of the world’s population; however, this estimate may have been inflated due to the confusion with the much more frequently encountered E. dispar [3]. The true worldwide prevalence of E. histolytica is closer to one percent. The prevalence of infection is highest in areas of crowding, poor sanitation, and the tropics. In temperate climates, the majority of cases are usually asymptomatic. In the United States, amebiasis is more common in rural areas and in areas of low socioeconomic status. Oral-anal sex is a risk factor for infection [1].

In 1997, 68 cases of amebiasis were reported to the Florida Department of Health [5]. The incidence rate in 1997 was 0.46 cases per 100,000. The incidence in males was 0.57 per 100,000, and 0.36 per 100,000 in females (a relative risk of 1.58). Ninety-one cases were reported in 1998. The reported incidence of amebiasis in 1998 was 0.60 cases per 100,000. In 1998, the gender difference in morbidity decreased: 0.68 per 100,000 males, and 0.52 per 100,000 females (a relative risk of 1.31).

References

1. Benenson AS (ed.). Control of Communicable Diseases Manual, 16th Edition. United Book Press, Baltimore, 10-13; 1995.
2. American Academy of Pediatrics. Peter G (ed.) 1997 Red Book: Report of the Committee on Infectious Diseases, 24th Edition. Elk Grove, IL, 132-133; 1997.
3. Markell EK, John DT, and Wojciech KA. Markell and Voge’s Medical Parasitology, 8^th edition. W.B. Saunders Company, Philadelphia, 25-43; 1999.
4. Hoffner RJ, Kilaghbian T, Esekogwu VI, and Henderson SO. Common presentations of amebic liver abscess. Annals of Emergency Medicine, 34(3):351-5; 1999.
5. Unpublished data. Bureau of Epidemiology, Florida Department of Health, Tallahassee, FL.

CDC PUBLISHES SURVEILLANCE SUMMARY ON PUBLIC HEALTH

INDICATORS AFFECTING OLDER ADULTS

The Centers for Disease Control and Prevention (CDC) published a surveillance summary titled "Surveillance for Selected Public Health Indicators Affecting Older Adults -- United States" in the December 17, 1999, issue of the MMWR. This 168-page report commemorates the United Nation's proclamation of the "International Year of Older Persons" (10/1/98 - 12/31/99), and addresses several factors of morbidity and mortality among adults aged greater than or equal to 65 years including findings related to influenza and pneumococcal vaccination rates.

A discussion of influenza and pneumococcal vaccination is included in the section titled "Surveillance for Use of Preventive Health-Care Services by Older Adults, 1995-1997." The report notes "in 1997, a total of 90% of U.S. deaths attributed to pneumonia and influenza occurred among persons aged greater than or equal to 65 years, making these illnesses the fifth leading cause of death for this age group. During influenza epidemics, persons aged greater than or equal to 65 years face increased risk for influenza-associated hospitalizations and deaths. Persons aged greater than or equal to 65 years are also at increased risk for invasive pneumococcal disease, including bacteremia and meningitis, with an estimated annual incidence of 50-83 cases/100,000 population compared with 15-30 cases/100,000 among persons of all ages."

According to the summary report, a "Healthy People 2000" objective is to increase influenza and pneumococcal vaccination levels to greater than or equal to 60% among persons aged greater than or equal to 65 years. However, as the year 2000 nears, the report notes that national coverage levels for pneumococcal vaccination still fall short of this goal. "...during 1997, 65% of older adults reported receiving influenza vaccination in the past 12 months, and only 45% reported ever receiving pneumococcal vaccination."

In the section titled "Overview," the report asserts that "all adults aged greater than or equal to 65 years should receive influenza vaccinations annually; pneumococcal vaccination should be administered once, but can be repeated for certain groups at high risk after 5 years. Influenza and pneumococcal vaccinations are cost-effective compared with other preventive measures and can be cost-saving; in addition, they have been reported to be effective in reducing serious complications and hospitalizations by approximately one half. Every effort should be made to increase vaccination coverage among older adults, particularly among those who suffer from chronic illnesses."

With the onset of the 21st century, the elderly are becoming a primary target for public health prevention strategies as "growth in the number of older adults (persons aged greater than or equal to 65 years) in the United States will produce an unprecedented increase in the number of persons at risk for costly age-associated chronic diseases and other health conditions and injuries."

For information on how to obtain a free electronic subscription to the MMWR, see the instructions that follow article four.

Some of the most interesting material written about Florida’s history of medicine and patient care was recorded for posterity in letters, log books, diaries and official reports penned by the Spanish military when they first began to colonize St. Augustine. In the November 1990 historical issue of the Journal of the Florida Medical Association (Vol.77, No. 11, pp 960-63), Robert Hawk provides a unique overview of Spain’s struggle to provide adequate medical care for troops in Florida during the 16^th and 17^th Centuries in an article entitled "Military Medicine in Florida: The first 200 years." Selected excerpts follow:

During the first 200 years of permanent European presence in Florida, the only significant settlement was at St. Augustine…At the time of St. Augustine’s establishment by Pedro Menendez de Aviles in 1565, military medical theory, education, practice and organization had been undergoing revolutionary changes in Europe for nearly 75 years. By the end of the 15^th century, Spain had the most modern and effective military medical delivery system in the western world…

While the delivery system for military medicine in the field was much improved, the actual state of medical theory, education and practice remained rooted in the middle ages, dominated by the teachings of the 5^th century Roman physician, Galen as revised by Avicenna in the 10^th century…

When St. Augustine was founded, the Spanish government had a mandated system of military medical support for all presidios. Each was to have at least one physician, one barber-surgeon and one apothecary. A hospital was to be established in each presidio, staffed, equipped and supplied to provide adequate care for both wounded and diseased soldiers. Each soldier’s pay was to be docked to pay for these services.

Menendez brought no physicians but did bring two surgeons, an apothecary and five barbers with his expedition to conquer and colonize Florida…Within ten years, all those who had come with a conquering fleet were gone to other colonies, died or had returned to Spain. St. Augustine and Florida were left to do the best they could for the next 200 years.

For awhile, the best was very good indeed, even if under exceptionally unusual conditions. In about 1579, Juan de LeConte, probably a French Hugenot, was shipwrecked near Santa Elena and transferred to St. Augustine as a prisoner. Records indicate he was an excellent physician-surgeon and a knowledgeable apothecary…For decades, he was virtually a one-man military medical system for Florida…He served…until approximately 1620 when he retired to Cuba where he died in 1630.

LeConte and Florida’s military medical system were assisted by at least two of Florida’s Governors. During the 1580’s, Catalina Menendez, sister of the Governor Pedro Menendez Marques, cared for sick and injured soldiers in her home at her own expense, serving as a nurse with one female Royale slave to help her. Another Governor, Gonzalo Mendez de Canzo, established a military hospital in 1597. When this first official military hospital burned in 1599, he built another and it lasted, in one for or another, for several decades into the 17^th century to be replaced by the friars of St. Francis stationed in the presidio.

With the retirement and death of LeConte, Florida was not to experience adequate medical care for its garrison until near the middle of the 18^th century. Barber-surgeons and apothecaries came and went, and there is little evidence any were adequately trained to perform their assigned tasks. Florida needed real military medical care as the final half of the 17^th century was characterized by frequent back country wars with English supported Indian raids, occasional province-wide epidemics of the plague, measles, smallpox, syphilis and various supposedly climate-induced diseases, most probably typhoid, dysentery and yellow fever…

Editorial Note: The hospital established by Governor Gonzalo Mendez do Canzo in 1597 has been declared by some as the first hospital in the New World. When writing King Philip II on February 23,1598, about the construction of a small frame hospital adjoining a wooden church in the city, the Governor indicated that many soldiers and Indians had been treated for fevers at the institution the previous summer. He also used that opportunity to request that the King declare the giving of alms to defray the 500 ducat deficit which hospital management had incurred. (Source – State Board of Health, Health Notes, August 1959)

8. Weekly Disease Table: Week 52