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.

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Zuber D. Mulla, MSPH, Bureau of Epidemiology; Pam Tiffany, RN, Osceola County Health Department; Ron Baker and Paul Fiorella, PhD, Bureau of Laboratories

During January 2000, a one-month-old Osceola County child developed a fever and experienced diarrhea. The child’s pediatrician ordered a stool culture. The stool yielded Salmonella group C1. The child was not hospitalized.

Questioning by the Osceola County Health Department revealed that the household contained a pet reptile, a bearded dragon (Pogona vitticeps). The bearded dragon was a Christmas gift in 1999. The child had arrived in the house on January 11, 2000. The onset of illness in the child was January 18, 2000. A family member reported that the bearded dragon’s cage had been washed in the kitchen near the infant’s bottle nipples. It is also possible that the owner of the bearded dragon, a 10-year-old girl, may have played with the dragon and then fed the infant.

Stool from the ill child and the dragon were sent to the DOH Central Laboratory in Jacksonville. The dragon’s stool also yielded Salmonella group C1. Pulsed field gel electrophoresis (PFGE) was performed. The DNA fingerprints of the Salmonella isolates were an exact match. Both isolates were serotype Tennessee.

An adult in the house was aware that "turtles" and "iguanas" are reservoirs of Salmonella spp., but apparently did not know that all reptiles may carry Salmonella. No other household members became ill. The bearded dragon has been placed outside and will eventually be donated to a zoo.

A recent report by the Centers for Disease Control and Prevention (CDC) indicates that some reptile owners are unaware that reptiles place them and their children at risk for salmonellosis [1]. Many reptiles are colonized with Salmonella species and intermittently shed the bacteria in their feces. Persons become infected by ingesting Salmonella after handling a reptile or objects contaminated by a reptile and then failing to wash their hands properly. Either direct or indirect contact with infected reptiles and their environment can cause human illness. The risk of transmission can be reduced by washing hands with soap and water after contact with the reptile or objects that have come into contact with the reptile. Children who are less than five years of age and immunocompromised persons should avoid direct or indirect contact with reptiles. The CDC’s recommendations [1] are summarized below.

1. Pet store owners, veterinarians, and pediatricians should provide information to owners and potential purchasers of reptiles about the risk for acquiring salmonellosis from reptiles.
2. Persons should always wash their hands thoroughly with soap and water after handling reptiles or reptile cages.
3. Persons at increased risk for infection or serious complications of salmonellosis (e.g., children aged less than 5 years and immunocompromised persons) should avoid contact with reptiles.
4. Pet reptiles should be kept out of households where children aged less than 5 years or immunocompromised persons live. Families expecting a new child should remove the pet reptile from the home before the infant arrives.
5. Pet reptiles should not be kept in child care centers.
6. Pet reptiles should not be allowed to roam freely throughout the home or living area.
7. Pet reptiles should be kept out of kitchens and other food-preparation areas to prevent contamination. Kitchen sinks should not be used to bathe reptiles or to wash their dishes, cages, or aquariums. If bathtubs are used for these purposes, they should be cleaned thoroughly and disinfected with bleach.

1. CDC. Reptile-Associated Salmonellosis – Selected States, 1996-1998. Morbidity and Mortality Weekly Report 1999;48(44):1009-1013. Errata in the Morbidity and Mortality Weekly Report 1999;48(45):1051.

Dean Bodager, R.S., D.A.A.S., M.P.A. , Bureau of Environmental Epidemiology

Cynthia Goldstein-Hart, M.P.H., Polk County Health Department

Ed Dixon, Highlands County Health Department

The Florida Department of Health received information from the CDC on Monday, February 14, 2000 that the New York State Health Department had detected an outbreak of gastrointestinal illness involving 15 of 45 attendees of a company lunch at a New York car dealership on Wednesday, February 9. Preliminary reports indicated that the catered lunch, also known as a "banquet in a box," was prepared by three food service facilities in Toledo, Ohio on Monday February 7. The boxed banquets were assembled by the primary caterer and shipped to New York State on Monday. They were delivered to the car dealership on the morning of Wednesday, February 9, and consumed at noon. It was learned that the food service company catered food exclusively for the corporation and had shipped similar boxed lunches to 53 dealerships throughout the nation from Monday, February 7^th through Wednesday, February 9^th. The banquet in a box consisted of ham, turkey, chicken tenders, breads, cheeses, potato salad, three types of pasta salad, snack mix, chips, various dips and condiments, and assorted desserts.

Four dealerships located in Polk, Highlands, Osceola, and Orange counties were listed as receiving the boxed banquet. The County Health Department epidemiology teams in these four counties contacted each automobile dealership and it was learned that dealerships in Lakeland (Polk County) and Sebring (Highlands County) had employees that attended banquets on February 9^th and subsequently experienced gastrointestinal illness.

The epidemiology teams at the Polk County Health Department and the Highlands County Health Department investigated these gastrointestinal illness outbreaks coordinating with the nationwide investigation directed by the CDC. The resulting EpiInfo databases were forwarded to the CDC for inclusion in the nationwide epidemiological analysis. The Sebring cohort consisted of 24 people all of which were interviewed. A total of 13 (54.2%) people reported gastrointestinal illness subsequent to the banquet in a box event on February 9^th at the dealership. Described symptoms include abdominal cramps (100%), diarrhea (84.6%), chills (76.9%), headache (76.9%), vomiting (61.5%), nausea (38.5%), fever (15.4%) and muscle aches (7.7%). The mean incubation period was 32 hours with a range of 6 to 66 hours.

The Lakeland dealership cohort was comprised of 38 people of which 37 were interviewed. A total of 25 (67.7%) reported gastrointestinal illness following food consumption at their February 9^th banquet in a box celebration. Symptoms included diarrhea (88.0%), abdominal cramps (68.0%), nausea (64.0 %), vomiting (60.0%), chills (36.0%), headache (36.0%), muscle aches (28%), and fever (20.0%). The mean incubation period was 29 hours with a range of 1 to 58 hours. Duration of illness for both cohorts was reported to be approximately 2 days. Secondary cases were reported from four persons interviewed at the Lakeland dealership. Statistical epidemiological analysis of the separate cohorts for significant food product exposure was inconclusive. When the two cohorts were combined and exposure to all available pasta salads were combined into one variable the results were a risk ratio of 2.29, CI=0.87 to 6.00, p=0.0323559, Fishers exact.

As of March 7, 2000 the CDC reports that PCR testing of 41 stools from 9 states (WI, VA, GA, FL, NY, PA, OH, IL, KS) was complete. A total of 29 specimens was positive for Norwalk-like virus. Sequencing results have been completed for 13 stool specimens from 8 states that are all identical. The stool specimens that were received from the implicated catering staff in Ohio were all negative for the Norwalk-like virus. Sera results of the employees are pending.

The analysis of the nationwide data included 297 ill and 375 well persons from 12 states (FL, GA, IL, KS, NC, OH, OK, PA, UT, VA, WI, WV). The median age of ill persons is 37 with a range of 10 months to 89 years. The median number of days ill is 3 days with a range of <1 to 8 days. Symptom profile of cases are described as nausea (76%), vomiting (59%), abdominal cramping (80%), diarrhea (89%), bloody diarrhea (2%), fever (41%), headache (59%), chills (63%) and myalgias 52%.

Univariate analysis shows a significant association between illness and exposure to each of the four salads (potato, marinated vegetable, salami pasta and artichoke pasta). When these salads are combined as one exposure, the risk ratio is 3.69, confidence interval 2.72-5.00. Of 297 ill persons, 281 were exposed to the salads, compared with 243 of the 367 well respondents. The implicated catering facility in Toledo, Ohio had numerous sanitation and hygiene discrepancies and was closed by local health authorities until compliance was achieved. Investigation is continuing to determine the health of the food workers who actually prepared the implicated pasta salads.

Roger Sanderson, RN, MA, Bureau of Epidemiology

National:

Since October 3, 1999, the World Health Organization (WHO) and the National Respiratory and Enteric Virus Surveillance System (NREVSS) laboratories have tested 73,576 respiratory specimens for influenza, from which 12,651 (17%) influenza isolates have been recovered. Influenza A accounted for 12,622 of the 12,651 (99.8%) isolates with 29 isolates being influenza B (0.2%). Of the 3,310 influenza A viruses sub-typed 3,266 (99%) were A (H3N2) and 44 (1.0%) were A (H1N1). Both influenza A and B were isolated in Florida during this time period.

During week 8, influenza activity was reported as widespread in Pennsylvania and regional in 10 states (Alabama, Arizona, California, Louisiana, Massachusetts, New Hampshire, New York, Ohio, Tennessee, and Virginia). Sporadic influenza activity was reported in 35 states, and 4 states reported no influenza activity. During Week 7 widespread influenza activity was reported in 1 states, regional activity in 11 states and sporadic activity in 34 states. No activity was reported for 3 states and 1 state did not report.

During Week 8, the proportion of deaths due to pneumonia and influenza (P&I) was 8.6% as reported by the vital statistics offices of 122 U.S. cities. This percentage is above the epidemic threshold of 7.6% for Week 8. The percentage of pneumonia and influenza deaths has exceeded threshold values for this time of year for 22 of the past 23 weeks. The current season’s P&I figures must be interpreted with caution because important changes have taken place in this year’s case definition that may be contributing to higher estimates of P&I mortality than in previous years. Tampa, St. Petersburg, Jacksonville and Miami are the Florida cities that contributed to this report.

Florida:

Since the beginning of Week 8 (February 20, 2000) a laboratory confirmed isolate of influenza A H3N2/Sydney-like was reported from Hillsborough County. Influenza A H3N2 has also been isolated from Alachua, Baker, Brevard, Broward, Clay, Collier, Duval, Escambia, Gadsden, Indian River, Lake, Leon, Martin, Miami-Dade, Orange, Palm Beach, Pasco, Pinellas, Sarasota, and Volusia counties since October 1, 1999. Previously, influenza B/Yamanashi-like isolate was collected from Broward and Indian River Counties. Untyped isolates of influenza A have been reported from Brevard, DeSoto, and Manatee counties. 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 8, 1% were due to ILI. This week influenza-like illness was reported from providers in 15 (Collier, Duval, Escambia, Indian River, Leon, Martin, Miami-Dade, Palm Beach, Pasco, Pinellas, Polk, Sarasota, Seminole, St. Lucie and Volusia counties) of the 29 Florida counties participating in the National Sentinel Physicians Surveillance Network.

Florida continues to experience a low level of influenza activity. The peak of ILI activity in Florida was in first week of January when the ILI was 5%. This was one week later than the national peak at 6% during Week 52.

The Weekly Disease Table will return soon to the Epi Update.