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:

1. Notice: 1999 Disease Report Deadline is Friday, April 28th

2. Announcement: Communicable Disease Epidemiology Regional Training to be Held May 9^th -10^th in Lake City

3. Necrotizing Fasciitis Due to Photobacterium damsela in a Man Lashed by a Stingray

4. New Meningococcal Group C Vaccine Showing Success in the UK

5. Hepatitis C Virus One-Pager

6. Announcement: CDC Toll-Free International Travelers' Information Line

7. Epidemiology Grand Rounds Follow-up: Statistical Process Control

8. Announcement: A.G. Holley State Hospital Grand Rounds for April 2000

9. Weekly Disease Table: Week 13

The Centers for Disease Control and Prevention (CDC) established May 12, 2000 as the deadline for 1999 disease reports from state epidemiology offices. County health departments should send all corrected and deleted records to the Bureau of Epidemiology by close of business Friday, April 28, so that the Bureau of Epidemiology may compile a complete report for CY 1999. Also, counties reporting to the Bureau electronically should send their final and complete week 53 reports (temp.zip) by close of business on April 28^th, 2000.

We thank you in advance for your attention and support in this matter.

Melanie Black, LCSW, Bureau of Epidemiology

The Bureau of Epidemiology is pleased to announce the next training program for county health department staff members, which will be held in Lake City, Florida on May 9-10, 2000. The target audiences for the regional training programs are county health department staff members and partner agencies who are involved in epidemiology. County health directors and administrators are welcome to attend.

This program will provide an overview of epidemiological principles such as disease reporting, disease surveillance and communicable disease outbreak investigation. On-line registration is now available through Friday, April 28, 2000 on the Bureau of Epidemiology Intranet web page.

Space is limited so please register as soon as possible.

Additional information will be provided in the Epi Update and on the Bureau of Epidemiology Web page. We intend to offer training programs in other regions of the state this year. If you are interested in hosting one of the training sessions or have questions related to this program, please feel free to contact Melanie Black, Professional Training Coordinator for the Bureau of Epidemiology.

Steven Wiersma, MD, MPH

Dolly Katz, PhD, DOH, Bureau of Epidemiology

Hepatitis C virus (HCV) typically produces a symptomless liver infection that can lead, over decades, to severe liver disease, including cirrhosis and liver cancer. Most of those infected are unaware that they have the disease, and may serve as unknowing sources of transmission. HCV is the most common chronic bloodborne infection in the United States. An estimated 3.9 million Americans (1.8% of the population) have been infected with HCV, and most of those have chronic infections. The virus is transmitted primarily through direct injection of contaminated blood, most commonly by injecting drug use and, before 1992, by blood transfusion. No vaccine is available and no medications have proven effective in preventing infection after exposure, including exposure from accidental needle sticks.

After the acute infection, which produces jaundice or mild, nonspecific symptoms in 20-30% of patients, most people (75-85%) develop chronic infections, characterized by the persistence of viral RNA in the blood. Of those chronically infected, 60-70% have continuous or intermittent elevations of the liver enzyme alanine aminotransferase (ALT), indicating chronic active liver disease. Chronic cases may be diagnosed during blood donor screenings, from liver function tests performed for routine physical exams, or after onset of liver disease. The disease progresses very slowly; within 20 to 30 years after infection, 10% to 20% of those with chronic disease will develop cirrhosis, and 1% to 5%, liver cancer. HCV causes an estimated 8,000 to 10,000 deaths a year in the U.S., with more than $600 million in associated medical and work-loss costs.

Based on national estimates, approximately 220,000 Floridians are chronically infected with the hepatitis C virus, and approximately 2,000 new cases occur each year. However, because the initial stages of hepatitis C infection are either asymptomatic or associated only with mild symptoms, most new infections are not diagnosed. Hepatitis C was made a notifiable disease in Florida in July 1999. Prior to that time, all Hepatitis C cases were classified as hepatitis non-A/non-B, of which about 100 were reported each year. By the end of January 2000, only 49 confirmed new cases of hepatitis C had been reported to the Florida Department of Health for the last six months of 1999. Demographically, Florida cases are similar to the rest of the U.S.: incidence begins to rise in the teen years and peaks in 30-39 year olds, with similar rates among males and females.

The infection is diagnosed by detection of hepatitis C virus antibodies in blood, usually with an enzyme immunoassay (EIA) followed by a confirmatory recombinant immunoblot assay (RIBA) or polymerase chain reaction (PCR). Diagnosis can also be made by detection of viral RNA using gene amplification techniques.

Since screening procedures for blood donors were instituted in the early 1980s, the predominant mode of HCV transmission in the U.S. has been injecting drug use, which accounts for an estimated 60% of new cases. Beginning in 1989, the estimated incidence of HCV infection dropped dramatically in the U.S., from an average of 230,000 new infections a year before 1989 to 36,000 in 1996. The decrease is correlated with a decline in cases among injecting drug users; the reasons for the decline are unclear, but may be related to risk-reduction behaviors among illegal drug users or to saturation of the injecting drug user population.

Although the prevalence of HCV infection is higher among persons with multiple sexual partners (9% among persons with 50 or more lifetime sexual partners), the risk of transmission between long-term steady partners is low. The risk of transmission from mother to child during birth is 5%-6%. Transmission among household contacts has been reported, but is uncommon. While hepatitis B is a well-recognized occupational hazard for health care workers, HCV appears to be less of a threat. Rates of HCV infection in health care workers are the same as or lower than rates in the general population, although unintentional needle stick injury still poses a risk. Previous studies of transmission have found no increased risk associated with medical, surgical or dental procedures; tattooing; acupuncture; ear piercing; or foreign travel, an indication either that these are not risk factors or that the excess risk is too low to detect.

Treatment with alpha-interferon and other drugs has low to moderate effectiveness in reducing ALT to normal levels and eradicating detectable viral RNA in serum. Treatment effectiveness depends greatly on the genotype of the virus; the most common genotype in the U.S is 1, which has the lowest response rate to therapy. Management of HCV infection also includes avoidance of alcohol and vaccination against hepatitis A and B. The effectiveness of treatment of infected persons in preventing transmission is unknown.

No vaccines are currently available to prevent HCV infection, and no medication has been approved for post-exposure prophylaxis. Prevention of HCV infection in the population currently depends on :

• screening of blood and tissue donors;
• risk-reduction counseling and services for high-risk groups like injecting drug users;
• screening (identification, testing, and counseling) of persons at high risk for HCV infection;
• improved population-based surveillance for acute and chronic HCV infection.

Screening programs should include persons who

• ever, even once, injected illegal drugs, including those who injected once or a few times many years ago and do not consider themselves drug users;
• received clotting factor concentrates produced before 1987;
• were ever on chronic (long-term) hemodialysis;
• have persistently abnormal ALT levels;
• received organ transplants before July 1992;
• received transfusions of blood or blood components before July 1992;
• were notified that they received blood from a donor who later tested positive for HCV infection;
• were born to HCV-positive women;
• are healthcare, emergency medical, or public safety workers who had needle stick, sharps, or mucosal exposures to HCV-positive blood.

1. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepaatitis C virus (HCV) infection and HCV-related chronic disease. MMWR 1998;47(No. RR-19).

The following information was excerpted from IAC Express (serial online), Issue Number 154, April 3, 2000

After our March Grand Rounds session, many participants had questions about the use of statistical process control. Heidi Orme, MSPH, provided the following list of references regarding this analytical method.

Topic: HIV Epidemiology Update

TB Update-1999 Review and Priorities for the Future

Date: Wednesday, April 12, 2000

Place: Auditorium

Time: 10:00 a.m. - 12:00 p. m. (EST)

Objectives: By the completion of the presentation, the participants will be able to:

• Compare the HIV/AIDS epidemic in the context of the national and global epidemics.
• Explain the magnitude and direction of the HIV/AIDS epidemic in Florida, including historic and current trends in morbidity and mortality.
• Identify recent shifts in the demographics of the epidemic.
• Demonstrate an understanding of the strengths and limitations of the HIV/AIDS data.

Lunch: Provided free - 12:00 p.m. (reservations required by 4/11 at 10 a.m.)

Sponsors: A. G. Holley State Hospital, American Lung Association of Florida, Inc.,

Teleconference: For those unable to attend in person, you may listen to the lecture via a 30 line conference call # reserved for this purpose. Long distance charges may apply to your phone. Those able to use Suncom will be billed at the state rate of about 7 cents per minute. Please put your phone on mute so you won't disturb the speaker. Questions will be allowed at the end. If available, copies of speaker slides will be e-mailed to you when you register.

Future Topics: The next scheduled A.G. Holley Grand Rounds will be on Thursday, May 11, 2000. Lennox Jeffers, MD, University of Miami, School of Medicine will present "Treating Hepatitis C."