Division of Disease Control and Health Protection

Richard S. Hopkins, MD, MSPH, Bureau Chief, State Epidemiologist

Steven Wiersma, MD, MPH, Deputy State Epidemiologist

Don Ward, Surveillance Section Administrator, Epi Update Managing Editor

Jill H. Parker, MSP, Epi Update Editor

William J. Bigler, PhD, MS, Senior Epidemiologist, Field Operations Section Administrator

Ursula E. Bauer, PhD, Chronic Disease Epidemiologist, Survey Research Section Administrator

Dan Thompson, MPH, Chronic Disease Section Administrator

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.

"Folic Acid, Birth Defects and PRAMS: Using Data to Guide the Development and Evaluation of a Prevention Initiative in Florida"

Jane Correia, Florida Department of Health

Lori Reeves, MPH, East Central Florida Chapter, March of Dimes

11:00 AM - 12:00 PM EST

Recognizing the importance of ascertaining data on the current level of knowledge among its study population, the PRAMS Survey first included a question related to folic acid in 1996. When looking for Florida specific data to include in grant proposals, PRAMS proved to be the sole source for meaningful information. Working in collaboration, the Florida Department of Health and the Florida March of Dimes Chapters used the PRAMS data as supporting material in grant proposals that have resulted in $360,000 in funding to support important public health initiatives. Being able to accurately describe the need for improved education among Florida's women and health care professionals was essential to the success of these proposals. Folic acid plays an essential role in the prevention of major birth defects and represents an important public health opportunity to improve the lives of families across the nation.

Further details regarding the audio-conference call and PowerPoint files will be posted on the Bureau of Epidemiology Intranet web site. Information about upcoming topics and presenters will also be posted in future Epi Updates.

While we realize you may not always be able to call in at 11:00 AM, it can be distracting to the speakers and others in the audience when participants dial-in throughout the hour. Please try to call in on time and remember to put your phones on mute so as not to disturb others. Thank you for your cooperation.

The Bureau of Epidemiology is pleased to announce that the next Annual Statewide Epidemiology Seminar will be held in Clearwater on October 5^th-6^th. The meeting will provide current information and education to health care professionals regarding the reporting, investigation, and control of communicable and non-infectious diseases of public health significance, with the focus of improving the health of Florida residents and visitors. The primary audience is county health department epidemiology and other related staff. Private physicians, practitioners, professionals in infection control, state and private laboratory staff, etc. are also welcome. Students enrolled in a public health program are also encouraged to participate in the annual seminar. The agenda and registration information will be provided in the Epi Update and on the Bureau of Epidemiology web sites (Intranet and Internet) within the next three weeks.

Brochures and registration forms (including a tentative conference schedule) for the 2000 AFEM were mailed last Friday to everyone on the AFEM mailing list. Registration information is also available on-line from the AFEM website.

Partial sponsorship for the AFEM conference has been secured from Eli Lilly and Company in Indianapolis, Indiana. They are sponsoring the Poster Session and Student Awards, in particular, and will have a representative at the conference. Please encourage all interested parties at your institution/organization to register for the AFEM.

Frances Bosbyshell, R.N., M.P.H. and Jylmarie Kintz, M.P.H., Hillsborough County Health Department, Epidemiology, Albert Vincent, Ph. D., Associate Professor, University of South Florida, Julie Larkin, M.D., Hillsborough County Health Department, Associate Professor, University of South Florida

In April 2000 the Epidemiology Program at the Hillsborough County Health Department received a report of meningococcal meningitis. The patient, a 30-year-old black male, presented at a local emergency room with a one-day history of chills, headache, neck stiffness, and numb feet. He went to the hospital immediately, having recognized the symptoms from a previous episode, and was admitted. Upon examination, the patient was noted to have several petechial lesions on his arms and trunk as well as bilateral conjunctival hemorrhage.

A history was compiled from the patient interview, review of previous epidemiology records, and from hospital medical records. Bacterial meningitis (due to Neisseria meningitidis Group Y) was confirmed by CSF culture at the hospital laboratory and Department of Health Laboratory. In 1996 the same patient had presented to the same hospital with meningeal symptoms of two days duration, at which time he was also CSF culture-positive for Neisseria meningitidis Group Y. Furthermore, he gave a history of meningitis and gonorrhea diagnosed out of state in 1989. Given this history of recurrent Neisseria disease, the patient was tested for immune deficiencies. In both 1996 and 2000 he was found to have subnormal levels of total complement (CH50).

Complement deficiency states may be inherited or acquired. Inherited defects are rare, with a prevalence of approximately 0.03%. Acquired deficiencies can result from acute infection or chronic illnesses such as lupus. The complement and antibody systems work together to provide host defense against microorganisms. Complement consists of 30 proteins, activation of which results in a sequential triggering of subsequent components. The actions of the various complements include promoting inflammatory responses, killing of microbial pathogens, and formation of immune complexes. Complement effects are exerted early in the course of infection. Deficiencies are associated with increased susceptibility to certain infectious diseases. Management of complement deficiency consists primarily of preventive measures and patient education to recognize signs and symptoms early. Prevention of infection is best achieved through immunization against high-risk pathogens (1). In addition to the common childhood immunizations, meningococcal, pneumococcal and H. influenzae vaccines should be considered for complement deficient individuals.

Deficiencies of the terminal complement components (C5-8 and properdin) result in greatly increased susceptibility to Neisseria gonorrhoeae and Neisseria meningitidis (2). Meningococcal disease in complement-deficient individuals is caused by uncommon serogroups, particularly Y, W135, and X. The median age of first infection in deficient individuals is 17 years contrasted to 3 years in the general population. The significance of these age differences is unclear (1). Disease is generally less severe, except in properdin deficiency which is associated with fulminant meningococcal disease.

A high index of suspicion for underlying complement deficiency should arise when a patient presents with recurrent meningococcal disease. In our case, this high-risk individual was a candidate to receive the meningococcal vaccine, a quadravalent vaccine that contains groups A, C, Y and W135 (3). This vaccination had not been previously administered, although the patient had received the pneumococcal and H. influenzae immunizations. Meningococcal vaccine was administered in April 2000.

1. Mandell, Gerald, John Bennett and Raphael Dolin. Principles and Practice of Infectious Diseases, fourth edition, 1995
2. Riott, Ivan, Nathan Brostoff and David Male. Immunology, fifth edition, 1998.
3. Chin, James. Control of Communicable Diseases Manual, 17^th edition, 2000.

Ms. Robin Oliveri, Arbovirus Surveillance Coordinator and Dr. Lisa Conti, State Public Health Veterinarian

At present no Arbovirus Medical Alerts are issued for the state. During the period July 9 through July 15 the following arbovirus* activity was recorded for Florida.

(*mosquito-borne virus including St. Louis encephalitis [SLE] virus, Eastern Equine encephalitis [EEE] virus, West Nile [WN] virus and dengue virus):

Human: No new arbovirus cases were reported to the State Health Office during the week. For the year-to-date, 2 dengue cases were identified (residents of Putnam and Volusia counties, respectively). (Source: County health departments and Department of Health (DOH) laboratories from medical providers).

Sentinel chickens: No sentinel chicken seroconversions were identified (636 tested). For the year-to-date, one chicken from Flagler County seroconverted to EEE virus. (Source: DOH Tampa Laboratory from mosquito control agencies and county health departments) See attached figure (SentsitesJuly15.doc).

Equine: No horses were reported with arboviruses during the week. To date, 16 horses had laboratory results and clinical signs of EEE. (Source: Department of Agriculture and Consumer Services Laboratory from veterinarians)

Bird Mortality: The following dead bird reports were received: Alachua – one crow, Bay – one crow, one mocking bird. Both crows were determined to be too decayed for further testing. Although we are collecting information about any dead bird, at this time, the DOH is testing crows that have died within 24 hours prior to report. To date, 4 crows were tested and none were found to have arboviruses. (Source: Florida Fish and Wildlife Conservation Commission website and DOH Tampa Laboratory).

Mosquito Pools: No mosquito pools were tested at the DOH Laboratory for arboviruses during this period. (Source: DOH Laboratory and mosquito control agencies).

Thank you to everyone who participates in arbovirus surveillance. An updated map entitled EEE in Horses by Owner’s County of Residence and Month of Report (January through June 2000) is attached. The updated Florida Arbovirus Sentinel Sites map is also attached.

The following link was submitted by Roberta Hammond, Division of Environmental Health, Bureau of Environmental Epidemiology.

William J. Bigler, PhD

What do you think, Doctor?

Yours very truly,