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.

1. Satellite Teleconference Announcement: Introduction to the Merlin Web-based Reporting System

2. County Health Department Assistance Requested to Recruit Physicians for the National Influenza Sentinel Physicians’ Surveillance Network

3. Investigation of Multi-state Clusters of E. coli O157:H7 Cases

4. Weekly Arbovirus Activity Summary

5. Summary Report: Influenza Activity in Florida, 1999-2000 Season

6. Surgeon General Media Advisory on Hepatitis C

7. Three Lots of Imovax Rabies Vaccine Recalled

8. Bureau of Epidemiology "One-Pager" Series: Norwalk-like Viral Gastroenteritis

9. Internet Link: International Conference on Emerging Infectious Disease (ICEID)

10. Weekly Disease Table: Week 30

Title: Introduction to the Merlin Web-based Disease Reporting System

Date: August 14, 2000

Time: 2 – 4 PM EST

Satellite Test: 1:30 PM – 2:00 PM

Target Audience: County health department disease reporting and epidemiology staff

Objective: To introduce the Merlin web-based disease reporting system to county health department staff that report communicable disease data to the Bureau of Epidemiology.

Description:

The purpose of this teleconference is to introduce county health department disease reporting and epidemiology personnel to the Merlin web-based disease reporting system, which will be up and running in every county health department beginning January 1, 2001. The Merlin system will become the standard disease reporting system for the Bureau of Epidemiology, replacing the current paper-based disease reporting system. Participants will be guided through the system at its current stage of development and will have an opportunity for a question and answer session. Extensive training will be provided in future sessions to be announced.

Registration: Please register with your local satellite site coordinator by August 11, 2000. A list of the site coordinators for each county is posted on the Department of Health Intranet web site (go to Office of Performance Improvement, then click on "training").

Carina Blackmore, MS Vet.Med., PhD, Bureau of Epidemiology

It is time to start recruiting physicians for the 2000-2001 National Influenza Sentinel Physicians’ Surveillance Network. We need pediatricians and other primary care physicians who are interested and willing to:

1. Report clinical cases of influenza-like illness to CDC on a weekly basis between October 2000-May 2001
2. Submit throat swabs (free of charge) to our state labs for virus isolation testing.

Goals of the surveillance program are to better monitor the morbidity of disease locally and nationally; to collect influenza virus strains for vaccine development and to monitor the patterns of antigenic drift/ shift (mutations); and to detect potential pandemic influenza strains and possible bio-terrorist agents that cause respiratory symptoms.

Mike Friedman, M.P.H., Roberta Hammond, Ph.D., Bureau of Environmental Epidemiology

During the last few weeks, increasing numbers of E. coli O157:H7 cases have been reported throughout Florida. None of these cases has resulted in hemolytic-uremic syndrome (HUS). Twenty-six cases of E. coli O157:H7 have been reported recently with onsets of symptoms dating from June 25, 2000 to July 18, 2000. Florida has been averaging approximately 23 cases of E. coli O157:H7 per year. The molecular biology section of the Bureau of Laboratories in Jacksonville, has identified matching Pulse Field Gel Electrophoresis (PFGE) patterns among a cluster of six E. coli cases and another matching pattern among a cluster of four other E. coli cases.

There has not been any geographic clustering of reported cases of E. coli O157:H7 in the state. Cases seem to be scattered throughout Florida, including those with matching PFGE patterns. Ages of cases range from 5 to 91 years. Five of the six cases of E. coli with matching patterns had reported ground beef consumption a few days before their onset of symptoms; exposure to canteloupe has also been identified in the one case. Hamburger and ground beef exposure have been the most common food vehicles identified through case investigation. A second cluster of four E. coli cases with a different matching PFGE pattern has since been identified. Only limited information is available at this time on the one case reporting consumption of canteloupe.

PFGE patterns were sent out through the PulseNet Computer Network by Paul Fiorella, Bureau of Laboratories. PulseNet provides a forum for public health laboratories to share information that will help rapidly identify and stop episodes of foodborne illness. Matching PFGE patterns have also been identified by seven other states including: New York, Colorado, Minnesota, Wisconsin, California, Connecticut and Washington. Additional PFGE enzyme analysis is being performed by each state to ensure that the identified E. coli clusters are true matches.

According to the Centers for Disease Control and Prevention (CDC), forty cases of E. coli O157:H7 with matching PFGE patterns have been recently identified in eight states. Onset dates of cases have ranged from May 7, 2000 to July 11, 2000. The ages of cases range from 8 months to 93 years, with a median age of 20 years. The most commonly identified food vehicles have been ground beef & cantaloupe. Several of the cases purchased food items from one of two grocery store chains, however the significance of these data is not clear at this time.

The Connecticut and California Departments of Health have developed an E. coli questionnaire to better understand the recent E. coli clusters. The questionnaires are designed to collect extended food and water histories of E. coli O157:H7 matching cases.

There is also an E. coli O157:H7 PFGE matching pattern reported among 4 or 5 states at this time. This PFGE pattern does not match any Florida cases and only very limited surveillance information is available on these cases.

Carina Blackmore, MS Vet. Med., PhD, Bureau of Epidemiology

Influenza activity in Florida last winter began to increase in mid-December 1999 and peaked during the week ending January 7, 2000 (week 1). The percentage of influenza-like illness (ILI) patient visits to physicians participating in the influenza sentinel surveillance network increased above baseline levels (0-3%) 3 of the 4 weeks following the week ending December 18 (week 50) (Figure 1).

Twenty-seven percent of the specimens cultured in our state laboratories (n=522) were positive for influenza. Most (97%) of the isolates were influenza A/H3N2/ Sydney, however influenza A/H1N1 and influenza B were also isolated (Figure 1, Figure 2).

Fifty-three clinics in 24 Florida counties participated in the influenza sentinel surveillance network last year (Figure 2, Figure 3). The goal of this program is to have 1 sentinel physician/ 250,000 Florida residents, a goal we hope to achieve during the 2000-2001 season.

Sporadic outbreaks of influenza (regional activity) were reported to the state health office during weeks 52-2.

Influenza activity in Florida corresponded well with the influenza activity nationwide. Based on genetic testing of virus strains CDC concluded that overall, the 1999-2000 influenza vaccine strains were well matched to circulating influenza virus strains. However, worldwide influenza A\H1N1\New Caledonia and A\H3N2\Panama were more prevalent than last years vaccine strains (A\H1N1\Bayern and A\H3N2\Sydney) and will replace last years strains in the 2000-2001 influenza vaccine.

There are currently no Arbovirus Medical Alerts issued for the state. During the period 7/22/00 through 7/29/00, the following arbovirus* activity was recorded for Florida:

(*Mosquito-borne virus including St. Louis encephalitis virus, Eastern Equine encephalitis virus, West Nile encephalitis virus and dengue virus)

Human: No new arbovirus cases were reported to the State Health Office.

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

Bonnie Kwan, MPH, Hepatitis Program Coordinator and Steven Wiersma, MD, MPH, Deputy State Epidemiologist

The Surgeon General, Dr. David Satcher, issued a media advisory on Thursday, July 27, 2000 on hepatitis C. Hepatitis C, often referred to as the "Silent Epidemic", is believed to affect approximately four million Americans, which is four times the number of HIV infections nationally. In Florida, this translates to more than 270,000 hepatitis C infections. This advisory will be used to disseminate prevention recommendations on hepatitis C.

According to the recommendations published by the Centers for Disease Control and Prevention, the following individuals are at increased risk of hepatitis C and are urged to get tested: injection drug users (even once); transfusion or transplant recipients (prior to July 1992); recipients of a blood product for clotting problems produced before 1987; individuals on long-term kidney dialysis; individuals who have received needle sticks contaminated with HCV-infected blood; and individuals born to an HCV-positive mother.

The Florida legislature recognized the importance of viral hepatitis and supported the development of a comprehensive hepatitis and liver failure control and prevention program. Testing is available through the state laboratory and a contract for a state-wide hotline with additional home-based testing will be finalized soon.

The Centers for Disease Control and Prevention (CDC) published a "Notice to Readers" in the July 28, 2000, issue of the MMWR entitled "Voluntary Recall of IMOVAX

Rabies I.D. (Rabies Vaccine) Used for Pre-Exposure Prophylaxis." The notice reads as follows:

Norwalk-like viruses (NLV) are the most common cause of epidemic gastroenteritis in the United States [1]. Each year, approximately 23 million persons develop NLV gastroenteritis in the United States [1]. NLV gastroenteritis (also known as "winter vomiting disease") is usually a self-limiting, mild to moderate disease [2]. Persons of all ages are affected because previous infection confers only short-term immunity [1].

Signs and symptoms can include diarrhea, vomiting, abdominal pain, nausea, headache, and low-grade fever [2]. NLV are small, structured RNA viruses classified as caliciviruses. The incubation period is approximately 24 to 48 hours. Gastrointestinal symptoms last 24 to 48 hours. The likely mode of transmission is the fecal-oral route. NLV have been implicated in foodborne outbreaks and outbreaks where the mode of transmission was person-to-person [1,3]. The virus may be shed in feces up to 48 hours after recovery. Airborne transmission is also possible.

Humans were previously thought to be the only reservoir of NLV [2], but a recent report suggests that farms animals can also harbor these agents also [4]. Zoonotic transmission has not been documented.

Outbreaks of NLV gastroenteritis are often seen in long-term care facilities and other institutions where people live in close proximity. Facility staff should practice good hygiene including hand washing before and after contact with residents and guests. Hands are the most likely means by which viral spread occurs and therefore should be washed after contact with ill persons or contaminated clothing. Wearing masks when cleaning up diarrhea and vomitus of ill residents or handling soiled linen may prevent inhalation of droplet nuclei to which the virus is attached. Soiled linen should be transported in an enclosed manner, for example, in a plastic bag, and agitation of the linen should be kept to a minimum. For more information please refer to Morbidity and Mortality Weekly Report Volume 39, No. RR-5: Viral Agents of Gastroenteritis Public Health Importance and Outbreak Management.

Other recommendations:

1. Staff and visitors who are ill should remain at home
2. Do not move ill residents to other parts of the facility
3. Do not allow staff to work on more than one wing
4. Cancel communal activities for the duration of the outbreak

The Bureau of Laboratories (Tampa Branch) offers polymerase chain reaction (PCR) testing of stool specimens for NLV (see January 13, 1999, issue of the "Epi Update"). Stool should only be collected from acutely ill individuals or individuals who have recovered within the past two days. Please contact your Regional Epidemiologist from the Bureau of Epidemiology for information on the collection and shipment of stool for Norwalk testing.

Kathryn Snavely, Bureau of Epidemiology

Click on the link below to access selected presentations and panels from the recent International Conference on Emerging Infectious Diseases.