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EPI UPDATE
A weekly publication by the Bureau of Epidemiology
For August 30, 2000
"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.
Richard S. Hopkins, MD, MSPH, Bureau Chief, State Epidemiologist
Don Ward, Surveillance Section Administrator, Epi Update Managing Editor
Jill H. Parker, MSP, Epi Update Editor
Bureau of Epidemiology Frequent Contributors:
|
Steven Wiersma, MD, MPH,
Deputy State Epidemiologist |
William J. Bigler, PhD, MS,
Senior Epidemiologist |
Jodi Baldy, MPH,
Biological Scientist IV |
|
Ursula E. Bauer, PhD,
Chronic Disease Epidemiologist |
Lisa Conti, DVM, MPH,
State Public Health Veterinarian |
Regional Epidemiologists:
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Dolly Katz, PhD, MPH,
SE Florida |
Roger Sanderson, RN, MA,
SW Florida |
Carina Blackmore, MS Vet. Med., PhD,
NE Florida Carina Blackmore, MS Vet. Med., PhD, |
Zuber Mulla, MSPH,
Central Florida Carina Blackmore, MS Vet. Med., PhD, |
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.
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.
In this issue:
1. Ciguatera Intoxication, Palm Beach County
2. A Look at Fox Rabies in Florida
3. Don’t Forget to Register for the Annual Statewide Epidemiology Seminar to be Held in Clearwater, October 5-6, 2000
4. Live Satellite Broadcast: Medical Response to Chemical Warfare and Terrorism
5. Weekly Arbovirus Activity Summary
6. Florida Past – News Nuggets
7. Weekly Disease Table: Week 34
1. Ciguatera Intoxication, Palm Beach County
Janet Wamnes, M. S., Bureau of Environmental Epidemiology
Roberta M. Hammond, Ph.D., Bureau of Environmental Epidemiology
Jim Masters, Palm Beach County Health Department, Division of Epidemiology and Disease Control
Background
On August 22, 2000, the Palm Beach County Health Department, Division of Epidemiology and Disease Control (PBCHD-DEDC) was informed by an infection control nurse at a local hospital of a possible ciguatera intoxication occurring on August 16 after three persons consumed hog snapper at a local restaurant on August 15. A separate party who had also eaten at the same restaurant on August 15 informed the PBCHD-DEDC that one of their party had eaten hog snapper and had developed similar symptoms on August 16. On August 23, the health department became aware of 2 more cases via the Florida Poison Information Center. Fish from the same source, bought from the same fish market, had been consumed by 2 additional people on August 12 and they became symptomatic on August 13.
Investigation
The first group of three persons developed diarrhea and abdominal cramps within 5 hours after consuming the fish. Later they developed rashes, tingling and numbness in the gums, itching, weakness in legs, reversal of hot-cold sensations, and difficulty urinating, with recurring symptoms of severe itching and weakness. The person from the second party experienced symptoms including vomiting, diarrhea, abdominal pain (within 5 hours of ingestion), and later developed reversal of hot-cold sensations, body aches, itching, and weakness in the legs.
The Bureau of Environmental Epidemiology, the Palm Beach County Health Department, Division of Environmental Health (PBCHD-EH), and the Department of Business and Professional Regulation were immediately notified. A joint investigation of the restaurant was made on August 23. Invoices of the suspected fish, hog snapper, were provided to the inspectors. No leftover hog snapper was available at the restaurant. Ten (10) pounds of hog snapper fillets had been purchased from a local fish market on August 15.
In addition, on August 23, the Bureau of Environmental Epidemiology became aware of 2 more cases of possible ciguatera poisoning occurring after consuming 12 ounces each of hog snapper bought at the same fish market as above on August 12. These persons also developed symptoms compatible with ciguatera including vomiting, diarrhea, reversal of hot-cold sensations, itching, and weakness in the legs on August 13. The Florida Department of Agriculture and Consumer Services was immediately notified of the complaint and an investigation of the fish market was conducted on August 24.
Summary
A total of 6 cases of ciguatera intoxication from the consumption of fish bought at the same fish market from the same supplier and same lot were identified. Four of the cases consumed the fish at the same restaurant on the same day, August 15, 3 in one party, one in another party. Two of the cases had consumed fish 3 days earlier, August 12, at home. The fish market had bought 138 pounds of hog snapper (12 to 15 fish) from a licensed supplier in Miami-Dade County on August 12 (invoices were provided). According to the supplier, the fish had been caught in the Bahamas. All of the hog snapper had been sold. No leftover cooked or uncooked hog snapper was available for testing. No further cases were identified in this outbreak.
Ciguatera poisoning is a notifiable (reportable) disease in Florida (s. 64D-3.002(1)j), Florida Administrative Code) and should be reported to the local county health department by the attending physician. It is a form of human poisoning caused by the consumption of subtropical and tropical marine finfish which have accumulated naturally occurring toxins through their diet. Marine finfish most commonly implicated in ciguatera fish poisoning include the groupers, barracudas, snappers, jacks, mackerel, and triggerfish. Many other species of warm-water fish harbor ciguatera toxins. The occurrence of toxic fish is sporadic, and not all fish of a given species or from a given locality will be toxic. The ciguatera toxins can be recovered from toxic fish through tedious extraction and purification procedures. The mouse bioassay is a generally accepted method of establishing toxicity of suspect fish.
Clinical testing procedures are not presently available for the laboratory diagnosis of ciguatera in humans. Diagnosis is based on symptom history and recent dietary history. Initial signs of poisoning occur within six hours after consumption of toxic fish and include perioral numbness and tingling (paresthesia), which may spread to the extremities, nausea, vomiting, and diarrhea. Neurological symptoms include intensified paresthesia, arthralgia, myalgia, headache, temperature sensory reversal and acute sensitivity to temperature extremes, vertigo, and muscular weakness to the point of prostration. Cardiovascular signs include arrhythmia, bradycardia or tachycardia, and reduced blood pressure. Ciguatera poisoning is usually self-limiting, and signs of poisoning often subside within several days from onset. However, in severe cases the neurological symptoms are known to persist from weeks to months.
2. A Look at Fox Rabies in Florida
Dr. Lisa Conti, State Public Health Veterinarian
Foxes are known to be exquisitely sensitive to rabies virus , surpassing other animals in susceptibility (Winkler, 1975). Virus strain work since the 1980s at CDC and more recently at our DOH Jacksonville Laboratory shows that the foxes are being infected by raccoon rabies strain. During the 18-year period, 1975 through 1992, an annual average of 4 fox rabies cases were reported, largely seen in the northern part of the state. However, during 1993 through 1999, the annual mean increased to 22, with cases reported throughout Florida. For the year to date, 19 fox rabies cases have been reported. The increase may be explained, in part, by reduction of wildlife habitat - development of rural areas, and perhaps an increase in people feeding pets or wildlife that encourages commingling of rabies vector species.
According to James Moses of the St. Lucie County Health Department, their first animal to test positive for rabies since 1997 was a fox. One person was known to have been bitten by this animal and is undergoing anti-rabies treatment. Mark Crowley, Collier County Health Department, described a recent fox rabies situation as follows. "In this particular case, the fox followed a person into his home and bit the individual on the hand and foot. When Domestic Animal Services (DAS - animal control) arrived the fox was dead. Fortunately this occurred in a relatively low density population area of the county. DAS is going door-to-door in this area at our request to find out if other residents encountered the animal and to provide rabies prevention education/information."
In their press release, the Collier County Health Department and Collier County Domestic Animal Services urge all residents and visitors to take the following standard precautions that should reduce the possibility of rabies exposure to humans or pets:
- Avoid contact with wild animals, especially raccoons, feral cats, foxes, skunks, bats and bobcats.
- Make sure that your dogs and cats have current rabies vaccinations and are wearing rabies tags. If your pets must go outside, they must be leashed. Dogs and cats found running loose will be impounded.
- Do not feed your pets outside. Pet food attracts wildlife.
- Children and adults should stay away from wild animals and unknown dogs and cats. Children should inform an adult if they are bitten or scratched by an animal. Please educate children in this regard as a rabid animal can transmit the disease to domesticated animals which in turn can infect humans.
- Do not touch dead animals.
- Do not keep wildlife as pets.
If you have questions about rabies in Florida, please see the DOH website www.doh.state.fl.us, click on Epidemiology, then Health Topics, then rabies.
3. Don’t Forget to Register for the Annual Statewide Epidemiology Seminar to be Held in Clearwater,
October 5-6, 2000
The Bureau of Epidemiology is pleased to announce that the next Annual Statewide Epidemiology Seminar (ASES) will be held in Clearwater on October 5th-6th.
The meeting will provide current information and education to public health
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 epidemiologists 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.
Conference Registration
The regular registration fee for the ASES is $100 if postmarked on or before September 27, 2000 ($120 if submitted after September 27, 2000). Students providing valid identification are offered registration at a discounted fee of $50 if postmarked on or before September 27, 2000 ($60 if submitted after that date). Attached is the conference registration form. Registration forms and payments should be mailed or faxed to:
Gulfcoast North AHEC, Inc.
6763 Land O’ Lakes Blvd.
Land O’ Lakes, FL 34639
Note: Cancellations must be confirmed in writing (fax acceptable) and received by the Gulfcoast North AHEC by 5:00 pm on Wednesday, September 27, 2000 to receive a full refund. Refunds will not be offered for "no shows;" however, substitutions are welcome without additional cost.
Hotel Information
The ASES will be held at the Belleview Biltmore in Clearwater, Florida. A block of rooms has been reserved for the occasion ranging from $86 (single/double occupancy) to $159 per night. To obtain the special conference rate, reservations should be made no later than September 4, 2000. If you can not attend the meeting, please cancel your reservations no later than seven (7) days prior to your scheduled arrival date to avoid forfeiture of deposit. Please contact the Belleview Biltmore to make your reservations.
4. Live Satellite Broadcast: Medical Response to Chemical Warfare and Terrorism
Sponsored by the U.S. Army Medical Command 5, 6, and 7 December 2000
1230 to 1630 Eastern Standard Time (EST)
This live, interactive, three-day satellite broadcast will inform and educate health care professionals and first responders serving the military and supporting civil defense/domestic preparedness programs about chemical agents and the proper medical responses in the event of intentional or accidental chemical agent exposure. It will also discuss battlefield management, decontamination of casualties, and personal protective equipment. Discussions on antiterrorism will be integrated throughout. The
program will feature discussions with world-renowned scientists, researchers,
clinicians and counter-terrorism experts.
5. Weekly Arbovirus Activity Summary
Ms. Robin Oliveri, Arbovirus Surveillance Coordinator and Dr. Lisa Conti, State Public Health Veterinarian
There are currently no Arbovirus Medical Alerts issued for the state. During the period August 19 through August 26, 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: One dengue case from Leon County was reported to the State Health Office with a recent travel history to the Dominican Republic. This represents the third dengue case for the year (the other two were residents of Putnam and Volusia counties, respectively).
Sentinel chickens: No sentinel chicken seroconversion was identified among 680 chickens tested this week. To date, 9,340 sentinel sera have been examined among which 8 showed seroconversion to SLE and 3 to EEE. (Source: DOH Tampa Laboratory from mosquito control agencies and county health departments).
Equine: No horses were reported with arboviruses. To date, 53 horses have been tested with 16 showing seroconversion to EEE. (Source: Department of Agriculture and Consumer Services Laboratory from veterinarians).
Bird Mortality: Four dead birds were reported from the following counties: Escambia-1, Dade-1, Gilchrist-3, and Palm Beach-4. Test results are pending on the Dade County specimen. 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, 7 birds have been tested for arboviruses and were negative. (Source: DOH Tampa Laboratory and the Florida Fish and Wildlife Conservation Commission website).
Wild Bird: A captive Barbary Falcon was identified with EEE in Leon County on August 9, 2000.
Mosquito Pools: No mosquito pools were tested for arboviruses during this period. (Source: DOH Laboratory and mosquito control agencies).
6. Florida Past - News Nuggets
William J. Bigler, PhD
In the early 1900s the State Board of Health used every means at its disposal to reach the people with a variety of disease prevention and control initiatives, including fly control and the evils of patent medicines. In many cases it was difficult to get the message across. The Board was pleased to have the support of the "Power of the Press." It was not uncommon to find reprinted articles from local newspapers in the monthly Florida Health Notes. A few items from the March 1916 issue follow:
PATENT MEDICINE
It is impossible now-a-days to pick up a daily paper without seeing where Bill Smith gained fifty pounds a week by taking a certain popular medicine and where old lady Snoggins had been bedridden all her natural life, but after taking two doses is able to play football. We admit that this is past belief - marvelous.
Last week a friend of ours told us that he was in the habit of passing a certain drug store where a popular medicine is being sold. He passes this store three times a day. He noticed that he was gaining in weight and in two weeks had took [sic] on eight pounds. He was astounded and decided to change his route. In a few days he got back to his normal weight.
Alf Ziegenbiemingozk, a Russian, had lost his great grandpa in the Civil War. He picked up a daily paper and saw the ad. His next move was to a drug store, where he purchased a bottle. Going to the cemetery he dug up his grandpap, poured a dose down him and now his grandaddy can plow from sunup to sundown. He is getting younger every day and Alf fears that if he keeps getting younger he will soon be a baby and he will lose a good plow hand.
Mike Billinghurst looked like a knitting needle. Every time the wind blew it made such noise among Mike’s bones that it disturbed his friends. He bought a bottle. His manager is now busy trying to arrange a match with Jesse Willard this summer. Try a bottle. - Macclenny Standard
FLIES AND SCREENS
The state law says flies must be screened from all places where food, that is to be served uncooked, is offered for sale and that earth closets must be screened, and Sheriff Denmark says the law is to be enforced. Now why in common sense do you want to be forced to keep healthy? The law is for your own protection and if you have the proper regard for yourself you will keep it without being forced to do so.
It is a fact, beyond dispute, that flies, more than any other agency, are responsible for typhoid fever. More than twice as many soldiers died by typhoid fever than by Spanish bullets during the Spanish-American war, and this great death rate was due to flies.
First screen your closets and prevent infection as well as breeding, then screen your food to prevent your neighbor’s flies from infecting it. - Raiford Tribune
FLIES IN RESTAURANTS AND HOTELS
Restaurants or hotels in Miami in which flies are found are operating in direct violation of the city health ordinances. We have never seen a policeman, however, march in and place the offenders under arrest. The fly carries typhoid fever, tuberculosis and many other terrible diseases, and the strictest regulations should be enforced against them. - Miami Herald
PUBLIC HEALTH EDUCATION
With demonstration trains, showing how to preserve the health and safety of the people from the little baby up, the people of this great country are given excellent opportunity to learn some lessons that would otherwise be possible for only a few and at great expense to them. Education along the right lines is far better than laws which seek to compel although the latter are of course necessary. It is the same with physical and moral health. Teach the people how to live and act for their own best interests and they will come nearer observing the proper laws than in the case of observing the "thou shalt not" variety. - Fort Myers Press
7. Weekly Disease Table: Week 34
County-Confirmed Cases, Sorted Alphabetically by Disease
(NR represents years that the disease lacked status as a reportable condition)
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DISEASE |
1997 TO DATE |
1998 TO DATE |
1999 TO DATE |
3 YEAR AVERAGE
TO DATE |
1999 TOTAL CASES |
2000 TO DATE |
|
Anthrax |
0 |
0 |
0 |
0 |
0 |
0 |
|
Botulism |
0 |
0 |
0 |
0 |
4 |
0 |
|
Brucellosis |
0 |
2 |
1 |
1 |
3 |
2 |
|
Campylobacteriosis |
634 |
474 |
594 |
567.3 |
988 |
620 |
|
Ciguatera |
6 |
7 |
2 |
5 |
2 |
4 |
|
Cryptosporidiosis |
73 |
83 |
81 |
79 |
180 |
60 |
|
Cyclosporiasis |
62 |
6 |
3 |
23.7 |
5 |
6 |
|
Dengue |
2 |
2 |
2 |
2 |
3 |
2 |
|
Diphtheria |
0 |
0 |
0 |
0 |
0 |
0 |
|
E. coli O157:H7 |
35 |
25 |
34 |
31.3 |
55 |
51 |
|
E. coli , other (known serotype) |
5 |
3 |
13 |
7 |
15 |
7 |
|
Ehrlichiosis, Human |
2 |
0 |
1 |
1 |
2 |
3 |
|
Encephalitis, Eastern Equine |
2 |
0 |
0 |
0.7 |
3 |
0 |
|
Encephalitis, St. Louis |
0 |
0 |
0 |
0 |
4 |
0 |
|
Encephalitis, post-infectious1 |
7 |
3 |
3 |
4.3 |
5 |
4 |
|
Encephalitis, other (known organism) |
6 |
7 |
5 |
6 |
14 |
6 |
|
Giardiasis (acute) |
940 |
824 |
671 |
811.7 |
1322 |
797 |
|
Haemophilus influenzae , invasive1 |
17 |
29 |
35 |
27 |
53 |
34 |
|
Hansen’s Disease (Leprosy) |
0 |
3 |
2 |
1.7 |
3 |
3 |
|
Hantavirus Infection |
0 |
0 |
0 |
0 |
0 |
0 |
|
Hemolytic Uremic Syndrome |
3 |
6 |
6 |
5 |
7 |
8 |
|
Hemorrhagic Fever |
0 |
0 |
0 |
0 |
0 |
0 |
|
Hepatitis A |
305 |
319 |
416 |
346.7 |
796 |
306 |
|
Hepatitis B |
244 |
256 |
256 |
252 |
528 |
300 |
|
Hepatitis C |
NR |
NR |
33 |
NR |
55 |
26 |
|
Hepatitis Non-A, Non-B |
58 |
57 |
3 |
39.3 |
10 |
6 |
|
Hepatitis, perinatal B |
NR |
NR |
1 |
NR |
2 |
1 |
|
Hepatitis, unspecified |
5 |
7 |
10 |
1 |
17 |
7 |
|
Hepatitis, +HBsAg, pregnant woman |
NR |
NR |
191 |
NR |
448 |
253 |
|
Lead Poisoning |
871 |
1121 |
1065 |
1019 |
1810 |
527 |
|
Legionellosis |
18 |
23 |
14 |
18.3 |
27 |
30 |
|
Leptospirosis |
0 |
1 |
0 |
0.3 |
1 |
1 |
|
Listeriosis |
NR |
NR |
19 |
NR |
37 |
18 |
|
Lyme Disease |
17 |
26 |
19 |
20.7 |
51 |
24 |
|
Malaria |
50 |
37 |
54 |
47 |
97 |
53 |
|
Measles |
3 |
2 |
2 |
2.3 |
2 |
1 |
|
Meningococcal Disease (N. meningitidis) |
104 |
90 |
75 |
89.7 |
122 |
77 |
|
Meningitis, Group B Streptococci |
11 |
11 |
10 |
10.7 |
14 |
12 |
|
Meningitis, Haemophilus influenzae1 |
6 |
11 |
11 |
9.3 |
13 |
4 |
|
Meningitis, Streptococcus pneumoniae |
53 |
56 |
71 |
60 |
97 |
61 |
|
Meningitis, Listeria monocytogenes |
2 |
4 |
6 |
4 |
14 |
4 |
|
Meningitis, other bacterial (including unspecified) |
37 |
38 |
36 |
37 |
62 |
57 |
|
Mercury Poisoning |
2 |
0 |
2 |
1.3 |
7 |
7 |
|
Mumps |
8 |
9 |
3 |
6.7 |
6 |
2 |
|
Neurotoxic Shellfish Poisoning |
0 |
0 |
0 |
0 |
0 |
0 |
|
Pertussis |
48 |
29 |
57 |
44.7 |
85 |
42 |
|
Plague |
0 |
0 |
0 |
0 |
0 |
0 |
|
Poliomyelitis |
0 |
0 |
0 |
0 |
0 |
0 |
|
Psittacosis |
0 |
1 |
0 |
0.3 |
0 |
0 |
|
Q Fever2 |
NR |
NR |
NR |
NR |
0 |
0 |
|
Rabies, Animal |
195 |
133 |
125 |
151 |
186 |
107 |
|
Rocky Mountain Spotted Fever |
2 |
1 |
2 |
1.7 |
2 |
2 |
|
Rubella, including congenital |
1 |
3 |
0 |
1.3 |
1 |
3 |
|
Salmonellosis |
1144 |
1354 |
1443 |
1313.7 |
3071 |
1425 |
|
Shigellosis |
786 |
1342 |
888 |
1005.3 |
1491 |
828 |
|
Smallpox |
NR |
NR |
0 |
NR |
0 |
0 |
|
Staphylococcus aureus, (GISA/VISA) |
NR |
NR |
0 |
NR |
0 |
0 |
|
Staphylococcus aureus, (GRSA/VRSA) |
NR |
NR |
0 |
NR |
0 |
0 |
|
Streptococcal Disease, invasive Group A |
24 |
31 |
44 |
33 |
94 |
88 |
|
Streptococcus pneumoniae , invasive disease, drug resistant |
135 |
295 |
374 |
268 |
701 |
680 |
|
Tetanus |
1 |
2 |
2 |
1.7 |
3 |
0 |
|
Toxoplasmosis |
4 |
7 |
10 |
7 |
17 |
6 |
|
Typhoid Fever |
7 |
10 |
22 |
13 |
23 |
7 |
|
Vibrio cholerae (serogrp O1) |
0 |
0 |
0 |
0 |
0 |
0 |
|
Vibrio cholerae (serogrp Non-O1) |
6 |
6 |
8 |
6.7 |
10 |
4 |
|
Vibrio vulnificus |
9 |
16 |
10 |
11.7 |
23 |
3 |
|
Vibrio other (including unspecified) |
20 |
51 |
27 |
32.7 |
48 |
25 |
|
Yellow Fever |
0 |
0 |
0 |
0 |
0 |
0 |
1 Haemophilus influenzae can be the agent responsible for disease under three of the reportable conditions listed-: "Haemophilus influenzae, invasive" and under "Encephalitis, post infectious." Cases of Haemophilus influenzae meningitis are reported under "Meningitis, H. influenzae."
2 The reportable disease rule was revised in June 2000. Amebiasis and Toxic Shock Syndrome (Staphylococcal and Streptococcal) were deleted from the list of reportable diseases. Q Fever was added to the list of reportable diseases.
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