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.

2. Deep Infection Following a Body Piercing Event

3. Descriptive Epidemiology of Suicide in Volusia County

4. Factors Facilitating Dispersal of West Nile Virus

5. CDC Hospital Infections Program (HIP) Begins New Endeavor to Monitor Antimicrobial Use and Resistance

6. Weekly Disease Table: Week 36

Don’t forget to register for the Annual Statewide Epidemiology Seminar (ASES) which will be held October 5-6 in Clearwater, Florida. 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.

Bill L. Toth, MPH, Orange County Health Department

On August 31, 2000 the epidemiology section of the Orange County Health Department received a call from a news producer at WFTV, Channel 9. The producer called to follow-up on a body piercing complaint received from a viewer. The reporter alleged a young Orlando woman sustained a serious infection following a nipple piercing procedure. The TV station claimed to have known of the incident for three weeks and that the woman had to have part of her breast excised to the point of possibly restricting her ability to breast feed her future children. The news channel wanted to use the story to heighten public awareness of the dangers of body piercing, to follow up on the Department of Health’s progress in regulating piercing salons and, moreover, to seek advice for the public to follow when visiting salons. The request for an interview was welcomed. Epidemiology staff followed-up with the affected individual (name released by the station). A summary of the information obtained is as follows.

Current rules allow the public to report complaints of infection or other situations in body piercing salons, however the public may not be aware of the rule or method to report (see editorial note for reporting procedure information). Special voluntary reporting of incidents similar to this will be requested from walk-in clinics and emergency departments in Orange County.

Although the woman is of the opinion that the infection was the fault of the salon or operator, the span of time between the salon visit and onset of signs and symptoms is suggestive of individual failure in after-care follow up. The question of needle reuse on one individual may not account for the source of infection; health department nursing observation of piercing techniques suggests that the operators typically use relatively large bore needles. Removal of the needle allows for the wound to immediately close and disallows the jewelry to be inserted. The operator usually inserts the ring end into the bore and withdraws the needle while guiding the jewelry through the wound. In this case, the operator used two needles, one for each side or, in fact reused the needle. The individual did not provide eyewitness for the event due to her nervousness (she kept her eyes shut). Her personal description of the infection and ensuing discharge may be suggestive of a staphylococcal infection deep in the mammary ducts. To determine actual source of infection at this time may not be feasible.

Body piercing salons are now required to obtain an annual Department of Health license through their county health department. The licensure requirement is part of Florida Statute 381.0075, which went into effect on October 1, 1999.

The Department of Health has provided body-piercing salons with copies of the law stating the new licensing requirement. The new law requires the following:

• training in infection control procedures must be documented prior to the issuance of a license;
• salons must provide customers with instructions for after-care;
• salons must sterilize all instruments and jewelry directly used in piercing procedures;
• salons must sanitize all equipment indirectly used in piercing procedure;
• notarized parental or legal guardian consent is required for minors under the age of 18, with minors under the age of 16 requiring the accompaniment of a parent or legal guardian;
• salons must provide information on the mechanism for filing a complaint (complaints may be filed directly with the body piercing salon or the county health department in which the salon operates) and
• salons must have annual health department inspections completed.

For additional information, please contact Edith Coulter, Division of Environmental Health, Bureau of Facility Programs.

Zuber D. Mulla, MSPH, Bureau of Epidemiology, and Bonnie Sorensen, MD, MBA, Director, Volusia County Health Department

Central Florida newspapers have recently reported that the suicide rate in Volusia County is higher than expected [1, 2]. They have described this perceived cluster of suicides as "staggering" and an "epidemic." A suicide prevention and education conference has been planned for October 16, 2000, in Daytona Beach [3].

The Volusia County Health Department (CHD) and the Florida Bureau of Epidemiology have initiated a review of suicide data. Preliminary results are shown below. The annual number of suicides and age-adjusted annual suicide rates were obtained from the Florida Department of Health’s Public Health Indicators Data System (PHIDS) (rates were adjusted to the year 2000 standard million). PHIDS can be accessed on the Internet. Age-group specific rates were obtained from the WONDER Website (Mortality hyperlink) of the Centers for Disease Control and Prevention (CDC). Tests of statistical significance were performed using the Epi Info software package.

According to the PHIDS Website, 2068 Floridians committed suicide in 1999, and 80 were residents of Volusia County (Table 1). The frequency of suicides in Volusia County remained stable between 1996 and 1999.

The figure below shows temporal trends in age-adjusted suicide rates. Volusia County’s rates were consistently higher than the State’s rates between 1989 and 1998. The rates in Volusia County decreased between 1995 and 1998.

Our initial examination of age-group specific rates focused on white males because the Chief Medical Examiner of Volusia County indicated in a newspaper article that most of the Volusia County suicide victims in 1999 were white (79/80) and male (68/80) [1].

Table 2 shows suicide rates and relative risks for White males in Volusia County and Florida stratified by age during the period 1993-1997. (Data for 1998 and 1999 were not available at the WONDER Website). Among White males 20 to 24 years of age, Volusia County residents were 67% more likely to commit suicide than Florida residents. This result is statistically significant; that is, this result is not likely due to random chance.

There may be discrepancies in the number of suicides among Volusia County residents recorded in the Volusia County’s medical examiner’s database and the CDC’s database (Personal communication, Thomas R. Beaver, MD, Chief Medical Examiner, Volusia County, 08/21/00). This apparent gap will have to be investigated further.

Volusia CHD and the Bureau of Epidemiology will continue to examine the suicide rates in other race-sex groups, and if high-risk groups are identified, a case-control study of risk factors may be designed.

1. Gibbons, Timothy J. Suicides’ toll staggering: Volusia rate nearly double national average. The News-Journal, February 11, 2000, pages 1A and 15A.
2. Bryant, Purvette A. Suicides are up in Volusia: Why? Summit seeks answer to question. The Orlando Sentinel, July 30, 2000, pages K-1 and K-12.
3. Conference agenda. Suicide Prevention Coalition of Volusia and Flagler Counties.

Factors that may facilitate dispersal of WN [West Nile virus] include the movement of infected humans, infected vectors (ticks and mosquitoes), and infected amplification hosts (domestic birds, wild resident birds, and wild migratory birds). It is not difficult to envision ways in which this virus may quickly move around the country. Many cities have large populations of vector mosquitoes capable of transmitting this virus. These include Cx. pipiens in the northern half of the country, its close relative Cx. quinquefasciatus in the south, Cx. tarsalis in the west, and Cx. nigripalpus in the deep south. These species of mosquitoes are certainly among the most likely North American candidates to transmit WN to birds and humans. There are likely many other mosquito and tick species that could play a role in keeping WN circulating within a region. If WN is introduced into another region of the USA, it will, in time be observed in domestic avian populations. Nation-wide vigilance for WN is essential.

What Can be Done?

An important question concerning WN movement and transmission throughout North America is: ¨What can be done to monitor the movement and introduction of WN in new cities and localities throughout North America?¨ The answer is simple: surveillance, surveillance, surveillance, and more surveillance. Vector surveillance, amplification host surveillance, meteorological surveillance, and virus surveillance.

Mosquito and vector control programs throughout the USA already have considerable experience monitoring WN's close relative, SLE (see the page on SLE). St. Louis encephalitis has been a continuing problem particularly in the upper mid west, Florida, Louisiana, Texas, and California where there have been many severe outbreaks. A comprehensive integrated arboviral surveillance program for SLE in Florida has been proposed and implemented (see Day and Lewis 1992). Programs similar to this should be considered for areas that are at risk for arboviral transmission, especially WN, SLE, and dengue viruses. The dengue viruses present another potential problem for humans, especially in the southern USA.

It is only through vigilant surveillance that epidemics can be recognized before local, state, and federal health officials are blind-sided by the unexpected appearance of large numbers of infected humans in places like NYC. Accurate risk assessment of a vector borne epidemic will give all public health authorities time to institute control strategies and public awareness campaigns that will reduce the impact of an epidemic.

A second important question is: ¨What can be done to minimize the impact of WN, or other vector borne pathogens, when they do become established in a region.¨ It is essential that the most efficient and effective control or risk management strategies be applied. Authorities will make their decisions about what strategies to use based on scientific information about the pathogen and vectors involved, and local or regional environmental conditions. It is generally accepted that it would be enormously costly and very difficult to vaccinate large human populations to prevent a vector borne epidemic, even were vaccines for these viruses available. Vaccines are not currently available for the vast majority of arthropod-borne pathogens including WN and SLE.

Personal protection against biting arthropods, particularly when they are infected with dangerous pathogens, remains one of the most important ways to avoid disease. Avoid mosquitoes. Make sure screens are in good repair to prevent mosquitoes from entering houses. If you must enter areas where there is a threat of encountering infected mosquitoes, wear protective clothing. Finally, use a personal insect repellent that provides a reasonable Complete Protection Time (CPT). The CPT is the total time following repellent application that the treated individual will remain bite free. For example, under normal conditions the CPT for a 5% formulation of DEET (diethyl toluamide, presently the most effective insect repellent) is approximately 2 hours. The CPT for a 24% DEET formulation is more than 4 hours.

Fortunately, the USA has some of the best mosquito and arthropod control programs in the world. Vector control and personal protection against vectors and the diseases they carry are the best way to avoid infection with vector-borne pathogens. For example, strategies that might be effective against WN in NYC include: the source reduction of mosquito breeding sites; focal applications of insecticides directed against adult and immature mosquitoes; public service announcements to educated residents about the vector, the disease, and disease avoidance; tips to help prevent home-invasion by infected vectors; and information about the most effective means of personal protection. Recent SLE epidemics and outbreaks in Florida have proved that one of the most effective means of reducing human infection is to widely disseminate accurate information through the media in an effort to educate the public. An individual's first line of defense during a vector-borne disease emergency is knowledge and personal protection.

(The following information was excerpted from FOCUS, volume 10, number 3, July – August 2000, published by the CDC/NCID)

The CDC Hospital Infections Program (HIP) has begun the Antimicrobial Use and Resistance (AUR) component project to monitor antimicrobial use and resistance in hospitals that participate in HIP’s National Nosocomial Infections Surveillance System (NNIS). Participating hospitals provide data on antimicrobial use and resistance on a monthly basis. The AUR component provides a national estimate of the prevalence of select antimicrobial-resistant organisms isolated from hospitalized patients, details the amounts of antimicrobial agents used in these hospitals, and allows for interhospital comparison of select antimicrobial use and resistance prevalence. NNIS hospitals can use these data to help monitor use and resistance, as well as for quality improvement projects.

For additional information regarding the AUR component of NNIS, call 404-639-6101 or e-mail Rachel Lawton.

Fifteen of the 320 hospitals that participate in the National Nosocomial Infections Surveillance System (NNIS) are in Florida.