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. Weekly Influenza Summary Updates to Begin Next Week

3. NARMS 1999 Annual Report Summary

4. Weekly Arbovirus Activity Summary

5. Supercourse in Epidemiology, the Internet, Prevention, and Global Health Offered by the University of Pittsburgh; Organizers Looking for Public Health Professionals Fluent in Russian Language

6. Weekly Disease Table: Week 43

Don Ward, Surveillance Section Administrator

Merlin training dates have now been established for Bay, Highlands and Broward counties. The Bay County training session is scheduled for Tuesday, December 5^th. The Highlands County training session is scheduled for Thursday, November 16^th. The Broward County training session is scheduled for Wednesday, December 6^th. Due to low registration, the November 9^th training session scheduled in Tallahassee has been cancelled.

Please note that while we intend to provide training to everyone who wants to become a Merlin user, the primary audience for this initial training includes those who will be entering case reporting data (probably the same folks who now complete the 2016 forms) and their supervisors. Merlin training for all groups of users will be ongoing.

Updated schedules will be published in upcoming Epi Updates. Please register as soon as possible to avoid training session cancellation.

The confirmed training schedule (valid as of 11/01/00) is as follows:

Date Location Building/Room

November 9 (Thurs.) Duval County

November 14 (Tues.) Escambia County

November 15 (Wed.) Orange County

November 16 (Thurs.) Highlands County

November 17 (Fri.) Tallahassee 2585/110A

November 20 (Mon.) Tallahassee 4052/215L

November 28 (Tues.) Indian River CHD

November 29 (Wed.) Collier CHD

December 1 (Fri.) Tallahassee 2585/110A

December 4 (Mon.) Alachua CHD

December 5 (Tues) Bay CHD

December 6 (Weds.) Broward CHD

December 8 (Fri.) Tallahassee 2585/110A

December 11 (Mon.) Tallahassee 4052/215L

December 12 (Tues.) Hillsborough CHD

December 15 (Fri.) Tallahassee 2585/110A

December 19 (Tues.) Tallahassee 4052/215L

Carina Blackmore, MS Vet. Med., PhD

The national reporting system for sentinel surveillance of influenza is experiencing technical difficulties. However, data from Florida suggests low levels of influenza activity. Overall, two percent of patients seeking care by physicians in the influenza sentinel surveillance met the case definition for ILI (> 100 F + cough and or sore throat). Influenza-like illness activity was detected in 10 counties from Duval to Miami-Dade. Higher flu activity than expected for this time of year (>3%) was reported by physicians in Orange, Pasco and Polk counties. No new influenza isolations were made in our state laboratories.

The Bureau of Epidemiology coordinates a voluntary reporting system for influenza. We are interested in hearing about any outbreaks of influenza-like illness (fever > 100 degrees Fahrenheit AND cough or sore throat) in Florida. We use this information to give feedback on the level of influenza activity to the community in our state. It also helps us monitor the efficacy of the flu vaccine. The state lab does outbreak-related viral cultures for free. Virus isolates are regularly sent to CDC where they follow the genetic changes of the virus. These changes can eventually cause vaccine failures.

We can also provide help with outbreak investigations and control. In addition, rapid antigen testing (for flu A) is available at the state lab. By getting a quicker diagnosis it will be possible to institute control measures, such as preventive antiviral therapy, more rapidly and effectively.

Please call your regional epidemiologist or the Bureau of Epidemiology in Tallahassee. If you know the attack rate, the mortality rate and the vaccine coverage in the population of interest, great! If not, we will help you figure it out.

The earlier the better. Viruses can only be isolated from acutely ill patients. We can help you get swabs for virus isolation and rapid antigen testing.

Jodi Baldy, Staff Epidemiologist, Bureau of Epidemiology

The CDC’s National Antimicrobial Resistance Monitoring System prospectively monitors the antimicrobial resistance of non-Typhi Salmonella, Escherichia coli O157, Shigella, and Salmonella Typhi isolates. In 1999 there were 17 NARMS health department participants (CA, CO, CT, FL, GA, KS, Los Angeles County, MD, MN, MA, NJ, New York City, NY, OR, TN, WA, and WV), representing approximately 103 million persons (38% of the U.S. population) and 7 of the 9 U.S. Public Health Service regions.

NARMS-participating public health laboratories select every tenth isolate of non-Typhoid Salmonella and Shigella, every fifth E. coli O157, and each Salmonella Typhi (restricted to one isolate per person) received at their laboratory and forward the isolates to CDC for susceptibility testing.

Non-Typhi Salmonella – CDC tested 1499 isolates; 100 (7%) were from Florida. Overall, the antimicrobial agents to which Salmonella demonstrated the highest prevalence of resistance were tetracycline (19%), sulfamethoxazole (18%), streptomycin (17%), and ampicillin (16%). Sixteen (1%) isolates were resistant to nalidixic acid, six (0.4%) isolates were resistant to ceftriaxone, and one (0.1%) isolate (S. Senftenberg) was resistant to ciprofloxacin.

Among non-Typhi Salmonella isolates, 26% were resistant to one or more agents and 21% were resistant to two or more agents. Of the isolates tested, 24% were serotype Typhimurium and 18% were serotype Enteriditis. Among S. Typhimurium isolates, 49% were resistant to one or more antimicrobial agents and among S. Enteriditis isolates, 16% were resistant to one or more antimicrobial agents. The serotypes with the highest proportion of pansusceptible isolates were Javiana, (98%), Thompson (97%), and Branderup (96%).

In recent years, a mutidrug-resistant strain of S. Typhimurium has been identified. This strain is characterized not only by the multidrug-resistant pattern, but also by the phage type – DT104. Overall, 28% of the isolates were resistant to the five antimicrobial agents, ampicillin, chloramphenicol, streptomycin, sulfamethoxazole, and tetracycline (ACSSuT), to which S. Typhimuirium DT104 is commonly resistant. Florida contributed 14 (4%) of the S. Typhimurium isolates, and of these 6 (43%) were ACSSuT.

A second penta-resistant pattern – resistance to ampicillin, kanamycin, streptomycin, sulfamethoxazole, and tetracycline (AKSSuT) - also has emerged among Salmonella Typhimurium. These strains, however, are not DT104 by phage typing. Among the S. Typhimurium isolates tested, 11% had the AKSSuT resistance pattern. One (7.1%) isolate from Florida exhibited this pattern.

One Salmonella isolate was resistant to ciprofloxacin. The percentage of isolates with ciprofloxacin MICs >0.25 increased from 0.4% in 1996 (5/1326) to 1% in 1999 (15/1499). The percentage of Salmonella isolates resistant to nalidixic acid (a quinolone) also increased in 1999 (1%) from 1996 (0.4%). The percentage of Salmonella isolates with decreased susceptibility to ceftriaxone increased from 0.1% in 1996 to 2% in 1999.

NOTE: Although antimicrobial therapy is not recommended for routine treatment of salmonellosis, appropriate antimicrobial therapy can be life-saving for patients with invasive disease. Isolates from such infections should be monitored for antimicrobial resistance, particularly resistance to floroquinolones (e.g., ciprofloxacin). Fluoroquinolones (e.g., ciprofloxacin), third generation cephalosporins (e.g., ceftriaxone), and gentamicin are commonly used antimicrobial agents for the treatment of invasive salmonellosis. Resistance to nalidixic acid – the prototypic quinolone – has been found in some instances to precede resistance to the fluoroquinolones. Although increasing, the low prevalence of quinolone resistance in Salmonella in the U.S. and the lack of domestically acquired fluoroquinolone-resistant strains is in sharp contrast to the situation in England and Wales, where increasing prevalence has been reported. DT104, the second most frequently isolated Salmonella strain from humans in the U.K. in 1995, has emerged widely in the United States. Since fluoroquinolones are important in treating invasive Salmonella infections and most DT104 isolates are already resistant to a number of antimicrobial agents, continued monitoring of salmonella strains for resistance patterns is necessary. The development of fluoroquinolone resistance in a strain of Salmonella that causes severe human illness could have serious public health implications.

Salmonella Typhi – CDC tested 166 isolates of S. Typhi; 19 (11%) were submitted from Florida. Overall, 29% of the S. Typhi isolates were resistant to one or more antimicrobial agents. The most common resistances were to nalidixic acid (19%), sulfamethoxazole (17%), or streptomycin (14%). Ampicillin resistance was 13% and chloramphenicol resistance was 12%. None of the isolates tested were resistant to ciprofloxacin.

NOTE: Since 1989, strains of Salmonella Typhi resistant to chloramphenicol, ampicillin, and trimethoprim (i.e., multidrug-resistant [MDR] strains) have been responsible for numerous outbreaks in countries in the Indian subcontinent, Southeast Asia, and Africa. MDR strains have also been isolated with increasing frequency from immigrant workers in countries in the Arabian Gulf, as well as in developed countries from returning travelers. As a result of the widespread dissemination of such strains, chloramphenicol can no longer be regarded as the first-line drug for typhoid fever. Because strains are also resistant to ampicillin and trimethoprim, the efficacy of these antibiotics has also been impaired, and ciprofloxacin is now the drug of choice for typhoid fever.

Shigella – Among the 341 isolates tested, 91% were resistant to one or more antimicrobial agents and 65% were resistant to two or more agents. The most common resistances among all shigellae were to ampicillin (77%), tetracycline (57%), streptomycin (56%), sulfamethoxazole (55%), or trimethoprim-sulfamethoxazole (51%). Shigella sonnei accounted for 73% of isolates – these were most frequently resistant to ampicillin (80%), sulfamethoxazole (54%), or streptomycin (52%). Shigella flexneri, representing 23% of all isolates tested, were most commonly resistant to tetracycline (92%), ampicillin (77%), or chloramphenicol (64%). None of the isolates were resistant to ceftriaxone or ciprofloxacin. Florida submitted 14 isolates, or 4% of the total.

NOTE: There is a high prevalence of resistance to trimethoprim-sulfamethoxazole and ampicillin among Shigella isolates; these agents may no longer be appropriate for the empiric treatment of Shigella infections. Although no resistance to ciprofloxacin was identified, 2% of isolates were resistant to nalidixic acid, indicating the potential for the emergence of ciprofloxacin resistance. Continued monitoring of antimicrobial resistance is needed to inform physicians of effective treatment strategies for patients with Shigella infections.

E. coli O157 – 292 isolates were tested for antimicrobial sensitivity and of these, Florida submitted 13 (4%). Among all isolates tested, 10% were resistant to one or more antimicrobial agents and 4% were resistant to two or more agents. The most common resistances were to sulfamethoxazole (8%), tetracycline (3%), or streptomycin (3%).

NOTE: Until recently, E. coli O157 isolates were almost uniformly sensitive to antimicrobial agents. However, since the 1990s, these and other shiga toxin-producing E. coli strains have demonstrated slowly increasing levels of resistance to certain antibiotics, particularly streptomycin, sulfonamides, and tetracycline. Notwithstanding, antimicrobial therapy for O157 infection has not been demonstrated to be safe and efficacious, except for cases of cystitis and polynephritis. Tracking of antibiotic resistance in this organism reflects concern for the development and transmission of resistance genes to other pathogenic organisms. Multi-resistant E. coli have been selected by the use of broad spectrum antimicrobials in both livestock and humans. The development of antimicrobial resistance in E. coli creates problems due to their high propensity to disseminate antimicrobial resistance genes, which have been traced from E. coli in animals to E. coli in humans. The development of resistance in strains that are currently susceptible to antimicrobials could compromise therapy options.

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 October 21 through October 27, 2000, 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)

Sentinel chickens: Fifteen seroconversions to SLE and one seroconversion to EEE were identified. (Source: DOH Tampa Laboratory from mosquito control agencies and

county health departments).

The Supercourse offers a forum for information sharing among epidemiologists around the world. .

The Supercourse organizers are working to improve linkages with colleagues in Russia and are hoping to establish a Global Health Network Russian Speaking Group in the United States. If you know someone in public health who may speak Russian fluently and who would be interested in participating in the Russian Speaking Group, please contact Dmitry Ivanov, M.D., M.P.H.