For November 15, 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:

 

Regional Epidemiologists:

 

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. 

v       The Department of Health has a home on the World Wide Web at http://www.doh.state.fl.us

 

In this issue:

 1.  CDC Request for Heightened Hepatitis A Surveillance

2.  Haemophilus influenzae type b: Reported case in an unvaccinated child

3.  Epidemiology Grand Rounds for November 28, 2000

4.  Live Satellite Broadcast:  Medical Response to Chemical Warfare and Terrorism 2000

5.  Influenza and Respiratory Syncytial Virus Surveillance Summary Update (Week 44 - Week ending November 4, 2000)

6.  Weekly Disease Table: Week 45

1.  CDC Request for Heightened Hepatitis A Surveillance

Roberta M. Hammond, Ph.D., Food and Waterborne Disease Coordinator, Bureau of Environmental Epidemiology

(Note:  The clams referred to below are not known to have been distributed in Florida, no related cases of hepatitis A have been identified, a recall has already been done, and there were no retail sales of the clams.  This represents a new dilemma - a contaminated product with HAV sequences (it is unknown if infectious virus was actually present, not all clams tested had positive results) and there are no known human cases. On the other hand, we are unlikely to find cases unless persons with hepatitis A are specifically asked about eating this mislabeled product. The notice may prove especially useful for querying cases that don't have the usual risk factors for hepatitis A.)

 

In September 2000, the FDA issued a recall for "Good Fortune Frozen Clams" (clams on the half shell). The clams were labeled as cooked but were actually raw, and several cases of acute gastroenteritis (cause undetermined) shortly after consumption were reported in Westchester County, NY.

The clams were imported by Universal Group Limited from the People's Republic of China, and packed in 2 lb bags, with 10 bags per carton. The product was distributed to wholesale customers by Interstate Restaurant Supplies and Alpha Seafood, Linden, NJ. Over 4200 cartons were distributed to AL, AZ, CT, GA, KY, MA, MO, NC, NJ, NY, OH, PA, RI, SC, and TN between May 15 and September 15, 2000; other states may have also received shipments. Thus far 3100 cartons have been recalled and destroyed; the remainder were presumably consumed. Clams were not distributed to retail stores and are not likely to have been purchased by individual consumers. Exposure to clams would most likely occur in a restaurant.

As part of this investigation, clams were tested at an FDA laboratory for several enteropathogens, including Vibrio species, Listeria monocytogenes, Salmonella, Norwalk-like viruses, and hepatitis A virus (HAV). Recently, HAV sequences were detected by polymerase chain reaction in some samples of the recalled product.

Although none of the above-mentioned gastroenteritis cases have been confirmed to be hepatitis A, we are alerting state health departments to encourage them to look for cases of hepatitis A that may be associated with exposure to these clams.  State and local health departments should ask persons recently diagnosed with hepatitis A about eating clams during the 2-6 weeks before illness onset. Because the clams were labeled as "cooked", persons with hepatitis A should be asked about having eaten raw or cooked clams. Sera from persons with hepatitis A possibly associated with eating these clams should be saved (frozen), for possible molecular analysis.

Please report any cases possibly associated with eating clams, and any questions about this notice, to Dr. Deblina Datta of the Hepatitis Branch.  Please also notify Dr. Roberta Hammond (DOH) and Dr. Steve Wiersma (DOH) of any potential cases.

 

2.  Haemophilus influenzae type b: Reported case in an unvaccinated child

Marc Traeger, MD, Florida EIS officer

In September 2000, a case of H. influenzae type b (Hib) was reported in a 16 month-old girl in Brevard County. She had not received any vaccinations. The infection was listed as primary bacteremia. The child was hospitalized and had an uneventful recovery.

The Brevard County Health Department investigation revealed that the parents of this child were opposed to immunization, and received their health care from a non-allopathic (chiropractic) health provider, who was also opposed to immunization.

The Brevard CHD administered chemoprophylaxis to the household members. In households with at least 1 contact younger than 48 months of age who is incompletely immunized against Hib, rifampin prophylaxis is recommended for all household contacts except pregnant women, regardless of age. Limited data has shown rifampin prophylaxis decreases the risk of secondary invasive illness in exposed household contacts. Current recommendations suggest a rifampin dosage of 600 mg daily in adults, and 20 mg/kg up to 600 mg daily in children, for 4 days, in all household contacts. Other treatment and chemoprophylaxis recommendations may be found in the “Red Book” (1).

H. influenzae may cause otitis media, sinusitis, epiglottitis, septic arthritis, occult febrile bacteremia, cellulitis, meningitis, pneumonia, and empyema, and infections may result in chronic disabilities or death.

 

Epidemiology

 

H. influenzae is found in the upper respiratory tract, and is transmitted person-to-person by direct contact or through inhalation of droplets of respiratory tract secretions containing the organism. The neonate may acquire H. influenzae by aspirating amniotic fluid or genital tract secretions containing the organisms during birth. Asymptomatic colonization by H. influenzae strains is common.

Before introduction of effective vaccines, H. influenzae was the most common cause of bacterial meningitis in children in the United States, and the vast majority of these infections were caused by type b strains (Hib). Rates of all Hib disease dropped 99% since 1988, when Hib conjugate vaccines were developed and made available for children, while rates of non-type b infection are thought to have changed very little.

In Florida, H. influenzae immunization rates (three doses) in children aged 19-35 months were estimated to be about 93% in Florida in 1998 (2).

Reported H. influenzae disease in children, 1999-2000.

H. influenzae reports in Florida children were reviewed for 1999 and 2000. This year, 11 cases have been reported so far (3 meningitis, 2 pneumonia, and 6 bacteremia). Two cases of serotype b were reported among these 11 including this case; the other case involved a vaccinated 11 year-old with bacteremia. In the 9 non-type b H. influenzae cases in children this year where vaccination information was available, all had been fully vaccinated for Hib.

In 1999, 7 cases of H. influenzae bacteremia occurred, two were type b. Of the type b cases, one was immunized and one was a neonate too young for immunization. Seven cases of H. influenzae meningitis in children were reported. None of them were type b and all the children had been vaccinated.

Florida Statute Chapter 232.032 requires immunization of children against communicable diseases, such as Hib, to attend school. However, children may be exempted from this rule if there are contraindications as determined by a physician, or if the parent or guardian of the child objects in writing that the administration of immunizing agents conflicts with his or her religious tenets or practices.

Information on recommended interventions to increase vaccination coverage among various groups may be found in the June 18, 1999 MMWR (3).

1 American Academy of Pediatrics. Haemophilus influenzae Infections. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. 25^th ed. Elk Grove Village, IL: American Academy of Pediatrics:[263-266]

2 Herrera GA, Smith P, et. al. National, state, and urban area vaccination coverage levels among children aged 19-35 months – United States, 1998;Mor Mortal Wkly 2000 Sep 22;49(9):1-26.

3 Vaccine-Preventable Diseases: Improving Vaccination Coverage in Children, Adolescents and Adults. A Report on Recommendations of the Task Force on Community Preventive Services; Mor Mortal Wkly 1999 June 18;48 No. RR-8.

 

3.  Epidemiology Grand Rounds for November 28, 2000

Topic:  Dietary Guidelines for Americans 2000

Presenter:  Nancy Spyker, MS., RD., LD, Public Health Nutrition Consultant, WIC and Nutrition Services

Time:

11:00 AM - 12:00 PM EST 

Presentation Outline:

1.      Revision of the Dietary Guidelines for Americans

2.      Comparison between the Dietary Guidelines for Americans 1995-2000

3.      Discussion of the dietary guidelines and implementation

 

Objectives:

Participants will be able to:

1.      Understand why and how the Dietary Guidelines for Americans are changed,

2.      Be able to list the Dietary Guidelines for Americans, and

3.      Choose to implement at least one of the Dietary Guidelines.

 

Important:

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. Also, please try to put your phone on mute when you call in so as not to disturb others. Note: Nursing CEUs (one hour per session) are now being provided for participation in Grand Rounds.

Additional Information:

Further details regarding the audio-conference call and PowerPoint files will be posted on the DOH Intranet site next week.  Information about upcoming topics and presenters will also be posted in future Epi Updates.  If either of these access points is unavailable to you, please contact Melanie Black to request presentation materials.

Future Topics:

January 30, 2001

Varicella Surveillance

Dr. Savita Kumar, Epidemiologist, Palm Beach County Health Department

 

February 27, 2001

Recreational Water-Related Outbreaks

Dr. Roberta Hammond, Biological Administrator II, Bureau of Environmental Epidemiology

 

4.  Live Satellite Broadcast:  Medical Response to Chemical Warfare and Terrorism 2000

(Sponsored by the U.S. Army Medical Command and The Bureau of Epidemiology)

 

Dates:  December 5,6,7, 2000

Where:  310A Prather Building and other locations

Time:  12:30 to 4:30 EST

Tallahassee Site Facilitator:  Melanie Black

 

Program Description:

Military and civilian medical systems must be prepared to care for casualties of battlefield or terrorist use of chemical agents.  In support of that mission, the United States Army Medical Research Institute of Chemical Defense (USAMRICD) presents its second annual satellite broadcast on the Medical Response to Chemical Warfare and Terrorism 2000.

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.  Discussion on antiterrorism will be integrated throughout.  The program will feature discussions with world-renowned scientist, researchers, clinicians and counter-terrorism experts.

Target Audiences:

Clinical health care professionals and all personnel involved in the management and care of persons exposed to chemical agents.

Accreditation:

The U.S.Army Medical Command is accredited by the accreditation Council for Continuing Medical Education to provide Continuing Medical Education to provide continuing medical education for physicians.  Maximum of 12 hours in category I.

Agenda:

Day 1-  Overview of pulmonary Agents and Vesicants

Day 2-  Overview of Nerve Agents and Cyanide

Day 3-  Field Management and Antiterrorism

Attendance:   

If you are interested in attending this broadcast in Tallahassee you will need to contact Melanie Black, Professional Training Coordinator, Bureau of Epidemiology, to register for the course. Space is limited to 30 people. If you are employed by a county health department, please contact your site coordinator to arrange this broadcast.

 

5.  Influenza and Respiratory Syncytial Virus Surveillance Summary Update (Week 44 - Week ending November 4, 2000)

Carina Blackmore, MS Vet. Med, PhD, Regional Epidemiologist

 

National report: During week 44 (October 29-November 4, 2000), 606 specimens were tested by World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories across the United States. Two influenza A viruses were identified: one A (H1N1) and one A (H3N2).  Since October 1, 17 influenza isolates [11 influenza A (H1N1), 2 influenza A (H3N2) and 3 influenza B] have been recovered from 4,066 specimens tested. One flu A isolate has not been further typed.

The percentage of all deaths due to Pneumonia and Influenza (P&I) as reported by the vital statistics offices of 122 U.S. cities was 6.3% during week 44.  This percentage is below the epidemic threshold of 7.6% for this time of year. 

Prior to the 1999-2000 season, a new case definition for a P&I death was introduced in the 122 Cities Mortality Reporting System. It was recognized that one potential effect of using this case definition was to increase P&I mortality measurement levels in comparison to previous seasons. During the summer of 2000, the P&I mortality data were analyzed to determine if the modified case definition had affected mortality estimates.  On the basis of this analysis, we estimate that there was an approximately 0.8% upward shift in 1999-2000 mortality estimates. The 0.8% shift did not represent a true increase in mortality.  To adjust for this upward shift in mortality estimates, the 122 cities P&I mortality baseline and epidemic threshold for the 2000-01 season have been adjusted upward as well. 

Twenty state and territorial health departments (Alaska, Arkansas, Colorado, Florida, Georgia, Hawaii, Indiana, Kansas, Kentucky, Louisiana, Maine, Michigan, Ohio, Nevada, New Mexico, Tennessee, Texas, Utah, West Virginia, and Wyoming) reported sporadic influenza activity. No influenza activity was reported from thirty states.

Florida: Data from Florida suggests low levels of influenza activity. Overall, one percent of 15,415 patients seeking care by reporting physicians in the influenza sentinel surveillance met the case definition for ILI during week 44. Influenza-like illness activity was detected in 13 counties from Escambia to Miami-Dade. Higher flu activity than expected for this time of year (>3%) was reported by physicians in Pasco County. Influenza A (H1N1) was isolated from 3 patients residing in Broward, Duval and Polk counties. Influenza B was isolated from Broward County. Three additional flu reports have been reported (collected in week 45). Two patients from Duval and one patient from Lake County were culture positive for Influenza A (H1N1).

Respiratory Syncytial virus (RSV) activity appears to be on the increase in Florida. Eleven hospital laboratories in the state reported that 25-42.5% of RSV tests performed were positive. This is an increase from week 43 when the percentage of positive tests ranged from 20-41.4%. The highest percentage was reported from Central Florida, the lowest from the Northeast. RSV activity appears to have picked up in the northeast during the second week of November and preliminary data from week 45 indicate that about 50% of the tests performed were positive for the virus. Additional RSV information may be found on the Bureau of Epidemiology web site at the link below:

http://www.doh.state.fl.us/disease_ctrl/epi/RSV/rsv.htm

 

6.  Weekly Disease Table: Week 45

County-Confirmed Cases, Sorted Alphabetically by Disease

(NR represents years that the disease lacked status as a reportable condition)

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	3	1	4	0
Brucellosis	0	3	2	1.7	3	2
Campylobacteriosis	866	709	765	780	988	822
Ciguatera	9	7	2	6	2	14
Cryptosporidiosis	139	138	136	137.7	180	142
Cyclosporiasis	66	6	3	25	5	6
Dengue	3	5	3	3.7	3	2
Diphtheria	0	0	0	0	0	0
E. coli O157:H7	44	41	51	45.3	55	79
E. coli, other (known serotype)	6	6	13	8.3	15	13
Ehrlichiosis, Human	2	0	2	1.3	2	3
Encephalitis, Eastern Equine	2	0	2	1.3	3	0
Encephalitis, St. Louis	8	1	2	3.7	4	0
Encephalitis, post-infectious1	13	6	3	7.3	5	5
Encephalitis, other (known organism)	10	15	6	10.3	14	7
Giardiasis (acute)	1453	1259	1022	1244.7	1322	1158
Haemophilus influenzae, invasive1	23	32	39	31.3	52	51
Hansen’s Disease (Leprosy)	0	4	3	2.3	3	4
Hantavirus Infection	0	0	0	0	0	0
Hemolytic Uremic Syndrome	5	11	7	7.7	7	12
Hemorrhagic Fever	0	0	0	0	0	0
Hepatitis A	473	445	594	504	796	432
Hepatitis B	323	346	360	343	528	411
Hepatitis C	NR	NR	42	NR	55	21
Hepatitis Non-A, Non-B	83	76	8	55.7	10	5
Hepatitis, perinatal B	NR	NR	2	NR		3
Hepatitis, unspecified	7	19	10	2	17	7
Hepatitis, +HBsAg, pregnant woman	NR	NR	255	NR	448	362
Lead Poisoning	1267	1542	1482	1430.3	1810	786
Legionellosis	22	31	21	24.7	27	42
Leptospirosis	0	1	1	0.7	1	1
Listeriosis	NR	NR	26	NR	37	28
Lyme Disease	32	43	35	36.7	51	46
Malaria	66	64	73	67.7	97	64
Measles	6	2	2	3.3	2	2
Meningococcal Disease (N. meningitidis)	129	106	98	111	122	94
Meningitis, Group B Streptococci	14	15	11	13.3	14	19
Meningitis, Haemophilus influenzae1	11	11	12	11.3	13	9
Meningitis, Streptococcus pneumoniae	69	71	81	73.7	97	83
Meningitis, Listeria monocytogenes	3	5	7	5	14	5
Meningitis, other bacterial (including unspecified)	55	51	47	51	62	83
Mercury Poisoning	2	0	4	2	7	9
Mumps	10	11	3	8	6	2
Neurotoxic Shellfish Poisoning	0	0	0	0	0	0
Pertussis	56	35	67	52.7	85	45
Plague	0	0	0	0	0	0
Poliomyelitis	0	0	0	0	0	0
Psittacosis	0	2	0	0.7	0	0
Q Fever2	NR	NR	NR	NR	0	0
Rabies, Animal	244	182	170	198.7	186	143
Rocky Mountain Spotted Fever	3	2	2	2.3	2	4
Rubella, including congenital	3	4	0	2.3	1	3
Salmonellosis	1947	2338	2418	2234.3	3071	2261
Shigellosis	1272	1874	1200	1448.7	1491	1094
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	31	37	61	43	94	113
Streptococcus pneumoniae, invasive disease, drug resistant	178	345	460	327.7	700	850
Tetanus	1	3	2	2	3	1
Toxoplasmosis	6	11	13	10	17	9
Typhoid Fever	12	13	23	16	23	9
Vibrio cholerae (serogrp O1)	0	0	0	0	0	0
Vibrio cholerae (serogrp Non-O1)	10	6	9	8.3	10	4
Vibrio vulnificus	15	27	21	21	23	12
Vibrio other (including unspecified)	24	58	35	39	48	34
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.