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.

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.

Dr. Richard Hopkins, Florida State Epidemiologist and Chief, Bureau of Epidemiology

There are 20 confirmed cases of hepatitis A from Lake and Sumter County, all in adults ages teen-55, equally male and female, with symptom onset 11/21/00-12/6/00. Another case is expected to turn positive today or tomorrow; three new cases were confirmed today. Staff from the Bureaus of Environmental Epidemiology and of Epidemiology are assisting Lake and Sumter County staff with the investigation. Cases have been extensively interviewed about a wide variety of possible common exposures, including day-care attendance by children, person to person exposure to other cases, foreign travel, sources of drinking water, sources of groceries and take-out food, and food service establishments eaten at. No obvious candidates for a common source emerged from these questionnaires, except for one fast food outlet mentioned by over 3/4 of cases. One employee of this same outlet is part of the outbreak but not the index case.

A questionnaire has also been developed to interview controls. It has been sent out to 8 interviewers. We hope to have 60-64 questionnaires completed by Friday 12/22. The questionnaire includes respondent’s age, excludes them if they may have had hepatitis in the past or present, and asks about grocery shopping locations, restaurants, and deli locations they may have eaten at between Oct 15 and Nov 15.

The Lake CHD is following up with contacts and administering immune globulin when appropriate. Employees at the one fast food outlet were given immune globulin because of the case in a co-worker. Blood for molecular testing by the CDC has been sent to Jacksonville, and then will be routed to the CDC.

Dr. Pellosie, Director of the Lake County Health Department, is currently fielding any press/media inquiries; all media inquiries should be referred to him. The Lake County Health Dept. phone number is 352-742-6320. We are emphasizing hand washing before food preparation and eating, and after using the bathroom, and that this disease is not spread by casual contact at the workplace or in schools.

Dr. Dolores Katz, Regional Epidemiologist, Southeast Florida

Kathryn Snavely, MPH, Reporting Systems Manager

Tuesday, December 19^th marked the end of preliminary training for county health department staff in the use of the Merlin intranet-based communicable disease reporting and analysis System. All but 10 counties were provided training in this round. Beginning January 1, 2001, Merlin will replace the previous 2016 form method of reporting communicable diseases to the Bureau of Epidemiology. As a statewide database, Merlin will also give counties and other Department of Health agencies the ability to view and analyze morbidity data on a real-time basis.

Throughout training there were many reporting questions that were asked. Some of the more frequent ones are below with their corresponding answers:

A. If they are new cases you will report them in the Merlin system. Updates and deletions cannot be entered into Merlin for cases that were reported on 2016 forms earlier in the year. You must FAX updates and deletions for year 2000 cases (reported on 2016) to the Bureau of Epidemiology.

Q. Should we be holding all our cases until Friday and do data entry at the end of the reporting week?

A. No, you should not hold all your cases until the end of the reporting week. The Merlin system was developed to enhance surveillance data by allowing counties to enter cases closer to the event date. The Merlin system is capable of managing more data than that possible in the 2016 fields and allows you to save cases before reporting them. You must click the ‘Report’ button to include the case in the weekly CDC file and you should be reporting cases as they are completed.

A. The first thing you should do is print any Debug Help screens or copy and paste them onto a Microsoft Word document along with your Change Control Form describing the problem and what function you were in when the error happened. The error pages can be emailed to the Merlin Helpdesk (listed in the Outlook global address list) or faxed to the Bureau of Epidemiology. The Change Control Form can be found in the Help section of Merlin under the Online Documentation and Change Control hyperlinks. You can also call Kathryn Snavely at S/C 205-4444, X 2447 if you are still having problems and need to enter data into Merlin. Only when all other options have been exhausted can you arrange another method for sending your morbidity data.

A. Yes. Merlin can save any amount of case data without reporting the data to the Bureau of Epidemiology. There are some required fields to save a case including last name and date of birth. Remember – just because you enter the case into Merlin, does not mean it’s reported to the Bureau of Epidemiology as a case of morbidity. The data can be accessed for analysis and viewing at all times, reporting is done only when you click the ‘Report’ button from the Case Status window.

A. In the Epi-Analysis section of Merlin you can create weekly reports by selecting your county, case status ‘Accepted’, and the time frame for the desired reporting week. Merlin will give you a line list of the cases that were reported as of those dates. Soon there will be reports in Merlin that you will be able to select ‘Weekly Morbidity Report’ for example.

A. Currently, all branches of CDC are not able to accept electronic case report forms although some of the extended data collected in Merlin will be transmitted with the weekly morbidity file. You will still need to fill out a paper CDC or state case report form for those disease conditions. Merlin’s extended data screens, or electronic case report forms, will have printing functions in place within the first couple months of 2001 so you can print them in their correct format directly from Merlin. There will also be Adobe Acrobat PDF files for some CDC case report forms available for download from Merlin. Please contact the Bureau of Epidemiology for questions on case report forms for specific disease conditions.

A. You can let the Bureau of Epidemiology know that you have no cases to report by sending an email to the Merlin Helpdesk with your county and the week number. Merlin will soon have a function that will eliminate the need to send that e-mail.

A. Both year 1999 and 2000 morbidity files will be available in Merlin sometime next quarter. This data is collected from the 2016 forms and will consequently have data only for those fields.

A. Currently, three types of report functions are available in the Merlin system: (1) a basic query reports capability, (2) a basic line list function and (3) the capacity to create an epi-curve. An export feature is being designed and should also be available next quarter. The export feature will initially give you all 2016 data. In the future, you will be able to do more analysis without leaving the Merlin Reporting System and will also be able to create your own export file.

If your county has not attended a training course for Merlin you will not have a user ID and password to use the system. All counties are expected to begin using the Merlin Reporting System for all morbidity reporting beginning with week #1, ending January 6^th. Please contact the Bureau of Epidemiology to arrange for training, S/C 205-4401.

Any other questions regarding the Merlin Reporting System can be directed to the Merlin Helpdesk email account found in the Global address book in Microsoft Outlook. Ongoing training will be offered by either telephone conference call year-round or at Regional Training and the Annual State Epidemiology Seminar (ASES).

Due to the holidays, the Grand Rounds tentatively scheduled for December 26, 2000 has been cancelled. Please plan on joining us on January 30, 2001 when Dr. Savita Kumar, Epidemiologist, Palm Beach County Health Department will discuss Varicella Suveillance.

Other future topics include:

February 27, 2001 Recreational Water Outbreaks Roberta Hammond, PhD
Bureau of Environmental Epidemiology

March 27, 2001 Arboviral Diseases Lisa Conti, DVM, MPH
Bureau of Epidemiology

The Epidemiology Grand Rounds, a monthly, one-hour audioconference conducted by the Bureau of Epidemiology, focuses on issues of epidemiologic interest to Florida public health providers, including; county health department directors and administrators, nursing directors and nurse epidemiologists, laboratorians, and other interested parties. Each session features a formal PowerPoint presentation followed by an opportunity for audience interaction. Presenters include representatives of the State Department of Health, county health departments, schools of public health and other experts in epidemiology and associated specialties. Richard Hopkins, M.D., MSPH, Florida's State Epidemiologist, will coordinate the presentations.

Nursing CEU's and environmental contact hours are now being provided when applicable. If you have any questions, please feel free to contact Melanie Black.

Dr. Carina Blackmore, Regional Epidemiologist, Northeast Florida

Florida: Data from Florida suggest low levels of influenza activity. Overall, one percent of 19, 493 patients seeking care by reporting physicians in the influenza sentinel surveillance network met the case definition for ILI during week 49. Influenza-like illness activity was detected in 20 counties from Escambia to Miami Dade. Higher ILI activity than expected for this time of year (>3%) was reported by physicians in Duval, Escambia and Orange counties. One culture positive specimen was reported for influenza this week. Influenza A (H1N1) was isolated from a patient in Escambia county. Since October 1, 31 influenza isolations have been reported to the state health office: 16 influenza A (H1N1) isolates from Broward, Charlotte, Duval, Escambia, Lake, Leon, Orange and Polk counties, one influenza A (H3N2) from Duval county, 7 untyped influenza A isolates from Alachua, Columbia, Hillsborough, Orange, Palm Beach and Pinellas counties) and 7 influenza B isolates from Brevard, Broward, Hillsborough, Leon and Volusia counties.

Respiratory syncytial virus (RSV) activity remains high but is declining in northeastern, central and the southwestern part of the state where 40.5-50.6% of tested specimens were positive for RSV. Twenty-six percent of RSV specimens tested in the southeast were positive. Twelve hospital laboratories in the state participate in this program.

National report: During week 49 (December 3-9, 2000), 39 of the 870 specimens tested by the WHO and National Respiratory and Enteric Virus Surveillance System (NREVSS) laboratories were positive for influenza type A virus and 12 were positive for type B virus. Thirty-three (85%) of the influenza A isolates were typed. All of them were influenza A (H1N1). Since October 1, 245 (2%) influenza isolates (138 influenza A (H1N1), 7 influenza A (H3N2) and 63 influenza B) have been recovered from 11,744 specimens tested. Influenza A(H3N2) have been identified in Florida, Hawaii, Kentucky and Missouri and influenza A (H1N1) in California, Colorado, Florida, Indiana, Massachusetts, North Carolina, Oklahoma, Pennsylvania, South Dakota, Texas and Wisconsin. In addition, unsubtyped influenza A isolates have been identified in Georgia, New York, North Dakota and West Virginia. Influenza B isolates have been recovered from patients in Alaska, California, Florida, Louisiana, Missouri, North Carolina, Oklahoma, Oregon, South Carolina and Texas.

CDC has antigenically characterized 22 influenza viruses (1 influenza A (H3N2); 19 influenza A (H1N1) and 2 influenza B) received from US laboratories since October 1. They are all similar to respective vaccine strains.

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 7.2% during week 49. This percentage is below the epidemic threshold of 8.1% for this time of year.

Influenza activity was assessed by state and territorial health departments as regional in 5 states (Georgia, Hawaii, Kentucky, Tennessee and Texas) and sporadic in 31 additional states (Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, llinois, Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Missouri, Nevada, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Utah, Virginia, Washington, West Virginia, Wisconsin and Wyoming). No influenza activity was reported from 13 states. One state did not report.

During week 49, 1% of patient visits to U.S. sentinel physicians were due to influenza-like illness (ILI). The percentage of ILI was within baseline levels of 0% to 3% in all 9 surveillance regions.