The Bureau of Epidemiology is available 24 hours a day, 7 days a week for consultation at our main number (SunCom 205-4401 or 850/245-4401) PLEASE NOTE: Consultation after 5 p.m. & on weekends is intended for emergencies.

Since December 1st 2000, a DOH Bureau of Epidemiology Florida hospital based early warning surveillance system has been monitoring daily patient visits to emergency rooms in 13 participating hospitals. One hospital is also reporting daily acute bed occupancy. The system aims to detect the onset of unexpected outbreaks of serious infectious diseases within Florida, which could herald a covert bioterrorism event. The most likely agents responsible for such bioterrorism events are those causing the diseases of plague, anthrax, smallpox, botulism and any of the hemorrhagic fevers.

In Utah in 1998/9, a previous trial of this method of surveillance (called Statistical Process Control) was conducted during December to April and was claimed to have identified the start of that state’s influenza epidemic. Examination of the chart shows the definite start of a rapidly upward trend of visits commencing on December 28, which was stated to be an earlier indication of excessive activity than the routine methods of detection, which were in use at the time.

Infection Control staff at all participating Florida hospitals are reporting one item only: the total number of patient visits to their emergency departments. The DOH provides a regular updated chart for each hospital plotting visits by day. The mean and + 3 standard deviations from the mean are displayed on the charts. The hospitals report daily through the Internet, or by telephone. Weekend visits are reported on Monday morning.

If an observed sequence of increasing visits occurs, as measured by 7 pre-defined criteria, DOH staff make a response to the hospital in question requesting comments on the increased activity. The responses are documented and (a) acted upon, (b) if found serious referred to the deputy state epidemiologist, and (c) whether acted upon or not, all are filed for future reference, thus building up a record of each individual hospital’s history. The records will be used in the future in developing computer based algorithmic analyses of the hospital’s data to improve its predictive value. These developments will be possible when sufficient historical data has been compiled.

Three responses have been required since December 1, but none has identified any real event. Investigation by the regional epidemiologist found the three higher than expected runs are explained by a general increase in visits to all hospitals from December to January, and is reflective of the increased activity at this time each year. This is due partly to a snowbird effect, partly the Christmas/New Year holiday effect, and also partly due to expected increased seasonal activity. Because of the relatively small increase in overall visits, we believe the surveillance system has confirmed the lack of influenza activity in the state this season. We would have expected a greater number of alerts than have been observed.

One of the major findings to date is that hospital emergency department visits vary by day of the week. For some hospitals, Sunday, and Monday are the busiest days of the week; in others a mid weekday is the busiest and in another Monday and Tuesday are the busiest days, not the weekend. These data are still in its preliminary stage and will be analyzed and reported in more depth as the project progresses. They will play a part in the overall interpretation of a sequence of increasing visits or any other unexpected activity, to assess whether the situation is outside the expected limits or not.

The hospitals represent the regions around Miami, Orlando, Jacksonville, St. Petersburg and Tallahassee. The long-term aim of the DOH is to have the data entered directly into a web based database, which will automate the surveillance, analysis and charting aspects of the system. There will still be the need for monitoring and evaluation of the data by an epidemiologist with knowledge of the system and the individual characteristics of the population from each of the regional locations within the state.

The system is working smoothly, without any apparent problems.

Our continuing and grateful thanks to Barbara Russell from Miami, Carol Frank from Tallahassee, Allyson McFauls, and Connie Andry from Jacksonville, Sherry Wolabaugh from Sarasota and Natalie O’Brien from St Petersburg, A special thanks to Ronnie Fetzko from Orange County Health Department who recruited the Orlando region hospitals in late January 2001 and is reporting their data daily.

On February 1, 2001, the Pinellas County Health Department was contacted by a local medical clinic regarding a cluster of illness following a catered luncheon at their facility. Twenty-four of the 40 medical staff attending a luncheon at the clinic on January 30^th catered by a local deli reported gastrointestinal symptoms that included predominantly diarrhea and vomiting. The onset of symptoms averaged 24 to 48 hours with a mean duration of 48-hours. This was the only common gathering for this group of persons where food and drink was served. A local deli had catered "la vache" roll-up sandwiches (cold cut and vegetable), which had been served buffet style in two shifts during a four-hour period on January 30^th. The medical clinic provided the Health Department line-listings of attendees and the luncheon menu. Norwalk virus was suspected at this time based on symptoms and onset times reported, high attack rates and also because ready-to-eat foods had been served.

The following day, the Pinellas County Health Department, Epidemiology Office had been contacted by two additional medical facilities that had catered sandwiches on January 30^th & 31^st from the same deli as the first clinic reporting illness. In each case, the catered luncheon was sponsored by same ALF facility soliciting physician offices in Pasco & Pinellas counties. The identical menu items served at both medical facilities included the same roll-up type sandwiches served at the first outbreak cluster previously described. Early case illness information identified high attack rates of 21/38 (55%) attendees and 30/52 (58%) attendees. Enteric and viral stool specimen collection was encouraged at this time at the three medical facilities. Some of the leftover roll-up sandwiches (turkey & ham) were collected from attendees and will be submitted for possible testing though the Tampa Regional Virology Laboratory. In addition to the clinic luncheons, the Pinellas County Health Department has since received a notification that two persons that had lunch on January 30th at the same deli had also become ill with gastrointestinal symptoms. Both persons had eaten "la vache" sandwiches. Some of the sandwiches served at one of the medical centers had also been taken home and served to two household members. Both persons later became ill.

The Pinellas County Environmental Health Office performed a joint investigation with Department of Business and Professional Regulations on February 2, 2001. An inspection of the catering deli and a food chain investigation was performed at that time. Food and patient history questionnaires were developed and are currently being administered at two of the three medical clinics that reported illness clusters. Analysis of the questionnaires may help to identify the specific food vehicle responsible.

In summary:

To date, a total of 79 suspected cases have been reported among 138 luncheon attendees from three unrelated medical clinics in Pinellas & Pasco counties and four persons from the community. Early data has identified a common caterer and common foods among the three illness clusters. The Pinellas County Environmental Health and DBPR offices performed an environmental investigation on February 2, 2001. Results from the field investigation indicated that the deli facility was not properly washing produce items during preparation. Food temperatures and employee hygiene were satisfactory. No employee illness was identified. Enteric and viral stool specimens have been collected and have been sent to the Tampa Branch Lab for analysis.  

"Recreational Waterborne Disease Outbreaks in Florida"
Roberta M. Hammond, PhD, Biological Administrator II
Bureau of Environmental Epidemiology, Florida Department of Health
Submitted by: Melanie Black, LCSW, Professional Training Coordinator

Tuesday, February 27
11:00 AM – 12:00 PM EST
Dial-in at (850) 487-8587 or SunCom 277-8587

Waterborne disease outbreaks are underreported both nationwide and statewide. Recreational waterborne disease outbreaks are also underreported. In the last 7 years (94-00), only 12 recreational waterborne disease outbreaks have been reported in Florida, with 6 in the last year. These outbreaks are easily preventable. This presentation describes the common pathogens involved in recreational waterborne disease outbreaks, along with some case studies of investigations that have taken place in Florida. Issues to consider when investigating these outbreaks will then be discussed, followed by a description of tests for cryptosporidium oocysts. Finally, some strategies for prevention and education will be listed.

Further details regarding the audio-conference call and Power Point files will be posted on the DOH Intranet site. Be sure and register on-line for nursing CEU's. This training is also approved for I contact hour for Environmental Health professionals certified under chapter 381.0101, Florida Statue. 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 e-mail Melanie Black at [Melanie_Black@doh.state.fl.us] or telephone (850) 245-4444 ext. 2448, SunCom 205-4444 ext. 2448 to request presentation materials.

While we realize you might 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. Please try to call in on time and remember to put your phones on mute so as not to disturb others. Thank you for your cooperation.

Long-time readers of the Epi-Update will remember Davis Janowski, an erstwhile editor of this publication. We encountered Davis yesterday on page 61 of the March 6, issue of PC Magazine, where he serves as the Associate Editor for Network Infrastructure. While he was here, Davis contributed several memorable well-researched and well-written articles; some created on his own, and others co-authored with Dr. Bill Bigler. We had no doubt that Davis would rise to the top of whatever he set out to do.

Editorial Note: Lest anyone think that we actually read and understand PC Magazine, Davis’ endeavors were called to our attention by a very proud father, Hank Janowski, Chief of the Bureau of Immunization.