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 late December 2000, an increase of Hepatitis A has been observed in a group of methamphetamine users and their contacts in Polk County. Twenty-two cases linked to this group have been reported since December (See Table). Of the 22 cases, 11 (50%) were males, and 22 (100%) were white non-Hispanics. Age ranged from 2 to 33 (median 18.5 years). Ten cases were classified as children (age <13) and 12 cases were adults (age 18+). The cases reside almost exclusively in small rural subdivisions of substandard housing. Only four of the twelve adults stated they were employed. One of the January cases was employed in a sensitive situation, as a cafe worker; however, no cases have been linked to this cafe.

Several cases have admitted to using methamphetamine and other drugs including marijuana and cocaine. The community the cases belong to is known to include injecting drug users. This injecting drug use practice places the user at risk for both hepatitis B and C along with other infectious diseases, such as HIV. A total of 12 cases had hepatitis B surface antigen results available, and all were negative. In addition, the 14 hepatitis C antibody results were negative.

This group has been very difficult to work with for a number of reasons. Individuals have frequently refused to provide information about contacts that would benefit from immune globulin prophylaxis. Contacts of cases have failed to keep appointments for prophylaxis at the local health department. In addition, cases have identified individuals who they described as being sick, possibly with hepatitis A, but would not assist with providing information that would allow the health department to contact them.

A number of government agencies are known to be involved with this population including the health department's STD and HIV outreach staff, the Department of Children and Families (child protective services), law enforcement agencies, and the Polk County Building Department (code enforcement). Due to the difficulties in working with this group, the Polk CHD has reached out to groups not normally considered public health partners. Recently a meeting was held with the county undercover narcotic detectives. This meeting provided the detectives with information about hepatitis A, and the outbreak. Their concerns regarding personal risk and protection were also addressed. In addition, there was a discussion of how law enforcement and the health department can assist each other. In addition to the narcotic unit, medical intake personnel at the county jail, probation officers and children and family services are being contacted and informed about the outbreak and asked to assist the health department in the identification of new cases.

There is a concern the population at risk will stop coming to hospital emergency rooms for care as it is learned that there is no treatment for hepatitis A, and that the health department will be notified and will contact them. To help overcome this problem the detectives have been alerted to notify the health department if they learn about possible cases.

During the last week of March, the U.S. Drug Enforcement Administration (DEA) closed down a large supplier of methamphetamine in Polk County. This may result in users from this area traveling to other areas, including in neighboring counties, seeking drugs. Also, the Polk County Sheriffs Department has information that methamphetamine users from neighboring counties frequent Polk County. Surrounding counties should be alert for the possibility that hepatitis A cases may be connected to this group.

According to a 1999 MMWR report, outbreaks have been reported among users of injecting and noninjecting drugs in the United States and in Europe. In the late 1980s, 10%–19% of reported hepatitis A cases occurred among persons who reported a history of injecting-drug use. More recently, outbreaks involving users of injected and noninjected methamphetamine have been reported in many communities in the midwestern and western United States, accounting for up to 30% of reported cases in these areas. Cross-sectional serologic surveys have demonstrated that injecting-drug users have higher anti-HAV seropositivity than the general U.S. population. Transmission among injecting-drug users likely occurs through percutaneous and fecal-oral routes (e.g., sharing needles, sharing contaminated "works," and having household or other close personal contact).

References:

Hutin Y, Sabin K, Hutwagner L, Schaben L, Shipp G, Lord D, Conner J, Quinlisk M, Shapiro C, Bell B. Multiple Modes of Hepatitis A Virus Transmission among Methamphetamine Users. Am J Epidemiol 2000 Jul 15; 152(2):186-92.

The source of this information is a weekly conference call in which the Bureau's epidemiologists present information about communicable diseases (one disease per week) including: etiology, clinical presentation, laboratory testing, treatment, epidemiologic analysis, and prevention strategies. These presentations provide background for discussions on the improvement of the state's intervention methods. We feel that the information included will be both interesting and useful to DOH epidemiologists across the state.

County health departments and other agencies are encouraged to direct citizens to report dead birds using the web site. If the reporter does not have access to the Internet site, local agencies can submit the information and post the report on their behalf. A link to the Department’s home page is included on the reporting site and will provide interested consumers the possibility to view additional information on West Nile Virus.

Once a bird has been identified through the database, an alert will be forwarded to the county health department director, the environmental health director and the county epidemiologist. To date, reports have been received from 46 counties across the state (see attached table). The following are the available resources to assist you with this initiative:

The Department of Agriculture and Consumer Services Veterinary Laboratory in Kissimmee will receive submitted specimens for necropsy (see attached protocol) and will remove the desired tissue samples and forward them to the Department of Health Laboratory in Tampa, FL.

The Tampa Laboratory will conduct viral assay on the tissues and virus isolation and report results back to the county and the Bureau of Epidemiology. This may take up to four weeks.

The decision to submit a carcass will be made by each county individually. Currently, our priority is to test any freshly dead birds (birds that have died within 24 hours or report).

(Week ending March 24, 2001-Week 12)

Florida: The 2000-2001 influenza season has been mild in Florida. The proportion of patient visits due to influenza-like illness (ILI) to physicians in the influenza sentinel surveillance program has remained within baseline levels (1-3%) throughout the season. During the last 5 weeks, only 1% of patients seeking care by reporting physicians in the influenza sentinel surveillance program met the case definition for ILI. One influenza virus isolations was reported from Miami-Dade County.

From February 1 to date, more than 80% of isolates (n=24) have been influenza B. Flu B isolates have been recovered from patients in Alachua, Duval, Franklin, Hillsborough and Leon counties. Two influenza A (H1N1) isolates from Charlotte and Hillsborough counties, 1 influenza A (H3N2) isolate from Miami-Dade county and 2 untyped influenza A isolates from Hillsborough and Palm Beach counties have also been reported. Since October 1, 2000,133 influenza isolations have been reported to the state health office.

National report: Influenza activity seems to be declining in the United States. For the current season, the overall national percentage of respiratory specimens positive for influenza appears to have peaked at 24% at the end of January (week 4). During weeks 10-12, ten percent of specimen tested in the South Atlantic region, which spans from Maryland to Florida, were positive for influenza. As in other parts of the country, the majority of these isolates (66%) were influenza type B.

Four hundred eighty five isolates have been antigencally characterized at CDC this year. Eighty-five percent of the characterized influenza B strains were more closely related to the B/Sichuan/379/99 strain than to B/Beijing found in the 2000-2001vaccine. B/ Sichuan virus will replace B/Beijing in the 2001-2002 years vaccine. Circulating influenza A virus strains have been very similar to this years vaccine strains. For this reason, influenza A/H1N1/New Caledonia and influenza A/H3N2/Moscow will remain the influenza A virus components of the 2001-2002 years vaccine.

During week 12, the state health departments in Arizona and Ohio, reported regional influenza activity. Thirty-six additional state and territorial health departments reported sporadic influenza activity and 11 states reported no activity.

The percentage of all deaths due to P&I as reported by the vital statistics offices of 122 U.S. cities was 7.7%, which is below the epidemic threshold for this time of the year.

One percent of patient visits to U.S. sentinel physicians during week 12 were due to influenza-like illness (ILI). The percentage of patient visits for ILI was within baseline levels (3%) in all 9 surveillance regions.