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 (SunCom 205-4401 or 850/245-4401) PLEASE NOTE: Consultation after 5 p.m. & on weekends is intended for emergencies.

On February 14, 2001, the epidemiology section of the Orange County Health Department (CHD) received a telephone call from an individual seeking immune globulin protection for a recent hepatitis A exposure from a roommate. Follow-up at a nearby hospital netted laboratory data indicating an immune globulin M (IgM) positivity for hepatitis A in an Orange County [FL] man. Further query revealed that the man worked in a local seafood restaurant as a server. A second server from the same restaurant with laboratory confirmation of hepatitis A was reported the next day. A third server, also from the same restaurant, and having signs and symptoms compatible with hepatitis A, was discovered though pre-immunization screening on February 16, 2001. She was seen by a physician and was determined to be IgM positive as well. All three servers experienced the onset of symptoms within a six-day interval.

Also on February 16, 2001, the Occupational Health Office at IBM contacted the Orange CHD to report four IgM confirmed cases with an additional probable case among IBM employees from France and Belgium. These cases were among a group of 23 IBM employees from France and Belgium who had been in Orlando for a convention and who had eaten at the same seafood restaurant where the servers worked. Onset dates for the IBM employees were similar to or overlapped the onset dates of the restaurant employees.

In order to find more cases, notice was sent through the Bureau of Environmental Epidemiology to Florida counties and nationwide via the EpiX early alert system and the CDC Foodborne Outbreak list serve of the potential outbreak with a request for reported cases with a history of travel from January 1-15, 2001. Travel history dates were based on reported exposures of known cases. The process of providing immunizations to restaurant employees reached the news media through one of the employee’s contacts. The report reached wire services and was broadcast nationally. Additional reports were received directly from individuals who were diagnosed in their home areas.

Current reported cases include thirty-six IgM confirmed cases with and additional five probable or suspected cases (87.8% confirmed). Exposures occurred in all cases from January 3 through January 13, 2001. The range of onset dates is January 29-February 28, 2001 (see Figure 1).

The Orlando, Florida area often presents an opportunity for cases to be dispersed to many states and countries. Thirty-six (36) confirmed and four probable cases have been reported from ten states, including Florida, Mississippi, Oklahoma, Texas, Utah, Illinois, Alabama, Massachusetts, Ohio, and Kentucky, and three foreign countries: Canada, France and Belgium. Severity of illness ranges from mild to that of one death due to fulminant hepatitis. Several cases were hospitalized. One case was so severe as to have been placed on a waiting list for a liver transplant, however he has since recovered.

As these cases were reported, public health workers and laboratories were contacted with a request to forward serum to the Bureau of Laboratories in Jacksonville for forwarding to the Centers for Disease Control and Prevention in Atlanta for RNA comparisons. Those results are still pending. Blood samples for 17 of 82 food workers working during the exposure period were also obtained. All were IgM negative. Samples from other food workers were unobtainable.

Through open-ended questioning, all of the confirmed cases cited eating at the same restaurant in which the servers were working. This suggests that all cases were exposed to a similar source, most likely an infected food worker. No other cases associated with this outbreak linked to other area restaurants were reported. Menu-specific questionnaires have been distributed to respective states and countries for the determination of better-defined transmission vehicles. Results are pending.

On March 7, 2001, the 47-year-old woman returned to the U.S. from a tour of Tanzania, Africa. Her intent was to complete her vacation at South Seas Plantation in Fort Myers. During her stay she began complaining of headaches and fever, which increased in severity until, on March 19, she presented at a local hospital for treatment. In the emergency department, history indicated that while in Africa she had utilized a locally –acquired prophylaxis against malaria. Due to episodes of nausea attributed to her malaria prophylaxis medication, she had discontinued its use four days after her return from Africa. Her illness began about six days later, two days before her admission.

In the emergency department her temperature was 102 F. and, except for the headaches, the remainder of the examination was unremarkable, as was her review of systems and past medical history. Thin slides were obtained (thick slides were not done) and the pathologist diagnosed malaria parasites with multiple large ring forms present. Admission to an infection disease service was completed and the health department notified.

On the day after her admission, in spite of treatment, her condition deteriorated and she developed septic shock and respiratory failure. CT studies revealed massive brain edema with subarachnoid hemorrhage and brain herniation. EEG revealed electro cerebral silence. The woman died 6 days after admission due to complications of Plasmodium falciparium.

Malaria is a parasitic disease with four human infectious agents: Plasmodium malariae, P.ovale, P. vivax, and P. falciparium. Of the four, P. falciparium causes the most serious clinical disease and may present with a variety of symptoms such as fever, chills, cough, sweats, respiratory distress, headache and diarrhea It is transmitted by the bite of the female Anopheles mosquito. As the mosquito feeds, it releases malaria sporozoites from its salivary glands that enter the blood and rapidly gain entry to the human host’s liver cells, where the parasites multiply and release large numbers of merozoites into the bloodstream. The merozoites enter erythrocytes and initiate the fever and chills that are typical of malaria symptoms. Incubation is generally from 7 to 14 days for P. falciparium, 8-14 days for P. vivax and P. ovale, and 7-30 days for P. malariae. Malaria should be considered in any febrile patient with a history of travel to an endemic area.

There are an estimated 300 to 500 million cases of malaria each year worldwide with approximately 1.5 to 2.7 million deaths. In Florida there were 90 cases of malaria reported in 2000, all imported, and so far this year there have been eight cases reported through week 12.

In the early 1900’s malaria was endemic throughout the United States, with an estimated 600,000 cases occurring in 1914. Improvements in socioeconomic conditions, water management, and vector-control efforts in the U.S. have eliminated malaria as public health problem, but the Florida environment and presence of competent vectors mandates that we continue aggressive vector control and surveillance activities or we may again see malaria as a Florida public health problem.

Malaria in the returning traveler is a preventable disease that continues to cause significant morbidity and mortality in the state of Florida. Travelers to malaria endemic parts of the world should receive appropriate prevention counseling and interventions from a travel medicine specialist. These interventions should be comprehensive and cover malaria as well as other infectious and non-infectious disease risk reduction information that is tailored to the specific nature and duration of the traveler’s plans.

A third challenge is that travelers may have already formed a definite idea of what they need prior to travel. For example, many travelers call travel medicine providers requesting "malaria pills" before their trip. It is important take this opportunity to educate travelers not to rely on chemoprophylaxis as the sole means of risk reduction. Reduction of mosquito bites is the primary defense against infection and involves remaining indoors during peak biting time, covering exposed skin surfaces, using of effective mosquito repellents, and sleeping under treated bed nets. A fourth challenge is improving compliance with recommended advice. Malaria chemoprophylaxis, for example, involves lengthy regimens that may have undesired side effects.

A fifth challenge involves the changing science of treatment and prophylaxis of malaria. Increasing drug pressure and consequent drug resistance has lead to rapidly changing recommendations for the prophylaxis and treatment of malaria. In addition, alternative medicine and non-FDA approved pharmaceuticals may be available to the traveler. It is important for travel medicine specialists to stay current on new advances. Also, consultation on managing the patient with malaria is available by contacting the CDC’s malaria hotline, (770) 488-7788 (Monday--Friday, 8 a.m. to 4:30 p.m. eastern standard time). After business hours, weekends, and holidays, contact CDC's security station, telephone, (404) 639-2888 and ask to page the on-call person for malaria questions.

1. Chin, James [2000] Control of Communicable Disease Manual, American Public Health Association, p310, Washington DC.

2. Rankel, Robert [1995] Conn’s Current Therapy, W.B. Saunders Company, p.92, Philadelphia, Pennsylvania.

3. MMWR [2001] Malaria Surveillance – United States 1996, March 30, 2001/Vol. 50/No. SS-1, U.S. Department of Health and Human Services, Center for Disease Control and Prevention, Atlanta, Georgia.

 

"Surveillance for West Nile (WN) Virus"

Dial-in by 11:10 AM at (850) 487-8587 or SunCom 277-8587

Abstract

Florida is conducting WN virus surveillance in addition to St. Louis encephalitis and eastern equine encephalitis monitoring activities. During its brief history, WN has manifested itself in the United States with bird die-offs, especially American crows. Thus, tracking bird mortality in Florida is considered a useful tool for WNV detection and surveillance. WN has also caused morbidity and mortality among people and other animals, and has been identified in a number of vector species. No human or animal cases have been reported in Florida. The state's interagency effort includes looking for evidence of WN virus in wild birds, sentinel chickens, horses and people and a protocol for mosquito surveillance when WN virus is detected in Florida.

Further details regarding the audio-conference call and PowerPoint files will be posted on the Bureau of Epidemiology Intranet web site. Be sure and register online for nursing CEU's and contact hours for environmental health professionals. We will also be providing CEU's for Veterinary Medicine. Information about up-coming topics and presenters will also be posted in the Epi Update. If either of these access points is unavailable to you, please e-mail Melanie Black [Melanie_Black@doh.state.fl] 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 speaker 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.