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.

Marc Traeger, MD, EIS officer, Florida DOH; John M. Montgomery, MD, Health Services Director, Director of Epidemiology, Duval County Health Department.

Recent publications surrounding meningococcal disease, the recent meningococcal outbreak and vaccination campaign at the University of North Florida in Duval County, and the beginning of the fall semester in universities across Florida and the U.S. make this an opportune time to update ourselves on the latest information and recommendations surrounding meningococcal disease in college students and young adults.

The August 8, 2001 issue of JAMA (URL http://jama.ama-assn.org/ ) includes 3 articles on the subject: "Risk Factors for Meningococcal Disease in College Students" (1), "Invasive Meningococcal Disease in Adolescents and Young Adults" (2) and the editorial "Toward Control of Meningococcal Disease, Reducing Risk in College Students" (3). Another publication describing the Florida Department of Health’s investigation of the Putnam County community outbreak in 1998-1999, "Marijuana Use and Social Networks in a Community Outbreak of Meningococcal Disease" (4) was published in the Southern Medical Journal in May.

In the first study, Bruce et al (1) performed a prospective surveillance study with nested case-control study of US college students with meningococcal infection from September 1, 1998 to August 31, 1999. They found that although college students in general had a lower rate of severe meningococcal disease than the general population of 18 to 23 year olds, the rate among freshmen living in dormitories was more than 3 times that in the general population (the incidence rate for undergraduates was 0.7 per 100,000 persons vs. 1.4 per 100,000 for the general population of 18- to 23-year old nonstudents, and 5.1 per 100,000 for freshmen living in dormitories; all statistically significant). Illness due to meningococcal serogroups that should be preventable with the currently available vaccine occurred in 68% of cases.

The Florida county health departments and Bureau of Epidemiology’s surveillance section all contributed to this study when investigating meningococcal cases, by determining whether the patients between 17 and 30 years of age were college students and including that information on report forms.

In the second study, Harrison et al (2) characterized the occurrence of meningococcal disease in those aged 15 through 24 years in Maryland from 1990 through 1999. In this study, 24% of cases occurred in the 15-24 year age group. This age group had a strikingly high case-fatality rate of 24%, and 83% of cases in the age group were caused by serogroups preventable with the licensed meningococcal vaccine. The authors found that the overall incidence of meningococcal infection in 15 through 24 year olds in Maryland increased and then declined during the 1990s (incidence peaked at 2.1 per 100,000 in 1996-1997 and fell to 1.0 per 100,000 in 1998-1999).

In his editorial, Wenger (3) states that these studies demonstrate that meningococcal disease in this age group is severe, and a targeted approach of immunizing college freshmen who live in dormitories may be the most efficient way to make an impact on meningococcal disease, though he acknowledged that one could argue that immunizing all college freshmen would have a larger impact, albeit a less efficient one.

Cigarette smoking is a known risk factor for meningococcal infection and was reported in nearly half or the 15- through 24-year-old cases in the study by Harrison et al. (2). The association of marijuana use and social networks in a meningococcal outbreak was brought out in the report by Krause et al. (4), and serves as a reminder to consider social links and activities while investigating outbreaks, and to promote avoidance of risk behaviors associated with disease when given the opportunity.

In Florida 2000, 18 confirmed cases of meningococcal disease occurred in the 15-19 year-old age group, and 12 cases occurred in the 20-24 year-old age group (incidence rates of 1.8 and 1.3 per 100,000 persons respectively).

An outbreak of meningococcal disease between May and July 2001 was detected at the University of North Florida in Duval County, and a vaccination campaign was held there July 31-August 1. See Epi Update issues from August 3, 2001 and July 27, 2001 for a description of this event.

The Advisory Committee on Immunization Practices has recommended that college students be advised of the risks and benefits of immunization and that the students should decide at that point whether they should be immunized. (5) The Florida Department of Health has issued a letter for distribution to all college freshmen about to start classes with information regarding this topic.

References:

1. Bruce, MG et al. Risk Factors for Meningococcal Disease in College Students. JAMA 2001; 286:688-693.
2. Harrison, Lee et al. Invasive Meningococcal Disease in Adolescents and Young Adults. JAMA 2001; 286:694-699.
3. Wenger, J. Toward Control of Meningococcal Disease, Reducing Risk in College Students. JAMA 2001; 286:720-721.
4. Krause, G, Blackmore, C, Wiersma, S, Lesneski, C, Woods, C, Rosenstein, N, Hopkins, R. Marijuana Use and Social Networks in a Community Outbreak of Meningococcal Disease. Southern Medical Journal 2001; 94:482-485.
5. Centers for Disease Control and Prevention. Prevention and Control of meningococcal disease and meningococcal disease in college students: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2000; 49:1-32.

Submitted by Roger Sanderson, RN, MA, Bureau of Epidemiology

OSHA estimates that 5.6 million workers in the health care industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and others. According to the CDC in March of 2000, it is estimated that 600,000 to 800,000 needlestick injuries (NSIs) and other percutaneous injuries occur annually among health care workers. Studies show that nurses sustain the majority of these injuries and that as many as one-third of all sharps injuries have been reported to be related to the disposal process. The CDC estimates that 62 to 88 percent of sharps injuries can potentially be prevented by the use of safer medical devices. Needlestick injuries and other sharps-related injuries that result in occupational bloodborne pathogens exposure, continue to be an important public health concern.

As a result of these concerns The Needlestick Safety and Prevention Act (Public Law 106-430) was passed unanimously by Congress and signed by President Clinton on Nov. 6, 2000. This act mandated specific revisions of OSHA's bloodborne pathogens standard within six months.

OSHA has created the following www site that answers may of the questions about needlesticks. This site contains numerous links to other sites. Also contained are references and articles on studies that document the problems of needlesticks and disease transmission. In addition there are fact sheets, a powerpoint presentation, and a wealth of information about the subject.

The CDC has recently published guidelines for those occupational exposures that place health care professionals (HCP) at risk for HBV, HCV or HIV infections. This report updates and consolidates previous recommendations for management and postexposure prophylaxis for HBV, HCV and HIV.

Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis June 29, 2001 / 50(RR11);1-42

Carina Blackmore, MS.Vet.Med., Phd. Bureau of Epidemiology

Each year influenza viruses cause significant morbidity and mortality in Florida. To better monitor the disease in our state the Florida Department of Health has, for the past 4 years, coordinated a voluntary influenza sentinel physician surveillance network. Other goals for this program are: (1) to monitor the antigenic changes of circulating virus strains (2) develop a surveillance system that will provide an early warning and adequate monitoring capabilities in the setting of the next influenza pandemic and (3) provide medical practitioners and other Florida residents with current and accurate information regarding the incidence and severity of the disease in our state.

The Florida Influenza Sentinel Physician Surveillance Network is part of a national influenza surveillance network coordinated by the Centers for Disease Control and Prevention (CDC). The program has two components: 1. Participating primary care providers report the number of patients diagnosed with influenza-like illness weekly to CDC either by telephone or via the Internet. 2. They also submit laboratory specimens for influenza virus isolation and strain typing, free of charge, to the Florida Department of Health Bureau of Laboratories. All participants will receive weekly updates on the clinical and laboratory influenza surveillance results free of charge through our newsletter, the Epi Update, and the CDC’S MMWR (a subscription valued at $130.00). Participants will also receive a free subscription to the journal Emerging Infectious Diseases.

We are currently looking for additional physicians who are willing to help us monitor influenza activity in the general population during the 2001-2002 season. Last year we had 52 participants in this important surveillance program but our ultimate goal is to have 70 sentinel physicians across Florida.

Steven T. Wiersma, MD, MPH, Acting State Epidemiologist and Chief, Bureau of Epidemiology

Botulism

A suspect case of infant botulism has been confirmed in a 20 day-old female hospitalized in Jacksonville. This child, a resident of Georgia, presented to the hospital with a two-day history of lethargy and decreased oral intake. The child's condition rapidly progressed to flaccid paralysis with respiratory failure. The hospital staff treated the child supportively including mechanical ventilation and an extensive medical work-up was undertaken.

A request for botulism testing generated a call from the hospital laboratory to the Bureau of Epidemiology. A medical epidemiologist from the Bureau of Epidemiology is charged with triaging request for botulism testing on behalf of the CDC Botulism Laboratory. This case met the criteria for testing, and after consultation with the CDC, specimens were shipped. In addition, the treating physicians were referred to the California Department of Health Services, Infant Botulism Treatment and Prevention Program for consideration of Human Botulism Immune Globulin (BIG). BIG is becoming the "standard-of-care" for paralyzed, critically ill patients with infant botulism.

This case continues to be investigated by the Duval CHD and Georgia Health Department officials.

Link to Infant Botulism Treatment and Prevention Program http://www.dhs.ca.gov/ps/dcdc/html/ibtindex.htm

Typhoid Fever

A laboratory-confirmed case of typhoid fever has been reported in a Florida laboratorian with no travel history. This case is currently under investigation but highlights the need for all laboratory workers to review the ACIP guidelines for use of typhoid fever vaccine. These guidelines state that typhoid vaccine is indicated for microbiology laboratorians who work frequently with S. typhi.