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.

Zuber D. Mulla PhD., MSPH, Bureau of Epidemiology; Paul Fiorella PhD., Bureau of Laboratories; Roger Sanderson RN. MA., Bureau of Epidemiology

On July 20, 2001, the Molecular Biology division of the Bureau of Laboratories contacted the Bureau of Epidemiology regarding a group of 11 cases of salmonellosis. All of these cases had been caused by Salmonella serotype Rubislaw (SSR). All of the isolates had an identical DNA fingerprint according to pulsed-field gel electrophoresis (PFGE) when digested by the enzyme Xbal. The range of the "event" dates were December 2000 – July 2001. (The average annual number of SSR isolates sent to the Bureau of Laboratories in Jacksonville during 1999-2000 was 26.) When the 11 isolates were digested with a second enzyme, two clusters, rather than one, were discovered.

Demographic and preliminary epidemiologic data were obtained from electronic field reports from the Bureau of Epidemiology’s Surveillance Section. Detailed epidemiologic data had been collected by the respective county health departments. These documents were requested from the county health departments and all available data were reviewed to determine if there was clustering by age, race, sex, ethnicity, county of residence, event month, and the likely source of infection.

Table 1 summarizes key demographic and epidemiologic data on 11 cases of gastroenteritis due to SSR. Case 11 has not been reported to the Bureau of Epidemiology. Cases 3 and 4 could not be contacted by the Lee County Health Department. Case 7 could not be contacted by the Hillsborough County Health Department.

Six of the cases (55%) were infants (age<12 months). This proportion (55%) appears to be significantly higher than expected. Of the 2813 cases of salmonellosis (all serotypes) reported to the Bureau of Epidemiology in calendar year 2000, only 25% were infants (Fisher’s exact test p=0.04). However, salmonellosis is endemic in Florida infants. In 1998, the incidence of salmonellosis in Florida in children less than one year of age was 387 cases per 100,000. In contrast, the incidence of salmonellosis in individuals who were one year of age or older was 21 cases per 100,000 (a relative risk of 18.4 for infants compared to non-infants).

Sixty-four percent of the cases were male. No clustering by county of residence or source of infection was detected. The likely source of infection for Case 5 was a pet turtle. SSR has been isolated from reptiles including turtles in the past [1, 2].

An interesting observation is that 2 of the 11 cases had invasive infections. Case 1 developed meningitis and Salmonella was found in her cerebrospinal fluid. A blood culture obtained from Case 7 yielded Salmonella.

PFGE detected a group of 11 isolates of SSR; however, no epidemiologic links could be identified. It appears that this grouping does not represent an outbreak. The quantity and quality of the epidemiologic data are variable. Epidemiologic data are critical to linking cases of disease. The Molecular Biology division of the Bureau of Laboratories is in the process of performing PFGE on earlier SSR isolates and will continue, along with the Bureau of Epidemiology, to monitor the molecular epidemiology of SSR infections in Florida.

Steven Wiersma, MD, MPH-Acting Bureau Chief and State Epidemiologist

Following the recent terrorist events, and considering that the threat may not be over, the Bureau of Epidemiology would like to remind our partners of the need to rapidly report and investigate unusual disease patterns and other indicators of potential bioterrorist events.

County health departments should remind their disease surveillance constituents that disease reporting goes beyond the named diseases listed in 64D-3 FAC, and includes any suspect disease of public health significance. Section 381.0031of the Florida Statutes states, "Any practitioner, licensed in Florida to practice medicine, osteopathic medicine, chiropractic, naturopathy, or veterinary medicine, who diagnoses or suspects the existence of a disease of public health significance shall immediately report the fact to the Department of Health." 64D-3.002 also states the requirement for the reporting of disease outbreaks.

The Bureau is willing to assist CHDs in surveillance and investigation issues. Health professionals should call the appropriate CHD for assistance. CHDs can call the Bureau of Epidemiology at SC 205-4401 or 1-850-245-4401 or contact a regional epidemiologist for assistance.

Please forward this message to any other appropriate healthcare personnel. This is a good time to strengthen the excellent disease surveillance and investigation systems we have in place to prevent disease.

Bradie Metheny (C)

Reprinted from a CSTE announcement.

September 13, 2001

HHS Secretary Tommy Thompson activates national medical disaster system: hundreds of personnel, tons of supplies deployed to New York City and the Pentagon. Hundreds of medical and other health services-related personnel were on site to assist in New York City and at the Pentagon by midday Wednesday, September 12, following the first-ever decision to launch the National Disaster Medical System (NDMS).

HHS Secretary Tommy Thompson also has authorized the first emergency use of the two-year-old National Pharmaceutical Stockpile at the Centers for Disease Control and Prevention in response to the September 11 terrorist attacks. The Department of Health and Human Services is the primary agency for coordinating health, medical and health-related social services under the federal emergency response plan, explained an HHS spokesperson. "The department's Office of Emergency Preparedness (OEP) is the 'medical 911' for all national and catastrophic disasters both natural and manmade. Also part of the HHS response is CDC's release of one of the nation's eight "12 hour Push Packages" containing pharmaceuticals, intravenous supplies, airway supplies, emergency medication, bandages and dressings and other material to cover a spectrum of medical needs. Each "package" involves several truckloads of material and owes its name to the goal of being deployed in 12 hours from the time it is requested.

In this case, the shipment arrived in New York at 9 PM Tuesday night, within seven hours of Secretary Thompson's request. In addition to the standard package, CDC provided 84,000 bags of intravenous fluid, 350 portable ventilators and 250 stationary ventilators to meet the special needs of the New York emergency. Included in the CDC response are four epidemiologists and two laboratory experts to assist in assessing medical needs and capacity planning for treating victims in New York area hospitals. In addition, CDC provided pharmacists, public health experts and 11 technical assistance personnel to help distribute push-package materials. The CDC has also been working with tetanus vaccine manufacturers and the public health departments of New York and Washington, DC, and confirmed yesterday that adequate supplies of tetanus vaccine are being sent directly to each location by manufacturers or related health departments. Vaccine manufacturer Aventis Pasteur has shipped 50,000 doses of tetanus-diphtheria vaccine to replenish the local supply in New York City.

The CDC also has activated its Health Alert Network, which provides rapid information nationally to all health departments. The agency has issued a precautionary advisory to state and local health departments to be alert to any unusual disease symptoms -- a standard emergency procedure to ensure speedy reporting. As of last night no reports had resulted from this alert. The CDC Health Alert Network also is being used to provide information on safe handling of bodies and ensure against spread of disease. In addition, CDC provided information regarding dust hazards arising from the collapse of the World Trade Towers. When Thompson activated the NDMS, his action placed 80 disaster medical assistance teams (DMATs) nationwide at the ready for deployment if needed. In total, OEP has deployed 328 medical personnel from disaster readiness teams to assist health providers in New York and Washington, DC. DMAT teams come from sponsoring organizations, such as major medical centers or other health organizations, that sign a Memorandum of Understanding with PHS to sponsor, organize and train the team, then coordinate its dispatch when it is called upon. The teams are designed to be self-sustaining for 72 hours while providing care at an emergency site. In New York, a total of 211 emergency medical personnel from five teams were at Stewart National Guard Base in Newburg awaiting assignment. DMATs sent to the area include 25 personnel from Lyons, NJ; 44 from White Plains; 41 from Boston; 52 from Worcester, MA; and 49 from Providence, RI. Three DMATs have been deployed to the Washington area: 46 medical personnel from the U.S. Commissioned Corps DMAT in Rockville, MD; 35 from Winston-Salem, NC, and 36 from Atlanta, for a total of 117 medical personnel. In addition, OEP has deployed about 270 mortuary services personnel to assist in retrieval, identification and preparation for burial of those killed at both disaster sites. Thompson said at a press conference last night that four Disaster Mortuary Operational Response Teams (DMORTs) with a total of 169 personnel have been deployed to the New York area from throughout the East Coast. They also are staging at the Stewart National Guard Base, to be used at the World Trade Center site. Three DMORTs with 102 personnel were assigned to the Pentagon site. The PHS Commissioned Corps was put on readiness alert Tuesday, making some 5,700 corps personnel available for deployment. In particular, about 800 corps officers who make up the Commissioned Corps Readiness Force, are on stand-by for immediate deployment if needed to meet local needs for specific medical skills.

Secretary Thompson said he has been in touch with the major blood suppliers to assist in bringing about maximum blood donation so supplies will be adequate to treat victims. NIH opened its blood center for donation by the public and by yesterday had collected all they could receive at present. FDA has been in close contact with key national and local blood suppliers to facilitate the availability of adequate blood supplies to meet urgent needs, particularly in New York City and Washington, DC. Recognizing the need for rapid, high-volume collections, FDA provided guidance yesterday to help make more blood available for the emergency and to also insure the safest possible blood collections under these emergency circumstances.

Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology

The Sixth Annual Emergency Preparedness Satellite Seminar sponsored by USDA/APHIS, FEMA and DOD which was to be broadcast on September 19^th and 20^th, 2001 has been postponed due to the national emergency. The broadcast will be rescheduled. However, at this time FEMA is not in a position to discuss another date.

Please feel free to contact me either by email [Melanie_Black@doh.state.fl.us] or telephone (850) 245-4444 ext. 2448 (SunCom 205-4444 ext. 2448).

Reprinted with the permission of the Mississippi Morbity Report.

Lyme disease is a systemic tick-borne illness caused by infection with Borrelia burgdorferi. It is rarely fatal, but its course may be long and debilitating with cardiac, neurological, and joint involvement (1-3). Initial symptoms can include a flu-like syndrome with headache, stiff neck, myalgia, artharalgia, malaise, and low -grade fever. Often, a more or less circular, painless, macular dermatitis – called erythema migrans (EM) --- is present at the bite site (4-6). The EM lesion is frequently said to be pathognomonic for Lyme disease, although it seems not develop in all patients. EM lesions usually increase steadily in size with subsequent central clearing . The number of reported Lyme disease cases, nationwide, increased significantly from 1992 to 1996; 16,461 cases were reported to the CDC in 1996 (7). Although cases occur in most states and the District of Columbia, the vast majority are from the northeastern and north central states. Antibiotics are effective in the most cases of Lyme disease, especially of treatment is initiated early.

There is controversy about whether or not true Lyme disease occurs in the southern United States. Some physicians and researchers are convinced that it does, and numerous cases are reported to state health departments and the CDC each year. In fact, Mississippi reports about 20 cases of Lyme disease annually. Proponents say, evidence of Lyme disease in the South include clinical syndromes consistent with Lyme disease, serologic test results sometime indicative of infection with B. burgdorferi, and rashes that resemble the EM lesion. Other physicians adamantly contend that there is no Lyme disease in the South. They show as evidence invariably negative data from extensive retesting and follow-up of patients with suspected Lyme disease. For example, in 1999, the Mississippi Department of Health investigated 48 cases of physician-diagnosed, locally acquired Lyme disease. Each medical record was reviewed, and blood samples were drawn for enzyme-linked immunosorbent assay (ELISA) and Western blot analysis. Results indicated that only 1 sample was ELISA-positive; none were positive by Western blot, the confirmatory test (S. Slavinski, DVM, Mississippi State Department of Health, personal communication, August 2000). Therefore, no evidence of infection with B. burgdorferi could be found.

Vectors. There is no reason why Lyme disease should not occur in the southern United States. The tick vector of Lyme disease, Ixodes scapularis, is found in the South (see Figure 1). And there have been isolations of true B. burgdorferi from both rodents and ticks in the southern states (South Carolina, Georgia, Florida, Georgia, and Texas) (8-10). However, this is rare. In Texas, for example, several hundred thousand ticks (numerous species have been analyzed for B. burgdorferi and only a very small percentage were positive (J. Rawlings, MPH, Texas Department of Health, personal communication, September 200). Contrast this with the northeastern United States, where approximately 50% of I. scapularis ticks are infected (11). A small percentage of Lone Star ticks, Ambloyomma americnum, have been reported to harbor spirochetes that react with reagents prepared against B. burgdorferi. In one study, the authors called the spirochetes B. lonestari (12). Therefore, the Lone star tick may be a vector of some Lyme disease-like illness in the southern United States caused by this new spirochete, as of yet undescribed.

Infections. Cases of Lyme disease-like illnesses– that meet the CDC case definition for Lyme disease—do occur in the South. Interestingly, these cases apparently respond to treatment with antibiotics, indicating a bacterial case of some type. However, a bona fide (widely accepted) B. burgdorferi isolate from a patient in this part of the country is lacking despite numerous attempts to isolate organism from EM lesions.

Hypersensitivity reactions? Further complicating the issue is an apparent hypersensitivity reaction to the saliva of the Lone Star tick that sometimes occurs 1 to 3 days following the bite. This hypersensitivity reaction resembles EM and is often 6 to 8 cm in diameter, the ring-like, raised, and vesicular. While studies of such lesions are lacking, they are probably not true EM an lesions because there is little or no incubation period, the lesions often fade in a few days and the lesions are vesicular. EM ;lesions may be vesicular, but usually are not. In fact, they are often flat, almost imperceptible by touch. In southern states where physicians do not see many cases of true Lyme disease, these hypersensitivity reactions may be mis-diagnosed as the real thing.

While some researchers, insist that Lyme disease does not occur in the southern United States, it is unwise at this point to exclude Lyme disease from the differential diagnosis in person with that possible tick-borne illness in this region. Empirical evidence supports the presence of a Lyme-like illness in the South, perhaps caused by another, closely related Borrelia spirohete. Some may be coming. The CDC recently issued several grants to study Lyme disease; several of these were specifically targeted toward unraveling the mystery of Lyme disease in the South.

1. Sigal LH. Early disseminated Lyme disease: cardiac

manifestations. Am J Med. 1995;98 (suppl 4A):25S-29S.

2. Halperin JJ. Neurroborreliosis. Am J med. 1995;98 (suppl

4A):52S-59S.

3. Spach DH, Liles WC, Campbell GL, et al. Tick-borne

diseases in the United States. N Engl J Med. 1993;329:

936-947.

4. Nadelman RB, Wormser GP. Erythema migrans and early

Lyme disease. Am J med. 1995;98(suppl 4A);15S-24S.

5. Malane MS, Grant-Kels JM, Feder HMJ, Luger SW.

Diagnosis of Lyme disease based upon dermatologic

manifestations. Ann Intern Med. 1991;114:490-498.

6. Masters EJ. Erthema migrans. Postgrad Med. 1993; 94:23-30.
7. Centers for Disease Control and Prevention. Lyme

disease – United States, 1996. MMWR. 1997;46(RR-23):

531-535.

8. Durden LA, McLean RG, Oliver JH, et al. Ticks, Lyme

disease spirochetes, trypanosomes, and antibody to

encephalitis viruses in wild birds from coastal Georgia and

South Carolina. J Parasitol. 1997;83:1178-1182.

9. Sanders FH, Oliver JH. Evalutaion of Ixodes scapularis,

Amblyomma americanum, and Dermacentor variabillis (Acari:

lxodidae) from Georgia as vectors of a Florida strain of the

Lyme disease spirochete, Borrelia burgdorferi. J Med

Entomol. 1995;32:402-406.

10. Oliver JH, Chandler FW, Luttrell MP, et al. Isolation and

transmission of the Lyme Disease spirochete from the

southeastern United States. Proc Natl Acad Sci U S A.

1993;90:7371-7375

11. Lane RS. Competence of ticks as vectors of microbial

agents with an emphasis on Borrelia burgdorferi. In:

Soneshine DE, Mather TN eds. Ecological Dynamics of

Tick-borne Zoonoses. New York: Oxford: University Press;

1994:45-67..

12. Barbour AG, Maupin GO, Teltow GJ, et al. Identification of

Adapted with permission from: Goddard J,

INFECTIONS IN MEDICINE 18(3): 132-133,

copyright 2001, Cliggott Publishing Company,

Darien, CT.

Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology

"Emerging Pathogens"

Timothy Dolan, Ph.D., ABMM, Laboratory Coordinator, Manatee County Health Department, Florida Department of Health

11:00 AM – 12:00 PM EST

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

"Infectious diseases are a continuing menace to all people, regardless of age, gender, lifestyle, ethnic background, and socioeconomic status. They cause suffering and death, and impose an enormous financial burden on society. Although some diseases have been conquered by modern advances, such as antibiotics and vaccines, new ones are constantly emerging (such as AIDS, Lyme disease, and Hantavirus pulmonary syndrome), while others reemerge in drug-resistant forms (such as malaria, tuberculosis, and bacteria pneumonias).

Because we do not know what new diseases will arise, we must always be prepared for the unexpected. For example, in 1997, an avian strain of influenza that had never before attacked humans began to kill previously healthy people in Hong Kong. This crisis raised the specter of an influenza pandemic similar to the one that killed 20 million people in1918. Also in 1997, strains of Staphylococcus aureus with diminished susceptibility to vancomycin were reported in Japan and the United States.

If we are unable to replace drugs like vancomycin as they lose their effectiveness-and to limit the emergence and spread of resistance-some diseases may become untreatable, as they were in preantibiotic era. In addition, the recent discovery that a strain of the virus that causes HIV/AIDS has been circulating at least since 1959 illustrates the furtive way in which emerging infectious agents can insinuate themselves into human populations and remain undetected for years before emerging explosively as public health problems. Each of these examples reminds us that we are barely one step ahead of the microbes and underscores our need for a strong and vigilant public health system.

http://www.cdc.gov/ncidod/emergplan/planrequest.htm

Further details regarding the audio-conference call and the PowerPoint files will be posted on the Bureau of Epidemiology Intranet web site. Be sure and register online at the end of the program to obtain nursing and laboratory CEU’s. Environmental contact hours will also be available for this program. Information about upcoming topics and presenters will also be posted in the Epi Update. If either of these access points is unavailable to you, please email Melanie Black [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 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.

Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology

As part of the bioterrorism preparedness activities, the Bureau of Epidemiology has developed a brochure entitled Bioterrorism: Guidelines for Hospitals, which addresses awareness, surveillance, communication and planning for the management of suspected biological attacks. These brochures will be mailed out to all county health departments, hospitals, rural health clinics and community health centers in the state of Florida.

Please see the attached pdf file for brochure content. If you have questions regarding this a4ctivity, please contact Melanie Black by email [Melanie_Black@doh.state.fl.us] or telephone (850) 245-4444 ext. 2448 (SunCom 205-4444 ext. 2448).

Information provided by the DOH, HIV/AIDS Program.

The Hepatitis and Liver Failure Prevention and Control Program at the Florida Department of Health (FDOH) is continuing its education and awareness campaign to inform the public about hepatitis A, B, and C, including information about risk factors, testing, treatment, and prevention. Through brochures, posters, the Internet, and the media, we aim to raise awareness about hepatitis and to encourage individuals who may have been exposed to the viruses to seek information and testing.

To help prepare for the anticipated increase in demand for information about hepatitis A and B, a copy of the Hepatitis A and Hepatitis B Guidelines and Recommendations

CD-ROM is being made available to each county health department and other partners. The CD contains information that will describe the natural history of hepatitis A (HAV) and hepatitis B (HBV) infections, list the serologic and laboratory tests available to diagnose and evaluate patients with HAV and HBV infections, describe methods to assess a client’s risk for HAV and HBV infections, and describe methods to counsel infected individuals. We encourage health professionals to use this information to respond to their patients’ questions and concerns.

We are committed to Florida’s Hepatitis and Liver Failure Prevention and Control Program and anticipate a successful hepatitis public education and awareness campaign within the state. If you have any questions or comments about Florida’s Hepatitis and Liver Failure Prevention and Control Program, the hepatitis awareness campaign, or the CD-ROM please contact: Sandy Roush at (850) 245-4426.

The Weekly Disease Table is not available this week. Look for an updated table in next week’s issue.