A Publication by the Bureau of Epidemiology
October 17, 2001
"The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow."
--Foege WH et al. Int. J of Epidemiology 1976; 5:29-37.
Steven T. Wiersma, MD, MPHBureau Chief and State Epidemiologist
Don Ward, Surveillance Section Administrator, Epi Update Managing Editor
Samuel Crane, MPH, Special Projects Surveillance Coordinator, Epi Update Editor
Bureau of Epidemiology Frequent Contributors:
Kathryn Snavely, MPH
Reportable Disease Manager
Jodi Baldy, MPH,
Biological Scientist IV
Ursula E. Bauer, PhD,
Chronic Disease Epidemiologist
Lisa Conti, DVM, MPH,
State Public Health Veterinarian
Dolly Katz, PhD, MPH, SE Florida
Roger Sanderson, RN, MA, SW Florida
Carina Blackmore, MS Vet. Med., PhD, NE Florida
Zuber Mulla, PhD MSPH,
Central Florida Carina Blackmore, MS Vet. Med., PhD,
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.
The Department of Health has a home on the World Wide Web at http://www.doh.state.fl.us
For information on diseases and conditions of public health importance go to MyFlorida.com, click on Health and Human Services, then Consumers--Diseases and Conditions.
In this issue: Health Alert !!
1. Florida Reports Two Additional Human Cases of West Nile Virus
April Crowley 1-850-245-4111
Carina Blackmore, MS Vet Med., PhD 1-877-631-5445 (toll-free pager)
October 16, 2001
TALLAHASSEEThe Florida Department of Health announced today that two more
human encephalitis cases caused by the West Nile (WN) virus have been reported. One case is in a 45-year-old male from Monroe County, and the other is a 74-year-old male resident of Putnam County. Due to previous WN activity, both of these counties have been under a medical alert, and will remain so until further notice. So far this year, there have been 11 reported human cases of WN in Florida.
Health officials want all citizens living in counties under the medical alert to be on heightened awareness.
A total of 49 counties are included in this alert: Alachua, Baker, Bay, Bradford, Calhoun, Citrus, Clay, Collier, Columbia, Dade, Dixie, Duval, Escambia, Flagler, Franklin, Gadsden, Gilchrist, Gulf, Hamilton, Hernando, Highlands, Holmes, Jackson, Jefferson, Lafayette, Lake, Lee, Leon, Levy, Liberty, Madison, Marion, Martin, Monroe, Nassau, Okaloosa, Pasco, Putnam, Santa Rosa, Seminole, St. Johns, Sumter, Suwannee, Taylor, Union, Volusia, Wakulla, Walton and Washington counties.
Remember, all mosquito-born illnesses are preventable. Even though the weather is changing, the Department of Health is still urging all Floridians to take the following precautions against mosquito bites:
For more information on mosquito-borne encephalitis, including reporting human cases and dead birds, visit the DOH Bureau of Epidemiologys Arboviral Encephalitis and West Nile Virus website at MyFlorida.com (click on Health and Human Services, then Consumers Diseases and Conditions, then Arboviral Encephalitis or West Nile Virus) or call the Bureaus toll-free hotline at 1-888-880-5782 for recorded information.
2. Public health update: Second Anthrax Case
Press Contact: 561-712-6488/561-712-6400
October 15, 2001
PALM BEACH COUNTY, FL -- The Palm Beach County Health Department, Florida Department of Health and Centers for Disease Control and Prevention has confirmed that the 73- year-old male employee of American Media Inc., hospitalized since the beginning of October, has been diagnosed as a case of anthrax disease.
The overall picture of clinical symptoms combined with positive results on laboratory tests suggests to health officials that this individual has anthrax disease. The diagnosis cannot be yet confirmed according to the strictest diagnostic criteria, which require isolation of the bacteria from a clinical specimen such as blood, lung samples or spinal fluid. The individual has been receiving appropriate anthrax treatment since his hospitalization due to his connection with the current anthrax investigation in Palm Beach County. His condition is improving and the public health officials are encouraged by his progress.
This is the second case, though not confirmed by the strictest diagnostic criteria, identified as part of the ongoing investigation in Palm Beach County. The first case was reported in early October, resulting in a fullscale public health investigation. The investigative team made up of the Florida Department of Health, CDC and Palm Beach County Health Department continues to pursue the individuals who have been potentially exposed and locations of possible contamination.
To date, there have not been any additional illnesses associated with this epidemiological investigation. Public health officials do not expect to see any additional illness because more than two weeks have passed since the index case was potentially infected with anthrax disease. This type of anthrax usually has an incubation period of one to seven days from exposure to onset of symptoms.
3. Public Health Notice
October 16, 2001
The Palm Beach County Health Department in conjunction with the Florida Department of Health and the Centers for Disease Control and Prevention is advising all individuals who meet the following criteria to continue their prescribed antibiotic treatment for prevention of anthrax for the recommended 60 days (unless otherwise notified by the Palm Beach County Health Department):
Many individuals received a 15-day supply of antibiotics. Individuals who need antibiotics to complete the recommended 60-day regimen can pick them on Wednesday, Thursday and Friday from the Delray Beach Health Center. Individuals working at the AMI building who will be giving a second blood specimen on Wednesday can pick their medications up at that time.
All other individuals who do not meet these criteria should stop taking antibiotics to prevent anthrax. These individuals include:
The public health investigation has confirmed exposures to anthrax spores at AMI. Currently, there has only been two confirmed case of anthrax disease identified in the Palm Beach County public health investigation. As time goes by, it is less likely that individuals who worked in or visited the AMI building between August 1, 2001 and October 7, 2001, will become sick from anthrax disease if they continue their antibiotic treatment as directed.
If you have any questions about this public health notice, please call (561) 582-5666.
4. CDC Guidelines for State Health Departments
Revised October 14, 2001
"These guidelines are the latest version released from the CDC and do not necessarily reflect the views of the Florida Department of Health. However, these guidelines represent a good informational resource for both the public and medical providers. Note that Amoxicillin has been left off the list of recommended post exposure prophylaxis. The FLDOH is currently checking this decision and trying to resolve any confusion regarding therapy".
I. Advice to the Public
How To Handle Anthrax and Other Biological Agent Threats
Many facilities in communities around the country have received anthrax threat letters. Most were empty envelopes; some have contained powdery substances. The purpose of these guidelines is to recommend procedures for handling such incidents.
DO NOT PANIC
1. Anthrax organisms can cause infection in the skin, gastrointestinal system, or the lungs. To do, so the organism must be rubbed into abraded skin, swallowed, or inhaled as a fine, aerosolized mist. Disease can be prevented after exposure to the anthrax spores by early treatment with the appropriate antibiotics. Anthrax is not spread from one person to another person.
2. For anthrax to be effective as a covert agent, it must be aerosolized into very small particles. This is difficult to do, and requires a great deal of technical skill and special equipment. If these small particles are inhaled, life-threatening lung infection can occur, but prompt recognition and treatment are effective.
Suspicious Letter or Package
1. Do not shake or empty the contents of any suspicious envelope or package; DO NOT try to clean up powders or fluids..
2. PLACE the envelope or package in a plastic bag or some other type of container to
prevent leakage of contents.
3. If you do not have any container, then COVER the envelope or package with anything
(e.g., clothing, paper, trash can, etc.) and do not remove this cover.
4. Then LEAVE the room and CLOSE the door, or section off the area to prevent others
from entering (i.e., keep others away).
5. WASH your hands with soap and water to prevent spreading any powder to your face or skin.
6. What to do next
If you are at HOME, then report the incident to local police.
? If you are at WORK, then report the incident to local police, and notify your
? building security official or an available supervisor.
7. If possible, LIST all people who were in the room or area when this suspicious letter or package was recognized. Give this list to both the local public health authorities and law enforcement officials for follow-up investigations and advice.
8. Remove heavily contaminated clothing and place in a plastic bag that can be sealed; give the bag to law enforcement personnel.
9. Shower with soap and water as soon as possible. Do not use bleach or disinfectant on your skin.
II. Advice to State and Local Health Officials
A. Asymptomatic patient WITHOUT known exposure
? Provide reassurance to the patient about the rarity of infection without known exposure.
? Recommend the patient see a health care provider for further concerns and/or diagnostic tests.
? Discourage use of nasal swabs for diagnosis of exposure. (Nasal swabs and blood serum tests are used as an epidemiological tool to characterize an outbreak when there is a known biologic agent.)
B. Asymptomatic patient WITH potential exposure
? Conduct an individual risk assessment and refer to a health care provider if post-exposure prophylaxis is necessary.
? Decontaminating the patient, other than by washing with soap and water, is not routinely recommended.
Post-exposure Prophylaxis (PEP) Recommendations
Initial therapy and Duration
Adults (including pregnant women and immmunocompromised)
Ciprofloxacin 500 mg po BID Or Doxycycline 100 mg po BID 60 days
Ciprofloxacin 15-20 mg/kg po Q12 hrs Or Doxycycline:
>8 yrs and >45 kg: 100 mg po BID, >8 yrs and = 45 kg: 2.2 mg/kg po BID,
= 8 yrs: 2.2 mg/kg po BID 60 days
C. Patients with symptoms compatible with anthrax
? Confirm the diagnosis by obtaining the appropriate laboratory specimens based on the clinical form of anthrax that is suspected (inhalational, gastrointestinal, or cutaneous).
- Inhalational anthrax: blood, CSF (if meningeal signs are present); chest X-ray
- Gastrointestinal anthrax: blood
- Cutaneous anthrax: vesicular fluid and blood
Evaluation of possible anthrax infection for individuals not connected with the AMI incident in Florida should be performed through standard laboratory tests, following the Laboratory Response Network (LRN ) Level A Clinical Guidelines for rule-out and presumptive testing http://www.bt.cdc.gov (follow the link for Resources: Agents/Diseases - Bacillus anthracis)
a. Presumptive identification criteria (level A LRN laboratory)
1. From clinical samples, such as blood, CSF, or skin lesion (vesicular fluid or eschar) material: encapsulated Gram-positive rods
2. From growth on sheep blood agar: large Gram-positive rods
4. Non-hemolytic on sheep blood agar
Additional LRN level B laboratory criteria for confirmation of B. anthracis are available through State Public Health Laboratories and involve:
b. Confirmatory criteria for identification of B. anthracis (level B LRN laboratory)
1. Capsule production (visualization of capsule), and
2. Lysis by gamma-phage, or
3. Direct fluorescent antibody assays (DFA)
Rapid screening assays, such as nucleic acid signatures and antigen detection, which can be performed directly on clinical specimens and environmental samples, are being made available for restricted use in LRN B and C level laboratories.
III. Signs and Symptoms of Anthrax Infection
Inhalational anthrax: A brief prodrome resembling a viral respiratory illness followed by development of hypoxia and dyspnea, with radiographic evidence of mediastinal widening. This, the most lethal, form of anthrax results from inspiration of 8,000-40,000 spores of B. anthracis. The incubation of inhalational anthrax among humans is unclear, but it is reported to range between 1 and 7 days possibly ranging up to 60 days. Host factors, dose of exposure and chemoprophylaxis may play a role. Initial symptoms include sore throat, mild fever, muscle aches and malaise. These may progress to respiratory failure and shock. Meningitis frequently develops. Case-fatality estimates for inhalational anthrax are based on incomplete information regarding exposed populations and infected populations in the few case series and studies that have been published. However, case-fatality is extremely high, even with all possible supportive care including appropriate antibiotics. Records of industrially acquired inhalational anthrax in the United Kingdom before antibiotics were available reveal that 97% of cases were fatal. With antibiotic treatment the fatality rate is estimated to be at least 75%. Estimates of the impact of the delay in post-exposure prophylaxis or treatment on survival are not known.
Gastrointestinal anthrax: Severe abdominal distress followed by fever and signs of septicemia. This form of anthrax usually follows the consumption of raw or undercooked contaminated meat and is considered to have an incubation period of 1-7 days. An oropharyngeal and an abdominal form of the disease have been described in this category. Involvement of the pharynx is usually characterized by lesions at the base of the tongue, sore throat, dysphagia, fever, and regional lymphadenopathy. Lower bowel inflammation usually causes nausea, loss of appetite, vomiting and fever, followed by abdominal pain, vomiting blood, and bloody diarrhea. The case-fatality rate is estimated to be 25-60%, the effect of early antibiotic treatment on that case-fatality rate is not defined.
Cutaneous anthrax: A skin lesion evolving from a papule, through a vesicular stage, to a depressed black eschar. This is the most common naturally occurring type of infection (>95%) and usually occurs after skin contact with contaminated meat, wool, hides, or leather from infected animals. Incubation period ranges from 1-12 days. Skin infection begins as a small papule, progresses to a vesicle in 1-2 days followed by a necrotic ulcer. The lesion is usually painless, but patients also may have fever, malaise, headache and regional lymphadenopathy. The case fatality rate for cutaneous anthrax is 20% without, and less than 1% with, antibiotic treatment.
IV. Advice to Laboratory Personnel
These guidelines provide background information and guidance to clinical laboratory personnel in recognizing Bacillus anthracis in a clinical specimen. They are NOT intended to provide training for laboratory identification of B. anthracis. Clinical lab personnel will most likely be the first ones to perform preliminary testing on clinical specimens from patients who may have been intentionally exposed to the organism, and will play a critical role in facilitating rapid identification of B. anthracis. Laboratory confirmation of B. anthracis should be performed at the State Public Health Laboratory.
Any suspected isolate of B. anthracis must be reported to the State Public Health Laboratory IMMEDIATELY. The State Public Health Laboratory is available for consultation or testing 24 hours per day and can be reached through the Department of Health Communicable Disease Epidemiology 24-hour emergency number. Following an appropriate consultation with the State Public Health Lab regarding a suspected isolate of B. anthracis, communication should then be established with the local FBI field office for possible law enforcement involvement.
A. Handling laboratory specimens (possible B. anthracis)
- Wear gloves and protective gowns when handling clinical specimens
B. Role of the clinical laboratory
C. Presumptive identification of Bacillus anthracis
? Direct smears from clinical specimens
Gram stain morphology of B. anthracis
? Broad, gram-positive rod: 1-1.5 x 3-5 µ
? Oval, central to subterminal spores: 1 x 1.5 µ with no significant swelling of cell
? Spores usually NOT present in clinical specimens unless exposed to atmospheric O2
Colonial characteristics of B. anthracis
Presumptive identification key for Bacillus anthracis
If B. anthracis is suspected
-lysis by gamma phage
-capsule detection (by DFA)
-detection of cell-wall polysaccharide antigen by DFA
Surfaces and non-sterilizable equipment
Contaminated instruments (pipettes, needles, loops, micro slides)
Accidental spills of material known or suspected to be contaminated with B. anthracis
For contamination involving fresh clinical samples:
F. Packaging and transporting protocol
Packaging and labeling specimens is the same as for any infectious substance
Transporting specimens to the DOH Public Health Lab
G. Helpful web sites
H. References for laboratory guidelines