EPI UPDATE

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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.

Robin Terzagian, Regional Food and Waterborne Disease Epidemiologist and Roberta M. Hammond, Ph.D., Bureau of Environmental Epidemiology

On November 19, 2001, the Charlotte County Health Department was informed by a local hospital of a possible neurotoxic shellfish poisoning (NSP) that occurred on November 13, 2001. Two Sarasota County residents from the same household consumed homemade oyster chowder on November 13, 2001 and subsequently experienced symptoms consistent with NSP. Predominant symptoms included tingling, numbness, and burning of the arms, fingers and face. The suspected cases were a 59-year-old female and a 75-year-old male. The only symptom the male experienced was tingling in the face. Onset of symptoms began 3-3.5 hours after consuming the chowder and lasted about 5-7 hours. Both suspected cases went to the hospital, the female was admitted for further observation.

The oysters were recreationally harvested by the infected persons from Stump Pass in Charlotte County while canoeing on November 12. The oysters were kept in water for a few hours and were then refrigerated. Prior to use, the oysters were scrubbed, steamed and then added to the chowder.

Stump Pass has been closed for commercial shellfish harvesting due to red tide (caused by Gymnodium breve renamed Karenia brevis dinoflagellates) since August 22, 2001. Red tide is a harmful algal bloom (HAB), resulting from the multiplication of single-celled algae called Karenia brevis. Red tide is a natural phenomenon and is not caused by man-made pollution. Red tide refers to a bloom of toxic or harmful marine microorganisms that may color the water or be invisible; toxins may also be released. Shellfish accumulate large amounts of brevetoxin and can then cause NSP after consumption. Commercial shellfish harvesting areas are closed by the Department of Agriculture and Consumer Services Molluscan Shellfish Program when red tide occurs.

According to the Florida Fish and Wildlife Conservation Commission, Florida Marine Research Institute, the current red tide status for the SW Coast of Florida is:

NSP is a notifiable disease in Florida (s. 64D-3.002(1)qq, Florida Administrative Code. NSP is an illness caused by eating shellfish that have accumulated brevetoxin and its derivatives. The main symptoms include tingling and/or numbness of the lips, tongue, throat, hands and feet. Symptoms tend to be mild and resolve quickly and completely. Onset of this disease occurs within a few minutes to a few hours; duration is fairly short, from a few hours to several days. Recovery is complete with few sequellae; no fatalities have been reported. Other shellfish poisonings include: Paralytic Shellfish Poisoning (PSP), Diarrheic Shellfish Poisoning (DSP) and Amnesic Shellfish Poisoning ASP). An earlier outbreak of NSP in Sarasota County affecting 3 people and caused by recreationally harvested clams was documented in the Epi Update in the fall of 1996, with a table summarizing the different shellfish poisonings.

Note: Cases of NSP in Florida are often misdiagnosed as PSP which can cause a much more serious illness that can result in death. According to the Florida Marine Research Institute, no algal species that cause Paralytic Shellfish Poisoning (PSP) have been verified in the Gulf of Mexico. PSP cases have been reported from the following states: Alaska, California, Maine, Massachusetts, Oregon, Tennessee (seafood from elsewhere), and Washington.

Information on the status of red tides in Florida can be obtained from the Florida Marine Research website at: http://www.floridamarine.org/features/category_sub.asp?id=4434. Information on the harvesting status of commercial shellfish beds in Florida can be obtained at http://www.floridaaquaculture.com/. Click on Shellfish Harvesting, then click on the drop down menu arrow and choose Shellfish Harvesting Daily Area Status.

References:

1. Control of Communicable Diseases Manual, 17^th Edition, 2000, James Chin, M.D., Editor, APHA.
2. FDA Badbug Book: http://www.cfsan.fda.gov/~mow/chap37.html

Carina Blackmore, M.S. Vet. Med., Ph.D., Bureau of Epidemiology
Samuel Crane, MPH, Bureau of Epidemiology

National Influenza Virus Report: During week 47 (November 18-24, 2001), 3 specimens tested by the World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories across the United States were positive for influenza. Since September 30, a total of 8,140 specimens for influenza viruses have been tested and 74 (0.9%) were positive. Of the 74 isolates identified, 71 were influenza A viruses and 3 were influenza B viruses. Forty-five (63%) of the influenza A viruses were subtyped, 44 were influenza A (H3N2) and one was an influenza A (H1N1) virus. Thirty-nine (55%) of the influenza A isolates were isolated in Alaska. Influenza A has also been identified in Alabama, Arizona, Colorado, Florida, Hawaii, Kentucky, Louisiana, Minnesota, New York, North Carolina, North Dakota, Texas, Utah, Washington and Wisconsin. The influenza B isolates were identified in Louisiana, Michigan and Texas.  The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) overall was 1.4%, which is less than the national baseline of 1.9%. The proportion of deaths attributed to pneumonia and influenza as reported by the vital statistics offices of 122 U.S. cities was 6.1% during week 47. This percentage is below the epidemic threshold of 7.4% for this time. The state health department in Alaska reported regional influenza activity this week. Sporadic activity was reported from 21 states (Arizona, California, Colorado, Florida, Georgia, Indiana, Iowa, Kansas, Kentucky, Maine, Michigan, Missouri, Nevada, New Mexico, New York, North Carolina, Texas, Vermont, West Virginia, Wisconsin and Wyoming), 18 states reported no influenza activity.

Florida Influenza Virus Report: Influenza activity remains low in Florida and less than one percent of patients seeking care by physicians in the influenza sentinel surveillance met the case definition for ILI (> 100 F + cough and or sore throat) during week 47. Influenza-like illness activity was detected in 12 counties from Escambia to Monroe. Higher flu activity than expected for this time of year (>2%) was reported by physicians in Brevard, Escambia, Monroe and Polk counties. Positive rapid influenza antigen tests were reported from Marion (1) county this week. Between September 4 and November 27, influenza A (H2N3) was isolated from 5 patients residing in Broward, Collier and Palm Beach counties. In addition, positive rapid antigen tests were reported from Duval County (1), Marion (2), Miami-Dade (6) Okaloosa (2) and Volusia (2) Counties.

Florida Respiratory Syncytial Virus Report: Current data reported from November 23 – November 30, 2001, suggest high levels (according to the CDC definition of two consecutive weeks of over 10% of specimens reporting positive) of RSV activity throughout all regions of Florida. The Florida RSV Surveillance Project analyzes data from four regional areas encompassing 27 sentinel reporting facilities. The four regions performed a total of 511 RSV diagnostic tests with 156 returning positive. This data represents an overall percent positive rate of 30.5%. Between November 23 and November 30, all four regions reported over 20% positivity rates. Northeast and Southwest Florida led the regions with 48% and 36.5% respectively. Total numbers reported for November state wide were, 2708 total tests and 742 positives. These numbers represent an overall state percent positive of 27.4% for the month of November.

Carina Blackmore M.S. Vet. Med., Ph.D.

When you have a moment, please check out the new and improved flu website of the National Immunization Program at CDC. http://www.cdc.gov/nip/Flu/default.htm The site has links to information about the disease, the vaccine, vaccination target groups, including travelers, and vaccine supply, both directed to the general public and health care providers. Another piece of interest may be a recently added table comparing symptoms and treatment guidelines for cold, flu and anthrax.

This is a summary by A. Zuger of an article entitled, Contribution of influenza and respiratory syncytial virus to community cases of influenza-like illness: An observational study. Zambon MC et al. Lancet 2001 Oct 27; 358:1410-1416.

Submitted by Carina Blackmore M.S. Vet. Med., Ph.D., Bureau of Epidemiology

Think Flu, Think RSV

Respiratory syncytial virus (RSV) is not only a neonatal pathogen but also a frequent cause of serious community-acquired pneumonia among adults. In addition, it may cause a good proportion of wintertime flulike illness in patients of all ages. To evaluate the prevalence of RSV in community settings, general practitioners across England and Wales prospectively obtained nasopharyngeal swabs from outpatients with fever and cough (but not necessarily high fever or myalgia) during the October-April flu seasons of 1995-1996, 1996-1997, and 1997-1998.

A total of 2226 swabs were analyzed by culture for influenza virus and by PCR for both influenza and RSV; 709 (32 percent) were positive for influenza, and 480 (22 percent) were positive for RSV. RSV was detected earlier than influenza each winter, and it circulated with influenza throughout the sampling periods. During 2 of the 3 years, RSV caused more flulike illness than did influenza in children younger than age 5. Among patients older than 15, RSV caused varying proportions of illness from year to year. Notably, in the very mild flu season of 1997-1998, the vast majority of patients older than 15 whose swabs yielded a pathogen had RSV.

Comment: Influenza may cause only a fraction of flulike illness each winter. The major role played here by RSV, if confirmed elsewhere, will indicate important new directions for prevention and treatment. Meanwhile, clinicians who plan to use neuraminidase inhibitors for influenza treatment this season should keep this study in mind, and try to be as sure of their diagnoses as possible.

Jodi Baldy, MPH, Bureau of Epidemiology

The Florida Professionals in Infection Control (FPIC), held their annual conference November 6-8 at the Orlando Airport Marriott. The program included a general session with noted state and national speakers, 3 breakout sessions, and a vendor fair combined with poster presentations.

Several staff members from the Department of Health were invited to speak on topics relevant to current issues and concerns. During the November 6 general session, Steven Wiersma, MD, MPH, Bureau Chief and State Epidemiologist, gave an update on the state of Florida’s disease control activities. Carina Blackmore, MS, PhD, presented on the topic of influenza pandemic planning. Regional Epidemiologist, Roger Sanderson, talked about Creutzfeldt-Jacob Disease (CJD), including variant CJD. Jodi Baldy, MPH, Bureau of Epidemiology, presented invasive Streptococcus pneumoniae (SP) data for Florida on the prevalence of penicillin and drug resistance collected during 1999 and 2000 surveillance periods. In addition to providing SP surveillance data, she maintained the Bureau’s display board, exhibiting information and making available handouts on many of the disease investigation issues currently in the news - bioterrorism, hepatitis, CJD, West Nile Virus, and others. Dean Bodager, RS, MPA, representing the Bureau of Environmental Epidemiology, conducted one of the breakout sessions on foodborne outbreaks. Pablo Gonzales, DOH Dade-Miami CHD, also conducted a breakout session on infection control issues in Emergency Management.

The infection control – DOH partnership has been strengthening over the last several years and is proving to a valuable alliance, especially in the wake of recent bioterrorism activities: Palm Beach, Broward, Dade, and Martin Counties all participated in a special hospital ICU surveillance system throughout the month of October in order to identify possible anthrax cases. Hospital ICPs also responded quickly to the DOH request for assistance with a special postal workers’ surveillance system, which was designed to quickly detect additional anthrax cases in this group of people. An Emergency Room Surveillance System, which measures ER aberrations, is currently in operation. This system is made up of 18 hospitals and continues to develop and expand.

In an effort to maintain high quality presentations in the Epi Update, we are re-emphasizing the following guidelines for submission of articles:

• All articles are due no later than Wednesday at noon of the week in which they are intended to be published.
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We understand there will be exceptions to these guidelines. Referrals to websites, other publications and brief announcements can still be e-mailed with your comments and/or suggestions.

Thank you for your attention to these guidelines.

If you have questions regarding the guidelines or formatting, please e-mail your requests to Sam Crane (Samuel_Crane@doh.state.fl.us).

7. Weekly Disease Table (Week 48)

* The column of data representing the "3-year average to week ##" is the average of years 1998, 1999 and 2000 cases to the current listed week (##).