A Publication by the Bureau of Epidemiology
January 24, 2002
"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, MPH—Bureau Chief and State Epidemiologist
Don Ward, Deputy Bureau Chief (Management), Epi Update Managing Editor
Samuel Crane, MPH, Special Projects Surveillance Coordinator, Epi Update Editor
Bureau of Epidemiology Frequent Contributors:
Kathryn S. Teates, MPH
Surveillance Section Administrator
Jodi Baldy, MPH,
Biological Scientist IV
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,
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In this issue:
1. CDC Releases New Bioterrorism Web Resources for Clinicians, Lab Professionals, and Public
This is an official CDC Health
Distributed via the Health Alert Network
January 18, 2002
Atlanta-The Centers for Disease Control and Prevention (CDC) unveiled today a redesigned Web site offering both new and updated bioterrorism resources for health professionals and the public."
The site at www.bt.cdc.gov addresses the need for up-to-date and accurate information on health threats arising from exposure to biological, chemical, or radiological agents. The redesigned site, which focuses on Public Health Preparedness and Emergency Response, is the official federal site for medical, laboratory, and public health professionals to reference when providing information to the public and for updates on protocols related to health threats such as anthrax. CDC redesigned the site in response to overwhelming demand from the public and professionals for credible information during the anthrax crisis. In October 2001, CDC experienced more than a 100 percent increase in traffic to its main Web site, www.cdc.gov, which links directly to www.bt.cdc.gov. CDC was the most visited federal government Web site in the nation in October, registering more than 9.1 million unique visits. "As a result of recent events, we find that not only health professionals, but people from all walks of life want information on health threats directly from our agency's Web site," said CDC Director Jeffrey P. Koplan, MD, MPH. "This new site makes the most-requested information on public health preparedness and emergency response easier to find and update quickly." The new site offers easy-to-use categories requested by key audiences, including clinicians. CDC worked with the Communication Technologies Branch (CTB) at the National Cancer Institute to test the site for usability with a sample of potential users in Rockville, MD. CTB also conducted a review of the Web site using its Research-Based Web Design and Usability Guidelines ( http://usability.gov/guidelines; http://usability.gov.) CDC will continue to add information to the site as part of its increased role in responding to health threats that involve biological, chemical, or radiological agents. CDC's other information resources include a hotline: 1-888-246-2675 (English) and 1-888-246-2857 (Spanish) available Monday through Friday, 8 a.m. to 10 p.m. EST; Saturday and Sunday, 10 a.m. to 8 p.m.
CDC protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national and international organizations.
2. Validation of Meningococcal Disease Surveillance Data
Zuber D. Mulla, MSPH, PhD, Bureau
Rhonda Fetzko, RN
Meningococcal disease (defined as meningococcal meningitis and/or meningococcemia) [MD] is a reportable condition in Florida. Cases of MD in Florida residents are reported to county health departments or the Bureau of Epidemiology. These data are entered in a surveillance database that is maintained by the Bureau of Epidemiology.
We attempted to validate three years of MD surveillance data. Hospital discharge data from Florida’s Agency for Health Care Administration (AHCA) were used as gold standards. If one assumes that every case of MD in a Florida resident was hospitalized and that the hospitalization took place in a Florida hospital, then the choice of AHCA data is a logical one.
The expected result was that the number of cases of MD in the Bureau of Epidemiology’s database would be equal to the number in the AHCA database. At worst, the Bureau’s database might lack one or two cases that existed in the AHCA database. This scenario is possible. Even though MD is a high-profile disease, it is possible that a hospital might never report a case of MD to the Department of Health (Personal communication: Dr. Carina Blackmore, Bureau of Epidemiology).
Material and Methods
Public use data on hospital discharges occurring in calendar years 1996, 1997, and 1998, were obtained from AHCA. Principal and secondary diagnoses in the AHCA database are coded using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). A case of MD was defined as patient whose principal diagnosis code was 036.0 (meningococcal meningitis), or 036.1 (meningococcal encephalitis), or 036.2 (meningococcemia).
Cases who were not residents of Florida or who had an invalid value for their county of residence were excluded from the analysis. Also, cases that were discharged to another hospital were excluded from the analysis so as to avoid inclusion of duplicate patient records.
Bureau of Epidemiology data:
The Bureau’s database contains data on Florida residents and a few nonresidents . The few nonresidents in the database receive a Florida county code but retain their actual zip code; therefore, out-of-state residents were excluded based on their zip codes. Cases who had non-Florida zip codes were excluded from analysis.
Cases of MD who had event dates in 1996, 1997, or 1998, were included in the analysis. Event date was defined as a date of onset, date of diagnosis, date of a laboratory result, or date that the case was reported to the county health department . A case of MD was defined as meningococcal meningitis (ICDCODE of 3600) or meningococcemia (ICDCODE of 3620).
The SAS System (Release 6.12 for Windows) was used to manage and analyze the data.
For 1996 and 1997, the Bureau’s database contained a greater number of cases than AHCA’s database (Table). In 1998, however, AHCA’s database contained 117 cases while the Bureau’s contained 92 cases (78.6%).
The median length of stay in the hospital was seven days for MD cases in 1996, 1997, and 1998 (data not shown).
Table. Agreement between the Agency for Health Care Administration (AHCA) and Bureau of Epidemiology (HSDE) Databases: Meningococcal Disease
There are at least two possible reasons why the AHCA database contained fewer cases than the Bureau’s. One, Florida MD cases (especially ones living near the northern border) may have traveled to another state (such as Alabama or Georgia) for treatment. These cases would not be captured by Florida’s AHCA, but, due to the reciprocal notification process used by state health departments, would most likely be captured in the Bureau’s database. In the 1996 HSDE database, 24 of the 200 MD cases were from counties that border Alabama or Georgia. In the 1997 HSDE database, 15 of the 162 MD cases were from these border counties.
In 1998, the AHCA database contained more records than the HSDE database. This could be due to readmission of patients due to MD complications. The AHCA database does not contain a unique identifier so it is very hard to unduplicate the database unless you are dealing with very rare conditions and brief periods of time. The AHCA database records hospitalizations, not necessarily unique episodes of morbidity as a public health surveillance database does.
Also, the presence of a record in a particular year of the AHCA data does not necessarily mean that the case developed the illness in that year. A case who developed MD on December 31, 1996, and was discharged on January 1, 1997, would appear in the Bureau’s 1996 surveillance database but not in AHCA’s 1996 database. This case would appear in the 1997 AHCA discharge database.
In conclusion, the public use AHCA files may not be appropriate gold standards. Access to the confidential AHCA files would improve attempts at validation.
3. Minimizing Human Exposure to "Mad Cow Disease" Agent
Submitted by Lisa Conti, DVM,
MPH, Bureau of Epidemiology
Food Safety and Inspection Service (FSIS)
January 15, 2002
FSIS is considering implementing a number of measures to minimize human exposure to materials that could potentially contain the agent that causes Bovine Spongiform Encephalopathy (BSE). Scientific and epidemiological studies have linked variant Creutzfeldt-Jakob Disease (vCJD), a chronic and fatal neurodegenerative disease that affects humans, to the consumption of beef products contaminated with the BSE agent. Neither vCJD nor BSE has been detected in the U.S. and the recently released Harvard Risk Assessment on BSE finds that, owing to already ongoing Federal programs, the U.S. is highly resistant to the introduction and spread of BSE in the U.S. cattle herd. However, FSIS believes that additional measures should be considered to minimize human exposure to BSE agents in the unlikely event that it is introduced in the U.S. This paper provides FSIS¹s thinking on policy options currently under consideration. FSIS requests public comment on the options discussed in this paper. Comments may be submitted to the FSIS Docket Room, Room 102, 300 12th Street SW, Washington, DC 20250-3700 and should be marked "FSIS current thinking on BSE." Copies of the Harvard Risk Assessment and this paper are available for viewing or copying in the FSIS Docket Room and on the Internet at: http://www.fsis.usda.gov/oa/topics/bse.htm
Click here to view full article
4. Influenza Virus Surveillance Summary Update
Carina Blackmore, M.S. Vet. Med., Ph.D.
Week ending January 12, 2002-Week 1
National report: During week 2 (January 6-12, 2002), 96 (8.9%) of 1076 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 22,888 specimens for influenza viruses have been tested and 904 (3.9%) specimens from 41 states were positive. Of the 904 isolates identified, 885 (98%) were influenza A viruses and 19 (2%) were influenza B viruses. Three hundred and fifty-one viruses were subtyped, 345 (98%) were influenza A (H3N2) and 6 were influenza A (H1N1) viruses. Three hundred and sixty-five (40%) of the 904 influenza viruses isolated nationwide were from Alaska (n=153, 17%) and Hawaii (n=212, 23%). The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) overall was 1.6%, which is below 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 7.0% during week 2. This percentage is below the epidemic threshold of 8.1% for this time. Influenza activity was reported as widespread in Colorado, Pennsylvania and Utah, regional in Alaska, Connecticut, Louisiana, Maryland, Massachussetts, Nebraska, New York, Tennessee, Texas, Vermont, Virginia and Washington this week. Sporadic activity was reported from 33 states, including Florida.
Florida: Influenza activity, calculated based on the proportion of patients with influenza-like illness (ILI) seeking care by physicians participating in the Florida Sentinel Physicians Surveillance Network, continues to be below 2% (1.5%) this week. Influenza-like illness activity was detected in 15 of 22 participating counties from Escambia to Monroe. Higher flu activity than expected for this time of year (>2%) was reported by physicians in Alachua, Brevard, Escambia, Monroe, Palm Beach, Polk and Seminole Counties. Seventeen cases of influenza A were laboratory confirmed this week. Influenza A (H2N3) was confirmed from Broward (1) Duval (4), Indian River (1), Leon (6), Levy (1), Marion (1), Monroe (1) and Pinellas (1) Counties and our first influenza A (H1N1) isolate this season was recovered from a patient in Duval County. Between September 4 and January 24, influenza A (H3N2) was isolated from 34 patients residing in Broward, Collier, Duval, Hillsborough, Indian River, Leon, Levy, Marion, Monroe, Palm Beach, Pinellas, Polk, and St John’s Counties and infections with influenza A of unknown subtype, was diagnosed in patients in Gadsden, Martin, Pinellas, Palm Beach and Hillsborough County. Influenza B was isolated from 2 patients in Hillsborough County. In addition, positive rapid antigen tests were reported from Duval County (1), Hillsborough (11), Palm Beach (1), Marion (8), Miami-Dade (13) Okaloosa (2) and Volusia (6) Counties.
5. Weekly Disease Table (3)
The weekly disease table for week three is not available.