EPI UPDATE

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1. Press Release: Creutzfeldt-Jakob Disease
2. MRSA Outbreak in Podiatry Patients
3. Norwalk Virus Outbreak in Pasco County
4. Weekly Disease Table

1. Press Release: The following is a press release issued by John O. Agwunobi, M.D., M.B.A., Florida Secretary of Health on April 18, 2002

"FOR IMMEDIATE RELEASE Contact: Rob Hayes

The Florida Department of Health (FDOH) and the Centers for Disease Control and Prevention (CDC) are investigating a possible case of variant Creutzfeldt-Jakob Disease (vCJD) in a 22-year-old female, Florida resident. We have determined this to be a suspected case of imported vCJD from the United Kingdom. All evidence indicates that her illness poses no threat to the public or agriculture industry in Florida and the rest of the United States.

Again, all of our information leads us to believe the affected individual represents a case of imported vCJD. While living in the United Kingdom, we believe the young woman was exposed to and contracted the disease more than a decade ago.

Although experience with this new disease is limited, all existing evidence indicates that it cannot be spread through the air or by physical contact. The Florida Department of Health, the Florida Department of Agriculture and Consumer Services and the CDC are working closely together to gather more facts about this case. Updates will be provided as more information becomes available.

We urge the media and public to join the FDOH in protecting the privacy of the affected individual and her family during this most difficult time. More information and important web links on the disease, vCJD, can be found on the FDOH website at http://www9.myflorida.com/Disease_ctrl/epi/htopics/popups/cjd.htm

In the United Kingdom and parts of Europe, this disease of humans called vCJD has been associated with a disease of cattle called Mad Cow Disease, also known as Bovine Spongiform Encephalopathy (BSE). BSE has never been detected anywhere in the US or Florida. Florida residents wishing to ask questions about vCJD may call their local county health department toll-free at 1-800-480-7738. "

On April 10, an infectious disease specialist from the Orlando area notified the Orange County Health Department (CHD) of 11 cases of methicillin resistant Staphylococcus aureus (MRSA) occurring in persons having been seen by an Orlando/Kissimmee-based podiatry group on March 27-29, 2002. Patients seen in hospital admissions and in clinic were reported to have swelling, erythema, and purulent abcesses at post-injection sites. Each of the 11 persons reported received a similar treatment consisting of a Lidocaine and steroid combination injected into the plantar fascia (a ligament-like band running from the heel to the ball of the foot). This podiatry group consists of eight doctors practicing at one or more of 13 clinic sites in five central Florida counties.

As of April 17, 13 confirmed or suspect cases have been diagnosed with MRSA infection by the podiatry group. Five persons were hospitalized; one still remains hospitalized. The remaining nine cases were treated for MRSA infection by the podiatry group on an out patient basis. It has been determined that the 13 cases received their injection therapy from one of two podiatrists at the podiatry clinic located in Kissimmee (Osceola County), Florida. No other doctors in this podiatry group or other clinic sites have diagnosed and/or treated MRSA cases. No new MRSA cases have occurred since the podiatry group ceased using the Lidocaine from the possibly contaminated lot.

For testing purposes, the podiatry group gave the infectious disease specialist one multi-use-vial of Lidocaine and one multi-use vial of Dexamethasone phosphate, each of which was used in the podiatric procedures. In addition, the Orange CHD recovered opened vials of each, Lidocaine, Dexamethasone phosphate, Kenalog, and Depo-Medrol, all of which were used during the podiatric procedures. All opened vials were then sent to the Jacksonville Laboratory for testing. To date no growth has appeared from those samples. Subcultures from infected wounds of four patients have been forwarded to the Jacksonville Laboratories, as well, for confirmation and pulsed field gel electrophoresis (PFGE). Should cultures be recovered from the medications, they will be compared by PFGE with the human cultures.

The source of MRSA infection among these patients is still under investigation. The Orange CHD is working very closely with the podiatry group and state and local health officials. If there are additional comments or questions regarding this investigation please contact Bill Toth at 407-623-1212 (suncom334-1212), Carmela Mancini at 850-251-6229, or the Bureau of Epidemiology at 850-245-4401.

Submitted by Roberta Hammond, Ph.D. Bureau of Environmental Epidemiology

Investigation Team:

Pat Burjony, MB, chB, Health Services Supervisor, Pasco County Health Department

Rex Joyner, BBA, MSED, Health Services Representative, Pasco County Health Department

Greg Crumpton, Environmental Specialist II, Pasco County Health Department

Mike Friedman, MPH, Regional Food and Waterborne Disease Epidemiologist, Bureau of Environmental Epidemiology

The Pasco County Health Department was contacted on March, 28, 2002 by a local nursing home regarding a grouping of gastrointestinal illness among residents and nursing staff.  The facility had noticed a few cases on March 26, 2002 and observed an increasing number of cases each day since then.  Early reports identified that 16 staff and approximately 42 residents had exhibited diarrhea, vomiting and abdominal pain symptoms lasting 24-48 hours.  The facility is a 120-bed long-term care facility. The previous week, one resident at the facility had gastrointestinal symptoms.  The Pasco County Epidemiology office was notified on April 3, 2002 that a nursing home facility in New Port Richey was also experiencing a grouping of gastrointestinal illness among residents and nursing staff.  This was the second reported outbreak in an institutional setting within the last week in West Pasco.  Reported symptoms included; diarrhea, vomiting, abdominal pains and fever.  It was reported that so far 35% of the 114 residents had become ill and an unidentified number of staff have also become ill.  This included one food service employee. The first reported cases at this facility were among nursing staff with onsets of symptoms on March 30, 2002. The first resident cases occurred in a single wing of the nursing home and then spread to all but one wing of the facility. Nursing staff at this facility provide care to residents in several wings of the facility. Two of the residents had been sent to the hospital for precautionary reasons.

Both of the nursing home facilities had already taken numerous precautionary steps to help prevent additional cases. These included; limitation of visitors and a posted notice on the front door, feeding ill persons in their rooms, limiting group activities, and increasing hand washing awareness.  The facility’s administration was commended for early reporting of these incidents; thus allowing for patient specimens to be collected soon after onsets of symptoms.

An investigation of this outbreak was performed by the Pasco County Health Department and the Bureau of Environmental Epidemiology. Line-listings (including medical and food histories) of ill residents and staff were requested from both nursing home facilities. In addition, maps showing the layout of the facilities, staffing patterns and food service menus from previous meals served at each facility were requested from the administration. Spot maps tracking cases from both facilities were developed. Resulting data were analyzed by the investigatory staff. Each facility was requested to collect 10-12 stool specimens from ill residents and staff for viral studies. In addition, each facility had already sent enteric pathogen specimens from a few ill patients for laboratory tests. A food service investigation was also performed at both nursing home facilities.

Stool specimens for viral testing through the Bureau of Laboratories tested positive for Norwalk virus serogroup G-2. Each of the nursing home facilities had 9 of 11 submitted specimens test positive for Norwalk virus. None of the stool specimens submitted for enteric pathogens tested positive. A review of the line-listing information provided showed that the predominant symptoms reported from both nursing home facilities were very similar. Reported symptoms included diarrhea, vomiting, abdominal pains and some fever. Duration of illness was also very similar among the two nursing homes. Duration of illness ranged from 24 to 72 hours with a mean of 48 hours. One of the nursing staff does work at both of the nursing home facilities. This employee did not become ill. Other agency nursing staff may also work at both facilities, however this information was not confirmed. It was also believed that one of the nursing staff had a child who attended a home day care in the area that was exhibiting similar symptoms.

The food service investigation at both facilities determined that both were very well organized and no temperature, sanitation or employee hygiene problems were observed.  The facilities had been inspected by the county health department a week before and no major violations had been noted. Both facilities are on public water and sewer.  Only one of the food service staff had reported having gastrointestinal symptoms.  It was determined that the symptoms had begun two days after other reported illness at that particular facility. In addition, the majority of food service personnel and other staff that consume the same meals as the residents did not become ill.

This investigation of both outbreaks began as a foodborne outbreak investigation. Data collected during the outbreak investigations helped to clarify that both outbreaks were likely to be person-to-person transmission. Reported cases at each facility exhibited a temporal distribution of cases over a 5 to 6 day period. A wave of secondary cases among resident and staff was also observed at one of the nursing home facilities. The incubation period, symptomology and duration of the illnesses suggest an etiology of Norwalk virus. This was confirmed through viral studies performed. According to the Tampa Branch Virology Laboratory, the serogroup G2 is the most common form of Norwalk virus identified this year.  It is possible that the illnesses at the two facilities may have been related, however it is much more likely that index cases from both outbreaks were from existing cases in the community. A large amount of gastrointestinal illness among the community had been reported during this time. The spread of the virus within each facility may have been due to nursing staff working in multiple wings of the facilities or due to residents attending various activities within each facility.

4. Weekly Disease Table (Week 15)

* The column of data representing the "3-year average to week ##" is the average of years 1999, 2000 and 2001 cases to the current listed week (##).