EPI UPDATE

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:

1. Wiersma Presented Brachman Award
2. Results From the DOH Employees Tobacco Survey
3. Streptococcus pneumoniae and Fluoroquinolone Resistance
4. Anthrax Consensus Statement (Link)
5. Arboviral Activity Summary
6. Influenza Surveillance Update
7. Weekly Disease Table

Submitted by Marc Traeger, MD, Bureau of Epidemiology, Florida EIS, Officer

Steven Wiersma, MD, MPH, Florida Department of Health State Epidemiologist, and Chief of the Bureau of Epidemiology was awarded the Phillip Brachman Award by Centers for Disease Control and Prevention (CDC) EIS (Epidemic Intelligence Service) officers on Thursday, April 25, 2002 during the 51^st annual EIS conference in Atlanta, Georgia.

The Brachman Award is awarded for excellence in teaching epidemiology to EIS officers during their 2-year EIS fellowships. EIS officers, commonly referred to as the "disease detectives," respond to public health investigations throughout the world. This year, 136 of the 146 EIS officers were deployed to activities and investigations related to terrorism. Twelve traveled to West Palm Beach, Florida to assist in the anthrax investigation that began there on October 2. EIS officers, in the midst of long hours under difficult circumstances during terrorism-related investigations, found that Dr. Wiersma and epidemiologists in New York, New Jersey, Connecticut, Virginia, Maryland and Washington, D.C. provided outstanding guidance, insight, leadership and epidemiologic skills throughout the investigations. Dr. Wiersma shares the award this year with epidemiologists in those states and in the District of Columbia.

We extend our congratulations to Dr. Wiersma. The Brachman Award recognizes the outstanding contributions Dr. Wiersma has made to Florida and the field of epidemiology world-wide.

Submitted by Marie A. Bailey, MSW, Chronic Disease Epidemiology Section, Bureau of Epidemiology

In February and March 2001, the Bureaus of Chronic Disease Prevention and Epidemiology jointly developed and implemented a web-based survey of Department of Health (DOH) employees statewide to determine current tobacco use status, need for cessation services, awareness of available services, and the impact of workplace policies on the prevalence of tobacco use among DOH employees. The two bureaus collaborated in the development of the survey instrument. Survey administration and data collection and analysis were conducted by the Bureau of Epidemiology. Survey results were provided to the Bureau of Chronic Disease Prevention for use in policy and program planning and development.

Almost 6,500 employees responded to the survey, providing valuable information about the needs, concerns, and opinions of our workforce. The full report is available electronically at http://www.doh.state.fl.us/family/tobacco/index.html. (Scroll down the window to Employee Tobacco Survey Results; then click on that link. Adobe Acrobat Reader may be needed to view the report. A link to the Reader is provided on the website.)

Prevalence of smoking in the DOH sample is low compared to the prevalence in a comparable subset of the Florida adult population (14.4% versus 22%). The prevalence of cigarette use in the DOH sample also falls in expected demographic patterns: for example, non-Hispanic Whites are more likely to be current smokers than other racial/ethnic groups, and respondents who are college graduates are less likely than respondents with fewer years of education to be current smokers.

Of current smokers in the DOH sample, 26.8% report that their workplace does not offer tobacco use cessation programs, and half (49.9%) of current smokers do not know whether such programs are offered at their workplace. Over 70% of respondents who smoke reported that they do not know whether tobacco use cessation support is available in their county, and 51.6% reported a need for more tobacco use cessation programs in their county.

Analyses of employees’ knowledge of current workplace policies on smoking either in public areas or work areas indicate that between 16% and 23% of all respondents either do not think there is an official policy or do not know the correct official policy. Generally, those respondents who cited the correct workplace policies on smoking also agree with those policies: (1) that smoking is allowed only in outdoor public areas, and (2) that smoking is not allowed in any work area.

Regarding five workplace policies on tobacco use, findings suggest that: (1) some restrictions on cigarette use have become normative, socially accepted, and even expected; and (2) restrictions on smoking away from the work site during official work hours have not achieved the same level of acceptability. Just one-half of respondents agree with a policy to prohibit tobacco use on department grounds and just over one-half disagree with a policy to prohibit tobacco use during official work hours at any location.

Recommendations based on these survey results, and the Department’s responses, include the following:

Educate employees about current workplace policies on tobacco use. Clear policy statements should be provided to each employee and should be posted in areas where smoking is known to occur.

Enforce current workplace policies on tobacco use. All employees should be given a clear understanding of the disciplinary actions that would result from policy violations. The intent is not to penalize smokers; rather, it is to treat all employees fairly. Workplace policies on tobacco use, like all other department policies, must be adhered to by all employees.

Implement and promote proven and effective tobacco use cessation programs at the workplace, and provide access to community resources. Current services should be augmented by a variety of proven and effective programs at the workplace and in communities. An exciting new opportunity for DOH employees as well as all adults in Florida who are trying to quit tobacco use is the Florida Quit-for-Life Line. This free telephone-based service offers professional counseling, self-help materials, and discounts on pharmacotherapy (the nicotine patch) in Spanish, English, Haitian-Creole, and TDD for the hearing impaired. The Department of Health has contracted with the American Cancer Society to provide this service, which includes specialized protocols for smokers, spit tobacco users, and a link to the national Great Start prenatal smoking cessation telephone service. Florida residents may call toll-free 1-877-U CAN NOW (1-877-822-6669) for cessation assistance through the Quit-for-Life Line.

Involve employees in the developmental and implementation process of any policy change. As a result of this recommendation, the Secretary has charged the Bureau of Chronic Disease Prevention with forming work groups to recommend effective initiatives to educate employees about current policies and available services; to recommend improvements to policies and services; and to enhance communication about any proposed policy changes or the availability of new services. Current smokers, former smokers, and employees who have never smoked all have valid perspectives to contribute to these work groups. Participation will be considered work time, and supervisors are encouraged to approve participation for those employees who are interested.

Inquires about the recommendations should be directed to Jenna Bevino, Chronic Disease Tobacco Control Program Manager, at 850/245-4444 x3808, Suncom 205-4444 x3808, or via email at jenna_bevino@doh.state.fl.us. Questions about the survey analysis may be directed to Marie Bailey, Research and Evaluation Consultant for the Chronic Disease Tobacco Control Program, at 850/245-4444, X2434, Suncom 205-4444, X2434, or email marie_bailey@doh.state.fl.us.

3. Streptococcus pneumoniae and Fluoroquinolone Resistance

Jodi Baldy, MPH, Bureau of Epidemiology

Due to the high beta-lactam and multi-drug resistance rates of Streptococcus pneumoniae in the United States, the rate of use of non-beta-lactam antimicrobial classes has increased. The fluoroquinolones are one such antimicrobial class. To evaluate whether rates of fluoroquinolone resistance have increased in the United States, these researchers evaluated possible changes in the in vitro activities of ciprofloxacin, levofloxacin, gatifloxacin, and moxifloxacin against S. pneumoniae over a 5-year period between 1994-1995 and 1999-2000, in which 4,650 geographically diverse clinical isolates were collected. A second objective of the study was to characterize the fluoroquinolone-resistant S. pneumoniae isolates at a molecular level.

Results of the evaluation indicated that the in vitro activities of the fluorquinolones studied did not change over the 5 years encompassed by these studies. It was found that the newer fluoroquinolones – gatifloxacin and moxifloxacin – have 4 to 8 times greater in vitro activities against S. pneumoniae than either levofloxacin or ciprofloxacin. They also found that the development of fluoroquinolone resistance appears to be a stepwise process in which strains with first-step mutations go on to develop a second-step mutation.

Much higher rates of fluoroquinolone resistance in S. pneumoniae isolates have been reported in other parts of the world: Spain, 5.3%; Hong Kong, 12.1%; and Northern Ireland, 15.2%. The low rates of fluorquinolone resistance in the U.S. require continued surveillance for changes in rates of resistance and vigilance with respect to the appropriate use of these antibiotics.

Brueggemann, AB et al. Fluoroquinolone resistance in Streptococcus pneumoniae in the United States since 1995-1995. Antimicrob Agents Chemother. 2002 March; 46:680-688.

NOTE: The first quinolone, nalidixic acid, was introduced in 1962. Since then, second-, third-, and fourth-generation fluoroqiunolones have been introduced and have improved coverage of gram-positive organisms. The presently available fluoroquinolones with activity against S. pneumoniae are levofloxacin, sparfloxacin, gatifloxacin, moxifloxacin, and trovafloxacin. Year 2001 S. pneumoniae surveillance in Florida indicates 0.6% of isolates as fully resistant and 0.5% as intermediate to levofloxacin. Year 2000 Active Bacterial Core surveillance (ABCs) reported levofloxacin resistance for S. pneumoniae to be 0.3%.

Thanks to Dr. James Cresanta for providing the following links for the American Medical Association’s Anthrax Consensus Statement.

17-page article in the .pdf version - see today's issue of the JAMA http://jama.ama-assn.org/issues/v287n17/fpdf/jst20007.pdf

Table of Contents for today's issue: http://jama.ama-assn.org/issues/v287n17/toc.html

Lisa Conti, DVM, MPH, State Public Health Veterinarian and Robin Oliveri, Arbovirus Surveillance Coordinator

There are currently no Arbovirus Medical Alerts issued for the state. During the period April 20 through April 26, 2002, the following arbovirus activity (St. Louis encephalitis [SLE] virus, eastern equine encephalomyelitis [EEE] virus, West Nile [WN] virus and dengue virus) was recorded for Florida:

Human: No new arbovirus cases were reported to the State Health Office.

Sentinel Chickens: 1 seroconversion to EEE was identified in Orange 529 samples tested; 15 counties submitting sentinel specimens.

Equine*: One Miami-Dade County horse was reported with WN.

Bird Mortality: A crow from Putnam County was reported with WN this week. Also during this week, 125 dead birds were reported, of which 19 (15.2%) were crows and 4 (4%) were jays. Cumulatively, 2,020 reports have been made for 2,956 dead birds, 460 were tested.

To report dead birds use http://wld.fwc.state.fl.us/bird/ or call toll free 1- 800-871-9703.

NOTE: Online bird identification: http://www.mbr-pwrc.usgs.gov/id/framlst/framlst.html

Mosquito Pools: No positive mosquito pools were identified among 190 tested for arboviruses during this period. Cumulatively, 419 mosquito pools have been submitted for testing.

• West Nile Virus state totals: 4 dead birds, 6 horses* and 5^** sentinel chickens.

• Alachua: 1 dead bird (1 hawk)
• Liberty: 1 dead bird (1 wild turkey)

• Marion: 4 horses

• Miami Dade: 1 horse

• Palm Beach: 2 sentinel chicken, 1 dead bird (1 peacock)

• Polk: 1 horse

• Putnam: 1 dead bird (crow)

• Volusia: 1 sentinel chicken

• Walton: 2** sentinel chickens

• Eastern Equine Encephalomyelitis virus state totals: 26 sentinel chickens, 3 horses^*

• Hillsborough: 4 sentinel chickens

• Lake: 1 horse

• Orange: 9 sentinel chickens

• Pinellas: 1 sentinel chicken

• Polk: 2 horses

• Seminole: 3 sentinel chickens

• Volusia: 4 sentinel chickens

• Walton: 5 sentinel chickens

• No human cases

• No positive pools

For more information please see the DOH website at http://www.doh.state.fl.us/disease_ctrl/epi/htopics/arbo/index.htm

Data sources: county health departments, Department of Health (DOH) laboratories, medical providers, mosquito control agencies, Department of Agriculture and Consumer Services Laboratory, veterinarians, Florida Fish and Wildlife Conservation Commission website