EPI UPDATE

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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. Lupus Hospitalizations in Northwest Orange County
2. Nationwide Recall of Imported Cantaloupe
3. Expert Consensus Statement for Hemorrhagic Fever
4. State of Arthritis in Florida
5. Weekly Disease Table (Week 19)

Zuber D. Mulla, Ph.D., Florida Department of Health, Bureau of Epidemiology
Bill L. Toth, Jr., M.P.H., Orange County Health Department, Office of Epidemiology

Background

Certain members of a farming community in northwest Orange County have expressed concerns about the local prevalence of systemic lupus erythematosus (SLE). They believe the prevalence of SLE in the Apopka area of Orange County is higher than expected and is linked to environmental hazards. Dialogue between the Orange County Health Department’s Office of Epidemiology and local citizens was initiated.

A recent epidemiologic study [1] investigated the association between exposure to pesticides (chlorinated pesticides and organophosphates) and prevalence of SLE in Nogales, Arizona. In 1996, a citizens group in Nogales reported to the Arizona Department of Health Services their concerns about a possible excess prevalence of SLE due to exposure to environmental contamination in the area. That study found no statistical association between elevated levels of pesticides and disease status.

There is no state-mandated surveillance of SLE in Florida. In other words, physicians and laboratories are not required to report new diagnoses of SLE to the Florida Department of Health. Incident disease ("new cases") is not tracked by the health department.

The ideal method to examine whether or not the incidence of SLE in the Apopka area is higher than expected would be to access a population-based registry (which does not exist in Florida to our knowledge) or conduct a study in which private physicians are interviewed and medical records are reviewed. A less optimal method to elucidate the descriptive epidemiology of SLE in this area would be to examine mortality data or hospitalization data.

This analysis compared the SLE hospitalization rate in the Apopka area to the Florida hospitalization rate for the period 1992-1998.

Materials and Methods

The public use hospital discharge file of the Florida Agency for Health Care Administration (AHCA) was the source of patient data for this analysis. The diagnoses in the AHCA database are coded using the International Classification of Diseases, 9^th Revision, Clinical Modification. The AHCA public use file contains clinical and demographic information on individuals hospitalized in Florida hospitals. There are no unique identifiers in this AHCA database. The same person could be admitted twice to hospitals in Florida in the same year for the same diagnosis and would appear twice in the AHCA database. A case of SLE was defined as a patient with a principal discharge diagnosis of 710.0.

The total number of SLE discharges in Florida between 1992 and 1998 was divided by the population of Florida from 1992 through 1998 (a sum of annual population estimates). This hospitalization rate was then compared to the hospitalization rate for the Apopka area. Annual Florida population estimates are found at the website of the Florida Department of Health: http://www.doh.state.fl.us/planning_eval/phstats/public_health_stats.htm#POPULATION

The Apopka area was defined as the following zip codes, as they existed in 1990: 32703, 32712, and 32798. Population estimates for these zip codes for the years 1992-1998 were not readily available so population estimates for these zip codes from 1990 were used. These figures were obtained from the website of the U.S. Bureau of the Census: http://www.census.gov The 1990 figures were multiplied by seven to estimate the population between 1992 and 1998. We assumed the population of the Apopka area was stable from 1990 through 1998. As described above, the number of SLE discharges in residents of the Apopka area from 1992-1998 was divided by the appropriate population estimate.

Results

A total of 5311 SLE discharges were identified in Florida. The population was 9,611,615. The hospitalization rate due to SLE in Florida during this period was 5.33 per 100,000 population. This is a crude rate; that is, it is not adjusted for age or race or gender, etc.

Twenty-three SLE discharges were identified in the Apopka area during 1992-1998. This figure was divided by the population of 393,666. The resulting hospitalization rate is not different from the Florida rate: 5.84 per 100,000.

Discussion

In this report we demonstrated a novel approach to quantifying the burden of SLE in the Apopka area. Investigators at Johns Hopkins University studied the incidence of hospitalizations and the risk factors for hospitalizations among a cohort (the Hopkins Lupus Cohort) of SLE cases [2]. The authors concluded that hospitalization was common among the Hopkins Lupus Cohort. The three most common causes of hospitalization were active lupus, infection, and medical complications of SLE.

Our analysis found that the crude hospitalization rate due to SLE in residents of the Apopka area was similar to the Florida rate. Statistical significance testing was not performed. The two rates quoted in this report were assumed to be parameters (which have no sampling error/variance), not statistics.

The population of the Apopka area, as defined in this analysis, may actually be larger than 393,666. However, as this population figure increases, then the hospitalization rate for the Apopka area decreases, so this study did not underestimate the hospitalization rate due to SLE by assuming a stable population from 1990 through 1998.

References

1. Balluz L et al. Investigation of Systemic Lupus Erythematosus in Nogales, Arizona, American Journal of Epidemiology, 2001; 154:1029-1036.
2. Petri M and Genovese M. Incidence of and risk factors for hospitalizations in systemic lupus erythematosus: a prospective study of the Hopkins Lupus Cohort, Journal of Rheumatology, 1992; 19:1559-1565.

Submitted by Roberta Hammond, PhD., Bureau of Environmental Epidemiology

FOR IMMEDIATE RELEASE

May 11, 2002

I. KUNIK COMPANY Contact: Lawrence Kroman
2000 Industrial Drive 956-686-4324
McAllen, Texas 78504

NATIONWIDE RECALL OF SUSIE BRAND IMPORTED CANTALOUPE DUE TO POTENTIAL HEALTH RISK

The I. Kunik Company of McAllen, Texas is issuing a nationwide voluntary recall of its Susie brand cantaloupes because of their association with outbreaks of foodborne illness throughout the United States and Canada. The outbreaks of Salmonella poona that have infected dozens of people throughout parts of the United States and Canada are linked to the Susie brand of cantaloupe which is imported from Mexico and distributed in the United States and Canada.

Salmonella poona is an organism which can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems. Healthy persons infected with Salmonella poona often experience fever, diarrhea, nausea, vomiting and abdominal pain. In rare circumstances, infection can result in the organism getting into the bloodstream and producing more severe illnesses such as arterial infections (i.e., infected aneurysms), endocarditis and arthritis.

The cantaloupe was sold in retail stores and restaurants and possibly used in other institutions. Fresh cantaloupe has a shelf life of 7-10 days.

This recall resulted from an FDA traceback of these foodborne outbreaks. As a result of this investigation, FDA has taken steps to prevent the importation of any other contaminated cantaloupe. FDA is detaining all cantaloupe imported by I. Kunik from Mexico. The agency is also working with the company, states and other government agencies to investigate this matter.

Retailers, restaurants and food service operations should determine if any of their existing stock of cantaloupe was purchased or sold under the Susie brand name, and if so, remove it from sale. Any cantaloupe bearing this brand name should not be consumed.

Although Susie brand is the only brand of cantaloupe associated with this outbreak, FDA continues to recommend that consumers take the following steps with cantaloupe and other produce to reduce the risk of foodborne illness.

• Purchase produce that is not bruised or damaged. If buying fresh cut produce, be sure it is refrigerated or surrounded by ice.

• After purchase, put produce that needs refrigeration away promptly. (Fresh whole produce such as bananas and potatoes do not need refrigeration.) Fresh produce should be refrigerated within two hours of peeling or cutting. Leftover cut produce should be discarded if left at room temperature for more than two hours.

• Wash hands often. Hands should be washed with hot soapy water before and after handling fresh produce, or raw meat, poultry, or seafood, as well as after using the bathroom, changing diapers, or handling pets.

• Wash all fresh fruits and vegetables with cool tap water immediately before eating. Don't use soap or detergents. Scrub firm produce, such as melons and cucumbers with a clean produce brush. Cut away any bruised or damaged areas before eating.

• Wash surfaces often. Cutting boards, dishes, utensils, and counter tops should be washed with hot soapy water and sanitized after coming in contact with fresh produce, or raw meat, poultry, or seafood. Sanitize after use with a solution of 1 teaspoon of chlorine bleach in one quart of water.

• Don't cross contaminate. Use clean cutting boards and utensils when handling fresh produce. If possible, use one clean cutting board for fresh produce and a separate one for raw meat, poultry, and seafood. During food preparation, wash cutting boards, utensils or dishes that have come into contact with fresh produce, raw meat, poultry, or seafood. Do not consume ice that has come in contact with fresh produce or other raw products.
  
• Use a cooler with ice or use ice gel packs when transporting or storing perishable food outdoors, including cut fresh fruits and vegetables.

3. Expert Consensus Statement for Hemorrhagic Fever

Submitted by Steven Wiersma, MD, MPH, Chief, Bureau of Epidemiology

Attached you find the link to an interesting JAMA Article (Expert Consensus Statement Hemorrhagic Fever) http://jama.ama-assn.org/issues/v287n18/rfull/jst20006.html .

Lisa Fisher, MSPH, Bureau of Chronic Disease Prevention and Ursula Bauer, PhD., (then) Bureau of Epidemiology

In 2000, the state of Florida began data collection through the Behavioral Risk Factor Surveillance System (BRFSS) on arthritis. Three questions were used to determine whether someone had arthritis and/or chronic joint symptoms. A person was defined as having arthritis/chronic joint symptoms if they answered "yes" to the first question or answered "yes" to both the second and third question. These questions were:

• Have you ever been told by a doctor that you have arthritis?
• During the past 12 months, have you had pain, aching, stiffness, or swelling in or around a joint?
• Were these symptoms present on most days for at least one month?

The prevalence of self-reported physician-diagnosed arthritis in Florida is estimated to be 25.7%, and the prevalence of chronic joint symptoms, without a physician diagnosis of arthritis, is estimated to be 5.7%, for a total prevalence of 31.4% among adults. Although arthritis/chronic joint symptoms affect people across the age span, prevalence is highest among those aged 65 years and older, among whom 58.2% have arthritis/chronic joint symptoms. This compares to a prevalence of 13.6% among those aged 18-44 years. The prevalence is higher among women (34.4%) than men (28.5%) and the prevalence among those with less than a high school education (40.5%) is higher than that among those with at least a high school education (30.3%).

While arthritis/chronic joint symptoms rarely cause death, they are the leading cause of disability and have a large impact on people’s quality of life, in particular, a person’s ability to perform usual activities including work, recreation or self-care. Those with arthritis/chronic joint symptoms are consistently more likely to report having fair or poor health (29.4%) than their counterparts without arthritis/chronic joint symptoms (8.7%). Overall, 14.6% of those with arthritis/chronic joint symptoms under the age of 65 years report being unable to work compared with 2.1% of those without arthritis/chronic joint symptoms. Finally, among those who have arthritis/chronic joint symptoms, 42.1% report being limited in their activities due to arthritis.

Read the complete report at: www.doh.state.fl.us/family/arthritis. To get involved in arthritis activities in the state, join the Florida Arthritis Partnership. Information is available at the web site.