A Publication by the Bureau of Epidemiology
July 15, 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
Catie Richards, Editorial Assistant
Please print out this material and share with epidemiology staff, county health department directors, administrators, medical directors, nursing directors, environmental health directors and others with an interest in information of this type. Thank you.
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.In this issue:
Announcement: Regional Epidemiology Seminar, July 18th – 19th 2002 in Sarasota, Florida
1. Reporting Chronic Hepatitis B and Chronic Hepatitis C in Merlin
Don Ward, Deputy Chief, Bureau of Epidemiology
There is continued uncertainty by some county health departments regarding the reporting of chronic hepatitis B and C into the Merlin system. While the reporting of these two diagnoses has historically been possible through Merlin, the absence of a case definition has delayed the initiative for statewide reporting. The Bureau of Epidemiology has formulated case definitions for chronic hepatitis B and C (based on CSTE drafts), and now encourages the reporting of all such diagnoses. The case definitions are as follows:
Case Definition: Chronic HBV Infection
Clinical description
Persons with chronic HBV infection may have no evidence of liver disease or may have a spectrum of disease ranging from chronic hepatitis to cirrhosis or liver cancer. Persons with chronic infection may be asymptomatic.
Laboratory criteria
Case Classification:
Case Definition: Hepatitis C Virus Infection, (Chronic or resolved )
Clinical description
Persons with HCV infection may have no evidence of liver disease or may have a spectrum of disease ranging from chronic hepatitis to cirrhosis or liver cancer. Persons with chronic infection may be asymptomatic.
Laboratory criteria
OR
Case Classification
Reporting specifics:
Chronic hepatitis B and C cases currently on CHD task lists can still be reported, even though the event dates are prior to 2002.
2. Town Hall Meeting on Fetal Alcohol Syndrome
Jane A. Correia, HSEE
The Fetal Alcohol Syndrome (FAS) Center for Excellence, established by the federal government through the Center for Substance Abuse Prevention, is seeking information about FAS/FAE issues and concerns. The FAS Center for Excellence is sponsoring a Town Hall Meeting on July 24th beginning at 4:30 pm. The meeting is being held at the Radisson Suite Resourt on Sand Key, 1201 Gulf Boulevard, Clearwater Beach, FL. To learn more about this event please see the attached brochure.
3. Norwalk Virus Outbreak in a Hendry County Nursing Home, April 2002
Investigation Team:
Jim Love, Environmental Health Director, Hendry/Glades County Health Department
Robin Terzagian, Regional Food and Waterborne Disease Epidemiologist, Bureau of
Environmental Epidemiology
Margie Alderman, Communicable Disease Nurse, Hendry/Glades County Health
Department
Michael Lo, MSPH, Florida Epidemic Intelligence Service Assignee, Collier County
Health Department
Submitted by: Michael Lo, MSPH, Florida Epidemic Intelligence Service Assignee, Collier County Health Department
Introduction and Background
On April 24, 2002, the Hendry/Glades County Health Department received a call from a local nursing home concerning an outbreak of vomiting and diarrhea among residents and staff. It was initially reported that at least 22 cases of vomiting and/or diarrhea lasting 1-2 days had occurred in this long-term care facility of 92 beds, with a number of staff falling ill also. There were generally no reports of low-grade fever. To prevent further spread of illness, the nursing home had closed its common dining room and discontinued all congregate recreational activities. On April 25, a team was dispatched to conduct an on-site investigation.
Methods
To expedite the investigation, a line listing of cases including information on date of illness onset, resident or employee name, room number (if resident), job position and work area (if employee), and symptoms was collected prior to the team’s arrival by the nursing home administration, which also provided daily food service menus and a map of the premises for review. A food service inspection was conducted, as was a general inspection of residents’ rooms and bathrooms. Two nursing staff employees were interviewed regarding their illnesses, one of which was the index case. One stool and one vomitus sample were collected from ill residents for laboratory analysis.
Results
No food service violations were noted. One food service worker reported illness 2-4 days after the initial cases and 10 days after the index case, however this illness may be unrelated to this outbreak due to pre-existing conditions and signs and symptoms. No hand washing by nursing staff was observed during the time of the inspection, nor was wearing of gloves or masks until prompted by the team’s presence, although hand soap and running hot water were present in all resident bathrooms checked.
The line-listing data were entered into Epi Info 2000 for analysis. Of 49 cases, 17 were employees and 32 were residents (2 were relapses). 25 reported diarrhea alone, 12 reported vomiting alone, 12 both vomiting and diarrhea, 9 headache, and 1 each of nausea and cramps. These cases generated the following epidemic curve with respect to date of illness onset:
Both the stool and vomitus samples tested positive for Norwalk-like virus G2. Anecdotal evidence provided by the index case pointed to a similar outbreak two weeks previously at a nearby day care center attended by the child of the index case as a possible source of the outbreak from the community.
Analysis and Conclusions
From the information thus gathered, the spread of the illness could be documented both spatially within the nursing home facility, and temporally in the sequence of residents’ rooms affected. The outbreak followed a pattern that was consistent with staff assignment areas, as the majority of cases occurred in one area that spread to a second adjacent area, while one wing of the facility had only a single case until April 25. This leads to the conclusion that the mode of transmission was not foodborne, but person-to-person by infected nursing staff. The scenario of this outbreak was almost identical to the ones reported in two Pasco County nursing homes in March (Epi Update, April 19, 2002), in which a Norwalk virus of serogroup G2 was also implicated.
Although the nursing home administration was commended for its effort in gathering case information from residents and staff for this investigation, it was clear from the epidemic curve above that the outbreak should have been reported much sooner than it was on April 24, the peak day of the outbreak. 42 of the 49 cases (86%) had occurred in the 7-day period from April 19 to April 25, the day of the on-site investigation. The administration was advised of this, and to reinforce frequent hand washing among its nursing staff as an effective means of disease control.
4. Announcement: Regional Epidemiology Seminar, July 18th – 19th 2002 in Sarasota, Florida
Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology
Registration for The Regional Epidemiology Seminar, which will convene this week in Sarasota, Florida, is now closed. We are truly excited about this renewed effort and the potential it offers for improving disease prevention in the state. Currently we have 22 counties from around the state participating. Updated information as well as information on accommodations and travel directions can be found on the Bureau of Epidemiology Internet web page http://www.doh.state.fl.us/disease_ctrl/epi/conf/training/index.htm
The next Regional Epidemiology Seminar will be held in the panhandle this fall.
If you are interested in hosting one of these seminars or have questions related to this program, please feel free to contact me (Melanie Black at (850) 245-4444, ext. 2448 or SunCom 205-4444, ext. 2448.