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. Medical Alert Issued for Escambia and Volusia Counties
2. Salmonella group C2 Outbreak in a Restaurant- Gainesville, Florida
3. Ministries of Health Database
4. Case Report Form Requirements and Merlin

5. Bioterrorism Considerations for Epidemiology and Surveillance

FOR IMMEDIATE RELEASE CONTACT: Bill Parizek

August 8, 2002 850-245-4111

TALLAHASSEE—Due to the recent increase of animals in Escambia and Volusia counties testing positive for West Nile (WN) virus, the Florida Department of Health (DOH) has issued medical alerts for those counties.

DOH’s Bureau of Epidemiology reports that Escambia County now has 18 dead birds that have tested positive for WN, nine of which were identified in the last week. No horses have been reported positive this year in Escambia or neighboring Santa Rosa County. Volusia County has 15 sentinel chickens and seven horses that have tested positive for WN.

Although there have been no human cases of West Nile virus discovered in Florida this year, DOH urges all Floridians to protect themselves against mosquito bites.

"I want to encourage everyone to take basic precautions to help limit their exposure to mosquitoes," advises DOH Secretary John O. Agwunobi, M.D., M.B.A. Agwunobi further emphasizes the following:

• Avoid outdoor activities at dusk and dawn when mosquitoes are likely to be active and biting;
• Eliminate stagnant water in birdbaths, lily ponds and any other receptacles in which mosquitoes might breed;
• If you must be outdoors when mosquitoes are active, cover up by wearing shoes, socks, long pants and long-sleeved shirts; and
• Use mosquito repellant containing DEET according to the manufacturer’s directions.

West Nile virus is a mosquito-borne illness (arbovirus) commonly found in Africa, West Asia, the Middle East, and more recently in the United States, including Florida. It causes disease, primarily in birds, (it has been found in more than 50 species), although it can also affect humans, horses and other mammals. Infected mosquitoes transmit the virus from birds to humans. There is no human-to-human or animal-to-human transmission. A number of mosquito species have been identified with WN virus including species active at dawn and dusk, and those active during the day.

The Department of Health laboratories provide testing services for patients with clinical signs and symptoms of West Nile virus. These may include: headache, fever, fatigue, dizziness, weakness and confusion. People over the age of 50 are at the greatest risk of contracting an arbovirus.

Health care providers and laboratories are required to report all suspected or confirmed cases of mosquito-borne encephalitis to their local county health department.

For more information on West Nile virus, visit the DOH Bureau of Epidemiology’s arbovirus Web site at MyFlorida.com (click on Health and Human Services, then Consumers – Diseases and Conditions, then Arboviral Encephalitis) or http://www.doh.state.fl.us/disease_ctrl/epi/htopics/arbo/index.htm or call the Bureau’s hotline at 1-888-880-5782 for recorded information.

Investigation Team:

Jerne Shapiro, Florida Epidemic Intelligence Service Officer- Alachua County
Sally Bethart, Epidemiology Nurse- Alachua County
Don Windham, Regional Food and Waterborne Disease Epidemiologist, Bureau of Environmental Epidemiology
Tom Belcuore, Director- Alachua County Health Department

Submitted by: Jerne Shapiro, MPH, Florida Epidemic Intelligence Officer- Alachua County

Background:

On June 3, 2002 the Alachua County Health Department (ACHD) received individual phone reports from a total of seven people who complained of diarrheal illness after eating at the same restaurant on 5-31-02. All seven patrons came from two separate dinner parties- a table of 3 and another of 4. The patrons ate at an Asian restaurant and grocery on Friday evening between 7:00-7:30pm. The patrons’ symptoms included: diarrhea, abdominal cramping, headache, chills, fever, fatigue, dizziness, and vomiting. The patrons were both Caucasian and Japanese, ranging in age from 27-51.

Methods:

A 72hr food history was collected and a line list prepared. The line list included: itemized food list, time of onset, date and time suspected food was eaten, patrons name, lab results, and symptoms. The cases were defined as patrons who tested positive for Salmonella. Stool samples were collected from all six symptomatic patrons, one asymptomatic patron, and all restaurant employees. The only available food specimen, the fish cake, was also collected. All samples were then analyzed at the state lab. A food service inspection was conducted.

Results:

Six of the seven patrons tested positive for Salmonella type C2 with matching DNA fingerprints. The one patron who tested negative for Salmonella, and had presented symptoms, was currently taking Doxycycline. Of the seven interviewed six patrons were symptomatic. However, the asymptotic patron’s stool sample did test positive. The fish cake was the only food sample available to be analyzed and tested negative for Salmonella.

The incubation period ranged from 2.5hr-51hr. The 51hr incubation time may have been due to leftovers taken home. The median time was 12hrs. The attack rate was 37%, with 19 patrons potentially exposed. Of the stool samples collected from the restaurant employees, one tested positive for Salmonella type C2. The DNA fingerprint matched those of the patrons. The employee, who was the owner, was asymptomatic and did not know when they became infected. The employee ate dinner the evening of 5-31-02 at the restaurant.

Conclusion:

The Department of Agriculture, who regulates the agency, preformed an investigation on 6-5-02 and cited 24 violations. However, the source of the Salmonella is unknown. The fish cake, pickle slices, and Kim-Chee were the commonly consumed foods by all patrons who tested positive for the Salmonella group C2. The Kim-Chee, fish cake, and pickle slices are not commonly associated with Salmonella, thus cross contamination needs to be considered as a possible source. The owner ate dinner on the night of 5-31-02 and reported eating the same foods. Consequently, it cannot be ascertained if the owner infected the food or if the owner also became infected upon eating the food.

Follow Up

The owner was withheld from food handling until two negative stool samples, 24hrs apart, were collected. Correction of all violations documented by the Department of Agriculture and Consumer Services.

Catie Richards, Editorial Assitant, Bureau of Epidemiology

The Bureau of Epidemiology has recently created a database containing contact information for all the ministries of health throughout the world. We currently have 202 country/states in our database. The contact inforamtion includes addresses, phone numbers, fax numbers and e-mails. There are also alternate contacts for some of the countries such as U.S. Embassy phone and fax numbers and other public health institutions phone and fax numbers. All of the country/states in the database don’t contain all of this info but there is some kind of contact info for all .

If you need any of this contact information please contact me (Catie Richards) at (850) 245-4444 ext 2416 or by e-mail at Catie_Richards@doh.state.fl.us.

Kathryn Teates, MPH, Bureau of Epidemiology

Roberta Hammond, PhD, Bureau of Environmental Epidemiology

Case report forms are currently required for 42 reportable communicable disease conditions.¹ Of those, 5 are collected in Merlin as extended data screens. Reportable disease conditions that do not have electronic submission capability in Merlin still need to be reported by paper case report forms to the Bureau of Epidemiology. In particular, it is important to continue completing the Cholera and Other Vibrio Illness Surveillance Report (CDC 52.79). Both CDC and FDA are closely monitoring vibrio data nationwide including exposure dates, pre-existing medical conditions, hospitalization dates, morbidity and exposure sources for molluscan shellfish, crustacean shellfish, other seafood and marine waters. These data are necessary for statewide shellfish management, shellfish sampling protocols, water sampling protocols, regulatory policies and disease prevention education efforts. Most paper case report forms are located on the web at the Florida Department of Health external website (http://www9.myflorida.com/disease_ctrl/epi/topics/surv.htm). If you need assistance with completing Cholera and Other Vibrio case report form, please contact your Regional Food and Waterborne Disease Epidemiologist. For assistance with all other case report forms, including the correct address or fax number to submit forms, please contact the Surveillance and Reporting Section in the Bureau of Epidemiology by emailing the Merlin Helpdesk.

Bureau of Epidemiology, Florida Department of Health

The Bureau of Epidemiology will be airing a live, interactive satellite broadcast on August 21, 2002 from 1:30 – 3:00 PM EST. The opening remarks will be provided by John Agwunobi, MD, MBA, Secretary, Department of Health and Steven T. Wiersma, MD, MPH, Bureau Chief, Bureau of Epidemiology and Douglas Holt, MD, Hillsborough County Health Department Director will provide up-to-date information on Bioterrorism Considerations for Epidemiology and Surveillance. This program, targeted to county health departments, physicians and other medical providers, will present current information on the importance of surveillance and epidemiology in a biological weapons attack, the status of the state’s bioterrorism surveillance programs and the plans for further development of surveillance systems. The program will include a question and answer session via toll-free telephone and fax lines. Additional information will be made available in next week’s Epi Update or you can contact Melanie Black, MSW, Professional Training Coordinator (850) 245-4444 ext. 2448 or SunCom 205-4444 ext. 2448.