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. Regional Epidemiology Seminar-Bay County Health Department
2. Arboviral Activity Summary through the Week Ending September 30, 2002
3. Community Acquired Methicillin Resistant Staphylococcus aureus Associated With Skin Abscesses

4. Traces of West Nile Virus Found in Breast Milk

Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology

The Bureau of Epidemiology is pleased to announce the next training program for county health department staff members, which will be held in Bay County on Thursday November 14^th & Friday November 15^th, 2002 The target audiences for the regional epidemiology seminar are county health department staff members and partner agencies who are involved in epidemiology. County health directors and administrators are welcome to attend.

This program will provide an overview of epidemiologic principles such as disease reporting, disease surveillance and communicable disease outbreak investigation. On-line registration will be available Monday, October 7, 2002 through Friday, November 1, 2002 and can be accessed through the Bureau of Epidemiology Internet site. Space is limited so please register as soon as possible.

Additional information will be provided in the Epi Update and on the Bureau of Epidemiology Web page. The next Regional Epidemiology Seminar will be held in Volusia County after the first of the year. We intend to offer training programs in other regions of the state. If you are interested in hosting one of the training sessions or have questions related to this program, please feel free to contact Melanie Black, the Professional Training Coordinator for the Bureau of Epidemiology. She can be reached at (850) 245-4444, ext.2448 or SunCom 205-4444,ext. 2448.

We are truly excited about the potential this program offers for improving disease prevention in Florida.

Lisa Conti, DVM, MPH, State Public Health Veterinarian and Caroline Collins, Arbovirus Surveillance Coordinator

Disclaimer: Please note that numbers are subject to change with confirmatory information.

There are Arbovirus Medical Alerts issued by the State Health Officer for 24 counties: Alachua, Brevard, Charlotte, Escambia, Flagler, Hernando, Hillsborough, Indian River, Lake, Lee, Manatee, Marion, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Putnam, Sarasota, Seminole, St. Johns, Sumter and Volusia.

During the period of September 24, 2002 through September 30, 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: One resident of Palm Beach County was diagnosed with West Nile encephalitis. However, this person traveled outside of the state during the incubation period and, thus will not be counted as a Florida case.

Sentinel Chickens: Ninety-nine WN seroconversions were confirmed in Alachua (1), Brevard (5), Charlotte (4), Citrus (6), Collier (5), Flagler (1), Hendry (4), Hillsborough (2), Lee (10), Leon (2), Manatee (4), Martin (5), Okeechobee (2), Orange (10), Osceola (4), Palm Beach (4), Pasco (2), Pinellas (2), Putnam (4), Sarasota (6) and Seminole (3), St Johns (7), Volusia (6) counties. No EEE seroconversions were confirmed this week. 797 samples were tested from 26 counties.

Equine*: Twenty-eight WN cases were reported from the following counties: Charlotte (1), Hernando (2), Levy (2), Manatee (1), Marion (14), Orange (1), Pasco (2), Sarasota (1), Sumter (1), Suwannee (1) -- representing the first WN activity in Suwannee County -- and Volusia (2).

Bird Mortality: Fifty-one dead birds were reported with WN from Alachua (1), Clay (1), Collier (1), Columbia (1), Escambia (17), Highlands (2), Jackson (2), Lake (5), Levy (1), Marion (3), Okeechobee (1), Orange (3), Palm Beach (2), Pasco (3), Sarasota (6) and Seminole (2) counties. 2,219 birds were tested and an additional 183 were too decomposed to be tested. To date, 6,914 bird reports were logged representing 8,108 dead birds; 823 (10%) were crows, 1,091 (13%) were blue jays and 227 (3%) were raptors.

To report dead birds use http://wildflorida.org/bird/ or 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 or http://data.acnatsci.org/ornithology/vireo.php

Mosquito Pools: No new mosquito pools were reported this week. 1,675 mosquito pools collected during 2002 have been submitted for testing.

Florida is currently at "Level 3" in the Arbovirus Response Plan (see http://www9.myflorida.com/disease_ctrl/epi/htopics/arbo/index.htm). An interagency press release was disseminated on February 18. DOH Press releases can be seen at http://apps3.doh.state.fl.us/IRM/PressReleaseSearch/search.cfm . To assure data dissemination in this second year of West Nile virus activity, weekly Friday afternoon Arbovirus Conference Calls began on May 17, 2002.

Article Submitted by: Carmela Mancini, MPH, EIS, Pinellas County

Carmela Mancini, MPH, EIS, Pinellas County

Sue Heller, RN, BSN, Epidemiologist Nurse, Pinellas County

Julia Gill, PhD, MPH, Epidemiology Program Manager, Pinellas County

Nosocomial and institutionally acquired Methicillin-resistant Staphylococcus aureus (MRSA) infections are common and well recognized. Outbreaks of community acquired MRSA, however are very rare, with only modest literature coverage. Recent findings suggest that MRSA is an emerging pathogen being acquired outside the nosocomial setting, yet the epidemiology and prevalence is not well understood. The emergence of MRSA in the community setting is of great public health importance and may have far reaching implications for antibiotic prescribing practices among private physicians and community health clinics.

On September 4, an individual notified the health department that he and several friends had developed purulent lesions on various parts of the body. Upon investigation it was determined that 10 individuals were experiencing similar skin abscesses. Nine of the ten individuals were interviewed face-to-face or by telephone. Some individuals also reported experiencing additional symptoms, including fever (30%), nausea (20%), fatigue (20%), headache (30%), vomiting (30%), itching (10%) and severe pain (10%). Several individuals had experienced symptoms for as long as two months. The lesions were of various sizes ranging from very small to 2-3 inches in diameter. Wound cultures were obtained from four individuals, all of which tested positive for MRSA. All 10 individuals were associated with the same Alcoholics Anonymous (AA) meeting either through attendance or contact with an attendee.

A line listing of individuals with skin lesions was created and 9 cases were interviewed in person or via a telephone call. Information collected included date of illness onset; signs and symptoms; residential status; history of hospitalization due to illness, transitional housing and AA meeting attendance. In addition, names and phone numbers of contacts were also collected. All individuals named as contacts were interviewed when possible. Cases were unable to provide some contacts’ last names, thus making contact investigation difficult.

A confirmed case was defined as a skin lesion occurring in a person or a contact to a person attending the implicated AA meeting as early as July 1 and with MRSA cultured from the site of infection. A probable case was defined as a skin lesion occurring in a person attending the AA meeting as early as July 1 or a skin lesion occurring in a contact to an AA meeting member.

Ten individuals had an illness that met the case definition; four confirmed and six probable cases. Seven cases were male and the median age was 32 (range: 18-55 years). All cases were white. Four cases were hospitalized, three were seen at the emergency department (ED) of the same hospital and three were seen by private physicians. Wound cultures were obtained from all hospitalized cases, three of which tested positive for MRSA and one tested positive for general Staphylococcus aureus. A wound culture was obtained from one case seen at the ED and one case seen by a private physician. Only the ED case tested positive for MRSA. No wound cultures were obtained from the remaining four cases.

All cases were linked to the same Alcoholics Anonymous (AA) meeting either through attendance or contact with an attendee. In addition to the AA meeting, some cases identified associations with transitional/half-way housing and/or drug rehabilitation centers. Local area rehabilitation centers, halfway houses, free clinics, a mobile medical van, and the county jail were notified of the health department’s investigation. When a personal visit could not be accomplished a telephone call was made to each of these organizations. In addition, the infection control group and the ED at the local hospital treating most of the cases cooperated with the health department. Information on lesions, staphylococcus infection, MRSA and good personal hygiene, especially hand washing were provided to all of the above facilities.

The Epidemiology Program at the Pinellas County Health Department has received numerous phone calls regarding the common existence of lesions and MRSA among persons living in transitional housing, homeless shelters, drug rehabilitation centers and the jail since this investigation began. Previously, this was not a common occurrence in Pinellas County. The "revolving door" between the jail, street and halfway houses could explain the prevalence and route of transmission among this transient population. Further investigation needs to be completed to explore this hypothesis.

The health department continues to monitor this situation and provides appropriate educational material and presentations to area clinics, rehabilitation centers, transitional housing and the local hospitals. In addition, cooperation in identifying potential cases continues to take place between the health department and community partners.

Borer A; Gilad J; Yagupsky P; Peled N; Porat N; Trefler R, et al. Community-Acquired Methicillin Resistant Staphylococcus aureus in Institutionalized Adults with Developmental Disabilities. Emerging Infectious Disease 2002 September; 8 (9): 966-70.

Groom, Amy; Wolsey, Darcy; Naimi, Timothy; Smith, Kirk; Johnson, Sue; Boxrud, Dave; Moore, Kristine A; Cheek, James. Community-Acquired Methicillin-Resistant Staphylococcus aureus in a Rural American Indian Community. JAMA. 2001; 286(10): 1201-05.

Lindenmayer, Joann M; Schoenfeld, Susan; O’Grady, Robert; Carney, Jan K. Methicillin-Resistant Staphylococcus aureus in a High School Wrestling Team and the Surrounding Community. Archives of Internal Medicine. 1998; 158(8): 895-99.

Morbidity and Mortality Weekly Report. 2001 October 26; 50(42): 919-22.

Written By: Denise Grady(Published in Pro-Med mail)

Submitted by: Lisa Conti, DVM, MPH, State Public Health Veterinarian

Traces of West Nile virus have been found in the breast milk of a mother who contracted the disease, probably from blood transfusions, health officials said yesterday. But so far her baby is healthy, despite being breast-fed while the mother was ill.

The case does not mean that current recommendations in favor of breast-feeding should change, according to the Centers for Disease Control and Prevention. Women should still be encouraged to breast-feed because it is so beneficial to infants, the C.D.C. said. But the centers also issued a statement saying women with documented West Nile infections might want to consult their doctors about breast-feeding.

But their doctors may not know what to advise. Dr. Lyle Petersen, a West Nile expert at the disease centers, said it was not known whether breast milk could transmit the virus to babies.

The mother in the new case, a 40-year-old from southeastern Michigan, gave birth on 2 Sep 2002 and had one transfusion that day and another on 3 Sep 2002. She ran a fever while in the hospital but was sent home on 4 Sep 2002 and continued to suffer from fever, headaches, malaise and nausea. She was readmitted to the hospital 13 days later and was found to be infected with West Nile.

Tests showed that the transfusion on 3 Sep 2002 carried the virus and that another patient who had received blood from the same donor also became ill.  The woman's breast milk was found to contain genetic material from West Nile, but that finding does not prove that whole live viruses were present.  Genetic material from West Nile has never been found in breast milk before, the disease centers said.

The baby is being tested for infection, and samples of the milk are being tested to find out whether the virus can be grown from them. That would indicate that live virus was present in the milk.

It is a good sign that the baby has remained healthy, Dr. Petersen said.  But he added that the incubation period of 2 to 14 days was not over and that in theory the baby could still become sick if the virus was transmitted in the milk. The mother nursed until 19 Sep 2002, when the West Nile diagnosis was made.

"We would expect the virus in breast milk to be present for only a very short period of time," Dr. Petersen said, adding that he would expect the risk to become negligible very quickly as the virus disappeared from the milk.

It is not known whether the virus can cause illness if it enters the body through the mouth and digestive tract, as opposed to entering the bloodstream through a mosquito bite, transfusion or organ transplant.

Dr. Petersen said that two other viruses in the same family as West Nile had been transmitted to people from drinking milk from cows or goats.  Neither of those viruses has been found in North America. One is from India and the other from eastern Europe and parts of Asia [tick-borne encephalitis is cauased by a flavivirus in this region that can be transmitted through drinking milk from infected animals. - Mod.MPP]. There is no information about whether those viruses pass into human breast milk.

Dr. Petersen said there were just two viral infections in which women are told not to breast-feed, H.I.V. and a very rare illness, human T-cell leukemia virus type 1. With other viral illnesses like colds and flu, he said, women are generally told to continue nursing because the illnesses are not severe enough to justify stopping.

"The benefits of breast-feeding are so great, we wouldn't want women to stop," he said.

Although mosquitoes are by far the most important source of infection, Dr. Petersen said, the illness in 2 transfusion recipients was further evidence that the virus could spread through blood and blood products. Transmission via blood is thought to have occurred in 3 other transfusion recipients. Officials theorize that 4 people, including one who died, contracted the disease from organ transplants.

There is no screening test to detect West Nile in the blood supply. Dr. Jesse Goodman of the Food and Drug Administration said his agency was "urgently working with manufacturers and others with potential blood screening tests to try to facilitate their availability."

The disease centers said that as of Thursday the reported West Nile cases this year totaled 2,206, with 108 deaths.

The agency also said the epidemic appeared to have peaked in the Southern states last month and in the last 2 weeks in Northern states. The tropical storm that struck Louisiana this week may be beneficial, Dr. Petersen said, because the mosquitoes that carry West Nile multiply better in small puddles of water than in floods.