A Publication by the Bureau of Epidemiology
October 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 Epidemiology1976; 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 athttp://www.doh.state.fl.us
For information on diseases and conditions of public health importance go toMyFlorida.com, click on Health and Human Services, then Consumers--Diseases and Conditions.
In this issue:
Merlin and Electronic Laboratory Reporting
The Diagnosis and Control of Hepatitis A
1. Merlin and Electronic Laboratory Reporting
Kathryn Teates, MPH, Communicable Disease Surveillance & Reporting Administrator
On Tuesday, October 8th, the Merlin development team published changes to the system that included the initiation of electronic laboratory reporting. This is the beginning of electronic laboratory reporting for the Bureau of Epidemiology and will provide state laboratory test results to county health departments within 24 hours of report. Transmitting laboratory test results electronically greatly reduces the time from the report of results by the laboratory to receipt by the county health department. County health departments will now be able to follow up on these results and implement disease control and prevention methods faster. Large, private, national laboratories like LabCorp and Quest will be included in the future.
Some of the new features added to the system with the publication of this version are:
The publishing of Electronic Lab Reporting was possible with input from counties and work from the Bureau of Epidemiology, Bureau of Laboratories, and the Bureau of Information Technology.
Any questions or comments regarding the Merlin Reporting System can be directed to the Merlin Helpdesk email account at Merlin_Helpdesk@doh.state.fl.us.
Note: The eletronic transmission of laboratory results from the state laboratory database to the Merlin system is much more than a systems enhancement; it is a monumental step in the potential for disease prevention. While this is not an end point it is a watershed event and is the result of a considerable team effort. The Florida DOH "ELR" process began in earnest in the winter of 2000-2001with joint applications development "JAD sessions," the product of which was a plan for the development and implementation of the ELR strategy. That plan has been validated by the finalization of the state laboratory to STD and Merlin connections. In addition to the current developers, all of the participants in the JAD process share in the recent success. Congratulations to all. ---Ed.
2. The Diagnosis and Control of Hepatitis A
David Atrubin, MPH, Florida Epidemic Intelligence Service Officer
Hepatitis A: a viral disease
Hepatitis A is an infection of the liver caused by the hepatitis A virus. Symptoms occur 2-6 weeks after exposure to the virus. Hepatitis A typically has an abrupt onset, with fever, fatigue, nausea, vomiting, diarrhea and lack of appetite, followed in some cases by jaundice (dark urine and yellowing of the skin and the whites of the eyes). The symptoms usually last a week or two, but in a small percentage of cases, they may last several months. Others, often those under 6 years of age, experience no symptoms at all. Hepatitis A is not a virus that causes a chronic or long-term condition.
Hepatitis A virus is found in the fecal matter (bowel movement) of an infected person. It is easily spread by household or close contact with a person who is infected with hepatitis A. Men who have sex with men (MSM) are at an increased risk of the infection. Hepatitis A is also spread by eating contaminated food or drinking contaminated water.
It is important that physicians are knowledgeable about the proper laboratory tests needed to diagnose hepatitis A. When acute hepatitis is suspected based on clinical presentation, sera should be collected from the patient, and liver enzymes as well as an acute hepatitis panel should be ordered. The acute hepatitis panel usually includes the following tests:
A positive lab test for IgM anti-HAV is the criterion most useful for confirming acute hepatitis A. IgM anti-HAV is usually detectable 5-10 days before the patient is symptomatic and can remain detectable for as long as 6 months after the infection (Bower et al., 1997).
Immunoglobulin G antibody to hepatitis A (IgG anti-HAV), which can ordered as a separate test or as part of an "immunity" hepatitis panel, is usually detectable soon after infection and remains in the system for life, providing lifetime immunity against the disease (Stapleton, 1995). The IgG test should not be used to diagnose acute hepatitis A.
Hepatitis E causes a similar clinical picture as hepatitis A, although it is rarely seen in Florida without a history of travel to a developing country. Specific tests are available and should be considered in persons with a travel history and negative hepatitis A tests.
Immunization and Prevention
If a person has been exposed to the hepatitis A virus within the last two weeks, immune globulin (IG) should be administered and is more than 85% effective in preventing the illness (Stokes and Neefe, 1945). It is most effective when given as soon as possible following exposure. IG is recommended for close contacts of a confirmed acute hepatitis A case. Persons requiring prophylaxis normally include household, sexual, drug, and daycare contacts. As an example, the Hillsborough County Health Department will make arrangements to provide IG to the appropriate contacts as soon as possible after exposure but necessarily within two weeks of the exposure.
The hepatitis A vaccine is a two shot series, given as a preexposure immunization, which is over 94% effective at preventing the disease (Clemens et al., 1995). If an exposed person is already symptomatic, the administration of either IG or the hepatitis A vaccine is not recommended. The Advisory Committee on Immunization Practice (ACIP) recommends the following groups be provided with vaccine:
(CDC Advisory Committee on Immunization Practices, 1999)
Good hand washing is an effective means of preventing the spread of hepatitis A. Proper hand washing should be practiced after using the bathroom or having any contact with feces and before preparing or eating food. Hands should be scrubbed with soap and water for 15 to 20 seconds and then dried with a clean towel. Faucets should be shut off using a paper towel to minimize the chance of contamination from the sink itself.
CDC. Prevention of Hepatitis A Through Active or Passive Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48(RR12).
Clemens R, Safary A, Hepburn A, Roche C, Stanbury WJ, Andre FE. Clinical experience with an inactivated hepatitis A vaccine. J Infect Dis 1995;171(suppl 1):S44-9.
Bower WA, Nainan OV, Margolis HS. Duration of viremia in naturally-acquired hepatitis A viral infections. [Abstract 103] In: Abstracts of the Infectious Diseases Society of America 35th Annual Meeting. Alexandria, VA: Infectious Diseases Society of America, 1997.
Stapleton JT. Host immune response to hepatitis A virus. J Infect Dis 1995;171(suppl 1):S9-14.
Stokes J, Neefe JR. The prevention and attenuation of infectious hepatitis by gamma globulin: preliminary note. JAMA 1945;127:144-5.
3. Statewide Epidemiology Seminar
Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology
The Bureau of Epidemiology has received approval from the Secretary’s office to convene the next Statewide Epidemiology Seminar. The seminar will be held on Thursday and Friday, February 27th and 28th. We are currently exploring options for the site. In addition, the bureau is in the process of developing an interesting, informative and challenging agenda, a list of exciting speakers and an excellent poster session, not to mention time and occasion for colleagues to interact. Be sure to take advantage of this once-a year opportunity!
Further details about this program will be made available in the Epi Update and on the Bureau of Epidemiology Internet website. Melanie Black, MSW, will be managing this activity and can be reached at (850) 245-4444 ext. 2448 or SunCom 205-4444 ext. 2448.
4. Training Opportunity: Regional Epidemiology Seminar
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 14th & Friday November 15th, 2002 The target audiences for the regional training programs 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 is now available through Friday, November 1, 2002 and can be accessed through the Bureau of Epidemiology Internet web site: http://www.doh.state.fl.us/disease_ctrl/epi/conf/training/index.htm. 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.