January 7, 2005

Epi Update Managing Staff:

John A. Agwunobi, MD, MBA, MPH, Secretary, Florida Department of Health
Landis Crockett, MD, MPH, Director, Division of Disease Control
Dian K. Sharma, MS, PhD, Bureau Chief, Bureau of Epidemiology, Editor-in-Chief
Jaime Forth, Managing Editor

"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., International Journal of Epidemiology 1976; 5:29-37



     A Report on Post-hurricane Carbon Monoxide
                 Poisoning in Volusia County
                                                                           by Andre Ourso, MPH
                                                                        

The 2004 Hurricane season was a very eventful one for the state of Florida. During August and September four major hurricanes made landfall in the state. Hurricanes Charley and Frances directly affected the majority of Volusia County on the state’s east coast. Hurricane Charley, making landfall in Punta Gorda on the afternoon of August 13^th moved in a north-northeast direction across the state. The eye wall reached Volusia County shortly after midnight August 14^th. Hurricane Frances made landfall September 5^th near Sewall’s Point north of Palm Beach County. The hurricane moved west-northwest and was large enough that it impacted most of Florida’s east coast ⁽²⁾. 

Following both hurricanes there were widespread power outages across Volusia County. Many residents were without electrical power for several days. Some residents relied on gasoline fueled generators for their power needs. These small generators emit carbon monoxide as a byproduct and may pose a dangerous threat to the public if not used properly. Carbon monoxide (CO) is an odorless, colorless gas that can cause serious illness and death. It is found in combustion fumes, such as those produced by cars and trucks, small gasoline engines, stoves, lanterns, burning charcoal and wood, and gas ranges and heating systems ⁽¹⁾. The gas accumulates in enclosed and semi-enclosed areas and often affects humans and animals in an insidious and often undetectable way. The common symptoms of CO poisoning include headache, dizziness, weakness, nausea, vomiting, chest pain, and confusion. Unconsciousness and death may result from high concentrations of CO in the blood ⁽¹⁾. The following information is a brief report on the incident cases of Carbon monoxide poisonings occurring in Volusia County between August 13^th and October 1^st.    

Methods
Information about carbon monoxide poisonings was collected in two ways. EVAC, the ambulatory and emergency transport company in Volusia County was contacted and requested to provide any information regarding response and transport of CO poisoning cases between the dates of August 13^th and October 1^st.  Additionally, five hospitals located in Volusia County were contacted to provide information on any CO poisoning patients treated at their facility between the dates specified above. Infection Control contacts cooperating with their medical records division or emergency department searched for any cases using the ICD 986 code for carbon monoxide poisoning. Data were collected in person by the Florida EIS officer. Medical records, physicians’ consults and EVAC transfer records were reviewed looking at date of the incident, appliance that was implicated as the cause of the incident, location of the appliance, symptoms, treatment and basic demographic information. If any of the information needed was not provided from EVAC or the local hospitals the patients were contacted by phone by the Florida EIS officer. All data were compiled using Microsoft Excel.

Results
There were a total of 11 carbon monoxide poisonings involving 31 individuals in Volusia County between August 13^th and October 1^st.  All incidents occurred a few days after each hurricane’s impact on the county and during widespread power outages. Nine incidents occurred within seven days of Charley’s impact on the area. Two other incidents occurred after Hurricane Frances (Graph 1). Of particular note, Florida Power & Light and Progress Energy, two of the largest providers of electricity to Volusia County, had the vast majority of power restored after Charley and before Frances made landfall. According to company Websites FPL had most electricity restored by August 27^th and Progress had most power restored by August 23^{rd (3, 4)}. 

Incidents were not concentrated in any one area or city in the county. Ten of the eleven incidents (91%) were a direct result of the use of gasoline fueled generators; one other incident involved a suicide attempt using car exhaust in a garage. Six carbon monoxide sources (55%) were located in an attached garage where ventilation was limited. Two generators were placed inside the home and two generators were also placed in very close proximity to air conditioner window units. The location of one other generator was unknown. Nineteen of 31 individuals (61%) involved in the incidents required hyperbaric chamber treatment. The other 12 individuals (39%) required only oxygen before being discharged from the emergency department. Fifteen (48%) of the 31 poisoned individuals were children or adolescents under the age of 18 (Table 1).     

Discussion
Carbon monoxide poisoning can be a serious hazard in the aftermath of a hurricane because of widespread electrical power outages that affect many people in the impact area. The majority of incidents occurred after Hurricane Charley, with a total of nine accidents occurring within seven days of Charley’s impact. Only two accidents occurred in the county in the aftermath of Hurricane Frances. There are some possible explanations for these occurrences. Charley was the first of four hurricanes and it is likely that the public was unaware and uninformed of the potential dangers associated with carbon monoxide emissions. The reduction of incidents after Frances may be because the public had been made more aware of the potential dangers of generator use. The county health director was able to inform and warn the public through various media outlets before Frances made landfall. Getting information out to the public before widespread power outages along with increased knowledge and experience operating gasoline fueled generators possibly led to the reduction in accidental carbon monoxide poisonings after Frances.      

Among the incidents that occurred in Volusia County, gasoline powered electrical generators were the most prolific appliance implicated in a CO accident. The garage also was the most common location for the placement of the generator. After speaking with some of the individuals affected by carbon monoxide, reasons for placing generators inside the garage or home included fear of theft, proximity to electrical outlets, insufficient extension cord length, and ignorance of proper ventilation of noxious fumes. Two generators were also found to be placed underneath and in very close proximity to air conditioner window units, the intake on the AC unit bringing carbon monoxide fumes into the home. The reason for these particular placements was the need to plug in the AC unit to the generator.

The brief descriptive report on post hurricane carbon monoxide poisonings has revealed that the common source of post hurricane CO poisonings is a gasoline powered electrical generator. In addition, placing the generator in an attached garage appears to be a risk factor for carbon monoxide exposure. Proper ventilation should be stressed, paying close attention to placing these appliances in open areas away from open windows and doors and away from any air intake vents. It is also recommended that when operating such an appliance a battery powered carbon monoxide detector can be placed in the home, similar to a smoke detector. It may be interesting to perform a more in-depth study at the state level, collecting a much larger data set.

A limitation to this report is the fact that there is very little reference data for carbon monoxide poisonings. Carbon monoxide incidents are usually grouped into general poisoning categories, so obtaining national or state rate estimates is very difficult. Surveys assessing behaviors and attitudes towards the dangers of carbon monoxide poisoning could also be included. Ultimately, if the public is aware of the potential dangers arising from generators and other fuel burning appliances the potential for accidents will decrease. It is paramount for local authorities and public health officials to warn residents about carbon monoxide poisoning through appropriate media outlets before a hurricane makes landfall and the power grid goes black.

Special thanks to Volusia County EVAC and the five area hospital infection control practitioners.  
 

References:

1. CDC. National Center for Environmental Health, Carbon Monoxide Poisoning Fact Sheet.  http://www.cdc.gov/nceh/airpollution/carbonmonoxide/cofaq.htm
2. National Hurricane Center, National Oceanic and Atmospheric Administration.  http://www.nhc.noaa.gov.
3. FPL. Hurricane Season 2004; Responding to Statewide Disasters.  http://www.fpl.com/storm/pdf/hurricane_season_2004.pdf. 
4. Progress Energy. Progress Energy Completing Hurricane Charley Damage Repair; Vast Majority of Customers Restored to Service.  http://www.progress-energy.com/about/news

Andre Ourso is an epidemic intelligence service fellow assigned to the Volusia County Health Department in Daytona. He can be reached at 386.519.8300.

Ed Note: Carbon monoxide poisoning was an issue in the wake of all four of the 2004 hurricanes. The Bureau of Epidemiology Division of Disease Control and the Division of Environmental Health are jointly working on a case control study of carbon monoxide poisoning throughout the state.  Look for a follow-up article concerning this study in a future issue of Epi Update. 

Second-hand Smoke Among Florida Public Middle and High School Students in 2004
                                             by Zhaohui Fan, MPH   

Second-hand smoke exposure means that students were in a room or car where someone else was smoking during the seven days prior to the survey. In March and April 2004, 7,364 public middle school students and 7,023 public high school students responded to the questions about second-hand smoke. The Florida Youth Tobacco Survey data show that in 2004: 

• More than half (57.5 percent) of middle school students and more than two-thirds (67.1 percent) of high school students were exposed to second-hand smoke.

• Parents, relatives and friends were the major sources of SHS exposure to students. Private places, such as homes and cars, were major locations where students were exposed to second-hand smoke.

• Public areas, such as schools, work places and restaurants, accounted for 8.2 percent and 14.4 percent of locations where middle school students and high school students were exposed to second-hand smoke, respectively.

• Over one in six middle and high school students reported that smoking was allowed inside their homes.

• Over one third of middle and high school students reported that someone living in their homes smoked cigarettes. 

When compared with FYTS data in the past, the latest survey data show that:  

• The prevalence of exposure to second-hand smoke decreased by seven percent for both middle and high school students from 1998 to 2004. High school students had higher prevalence of exposure to second-hand smoke than middle school students in all survey years. (Figure 1)

• The prevalence of allowing smoking inside the home decreased by 36 percent among middle school students and by 37 percent among high school students from 1999 to 2004. (Figure 2)

• The prevalence of reporting someone else smoked inside the home decreased by 14.7 percent and 11.9 percent among middle school students and high school students, respectively, during 1998-2004. (Figure 3)

Readers can review detailed information from this report online at the bureau’s Website at http://www.doh.state.fl.us/disease_ctrl/epi/topics/pubs.htm.

Flu Vaccines Available and Encouraged
for High Risk Floridians
                                          by Jaime Forth

In a press release from Secretary of Health John Agwunobi this week, it was announced that 8,000 additional doses of adult flu vaccine are being dispensed to health departments throughout the state of Florida, with more on the way as they become available.

The announcement followed earlier communications which encouraged high risk individuals to obtain vaccinations and outlined high-risk individuals to include:

Dr. Agwunobi also promoted use of the pneumonia vaccine, which helps to resist infections which frequently develop after influenza. Private physicians can provide pneumonia vaccines, as can county health departments, hospitals and nursing homes.

Flu season this year began October 3, 2004 and will run through May 21, 2005. For the latest update on how influenza is affecting specific parts of Florida, go to http://www.doh.state.fl.us/disease_ctrl/epi/htopics/flu/2005/index.htm

Jaime Forth is managing editor of, and a contributing writer to, Epi Update. She can be reached at 850.245.4444, ext. 2004.

       New Approaches to Drug Resistant Bacteria                                                                                                                 by Jaime Forth              
                        

The current arsenal at use in the battle against drug resistant bacteria consists of prevention, judicious use of antibiotics and development of a new class of antibiotics. Public health experts at the Centers for Disease and Control and elsewhere have broadcast public information campaigns designed to create awareness of the importance of handwashing and the dangers associated with overuse of antibiotics. Research scientists are doing their part to bring about change in a different milieu - the laboratory.

The use of aspirin for the treatment of pain and heart problems has long been known; however, researchers at Dartmouth Medical School have recently shown that the salicylic acid produced in the body when aspirin is ingested reduces the bacteria's ability to cling to host tissues. In an article posted in the Journal of Clinical Investigation, they describe how salicylic acid also affects the ability of staph infections to produce the toxins necessary to spread to other tissues. The team plans to conduct further tests on antibiotic therapy with aspirin.  http://www.jci.org/cgi/content/full/112/2/222?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=
&fulltext=bacterium+Staphylococcus+aureus+aspirin&searchid=1104952065538_4359&stored_search=
&FIRSTINDEX=0&journalcode=jci

Development of new antibiotics for treating super bugs is a rising public health priority, and persistent researchers are beginning to make headway in their efforts to produce antibiotics that will fight against drug-resistant bacteria.
At the Hebrew University of Jerusalem and Rockefeller University in New York, mathematical modeling has shown researchers that immature cells which resist antibiotics and remain in the body to reinfect a patient another day might successfully be attacked at a mature point in their growth state. Their findings were published in Science magazine.
http://www.sciencemag.org/cgi/content/abstract/305/5690/1622?maxtoshow=&HITS=10&hits=10&
RESULTFORMAT=&author1=Balaban&author2=Leibler&titleabstract=E-coli+bacteria+&searchid=1104952911120_7628
&stored_search=&FIRSTINDEX=0&fdate=6/1/2004&tdate=
12/31/2004

At Harvard Medical School this past summer, research colleagues exploited bacterial enzymes to produce a stronger class of antibiotics. Mixing and matching enzymes that could undo DNA, these new aminocoumarins would destroy the ability of bacteria to replicate. Their study was reported to the annual meeting of the American Chemical Society in August 2004.
http://www.chemistry.org/portal/a/c/s/1/home.html

Based upon the idea that eliminating plasmids could make bacterium resistant, researchers at the University of Illinois have been working on an idea called plasmid incompatibility. Writing in The Journal of the American Chemical Society, professor Paul J. Hergenrother explained, "if there is one plasmid in a cell and another one is introduced, then they compete with each other for resources. One of them wins and the other is eliminated."
http://pubs.acs.org/journals/query/nonsubscriberResults.jsp

Streptococcus pneumoniae place a tremendous economic and social burden on the American public. The estimated cost of inner ear infections alone each year is $5 billion. According to Thomas Leyh, PhD, professor of biochemistry at the Albert Einstein College of Medicine in New York and lead author of a published report on a molecular Achilles heel in the organism that causes pneumonia, Streptococcus pneumoniae take the lives of approximately 2700 people daily worldwide, a large percentage of whom are children under five. His laboratory is developing compounds for potential new antibiotics based on diphosphomevalonate, which could assist in closing the channel that allows S. pneumoniae to survive in the lungs.
http://pubs.acs.org/cgi-bin/sample.cgi/bichaw/2004/43/i51/html/bi048075t.html

Antimicrobial resistance, which includes penicillin-resistant pneumococcal, multidrug-resistant TB and vancomycin-resistant Staph., has increased the number and length of hospitalizations today. Until a solution has been reached by scientists, the plan which has emerged within the public health community is: Use of antibiotics should occur only when absolutely necessary, hospital infection control practices should be strictly enforced, and efforts should be made to eliminate antibiotics from animal feed.

Jaime Forth is managing editor of, and a contributing writer to, Epi Update. She can be reached at 850.245.4444, ext. 2004.

  A.G. Holley State Hospital to Present Grand Rounds  

"Mycobacterial Susceptibility in 2005" will be the topic of a two-hour presentation on Wednesday, January 26 presented by Dr. Steven Holland, chief of the NIAID Laboratory of Clinical Infectious Disease, at the state hospital located in Lantana, Florida.

The Grand Rounds, designed for nurses and laboratorians, will require reservations by January 19th and provides 2 hours of CEUS for each professional. The stated objectives are:

• The ability to identify clinical presentations of disseminated and pulmonary NTM

• The ability to clearly describe the components of the innate immune response involved in the protection as mycobateria disease

• Provide a list of the pathways of stimulation of the macrophage including actions of interferon gamma, IL-12 and MFkB

• Define the information that influences treatment options of disseminated and pulmonary NTM

Lunch will be provided at noon. The program is sponsored by the Florida AHEC Network and Everglades Area Health Education Center and supported by the A.G. Holley State Hospital, the American Lung Association of Florida, Inc., and the Florida Bureaus of TB, Refugee Health and Laboratories. Participation via teleconference is available.

    


           This Week on EpiCom
                                                           by Pete Garner
                                

• Norovirus suspected in three Lee County nursing homes, in an Escambia County nursing home, and a Broward County nursing home
• Bacterial meningitis in a child returning from cruise in Bahamas
• Brucellosis in adult in Hillsborough County

Pete Garner is administrator of the Bureau of Epidemiology Surveillance Systems Section in
Tallahassee.  He can be reached at 850.245.4444, ext. 2481.

                         Weekly Disease Table
                                                                      by D'Juan Harris, MSP

Click here to review the most recent disease figures provided by the Florida Department of Health Bureau of Epidemiology.

D'Juan Harris is a GIS specialist in the Surveillance Systems Section of the Bureau of Epidemiology.
He can be reached at 850.245.4444, ext. 2435.

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Epi Update is a journal of the Florida Department of Health Bureau of Epidemiology and is
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