| Friday, January 9, 2004
"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.
International Journal of Epidemiology
Epi Update Managing Staff:
John Agwunobi, MD, MBA, Secretary, Department of Health
Landis Crockett, MD, MPH, Director, Division of Disease Control
Acting Bureau Chief,
Epi Update Managing Editor
Jaime Forth, Copy Editor/ Writer
| This Week in the
Vaccine Not the Only Shortage
|A R T I C L E S|
Joann Schulte, DO, MPH, Medical Epidemiologist, Florida Department of Health
Donna Walsh, RN, BSN, Nursing Program Specialist, Orange County Health Department
Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology
Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology
Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology
Travis McLane, Surveillance Section Program Specialist, Bureau of Epidemiology
Angela Fix, MPH, Respiratory Disease Surveillance Epidemiologist, Melissa Covey, Influenza Surveillance Coordinator
Caroline Collins, Arbovirus Surveillance Coordinator and Carina Blackmore, DVM, Ph.D., Acting State Public Health Veterinarian, Bureau of Community Environmental Health
Vaccine Not the Only Shortage
Eleven childhood vaccines are used in United States; 8 of the 11 were in short supply in 2001 and 2002. There were also shortages of the influenza vaccine in 2000-2001. The more recent pediatric shortages include DTaP (diphtheria, tetanus, and acellular pertussis), MMR (measles mumps, and rubella), varicella (chickenpox), and pneumococcal conjugate vaccines. Children in the United States are immunized on a regular schedule (shown here) and the shortages have disrupted vaccination of children at regular ages in many states, including Florida.
Having sufficient numbers of people, including children, immunized against preventable diseases is important in controlling and eradicating diseases that once were routinely considered threats for epidemics. An example is pertussis (whooping cough), which now occurs only as small outbreaks; the grandparents and great-grandparents of today's children had siblings who died in childhood of pertussis in the early 20th century when hundreds of thousands of cases occurred each year. Another good example of a problem wherein limited vaccine supply can permit a disease to return in epidemic levels can be found in Russia, where diphtheria made a major comeback just as the Soviet Union broke up.
Vaccines are important because they protect individual people from disease and death and establish herd immunity. Herd immunity exists when enough people have been vaccinated against a disease and person-to-person transmission stops because immunity exists in the population. The epidemics of pertussis in the U.S. in the early 20th century and diphtheria in Russia were able to spread because herd immunity did not exist. In the case in United States, no pertussis vaccine existed in the early 20th century. In Russia, the vaccine supply was not readily available to protect against the disease.
The current example of influenza vaccine and the prior shortages of childhood vaccines are worrisome. Another disturbing factor is that there are few manufacturers producing many vaccines. The table below shows the problem.
It isn't too hard to figure out that if something goes wrong with manufacturing or some other problem develops, the number of cases could rise. The numbers of vaccine manufacturers are limited for several reasons. One is that the manufacturing process is difficult and a second is that the size of the vaccine market and profits made on vaccines are both relatively fixed. Most vaccines are given only once rather than several times to each patient. That's very different than a high blood pressure medication that may be taken every day for the rest of the person's life.
One suggested solution has been that a national vaccine stockpile be developed. Such stockpiles already exist for drugs and other medical supplies; these stockpiles were used after the Sept. 11, 2001 terrorist attack. In theory, this plan could have enough doses of the currently recommended vaccines available to immunize children. The Centers for Disease Control and Prevention has estimated that development of pediatric stockpile would take 4-5 years and expenditures of $705 million to assure adequate stocks of the existing recommended pediatric vaccine.
However, stockpiling a flu vaccine would be much more difficult for several reasons. The first is influenza changes every year because the virus mutates and an entirely new vaccine is manufactured each year. The second is that the demand for influenza vaccine has fluctuated dramatically from year to year. Last year, the manufacturers of the 2003-2003 influenza vaccine had millions of unused doses that were discarded.
There's no doubt that vaccines prevent disease in individual patients and can prevent epidemics in the United States. The question is how adequate supplies of vaccine can be guaranteed.
Additional reading material on vaccine supplies can be found at:
· http://aging.senate.gov/events/hr67gao.pdf (Flu Vaccine supply problems in 2001, prepared by Government Accounting Office GAO).
· http://www.gao.gov/new.items/d02987.pdf (Supply of pediatric vaccine, prepared by Government Accounting Office GAO).
Background. On Friday afternoon, November 7, 2003, the Orange County Health Department received a report from an area hospital infection control practitioner (ICP) of a suspect typhoid fever case in a child. The child was evaluated by an infectious disease consultant at the urgent care department of a children’s hospital. The child’s father was hospitalized at that same time with a preliminary blood culture report of gram negative rods. His symptoms included abdominal pain and fever of 103.4ºF. Travel history for the father and child was unknown at the time of the report. The infection control practitioner on-call planned to notify the Epidemiology on-call nurse if cultures were reported positive for typhoid fever on either patient.
Contact was made with the hospital microbiology department on November 10th for pending results on the father and child. The infection control practitioner reported that another child from the same family was hospitalized and the blood culture results for the father and his two children were Salmonella typhi. The ICP provided demographic information on the patients and travel history of the family to India.
Investigation. An epidemiological investigation was initiated by telephone interview with the father while hospitalized. He reported family travel history to India from September 27th through October 31st which included visiting relatives and friends, staying with parents in New Delhi, staying in two hotels, traveling four to five nights on a train, traveling by taxi, and eating and drinking local food and water. The father reported onset of illness on the day of their return, October 31st, including symptoms of fever as high as 103.4ºF, diarrhea, abdominal pain, headache, and nausea. One child developed symptoms of fever of 102ºF on November 4th, and the other child developed symptoms of fever of 104ºF and diarrhea and vomiting on November 8th. The mother of the children had a reported history of typhoid fever 15 years ago and was asymptomatic for the illness at the time of the report. The mother was treated with Cipro® and did not immediately submit specimens for testing. Rocephin® treatment was initiated on the father and two children in the hospital and completed by I.V. therapy in the home. The father also received Zithromax® from his primary care physician prior to his hospitalization and Cipro® while in the hospital. The family denied history of typhoid vaccine.
The father and his wife were employed in the medical profession. Their three-year-old child attended a preschool and his five-year-old sister attended public school. The mother was employed as an occupational therapist. The three-year-old child was excluded from attending preschool and the mother was restricted from returning to work until three negative stool specimens for Salmonella typhi collected twenty-four hours apart, one month after onset of symptoms and one week after completion of antibiotic therapy, per Florida Administrative Code 64D-3.013 and 64D-3.014 were received. Due to the father’s duties as a physical therapist, it was recommended that he return to work only after clearance from his primary care physician. The Orange County Health Department advised the hospital infection control practitioner and employee health physician of these recommendations. The parents were referred to the employee health physician for clearance to return to work. The pediatric infection control consultant for the preschool child was advised of the current Florida Administrative Code guidelines for return of patients diagnosed with typhoid fever to sensitive situations.
Follow-up. The preschool director was also contacted regarding a student diagnosed with typhoid fever and exclusion from the center until cleared by the Orange County Health Department. The child reportedly attended the preschool on November 3rd and 4th prior to onset of illness. Information was provided to the director on typhoid fever and infection control measures. The director sent letters to parents of enrolled children with information regarding typhoid fever. A local pediatrician’s office contacted the Orange County Health Department regarding a report received from an asymptomatic attendee’s parent regarding typhoid fever at the child’s preschool to confirm the information. No further cases have been reported from the school to date.
The nursing coordinator for Orange County Public Schools contacted the Orange County Health Department on November 10th to report a case of typhoid fever in an elementary school. Information on typhoid fever was provided to the health aide and infection control measures were reviewed. The health aide reported that the school practiced good handwashing and that soap supplies were available. The Orange County Health Department advised the health aide that the school-aged child diagnosed with typhoid fever may return to school with clearance from her physician twenty-four hours after cessation of symptoms. No further cases have been reported from the school.
The last reported typhoid fever case in Orange County was in 2001 in a child with an unknown source of infection. Reports of Salmonella typhi in Orange County are infrequent and are historically associated with travel outside of the United States. Although hardships can be created for patient cases and their contacts in implementing infection control measures for typhoid fever, diligence in determining sensitive situations and executing these measures has been essential in preventing the spread of the disease. Prompt reporting of suspected cases has been key in expediting the initiation of control measures.
The Regional Epidemiology Seminar, sponsored by the Bureau of Epidemiology will be held in Polk County, at the Admirals Inn, Winter Haven, Florida on Wednesday, February 25th and Thursday, February 26th, 2004. The target audiences for the regional training programs are county health department staff members who conduct epidemiologic investigations, who have not previously received this type or level of training.
This program will specifically address public health surveillance and communicable disease outbreak investigations. Topics such as principles of public health surveillance, improving provider reporting, principles of field epidemiology, historical overview of emerging pathogens and an outbreak scenario will be covered in this training. On-line registration will be available on Friday, January 9th and can be accessed through the Bureau of Epidemiology Internet web site: http://www.doh.state.fl.us/disease_ctrl/epi/conf/conf_call.html. The class will be limited to 45 participants. CEUs will be offered to nursing, environmental health and laboratorians.
Additional information will be provided in the Epi Update and on the Bureau of Epidemiology Web page. We intend to offer subsequent 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, Professional Training Coordinator, Bureau of Epidemiology 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
With most counties calling in to the bi-weekly conference calls, energetic discussions and the latest news and information is being promulgated to a wide audience with opportunity for live question and answer exchanges. If you weren't able to tune in to last week's call, here is a brief overview:
Bioterrorism Funding. Don Ward explained that staff are preparing a second re-direct to cover a few additional positions at the county health department level. The funding level for the remainder of the grant year is fixed for health departments for Schedule C, which means additional requests will not be entertained until next fiscal year.
Flu Vaccine Availability. Phyllis Yambor announced that the state of Florida received over 7,000 doses last week and over 4,000 pediatric doses were shipped this week.
Meningitis Incidence 2003. Dr. Schulte reported that 92 cases of bacterial meningitis were reported in 2003, with 74 cases confirmed. In future, we will aim for more thorough reports when presenting data; this should include date of death, serotype and lab results.
EpiCom 2003. Don Ward underscored the need to use EpiCom as a means of communication now, in preparation for future events. If and when a major outbreak occurs, EpiCom is the major vehicle through which the bureau will communicate reports and alerts, so it's best to become familiar with it now.
Training News. Melanie Black announced there will be a Grand Rounds on January 27th with David Atrubin, MPH, presenting on Inspiratory Stridor in Female Students at a High School in Tampa, Florida.
The Epi contact list is being updated for posting on the Web site. It has been distributed to all county health departments; if you haven't already done so, please review it and let Melanie know if any changes need to be made. After January 12th, the list will be posted as is.
The next regional epidemiology seminar will be held in Polk County on February 25-26th at the Admiral Inn Best Western in Cypress Gardens. Only 45 slots are available. Web site registration will be available in two weeks. Merlin training will be held in conjunction with this seminar.
This year's annual epidemiology seminar is planned to beheld again at Lake Mary in May. Watch the Epi Update for details.
The next conference call will be held on Friday, January 16th at 10:00 a.m. Watch the Web site for more details or call Melanie Black for more information.
Revises Infectious Disease Law
On December 17th, a notice was issued to hospitals and research labs throughout the country requesting proper handing of SARS specimens; however, since researchers have not been required to notify the government of the pathogens they have, it is not known which institutions hold SARS samples. The Japanese Health, Labor and Welfare Ministry began this month to gather this information. The Education, Science and Technology Ministry has announced no plans to ascertain which of its universities have access to the virus. Private research institutions likewise are apparently not affected by this new measure.
In a further effort to curb the virus from entering the country, the government installed thermography machines at 14 international airports and four international ports, and plans to develop a kit for medical workers which would verify the presence of the virus within the hour.
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Florida influenza-like illness (ILI) activity continues to increase statewide. Eighteen counties are reported as having high ILI% activity for the week ending December 27 (Week 52). Twelve counties reported an increase in ILI activity during the week ending December 27, eleven counties reported a decrease and three counties remained level. Four counties did not have at least 50% of the sentinels reporting or did not report last week and therefore the change in activity could not be determined. Of the 8,149 patients seen by the sentinel providers during the week ending December 27, 654 were seen for influenza-like illnesses (an overall state ILI activity of 8.03%). The number of patients seen by the sentinel providers during the week ending December 27 was down substantially from the previous week (8,149 vs. 14,465). This decline in patient visits may have contributed to a larger ILI% activity. Due to the holiday week, some sentinel providers reporting seeing no patients. The Florida ILI activity code reported to the Centers for Disease Control and Prevention (CDC) for the week ending December 27 was widespread. Widespread is defined as an increase in ILI activity in greater than or equal to half of all regions (sentinel counties), along with recent laboratory evidence of influenza or recent institutional outbreaks within those regions. Three counties have reported outbreaks of influenza or influenza-like illness for the week ending December 27. The previous week only one county reported any outbreaks. As of January 5, 2004, there have been four cases of influenza-associated pediatric deaths in Florida reported to the Bureau of Epidemiology. Two of these were encephalopathy cases in which the patient later died. A statewide summary of the county enhanced surveillance reports has been made available on EpiCom.
Influenza-Like Illness (ILI) Florida Summary
Sixty-eight sentinels from 58 public clinics and private offices submitted reports for 28 counties during the week ending December 27, 2003 (Week 52). Counties with the highest percentage of patients with ILI were: Okaloosa (2.31%, with 2 of 5 locations reporting); Pinellas (2.39%, with 4 of 8 reporting); Martin (2.48%, with 1 of 1 reporting); Marion (2.73%, with 1 of 1 reporting); Lake (3.05%, with 2 of 2 reporting); Broward (4.02%, with 4 of 7 reporting); Alachua (5.45%, with 1 of 2 reporting); Miami-Dade (5.63%, with 3 of 6 reporting); Orange (6.69%, with 5 of 9 reporting); Monroe (7.96%, with 1 of 1 reporting); Palm Beach (9.66%, with 4 of 5 reporting); Duval (10.06%, with 4 of 7 reporting); Sarasota (15.07%, with 1 of 1 reporting); Polk (18.06%, with 4 of 4 reporting); Brevard (18.75%, with 3 of 3 reporting); Pasco (22.22%, with 1 of 1 reporting); Indian River (22.47%, with 3 of 3 reporting); and Leon (31.30%, with 1 of 2 reporting). Five counties reported a low percentage of patients with ILI, and four counties reported no cases of ILI. A breakdown of ILI% reported for week ending December 27, 2003 by county is listed in Table 1.
Laboratory Specimen Testing in Florida
Forty-four of the 105 specimens received by the Jacksonville Central and Tampa Branch laboratories for influenza isolate testing during the week ending December 27, 2003 (Week 52) were found positive for influenza A. Of these 44 viruses, 30 were A (H3N2), 29 were influenza A, unknown. These viruses came from Alachua, Broward, Citrus, Duval, Hernando, Hillsborough, Indian River, Lee, Leon, Marion, Orange, Palm Beach, Pasco, Pinellas, Polk, St. Johns, Volusia, and Wakulla counties. Culture testing continues on 15 of the unknown 29 influenza A specimens received during week 52 that were found positive for influenza A through PCR testing. The CDC has returned results from 9 specimens collected from Florida during October and November. All were positive for influenza A(H3N2): 5 were similar antigenically to the vaccine strain A/Panama/2007/99 (H3N2), and 4 were similar to the drift variant, A/Fujian/411/2002 (H3N2).
From September 28, 2003 to December 27, 2003, the Florida laboratories tested a total of 409 specimens and found 147 positive for influenza A (H3N2) and 49 that were unknown A or had culture results pending. The remaining specimens were negative for influenza. Table 2 details isolates found since September 28, 2003 by county.
Rapid Testing Performed by Private Laboratories in Florida
Reports received from non-sentinel, private hospitals and private laboratories since September 28, 2003 are summarized in Table 3.
National Influenza Surveillance
This section summarizes the weekly influenza report from the Centers for Disease Control and Prevention. More detailed information can be found at their website: http://www.cdc.gov/ncidod/diseases/flu/weekly.htm and at http://www.cdc.gov/ncidod/diseases/flu/vacfacts.htm#01
Influenza-Like Illness Report for the Week ending December 27, 2003
The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) was 9.4% nationwide. This is above the national baseline of 2.5%. The percentage of patient visits for ILI increased in 7 surveillance regions. On a regional level, the percentage of visits for ILI ranged from 11.4% in the East North Central region to 5.8% in the east South Central region. The South Atlantic region, in which Florida is located, reported 10.4% of patient visits were due to ILI. Due to wide variability in regional level data, it is not appropriate to apply the national baseline to regional level data. National percentage and regional percentages of patient visits for ILI are weighted on the basis of state population.
Antigenic Characterization: CDC has antigenically characterized two influenza A (H1) viruses, 357 influenza A (H3N2) viruses, and two influenza B viruses that were submitted by U.S. laboratories since October 1, 2003. The influenza A (H1) viruses were similar antigenically to the vaccine strain A/New Caledonia/20/99. Of the 357 A (H3N2) viruses characterized, 91 (25.5%) were similar antigenically to the vaccine strain A/Panama/2007/99 (H3N2), and 266 (74.5%) were similar to the drift variant, A/Fujian/411/2002 (H3N2). The influenza B viruses were similar to B/Sichuan/379/99, which is in the 2003-04 vaccine.
Influenza drift variant, A/Fujian/411/2002 (H3N2), found in the United States and Europe
The Influenza A drift variant, A/Fujian/411/2002 (H3N2) predominated the Australian and New Zealand outbreaks that peaked in mid-to-late August 2003, and has been detected in many countries in the Northern Hemisphere, including the United States. The CDC expects the current U.S. vaccine will offer some protective immunity against the A/Fujian/411/2002-like viruses because these viruses are related to the vaccine strain, A/Panama/2007/99. Antibodies produced against the vaccine virus cross-react with A/Fujian/411/2002-like viruses, but at a lower level.
U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) Laboratories Report
Since September 28, 2003, 14,942 (29.4%) of the 50,743 specimens tested for influenza viruses were positive. Three thousand five hundred seventy-six influenza A (H3N2) viruses, one influenza (H1) virus and 95 influenza B viruses have been identified. Weekly ratios rather than proportions are presented in the 2003-2004 Summary By Region because specimens reported positive for influenza virus each week may include specimens submitted for testing during an earlier week.
122 US Cities Vital Statistics Mortality Report
The percentage of all deaths due to pneumonia and influenza was 9.0. This percentage exceeds the epidemic threshold of 7.9 for the week ending December 27, 2003.
International Influenza Activity
World Health Organization Communicable Disease Surveillance and Response
WHO reported on January 5, 2004 the first laboratory confirmed case of SARS in a 32-year-old man in the southern Chinese province of Guangdong. The patient was hospitalized on December 20, 2003, four days after the onset of symptoms. WHO reports follow-up on all persons in contact with the patient indicates contacts are free of symptoms and most have been released from quarantine. Surveillance has been intensified in Guangdong and other provinces. For more information about this report please visit the WHO website at http://www.who.int/csr/don/2004_01_05/en/.
No new influenza updates were found as of January 5, 2004. WHO influenza updates to date included the following items:
WHO issued Update 5 on December 23, 2003 in which an outbreak of avian influenza A (H5N1) in poultry at a farm in the Republic of Korea has resulted in the detection of infected chickens at nine poultry farms in 4 provinces. An estimated one million chickens and ducks are to be culled. No human A(H5N1) cases have been reported.
On December 10, 2003 WHO reported a case of avian influenza A(H9N2) in Hong Kong Special Administrative Region of China. The patient, a five-year old boy, was hospitalized and has recovered. The only other reported case of influenza A(H9N2) virus in Hong Kong occurred in 1999.
Significant increases in influenza activity associated with influenza A(H3N2) in some countries in the northern hemisphere and in Africa is reported. Counties with declining influenza activity include Portugal, Spain and the United Kingdom, and most parts of Canada. Countries in Asia most frequently report influenza B viruses; sporadic cases of influenza B have been found in Europe and North America. An influenza A(H1) outbreak that had begun in Iceland during early October had ended by mid-November.
FluWatch Report from the Canadian Centre for Infectious Disease Prevention and Control
For more information about the FluWatch report, please visit their website
For more information about the EISS report, please visit their website at http://dev.eiss.org/cgi-files/bulletin_v2.cgi
WHO Collaborating Centre for Reference and Research on Influenza, Melbourne Australia
Australia’s winter months are from May to October. One of Australia’s biggest influenza seasons since 1998 peaked from mid to late August 2003, and by October cases of influenza had generally subsided. Influenza A (H3) viruses were cited as the primary cause of outbreaks, with little A (H1) or B viruses isolated during the season. For more information about Australian influenza, please visit the Melbourne, Australia Branch website at http://www.influenzacentre.org/ (specific article can be found at http://www.influenzacentre.org/flunews.htm#subsiding).
2002-2003 Influenza Surveillance Summaries
An international summary of the 2002-2003 influenza surveillance season (October-September) can be found on page 303 in the November 7, 2003 edition of the WHO’s Weekly Epidemiological Record (Vol. 78) at http://www.who.int/wer/2003/wer/2003/wer7845/en.
WHO Recommended composition of influenza virus vaccines for use in the 2004 influenza season http://www.who.int/csr/disease/influenza/recommendations2004/en/
* Reporting is
incomplete for this week. Numbers may change as more reports are received
The Bureau of Epidemiology encourages Epi Update readers not only
to register with the EpiCom system at
but to browse EpiCom and to contribute public health observations
related to any suspicious or unusual situations or circumstances as
EEE virus activity: Six seroconversions to EEE virus were confirmed in Walton County, all at the same flock site. In 2003, 52 of Florida’s 67 counties reported EEE virus activity, compared to 27 counties reporting EEE in 2002.
WN virus activity: Eight seroconversions to WN virus were confirmed in sentinel chickens from five counties. In 2003, 60 counties reported WN virus activity, compared to 56 in 2002.
SLE virus activity: One seroconversion to SLE virus was confirmed in Lee County. In 2003, six counties reported SLE activity, all in sentinel chickens. In 2002, there was a human case of SLE from Escambia County and two positive mosquito pools in Lee County.
See the web page
for maps and more information: http://www.doh.state.fl.us/Environment/hsee/arbo/index.htm