Epi Update - January 16, 2004

►January Grand Rounds Topic Will Be Inspiratory Stridor

Bureau of Epidemiology Grand Rounds Program
Date: January 27, 2004
Topic: Inspiratory Stridor in Female Students at a High School in Tampa, Florida
Presenter: David Atrubin, MPH, Florida EIS Fellow, Hillsborough County Health Department, Bureau of Epidemiology, Florida Department of Health

Four reports in an ongoing series of analyses of the Florida Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2000 and 2001 have just been released and are available on the Bureau of Epidemiology Website at http://www.doh.state.fl.us/disease_ctrl/epi/prams/prams.htm.

The first report concerns the use of folic acid among Florida women to help prevent birth defects. The CDC estimates that 50 to 70% of neural tube birth defects could be prevented if all women of child-bearing age consumed 0.4 mg of folic acid each day before pregnancy and during the first month of pregnancy. The second report presents information collected regarding cigarette smoking during pregnancy among Florida women. The third report focuses on domestic abuse during pregnancy, a serious public health concern with implications for both mother and infant. The fourth report deals with low birth weight outcomes among Florida women, a factor which contributes to added medical costs and infant mortality.

Following a series of meetings with numerous working groups, the FDA's Center for Biologics Evaluation and Research has provided a definition of xenotransplantation as "any procedure that involves the transplantation, implantation or infusion into a human recipient of either (a) live cells, tissues, or organs from a nonhuman animal source, or (b) human body fluids, cells, tissues or organs that have had ex vivo contact with live nonhuman animal cells, tissues organs."

The organization has also published guidance for public health epidemiologists, veterinarians and other professionals regarding the risks of potential transmission of zoonotic or unrecognized infection from source animals to immunosuppressed recipients, and possibly beyond, to the population at-large. The documents are primarily aimed at minimizing risks including controlling source animal production, providing precautionary measures for clinical trials, archiving and clinical follow-up.

After the first cases of West Nile virus were identified in the U.S. in 1999, it moved steadily westward and is now believed to be headed south, toward Central America and the Caribbean.

This particular arbovirus started out small in this country. When Dr. Deborah Asnis, an infectious disease clinician in the borough of Queens spotted two cases of encephalitis and followed-up with a collaborative investigation resulting in the identification of West Nile virus as the cause, it came as a surprise to medical practitioners here in the Western Hemisphere. The flavivirus is endemic in Africa, the Middle East and Asia. But although no one knows for sure how it arrived here, there is no doubt its arrival has reached epidemic proportions. By 2002, 4,100 cases of the virus were identified in the U.S., resulting in 284 deaths. In 2003, the number climbed to 8,900 cases, among which 2,500 were encephalitis.

Arboviruses require host bodies in which to thrive, and vectors to spread the infection. Mosquitoes are the primary vectors for West Nile virus and birds are the usual vertebrate hosts. Humans are secondary, though not very efficient, hosts because we rarely develop viral loads in our blood high enough to infect mosquitos. In countries like Africa and Asia where the virus has existed for over 60 years, birds and other animals have built up a resistance to the virus; but in the U.S., immunity has not yet developed in these creatures so the death of wild birds, sentinel chickens and horses is used an early warning system by state health epidemiologists to register that something is amiss. This ability to use surveillance as an early warning system sets West Nile apart from other domestic arboviruses.

The best protection against West Nile virus and other arboviral diseases is to fight the mosquito bite. But one thing is sure, according to Dr. Lyle Petersen, the CDC's top West Nile specialist, "where West Nile has been, it stays."

►Bureau Welcomes Epidemiologist

This month the Bureau of Epidemiology welcomed Lilian Kigonya, MD, MPH, who has assumed management of our structured system for surveillance of reportable diseases in Florida. Primary among her responsibilities will be providing consultation and training to CHDs in reportable disease surveillance, conducting special analyses of other surveillance information and serving as a response team member for disease outbreaks or bioterrorism events.

Dr. Kigonya came to us from New York, where she worked for the American Lung Association as a public health specialist developing the first-ever streamlined reporting system for TB in Rockland County. She also managed the transmission of reportable TB data to New York State and conducted analyses of TB morbidity in Rockland County. Prior to that she studied at the Hebrew University of Jerusalem for her MPH, where she conducted research into mortality in women in relation to their childbearing history.

She originally came to the U.S. from Uganda, where she attended Makerere University Medical School, completing her studies in 1997. Following graduation she interned at Mulago National Hospital in pediatrics and obstetrics/gynecology, and also gained experience in chronic and infectious disease management. Later, her desire to be involved in humanitarian efforts led her to an international organization, which assigned her to Central Uganda as a health and nutritional coordinator. From there, her team traveled to Northern Uganda to implement community development projects under wartime conditions and care for internally displaced persons living in camps. As the only doctor on the team, she spearheaded training and supervision of health staff in immunization, control of communicable diseases, sanitation, and prenatal care.

A December 22 injunction that halted the Pentagon's anthrax vaccination program has been lifted by a federal judge, and the military has resumed giving injections to servicemen and women deployed to high risk areas for protection against exposure to anthrax.

Although the FDA had pronounced the vaccinations safe and effective against all forms of anthrax, six uniformed personnel legally challenged the military's authority to require the vaccinations, based on their argument that the drug is investigative only, and unsafe. Over 900,000 military personnel received the vaccine before the legal restraint was ordered.

AVA is the only licensed human anthrax vaccine in the U.S., manufactured by BioPort Corporation of Lansing, Michigan. The culture contains no bacteria. The strain is a toxigenic, nonencapsulated strain. The efficacy was tested in several studies in animals and one controlled trial in humans. A CDC Advisory Committee on Immunization Practices report on the use of anthrax vaccine in the U.S. found that although adverse reactions were noted in trial data, there are no published studies with definitive documented occurrences of chronic diseases following anthrax vaccination. A copy of the report can be found at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4915a1.htm.

Florida influenza-like illness (ILI) activity statewide decreased for the week ending January 3, 2004 (Week 53) compared to the previous weeks. Sixteen counties reported as having high ILI% activity for the week. Nine counties reported an increase in ILI activity during the week ending January 3, twelve counties reported a decrease and five counties remained level. Five 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 11,762 patients seen by the sentinel providers during the week ending December 27, 596 were seen for influenza-like illnesses (an overall state ILI activity of 5.07%). The Florida ILI activity code reported to the Centers for Disease Control and Prevention (CDC) for the week ending January 3, 2004 was widespread. Widespread is defined as an increase in ILI activity in greater than or equal to half of all regions, along with recent laboratory evidence of influenza or recent institutional outbreaks within those regions

Influenza or ILI Outbreaks: Five counties reported outbreaks of influenza or influenza-like illness across the state. The previous week only one county reported any outbreaks.

Pediatric Encephalopathies: Two cases of laboratory confirmed influenza-associated encephalopathy have been reported to the Bureau of Epidemiology since December 21, 2003. Both patients passed away.

Pediatric Deaths: Since December 21, 2003, there have been four laboratory confirmed cases of influenza-associated pediatric deaths in Florida reported to the Bureau of Epidemiology. Two of these were encephalopathy cases previously mentioned.

Notes: Some counties are reporting that school is back in session and so far, there have been no reports of increased absenteeism in those areas. A few counties reported an increase in influenza-like illness (ILI) activity in walk-in clinics and hospitals.

A statewide summary of the county enhanced surveillance reports has been made available on EpiCom.

Seventy-six sentinels from 69 public clinics and private offices submitted reports for 30 counties during the week ending January 3, 2004 (Week 53). Counties with the highest percentage of patients with ILI were Okaloosa (2.06%, with 4 of 5 locations reporting); Walton (2.22%, with 1 of 1 reporting); Marion (2.51%, with 1 of 1 reporting); Pinellas (4.85%, with 6 of 8 reporting); Alachua (5.26%, with 1 of 2 reporting); Broward (5.60%, with 5 of 7 reporting); Osceola (5.88%, with 2 of 2 reporting); Lake (6.77%, with 2 of 2 reporting); Palm Beach (8.04%, with 4 of 5 reporting); Brevard (8.67%, with 3 of 3 reporting); Indian River (9.41%, with 3 of 3 reporting); Orange (11.42%, with 4 of 9 reporting); Polk (12.76%, with 3 of 4 reporting); Monroe (12.81%, with 1 of 1 reporting); Leon (17.04%, with 2 of 2 reporting); Putnam (39.30%, with 2 of 1 reporting). Eight counties reported a low percentage of patients with ILI, and six counties reported no cases of ILI. A breakdown of ILI% reported for week ending January 3, 2004 by county is listed in Table 1

Thirty-five of the 74 specimens received by the Jacksonville Central and Tampa Branch laboratories for influenza isolate testing during the week ending January 3, 2004 (Week 53) were found positive for influenza A. Of these 35 viruses, 27 were found positive for A (H3N2), and 8 were found positive for Influenza A, unknown. These viruses came from Alachua, Brevard, Broward, Dade, Duval, Hillsborough, Indian River, Leon, Monroe, Osceola, Palm Beach, Pinellas, Polk, Putnam, St Johns, and Volusia, counties. Culture testing continues on 5 of the unknown 8 influenza A specimens received during week 53 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 January 10, 2004, the Florida laboratories tested a total of 483 specimens and found 153 positive for influenza A (H3N2) and 55 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.

Reports received from non-sentinel, private hospitals and private laboratories since September 28, 2003 are summarized in Table 3.

This section summarizes the weekly influenza report from the Centers for Disease Control and Prevention. More detailed information can be found at their website

The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) was 6.2% nationwide. This is above the national baseline of 2.5%. The percentage of patient visits for ILI decreased in all nine surveillance regions. On a regional level, the percentage of visits for ILI ranged from 8.3% in the West South Central region to 3.4% in the Mountain 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, 454 influenza A (H3N2) viruses, and five influenza B viruses that were submitted by U.S. laboratories since October 1, 2003. The influenza A (H1) viruses were similar antigentically to the vaccine strain A/New Caledonia/20/99. Of the 454 A (H3N2) viruses characterized, 98 (21.6%) were similar antigenically to the vaccine strain A/Panama/2007/99 (H3N2), and 356 (78.4%) were similar to the drift variant, A/Fujian/411/2002 (H3N2). Four of the influenza B viruses were similar to B/Sichuan/379/99 and one influenza B virus was similar to B/Hong Kong/330/2001.

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, 16,174 (28.0%) of the 57,831 specimens tested for influenza viruses were positive. Three thousand nine hundred twenty-six Influenza A (H3N2) viruses, one Influenza A (H1) virus and 109 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 9.4. This percentage is at the epidemic threshold of 8.0 for the week ending January 03, 2004.

The December 23, 2003 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 14 farms in 4 provinces and 18 additional farms are under surveillance.

WHO influenza updates and reports to date have also included the following items:

For more information about the WHO Communicable Disease Surveillance and Response Updates, please visit their website at http://www.who.int/csr/en/.

FluWatch Report from the Canadian Centre for Infectious Disease Prevention and Control

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.

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/wer7845/en/.

The Bureau of Epidemiology encourages Epi Update readers not only to register with the EpiCom system at https://www.epicomfl.net but to browse EpiCom and to contribute public health observations related to any suspicious or unusual situations or circumstances as appropriate.

►Mosquito-Borne Disease Update

Weekly Update: During the period January 4-10, the following arboviral activity (St. Louis encephalitis [SLE] virus, eastern equine encephalomyelitis [EEE] virus, West Nile [WN] virus and dengue virus) was recorded for Florida:

Human: No arboviral infections were confirmed in Florida residents this week. No counties are under medical alert. In areas with high concentrations of mosquitoes, people are still encouraged to take precautions against mosquito bites, such as wearing mosquito repellent and eliminating stagnant water in birdbaths, ponds and other receptacles in which mosquitoes might breed.

Sentinel Chickens: This week, 931 samples were tested from 12 counties. There were 30 presumptive flavivirus-positives, but no confirmed seroconversions yet.

Wild and Captive Birds**: None this week. For capture counts and historical data, go to http://www.pherec.org/DECS and click on “Arbovirus Ecology” to download the database, then the "Bird Serology" tab.

In summary, to date, none of Florida’s 67 counties have reported confirmed arbovirus activity during 2004.

Disclaimer: Please note that data is subject to change with confirmatory information.

For more surveillance information, please see the DOH web site at: http://www.doh.state.fl.us/Environment/hsee/arbo/index.htm or call the Disease Outbreak Information Hotline which offers updates on medical alert status and surveillance at 888-880-5782.

*Equine cases are determined by the Department of Agriculture and Consumer Services.

**Wild captured bird information is provided by the John A. Mulrennan Public Health Entomology Research and Education Center.


Friday, January 16, 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 1976; 5:29-37 Epi Update Managing Staff: John Agwunobi, MD, MBA, Secretary, Department of Health Landis Crockett, MD, MPH, Director, Division of Disease Control Don Ward, Acting Bureau Chief, Epi Update Managing Editor Jaime Forth, Copy Editor/ Writer		This Week in the News ►January Grand Rounds Topic Will Be Inspiratory Stridor Female students at a Tampa high school presented inhalation problems between January and October 2003. An investigation ensued. ►Pregnancy Risk Assessment Monitoring System (PRAMS) Reports Released The four latest reports in an ongoing series of analyses on risk factors during pregnancy have just been released. Here's information and the Website address where you can preview them. ►FDA Issues Guidance on Xenotransplantation The FDAs Center for Biologics Evaluation and Research has issued information concerning procedures involving human recipients of live cells, tissues or organs from nonhuman animal sources. ►West Nile Virus Here to Stay The virus, which was first observed in this country in New York in 1999, started out small. In subsequent years, however, it has made its way west and numbers continue to climb. ►Bureau Welcomes Epidemiologist Only just arrived from New York, Lillian Kigonya, WBBS, MPH, will coordinate reportable disease surveillance at the Bureau of Epidemiology. We introduce you to our newest staff member. ►Pentagon Resumes Anthrax Vaccination Program A three-month halt on vaccinations has been lifted and soldiers enroute to high risk assignments such as South Korea, Iraq and Afghanistan are again receiving their shots. ►Florida Influenza Surveillance for the Week Ending January 3, 2004 Reports from the nation and around the world for Week 53. ►This Week on EpiCom New influenza cases continue to be reported throughout the state. A new link has been posted to the site. ►Mosquito-Borne Disease Update A report outlining activities for January 4-10, 2004 for confirmed cases.
		*A R T I C L E S*
*David Atrubin, MPH, EIS Fellow, Hillsborough County Health Department, Bureau of Epidemiology* Curt Miller, Statistician, Chronic Disease Surveillance, Bureau of Epidemiology Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology *Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology* *Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology* Angela Fix, MPH, Respiratory Disease Surveillance Epidemiologist, Melissa Covey, Influenza Surveillance Coordinator Pete Garner, Surveillance Systems Manager, Bureau of Epidemiology Caroline Collins, Arbovirus Surveillance Coordinator and Carina Blackmore, DVM, Ph.D., Acting State Public Health Veterinarian, Bureau of Community Environmental Health		►January Grand Rounds Topic Will Be Inspiratory Stridor Bureau of Epidemiology Grand Rounds Program Date: January 27, 2004 Topic: Inspiratory Stridor in Female Students at a High School in Tampa, Florida Presenter: David Atrubin, MPH, Florida EIS Fellow, Hillsborough County Health Department, Bureau of Epidemiology, Florida Department of Health Abstract: Fifteen teenage girls from the same high school reported experiencing an inspiratory stridor (a high pitched, rattling noise coming from the larynx area upon inhalation) during the period of January 1 – October 31, 2003. Nine of these students had onset dates during the last two weeks of September 2003. The results of endoscopy procedures performed on the affected students showed varying degrees of inflammation of the mucosa just above the arytenoids. In addition to the inspiratory stridor, other symptoms experienced by the ill students included shortness of breath or difficulty breathing (especially after physical activity), chest pain, headaches, dizziness, numbness and tingling of the mouth or fingers and anxiety. Of the 15 inspiratory stridor cases, 8 are members of the high school dance team, 5 are members of the high school band and 2 are not affiliated with either organization. The dance team and band members often practice and perform together, and they were all in the vicinity of polyurethane and paint fumes during a band camp held July 21-25, 2003 at the high school. The first inspiratory stridor case, however, precedes these exposures by 6 months, and two of the cases did not attend this band camp. Additional Information: The grand rounds presentation will begin promptly at 11:00 AM, EST on Tuesday, January 27, 2004 PowerPoint slides and the dial-in number will be available on the Bureau of Epidemiology intranet website on Monday, January 26, 2004. CEUs will be provided for nursing. Back to top ►Pregnancy Risk Assessment Monitoring System (PRAMS) Reports Released Four reports in an ongoing series of analyses of the Florida Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2000 and 2001 have just been released and are available on the Bureau of Epidemiology Website at http://www.doh.state.fl.us/disease_ctrl/epi/prams/prams.htm. The first report concerns the use of folic acid among Florida women to help prevent birth defects. The CDC estimates that 50 to 70% of neural tube birth defects could be prevented if all women of child-bearing age consumed 0.4 mg of folic acid each day before pregnancy and during the first month of pregnancy. The second report presents information collected regarding cigarette smoking during pregnancy among Florida women. The third report focuses on domestic abuse during pregnancy, a serious public health concern with implications for both mother and infant. The fourth report deals with low birth weight outcomes among Florida women, a factor which contributes to added medical costs and infant mortality. Back to top ►FDA Issues Guidance on Xenotransplantation Following a series of meetings with numerous working groups, the FDA's Center for Biologics Evaluation and Research has provided a definition of xenotransplantation as "any procedure that involves the transplantation, implantation or infusion into a human recipient of either (a) live cells, tissues, or organs from a nonhuman animal source, or (b) human body fluids, cells, tissues or organs that have had ex vivo contact with live nonhuman animal cells, tissues organs." The organization has also published guidance for public health epidemiologists, veterinarians and other professionals regarding the risks of potential transmission of zoonotic or unrecognized infection from source animals to immunosuppressed recipients, and possibly beyond, to the population at-large. The documents are primarily aimed at minimizing risks including controlling source animal production, providing precautionary measures for clinical trials, archiving and clinical follow-up. Meeting transcripts, documents and other information can be accessed at http://www.fda.gov/cber/xap/xap.htm. Back to top ►West Nile Virus Here to Stay After the first cases of West Nile virus were identified in the U.S. in 1999, it moved steadily westward and is now believed to be headed south, toward Central America and the Caribbean. This particular arbovirus started out small in this country. When Dr. Deborah Asnis, an infectious disease clinician in the borough of Queens spotted two cases of encephalitis and followed-up with a collaborative investigation resulting in the identification of West Nile virus as the cause, it came as a surprise to medical practitioners here in the Western Hemisphere. The flavivirus is endemic in Africa, the Middle East and Asia. But although no one knows for sure how it arrived here, there is no doubt its arrival has reached epidemic proportions. By 2002, 4,100 cases of the virus were identified in the U.S., resulting in 284 deaths. In 2003, the number climbed to 8,900 cases, among which 2,500 were encephalitis. Arboviruses require host bodies in which to thrive, and vectors to spread the infection. Mosquitoes are the primary vectors for West Nile virus and birds are the usual vertebrate hosts. Humans are secondary, though not very efficient, hosts because we rarely develop viral loads in our blood high enough to infect mosquitos. In countries like Africa and Asia where the virus has existed for over 60 years, birds and other animals have built up a resistance to the virus; but in the U.S., immunity has not yet developed in these creatures so the death of wild birds, sentinel chickens and horses is used an early warning system by state health epidemiologists to register that something is amiss. This ability to use surveillance as an early warning system sets West Nile apart from other domestic arboviruses. The best protection against West Nile virus and other arboviral diseases is to fight the mosquito bite. But one thing is sure, according to Dr. Lyle Petersen, the CDC's top West Nile specialist, "where West Nile has been, it stays." Back to top ►Bureau Welcomes Epidemiologist This month the Bureau of Epidemiology welcomed Lilian Kigonya, MD, MPH, who has assumed management of our structured system for surveillance of reportable diseases in Florida. Primary among her responsibilities will be providing consultation and training to CHDs in reportable disease surveillance, conducting special analyses of other surveillance information and serving as a response team member for disease outbreaks or bioterrorism events. Dr. Kigonya came to us from New York, where she worked for the American Lung Association as a public health specialist developing the first-ever streamlined reporting system for TB in Rockland County. She also managed the transmission of reportable TB data to New York State and conducted analyses of TB morbidity in Rockland County. Prior to that she studied at the Hebrew University of Jerusalem for her MPH, where she conducted research into mortality in women in relation to their childbearing history. She originally came to the U.S. from Uganda, where she attended Makerere University Medical School, completing her studies in 1997. Following graduation she interned at Mulago National Hospital in pediatrics and obstetrics/gynecology, and also gained experience in chronic and infectious disease management. Later, her desire to be involved in humanitarian efforts led her to an international organization, which assigned her to Central Uganda as a health and nutritional coordinator. From there, her team traveled to Northern Uganda to implement community development projects under wartime conditions and care for internally displaced persons living in camps. As the only doctor on the team, she spearheaded training and supervision of health staff in immunization, control of communicable diseases, sanitation, and prenatal care. Back to top ►Pentagon Resumes Anthrax Vaccination Program A December 22 injunction that halted the Pentagon's anthrax vaccination program has been lifted by a federal judge, and the military has resumed giving injections to servicemen and women deployed to high risk areas for protection against exposure to anthrax. Although the FDA had pronounced the vaccinations safe and effective against all forms of anthrax, six uniformed personnel legally challenged the military's authority to require the vaccinations, based on their argument that the drug is investigative only, and unsafe. Over 900,000 military personnel received the vaccine before the legal restraint was ordered. AVA is the only licensed human anthrax vaccine in the U.S., manufactured by BioPort Corporation of Lansing, Michigan. The culture contains no bacteria. The strain is a toxigenic, nonencapsulated strain. The efficacy was tested in several studies in animals and one controlled trial in humans. A CDC Advisory Committee on Immunization Practices report on the use of anthrax vaccine in the U.S. found that although adverse reactions were noted in trial data, there are no published studies with definitive documented occurrences of chronic diseases following anthrax vaccination. A copy of the report can be found at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4915a1.htm. Back to top ►Florida Influenza Surveillance for the Week Ending January 3, 2004 Summary Florida influenza-like illness (ILI) activity statewide decreased for the week ending January 3, 2004 (Week 53) compared to the previous weeks. Sixteen counties reported as having high ILI% activity for the week. Nine counties reported an increase in ILI activity during the week ending January 3, twelve counties reported a decrease and five counties remained level. Five 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 11,762 patients seen by the sentinel providers during the week ending December 27, 596 were seen for influenza-like illnesses (an overall state ILI activity of 5.07%). The Florida ILI activity code reported to the Centers for Disease Control and Prevention (CDC) for the week ending January 3, 2004 was widespread. Widespread is defined as an increase in ILI activity in greater than or equal to half of all regions, along with recent laboratory evidence of influenza or recent institutional outbreaks within those regions Enhanced Surveillance for Influenza 2003-2004 Season for Week 53 Influenza or ILI Outbreaks: Five counties reported outbreaks of influenza or influenza-like illness across the state. The previous week only one county reported any outbreaks. Pediatric Encephalopathies: Two cases of laboratory confirmed influenza-associated encephalopathy have been reported to the Bureau of Epidemiology since December 21, 2003. Both patients passed away. Pediatric Deaths: Since December 21, 2003, there have been four laboratory confirmed cases of influenza-associated pediatric deaths in Florida reported to the Bureau of Epidemiology. Two of these were encephalopathy cases previously mentioned. Notes: Some counties are reporting that school is back in session and so far, there have been no reports of increased absenteeism in those areas. A few counties reported an increase in influenza-like illness (ILI) activity in walk-in clinics and hospitals. A statewide summary of the county enhanced surveillance reports has been made available on EpiCom. Influenza-Like Illness (ILI) Florida Summary Seventy-six sentinels from 69 public clinics and private offices submitted reports for 30 counties during the week ending January 3, 2004 (Week 53). Counties with the highest percentage of patients with ILI were Okaloosa (2.06%, with 4 of 5 locations reporting); Walton (2.22%, with 1 of 1 reporting); Marion (2.51%, with 1 of 1 reporting); Pinellas (4.85%, with 6 of 8 reporting); Alachua (5.26%, with 1 of 2 reporting); Broward (5.60%, with 5 of 7 reporting); Osceola (5.88%, with 2 of 2 reporting); Lake (6.77%, with 2 of 2 reporting); Palm Beach (8.04%, with 4 of 5 reporting); Brevard (8.67%, with 3 of 3 reporting); Indian River (9.41%, with 3 of 3 reporting); Orange (11.42%, with 4 of 9 reporting); Polk (12.76%, with 3 of 4 reporting); Monroe (12.81%, with 1 of 1 reporting); Leon (17.04%, with 2 of 2 reporting); Putnam (39.30%, with 2 of 1 reporting). Eight counties reported a low percentage of patients with ILI, and six counties reported no cases of ILI. A breakdown of ILI% reported for week ending January 3, 2004 by county is listed in Table 1 Laboratory Specimen Testing in Florida Thirty-five of the 74 specimens received by the Jacksonville Central and Tampa Branch laboratories for influenza isolate testing during the week ending January 3, 2004 (Week 53) were found positive for influenza A. Of these 35 viruses, 27 were found positive for A (H3N2), and 8 were found positive for Influenza A, unknown. These viruses came from Alachua, Brevard, Broward, Dade, Duval, Hillsborough, Indian River, Leon, Monroe, Osceola, Palm Beach, Pinellas, Polk, Putnam, St Johns, and Volusia, counties. Culture testing continues on 5 of the unknown 8 influenza A specimens received during week 53 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 January 10, 2004, the Florida laboratories tested a total of 483 specimens and found 153 positive for influenza A (H3N2) and 55 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 January 3, 2004 The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) was 6.2% nationwide. This is above the national baseline of 2.5%. The percentage of patient visits for ILI decreased in all nine surveillance regions. On a regional level, the percentage of visits for ILI ranged from 8.3% in the West South Central region to 3.4% in the Mountain 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, 454 influenza A (H3N2) viruses, and five influenza B viruses that were submitted by U.S. laboratories since October 1, 2003. The influenza A (H1) viruses were similar antigentically to the vaccine strain A/New Caledonia/20/99. Of the 454 A (H3N2) viruses characterized, 98 (21.6%) were similar antigenically to the vaccine strain A/Panama/2007/99 (H3N2), and 356 (78.4%) were similar to the drift variant, A/Fujian/411/2002 (H3N2). Four of the influenza B viruses were similar to B/Sichuan/379/99 and one influenza B virus was similar to B/Hong Kong/330/2001. 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, 16,174 (28.0%) of the 57,831 specimens tested for influenza viruses were positive. Three thousand nine hundred twenty-six Influenza A (H3N2) viruses, one Influenza A (H1) virus and 109 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 9.4. This percentage is at the epidemic threshold of 8.0 for the week ending January 03, 2004. International Influenza Activity World Health Organization Communicable Disease Surveillance and Response. WHO reported in its January 7, 2004 Update 6 continued increased in influenza activity associated with A/Fujian/411/2002-like viruses in some countries in central and eastern Europe, sporadic influenza A (H3N2) and B in Algeria and Madagascar, Hong Kong Special Administrative Region of China, Japan and Thailand. Influenza activity declined Belgium, France, Norway, Portugal, Spain and the United Kingdom (western European Countries) and Canada. The December 23, 2003 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 14 farms in 4 provinces and 18 additional farms are under surveillance. WHO influenza updates and reports to date have also included the following items: 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/. 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. An Influenza A (H1) outbreak that had begun in Iceland during early October had ended by mid-November. World Health Organization Communicable Disease Surveillance and Response For more information about the WHO Communicable Disease Surveillance and Response Updates, please visit their website at http://www.who.int/csr/en/. FluWatch Report from the Canadian Centre for Infectious Disease Prevention and Control For more information about the FluWatch report, please visit their website at http://www.hc-sc.gc.ca/pphb-dgspsp/fluwatch/index.html Report from the European Influenza Surveillance Scheme (EISS) 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/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 [Please click here for report including graphs and tables] Back to top ►This Week on EpiCom The reporting of flu and ILI outbreaks via EpiCom is successful and continuing. A link to MRSA material was posted to the Community Acquired MRSA Forum/Topic on EpiCom. The Bureau of Epidemiology encourages Epi Update readers not only to register with the EpiCom system at https://www.epicomfl.net but to browse EpiCom and to contribute public health observations related to any suspicious or unusual situations or circumstances as appropriate. Back to top ►Mosquito-Borne Disease Update Weekly Update: During the period January 4-10, the following arboviral activity (St. Louis encephalitis [SLE] virus, eastern equine encephalomyelitis [EEE] virus, West Nile [WN] virus and dengue virus) was recorded for Florida: Human: No arboviral infections were confirmed in Florida residents this week. No counties are under medical alert. In areas with high concentrations of mosquitoes, people are still encouraged to take precautions against mosquito bites, such as wearing mosquito repellent and eliminating stagnant water in birdbaths, ponds and other receptacles in which mosquitoes might breed. Sentinel Chickens: This week, 931 samples were tested from 12 counties. There were 30 presumptive flavivirus-positives, but no confirmed seroconversions yet. Bird Mortality: One reported positive this week. *Equine and other mammals: None reported positive this week. Wild and Captive Birds: None this week. For capture counts and historical data, go to http://www.pherec.org/DECS and click on “Arbovirus Ecology” to download the database, then the "Bird Serology" tab. Mosquito Pools: None this week. In summary, to date, none of Florida’s 67 counties have reported confirmed arbovirus activity during 2004. Disclaimer: Please note that data is subject to change with confirmatory information. For more surveillance information, please see the DOH web site at: http://www.doh.state.fl.us/Environment/hsee/arbo/index.htm or call the Disease Outbreak Information Hotline which offers updates on medical alert status and surveillance at 888-880-5782. Equine cases are determined by the Department of Agriculture and Consumer Services. Wild captured bird information is provided by the John A. Mulrennan Public Health Entomology Research and Education Center. See the web page for maps and more information: http://www.doh.state.fl.us/Environment/hsee/arbo/index.htm Back to Top*
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