| 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
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
Grand Rounds Topic Will Be Inspiratory Stridor
|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
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
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.
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.
Meeting transcripts, documents and other information can be accessed at http://www.fda.gov/cber/xap/xap.htm.
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."
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.
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
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 ActivityWorld 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:
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
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]
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
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.
*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