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Steven
Wiersma, MD, MPH, State Epidemiologist and Chief, Bureau of Epidemiology
Alan Rowan, PhD, MPA,
Program Manager, Florida Epidemic Intelligence Service
Christine S.
Cook,
R.N., B.S.N., M.S.H., Government Operations Consultant II,
Duval County Health Dept
Natalie Tackett,
Bureau of Epidemiology
Submitted by:
Carina Blackmore, M.S.
Vet. Med., Ph.D., Bureau of Epidemiology
Carina Blackmore, M.S.
Vet. Med., Ph.D., Bureau of Epidemiology
Don Ward, Deputy Chief, Bureau of Epidemiology
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►Dr.
Blackmore Appointed as Acting Public Health Veterinarian
I have
appointed Dr. Carina Blackmore as Acting, State Public Health Veterinarian
effective immediately. Please
refer any issues that Dr. Lisa Conti would have covered directly to Dr.
Blackmore. Dr. Blackmore will
assume all of the responsibilities previously held by Dr. Lisa Conti prior
to her move to the Division of Environmental Health.
Dr. Carina Blackmore received her veterinarian training at the Swedish
University of Agricultural Sciences in Uppsala and graduated in 1989.
She practiced large and small animal veterinary medicine until
1991. She studied biological
science at Notre Dame and graduated with a PhD in vector biology in 1996.
Her research was on the epidemiology of bunyaviruses in Indiana. She taught biology, anatomy and physiology for two years at
Valdosta State University in Valdosta, Georgia, before joining the Bureau
of Epidemiology in 1998 as a Regional Epidemiologist based in
Jacksonville. Dr. Blackmore
was previously the acting State
Public Health Veterinarian during the first year of Florida’s WN
virus epidemic, in 2001. As
Regional Epidemiologist she provides consultation to County Health
Departments, primarily in NE Florida.
She also serves as the influenza surveillance coordinator, and has had important roles in outbreak response throughout the
state.
Please join me in congratulating Carina for accepting these new challenges
and in accomplishing her additional duties and in wishing Lisa the best in
her new position.
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►Recruitment
Open for Florida Epidemic Intelligence Service (FL-EIS) Class of 2003
The Florida-EIS, headquartered at the Florida Department of Health in
Tallahassee, is a unique, two-year, post-graduate applied epidemiology
program for health professionals under the direction of the Bureau of
Epidemiology. It will recruit and train epidemiologists to assist county
health departments in identifying and resolving disease outbreaks and to
become leaders in the field of public health. The long-term goal of this
program is to increase the capacity of the Department of Health to respond
to new challenges in disease control and prevention.
The Bureau of Epidemiology will provide salary and didactic training and
participants will be matched with qualifying county health departments to
spend their time working along with trained epidemiologists and public
health professionals. There will be 6 openings for graduates of MPH
programs and others who demonstrate similar skills and backgrounds. This
program will provide a practical field epidemiology training program for
successfully matched candidates. This program is modeled on the federal
Centers for Disease Control and Prevention (CDC) EIS program and the
California EIS program. The Bureau of Epidemiology has a long history of
training CDC EIS officers who have gone on to hold senior positions in
public health and other areas.
Participants will serve on the front line working side by side with local,
state and federal investigators to:
- Conduct
epidemiologic investigations, research, and public health
surveillance;
- Present
epidemiologic papers at scientific and medical conferences;
- Publish
their work in the scientific literature;
- Disseminate
vital public health information to the media and the public
- Florida
EIS assignees have unique opportunities to apply training and skills
to actual public health problems and issues;
- Establish
mentorships with recognized experts from around the world;
- Attend
training courses in computers, biostatistics and epidemiology. .
Eligibility
criteria
Health professionals who meet one of the following qualifications and have
a strong interest in applied epidemiology are eligible to apply to the
Florida EIS:
- Persons
with a master's or doctoral degree in a health related field (e.g.
MPH, PhD, DrPH) having taken at least one course in epidemiology and
one course in (bio)statistics during graduate/professional school or
persons with significant experience working in public health.
- Physicians
(MDs, DOs) with at least one year of clinical training and an active
medical license in the U.S. (U.S. citizens or permanent residents).
- Doctoral-degree
recipients (PhDs, DrPHs, or equivalent) in health-related fields such
as epidemiology, biostatistics, and the social behavioral, and
nutritional sciences.
- Nurses,
dentists, and PharmDs, with a Master of Public Health (MPH) or
equivalent degree and an active license in the U.S. (U.S. citizens or
permanent residents).
- Veterinarians
with a Master of Public Health (MPH) or equivalent degree or
demonstrated public health experience or course work, and an active
license in the U.S. (U.S. citizens or permanent residents).
Stipends
Each trainee will receive a salary and benefits of approximately mid-$30K
to mid-$40K per annum depending on experience.
How
to apply:
Requirements
- Curriculum
vitae in standard format
- Personal
statement
- Three
references
- Transcripts
from highest degree granting programs
- Copy
of U.S. clinical license (if applicable)
- Interviews
in Tallahassee (offered to a limited number of applicants by
invitation after prescreening of above materials.)
Application
timetable
- March
28, 2003: Application for 2003 class
- April
22 – 25, 2003: Orientation
- May
19, 2003: Assignments begin
Mail
application requirements to:
Florida Department of Health
4052
Bald Cypress Way, Bin #A-12
Prather
Building, Room 320
Tallahassee,
Florida 32399-1720
If
you have questions about the program contact Dr. Alan Rowan at (850)
245-4444 Ext. 2442 or by e-mail to Alan_Rowan@doh.state.fl.us.
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►Empyema
Investigation Summary
DCHD Epidemiology Division
January 31, 2003
Background
On Wednesday, January 15, 2003, the Epidemiology Division received a
telephone call from the Chief of Pediatric Infectious Diseases at a
Northeast Florida hospital, expressing concern regarding an unusually
large number of children presenting with complicated pneumonia/empyema.
Reportedly, physicians at this hospital see approximately one case
of pediatric thoracic empyema per month.
During the previous four weeks (range 12/10/02 – 01/15/03), seven
children were hospitalized and treated for complicated pneumonia with
pleural effusions, six of who were treated for empyema under the care of
different physicians. Empyema is a collection of pus in the pleural cavity (lining
of the lung). Most often,
empyema is caused by Streptococcus pneumoniae, Haemophilus influenza or
Staphylococcus aureus. A VATS
(video-assisted thoracic surgery) procedure is performed to remove the pus
and damaged tissue, thus enabling the child to breathe better.
The case definition for inclusion into the investigation included
all children with a diagnosis of complicated pneumonia with pleural
effusions on x-ray.
Methods
Between Friday, January 17 and Tuesday, January 28, 2003, Epidemiology
staff reviewed the medical records using the standard case report form
with extra emphasis on lab results and treatment.
The record review process was lengthy, because two of the medical
records were off site and had to be ordered.
When possible, parents of ill children were also personally
interviewed by Epidemiology Division staff.
A database specific to empyema was created using Epi Info 2002, a
statistical software program from the CDC. The collected data was entered into the database and
analyzed. Surveillance for
empyema was expanded to include other large hospitals in the state with
pediatric clientele.
Findings
Enhanced surveillance:
No other clusters of empyema were identified in the state during the
period of interest.
Data analyses:
Data analyses did not identify any links between cases.
Specific results are as follows:
Demographics: Infected
children ranged in age from 2 – 15 years.
Gender breakdown consisted of four males and three females.
Racial breakdown was six white children / one black child.
No children resided in the same zip code or attended the same
school/daycare. Only two of
seven children had a history of daycare attendance.
One of seven children attended school.
Household size ranged from three to five members.
Two of seven children resided in households with a smoker.
Two out of seven children had pets.
One of seven children had a history of immunosuppression.
Two of seven children had history of travel outside of Northeast
Florida in the month prior to illness onset.
One child had a history of airline travel to Michigan.
The second child had a history of travel to Orlando, FL to vacation
at multiple theme parks.
Clinical/Laboratory data: Three
of seven children presented with sore throat prior to onset of pneumonia.
All children were admitted to the hospital between
12/10/2002-01/15/2003 with a diagnosis of pneumonia.
Most children were started on antibiotics prior to the collection
of laboratory cultures. Common antibiotic therapy (six out of seven children)
included Rocephin and Vancomycin. As
a result, most cultures resulted in no growths.
Two children had laboratory tests indicative of Group A
beta-hemolytic streptococcus. One
child was recovering from scarlet fever at the time of pneumonia onset. She had a Quick Strep Ag (+).
Another child had a throat culture with a heavy growth of Group A
Beta-Hemolytic Streptococcus. Gram-positive
cocci were seen on initial examination of lung tissue from these two
patients, but the cultures failed to grow out. Six
out of seven children were diagnosed with empyema, resulting in a VATS
procedure. Two children
required multiple VATS procedures. Interestingly,
each child presented with low hemoglobin <11 (normal range 14
– 17 depending on age) at some point during hospitalization.
Two children required blood transfusions.
| Pt # |
Age
(yrs) |
Gender |
VATS
procedure |
(+)Strep
Test |
Lowest
Hemoglobin
|
History
of Immunosuppression |
| 1 |
2 |
Male |
Yes |
Not done |
10.1 |
No |
| 2 |
4 |
Male |
Yes |
Yes |
6.7 |
No |
| 3 |
15 |
Male |
Yes |
Not done |
11.0 |
No |
| 4 |
5 |
Female |
Yes |
Yes |
10.0 |
No |
| 5 |
2 |
Male |
Yes |
Not done |
8.4 |
No |
| 6 |
6 |
Female |
No |
Not done |
11.0 |
Yes |
| 7 |
4 |
Female |
Yes |
Not done |
6.1 |
No |
| Mean |
5.4 |
|
|
|
9.0 |
|
Discussion
Due to the small number of cases and lack of laboratory evidence, no
link or common agent could be identified.
Enhanced surveillance will remain in effect for two months.
Additional Reading
Byington, CL, Spencer, LY, Johnson, TA, Pavia, AT, et al.
An epidemiological investigation of a sustained high rate of
pediatric parapneumonic empyema: risk factors and microbiological
associations. Clin Infect Dis
2002 Feb 15:34(4):434-40.
Cohen, G, Hjortdal, V, Ricci, M, Jaffe, A, Wallis, C, et al.
Primary thoracoscopic treatment of empyema in children.
J Thorac Cardiovas Surf 2003 Jan;125(1):79-84.
Lewis, RA, Feigin, RD. Current
issues in the diagnosis and management of pediatric empyema.
Semin Pediatr Infect Dis 2002 Oct;13(4):280-8.
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►Florida
Youth Survey Trainings Held This Week
Trainings for the upcoming 2003 Florida Youth Survey (FYS) were held
February 24th and 25th in Orlando and Tallahassee
respectively. FYS
Coordinators from 34 of the 41 selected counties were represented.
This will be the 6th annual survey administration, which
began with the Florida Youth Tobacco Survey (FYTS) in 1998.
The 2003 FYS will include four survey instruments: the FYTS, the
Communities that Care/Florida Youth Substance Abuse Survey (CTC/FYSAS),
the Youth Risk Behavior Survey (YRBS), which is administered to High
School students only, and the newest addition to the survey effort, the
Youth Physical Activity and Nutrition (YPAN) survey, which will be
administered only in Middle Schools.
The 2003 survey window for complete administration is scheduled for March
17-April 30. While data
collection will be for state-wide numbers and not county-level data this
year, the project is a considerable undertaking. County coordinators were given instruction in the tedious
administration process and will begin contacting their selected schools
over the next two weeks.
For more information regarding the FYS 2003, please contact Natalie
Tackett at 850/245-4444 x2440 or natalie_tackett@doh.state.fl.us.
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►Avian
Influenza Confirmed in Hong Kong Residents
Two human cases of influenza A (H5N1)
infection have been confirmed in a single family of Hong Kong residents
who recently traveled to Fujian Province on mainland China. The first
patient, a 9-year-old boy, was hospitalized in Hong Kong but is
recovering. The second patient, the father of the 9-year-old boy, died in
a Hong Kong hospital on February 17. Additional family members had
respiratory symptoms, and the boy's 8-year-old sister died while the
family was in China. The cause of her death and of the other respiratory
illnesses in her family is not known.
There is currently insufficient information to determine whether this
family was infected from a common source or whether illness spread within
the family from person to person. The Department of Health in Hong Kong
SAR has intensified its surveillance for influenza among patients with
influenza-like illness or atypical pneumonia. At present, levels of
influenza activity in Hong Kong SAR are not unusual. In addition, there is
currently no evidence of spread of influenza A (H5N1) infection from this
family to contacts in China or Hong Kong or to their medical attendants.
For more information, visit the Hong
Kong Department of Health Web site (http://www.info.gov.hk/dh/new/bulletin/bullet.htm).
This is the first time since 1997 that human influenza A (H5N1) cases have
been identified anywhere in the world. During the 1997 outbreak in Hong
Kong, 18 people with influenza A(H5N1) infection were hospitalized and six
of these patients died. Prior to 1997, influenza A (H5N1) had been found
only in birds. During the 1997 outbreak in Hong Kong, transmission of the
virus to people occurred primarily from direct contact with birds.
Efficient, sustained transmission of the virus from person to person did
not occur. Approximately 1.4 million chickens were destroyed in Hong Kong
to remove the source of the virus. No further human cases of influenza A
(H5N1)-related illness had been documented until February 2003, although
H5N1 has periodically been detected in chickens and ducks, and more
recently, in wild birds in Hong Kong. Additional information about the
1997 A (H5N1) outbreak can be found on the CDC website at
Update:
Isolation of Avian Influenza A(H5N1) Viruses from Humans -- Hong Kong,
1997-1998 MMWR 46(52);1245-1247
and
Isolation
of Avian Influenza A(H5N1) Viruses from Humans -- Hong Kong, May-December
1997 MMWR 46(50);1204-1207.
CDC is in communication with the World
Health Organization (WHO) regarding these human cases of influenza A
(H5N1) illness and will continue to monitor the situation. There is no
indication that the virus has spread outside Asia. CDC and WHO have issued
no restrictions on travel or trade to Hong Kong or China. Influenza
activity in the United States is at moderate to high levels. Influenza A
(H1N1), A (H1N2), A (H3N2), and influenza B viruses have been identified
in the United States and all are well matched by the 2002-03 influenza
vaccine. The current vaccine does not protect against infection with
influenza A (H5N1) virus. U.S. residents who are traveling outside the
United States should consult their physician for advice about whether they
should be vaccinated against influenza and about the use of influenza
antiviral medications.
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►
Influenza Virus Surveillance Summary Update
Week ending February 15, 2003-Week 7
Florida:
During week 7 (February 9-15, 2003) influenza activity, calculated based
on the proportion of patients with influenza-like illness (ILI) seeking
care by physicians participating in the Florida Sentinel Physicians
Surveillance Network was 3.2%. This is the highest influenza activity
reported so far this season and also higher than the national baseline of
1.9%. Higher flu activity than expected for this time of year
(>2%) was reported by physicians in Alachua, Brevard, Duval, Indian
River, Leon, Levy, Okaloosa, Palm Beach and Polk counties. The influenza
activity is wide spread. During the last three weeks over 65 laboratory
confirmed influenza cases (primarily influenza A (H1N1) and influenza B)
were reported from 15 counties across the state. This week influenza A
H1N1 viruses were reported from Duval, Indian River and Madison counties,
influenza A of unknown subtype from Duval and Pinellas counties and
influenza B from Duval, Indian River and Leon counties.
National report: Four hundred
fifty one isolates (207 influenza A and 244 influenza B viruses)
were made from 2,527 specimens tested by the World Health Organization
(WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS)
collaborating laboratories this week. Since September 29, 7.9%
(n=3,830) of the 42,652 specimens tested nationwide have been positive.
Four hundred and eighty two (33%) of the 1,442 influenza A viruses have
been subtyped; 409 were influenza A H1 viruses and 73 were influenza A
(H3N2). Laboratory confirmed influenza has been reported from all 50
states. The majority of influenza B isolates (52%; n=1,247) were
identified in Texas and Missouri. Influenza A viruses were reported more
frequently than influenza B viruses (range 56%-86%) in the Mountain, East
North Central, Pacific, and Mid-Atlantic regions. Influenza B were
reported more frequently in the South Atlantic, West South Central and
East South Central regions. CDC has characterized 45 influenza A (H1N1),
19 influenza A (H1N2), 28 influenza A (H3N2) and 86 influenza B isolates
antigenically. All influenza A strains were similar to corresponding
vaccine strains. One influenza B strain was more similar to
B/Shizuoka/15/01 than to the vaccine strain (B/Hong Kong/ 330/01). The
proportion of patient visits to sentinel physicians for influenza-like
illness (ILI) was 3.0% nationwide. The State and Territorial
Epidemiologists in eleven states (Colorado, Indiana, Iowa, Kansas,
Missouri, North Carolina, Rhode Island, Tennessee, Texas Utah, Virginia
and Wisconsin) reported widespread influenza activity. Flu outbreaks were
reported in 23 additional states. Thirteen states reported sporadic
influenza activity. The proportion of deaths attributed to pneumonia and
influenza as reported by the vital statistics offices of 122 U.S. cities
was 7.3% during week 7. This percentage is below the epidemic threshold of
8.3% for this time.
An avian flu virus strain, influenza A H5N1, has been recovered from two
influenza cases in Hong Kong. CDC has issued recommendations on increased
influenza surveillance in the United States. Of particular importance is
to consider influenza cultures on patients, with recent travel histories
to Asia, who are hospitalized with unexplained pneumonia, acute
respiratory distress syndrome or severe respiratory illness.
For additional information on influenza and influenza surveillance
results, please visit our website at http://www.doh.state.fl.us/disease_ctrl/epi/htopics/flu/index.htm
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►Bureau
of Epidemiology to Host CHD Conference Calls
Beginning
on Friday, March 21, and on alternating Fridays thereafter, the Bureau of
Epidemiology will host a scheduled conference call with county health
department staff. The purpose
of the call is to update CHD staff on
Bureau activities and to discuss issues of mutual interest.
Each week’s agenda will be determined by input from the CHDs and
Bureau staff. While the majority of agenda topics will probably be
directed to surveillance and investigations, any other CHD/Epi topics are
appropriate. Any CHD staff
are welcome to participate and staff conducting disease control activities
are encouraged to attend. The
calls will use the technology employed in the Bureau’s Grand Rounds,
that is, any presentation material will be posted on the intranet the day
before the call. The bi-weekly “epi-calls” will begin at 10AM and last
no longer than an hour. The
number for the call is (850)
487-8587 or Suncom 277-8587. Please
e-mail suggestions for agenda items to Don Ward at donald_ward@doh.state.fl.us.
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►
Weekly Disease Table
: Week 8
Florida Department of
Health, Bureau of Epidemiology
Weekly Morbidity Report, Week 8, ending
February 22, 2003
Selected Diseases and Conditions (Confirmed Cases Only)
www.doh.state.fl.us/disease_ctrl/epi/Disease%20Table/2003_weekly/diseasetable.htm
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