Background
On February 8, 2006, a local physician notified the Office of Epidemiology and Disease Control of the Miami-Dade County Health Department (OEDC) about a suspected Pertussis outbreak among fire fighters. The reporting physician works at the Miami-Dade County Fire Fighter Wellness Center (FFWC). According to the initial report, a total of 32 fire fighters had required clinical services during the last seven weeks due to complaints of cough and/or fever. This center serves a population of approximately 1,500 fire fighters distributed through 48 facilities in Miami-Dade County. Each Miami-Dade County fire fighter might work at different facilities during the course of a week or month. A fire fighter’s regular work shift lasts 24 hours which may be spent in common dormitories within the station. There is a 48-hours resting period between shifts.

Initial single serological reports showing elevated levels of immune globulin G (IgG), M (IgM) and A (IgA) titer for B. Pertussis induced the Wellness Center’s physicians to consider B. Pertussis as the possible etiologic agent of this outbreak.   

Methods
Epidemiological Investigation -
OEDC investigators carried out a field investigation to ascertain the magnitude and etiology of this respiratory outbreak. After contacting the physician and managers of the FFWC to request their authorization to access the patients’ medical records, two investigators from the OEDC reviewed the medical records of all patients with respiratory complaints who visited the facility during the period; 35 additional cases with respiratory symptoms were identified during the course of the investigation. The information retrieved from the medical records included the patients’ age, gender, date of onset, duration, and severity of symptoms, treatment and laboratory results. For the purposes of this outbreak investigation a case was defined as a Miami-Dade County fire fighter complaining of cough and/or fever, accompanied by sore throat, and/or other respiratory symptoms with onset of symptoms not earlier than December 12^th, 2005.  

Laboratory and environmental investigation -
Initial laboratory tests requested by the physicians at FFWC included single serologic testing for B. pertussis, Influenza Rapid Test, and bacterial culture for Pertussis. The OEDC investigators requested additional serologic tests including bacterial culture for Pertussis, respiratory viruses serology (Influenza A, Influenza B, Para-influenza 3, Adenovirus, Mycoplasma pneumoniae, Cytomegalovirus), and respiratory virus isolation (influenza A and B, adenovirus, parainfluenza 1, 2, and 3, and respiratory syncytial virus) through the Florida Department of Health Lab, Miami and Jacksonville branches.    

Results
Epidemiological Investigation -
Twenty-six out of sixty-seven (38.8%) patients with respiratory symptoms met the OEDC case definition for this outbreak. The attack rate among the Miami-Dade fire fighter population was 1.7% (26/1500). The mean age among cases was 38 years old (range 22-51); median age was 37.7. Nineteen cases were males (73.1%) and seven were females (26.9%). Eight (30.8%) of the twenty-six cases that met the case definition reported cough lasting more than two weeks, 15 (57.7%) cough lasting less that two weeks, and 3 (11.5%) had cough of unknown duration. All cases reported fever, defined as at list 100ºF.  The first twenty cases received antibiotic treatment with erythromycin or trimethoprim-sulfamethoxazole. After the first’s positive influenza rapid tests results arrived, the remaining six cases were treated with oseltamivir (Tamiflu). All twenty-six cases fully recovered from this illness; none of them developed clinical complications.  

An Epi-curve was created based on the information retrieved from the medical records of the 26 cases that met the case definition (Fig 1). The index case was a 32 year-old male with onset of symptoms on December 15, 2005. The peak of this outbreak was between 01/31/06 and 02/04/06 (9 cases).

Laboratory -
Specimens from fourteen cases (53.8%) were submitted to the lab to perform B. pertussis/B. parapertussis bacterial culture; three of these specimens could not be processed due to the use of wrong culture medium. All eleven specimens finally tested for B. pertusis/B. parapertussis were negative. PCR was not available at either of the participating laboratories. 

Three (27.3%) of the eleven specimens submitted for influenza rapid test were positive for influenza A. Two cases (33.3%) of the six whose specimens were submitted for respiratory viral serology isolation were positive for Influenza A. No other virus was identified among these cases.  

Discussion and conclusions
A single DFA test for B. Pertussis has low specificity (frequent false positive results) and is not a confirmatory test. The gold standard laboratory test for diagnosis of B. Pertussis is isolation by bacterial culture; Polymerasa chain reaction (PCR) testing of nasopharyngeal swabs is also a recommended technique. Furthermore, a paired convalescent-phase specimen for serological diagnosis of pertussis has good sensitivity and specificity when the acute serum is obtained early on the course of the illness.   

The epidemiological investigation and laboratory results suggest that Influenza A was the agent responsible for this outbreak. Apparently there was an ongoing influenza transmission among the fire fighter population throughout the months of December 2005, January and February 2006; the spread of this disease was facilitated by the frequent deployment of fire fighters at more than one facility during any given week, added to the mixture of staff members from different stations on any working shift.  

Additionally, the OEDC investigators found out that the fire fighters didn’t receive the influenza vaccination this season, making them more vulnerable to this pathogen. 

Finally, preventive measures were recommended, including education in basic personal hygiene, hand washing, and respiratory etiquette, emphasizing the importance of avoiding the transmission of influenza via unprotected coughs and sneezes. A strong recommendation was made regarding the need to provide influenza vaccination to all fire fighters as soon as possible and to take the necessary steps to ensure compliance with the recommended annual influenza vaccination in the future.  

References: 

1.             Heymann, D. Control of Communicable Diseases Manual.  18^th Edition. Washington, DC, American Public Health Association, 2004.

2.             CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2005;54(No. RR-8).

3.             CDC. Interim influenza vaccination recommendations, 2004--05 influenza season.
MMWR 2004;53:923--4.

4.             CDC. Influenza Antiviral Medications: 2005-06 Interim Chemoprophylaxis and Treatment Guidelines. http://www.cdc.gov/flu/han011406.htm

5.             MMWR Recommended antimicrobial agents for Treatment and Postexposure Prophylaxis of Pertussis (2005)

Claudio Micieli, Marie Etienne are staffmembers of the Miami-Dade Health Department, Office of Epidemiology and Disease Control. Fermin Leguen is a senior physician at the Miami-Dade Health Department. Dalisla Sota is on staff at the Metro Dade Fire Fighter's Wellness Center.      

During the past several months, increased attention has been paid to the potential for the emergence of H5N1avian influenza to become a pandemic. For such an event to happen, the avian influenza strain would have to mutate to become easily transmitted from person-to-person.  Such a pandemic did occur in United States in 1917-18 at the end of World War I when H1N1 strain arrived. 

In Florida, the H1N1 cases were first reported at the end of September 1918 and are thought to have been associated with troop movement in and out of Jacksonville. The state population was approximately 1 million persons at the time, and cities like Miami and Orlando had less than 30,000 populations each. Figure 1 shows the reported morbidity in 1918. Overall 13,155 cases were reported in 1918. The peak week was the 4th week of October when 7869 cases were reported. Figure 2 shows the same morbidity curve with the peak week removed to give a better idea of how widespread the disease was. Beginning in early October, schools were closed across the state for 3-4 weeks to curb spread of the disease. 

The mortality of the 1918 pandemic is illustrated in Figures 3 and 4 and are reproduced from the 1918 vital statistics report. Figure 3 shows that the first deaths were reported on September 26 and continued to increase through October. The deaths include both influenza and pneumonia deaths, just as influenza mortality is tracked today. A comparison line shows the 1917 deaths. In 1918, a total of 4114 deaths were attributed to the pandemic influenza with 85 in September, 2712 in October, 934 in November and 383 in December. The highest number of deaths – 145 – was reported on October 17. In 1917, 170 deaths were attributed to influenza and pneumonia- related complications. 

Figure 4 tracks the age distribution of those who died. The mortality is highest in the young, healthy adults who were in their 20s, 30s, and 40s. Young infants, under 1 year of age, also had high mortality with about 5% of the deaths.  

We expect if a similar pandemic were to occur today, there may be high mortality because the US population would not have been exposed to the virus previously. The public health message to be promulgated from this potential scenario is prevention: washing hands, covering coughs, staying home when ill, and using basic disease control measures may do more to affect the outcome of an outbreak than later medical intervention.

Fig. 1

Fig. 2
 

Fig. 3

Fig.4

Joann Schulte is administrator of the Investigations Section in the Bureau of Epidemiology in Tallahassee. She can be reached at 850.245.4444, ext. 4415.

Florida Alliance for Antimicrobial Resistance
Reduction Becomes Reality
by Sonia Clavijo, MD, MPH

 
A statewide group whose mission is to reduce the emergence and spread of antimicrobial resistance in Florida is being formed under the name FLorida Alliance for Antimicrobial Resistance Reduction, or FLAARR. 

Under the leadership of the state Department of Health, Bureau of Epidemiology the alliance will work with agencies and individuals to communicate and facilitate a statewide effort aimed at drastically reducing the rising number of antimicrobial resistance cases seen in Florida today.  

Throughout the world, bacteria and other pathogens are no longer susceptible to first generation antimicrobials, and a growing percentage is developing resistance to the newest drugs. Multidrug resistance is now common in hospitals and communities. Several state health departments have created similar statewide partnerships to address the problem and with the creation of FLAARR, the FDOH is joining their ranks.  

Central to this effort will be alliance members who are willing to meet periodically,  join work groups, and contribute their skills to develop guidelines, conduct health education initiatives, conduct surveillance, share resources, and promote appropriate use of antimicrobials and infection control measures. Anyone interested in serving with this group should contact Sonia Clavijo, MD, MPH, at the Bureau of Epidemiology at FLAARR@doh.state.fl.us.

Sonia Clavijo is statewide coordinator for antimicrobial resistance at the Bureau of Epidemiology in Tallahassee.

Department of Health Welcomes
State Epidemiologist John Middaugh
by Jaime Forth

Dr. John P. Middaugh joined the Department of Health staff in January as Florida's new state epidemiologist, ending the search to replace Dr. Steven Wiersma, who left to accept a post at WHO headquarters in Geneva.

Educated at the University of Wisconsin Medical School, Dr. Middaugh interned at Harborview Medical Center in Seattle in 1972 before taking a year-long sabbatical to perform mission work at an Ethiopian hospital. When he returned to the US, he resumed residency in internal medicine at Case Western Reserve University in Cleveland, Ohio. Afterwards, he enrolled in the CDC's EIS program and was sent to Anchorage, Alaska.

As his CDC commitment ended, he was offered a position as director of a health center in Anchorage. A year later, he launched a career in epidemiology in a state with no counties, no chief epidemiologist, and no direct roads to significant parts of the population. The challenges were many but rewarding. And, for the past 25 years, Dr. Middaugh has served as state epidemiologist and chief of the section of epidemiology in the Alaska Department of Health and Social Services.

Now in Tallahassee, Dr. Middaugh reflects on the science of epidemiology and what makes a good epidemiologist. When asked, he prefers to address the question philosophically. "Epidemiology is more a tool and a method," he says. "Combined with expertise in specific program areas, the more skilled epidemiologist is one who has the ability to collaborate with many others to investigate the causes of illnesses and injuries in populations."

Surveying the work ahead, he's eager to learn about Florida and its inherent challenges. He hasn't experienced a hurricane since he was a child living in the Northeast. And, he's anxious to travel the state and explore. So far, he's seen the Orlando airport and the road that leads to Tallahassee, the city of Perry, Alligator Point south of Tallahassee, and St. George Island on the Gulf. There's much more to learn, see and do.

Jaime Forth is managing editor of Epi Update and can be reached in Tallahassee at 850.245.4444, ext. 2440.


 

Exposed to the Florida Poison Information
Control Network
by Robyn Kay, MPH and Joann Schulte, DO, MPH

The Florida Department of Health (FLDOH) and the Florida Poison Information Control Network (FPICN) collaborated on the first Florida Poison Control Surveillance Report following hurricane Dennis in July 2005. The objectives were to 1) monitor the statewide exposure to various exposure categories 30 days prior to the hurricane’s landfall and days following the hurricane, 2) detect and prevent additional health hazards, and 3) target public health message directly to the county impacted by the hurricane. 

Florida Legislature established the Florida Poison Information Control Information Network in 1989. According to 2005 Florida statute 395.1027, three certified regional centers were established to cover the north, central, and southern regions of Florida. Each center must be associated with a level 1 trauma center and affiliated with an accredited medical school or college of pharmacy.  

Center locations:

Jacksonville: Shands Jacksonville Medical Center/ University Florida Health Science Center and Data Center
Tampa: Tampa General Health Care/ University of South Florida
Miami: Jackson Memorial Hospital/University of Miami 

If the call volume exceeds the capacity of any one center, the system has the ability to rollover the calls to another center.  

The public, healthcare professionals, law enforcement, emergency medical services, schools, and restaurants may call toll free 1-800-222-1222 for information. Each regional center has a director and Specialists in Poison Information (SPIs) available 24/7 for consultation. Each SPI is trained to assess, triage, monitor, follow-up, and manage all poison information and exposures. SPIs may be registered nurses, pharmacists, physicians, or physician assistants. Board certified toxicologists are available for consultation.  

The Centers for Disease Control and Prevention (CDC) and the American Association of Poison Control Centers (AAPCC) use the Toxic Exposure Surveillance System (TESS) to detect potential public health threats (poisonings, biological, or chemical exposures) (1-3). TESS contains a common dataset used by regional poison centers throughout the United States. Florida’s TESS data is maintained by FPICN. However, FPICN collects additional variables such a personal identifiers, case notes, fields specific to long term, and ad-hoc monitoring efforts.  

During the 2005 hurricane season, FLDOH and FPICN monitored the frequency of carbon monoxide, hydrocarbon fuels, batteries, fire/matches/explosives, bite/stings/snakes, contaminated/polluted/sewage water, and food poisoning exposures reported to FPICN.  Graphs were generated daily on the Florida Department of Health secure web-based communication network EpiCom and CDC’s Epi-X. The Florida Department of Health Incident Management Team received daily reports. Local county officials used the information to foster constant awareness of public health hazards before, during, and after the landfall of hurricanes.  

FPICN data are used by FLDOH to monitor exposures to red tide, pesticides, and chemicals. FLDOH and FPICN are currently collaborating on future projects.  

Figures 1 and 2 illustrate the differences in the frequency of exposures between an active and non-active hurricane season. Types of data available from include 1) statewide data, 2) regional data, 3) county data,  4) zip code data (inland versus coastal areas, 5) Individual Case Reports, and 6) Food Poisoning Reports.

Florida Department of Health Headquarters staff members have been extensively trained on the FPICN system. To request FPICN data for your county, please contact the following for the specific exposures:         

Robyn Kay, General Requests
            Andrew Reich, Aquatic Toxins
            Alan Becker, Chemical
            Rosanna Barrett, Pesticides
            Regional Food and Waterborne Epidemiologist, Food and Waterborne Illness        

References:  

1. CDC. Investigation of a Ricin-Containing Envelope at a Postal Facility---South Carolina, 2003. MMWR 2003;52: 1129-1131

2. Watson WA, Litovitz T, Rubin C, Kilbourne E, Belson M, Patel M, Schier J, Funk A. Toxic Exposure Surveillance System In: Syndromic Surveillance: Reports From a national Conference, 2003 MMWR; 53 ( Suppl): 262

3.  Funk A, Schier J, Belson M, Patel M, Rubin C, Watson W, Litovitz T, Kilbourne E. Using the Toxic Exposure Surveillance System to Detect Potential Chemical Terrorism Events. In: Syndromic Surveillance: Reports From a national Conference, 2003 MMWR; 53(Suppl):239.

The authors would like to acknowledge the Florida Poison Control Directors Dr. Jay Schauben-Jacksonville, Dr. Richard Weisman- Miami, and Dr. Vincent Speranza- Tampa for their commitment to public health surveillance.

A special thank you to the Richard Hopkins MD MSPH, Aimee Pragle MS, Carina Blackmore DVM, PhD, Alan Becker PhD, and Roberta Hammond PhD. 

Robyn Kay is an epidemiologist in the Investigations Section of the Bureau of Epidemiology, and works in Duval County. Joann Schulte is administrator of the Investigations Section, headquartered in Tallahassee.

Results from 2005 Florida Youth
Risk Behavior Survey Show Changes
by Melissa Murray, MS and Zhaohui Fan, MD, MPH

The Bureau of Epidemiology is pleased to announce the release of the 2005 Florida Youth Risk Behavior Survey (YRBS) results. The Florida Departments of Education and Health partnered to implement the 2005 YRBS, which was administered in March and April of 2005 to 4,654 students in 75 high schools throughout the state. The overall response rate was 66 percent, which allowed for the data to be weighted and generalize to all Florida public high school students. Data from this survey can provide state and local school health program planners with information needed to provide appropriate educational programs designed to reduce youth risk behaviors and support positive, health-promoting behaviors. 

The YRBS, sponsored by the Centers for Disease Control and Prevention is administered in the spring of odd-numbered years. The YRBS collects anonymous, self-reported data related to risk behaviors from the six categories that have been determined to have the most detrimental effect on children and adolescents. The risk behavior categories include:  physical inactivity, poor nutrition, risky sexual behaviors, alcohol and other drug use, tobacco use, and unintentional injuries and violence.   

Findings from the YRBS show significant decreases from 2001 to 2005 in the areas of injury and violence related behaviors and activities. Specifically, the percentage of students who:

• never or rarely wore a seatbelt when riding in a car driven by someone else decreased from 15.6 percent to 12.5 percent;
• rode in a vehicle driven by someone who had been drinking alcohol in the past month decreased from 31.5 percent to 27.2 percent;
• drove a vehicle when they had been drinking in the past month decreased from 12.9 percent to 10.2 percent;
• did not go to school because they felt unsafe on their way to or from school decreased from 14.0 percent to 7.8 percent;
• were threatened or injured with a weapon on school property in the past 12 months decreased from 9.2 percent to 7.9 percent; and,
• were in one or more physical fights during the past 12 months decreased from 32.8 percent to 30.0 percent.

The results of the 2005 YRBS will be posted to the Bureau of Epidemiology’s website at http://www.doh.state.fl.us/disease_ctrl/epi/Chronic_Disease/YRBS/Intro.htm. If you would like to submit a request for YRBS data, please use the data request form on this website or contact Zhaohui Fan at 850.245.4444 extension 2418. 

Melissa Murray is the BRFSS coordinator and Zhaohui Fan is a chronic disease epidemiologist within the Chronic Disease Surveillance Section of the Bureau of Epidemiology.