Friday, April 9, 2004

         This Week in the News

Foege, WH., et al., 
International Journal of Epidemiology
1976; 5:29-37

A R T I C L E S

Background. On March 27, 2004, a ten-year old male visiting Southwest Florida with his parents was taken to a local emergency room with complaint of fever, malaise, nausea and headache. As part of the workup a blood culture was taken, an injection of 1.5 gms of Rocephin was given, and the child was sent home for observation pending laboratory results or a change in symptoms. 

Before the final laboratory report was known, the ten-year old and his family boarded an aircraft to return home to Indiana. Shortly after the family boarded the aircraft, the health department received a phone call from the local hospital with a final report that was positive for Neisseria meningitides. 

Methods. Acting on the premise that it was imperative to locate the family for medical intervention, the Lee County Health Department epidemiology staff contacted the Airport Operations Center (OPS) for assistance in identifying the airline and flight number. They knew only the family name and their Indiana address.  Based on inquiries, the health department staff believed the family left the Southwest Florida International Jetport at about 0900 hrs. Airport OPS investigators felt that the family could have a destination of either Chicago or Indianapolis, based on the fact that the two jetports are within 150 miles of the family?s residence. 

The Department of Health was notified and in turn the Center for Disease Control and Prevention, Division of Global Migration and Quarantine. Since the flight was less than eight hours duration the passengers and crew were not in danger, unless the child became unstable during the flight resulting in emergency contact by flight crew (ex. CPR). 

It was eventually ascertained that the family had not departed Southwest International jetport after all, but had taken a flight from St. Petersburg to Indianapolis. The airline medical operation center was notified and advised of the situation. Again, because of the flight duration (less than eight hours) there was no need to obtain a passenger list. 

A break came in the investigation at about 1300 hours when, during the flight, the child produced a high fever with head and neck pain, along with a petechial rash, resulting in the mother calling the hospital in Lee County, who directed her to call the Lee County Health Department epidemiology office. 

The mother was instructed to immediately take the child to the nearest hospital emergency room and have the physician call the Lee County CHD. After talking to the Indiana hospital, confirmatory lab results were faxed to the attending physician. The child was admitted for treatment. 

The child?s mother was then interviewed telephonically by an epidemiologist at the Lee County CHD. She revealed that the family vacation included a total of three families (13 individual, including several children) who also boarded flights home the same day. A list of contacts was taken and health officials we were able to contact every family.  

Results. By 1800 hours the same day, each contact had received prophylaxis either through the local emergency room or their private physician. Working in concert with local, state, and federal agencies this child received medical care and all contacts received prophylaxis, all within nine hours of the CHD receiving notification of a positive laboratory report for N. Meningitides.
 

According to data from the Florida Pregnancy Risk Assessment Monitoring System (PRAMS) survey for 2000 and 2001, overall, over half (50.5%) of new mothers placed their infants on their backs to sleep, in contrast to 23.2%  who placed their newborns on their sides to sleep, and 18.9% who placed their babies on their stomachs to sleep. 

The prevalence of placing infants on their backs to sleep among women in Florida was: 

• Higher among both Hispanic women (58.2%) and non-Hispanic white women (43.9%) than among non-Hispanic black women (29.6%).
• Increasing by maternal age: 37.7% among women aged 19 years and under , 42.5% among those aged 20 to 24 years, 52.5% among women between the ages 25 and 34 years, and 54.6% among those aged 35 years and over.
• The highest among women with more than a high school education (56.0%); 45.2% among those with a high school education; 37.1% among those with less than a high school education.Increasing by annual household incomes:
•  39.6% among women with household incomes of $15,600 and under; 51.3% among women with household incomes between $15,601 and $39,600; 59.3% among those with household incomes over $39,600.

• Higher among non-Medicaid recipients (54.2%) than among Medicaid recipients (40.1%).
• Higher among married women (53.0%) than among those who non-married women (40.9%).
• Higher among normal weight births (49.0%) than among low birth weight births (41.9%).
• Higher among full-term births (49.3%) than among pre-term births (40.7%).
• Higher among women with intended pregnancies (51.3%) than among those with unintended pregnancies (45.9%).
• Lower among infants who spent time in a neonatal intensive care unit (41.3%) than among those who spent no time in a neonatal intensive care unit (50.1%).

This study shows that women in Florida who have the highest prevalence of placing their newborns on their backs to sleep are Hispanic or non-Hispanic white, are 20 years of age and older, have higher levels of education or income, are non-Medicaid recipients, are married, have normal weight infants, have full-term pregnancies, have intended pregnancies, or have infants who spend no time in a neonatal intensive care unit.  These findings may assist health providers and program planners in Florida in providing effective information for increasing the prevalence of infant back sleep position. 

The Florida Pregnancy Risk Assessment Monitoring System is a random survey of recent mothers of live-born infants. It is designed to monitor the physical, economic, and social health of Florida mothers and newborns. PRAMS data are ?weighted? so that the resulting estimates can be generalized to the entire state population. PRAMS data from 2000 and 2001 were combined to increase sample size and precision of estimates for this study.
Florida PRAMS is supported by grant number U50/CCU407145 from the Centers for Disease Control and Prevention.

There will be two new activities added to the program this year. The evening of May 17^th there will be a dessert reception and the opportunity to pre-register for the first day, as well as a ?County Showcase? which will provide county health departments the opportunity to bring educational resources they have developed for healthcare professionals, and share them with other county health departments. These items will be on display throughout the seminar. If your county would like to participate, please contact Melanie Black. 

The poster session and reception will be held the evening of May 18^th.  The event will be judged again this year, with awards given for the best infectious disease poster, as well as for the best presentation by a Florida EIS fellow, the best chronic disease poster and, finally, the best county health department display. The winners will be announced at the following day?s luncheon. Another added feature to this year's program will be the ?Golden Partnership? awards, presented to partners which have made significant contributions supporting disease surveillance and epidemiology.

To take advantage of the special group rate ($71.00), be sure to make your hotel reservations early. Call the Marriott directly at 407.995.1100 or through their reservation line at 800.228-9290. Refer the booking agent to the Florida Department of Health, Bureau of Epidemiology Seminar to receive the group rate. You can also reserve accommodations through the hotel website at www.marriott.com/MCOML. Click on the red button labeled Reserve a Room, enter the dates, and then scroll down to the box labeled ?Group Code.? Enter FBEFBEA to receive the group rate and follow the instructions to complete the arrangement. 

Further information can be found on the Bureau of Epidemiology Internet website http://www.doh.state.fl.us/disease_ctrl/epi/conf/training.html, or contact Melanie Black at the Bureau of Epidemiology in Tallahassee at 850.245.4444, ext. 2448.
 

Methods:
The St.JCHD Environmental Health Division, Epidemiology and Nursing Program and the regional environmental epidemiologist (Bureau of Community Environmental Health) began an epidemiological investigation on Wednesday February 25, 2004. The Florida Department of Business and Professional Regulation conducted an inspection of the restaurant on February 26. Questionnaires were prepared for both groups and were administered by telephone. Stool samples were collected from ill attendees of the Cub Scout meeting as well as restaurant employees who had been ill with gastroenteritis. 

Statistical analysis of the data obtained from the interviews was conducted using Epi Info version 6. A case was defined as any attendee of the two meetings or any restaurant employee experiencing three or more episodes of vomiting and/or diarrhea and/or any three of the following symptoms: nausea, low-grade fever, cramps, headache, chills or fatigue between February 22-25. 

Results:
There were 102 interviews completed for the Cub Scout group, 55 of which were patient cases. There were 35 interviews completed for the soccer group, 17 of which were patient cases. Of the restaurant employees, six reported illness and four were classed as patient cases. The incubation periods for the Cub Scout group ranged from 3-72 hours with an average incubation of 33.7 hours. Incubation periods for the soccer club ranged from 2-44 hours with an average of 30.6 hours. With the two groups combined, the average incubation period was 32.1 hours. The primary onset date of illness for both groups was Tuesday, February 24 (See Figure 1). The duration of illness for both groups ranged from 1-6 days with an average of two days. Onsets of illness for the four ill employees were: (1) 7:00 a.m. on Monday, February 23, (2) 9:00 p.m. Monday, February 23, (3) 4:00 a.m. on Wednesday, February 24 and (4) Thursday February 25. Primary symptoms in the employees were nausea, diarrhea, vomiting and fatigue (See Tables 1-2).  

Nineteen enteric stools and 16 viral stools were collected for analysis. All enteric results were negative for bacterial pathogens. Twelve of the 16 viral samples were positive for Norovirus G2. Of these 12 positives, three were from restaurant employees. 

Statistical analysis results implicated consumption of the salad as the having the highest significant risk for illness (See Table 3). Consumption of the house dressing also had a risk association, but of a much less degree, and may be a result of confounding where those eating salad were also likely to have dressing.  

The inspection and epidemiological assessment at the restaurant found that several food workers in the facility had also become ill with gastroenteritis. The onset of the first ill person associated with this outbreak and who was positive for Norovirus G2, began at 7:00 a.m. on Monday, February 23. This person was a food worker in the restaurant who washed and cut the lettuce used for the salads on Sunday, February 22. The lettuce was initially stored in three 22 quart buckets. Each bucket was to be used specifically for salads in the restaurant dining room, banquet building or for catered meals. The three buckets of lettuce prepared by this pre-symptomatic infected person that day were, however, commingled into one large chill box that was used for salads in all three locations. 

Conclusions:
The investigation determined that this was an outbreak of foodborne Norovirus gastroenteritis. The implicated food was the lettuce used for salads on Sunday, February 22. The statistical analysis indicated that persons eating the salad were 16.75 times more at risk of becoming ill then those who did not consume any salad. The source of the pathogenic virus was a pre-symptomatic food worker who handled the lettuce Sunday evening, became symptomatic early the next morning and was positive for Norovirus G2. Twelve of 16 stool samples analyzed were positive for Norovirus G2. Nine positives were from attendees of the Cub Scout meeting and three were from food workers. 

Recommendations:
Norovirus is an enteric virus of human origin. It is shed in human feces during infection in high numbers and can continue to be shed up to 22 days after symptoms have ceased. It is highly infective even at doses as low as 10 viral particles. Fecal contamination of hands after toilet use and subsequent lack of handwashing or inadequate handwashing can spread viral particles to foods, surfaces, and to other persons. 

Ready-to-eat foods such as lettuce for salads that are touched by infected food handlers without subsequent cooking are very susceptible to contamination by Noroviruses. The viral particles are durable in these foods and cause infection in persons ingesting the contaminated items. 

Proper hand washing after toilet use is the best method for preventing food borne Norovirus infection. Handwashing is especially critical prior to preparation of foods. Persons who have been ill with gastrointestinal symptoms must not handle foods at all during illness and must be restricted from food handling for at least 72-96 hours after cessation of symptoms.
[Click here for article with tables and graphs]
 

►CDC Provides Funding to Implement HIV Incidence Surveillance 

The Bureau of HIV/AIDS has been funded by CDC to develop and implement HIV Incidence Surveillance. The development of this surveillance initiative has been driven by a need to determine national, state and local HIV incidence rates and provide data that will accurately characterize current HIV transmission. In the past, biomedical technology did not distinguish between recent and chronic HIV infection. Therefore, HIV surveillance has been limited to monitoring prevalence, the number of individuals with HIV at any given time. The incidence of HIV infection, the number of new infections occurring within a given time period, has not been measured. However, new serologic testing methods may distinguish between recent and long-standing HIV-1 infection, and these methods should allow the determination of HIV incidence estimates. The most studied of these methods is Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS).   

HIV Incidence Surveillance will be implemented throughout Florida. During the first year, all HIV testing sites (County Health Department (CHD) and non-CHD) that use the state laboratory will be included. In subsequent years, HIV Incidence Surveillance will be expanded to include testing facilities that use commercial laboratories. The STARHS method will be applied to remnant diagnostic specimens (blood only) that test positive for HIV antibodies. Since STARHS is classified as an Investigational New Drug under the U.S. Food and Drug Administration, it is necessary to obtain informed consent from clients prior to performing STARHS. Furthermore, to calculate population-based statistical estimates of incidence, data must be collected about the client?s testing history.  

HIV Incidence Surveillance will help us to estimate recent HIV infection within the population. Learning how and where recent HIV transmission is happening will help us better understand the epidemic and how it is affecting our communities. Once this is achieved, HIV prevention efforts can be focused more effectively and can more efficiently promote a decrease in the incidence of new HIV infections.
 

Poster presentations give conference attendees a great opportunity to share research with colleagues and friends. Examples of poster topics include results of an outbreak investigation, new prevention programs at the local level or new laboratory methods in disease control. The session also presents an opportunity to demonstrate new computer and Web-based systems related to public health. 

Format for posters will follow the basic scientific paper outline, where applicable: 

Background ? the problem under investigation or hypothesis
Methodology ? the experimental methods used, including type of study, number of cases, etc.
Results ? a summary of essential results
Conclusions ? summary of findings, supported by your results (the conclusions should be numbered if multiple points are presented). 

The poster session and reception will occur the first evening of the seminar. Posters can be displayed in a three-fold form board format or any other appropriate conference style. Whichever method you choose, be sure to have a primary and secondary point of contact for presenting your poster. Each presenter will be responsible for insuring his or her display is set up prior to the beginning of the session, and removed promptly afterward. Technical assistance will be available through Bureau of Epidemiology staff. 
 

According to the Centers for Disease Control and Prevention (CDC), over 900,000 children in the United States are not adequately immunized. Each day, 11,000 children are born in the U.S. who are in need of protection from 11 vaccine preventable diseases by the age of two. 

National Infant Immunization Week offers an excellent opportunity to reaffirm our commitment to preventative child health care through immunizations. By working with local organizations, leaders, medical societies, immunization coalitions, the media, and outreach programs, the message about the importance of childhood immunizations can be delivered to parents throughout the state. This event is also an ideal time to contact local medical organizations and encourage implementation of the Standards for Pediatric Immunization Practices, which is an essential element to maintaining and improving immunization coverage levels. For further information regarding National Infant Immunization Week, please visit the CDC?s National Immunization Program (NIP) Web site at www.cdc.gov/nip, or contact Tom Bendle of the Bureau of Immunization at (850) 245-4444, extension 2391, or Suncom 205-4444, extension 2391. 

2004 Immunization Summit 
The Department of Health, Bureau of Immunization is excited to kick off this year?s National Infant Immunization Week with a statewide summit on childhood immunizations to be held in Orlando, April 23 & 24.  The two-day agenda is packed with immunization experts from the state of Florida as well as the Centers for Disease Control and Prevention. We look forward to this exciting, informative event. 

Martin and Palm Beach County prisons continue to report a high number of MRSA cases.

The Bureau of Epidemiology encourages Epi Update readers to not only register on the EpiCom system at https://www.epicomfl.net but to browse EpiCom frequently and contribute public health observations related to any suspicious or unusual occurrences or circumstances, as appropriate. EpiCom is the primary method of communication between the Bureau of Epidemiology and other state medical agencies during emergency situations.
 

WN Virus activity: There were two seroconversions to WN virus reported this week in sentinel chickens from Indian River (3/17) and Pinellas (3/15) counties. A live house sparrow (captured 3/17) was reported flavivirus positive from Santa Rosa County. So far this year, there have been 53 seroconversions to WN virus in 10 counties, two WN-confirmed dead birds from Marion and Miami-Dade counties, four WN-positive live birds from three counties and one WN-confirmed horse from Polk County. To date, 16 counties have reported confirmed WN virus activity this year. 

SLE Virus activity:  None this week. So far this year, five sentinel chickens from Lee County have tested positive for SLE. 

EEE Virus activity:  There were two seroconversions to EEE virus reported this week in sentinel chickens from Hillsborough (3/16) and Volusia (3/22) counties. A live blue jay (captured 3/12) was reported EEE positive from Okaloosa County. To date, 12 sentinel chickens, three horses and six live birds have tested positive for EEE virus, for a total of ten counties reporting EEE virus activity this year. 

Highlands J Virus activity:  None this week. To date, there has been one seroconversion to Highlands J virus in a sentinel chicken from Volusia County.

See the web page for maps and summary information on 2003 activity: http://www.doh.state.fl.us/Environment/hsee/arbo/index.htm

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

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