Friday, April 23, 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

Bureau of Epidemiology Grand Rounds Program
Tuesday, April 27, 2004 11:00 AM-12:00 PM, EST
Topic: Analysis of Surveillance Data for Haemophilus influenza Invasive Disease 1992-2003. With emphasis on the adult population greater than 65 years of age.
Presenter: Lilian Kigonya, MB., Ch.B MPH, Bureau of Epidemiology, Florida Department of Health 

Invasive Haemophilus influenza disease is reportable in Florida and surveillance includes monitoring for types of disease and mortality. Nationally, cases of invasive Haemophilus influenza among children declined dramatically in the 1990’s after the introduction of the conjugate pediatric vaccine. The other traditional risk group for infection with Haemophilus influenza is the elderly and because Florida has a large population of elderly residents, we looked at morbidity caused by Haemophilus influenza in that age group for the years 1992 to 2003.  

Haemophilus influenza surveillance data were retrieved from Merlin, the web-based electronic reporting system of Florida. The data set Included 891 reported cases of Haemophilus influenza invasive disease for the years 1992-2003. The highest proportion of cases (46%) was seen in adults aged 65 and older, followed by children aged 4 years and younger (22%) with the lowest (5%) in those aged 5 years to 14 years. There has been an increase in the rate of H. influenzae invasive disease cases among adults aged 65. Evidence suggests immunization against H. Influenza type b among children indirectly prevents adult invasive disease. The results from our surveillance data did not support this hypothesis. 

Additional Information: The grand rounds presentation will begin promptly at 11:00 a.m., EST on Tuesday, April 27, 2004. PowerPoint slides and the dial-in number will be available on the Bureau of Epidemiology intranet website on Monday, April 26. CEUs will be provided for nursing. Please remember you must complete the entire registration form including the evaluation and test questions. Registration for CEUs will be accepted April 27- April 29. Registrations received prior to the beginning of the program will not be accepted. If additional information is needed, contact Melanie Black, MSW, professional training coordinator at 850.245.4444, ext. 2448, SunCom 205.4444, ext. 2448 or email Melanie_Black@doh.state.fl.us.
 

Rabies is endemic among Florida wildlife. Although thousands of people and pets are exposed to potentially rabid animals each year in the state, human cases are rare. The public health prevention strategies used to minimize human rabies include animal control and pet vaccination laws as well as effective and accessible post-exposure vaccination treatments for those bitten. Human rabies is still common in many other parts of the world. The two most recent human rabies cases reported in Florida were infected by dog bites in Mexico and Haiti respectively.  This case report describes a recent case of dog rabies in an individual bitten during a visit to Haiti.  

A 41-year old male presented at a South Florida emergency room with a two day history of dysphagia and choking after a brief episode of hoarseness and fever. The clinical examination, blood tests, x-rays and MRI were normal but he was admitted for observation with a preliminary diagnosis of an upper respiratory infection and laryngitis of viral origin. Over the next two days his condition was unchanged. The patient exhibited periodic anxiety attacks, especially during attempts to examine his mouth and throat. A referral for psychiatric evaluation was discussed. On the third day in the hospital he became febrile (103 F) and developed an elevated white blood cell count (14.5). Rabies was added to the list of differential diagnoses when it was revealed that the man had a history of a dog bite on his fingertip 8 months prior while visiting family in Haiti. Ante-mortem rabies testing was requested but the testing was never completed. A lumbar puncture was also ordered but not done. Over the next 24 hours he became lethargic and decreasingly responsive. He developed liver failure and hypokalemia and died less than 4.5 days after admission. The rabies diagnosis was made post-mortem by the local medical examiner and the case was reported to the local health department. Slides and brain tissues were forwarded to CDC for confirmation. Molecular testing at CDC confirmed rabies dog strain as the cause of the infection. Only one close family member needed post-exposure prophylaxis (PEP) treatment.  

There are several important lessons to learn from this case. Although rabies is a rare disease in Florida it needs to be considered as a differential diagnosis of fatal viral encephalitis cases with short morbidity periods if no known cause of disease has been established. The final diagnosis of rabies is made post-mortem, but ante-mortem testing may be helpful in determining the need for PEP of close family contacts and health care workers. Testing is available at CDC and can be arranged through your county health department. Hospitalized patients suspected to have rabies need to be placed on contact precautions. 

Individuals traveling to countries with endemic rabies in both pets and wildlife should consider getting vaccinated against the disease, especially if the travel involves extensive unprotected outdoor, evening, and nighttime exposure to animals in rural areas. People bitten or scratched by animals in foreign countries need to be evaluated promptly and carefully to determine the need for PEP. A prior rabies vaccination history does not exempt the person from PEP but does shorten the PEP regimen from five to two doses. 

More information about rabies and rabies prevention can be found in the 2003 Guidebook on Rabies Prevention and Control in Florida:      http://www.doh.state.fl.us/Disease_ctrl/epi/Rabies_Guidebook/Rabies_Guidebook2003.pdf
 

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 call their reservations 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. We asked the health center to flag the patient's chart so the health department could be notified when the child returned and the CHD could contact the mother and evaluate the home for the source of lead. 

In the interim, our staff called the Women's Infant and Children office and found that the mother was a client, but not expected to return to the office soon. We also verified that the child was not a client of the Healthy Start Program. 

Staff members from both the epidemiology and environmental health sections attempted several home visits and found the house unoccupied and in extremely poor condition. 

With no viable way to contact the mother, our staff began following other avenues to locate the child. Because of the condition at the current address, we reviewed county tax assessment records (public records available online) and found that the house was rented. We were unable to locate the landlord. 

We then talked with the health center staff and found that the Department of Children and Families (DCF) had made an inquiry about the family. Contacting the DCF, we found that there was an open case on the family; therefore, we reviewed our information with DCF investigators.

Findings: 
1. Mother was a fugitive from justice.
2. The house address that had been given was false.
3. The children (there are 4) were usually left in the care different persons.
4. The DCF investigators knew where the children were living and had made the decision to place them under DCF protection. 

Working with DCF, all four children are now being evaluated for lead levels and will began treatment where appropriate. Working with DCF, the health department is attempting to evaluate the housing units in which the children were present during the prior 6 months, in order to locate the source of the lead contamination. 

Results. Personnel at the health department could have merely logged and reported the elevated lead level and allowed the primary care provider to wait until the mother brought the children in for a follow-up appointment; or they could have tried to locate the child even though accurate contact information was not available. In this case, we most likely would have lost the child to follow-up and never found out about the three siblings that needed evaluation. Instead, working with several agencies, all children received care in a timely fashion, and a poor outcome was avoided.
 

Comparative Analysis of Serologic Assays for the Detection of Antibodies to Eastern Equine Encephalomyelitis Virus in Sentinel Chickens

Florida’s mild climate supports year round enzootic transmission of arthropodborne (arbo) viruses, such as St. Louis Encephalitis virus (SLEV), West Nile virus (WNV), and Eastern Equine Encephalomyelitis virus (EEEV). First isolated in 1960 from two Florida blue jays, Highlands J virus (HJV) is endemic to the state and vectored by the same mosquitoes as EEEV.  EEEV and HJV are both alphaviruses, but HJV is not pathogenic to humans, occasionally causes encephalitis in horses, and is a recognized pathogen in some bird species (turkeys, emus, etc).

In 2003, sentinel chickens detected significantly greater alphavirus activity than seen in the previous 15 years for the state of Florida. This increase raised concerns that bridging into the human population had become a serious threat as well as an important issue for veterinary health. Serologic antibody assays routinely employed for alphaviral detection include the hemagglutination inhibition (HAI) test and IgM antibody capture enzyme-linked immunosorbent assay (MAC-ELISA). The objective of this study was to determine if cross-reactions with Highlands J virus were impacting these diagnostic tests routinely performed for identification of EEEV by comparison with results from the serum neutralization plaque reduction test (PRNT), the gold standard assay for detection of antibodies to arboviruses. 

For 2003, 4,361 adult sentinel chickens were maintained at 285 potential enzootic transmission sites in 35 Florida counties. County mosquito control districts or county health departments throughout the state submitted 44,364 sentinel chicken sera specimens to the Florida Department of Health, Bureau of Laboratories, Tampa Branch (TBL) for arboviral serology testing. The HAI test detected 476 alphavirus positive sentinels. We tested 316 of these chickens in the PRNT, which identified 176 EEEV antibody positive sentinels and 75 HJV antibody positive sentinels. Our results indicate that Highlands J virus is extensively cross-reactive in the HAI test and that the MAC-ELISA is more specific then the HAI for the detection of antibodies solely to EEEV. We demonstrated that higher alphavirus antibody titers in the HAI test were positively correlated to antibody titers to EEEV in the PRNT assay.

Analysis of alphaviral activity by county indicates widespread transmission of HJV across the northern and panhandle regions of the state; however EEEV activity was greater than HJV activity in all but four counties tested. In 2003, for sentinels confirmed in the PRNT (n=316), onset of EEEV activity occurred in March, peaked in June, and declined over the remainder of the year. HJV activity first appeared in the month of May, peaked in July, and rapidly declined through the month of November.  

This study recommends implementation of additional confirmatory tests by the MAC-ELISA and serum neutralization plaque reduction test (PRNT) for the detection of antibodies to Eastern equine encephalomyelitis virus and Highlands J virus in sentinel chickens for the state of Florida. Consequently, distinguishing between the two agents can reduce the expenditure of resources on unnecessary vector control and medical alerts to protect the public health from Highlands J virus.
 

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). 

Be sure to include the abstract title, author names, and the institution where the work was completed, in large letters centered at the top of the poster. 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 ensuring 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.  

Additional Tips for Poster Preparation

• Posters should stimulate discussion, not require a long presentation by the author. Therefore, keep text to a minimum, emphasize graphics, and make sure every item in your poster is necessary.

• When choosing a background, remember that neutral or gray colors will be easier on the eyes than a bright color. Color photos look best when mounted on gray.

• Draw a rough sketch of your poster first. You may find it helpful to use graph paper and small pieces of paper (e.g., Post-it Notes cut to size) to better visualize where the components of your poster will go.

• Materials must be easily read at a distance of 4 feet. Carelessly prepared handwritten copy is unacceptable. As a rule of thumb, use a font size of at least 14 point and double space the text.

• Place related materials (e.g., photo with accompanying text) close together, and then highlight by framing with blank space.

• Space your information proportionally: divide your poster either horizontally or vertically into three or four sections, and place your materials within those spaces.

• Supplement your poster with handouts.

If you would like to participate, please submit the title and/or abstract for your poster to Karen Wheeler via e-mail at karen_wheeler@doh.state.fl.us  no later than May 3.
 

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.
 

West Nile (WN) Virus activity: There was one seroconversion to WN virus reported this week in a sentinel chicken from Hillsborough (4/6) County. So far this year, there have been 56 seroconversions to WN virus in 11 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, 17 counties have reported confirmed WN virus activity this year. 

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

Eastern Equine Encephalomyelitis (EEE) Virus activity: Two live birds captured in Santa Rosa County (a sparrow on 3/26 and a blue jay on 4/3) were reported EEE positive this week. To date, 15 sentinel chickens, three horses and eight live birds have tested positive for EEE virus, for a total of nine counties reporting EEE virus activity this year. 

Highlands J (HJ) Virus activity: None this week. To date, there have been ten seroconversions to Highlands J virus in sentinel chickens from four counties.

Bureau of Epidemiology

 Epi Update Archives

Florida Department of Health

My Florida

Contact Us

CDC