May 2, 2003
"The reason for collecting,
Foege WH et al.
|This Week in the
► Update on Human Avian Influenza A (H7N7)
A report on developments in The Netherlands plus an overview of recent activities in the United States.
► FPHA 3rd Annual Meeting
The Florida Public Health Association is holding its 3rd annual regional meeting in St. Augustine on May 9th. The deadline for registration is fast approaching.
► Clinician Outreach and Communication Activity
Some of the latest information on SARS can now be accessed through specific Web pages designed for easy access.
► Investigation of Gastrointestinal Outbreak in Pasco County
Following a report by an infection control nurse to officials at the Pasco County Health Department, an investigation ensued to determine the cause and effects of norovirus serogroup G2.
►Improving Detection of Potential Vancomycin Intermediate and Resistant Strains of S. aureus
The need for collaborative efforts between local county health departments and the state health office has been underscored by the emergence of Vancomycin resistant S. aureus.
► Bureau of Epidemiology Seminar
Scheduled for June 3-4 in Orlando, will be held at the Orlando Marriott. Hotel information is now available.
► Weekly Influenza Report - Week 16
Confirmed cases only for the week ending April 19, 2003.
► Arboviral Activity Summary
Statistics provided for the week ending April 28, 2003.
► Weekly Disease Table
Florida Department of Health, Bureau of Epidemiology,
Weekly Morbidity Report, Week 17, ending April 26, 2003
Selected Diseases and Conditions (Confirmed Cases Only)
A r t i c l e s:
Centers for Disease Control & Prevention, Atlanta, GA
Health Planning Council of Northeast Florida
CDC Terrorism and Emergency Response Update Service
Lisa Alleyne, Pasco CHD, Mary Boone, Pasco CHD, Michael Friedman, MPH, Bureau of Environmental Epidemiology
Kathryn S. Teates, MPH, Communicable Disease Surveillance & Reporting Manager
Kathryn S. Teates, MPH, Communicable Disease Surveillance & Reporting Manager
Caroline Collins, Arbovirus
Surveillance Coordinator and Carina Blackmore, M.S. Vet. Med., Ph.D.,
Deputy State Public Health Veterinarian
The 5 D's of Prevention:
Dusk: Avoid being outdoors when
Dawn: mosquitoes are most active.
Dress: Cover your skin with protective clothing
Deet: Protect bare skin with mosquito repellent.
Drain: Empty containers holding stagnant water in which mosquitoes breed.
Please Note! Some numbers are
subject to change with confirmatory information
Update on Avian Influenza A
Human Cases of H7N7 Infection in The Netherlands: As of April 25, 2003, the National Influenza Center in The Netherlands reported that 83 confirmed cases of human H7N7 influenza virus infections had occurred among poultry workers and their families since the H7N7 outbreak began in chickens at the end of February 2003. The vast majority (79) of these people had conjunctivitis, and 6 of those with conjunctivitis also reported influenza-like illness (ILI) symptoms (e.g., fever, cough, muscle aches). One person had ILI only (no conjunctivitis) and 2 persons had mild illness that could not be classified as ILI or conjunctivitis. In addition, one individual, a 57-year-old veterinarian who visited one of the affected farms in early April, died on April 17 of acute respiratory distress syndrome (ARDS) and related complications from H7N7 infection. Dutch authorities have reported evidence of possible transmission of H7N7 influenza from 2 poultry workers to 3 family members. All 3 family members had conjunctivitis and one also had ILI.
Public Health Monitoring: CDC is in communication with public health officials in The Netherlands and the World Health Organization (WHO) regarding the recent human cases of influenza A (H7N7) illness in The Netherlands and will continue to monitor the situation. CDC has begun production of a reagent kit that would allow laboratories to identify influenza A (H7N7) viruses. To enhance timely detection of any additional human influenza cases due to these viruses, WHO recommends that affected countries conduct enhanced surveillance for influenza among humans and animals and conduct studies to better understand possible transmission patterns. CDC and WHO have issued no restrictions on travel to The Netherlands. Additional information from WHO can be found at http://www.who.int/csr/don/2003_04_24/en/.
Influenza in the United States: Influenza activity in the United States is at low levels. Influenza A (H1N1), A (H1N2), A (H3N2), and influenza B viruses have been identified in the United States during the 2002-03 season and have been well matched by the current influenza vaccine. The current vaccine does not protect against infection with the influenza A (H7N7) 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.
For interim laboratory biosafety guidelines for handling and processing specimens associated with SARS
For interim domestic guidance for management of school students exposed to SARS
For interim domestic guidance for management of exposures to SARS for health care and other institutional settings
For addition of SARS Coronavirus Sequencing Page, Tree and Sequence PDFs
For interim guidelines about SARS for persons in the general workplace environment
A fact sheet for close contacts of SARS patients
Introduction: On February 10, 2003 the Pasco County Health Department was notified by the infection control nurse at a local nursing home that several residents and staff at the facility were exhibiting gastrointestinal symptoms of nausea, vomiting and diarrhea, with onset times averaging one to two days. Twenty-six residents and 17 staff members were affected. Of the ill staff members, 10 CNAs, four nurses, and three non-medical employees were affected.
Methods: Strict hand washing procedures, restriction of ill residents to their rooms and in-service training for staff were implemented immediately. All sick employees were restricted to the west wing. There were no reports of illness affecting residents in the east wing. The door separating the two wings was locked. A notice was posted informing all visitors of the requirement to check in at the nurses station, where they were notified of the outbreak and of the need to wash hands before and after visiting with residents.
An investigation of the facility was performed on February 12 by members of the Pasco County Health Department and the Bureau of Environmental Epidemiology. A line listing of all ill residents and staff was obtained. Information on patient food history and names of residents on tube feeding was provided. Eleven vomitus and stool samples from residents and staff were submitted for viral testing to the Tampa Branch of the Bureau of Laboratories. The investigators toured the west wing of the facility.
Results: Of the 11 specimens examined, only one tested positive for norovirus serogroup G2. The remaining 10 specimens were negative, with no additional testing performed. A review of the line listing showed staff and residents exhibited like symptoms of nausea, vomiting, diarrhea and abdominal pain. Duration of the illness was also similar, lasting from 24-28 hours. Before onset, staff movement between east and west wings of the facility was uninhibited. There was no illness among residents in the east wing. A tour of the west wing showed all rooms were well maintained and proper medical procedures observed.
The food services investigation showed the kitchen area to be well maintained and organized. The last quarterly inspection was November 2002 with no major violations noted. The facility receives its water from a public source. Of the ill staff members, only one was a food service worker, with the individual often interacting among residents during mealtime.
Conclusions: Upon review of the data, it was concluded that the most likely method of transmission was person-to-person. Cases reported varying onset times spaced over a five-day period. Only one specimen tested positive for norovirus but based on symptoms, incubation periods and duration, there is a high probability that the other cases were also caused by the same pathogen. The fact that the virus was contained to the west wing could be attributed to good hygiene control by facility staff.
Vancomycin resistant S. aureus is rare and its emergence underscores the need for a collaborative effort between the county health departments and the state health office to prevent the spread of this and other antimicrobial-resistant microorganisms and control the use of anti-microbial drugs in health-care settings.
In 1997, the Healthcare Infection Control Practices Advisory Committee published guidelines for the prevention and control of staphylococcal infection associated with reduced susceptibility to vancomycin (2); plans to contain vancomycin resistant S. aureus on the basis of CDC recommendations have been established in Florida. In the health-care setting, a patient with colonized with potentially resistant strains of S. aureus should be placed in a private room and have dedicated patient-care items. Health-care workers providing care to such patients should follow contact precautions (i.e., wearing gowns, masks, and gloves and using antibacterial soap for hand washing).
Any suspected resistant S. aureus organism should be tested for resistance to vancomycin using a MIC method and confirmed by one of the Florida State Branch Laboratories. Efforts should be made to encourage all clinical microbiology laboratories outside the state branch lab system to retain and report specimens with reduced susceptibility to vancomycin.
S. aureus with evidence of either intermediate or complete
resistance to vancomycin (not MRSA) is reportable in Florida. The
isolation of S. aureus with confirmed or presumptive
vancomycin resistance should be followed up and the Bureau of Epidemiology
should be notified by the local county health department immediately. All
suspect cases should be followed up with the reporting provider or
laboratory to confirm and possibly repeat susceptibility testing on the
2. CDC. Interim guidelines for prevention and control of staphylococcal infections associated with reduced susceptibility to vancomycin. MMWR 1997;46:626--8,635.
Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology, Florida Department of Health
The Bureau of Epidemiology Statewide Epidemiology Seminar, is scheduled for June 3 – 4, 2003 at the Orlando Marriott, in Lake Mary, Florida. We are in the process of developing an interesting, informative and challenging agenda, a list of exciting speakers and an excellent poster session, not to mention time and occasion for colleagues to interact.
Hotel reservations can be made by calling the Orlando Marriott directly at (407) 995-1100 or by calling their toll free reservation line (800) 228-9290. Please refer to the FDOH-Epidemiology Statewide Seminar-June 2-4, 2003, group code FDOFDOA. You can also reserve a room on-line by going to their website www.marriott.com/MCOML, click on the red button "Reserve a Room", enter the dates requested and then arrow down to the bottom of the screen. In the box labeled "Group Code" enter FDOFDOA then hit enter. Follow the instructions to complete the reservation.
The agenda and registration form should be available Monday, May 5, 2003 on the Bureau of Epidemiology Internet website. Melanie Black, MSW, will be managing this activity and can be reached at (850) 245-4444 ext. 2448 or SunCom 205-4444 ext. 2448.
National report:* During week 16, twelve isolates (7 influenza A and 5 influenza B viruses) were made from 600 specimens tested by the World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories this week. The proportion of deaths attributed to pneumonia and influenza as reported by the vital statistics offices of 122 U.S. cities was 7.6% during week 16. This percentage is below the epidemic threshold of 7.9% for this time. The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) was 1% nationwide. The State and Territorial Epidemiologists in Alaska reported widespread influenza activity. Four states (Idaho, Montana, North Dakota, and Ohio) reported regional activity, and 32 states and New York City reported sporadic influenza activity. Nine states reported no influenza activity. During the past 3 weeks (weeks 14-16), 22.7% of the specimens tested for influenza in the New England region were positive, between 6.2% and 10.3% of the specimens tested for influenza in the Pacific, Mountain, West North Central, and East North Central regions were positive, and less than 3.0% of the specimens tested for influenza in the East South Central, West South Central, Mid-Atlantic, and South Atlantic regions were positive. However, during the past 3 weeks (weeks 14-16), influenza A viruses were reported more frequently than influenza B viruses in all nine surveillance regions.
Since September 29, 11.5% (n=10,148) of the 88,142 specimens tested nationwide have been positive. Two thousand eight hundred and seventeen (50%) of the 5,647 influenza A viruses have been subtyped; 2,196 (78%) were influenza A (H1) viruses and 621 (22%) were influenza A (H3N2) viruses. Laboratory confirmed influenza has been reported from all 50 states. Influenza A viruses were reported more frequently than influenza B viruses (range 57% - 87%) in the New England, East North Central, Mountain, Pacific, and Mid-Atlantic regions, and influenza B viruses were reported more frequently than influenza A viruses (range 58% - 80%) in the South Atlantic, West North Central, West South Central, and East South Central regions. However, during the past 3 weeks (weeks 14-16), influenza A viruses were reported more frequently than influenza B viruses in all nine surveillance regions. CDC has characterized 140 influenza A (H1N1), 46 influenza A (H1N2), 82 influenza A (H3N2) and 222 influenza B isolates antigenically. The neuraminidase typing for 42 H1 viruses is pending. 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 Netherlands reported in April the first fatal human case of influenza A (H7N7).
An outbreak of highly pathogenic avian influenza A (H7N7 HPAI) in chickens began during February 2003 in The Netherlands and, despite control measures (restricting transport and culling), has spread to Belgium and Germany, to swine herds in The Netherlands, and humans. Of the 83 confirmed cases of human H7N7 in the Netherlands, 79 exhibited conjunctivitis and 13 had mild ILI. Possible human-to-human transmission was suggested when three family members of two poultry workers fell ill with a minor respiratory disease. The WHO Influenza Collaborating Centers are to begin production of a reagent kit to identify H7N7 viruses. More information about this outbreak of H7N7 HPAI can be found at: http://www.who.int/csr/don/2003_04_24/en/
Asia. An avian flu virus strain, influenza A (H5N1), was recovered from two influenza cases in Hong Kong earlier this year. CDC has issued recommendations on increased influenza surveillance in the United States. Of particular importance is consideration of influenza cultures on patients with recent travel histories to Asia who are hospitalized with unexplained pneumonia, acute respiratory distress syndrome or severe respiratory illness.
* Reporting is incomplete for this week. Numbers may change as more reports are received.
For additional information on influenza and influenza surveillance results in Florida, please visit our website at http://www.doh.state.fl.us/disease_ctrl/epi/htopics/flu/2002/index.htm
Links to current diseases of concern: Severe Acute Respiratory Syndrome (SARS) http://www.doh.state.fl.us/PHNursing/SARS/SARSindex.html
Arboviral Activity Summary - Through the Week Ending
April 28, 2003
Human: No cases of arboviral meningo-encephalitis were reported this week.
Gilchrist County is under Medical Alert for EEE virus.
Sentinel Chickens: Two seroconversions to EEE virus were confirmed in Alachua County. This week, 638 samples were tested from 17 counties.
Bird Mortality: No dead birds were reported positive for arbovirus this week.
Equine*: Three EEE virus infections in horses were reported from Alachua, Hernando and Levy counties.
Wild and Captive Birds: See http://www.pherec.org/DECS Arbovirus Ecology to view database.
Mosquito Pools: No mosquito pools were reported positive for WN or EEE virus this week.
Current Bird Mortality Reporting Guidelines:
1. Report dead birds to www.wildflorida.org/bird/. From that site, you can link to online bird identification sites. There is value in the information submitted even if the bird is not tested, especially for those counties which don't have sentinel chickens or who have sites situated sparsely in the county.
2. The DOH Lab in Tampa will test anything that's shipped in good condition. Instructions for submission of dead birds are found at: http://www9.myflorida.com/disease_ctrl/epi/htopics/arbo/index.htm Select "How do I report?" then choose "Protocol for Collecting and Shipping Bird Carcasses" under "Dead Birds" subtopic.
3. If local agency must cut back on bird submissions, consider only sending crows and jays.
4. If personnel are not able to offer pick-up service, have a drop off station and provide the caller with clear handling instructions. A county may modify their testing approach depending on the availability of other surveillance systems in the county.
The Disease Outbreak Information Hotline offers updates on medical alert status and surveillance at 888-880-5782. Florida is currently at "Level 1" in the Arbovirus Response Plan (see http://www9.myflorida.com/disease_ctrl/epi/htopics/arbo/index.htm). DOH Press releases can be seen at http://apps3.doh.state.fl.us/IRM/PressReleaseSearch/search.cfm .
2003 Cumulative Arbovirus Activity by County
1. Human Surveillance: No activity has been reported for WN, SLE, EEE or Dengue.
2. Animal Surveillance
West Nile Virus: Positive samples from
21 sentinel chickens in 9 counties, one
horse in one county and one dead bird in one
received. In all, ten of Florida’s 67 counties reported WN virus
activity, providing evidence of WNV circulating primarily in the state’s
coastal regions. Date of first known positive bleed (sentinels),
date of death (birds)
and date of disease onset (horses)
is shown in parentheses.
Eastern Equine Encephalomyelitis Virus
Positive samples from 31
horses in 17 counties, 2
dead birds in 2 counties, and 10
sentinel chickens in 6 counties were
received. To date, 22 of Florida’s 67 counties have reported EEE virus
activity. Date of disease onset (horses),
date of death (birds)
and date of first known positive bleed (sentinels)
is shown in parentheses, unless otherwise indicated.
For more information please see the DOH website at http://www.doh.state.fl.us/disease_ctrl/epi/htopics/arbo/index.htm
The Disease Outbreak Information Hotline offers updates on medical
alert status and surveillance at 888.880.5782. Florida is currently at
Level I in the Arbovirus Response Plan. DOH press releases can be viewed
|Bureau of Epidemiology|