Epi-Update Weekly Publication of Bureau of Epidemiology

Friday, May 9, 2003


"The reason for collecting, 
analyzing and disseminating information on a disease
is to control that disease. 
Collection and analysis 
should not be allowed 
to consume resources 
if action does not follow."

Foege WH et al. 
Int. J of Epidemiology
1976; 5:29-37



 Epi Update Managing Staff
John Agwunobi, MD, MBA,
Secretary, Department of Health 

Landis Crockett, MD, MPH, 
Director, 
Division of Disease Control 

Don Ward, 
Deputy Bureau Chief 
Epi Update Managing Editor 

Jaime Forth, 
Editorial Assistant 

 

This Week in the News:

► Alcohol-Based Hand Sanitizers in Food Service Settings
A report on the latest findings by The Centers for Disease Control and Prevention. 

► Statewide Epidemiology Seminar June 3-4
This annual seminar will be held at the Orlando Marriott in beautiful Lake Mary, Florida. Registration, plus accommodations information, is now available online. 


► Merlin Reporting System Classes Underway 
Dates for regional classes will soon be determined.  In the meantime, here's what you need to know about Merlin.
► Call for Conference Posters
A reception and poster session will be part of the Statewide Epidemiology Seminar next month. Find out how to participate.  


 ► Infection Control Seminar Slated for Pensacola
The Northwest Florida Infection Control Practitioners Association annual seminar, entitled "Breaking the Chain," will be held on Friday, May 16th at the Pensacola Civic Center.    
► Helpful Hints for Merlin 
 Having a little difficulty responding to those pesky "Requests for More Information"?  Help is on the way!


► Weekly Influenza Report - Week 17
Confirmed cases only for the period April 20-26, 2003. 


 ► Arboviral Activity Summary
Statistics provided for the week ending May 5, 2003.


► Weekly Disease Table
Florida Department of Health, Bureau of Epidemiology, Weekly Morbidity Report, Week 18, ending May 3, 2003.
Selected Diseases and Conditions (confirmed cases only)

A r t i c l e s:

    

 

  Roberta M. Hammond, Ph.D., Bureau of Epidemiology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology

 

 

 

 

 

 

 

  Travis McLane, Surveillance Program Specialist, Bureau of Epidemiology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Ronee' Wilson, MPH, Surveillance Section Epidemiologist, Bureau of Epidemiology

 

 

 

 

 

 

 

 

 

 

 

 

Vivian Logsdon, President, Northwest Florida Infection Control Practitioners Association

 

 

 

 

 

Ronee' Wilson, MPH, Surveillance Section Epidemiologist, Bureau of Epidemiology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  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

 

 

 

 

 

 

 

 

 

 

 

 

Please Note!  Some numbers may change with confirmatory information

 

 

► Alcohol-Based Hand Sanitizers in Food Service Settings

 The U.S. Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) are working together to control the transmission of pathogens that can result in food borne illnesses. Transmission of pathogenic bacteria, viruses and parasites from raw food or from ill workers via improperly washed hands continues to be one of several major factors in the spread of food borne illnesses.

FDA's Food Code contains federal recommendations for preventing food borne illness in restaurants, grocery stores, institutions and vending machines. To maintain consistency with national food regulatory policy, local, state and federal regulators use the FDA Food Code as the model for development or revision of their own food safety rules. The Food Code contains specific hand hygiene guidance for retail and food service workers. Hand sanitizers, meeting specific criteria described in section 2-301.16 of the Food Code, may be used after proper hand washing in retail and food service.

CAN ALCOHOL-BASED HAND GELS SERVE AS A SUITABLE ALTERNATIVE TO HAND WASHING FOR RETAIL AND FOOD SERVICE WORKERS?

CDC recently issued "CDC Guideline for Hand Hygiene in Health-Care Settings" (Morbidity and Mortality Weekly Reports, October 25, 2002). The guidance document recommends alcohol-based hand gels as suitable alternatives to hand washing for health-care personnel in health-care settings. These guidelines were not intended for food establishments. This exclusion is based on the differences in controlling common nosocomial pathogens in health-care settings and common food borne pathogens in retail and food service settings. Some significant differences between health-care settings and retail/ food service settings include:

1. TYPES OF PATHOGENS

In health-care, nosocomial bacterial pathogens and lipophilic viruses predominate, while food service and retail establishments are primarily concerned with a different set of fecal pathogens. Common nosocomial pathogens are typically transmitted from person-to-person in health-care settings.

Controlling the transmission of fecal bacteria, enteric non-lipophilic viruses, and protozoan oocysts, which can contaminate hands with a very high titer, is a particular concern in food service and retail settings. CDC estimates the non-lipophilic virus, Norovirus (Norwalk-like virus) to be the leading cause of food borne illness in the United States.

2. EFFICACY AND APPROVAL OF ALCOHOL-BASED HAND GELS

All alcohol-based hand gels applied to human skin are drugs, and must be covered by FDA's Over-the-Counter Drug Review or by an FDA-approved new drug application for legal marketing in the United States. Further, all ingredients, including emollients and perfumes that are constituents of alcohol hand gels used in retail and food service operations, must be approved as indirect food additives.

In health care settings, the antimicrobial efficacy of alcohol-containing handwashes for use in any setting remains under review by FDA. Some published studies indicate that moisture on the hands may interfere with alcohol efficacy. In addition, alcohol has been shown to be ineffective against protozoan oocysts and, depending on the alcohol concentration, time and viral variant, alcohol may not be effective against hepatitis A or other non-lipophilic viruses.

3. SOIL ON HANDS

The types of activities conducted in retail and food service may lead to increased potential for fatty and proteinaceous materials on the hands. These may not be visible. Proteinaceous materials are also known to neutralize alcohol efficacy. Fatty substances can coat and protect pathogens from the action of alcohol. Soap, friction, and running water effectively remove the proteinaceous and fatty materials, and reduce pathogens of concern.

Existing data do not demonstrate that alcohol-based hand gels effectively reduce infectious food borne pathogens at levels that occur on food workers' hands, especially if the hands are soiled with fatty and proteinaceous materials. Even in health-care settings, the CDC guidelines prefer soap and water to alcohol-based sanitizers for hands that are visibly soiled or contaminated with proteinaceous material.

CONCLUSION:  Proper hand washing, as described in the Food Code, continues to be a vital practice in retail and food service settings. Alcohol gels in place of hand washing do not adequately reduce important food borne pathogens on food workers' hands. Concern about using alcohol-based hand gels in place of hand washing with soap and water can be summarized as such:

· Alcohols have very poor activity against bacterial spores, protozoan oocysts, and certain nonenveloped (nonlipophilic) viruses; and

· Ingredients used in alcohol-based hand gels for retail or food service must be approved as additives under the FDA monograph or as a New Drug Application; and

· Retail food and food service work involves high potential for wet hands and hands contaminated with proteinaceous material. Scientific research questions the efficacy of alcohol on moist hands and hands contaminated with proteinaceous material.

FDA and CDC continue to monitor new data to ensure the best public health measures are in place for retail and food service establishments.

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► Statewide Epidemiology Seminar June 3-4   

 The Bureau of Epidemiology Annual Seminar will be held June 3-4 at the new Orlando Marriott in Lake Mary, located just 15 miles NE of downtown Orlando. 

To take advantage of our special group rate, be sure to make your hotel reservations early. Call the Marriott directly at 407.995.1100, or through their reservations line at 800.228.9290.  Refer the booking agent to the FDOH-Epidemiology Statewide Seminar, code FDOFDOH. 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 FDOFDOH and follow instructions to complete the arrangement.  

For further information, contact Melanie Black at the Bureau of Epidemiology in Tallahassee at 850.245.4444, ext. 2448.

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► Merlin Reporting System Classes Underway
Two very successful Merlin Basic Training classes were held last week in Hillsborough and Pinellas counties. In Tampa, 12 participants representing four County Health Departments attended, and in St. Petersburg, 18 representatives of the Pinellas County Health Department attended.

Merlin is a new reporting software package developed and used exclusively by Florida health professionals. The system serves as a central repository for real-time data reporting and as an information-gathering tool. Results are then forwarded by state officials to The Centers for Disease Control and Prevention in Atlanta.

A schedule for the remainder of the year is noted below. Exact dates have not been determined, but an e-mail announcement with solid dates and enrollment details will be released soon. Plan on attending at least one Merlin Basic Training this year to keep abreast of all the latest features and technology. Each presentation should provide you enough information to enable you to return to your computer thoroughly energized, and fully equipped to apply your newfound knowledge!

This list does not include Merlin Basic Training sessions that will be offered the day preceding Regional Epidemiology Training. For further information, contact Travis McLane in Tallahassee at 850.245.4444, extension 2413.

Month

Site

 Seats Available

 

    
June Palm Beach County HD 10
July Tallahassee (HQ) 10
July  Broward County HD 10
August Orange County HD 11
September Bay County HD 9
October Collier County HD  10
November Tallahassee (HQ) 10
December Hillsborough County HD 13

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 ► Call for Conference Posters

The Bureau of Epidemiology is actively seeking posters for its annual seminar in Lake Mary, Florida, scheduled for June 3-4, 2003. 

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 a 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 foam board format or any other appropriate conference style. Whichever method you choose, be sure to have a primary and secondary plan 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.  

If you would like to participate, please contact Ronee' Wilson at 850.245.4444, ext. 2445 by May 23rd. 

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► Infection Control Seminar Slated for Pensacola

A one-day seminar entitled "Breaking the Chain," will take place at the Pensacola Civic Center next Friday, May 16th. The seminar is designed primarily to provide updated information to health care professionals around the Florida Panhandle and conunties in Alabama but everyone is welcome to attend. Topics will include the current state of response and readiness regarding weaons of mass destruction, patient safety, recent guidelines announced by CDC/HICPAC, and revised JCAHO infection control standards.

For more details or to order a brochure, call or email Vivian Logsdon at Vivian_Logsdon@doh.state.fl.us, or 850.595.6639.

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► Helpful Hints for Merlin

Prior to the close of the 2002 database, you may have received an email from one of our Merlin EPI reviewers. This message probably included a request for additional information such as onset dates, symptoms, lab results, etc. To assist users with preparation of future reports, the following hints are offered:

Lab results are received by key county health department staff in three ways. One way is electronically, from state laboratories. These labs show up on your Unprocessed Electronic Labs task list in Merlin. Some lab results are entered by data entry staff at the state health office and are displayed on your Unattached Labs task list. After the electronic labs are processed, they are displayed on the Unattached Labs task list. Other lab results are received by mail.

Attaching Labs:

Electronic Lab Results: Lab results that appear on the Unprocessed Electronic Labs task list are submitted from the state laboratories. While processing the lab, you’ll have an opportunity to attach the electronic lab to a case, if one has been entered for that patient or profile. Click on the radio button next to the appropriate case at the bottom of the screen. Save it. If you process an electronic lab and do not attach it to a case, the lab result will be moved to your Unattached Labs task list (see Unattached Lab Results).

Unattached Lab Results: Lab results that appear on the Unattached Labs task list were entered manually by a state health employee or CHD staff. If you create a case based on a lab result that is on your Unattached Lab task list, you’ll need to attach the lab to the case before you report it. This can be performed from the Summary screen.

· From the Unattached Labs task list, select the lab result you want by clicking on the hyper linked lab number

· Click on the Summary button at the top of the lab result screen

· Under Unattached Lab Results, click on the hyper linked word "Attach" in the Action column.

· The ICD9-DX codes for the case and the lab must match if you want to attach the two.

Typically, users will receive an error message if they try to report a case in Merlin that does not include an attached lab result. However, there are exceptions to every rule! Hepatitis A is one condition that can be reported in Merlin without a positive lab result. A case of hepatitis A can be considered confirmed if it is epidemiologically linked to another case with a positive lab result.

Although it is technically possible to report hepatitis A cases in Merlin without an attached lab, a positive lab is required if the case is not epi-linked. If you do not have a positive lab result, make sure you document (in the case notes) the ways in which this case is epidemiologically linked.

Entering Symptoms/Onset Dates:

Documentation of symptoms and their onset dates is often necessary to confirm certain diseases and conditions by surveillance case definition. For example, the case definition screen for hepatitis A displays check boxes by statements concerning clinical criteria. If you check the box stating the patient had "Discrete onset of symptoms", "Jaundice", and was "Anti-HAV positive" make sure you document the symptoms and the onset dates in the Symptoms section either on the Basic Case screen or the Extended Data screen, and be sure to enter the case related lab results.

We hope these Merlin Helpful Hints are useful. Your hard work and dedication are appreciated!  Please feel free to contact the Merlin Helpdesk (Merlin_Helpdesk@doh.state.fl.us) with any questions or concerns, and, of course, continue to check issues of the EPI Update for upcoming Merlin training courses.

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► Weekly Influenza Report

 Florida: During week 17  (April 20-26, 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 1.52%. This is lower than the national baseline of 1.9%. Higher flu activity than expected for this time of year (>2%) was reported by physicians in Indian River, Polk, and Miami-Dade counties. Light to moderate influenza activity was seen in five other counties.  

International report:

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 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.  

* 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


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 ► Arboviral Activity Summary - Through the Week Ending May 5, 2003

 Weekly Update:  During the period April 29 through May 5, 2003, the following arboviral activity (St. Louis encephalitis virus [SLE], eastern equine encephalomyelitis virus [EEE] , West Nile virus [WN]  and dengue virus) was recorded for Florida:

Human:  No cases of arboviral meningo-encephalitis were reported this week. Gilchrist County is under Medical Alert for EEE virus.  

Sentinel Chickens: 

One seroconversion to WN virus in Lee County and seven seroconversions to EEE virus were confirmed in Alachua (2), Hillsborough, Orange (3) and Pasco counties.  This week, 877 samples were tested from 21 counties. 

Bird Mortality:  No dead birds were reported positive for arbovirus this week.  

Equine*:  Seven EEE virus infections in horses were reported from Bradford, Duval, Levy, Osceola, Suwannee, Union/Columbia and Volusia 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.  

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 at http://apps3.doh.state.fl.us/IRM/PressReleaseSearch/cfm.

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► Weekly Disease Table
Florida Department of Health, Bureau of Epidemiology, Weekly Morbidity Report, Week 18, ending April 26, 2003.
Selected Diseases and Conditions (confirmed cases only).  Access the very latest information at:

www.doh.state.fl.us/disease_ctrl/epi/Disease%20Table/2003_weekly/diseasetable.htm

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