Friday, May 14, 2004
This Week in the News
|"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.,
|►Epi-X Simulates Emergency Response to Assess Preparedness|
Test results should help evaluators learn how well and how quickly the participants reacted and followed the instructions in the alert message, and prepare them for handling future emergencies.
|►Outbreak of Norovirus Gastroenteritis, Fernandina Beach, January 2004|
A Nassau County resort was the setting for an outbreak that affected dozens of conference attendees and others.
►New Events to Unfold at This Year's Statewide Epidemiology Seminar
Epi Update Managing Staff:
|►Nipah Encephalitis One of New Crop of Emerging Diseases
The virus, spread primarily through pigs, is already known in parts of Asia.
Secretary, Department of Health
►Veterinary Medicine is Public Health in Practice
The notion that veterinary medicine is simply a private practice enterprise needs some amending, according to one public health official.
|Landis Crockett, MD,
Division of Disease
|►Two New Graduates in Bureau
These behind-the-scenes staff at the Bureau of Epidemiology make a difference in everyday operations at the bureau and in the world around them.
Acting Bureau Chief,
|►May Grand Rounds Presents Analysis of Locally Acquired Malaria Risk Factors
This analysis, provided by Dr. Fermin Arguello, will provide a summary of malaria activity in Florida between 1995 and 2003, and will demonstrate Florida resident-specific risk factors for death due to malaria infection.
|►This Week on EpiCom
Giant African snails, a Norovirus outbreak, and a varicella cluster at an elementary school. If you haven't logged on recently, you don't know what's going on around the state.
|►Mosquito-Borne Disease Update
A report outlining activities for the week of May 2-8, 2004 for confirmed cases.
A R T I C L E S
|Pete Garner, Surveillance Systems Manager, Bureau of Epidemiology||►Epi-X Simulates Emergency Response to Assess Preparedness|
Members of the public health team at the Florida Department of Health this week participated in an Emergency Notification Proficiency Test conducted by the Centers for Disease Control and Prevention. Phone calls, pager messages, and e-mails simulating an emergency similar to one which might be declared in the case of a bioterrorist attack were issued to selected users of Epi-X, the CDC-sponsored Epidemic Information Exchange Web site and emergency notification system.
Test participants were asked to respond to the emergency calls, either by calling a telephone response line or logging on to the Epi-X Web site, viewing a special alert message from CDC, and adding a time-stamped comment to the posting. These participants represented a variety of functional areas within the public health community such as county health departments and state laboratories as well as communicable disease and environmental epidemiology.
Users were also asked to complete a short survey indicating how they received the alert and their primary methods of receiving and responding to these types of notifications. From this, judges of the test results will be able to calculate how well and how quickly the participants reacted and followed the instructions in the alert message, as well as to gather information about how future emergencies might be handled better.
The Florida Department of Health and the Bureau of Epidemiology wish to thank the participants, on behalf of CDC and the citizens and visitors in Florida, for their dedication to the improvement of the public health response capabilities.
Additional information about Epi-X and how to participate in this surveillance program is available at http://www.cdc.gov/epix.
Editor?s Note: Florida?s own EpiCom system of information exchange and emergency notification is modeled after CDC?s Epi-X and monitors public health events occurring in and affecting Florida. Interested readers can apply for EpiCom registration at https://www.epicomfl.net.
|Kathleen Ward, RS, MSEH, Regional Environmental Epidemiologist, Bureau of Community Environmental Health and Kim Geib, MSN, ARNP, Public Health Information Contact, Nassau County Health Department|
Questionnaires were prepared and were administered by telephone to three of the four groups of conference attendees identified as having illness. One large group of 570 attendees was surveyed by e-mail for history of illness only. Twenty-three stool samples were collected from ill attendees and food service workers and analyzed for bacterial and viral pathogens.
Statistical analysis of the data obtained from the interviews was conducted using EpiInfo version 6. A case was defined as any attendee of the meetings and/or a 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 January 25 and February 2, 2004.
The primary onset date of illness for Group A was Wednesday, January 28 with an average incubation time of 36 hours. The onset dates of illness for Group B ranged from Sunday, January 25 to Friday, January 30. Onset dates of illness for Group C ranged from Tuesday, January 27 to Saturday, January 31. The onsets of illness for Group D ranged from Monday, January 26 to Monday, February 2. The onsets of illness for the eight ill employees were from Tuesday, January 20 to Saturday, January 31 (See Figure 1).
The average duration of illness for Groups A-D and the food service workers was two to three days. The primary symptoms for Groups A-D combined were diarrhea, nausea, cramps and fatigue (See Table 1). The primary symptoms for the ill food service workers were nausea, fatigue, gas, diarrhea and vomiting (See Table 2). Twelve enteric stools and eleven viral stools were collected for analysis. All enteric results were negative for bacterial pathogens. Five of the eleven viral samples were positive for Norovirus G2.
There were also several reports of secondary cases of gastroenteritis among family members of ill persons as well as illness among some of their coworkers who did not attend the conferences.
Statistical analysis of data from Group A showed a slight risk association of illness with consumption of pizza from the Monday, January 26 lunch (OR = 4.13, 95% Confidence Interval = 1.22 < OR < 14.35, P-value = 0.008). No other foods or beverages showed significant risk in the initial analysis. Statistical analysis of all the data is continuing.
The spread of the viruses via fomites, person-to-person and possibly aerosolization, accounts for the widespread days of onsets for Groups B-D, as well as an extended exposure related to the conference attendees? length of stay at the resort.
Group A had a shorter exposure time and had the majority of illnesses occurring on Wednesday, January 28. This is indicative of a point source exposure to the viruses. There was some slight statistical risk of illness associated with the Monday, January 26 lunch pizza.
However, the incubation period typical to Norovirus (average ~34 hours) would implicate the Monday, January 26 dinner and/or casino event as the exposure point. This would indicate that multiple foods, beverages or even fomites (e.g., surfaces, casino chips for example), could have served as vehicles for virus transmission.
Norovirus particles are very hardy, resistant to chlorine and can remain viable outside of the human host for weeks. Proper hand washing after toilet use is the best method for preventing food borne Norovirus infection. Hand washing is especially critical prior to preparation of foods.
Food service workers who are ill with gastrointestinal symptoms must be restricted from duties during illness. Norovirus can continue to be shed fecally for up to 22 days after infection; therefore, ill workers must be restricted from food preparation and serving duties for at least 72-96 hours after cessation of symptoms.
|Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology||►New Events To Unfold at This Year's Statewide Epidemiology Seminar |
The Ninth Statewide Epidemiology Seminar at the Orlando Marriott in Lake Mary, from May 18-19, is one week away with a record number of attendees having registered so far. This year the seminar will be attended by not only public healthcare professionals but professionals in the private sector, schools of public health, healthcare professionals from other states and a couple of international attendees. Registration is still available for anyone not wanting to miss this annual event sponsored by the Bureau of Epidemiology. Obesity, nosocomial infections prevalence in the US and their impact on Florida, antibiotic resistance, inter-species transfer of organisms, mosquito borne diseases, and using Florida?s survey data are among some of the topics that will be discussed. A complete agenda can be accessed from the Bureau of Epidemiology Internet website at http://www.doh.state.fl.us/disease_ctrl/epi/conf/training.html.
Several new activities have been added to the program this year. For the first time, the event will begin with an evening dessert reception and the opportunity to pre-register for the seminar. Coffee and dessert will be served from 7:00 ? 9:00 p.m. on Monday, May 17th in Salons ABC on the first floor of the hotel, giving attendees the opportunity to network with other healthcare professionals from across the state. Pre-registration will be held concurrently, to allow early arrivals a chance to pick up their seminar materials in a relaxed setting and avoid the morning rush. The following day, the seminar will begin in earnest, with the registration desk opening at 7:30 a.m. and opening remarks scheduled to begin at 8:15.
The bureau will also be hosting ?County Showcasing,? which will provide county health departments a venue for displaying educational resources they have developed for healthcare professionals and sharing them with their colleagues. These items will be on exhibit throughout the seminar. If you would like to participate in this event, please contact Melanie Black.
A record number of persons have submitted abstracts for the poster session this year! The poster session and reception for the 41 entrants will be held the evening of May 18th with awards given for the best infectious disease poster, 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 and awards presented by Deputy Health Director Dr. Bonnie Sorensen, Florida Department of Health. Another added feature to this year?s program will be the Golden Partnership Awards, to be presented to county health departments and state health offices which have made significant contributions to public health this past year in disease control and surveillance.
Further information can be found on the Bureau of Epidemiology Internet website at 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.
|Jaime Forth, Copy Editor / Writer, Bureau of Epidemiology
|►Nipah Encephalitis One of New Crop of Emerging Diseases |
It hasn't been listed lately on ProMed, the Internet communication tool for the International Society for Infectious Diseases. And it probably won't be mentioned on any cable news networks. But the Canadian government earlier this year issued a travel advisory, and last month the WHO instructed a team of epidemiologists to develop guidelines for case management of this virus.
The peoples of Malaysia, Singapore and Bangladesh are already familiar with the new virus known as Nipah. First identified in 1999 in Malaysia, this cousin of the Hendra, an equine virus primarily found in Australia, is a member of the family Paramyxoviridae. Epidemiologic evidence shows that human cases are acquired by direct contact with pigs, although exposure through other animals, such as fruit bats, has not been ruled out. No human-to-human transmission has been documented.
Infection by the Nipah virus brings symptoms within 4-18 days of exposure. Some persons experience myalgia or influenza-like symptoms requiring no hospitalization. Some cases progress to inflammation of the brain with disorientation, convulsions and coma and patients are hospitalized, but may recover with neurological problems. Others, about 40% of all seriously ill patients, will die. According to the University of Malaysia, the first outbreak was noted in 1998, and by the middle of June 1999, more than 265 cases, including 105 deaths, had been reported. More recently, in April 2004, Bangladesh reported and CDC confirmed a cluster of 30 human cases, including 16 deaths attributable to the virus.
Since the virus is a recent discovery, further research needs to be performed to limit future human cases; but biosecurity is an important consideration for the CDC, which states that there is no effective treatment or vaccine for animals or humans. Nipah is an emerging pathogen that can be engineered for mass dissemination due to its availability, the ease with which it could be produced and spread, and its potential for high morbidity and mortality rates.
The World Health Organization held a consultation earlier this month on zoonoses and surveillance systems to monitor and control these agents. Its final recommendations included integrating medical disciplines to work synergistically on new surveillance and response tools; facilitating early detection of potential zoonotic public health events; and national and regional integration of animal and human health data for future preparedness and control.
"Recommendations from WHO's Consultation on Zoonoses." World Health Organization. May 5, 2004. http://www.who.int/mediacentre/briefings/2004/mb3/en/
Yee Ai, See. "Profile of a Virus." Star Online. April 10, 2000. http://agrolink.moa.my/jph/dvs/nipah/star000410/nipah-profile.html
|Carina Blackmore, DMV, PhD, Acting State Public Health Veterinarian, Bureau of Community Environmental Health||►Veterinary Medicine is Public Health in Practice
I am often asked the question, why did you decide to leave veterinary medicine for public health, from working with animals to working with people? The question always takes me by surprise. Public health veterinarians don?t look at public health as a career change. It's just a shift in focus from four-legged to two-legged animals; it's still multi-species medicine, but with the emphasis shifting from species-specific diseases to diseases that cross species boundaries.
Veterinarians are attracted to public health for several reasons. The list of diseases transmitted between animals and man is long and diverse. More than 30 diseases can be transmitted between humans and their dogs alone. This makes the field exciting and filled with opportunities for research and new discoveries. Zoonotic diseases can be bacterial, viral, parasitic, fungal, insect-borne, or of prion origin. They are transmitted by a wide variety of routes. Many naturally occurring zoonoses are rare in humans. However, the human disease outcome is often very severe. The transmissibility and pathogenicity of zoonotic pathogens make many of them excellent candidates for bioterrorism agents. To be able to diagnose diseases in multiple animal species, all with their unique disease presentations, veterinarians receive in-depth training in the basic principles of pathophysiology and microbiology. Having a thorough understanding of the principles of disease transmission and epidemiology is especially valuable during emerging disease investigations.
The cost-effectiveness of population-based preventive medicine is also stressed in veterinary school and well understood among practitioners. Large animal veterinarians vaccinate, screen, quarantine and cull animals if necessary to eliminate diseases from the herd. A stimulating challenge more or less unique to veterinarians in public health is to develop disease prevention strategies aimed at modifying human behavior.
The work of veterinarians has always affected human health, whether it is through supplying safe food products, caring for beloved four-legged family members, or helping build successful family businesses. Large animal and slaughterhouse veterinarians provide a critical link between agriculture and human medicine.
(Ed Note: Be sure to catch Dr. Blackburn's presentation on trans species migration of infectious diseases next week at the statewide epidemiology seminar.)
|Jaime Forth, Copy Editor / Writer, Bureau of Epidemiology||►Two New Graduates at Epi Bureau|
The Bureau of Epidemiology is pleased to announce two new graduates among our staff.
Brittni Jones, who has worked in the Surveillance and Reporting Section for the past three years, graduated this week from Florida A&M University with a Bachelor of Science degree in biology, pre-med. Her next goal is to earn a Masters degree in public health from Rutgers University by 2006, prior to fulfilling her ultimate goal of earning a medical degree. Brittni, who is originally from New Jersey, performs case report tracking for Merlin, fields lab results questions, and works with the CDC to close out case reports.
Michelle Spinella acquired her PhD in International/Intercultural Developmental Education from FSU's College of Education in the Department of Educational Leadership and Policy Studies. Prior to her decision to return to school, Michelle worked in the film industry as a production coordinator in Chicago, New York and Miami. After various trips to Cuba to do fieldwork at the national film institute in Havana, she wrote her dissertation entitled, "Cinema in Cuban National Development: Women and Film Making Culture," which examined the educational use of film as a mass medium in Cuban national culture. At the Bureau of Epidemiology, she works on the PRAMS research project, conducting interviews with new mothers to determine behavior affecting maternal and infant health statistics.
We're proud of the successes of these graduates who worked very hard to achieve their goals, and wish both of them all the best as they look to the future.
|D. Fermin Arguello, MD, CDC Epidemic Intelligence Service Officer, Bureau of Epidemiology||
Bureau of Epidemiology Grand Rounds Program
|Pete Garner, Surveillance Systems Manager, Bureau of Epidemiology||►This Week on EpiCom|
- Announcement about the new CDC Web site with updated information on global and domestic malaria prevention and control. Features of the new site include:
- Nassau County reported 59 confirmed cases of Norovirus at a long-term health care facility.
- A Sarasota elementary school reported five cases of varicella in the same classroom. An investigation is ongoing.
- Giant African snails, immediate hosts of the lugworm which causes flu-like symptoms, have been found in several states in the Midwest. The outbreak originated in Miami. Humans can be infected through direct contact with snail secretions and by ingesting snails.
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.
|Arbovirus Surveillance Team: Caroline Collins, Kristen Payne and Calvin DeSouza, and Program Manager Carina Blackmore, DVM, Ph.D., State Public Health Veterinarian, Bureau of Community Environmental Health||►Mosquito-Borne Disease Update
No Florida counties are under medical alert. There have been no human cases confirmed yet this year. In areas with mosquitoes present, people are still encouraged to take precautions against mosquito bites.
West Nile (WN) Virus activity: There were four seroconversions to WN virus reported this week in sentinel chickens, one in Hillsborough (4/6) County, one in Indian River (4/22) and two in Walton (4/5, 4/12) County. So far this year, there have been 70 sentinel seroconversions to WN virus in 13 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, 19 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: There was one seroconversion to EEE virus reported this week in a sentinel chicken from Flagler County (4/26). To date, 17 sentinel chickens, six horses and six live birds have tested positive for EEE virus, for a total of 12 counties reporting EEE virus activity this year.
Highlands J (HJ) Virus activity: There were two seroconversions to HJ virus reported this week, one in Orange County (4/5) and one in Walton County (3/29). To date, there have been 12 seroconversions to Highlands J virus in sentinel chickens from four counties and one HJ-positive live bird from Santa Rosa County, for a total of five counties reporting HJ virus activity this year.
For more surveillance information, see the DOH Web site at http://www.doh.state.fl.us/Environment/hsee/arbo/index.htm or call the Disease Outbreak Information Hotline which offers updates on medical alert status and surveillance at 888.880.5782.