Background. On February 20, 2003, the Broward County Health Department was notified that a local day care center had closed in response to symptoms of vomiting and diarrhea in 59 children and 6 staff members. A subsequent report noted that 25% of persons who ingested a catered lunch became ill, while 36% who ate non-catered lunches were ill; thus, the catered lunch was determined not to be the causative agent. 

One child was hospitalized and a stool specimen of a sibling tested negative for bacterial pathogens. Viral testing was not conducted. The symptoms and duration of illness were suggestive of norovirus infection. It was noted that fomite transmission through the sharing of toys and fecal contamination in small children who are improperly washing their hands, can occur often in daycare settings.

After thorough cleaning and sanitization, the facility was reopened on February 24^th.

Investigation. A visit by health department officials included interviews with the director and staff members, a review of current operating procedures and an inspection of food service and storage practices.

Outcome. The following recommendations were made by investigators:

1. Staff members who change diapers should be excluded from food handling.

2. Procedures should be implemented to check the temperature of catered foods. Delivered food that is outside the proper temperature range should be refused. Daycare employees should pre-heat hot boxes early in the day to establish a proper holding temperature. Employees were made aware that hot boxes are designed only to keep food at a warm temperature of 140 degrees.

3. Daycare staff were advised to consider serving lunch earlier to accommodate the four hours from time of production to consumption rule for out-of-temperature foods.

4. Staff were advised not to immerse milk cartons in coolers on the floor of the kitchen area, since the use of ice chips as a coolant creates a potential for cross contamination of all cartons. Refrigerators must be equipped with ambient temperature indicators. If domestic rather than industrial refrigerators are used, they should be equipped to handle large amounts of food.

5. Because a sink is not situated near the diaper changing area, it was recommended that either the changing area be moved closer to the sink, or a sink be installed in easy proximity to the changing area.

6. There should be separate sinks for washing hands and sanitizing food utensils. Spray from soiled hands contaminates the surrounding area and is unsuitable for washing food utensils. It was recommended that all eating/drinking utensils be washed and sanitized using three-compartment sinks to wash, sanitize, rinse and allow utensils to air dry; or alternatively, install a dishwasher that can sanitize eating utensils at high temperatures.

7. Toys and other surfaces should be thoroughly cleaned between play time and class changes. A daily cleaning schedule which includes common carriers, rails, door knobs and floors should be strictly observed. Sleeping mats should be included in this routine.

8. Children should be supervised to ensure they clean their hands after use of toilet and play, and before meals and naps. The use of alcohol sanitizers may be used as an adjunct device, but not in lieu of thorough hand washing with soap and water. Placing sanitizers in each wash area or room may help reduce hand contamination.

9. Because recommendations to parents regarding safe lunch items for room temperature storage have gone unheeded, they should be advised to at least provide cooling containers for their children’s lunches.

10. A designated area should be established for children with cold and flu symptoms until they are symptom free or determined not to be contagious.

11. Floors should be sanitized. Soft surfaces should be cleaned routinely to remove dust and other debris, so children with asthma or upper respiratory ailments are not unduly exposed to pollen, dust or other irritants.

Anyone with questions regarding this incident should contact Karen LaFleur at the Department of Health-Environmental Epidemiology in Broward County, at 954.467.4841.

As a result of this new law, plus funding from the Blum-Lovler Foundation and urging from physicians around the country, The Johns Hopkins Center for Civilian Biodefense Strategies recently announced the opening of a new, not-for-profit Internet-based network designed for and operated by clinicians. Named Clinicians’ Biodefense Network, it will be used to facilitate communications between biodefense experts and local officials throughout the U.S. in the event of a bioterrorism attack.

The network has three main purposes: To provide an efficient method of rapid communications for clinicians; to link clinicians with biomedical researchers and public health experts for diagnostic and management information; and to transmit regular updates about trends in biodefense to industry professionals.

Recognized clinicians from around the country have been tapped to serve as clinical leaders, who will relay outbreak information from their communities to the Hopkins Center. This information will include a description of the disease, the scope of the outbreak and treatment strategies.

Top biomedical researchers and biodefense experts will perform as affiliated experts, available for consultation on scientific and technical issues which may arise in the aftermath of an attack. They’ll advise on treatment guidelines, laboratory testing, diagnostic information and mass casualty plans of action.

The third component of the network is network subscribers who can harvest, integrate and circulate the information to health care professionals in their clinical areas.

If you haven’t registered yet for the June 3-4 Bureau of Epidemiology Seminar, the deadline for registration and accommodations reservations is just a few days away.

The seminar will be held at the Orlando Marriott in Lake Mary, conveniently situated 15 miles outside downtown Orlando. A complete registration form listing agenda and confirmed speakers is accessible at http://www.doh.state.fl.us/disease_ctrl/epi/conf/training/index.htm.

A special group rate has been arranged through the Orlando Marriott. To make room reservations, call the Marriott directly at 407.995.1100 or call their main reservations line at 800.228.9290 and ask for the Lake Mary location. Use the code FDOFDOA and refer the agent to the FHOD Epidemiology Statewide Seminar. You can also reserve rooms through the hotel website at www.marriott.com/MCOML. The hotel site contains detailed information regarding area activities, driving directions and amenities.

A poster presentation and reception will take place the first night of the seminar. This year, for the first time, a panel of judges will be on hand to award displays in the following categories: Best presentation by a Florida EIS Officer, best infectious disease display, best chronic disease display, and best county health department display. Winners will be announced at the following day’s luncheon. Format for poster displays will follow a basic scientific paper outline using:

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
Conclusion – A summary of findings, supported by your results (numbered, if conclusions are multiple).

Posters can be displayed in three-fold foam board format or other appropriate conference style. Please note that each presenter will be responsible for ensuring his/her display is assembled prior to the beginning of the session, and removed promptly afterward. Technical assistance is available through Bureau of Epidemiology staff. To participate, or to arrange supplies, contact Ronee’ Wilson at 850.245.4444, ext. 2445 by close of business May 23^rd (that’s today!).

Surveys. Personnel in this section design and implement the Behavioral Risk Factor Surveillance System (BRFSS); the Pregnancy Risk Assessment and Monitoring System (PRAMS); the Florida Youth Tobacco Survey (FYTS); the Youth Physical Activity and Nutrition Survey (YPNS); the Youth Risk Behavior Survey (YRBS), and the Adult Tobacco Survey (ATS). Staff members also manage the Florida Cancer Data System (FCDS), aka the Florida Cancer Registry, which recently won awards from the NAACCR.

The BRFSS is an annual telephone survey of Florida adults on individual risk behaviors and preventive health practices related to the leading causes of morbidity and mortality in Florida. In addition to annual statewide BRFSS surveys, staff members implemented a large scale county BRFSS survey in 2002.

The PRAMS is a mail/telephone survey of mothers of Florida newborns, designed to provide information about risk factors for pregnancy adverse outcomes and ill health in newborns.

The FYTS is a statewide school-based survey of tobacco beliefs, attitudes and behaviors among middle and high school students. The YRBS is a statewide survey of behavioral risk factors that contribute markedly to the leading causes of death, disability and social problems among high school students. The YPNS is a survey of physical activity and nutrition among middle school students. All these school-based surveys are part of the Florida Youth Survey, which is coordinated with the Departments of Children and Families and Education, and the Governor’s Office on Drug Control.

The ATS is a new survey, currently in the field. Using BRFSS protocol, the ATS is a population-based telephone survey of adults on their tobacco use behaviors, attitudes and knowledge. This survey is being conducted in partnership with the Division of Health Access and Tobacco and with technical support from the CDC.

The FCDS is a statewide cancer registry mandated by state law. The registry receives over 80,000 cases annually and maintains a large database with over 1,300,000 cancer incidence records. It also maintains a cancer mortality file based on data provided from the Florida Bureau of Vital Statistics.

Epidemiological Studies. Staff in the Chronic Disease Section conduct epidemiological studies on chronic disease and risk factors for health professionals and the general public; provide epidemiologic consultations for county health departments and disease prevention programs, and perform analyses on numerous population-based data, including the aforementioned surveys, hospital discharge data, and mortality data. Study results are disseminated through print and electronic media and are presented at professional conferences and community meetings. Most of these reports are posted on the DOH web site:

As the Epi Update is a weekly bulletin, try to keep the article brief enough to enlighten readers, but stimulating enough to create a desire for more information. To facilitate inquiries, a point of contact is now included at the close of each article.

Font should be 10 point Ariel with no boxes, centering or other elements added to the text. Only final documents (not drafts or web links) are accepted. Charts, graphs or other data should be included as attachments; the article itself should be sent as an attachment to an e-mail message.

Do proof your information to ensure it’s factually correct prior to submission, and include the writer’s name, title, contact information and whatever professional designations are appropriate.

As the publication evolves, the content will shift more towards articles that are in-depth and deal with current issues, policy changes, outbreaks, Epidemiologic studies and research, reviews and analysis. However, announcements and other informational items will always be welcomed.

Have we piqued your interest? We hope so! The deadline for receipt of articles is noon every Wednesday. Sorry, no exceptions.

Since September 29, 11.8% (n=10,961) of the 83,129 specimens tested nationwide have been positive. Three thousand three hundred and thirty-five (53%) of the 6,267 influenza A viruses have been subtyped; 2,515 (75%) were influenza A (H1) viruses and 820 (25%) were influenza A (H3N2) viruses. Influenza A viruses were reported more frequently than influenza B viruses (range 58% - 86%) in the New England, East North Central, Pacific, Mountain, and Mid-Atlantic regions, and influenza B viruses were reported more frequently than influenza A viruses (range 53% - 79%) in the West North Central, West South Central, South Atlantic, and East South Central regions. CDC has characterized 173 influenza A (H1N1), 55 influenza A (H1N2), 104 influenza A (H3N2) and 222 influenza B isolates antigenically. The neuraminidase typing for 1 H1 virus 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).

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. It is particularly important 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.

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

Bird Mortality: Two dead birds from Alachua and Madison counties were reported positive for EEE virus this week.

Equine*: Twelve EEE virus infections in horses were reported from Alachua, Bradford, Dixie, Hamilton, Manatee, Marion (2), Orange, Osceola, Pasco (2) and Seminole counties. Five new counties reported cases: Hamilton, Manatee, Orange, Pasco and Seminole.

Wild and Captive Birds: See http://www.pherec.org/DECS Arbovirus Ecology to view database.

Mosquito Pools: No mosquito pools reported positive for WN or EEE virus this week.