June 17, 2005
Epi Update Managing Staff:
"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., International
Journal of Epidemiology 1976; 5:29-37
Within two hours a home visit was conducted to gather information on exposure and symptomology. The onset of illness occurred within the recognized incubation period of 1-14 days as stated in the Control of Communicable Diseases Manual. Symptoms were consistent with tularemia exposure and included upper respiratory symptoms, high fever and swelling of the regional lymph nodes. The primary physician had already ruled out most differential diagnoses. A blood sample was collected and delivered to the Tampa DOH Bureau of Laboratories for tularemia PCR and culture. The patient was under the care of the attending infectious disease specialist (IDS) at All Childrenís Hospital (ACH), but he was out of town. The covering IDS was telephoned for case consultation and the two agreed that the covering IDS would perform a chart review to assess the feasibility of obtaining a lymph node aspirate. The results of the PCR were reported from the lab that evening as negative. The family was contacted and notified of the results with the explanation that these were preliminary results on peripheral blood.
On May 26, the patient case was transferred to DCD. As advised by the covering IDS, a lymph node aspirate was ordered for June 2. However, the procedure was subsequently canceled because the ACH surgeon determined it was no longer warranted due to a decrease in the size of the lymph nodes.
On May 27, initial culture results from the Tampa laboratory showed no growth. The culture incubated for seven days with no growth on final observation.
On June 3, an appendectomy was performed on the patient.
On June 8, as advised by the attending IDS, no further action was intended for this patientís initial suspected illness, as the serology results from the specimen collected and then tested by Quest Diagnostics on May 24 were negative.
On June 9, a message was left with the patientís mother regarding closure of case and urging her to contact the PinCHD if the family required further assistance.
The accessibility of local health department contact information to the public on the Internet led to the call that initiated the case investigation. The prompt communication and cooperation between PinCHD divisions (DCD, PHP and ENV), DOH Bureau of Laboratories (Tampa Branch), and community partners facilitated the timely availability of laboratory results and investigation. The time of case investigation initiation to presumptive laboratory results was nine hours. If this had indeed been a case of tularemia or another level-A bioterrorism agent, the rapid response time would have been well within the 24-hour recommended response time by the Florida DOH.
Dr. Julia Gill is the epidemiology program manager at the Pinellas County Health Department and can be reached at
727.824.6932. Suzanne DeKay is an epidemiologist at the Pinellas CHD, and
Maria Donnelly is an EIS fellow assigned to the facility.
Eat Puffer and You Will Suffer
From 2002 through 2004 twenty eight cases (2002-21 persons, 2003-2 persons, and 2004-5 persons) were investigated and interviewed by county and regional epidemiologists/ environmental health professionals. Surveillance and extensive inquiries were vigorously pursued utilizing county health department foodborne illness logs, Florida Poison Control, local health care providers and hospital infection control practitioners/emergency departments.
A case was defined as a person who experienced tingling or numbness in the mouth and/or lips following the consumption of Florida puffer fish. A standardized questionnaire was used during the course of all interviews. Predominant symptoms described by the ill cases included generalized numbness or tingling in lips/arms/legs/face, vomiting, nausea, breathing difficulty, speech difficulty, confusion, headache, dizziness, diarrhea and muscle aches. Nine cases reported no symptoms.
Urine samples and puffer fish remnants were collected from several of the cases. The Centers for Disease Control and Prevention (CDC) and the United States Army Medical Research Institute Laboratory found the presence of saxitoxin in all five urine samples that were submitted. The environmental specimens of puffer fish were analyzed by the FDA. It was determined that the southern puffer fish collected were very toxic in the flesh, skin, mucous and gut. The USFDA regulatory limit for saxitoxin in shellfish is 80u/g saxitoxin equivalent toxicity/100g. Saxitoxin concentrations ranged from 200-5300 ug saxitoxin equivalent toxicity/100g.
Ed Note: This abstract was submitted and displayed as a poster at the 2005 statewide epidemiology seminar in Lake Mary. Look for other entries in upcoming issues of Epi Update.
Date: Tuesday, June 28, 2005 11:00 a.m. -12:00 p.m. ET
Of the 23 pertussis cases identified, 15 (65%) were confirmed; 7 by isolation of B. pertussis and 8 by epidemiologic linkage to a laboratory confirmed test. Eight (35%) cases were considered probable with serologic testing. Median age was 13 years old. Cases were found in a five major settings including daycare, middle school, high school, church and a home where multiple families stayed during the hurricane.
Due to the aftermath of Hurricane Ivan, many barriers were identified during the investigation. Several interviews were conducted by visiting individuals at their homes because of downed phone lines. Damage to roads and bridges increased travel time to hospitals and health care providers significantly. Additional interviewing and review were necessary to determine if any patient cases had spent time in shelters during the hurricane. Despite these barriers, the collaborative investigation team successfully completed the outbreak investigation while providing education and outreach to the community and health care providers.
Aimee Pragle is an EIS fellow assigned to the NE Florida Consortium; Dawn Ginzl is an EIS fellow assigned to the Orange County Health Department; Darci Lolley and Cathy Mellinger are assigned to the Florida Department of Health Bureau of Immunizations.
The Centers for Disease Control and Prevention has made available important information to public health practitioners on food safety, immunizations, mental health and other facets of hurricane disasters in the Internet. For general information, click on http://www.bt.cdc.gov/disasters/hurricanes/health.asp.
Information designed specifically for health
Key facts about hurricane recovery:
Carbon monoxide safety:
Jaime Forth is managing editor of Epi Update and can be reached at 850.245.4444, ext. 2440.
West Nile (WN) virus activity: Two seroconversions to WN virus were confirmed in sentinel chickens from Hillsborough and (South) Walton Counties.
Eastern Equine Encephalomyelitis (EEE) virus activity: Seven seroconversions to EEE virus were confirmed in sentinel chickens from Nassau (2), Orange (3), Putnam (1), and St. Johns (1). Six horses from Alachua (1), Flagler (2), Gilchrist (1) and Marion (2) Counties were confirmed with EEE this week.
St. Louis Encephalitis (SLE) virus activity: None yet this year.
Highlands J (HJ) Virus activity: None this week.
There are no counties currently under medical alert for mosquito-borne disease. Where mosquitoes are present, people are urged to take precautions against getting bitten.
Dead birds should be reported to www.wildflorida.org/bird/. See the web page for more information at www.MyFloridaEH.com. The Disease Outbreak Information Hotline offers recorded updates on medical alerts status and surveillance at 888.880.5782.
The Bureau of Epidemiology encourages
Epi Update readers to not only register on the EpiCom system at
https://www.epicomfl.net but to sign up for features such as automatic
notification of certain events
contribute appropriate public health observations related
any suspicious or unusual occurrences or circumstances. EpiCom is the primary method of communication
between the Bureau of Epidemiology and other state medical agencies during emergency situations.
Christie Luce is an EpiCom
consultant in the Surveillance Systems Section of the Bureau of
Epidemiology. She can be reached at 850.245.4444, ext. 2450.
Click here to review the most recent disease figures provided by the Florida Department of Health Bureau of Epidemiology.
D'Juan Harris is a GIS
specialist in the Surveillance Systems Section of the Bureau of