June 17, 2005

Epi Update Managing Staff:

John A. Agwunobi, MD, MBA, MPH, Secretary, Florida Department of Health
Landis Crockett, MD, MPH, Director, Division of Disease Control
Dian K. Sharma, MS, PhD, Bureau Chief, Bureau of Epidemiology, Editor-in-Chief
Jaime Forth, Managing Editor, Bureau of Epidemiology

"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



Ed note: You may notice that email addresses are no longer provided as a method of contact for contributing authors. We regret this inconvenience. This is a  new security measure designed to prevent Internet hackers access to Department of Health email accounts.

Suspect Tularemia Case from
Wild Rabbit in Pinellas County
by Julia Gill, PhD, MPH; Maria Donnelly, MSPH; Suzanne DeKay, MSPH, OPHP

On May 25, 2005 the Pinellas County Health Department (PinCHD) Environmental Health Division received a telephone call from a parent regarding his daughter, who was suspected of having contracted tularemia following exposure to wild rabbit blood in January 2005. He was subsequently referred to the Disease Control Division (DCD), Epidemiology Department. The case was transferred to PinCHD Public Health Preparedness personnel and an investigation was initiated. Pinellas County Animal Services and the Florida Department of Health (DOH) public health veterinarian were notified by telephone to assess the probability of this disease in the specific geographic area. The State of Florida Lab Reference Guide, created by the DOH and the University of South Florida Infectious Disease Institute was utilized to determine what types of samples would be needed for testing.  

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 Children’s 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 patient’s 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 patient’s 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
by George R. Jackow Sr., Dean Bodager, and Joy Hill

Background
Since 2002 a perplexing public health problem had suddenly emerged in the recreational waters of the Indian River Lagoon and Banana River. It involved Puffer fish previously thought to be safe for human consumption. From 2002 through 2004 twenty eight cases of Puffer fish poisoning were reported to the health department. All case exposures were subjected to Florida-caught Puffer fish extending from the Max Brewer Causeway in Titusville to the Pineda Causeway, north of Melbourne, Florida. The majority of individuals who consumed the Puffer fish experienced diverse symptoms including numbness in lips, mouth and face, tingling in fingers and toes, headache, dizziness, muscle weakness, nausea, vomiting, motor uncoordination, confusion, speech difficulty, memory loss and respiratory related problems. The onset of illness varied from 30 minutes to several hours. Hospitalization for some of the reported cases was necessary and the duration of hospital stays ranged from one day to several days. All patients survived the poisoning episodes. 

Methodology/Results
As a result of the puffer fish poisonings the scientific community assembled the resources to conduct intensive research in hopes of determining the source and cause of the poisonings. The epidemiological/environmental investigation process was initiated in 2002 through the New Jersey Department of Health and a Canadian Laboratory who analyzed the puffer fish samples and determined that they contained saxitoxin. Toxin profiles revealed dinoflagellate Pyrodinium bahamense, which was previously not known to be toxic in the Unites States. The Florida Fish and Wildlife Conservation Commission (FWC) and United States Food and Drug Administration (FDA) confirmed saxitoxin and dinoflagellate Pyrodinium bahamense from the Indian River Lagoon, and in other biota. 

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. 

Conclusions/Recommendations
In response to the puffer fish poisoning threat based upon the information and knowledge acquired during the investigations a number of regulatory and risk communication activities were applied. A temporary puffer fish harvest ban (commercial and recreational- extending from Volusia to Martin counties) was initiated by FWC covering a two year period. However, due to the persistence of toxicity in the Indian River Lagoon area, a permanent ban was put into effect. Even with the initial ban in place people were still consuming puffer fish and becoming ill. As a result of this ongoing condition a continuing education and outreach program was implemented to counteract the erroneous information disseminated by some of the professional and recreational fishermen and misinterpretation of data by the public at large.

Risk communication was critical and imperative and consequently, posters, flyers, press releases, information palm cards, advisories were issued to the public by FDA, FDACS, FDOH and FFWC. To focus attention on the severe reactions resulting from the consumption of puffer fish a collaborative effort involving the Brevard County Health Department, Florida Department of Health Environmental Epidemiology and Florida Fish and Wildlife Conservation Commission Public Information Coordinator were initiated. A 13-minute DVD entitled PUFFERFISH: POISON PREVENTION was produced and distributed to local government access cable for public viewing. Included in this DVD were two testimonials of previously ill individuals. This was a crucial element in the production because more individuals will listen to someone who has experienced a situation or condition than merely taking the government’s word or warning. Their involvement proved to be invaluable and consequential. Since the release of the DVD, no cases of puffer fish poisoning have been reported. At this juncture, the time and energy exerted by all parties concerned have paid dividends with positive outcomes. The worthiness of the project speaks for itself.
               
George Jackow Sr. is an environmental health specialist in epidemiology at the Brevard County Health Department and can be reached at 321.454.7105. Dean Bodager is a regional environmental epidemiologist in the Food and Waterborne Disease Program at the Bureau of Community Environmental Health in Tallahassee. Joy Hill is a public information coordinator in the Office of Informational Services, Florida Fish and Wildlife Conservation Commission.

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.

 
Pertussis Outbreak During Hurricane
to be Topic of June Grand Rounds
by Aimee Pragle, MS; Dawn Ginzl, MPH; Darci Lolley, MS and Cathy Mellinger, RN
 

Date: Tuesday, June 28, 2005 11:00 a.m. -12:00 p.m. ET 
Title: Management of a Pertussis Outbreak during Hurricane Ivan 
Presenters: Aimee Pragle, MS, NE Florida Consortium; Dawn Ginzl, MPH, Orange County Health Department; Darci Lolley, MS, Bureau of Immunizations; Cathy Mellinger, RN, Bureau of Immunizations

Abstract
Following Hurricane Ivan, public health staff in Florida provided assistance and response to impacted communities. In addition to surge capacity hurricane activities, Santa Rosa County Health Department continued an investigation of a localized pertussis outbreak. A collaborative team of county and state agency partners worked to conduct contact investigations, coordinate nasopharyngeal testing and prophylaxis, contact medical providers and laboratory facilities, and input data for disease reporting and analysis. 

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. 

Additional Information
The grand rounds presentation will begin promptly at 11:00 a.m. ET on Tuesday, June 28, 2005. The PowerPoint slides and dial-in number will be posted on the Bureau of Epidemiology intranet website on Friday, June 24. CEUs will be provided for nurses and laboratorians. If additional information is needed, contact Professional Training Coordinator Melanie Black, MSW at 850.245.4444 ext. 2448.

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.

 
CDC Provides Hurricane Preparedness
and Response Sites
by Jaime Forth

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 professionals:
http://www.bt.cdc.gov/disasters/hurricanes/hcp.asp

Key facts about hurricane recovery:
http://www.bt.cdc.gov/disasters/hurricanes/recovery.asp

Hurricane readiness:
http://www.bt.cdc.gov/disasters/hurricanes/readiness.asp

Carbon monoxide safety:
http://www.bt.cdc.gov/disasters/carbonmonoxide.asp

Jaime Forth is managing editor of Epi Update and can be reached at 850.245.4444, ext. 2440.

Mosquito-borne Disease Update   June 5 -11, 2005
Rebecca Schultz, MPH, Caroline Collins, Tasharra Kenion, Calvin DeSouza, Carina Blackmore, Ph.D.

Weekly Update: During the period June 5 -11, 2005, the following arboviral activity (St. Louis encephalitis [SLE] virus, eastern equine encephalomyelitis [EEE] virus, Highlands J [HJ] virus, West Nile [WN] virus and dengue virus) was recorded for Florida: 

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.

     

           This Week on EpiCom
                                      by Christie Luce

• Bacterial meningitis in St. Lucie
• Suspected Salmonella outbreak in Collier County
• Infant pertussis death in Polk County
• Bacterial meningitis case in Escambia County

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.
 

                         Weekly Disease Table
                                                          by D'Juan Harris, MSP

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 Epidemiology.
He can be reached at 850.245.4444, ext. 2435.

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