Friday, June 18, 2004

         This Week in the News
 

Foege, WH., et al., 
International Journal of Epidemiology
1976; 5:29-37

►Seminar Poster Winners in the Spotlight
The 2004 statewide seminar on epidemiology, co-sponsored by the Florida Infectious Disease Institute, featured an adjudicated poster session. For a list of the award winners, read further.
 

►Methicillin-Resistant Staphylococcus aureus (MRSA) in  Escambia County Jail
A thorough examination, conducted last month, of events surrounding a breakout at the North Florida facility.
 

A R T I C L E S

In a year when an unprecedented number of entries (41) were received and the topics were as diverse (from tobacco to susumber berries, from pregnancy to UV exposure) as ever seen, we wondered if we'd given our judges too difficult a task. But at the end of the evening, the results were in and the scores were impressive.

• Winner of Best Poster by an EIS fellow was Jose Lojo, MPH. His poster was entitled Laboratory-based Surveillance of Norovirus in Florida, January 2001-March 2004
• Best Infectious Disease Poster was Control of Shigelloses in Public Schools, by George Jackow, Saroj Aggarwal, MD, MBA, Cheryl Dunn, Beth Shepard, Richard Smith, Barry Inman, Jim Richardson and Pam Hamilton
• Named Best Chronic Disease Poster was Risk Factors for Lead Poising Among Immigrant Cuban Children, by Mary Jo Trepka, MD, MSPH, Vukosava Pekovic, MD, PhD, Juan Carols Santana, MD, and Guoyan Zhang, MD, MPH
• Kelly Granger, MPH, CHES submitted Best Poster by a County Health Department. Her poster was entitled UV Exposure from Mercury Vapor Lamps.

Deputy Director, Florida Department of Health, Dr. Bonnie Sorensen was on hand to present certificates and deliver congratulations at luncheon on May 18th, where the judges were also recognized for their role. Julia Gill, PhD, MPH, Pinellas County; Savita Kumar, MD, MPH, Palm Beach County; Roger Sanderson, MA, RN, Regional Epidemiologist; Karen Eaton, MBA, RN, Tallahassee; Fermin Leguen, MD, MPH, Miami-Dade County; and Sterling Whisenhunt, Seminole County, presided over the judging. 

The poster session was coordinated by Karen Wheeler, MPH, bioterrorism surveillance coordinator at the Bureau of Epidemiology.

Abstracts on award-winning posters as well as others submitted will be featured in upcoming issues of the Epi Update.
 

Announcements. Don Ward stated that after a protracted search for a state epidemiologist and a bureau chief, the positions remain to be filled.

There is a strong federal commitment to bioterrorism funding; any uncertainty states may be sensing could be due to the way in which the funding is routed through the CDC. This issue will continue to be addressed.

Medical Examiner Commissioners Meeting. Karen Wheeler reported that medical examiners in Florida have been connected to EpiCom. Their surveillance data on suspicious deaths, provided in real time, can give us the opportunity to react promptly, if needed, to related infectious diseases.

Surveillance Data Update. Carmela Mancini described the work staff is performing to   upgrade the current reporting system. After a review of the extended data on case definitions, the group decided that epidemiology contacts at the CHDs will be sent correspondence seeking clarification on Merlin reports. CHD personnel will be responsible for updating their data in Merlin. 

Investigating hepatitis or other infectious disease cases occurring in detention facilities or hospitals needs to be fully pursued so a complete set of data can be input to the Merlin report.

Soft tissue or waterborne microbacterium infections related to surgery in the Dominican Republic should be reported promptly.

County Outbreak Reports. (All reports were cited on EpiCom; full details can be viewed by logging on to the Web site).

Broward CHD/Community Acquired MRSA - Dr. Blankenship reported that after a report on May 13 of MRSA in inmates in the detention system, there was a walk-through by members of the CHD, and management at the jail implemented prevention measures. The number of patient cases has stabilized since then. The latest number is 31. The route of transmission appears to be random. Some cases were carried into the jail upon admission.

Indian River CHD/Bacterial Meningitis - Robin Szanc reported that a student athlete who had been in contact with others was the single confirmed case.

Bay CHD/Foodborne - Michael Fluharty stated a restaurant at St. Andrews caused 13 persons to report food poisoning with no fever. Another group of 18 persons reported food poisoning soon afterward. The DBPR was notified and inspected the restaurant. More calls from restaurant patrons followed. In the end, over 100 persons were affected. DBPR cited the restaurant for a number of health violations.
 

On May 26, 2004, the Escambia County Health Department (ECHD) was notified of an increase in the number of inmates at the Escambia County Jail (ECJ) with Staphylococcus aureus (Staph) infections suspected to be MRSA. Preliminary indications were of eight suspect cases of MRSA/Staph infections within the prior week. A case was defined as the occurrence of a skin boil or large pimple that was evaluated by the infirmary physician between May 22-27, 2004. The infirmary formally identified six cases that met the case definition. ECJ has approximately 1800 inmates. 

This report describes the site visit to the ECJ infirmary by the ECHD on May 27 and recommended control measures to prevent MRSA/Staph infections in the facility. During the visit, ECHD personnel were given the opportunity to speak with the three inmates in isolation, as well as their attending physician, the director of nursing, and a guard.   

General Facility:
The staff and cases were interviewed regarding sanitary conditions of the general inmate population: clean linens are distributed once a week, towels once or twice a week, razors once a week and jumpsuits twice a week. Each inmate is given a bar of soap and plastic soap dish at entry into the facility. Deodorant is not standard issue but can be purchased. No personal items (towels, razors, soap) were reported to be shared. Laundry is removed for cleaning, bagged, and sent to the laundry facility. The inmate population in each cellblock is responsible for helping to clean their personal hygiene facilities. The inmates share games, cards, books, and magazines.   

Infirmary Staff Discussion:
Six cases of MRSA/Staph infections among inmates were positively identified by infirmary staff (see Table 1, 2). Due to increasing MRSA/Staph infection concerns, new inmates are screened for active infections during their routine physical exam at entry into the facility. The attending physician indicated this process is effective in identifying cases of active infection among incoming residents. Culture and sensitivities are completed periodically. Currently, patients are responding to a 10 day regimen of doxycycline. Depending on the severity of the case, doxycycline is sometimes paired with  sulfamethoxazole / trimethoprim (Bactrim®). The physician indicated the back and groin were common sites of infection. Cases with draining lesions are isolated in a single occupancy infirmary room; those having non-draining lesions are considered non-infectious and not placed in isolation. On average, the physician reported draining one lesion per month. Isolation cases shower after others at the end of the day. The showers are disinfected after use. 

            Table 1.  Demographic Information, MRSA/Staph Cases, Escambia                               County Jail, May 22-27, 2004, (n=6)

                       Table 2. Clinical Information, MRSA/Staph Cases, Escambia County Jail, May
                       22-27, 2004, (n=6)

*      Cases had more than one boil location.
**     Lab work performed on two cases was confirmatory for MRSA. 
Antibiograms were not similar. No common exposure was identified among the six cases. 

Infirmary inmate interviews:
At the time of the site-visit by ECHD, there were three remaining cases under isolation in the infirmary. Contact isolation signs were appropriately placed on the doors of these isolation cells.  Cases indicated while in the infirmary they were given towels, linens, and jumpsuits every two days, although they were told on the morning of our visit that these items would be changed daily.  Razors are given weekly. Inmates continued to use the same issued bar of soap. The isolation cells (sink, toilet, floor) were cleaned daily by housekeeping personnel. Patient cases had a poor understanding of the transmission cycle and the prevention of MRSA/Staph infections.   

Two of the three inmates self reported to the infirmary after their boils/lesions became too painful to tolerate. Both found the initial boil several days before reporting to the infirmary. Both patients reported having a similar situation (the appearance of boils) within the past year before they were in the jail facility; one sought care for a lesion at the emergency department. The other indicated ?spider bites? as the source of infection. (No spider was found.)   

The third patient case was new to the facility. His infection was identified during the routine medical exam given at admittance to the facility. The boils had been present for several days before commitment to the facility and while still at home, the patient attempted to pop the boils.   

In all isolation cases, the lesions were appropriately covered. One of the patients was in need of having the dressings changed. It was reported that inmates are concerned about sending  undergarments to the laundry because they get lost. As a result, these items are hand-washed in the shared sinks by the owner and hung to dry. Patient cases reported no recent tattoos. One patient reported inmates use the shower area for physical fitness activities (push-ups, sit-ups). One patient reported obtaining a partially used deodorant solid from another inmate.   

Partial list of ECHD recommendations:

Inmate Population 

• Remind inmates daily to wash hands and keep personal spaces clean.
• Provide ECHD "Prevention of Staph Infections" information sheet.
• Request inmates immediately report any boil/pimple or ?spider bite? to the infirmary staff for evaluation and treatment.
• Continue to instruct inmates not to share personal hygiene items.
• Encourage all inmates to launder all items instead of hand-washing undergarments.

Facility Employees  

•  Provide ECHD "Methicillin-Resistant Staphylococcus aureus (MRSA) Questions and Asnwers" information sheet to facility employees

• Encourage employees with regular inmate contact to identify and report Staph infections among inmates.

      General

• Individual liquid soap is recommended. Bar soap stored in a plastic container is not able to drain well and can harbor bacteria.
• Continue to exclude inmates with boils/lesions from food service activities.
• Recreational equipment should be routinely cleaned after use.
• Chlorine bleach is recommended to launder items from known MRSA/Staph cases and items should be laundered separately from non-cases.
• Laundry should be washed with a 25 minute minimum hot cycle followed by a thorough heated drying.
• Continue regular cleaning of environmental surfaces and objects that are frequently touched.
• Survey general inmate population for beginning boils/lesions or ?spider bites.?
• Continue looking for active Staph infections when inmates enter the facility and consider giving inmates routine medical exams with the focus on identifying Staph infections.
• Consider providing all new inmates with educational materials on preventing infections as part of orientation to the facility.
• Sterilize or use disposable restraints (handcuffs, etc.).

  Refer to the BOP [Federal Bureau of Prisons] Clinical Practice Guidelines for the Management of Methicillin-Resistant Staphylococcus aureus (MRSA) Infections for further information.

 Infirmary

• For isolation cases, provide clean towels, jumpsuits and linens daily. Have used towels immediately bagged and sent to the laundry facility. 
• Continue wound monitoring of cases and provide new dressings when the covering becomes soiled or wet.
• Continue to maintain antibiotic regimen based on culture and sensitivity results received from laboratory analysis.
• Continue to isolate inmates with draining lesions.
• Common-use medical equipment that must be shared between patients must be adequately cleaned and disinfected before use by another patient.
• It is strongly recommended that antibiotic administration be directly observed.

Conclusions:
There are indications across the state that MRSA/Staph infections are becoming more prevalent in correctional facilities. Ongoing surveillance for MRSA/Staph infection is recommended. The incorporation of ECHD?s recommendations (see list above) will strengthen ECJ inmate care, and hopefully serve to prevent future cases.
 

Dr. Julie Gerberding, director of the CDC, said the agency will be realigned into 11 new functional centers, overseen by 4 coordinating centers, in an effort to adopt a more holistic approach to disease prevention. This will address an issue that surfaced during the year-long strategic development process, during which it became clear that much of the public is not familiar with the role of the CDC beyond newsmaking achievements in the fields of epidemiology and infectious disease. In addition, the leadership functions of the Offices of Global Health, and Terrorism Preparedness and Emergency Response will be augmented.

The 4 new coordinating centers will be:

• Coordinating Center for Infectious Disease (to include NCID, NIP and NCHSTP)
• Coordinating Center for Environmental and Occupational Health and Injury Prevention (to include NCEH / ATSDR, NIOSH and NCIPC)
• Coordinating Center for Health Promotion (to include NCCDHP, NCBDDD and Genomics)
• Coordinating Center for Public Health Information and Services (to include NCHS, informatics, the new National Center for Health Marketing, and the new Center for Public Health Informatics)

The 11 new functional centers will be:

• The National Center for Infectious Diseases (NCID)
• The National Immunization Program (NIP)
• The National Center for HIV, STD and TB Prevention (NCHSTP)
• The National Center for Chronic Disease Prevention and Health Promotion (NCCHPHP)
• The National Center on Birth Defects and Developmental Disabilities (NCBDDD)
• The National Center for Environmental Health / Agency for Toxic Substances and Disease Registry (NCEH-ATSDR)
• The National Center for Injury Prevention and Control (NCIPC)
• The National Center for Occupational Safety and Health (NIOSH)
• The National Center for Health Statistics (NCHS)
• The National Center for Public Health Informatics (new)
• The National Center for Health Marketing (also new)

The essential mission of CDC, to reduce morbidity and mortality through prevention, will not change. However, as new challenges presented by medical breakthroughs and population shifts, globalization and politics began to emerge, the agency felt a responsibility to identify ways to effectively address the new health issues raised by these occurrences.

The changes should be implemented by the beginning of the fiscal year, which starts October 1, 2004.
 

The The Bureau of Immunization has received supplemental grant funds for Calendar Year  2004. As in 2003, the bureau will use $400,000 of these funds to promote and enhance the county health departments' administration of pneumococcal vaccine among adults who are 65 years of age and older with emphasis on the at-risk elderly. The goal of this stipend is to help achieve the Healthy People 2010 goal of 90% immunization coverage for pneumococcal vaccine among adults aged 65 and above.

Specifically, the bureau will provide county health departments (CHDs) a stipend of $20.00 for each dose of pneumococcal vaccine administered to adults 65 years of age and older in addition to all at-risk adults in accordance with Recommendations of the Advisory Committee on Immunization Practices (ACIP). The stipend will be paid via journal transfer of funds in December for the number of doses administered retroactively between January 1 and November 30, 2004 as reported on the Client Information System doses administered report.

CHDs should be aware that the provision of this stipend does not preclude charging patients a nominal fee for the purchase and administration of pneumococcal vaccine. The $20.00 stipend will only be offered for as long as funds are available or until November 30, 2004, whichever comes first. 

The bureau encourages all CHDs to administer the pneumococcal immunization throughout the year and not limit this prevention to the influenza season. Refer to the ACIP published in the Morbidity and Mortality Weekly Report dated April 4, 1997, (Vol 46, No. RR-8) for additional information on the administration of pneumococcal vaccine. Note that the pneumococcal vaccine is recommended for adults aged 65 and older and only adults younger than than 65 who fall within the ACIP-recommended risk groups.

The Bureau of Immunization requests that all doses of the pneumococcal vaccine be entered into the immunization module. This will facilitate collection of data for adult immunization for  evaluation of any racial and ethnic disparities. Entry of the influenza immunizations will also contribute toward an adult immunization database. 

If you have any questions please contact the following staff at 850.245.4342: Pamela Thornton regarding the journal transfer process for funding and/or Deanna Hamilton regarding CIS doses administered.
 

► Center for Biological Defense Announces Training

A Mass Casualty Personnel Decontamination course will be held September 8-10 in Orlando at no cost to attendees. Covered topics will be WMD technologies, intro to terrorism, decontamination principles and procedures, decon equipment and configurations, medical considerations, and a mass casualty decon exercise. For reservations, call Steve Furnace or Ed Ghantt at 407.297.2096.

State and Local Anti-Terrorism Training will offer investigative and intelligence workshops, specialized trainings, train-the-trainer workshops, and narcotics task force anti-terrorism briefings. For further information, log on to http://www.iir.com/slatt/training/htm or e-mail slatt@irr.com.
        

 - Recalls of coconut gel, apple pie a la mode, raw alfalfa sprouts 

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.
 

West Nile (WN) Virus activity: There were three seroconversions to WN virus in sentinel chickens from Indian River and Martin counties. To date, 21 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 were two seroconversions to EEE virus in sentinel chickens from St. Johns County. Five out of six live wild birds (four blue jays and one brown thrasher) trapped in Okaloosa County on June 4th were found to be infected with EEE virus. To date, 15 counties have reported EEE virus activity this year. 

Highlands J (HJ) Virus activity: None this week. Five counties have reported HJ virus activity this year.    

See the Web page for more information at www.MyFloridaEH.com.   
 

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