Foege WH et al.
Int. J of Epidemiology
1976; 5:29-37



Epi Update Managing Staff:

John Agwunobi, MD, MBA,
Secretary, Department of Health 

Landis Crockett, MD, MPH, 
Director, 
Division of Disease Control 

Don Ward, 
Deputy Bureau Chief 
Epi Update Managing Editor 

Jaime Forth, 
Editorial Assistant 

A R T I C L E S

Fermin Arguello, M.D., EIS Officer, CDC and Bureau of Epidemiology and Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology

Kathryn Teates, MPH, Surveillance & Reporting Section Administrator, Bureau of Epidemiology

Robbie Bouplon, Field Services Coordinator,  Hepatitis and Liver Failure Prevention and Control Program

Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology

Don Ward,  Deputy Bureau Chief, Bureau of Epidemiology

Jaime Forth, Editorial Assistant, Bureau of Epidemiology

D'Juan Harris, MSP, GIS Specialist, Bureau of Epidemiology 

Caroline Collins, Arbovirus Surveillance Coordinator and Carina Blackmore, M.S., Vet Med. Ph.D., Deputy State Public Health Veterinarian

Please note that numbers are subject to change with confirmatory information

► Grand Rounds - Smallpox Vaccine Adverse Events Surveillance 2003

Abstract: Phase I: Smallpox Vaccine Adverse Events Surveillance - 2003: The Florida Experience

Between February 7 and April 18, 2003, Florida completed phase one of its civilian smallpox vaccination campaign. The Florida Department of Health (DOH) Bureau of Epidemiology in collaboration with County Health Departments (CHD) and CDC implemented a surveillance system for detecting and responding to smallpox vaccine-related adverse events (AE). Using the Florida DOH Provisional Smallpox Vaccine AE Case Definitions, AEs consisted of events occurring in a vaccinee known historically to be associated with vaccination and any event requiring hospitalization (i.e. Other Serious AE) or not requiring hospitalization but considered a significant health condition (i.e. Other Non-Serious AE) regardless of likely association with the vaccine. Each vaccinee was monitored at least 28 days post vaccination, and possible AEs were reported to the Bureau of Epidemiology by local clinicians and CHDs. Each report was investigated, a case status (i.e. case vs. noncase) was assigned, and each case was followed until a final diagnosis was determined. 

Of the 3,745 vaccinees, a total of 13 (0.3%) AE cases were reported, two (15%) were classified as Pyogenic Infections of the Vaccination Sight, six (46%) were classified as Other Serious AEs, and five (38%) were classified as Other Non-Serious AEs. Of the six Other Serious AE cases, one was hospitalized for acute cholecystitis, one for angina, one for chest pain and shortness of breath, one for a suspected focal neurological disorder, one for a skin lesion and urinary track infection, and one for exacerbation of an underlying lung condition then again for a myocardial infarction resulting in death. No vaccinia virus was recovered from autopsy samples. Of all vaccinees, this was the only (0.03%) death reported. No cases required Vaccinia Immunoglobulin or cidofovir for treatment. Though based on historical accounts numerous serious AEs were anticipated initially, only a small number of AEs actually occurred in Florida with the majority not likely associated with vaccination (i.e. Other Serious and Non-Serious AEs). This surveillance effort was thorough and resource intensive, and though we can speculate that Smallpox vaccine administered through such a carefully managed program is safe, duplicating this level of careful administration in the future may be difficult.

Additional Information:  Further details regarding the audio-conference call and the PowerPoint files will be posted on the Bureau of Epidemiology intranet web site. Be sure to register online at the end of the program to obtain nursing CEUs. CEUs for environmental health professionals and laboratorians are pending. Information about upcoming topics and presenters will also be posted in the Epi Update. If either of these access points is unavailable to you, please e-mail Melanie Black at Melanie_Black@doh.state.fl.us, or phone her at 850.245.4444 ext. 2448 or SunCom 205.4444 ext. 2448 to request presentation materials.

Important:  While we realize you may not be able to call promptly at 11:10 a.m., it can be distracting to the speaker and others when participants dial in throughout the hour. Please try to call on time and remember to set your phone on mute so as not to disturb others. We assure you this courtesy will be appreciated by all. Thank you!

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► Communicable Disease Surveillance Quality Control Results 

The Communicable Disease Surveillance & Reporting Section instituted monthly quality control (QC) measures in January 2003 for a new group of Bureau of Epidemiology data entry staff who began working with the bureau in December 2002. These control measures evaluate the accuracy and completeness of all reportable laboratory results entered directly into the Merlin Reporting System. Thirty laboratory results, 10 entries per staff member, are randomly selected at the end of each month. Each lab result is checked for accuracy in all fields entered on both the Profile and Unattached lab data entry screens. The total number of errors for each lab result and whether or not the lab was found in the files is recorded (Table 1). Only two staff members were entering lab results for March and April, so the total number of lab results selected for QC was 20. Feedback is given to the all data entry staff at the completion of each check. Individual QC checks for staff members become part of their personnel files and can be used in subsequent personnel reviews.

The results show that the total number of lab results varies from month to month. Sampling the same number of lab results for QC each month will therefore represent a different percentage of the total. The results also do not appear to show a correlation between the total number of lab results and the number of errors found. Most errors were found in the first two months the staff member was working. This is because training data entry staff includes instruction on assigning the correct Florida disease code to lab results. Hiring students who are biology majors or who have taken some basic microbiology courses shortens training time for this aspect of the job.

The three errors in the reported laboratory result in May were due to inconclusive anti-HAV IgM results sent to us by a laboratory that the staff member was not accustomed to seeing. These results are reported with an asterisk (*) under the result column and are not reported as reactive or positive.

The Communicable Disease Surveillance & Reporting Section will continue to perform QC checks each month and report through the Epi Update each quarter. Any questions regarding data entry or QC can be directed to the Merlin Helpdesk email account.

Table 1. Total lab results and number of errors by month for the Communicable Disease Surveillance & Reporting Section, Bureau of Epidemiology.

*  Represents all high priority lab results entered from the Bureau of Epidemiology into Merlin each month.
^† Three data entry staff entering lab results January and February. Two data entry staff available for data entry March and April.

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► National Immunization Program Satellite Broadcast Set

The CDC is sponsoring a National Immunization Program and Public Health Training network satellite broadcast and webcast on June 26, 2003, from 12 Noon - 2:30 p.m. EST. This live satellite broadcast will update health-care providers on current adult immunization practices, including hepatitis A and B. 

The program will highlight the 2002-2003 Recommended Adult Immunization Schedule and strategies to improve adult immunization coverage levels. This 2.5-hour broadcast will feature a question and answer session in which participants nationwide can interact with the course instructors via toll-free telephone lines. For more information, go to http://www.phppo.cdc.gov/phtn/adult-imm03. or contact Robbie Bouplon, Field Services Coordinator, at 850.245.4444, ext. 2447.

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► Bi-weekly Conference Call Reminder

Continuing the dialogue begun in March 2003, the bi-weekly conference call between county health department personnel and Bureau of Epidemiology staff is scheduled for June 27^th at 10:00 and should last no longer than one hour. The agenda will be determined by input from both health department personnel and bureau staff. While most of the topics will be aimed at surveillance and investigations, other CHD/Epi issues are appropriate for discussion. All CHD staff are welcome to participate, and Epi staff conducting disease control activities are encouraged to attend.  

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► First Nasal Mist Flu Vaccine Approved by FDA

In a press release dated June 17, 2003, the FDA stated that it has approved FluMist, an influenza vaccine that is the first nasally-administered vaccine to be marketed in the U.S.  It is also the first live virus influenza vaccine approved in the U.S. 

FluMist (Influenza Virus Vaccine Live, Intranasal) is approved to prevent influenza illness due to influenza A and B viruses in healthy children and adolescents ages 5-17 years, and healthy adults ages 18-49. Children 5-8 years old need two doses at least 6 weeks apart in their first year of influenza vaccination with FluMist, and individuals 9-49 years old need one dose.

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► AMA Announces Standardized Catastrophic Disaster Training  

A new voluntary training program has been developed by the American Medical Association (AMA) that seeks to standardize emergency response by public health officials to catastrophic disasters. Currently, there are concerns that many differences exist in medical terminology and practices among military and civilian professionals, which could hinder abilities to provide immediate care in the event of a chemical or biological catastrophe.

According to the AMA’s new Center for Disaster Preparedness and Emergency Response Director Dr. James James, formerly director of the Miami-Dade County Health Department, “We need to be thinking of standardization and what is required in terms of basic skills and knowledge to make our health care providers and physicians more ready.” To that end, coursework which addresses triage setup, decontamination, medical terminology and chemical and biological diagnoses and response will be offered to students at costs and locations which are expected to be confirmed within the next few months. Continuing Medical Education Credits for physicians and medical students will be applicable.

The courses were created by a team of military and civilian experts from the Medical College of Georgia, the University of Texas Southwestern Medical Center in Dallas, the University of Texas at Houston, and the University of Georgia. Oversight was provided by the U.S. Department of Health and Human Services.

For updates and information about training sessions near you, check the AMA and Department of Health and Human Services web sites. Internet training options will also be available in future.

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► The History of GIS for Epidemiological Applications 

Geographic Information Systems (GIS) is one of the many tools in the arsenal of epidemiologists for studying the distribution and determinant of infectious diseases and chronic illnesses in human populations. GIS utilizes the power of personal computers to combine geographic data (locations of static man-made and natural features on the earth’s surface; i.e. state boundaries, water features, etc.) with other types of information (names, addresses, and more) to generate visual maps and reports. GIS software integrates common database operations, such as query and statistical analysis, with the ability to see how data relates in space and time. The produced maps are useful in showing the places and events which occur there, like outbreaks of disease.

Mapping in epidemiological applications dates back to the mid-19^th century as a Cholera epidemic ravaged the city of London. A local epidemiologist, Dr. John Snow, had formed a theory five years prior to the 1854 London outbreak wherein he proposed that the poison from cholera reproduced in the human body and was spread through the contamination of food or water. Dr. Snow began investigating the 1854 epidemic by plotting the location of deaths related to Cholera. He produced maps showing the location of water pumps and the homes of people who died of Cholera. Finally, he was able to conclude that one particular pump was causing most of the outbreaks and was able to contain London's Cholera epidemic.

Epidemiologists at the Bureau of Epidemiology use maps created with GIS to survey and investigate the geographical sources of disease. Similar to the early works of Dr. Snow, the Bureau of Epidemiology utilizes GIS to map patterns of disease outbreaks by incidence and/or prevalence rates. These prevalence, or incidence, maps are one of the most common types used at the headquarters of the bureau, since they provide a generalized picture of risk and a benchmark to relate rates of disease trends over time. The final product is a map that gives scientific credibility to suspected spatial clustering of a disease. Once evidence of clustering has been established, it is relatively easy for epidemiologists to determine human susceptibility to a disease in a geographic area. This concept of identifying “hot spots” is an essential element for personnel to focus prevention efforts in specified regions.

Several bureaus within the Department of Health are in early development stages to make mapping capability available to DOH personnel on the intranet, and later the general public on the internet.   The Bureau of Epidemiology is planning to add a Geographic Information Report module to its Merlin reportable disease application. This web-based Merlin integrated application will allow end-users to create GIS "spot and shade" maps of reportable diseases and will require minimal training. Another advantage of internet-based maps is the ability to update maps in "real-time", as new information is entered into the maps' supporting databases. Lastly, internet-based maps have the same utility as printed GIS maps: They may be as simple as showing all the cases of food poisoning in Florida in 1999 or they may have sophisticated applications that allow the end user to build complex queries like "show me all the cases of food poisoning in Leon County during June - August, 1999 in zip code 32399."

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► Arboviral Disease Report - June 10-16, 2003

No human cases of arboviral meningo-encephalitis were reported yet this year. Gilchrist County has been under Medical Alert for EEE virus since mid-April. A summary of animal and mosquito surveillance follows. 

In sentinel chickens, 18 seroconversions to EEE virus were confirmed in seven counties and four seroconversions to WN virus were confirmed in three counties. Two dead birds from Columbia and Taylor counties were reported positive for EEE virus and two from Calhoun and Escambia counties were reported positive for WN virus this week. Five live wild birds captured in Santa Rosa County in May tested positive for EEE virus. See http://www.pherec.org/DECS  Arbovirus Ecology for more wild bird surveillance. In horses, nine EEE virus infections in horses were reported from seven counties. No mosquito pools were reported positive for WN or EEE virus this week. In summary for 2003 to date, 35 of Florida’s 67 counties have reported EEE virus activity and 21 counties have reported WN virus activity. 

The complete report can be viewed at: http://www9.myflorida.com/Environment/hsee/arbo/weekly_summary2003.htm

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► Weekly Disease Table 

Click on the link below to access the latest data regarding this week's disease figures provided by the Florida Department of Health, Bureau of Epidemiology.

Current week's disease table

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