June 24, 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



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An E. coli 0157:H7/HUS Outbreak Associated with
Three Petting Zoos in Florida 2005: A Summary Report
by Carina Blackmore, DVM, PhD and Dawn Ginzl, MPH
 

Escherichia coli O157:H7 was first recognized as a public health concern after a hamburger-associated outbreak in 1982. The Shiga-toxin producing bacteria can cause a severe gastro-intestinal illness with bloody diarrhea and abdominal cramps. The toxin may also induce hemolytic uremic syndrome (HUS), with subsequent renal failure and death. E. coli O157:H7 has been nationally notifiable since 1994. Most infections are believed to be acquired via food or water; however, several outbreaks have also resulted from direct contact with livestock. The animals are often asymptomatic and may shed the organism for extended periods of time. The outbreak summarized here was associated with direct contact with farm animals exhibited in petting zoos at three different fairs in Florida during February and March 2005.   

The outbreak was first recognized after two separate HUS case reports were posted on EpiCom on March 18 and March 21, 2005.  The two cases (a 5-yr-old F and a 7-yr-old M) both reported having visited a fair with a petting zoo a few days prior to becoming ill. The two children visited the same fair and did not have any other risk factors in common. The fair (Fair B) was held from March 3-13, 2005.  The Orange CHD epidemiology on-call nurse was also contacted on March 20 by one of their local hospital administrators who reported a cluster of pediatric HUS cases in her hospital. Interviews with the parents of the hospitalized children revealed that all had attended a petting zoo at Fair B or a new fair (Fair C, also held March 3-13)  within three weeks prior to becoming ill. E. coli O157:H7 isolates from the initial cases were sent to the Bureau of Laboratory in Jacksonville for PFGE typing.  

A conference call was held with county health department epidemiology staff in central and south Florida to discuss the initial results of the investigation and to launch intensified E. coli O157:H7 case finding activities. A questionnaire with an extensive list of questions about potential risk factors for E. coli O157:H7 infections (including questions about exposures to foods, water and animals) was developed in the Merlin Outbreak Module. 

The initial case definition was broad. As the outbreak investigation progressed, the case definition was made more specific and defined outbreak related cases by time, place and person as follows:  

n       Confirmed-persons who attended Fair A, B or C by 3/13/05 and had a lab diagnosis of E. coli O157:H7 within 10 days of fair attendance and/or had a lab diagnosis of HUS within 21days of fair attendance  

n       Suspect-persons who attended Fair A, B or C and developed symptoms of E. coli O157:H7 within 10 days of fair attendance and/or developed symptoms of HUS within 21 days of fair attendance and did not have an alternative diagnosis 

n       Secondary-persons who developed symptoms of E. coli O157:H7 and/or had a lab diagnosis of E. coli O157:H7 within 2-10 days of having close contact to a case or persons who developed symptoms of HUS and/or had a lab diagnosis of HUS within 21 days of having close contact to a case 

A list of animal vendors exhibiting at Fairs B and C was obtained from management of the two fairgrounds. The two fairs had only one vendor in common, an exhibitor of a farm animal petting zoo. The owner of the petting zoo was contacted on March 24, and the animals (sheep, goats and cattle) were placed under a voluntary quarantine for the duration of the outbreak investigation. In conversations with the animal owner it was also revealed that the same animals had been exhibited once before, at Fair A, held between February 10-21, 2005.  

An environmental investigation was undertaken at the three fair grounds and the petting zoo farm. Soil samples and environmental swabs were obtained from the petting zoo exhibit areas of the fairs. One hundred sixty eight animals exhibited at the fair, including the 37 animals exhibited at the farm animal petting zoo were also cultured. 

A total of 22 confirmed, 45 suspect and 6 secondary cases from 20 Florida counties were identified in this outbreak. All but one culture-confirmed case had isolates with matching PFGE patterns. Among the primary (confirmed and suspect) cases the median age was 4, 88% of the cases were white, and 53% female. Most cases were infected at Fairs B or C (only 3 cases associated with Fair A). Twelve cases developed HUS. There were no fatalities. E. coli O157:H7 with matching PFGE patterns were also recovered from the animal exhibit areas of Fairs B and C and from 6 animals from the implicated petting zoo.  

A case control study was conducted to determine behavioral risk factors for infection. The analyses of this study are underway and will help in the development of refined prevention guidelines. 

Petting zoo-associated E. coli O157:H7 infections are thought to be the result of hand-to mouth activities after animal contact. Consuming food and drinks in animal areas, poor hand washing practices after animal contact and leaving the animal area with visibly soiled clothing have also been identified as risk factors for E. coli O157:H7 infection. To prevent petting zoo associated outbreaks the National Association of State Public Health Veterinarians has developed disease control guidelines. You can find these at CDC’s website at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5404a1.htm. 

Dr. Carina Blackmore is the acting state veterinarian at the Bureau of Community Environmental Health and can be reached at 850.245.4732.  Dawn Ginzl is a Florida EIS fellow assigned to the Orange County Health Department and can be reached at 407.858.1400 ext. 1136.


 

Bi-weekly CHD Conference Call Sheds LIght
on Salmonella Serotyping and Guidelines
by Jaime Forth

The following excerpt is from the June 17, 2005 conference call between Bureau of Epidemiology staff and county health department personnel. This is a regularly scheduled call, drawing large participation from members of health departments throughout the state.

Medical Examiner Data Abstraction. Dr. Joann Schulte announced a new project under her direction concerning deaths that were investigated by medical examiners following the hurricane activity last year. Her study is interested primarily in deaths of the elderly resulting from chronic health conditions. Records from five counties have been completed so far and within the next month or so, the remainder should have been reviewed.

Salmonella Serotype Nomenclature. To end some of the confusion he has noted recently, Dr. David Beall led listeners through the correct way to designate Salmonella serotypes on lab slips. Antigens share serogroups, so he advised users to be cautious when identifying number/letter designations and corresponding serotypes.  Each state laboratory performs serogrouping but does not serotype every sample unless specifically requested. For in-depth guidance, he instructed listeners to refer to the information packet provided as an attachment to his PowerPoint presentation.

Salmonella Guidelines. Dr. Richard Hopkins called attention to Florida Administrative Code 64.d.3, which addresses infections in daycare facilities. Although shigella outbreaks are common, Salmonella outbreaks are rare and our guidelines treat them as equally hazardous events. Those rules may be revisited this year so that the language will provide consistency in the definition of a carrier and the length of time before return of a patient case to a daycare facility. Dr. Hopkins recommended following the controlling or specific language of the rules until these internal contradictions are corrected; when the time comes to adjust the language, the committee will invite comments from interested parties.

Asset Typing. Dr. Hopkins and Dr. Lucas have been working with committees to determine a method for evaluating the assets of current staff for placement on strike teams. This will assist in later decisions concerning whether to assemble teams first and train them together, or train individuals first and then assemble the teams. The committees will also identify the kinds of training needed for epidemiologists, and furnish that information to professional training personnel.

Rash Illness from Caterpillers - Hillsborough CHD. David Atrubin described a recent investigation which began when four day care centers reported children with rashes on various parts of their bodies. Private physicians had identified the marks as insect bites, scabies and various other diagnoses. Health department staff heard about an infestation of caterpillers at one of the day care centers and performed active surveillance, comparing data from the year 2004 with data from 2005, also visiting with an entolologist who diagnosed the rashes as contact dermatitis. It was discovered that children may or may not have touched the caterpillers, but hairs from the insect can become airborne and cause conjunctavirus in sensitive persons, so that may have been the method of transmittal to some of the children.

Tularemia - Pinellas CHD. Maria Donnelly stated that a worker at the Pinellas CHD received a call from a father whose daughter had been exposed to rabbit blood, and after a long illness affecting her lymph glands and with no other diagnosis, the physician was willing to consider tularemia as the possible origin. The Tampa state lab was contacted and acted immediately to provide specialized testing. Although the etiology of the illness is still unknown, the time from first contact to the time the test results were received was just 9 hours, and demonstrated that if a true biohazardous event had occurred, the CHD and lab are well-equipped to handle this kind of emergency synergistically.

Pertussis - Polk CHD. Colleen Sullivan reported a local hospital called the CHD to relay the news about the death of a 3 1/2 month old infant with co-morbidities. The child had become symptomatic with cough and cold symptoms, presented at a local emergency room, and was sent home with its mother. A few weeks later the mother returned when the baby's symptoms appeared worse, and the child was tested for pertussis. The results weren't available immediately so the child was again sent home with its mother. A few days later, the mother returned to the ER with the baby in high respiratory distress; the baby was admitted as a patient but then died. At the same time, the pertussis test returned with a positive result. Rrelatives were alerted and prophylaxed. Afterward, it became known that the infant had had a twin who had died at birth. The child had never received its first immunization for pertussis and had received only one vaccination for RSV. 

These conference calls occur on alternate Fridays from 10:00 to 11:00 a.m. ET. Anyone with items for the agenda should contact Melanie Black, MSW, professional training coordinator, at 850.245.4444, ext. 2448.
        
Jaime Forth is managing editor of Epi Update and can be reached at 850.245.4444, ext. 2440.
 

Florida PRAMS 2003 Comprehensive Surveillance
Data Book Released 
by Curt Miller

The Florida Department of Health, Bureau of Epidemiology is pleased to announce the latest report from the Florida Pregnancy Risk Assessment Monitoring System (PRAMS). The title of this report is “Florida PRAMS 2003 Surveillance Data Book”.   

This data book contains detailed statistics for all PRAMS variables (144) presented in three sections: Maternal Health and Behaviors, Prenatal and Postpartum Care, and Infant Health. To make navigation through the material as user-friendly as possible, the layout of the bookmarks follows that of the table of contents. Access the report at the Florida Department of Health website at http://www.doh.state.fl.us/disease_ctrl/epi/prams/reports/PRAMS_2003.pdf 

The release of the “Florida PRAMS 2003 Surveillance Data Book” marks the first time such a large-scale analysis has been published containing such a rich quantity of data. A similar analysis has been completed for a decade’s worth of Florida PRAMS data – from 1993 through 2003 – and will be posted online upon completion. This series of historic information is being produced retrospectively beginning with 2003, Florida’s most current PRAMS data.

Anyone with questions about these special reports can contact either Helen Marshall, PRAMS coordinator, at 850.245.4444 extension 2415, or Curt Miller, data analyst at 850.245.4444, ext. 2407.

Curt Miller is a data analyst in the Chronic Disease Section at the Bureau of Epidemiology in Tallahassee.  Contact him by calling 850.245.4444, ext. 2407.

Pneumococcal Vaccination Among Adults
with Diabetes in Florida, 2002
by Regan Glover, MS
 

Background
Pneumococcal disease is caused by bacteria (Streptococcus pneumoniae) that can attack different parts of the body. The bacteria can cause serious infections of the lungs (pneumonia), the bloodstream (bacteremia) and the covering of the brain (meningitis). Pneumococcal disease kills more people in the United States each year than all other vaccine-preventable diseases combined.¹ Vaccination of persons at risk for complications from pneumococcal disease is a key public health strategy for preventing associated morbidity and mortality in the United States. Pneumococcal vaccine is recommended for anyone aged 2 or older who, because of chronic health problems (such as diabetes) or age, has a greater chance of getting and dying from pneumonia. People with diabetes² may have abnormalities in immune function, which makes them more susceptible to infection and increases their chances of dying from pneumonia by about three times the rate of that for people without diabetes. One vaccination is usually enough to last a lifetime and can provide protection from other infections caused by the same bacteria. Therefore, receiving a pneumonia vaccination³ has the potential to reduce the risk of complications associated with diabetes.

Methods
Data from the 2002 Florida County Behavioral Risk Factor Surveillance System (BRFSS) survey were used for analysis and are based on a sample size of 34,551 respondents, of whom 3,582 reported being told by their doctors that they have diabetes. The focus of this report is pneumococcal vaccination among adults with diagnosed diabetes in Florida. 

Discussion
The prevalence of receiving pneumococcal vaccination among adults with diagnosed diabetes (43.5 percent) is significantly higher than among adults without diagnosed diabetes (20.8 percent). (See Table 1.) 
. 
The prevalence of receiving pneumococcal vaccination among adults with diabetes is significantly different by age. Adults with diabetes between the ages 18 and 44 years (19.4 percent) and adults 45 to 64 years of age (33.5 percent) have a lower prevalence of receiving vaccination than adults ages 65 years and older (60.5 percent). (See Figure 1.) 

The prevalence of receiving a vaccination is different among race/ethnic groups. Overall, Hispanics with diabetes are significantly less likely to receive vaccinations (12.4 percent) than non-Hispanic whites (49.9 percent) and non-Hispanic blacks (41.8 percent). Specifically, Hispanic men are significantly less likely to receive vaccination (8.3 percent) than non-Hispanic white men (48.1 percent). Hispanic women are also significantly less likely to receive vaccination (18.6 percent) than non-Hispanic white women (51.8 percent). (See Figure 2.) 

Receiving pneumococcal vaccination differs by marital status such that never-married adults with diabetes are significantly less likely to receive vaccination (25.6 percent) than adults who are married or living together (42.1 percent), or adults who are divorced, widowed or separated (52.0 percent). 

The prevalence of receiving a pneumococcal vaccination among adults with diabetes does not differ significantly by income or education. 

Conclusion
Receiving pneumococcal vaccination is more prevalent among adults with diabetes than among adults without diabetes. Among people with diabetes, Hispanic men and women, young and middle-aged adults, and the never-married are less likely to receive pneumococcal vaccination, and thus are at a greater risk for morbidity due to pneumococcal infections than are non-Hispanics, adults aged-65-years-and-older, and the married as well as the divorced. 

¹For more information on pneumococcal disease, visit the National Foundation for Infectious Diseases website at http://www.nfid.org/library/influenza/what/index.html.
² Diabetes is assessed by the question, “Have you ever been told by a doctor that you have diabetes?”
³ Pneumococcal vaccination is measured by the question, “Have you ever had a pneumonia shot?”

*Confidence intervals for Table 1 are constructed utilizing the SAS 9.1 version.

Regan Glover is an epidemiologist in the Chronic Disease Section of the Bureau of Epidemiology. To contact her, call 850.245.4444, ext. 2424.

AG Holley To Present Grand Rounds on
Control of TB Among the Homeless
by Jaime Forth

AG Holley State Hospital in Lantana, Florida will award continuing credits to nurses who attend a two-hour presentation on the epidemiology of tuberculosis in high risk homeless groups.

The grand rounds is scheduled for presentation on Wednesday, July 20 from 10:00 - 12:00 ET and will be accessible by conference call, although CEUs will not be awarded to those attending via teleconference. The speaker will be Dr. Masa Narita, director of the Seattle / Kings Counties TB Control Center in Washington. Dr. Narita is expected to review techniques used to control the disease among the homeless population in the state of Washington, identify obstacles in TB control among transient groups, and provide an outline of the epidemiology of TB.

Registration is required if attending in person. For more information, contact Affette McIntosh at 561.540.3364 or visit the departmental web site at http://www.doh.state.fl.us and choose Tuberculosis Training Opportunities.

Lunch will be provided with reservation. To listen to the lecture by conference call, simply dial 850.921.6623 at the start of the program. And, as always, to avoid disturbing the speaker, participants should remember to place their phones on mute.

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

Mosquito-borne Disease Update   June 12 - 18, 2005
Rebecca Schultz, MPH, Caroline Collins, Tasharra Kenion, Calvin DeSouza, Carina Blackmore, Ph.D.

Weekly Update: During the period June 12 -18, 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: Three seroconversions to WN virus were confirmed in sentinel chickens from Hillsborough, Pinellas and N. Walton Counties. Additionally, one seroconversion to be undetermined flavivirus was confirmed in N. Walton County. To date, 8 counties have reported confirmed WN activity compared to 21 at this time last year.

Eastern Equine Encephalomyelitis (EEE) virus activity: Twelve seroconversions to EEE virus were confirmed in sentinel chickens from Alachua, Duval, Nassau, Orange (2), Putnam (2), St. Johns (4), and Volusia Counties. Sixteen horses from Alachua, Columbia, Gilchrist (2), Highlands, Lake (2), Leon, Levy, Marion (2), Okaloosa, Okeechobee (2), Polk and Volusia Counties were confirmed with EEE virus infection this week. To date, 29 counties have reported confirmed EEE activity compared to 16 at this time last year.

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

• Suspected foodborne outbreak in Monroe County (Marathon)

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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