Forge 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, 
Copy Editor/Writer 

A R T I C L E S

Meghan M. Weems, MPH, Florida Epidemic Intelligence Service Officer, Bureau of Epidemiology

Carina Blackmore, DMV, Ph.D., Acting State Public Health Veterinarian, Bureau of Community Environmental Health

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

Alicia S. Postema, MPH, Influenza Branch, Centers for Disease Control and Prevention

Jaime Forth, Copy Editor/ Writer, Bureau of Epidemiology

Caroline Collins, Arbovirus Surveillance Coordinator and Carina Blackmore, DMV, Ph.D., Acting State Public Health Veterinarian, Bureau of Community Environmental Health

Please note that numbers are subject to change with confirmatory information

► Shigellosis Outbreak Hits South Florida Day Care Center
 
Investigators: Judith Ross, RN, BS Senior Community Health Nurse, Barbara F. Johnson, RN, BSN Senior Community Health Nursing Supervisor, Tommie Boyd, Institutional Health Nursing Program Specialist, Manjit K Singh, Environmental Health Specialist 2

Introduction: Shigellosis is a common acute diarrhea illness caused by the Shigella bacteria, spread via fecal oral route. Symptoms include diarrhea (often bloody), fever, nausea, vomiting, cramping, and malaise. Mild and asymptomatic infections do occur. Typical incubation period is one to three days. Secondary attack rates in households can be as high as 40% due to the small dose of bacteria required to produce symptoms. Shigella sonnei is the most common serotype found in the United States, and is common in institutional settings such as jails, day care centers, mental hospitals, and nursing homes. 

Background: On January 16^th, 2003, the Palm Beach County Health Department (PBCHD), Division of Epidemiology and Disease Control (Epi) was notified of a positive Shigella sonnei case in an attendee of a local day care center (day care center X). It is the policy of PBCHD that any child who attends day care must be excluded from day care if symptomatic with diarrhea until the diarrhea has ended. If the agent is identified, the child can only return to day care after a negative stool specimen is obtained. An investigation was immediately begun due to the highly communicable nature of shigellosis in institutional settings. Day care center X has a roster of 116 children who attend day care and after-care programs, ages 5 months to 10 years. The infant and toddler room has diaper-changing areas equipped with exam paper, gloves, bleach and water. The 2-year old room has its own bathroom with a diaper changing area. The 3, 4 and 5-year old rooms share two separate bathrooms with 4 toilets. 

Methods: Our case definition was set as any positive stool culture for shigella after January 5, 2003, found in an attendee/employee of day care center X, or any symptomatic person who could be epidemiologically linked to a positive shigellosis case who was an attendee/employee of day care center X.

A line list was obtained of all children who had been sent home with diarrhea or had been out of day care due to diarrhea since 1/5. No employees of the center reported having symptoms. No children had diarrhea at day care center X between 01/05-01/15. The patient case became symptomatic with bloody diarrhea on 01/08 (did not attend day care while symptomatic). The patient had attended day care on 01/06 and 01/07 before he became symptomatic with diarrhea. He was admitted to a local emergency department on 01/08. 

Staff from the PBCHD contacted the family members of each child who had diarrhea to arrange for stool testing. Contact was made with infection control practitioners at surrounding hospitals and area physician’s offices to make them aware of the situation and to urge them to promptly report any shigellosis cases. The director of day care center X was instructed to update the line list daily and immediately inform Epidemiology of anyone fitting the patient case definition. 

Each patient case/parent of a positive shigellosis case received a questionnaire asking specific questions about their illness (symptoms, onset date, possible risk factors etc.). An informational pamphlet about shigellosis (in English and Spanish) was sent to each patient's home along with the questionnaire. That pamphlet included the phone number to Epidemiology so any questions or concerns could be addressed.

Day care center X and Epidemiology coordinated to create a health alert on shigellosis that went home to each parent whose child attends day care center X. The health alert warned parents of the outbreak, how to prevent the spread of shigella, and what symptoms to look for in their child. The nursing program specialist of the PBCHD Institutional Health Program visited the day care center to give a presentation to employees and hang posters showing proper hand-washing practices. 

Results: Our investigation revealed 11 total cases between 1/08 and 2/08. None of the patient cases were employees of day care center X. Eight patient cases (73%) were attendees of day care center X. Three cases occurred in the 2-year old class and three cases occurred in the 3,4,and 5 year old class. One case occurred in the infant/toddler class, and one in the after school class. The other 3 cases (27%) were household contacts of those attendees (mother, grandmother, and father). Three cases (27%) were severe enough to be hospitalized (one child and two adults). The ages of cases ranged from 1 to 69 years old, with a median of 4 years and a mode of 2 years old. 10 of 11 cases (91%) were laboratory confirmed with the one probable case being an attendee and household contact of a confirmed case. All laboratory confirmed cases were serotyped as S. sonnei.

A representative of (PBCHD) inspected day care center X on 01/16. No delinquencies were found on inspection. The health alert was posted at the front desk informing visitors of the ongoing situation. Proper diaper changing procedures were observed. All sink and drinking water fountains were clean. Adequate soap and paper towels were found at all hand washing stations. The kitchen was clean and proper temperatures were observed. All toys were washed, rinsed, and sanitized every afternoon. Proper hand washing procedures were observed both in employees and attendees.

Discussion: This outbreak followed the pattern of a typical shigellosis outbreak. It was interesting to note that no employees were found to be symptomatic with diarrhea before, during, or after the outbreak. It is important that proper hand washing procedures are stressed to the household contacts of shigellosis cases as this outbreak proved that attack rates can be high in household contacts. The swift control and conclusion of this shigellosis outbreak confirms the need for all children to be excluded from day care when symptomatic with diarrhea until symptoms resolve.

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► Revised Recommendations Implemented for Potential Blood Donors

Between August 29, 2002 and March 1, 2003, CDC reported 21 confirmed cases of West Nile virus (WNV) meningo-encephalitis most likely acquired from blood transfusions. In addition, a blood transfusion-infected organ donor transmitted the virus to four transplant recipients. A study of the viremic blood donors revealed that 20% had symptoms of fever and headache at the time of blood donation. As a result of these findings FDA has put two new procedures into effect to minimize the risk of acquiring WNV from blood supplies. What follows is a summary of these new procedures. 

On June 1, 2003, FDA implemented new deferral questions to potential blood donors. All donors giving blood between June and November each year will be asked about any recent illnesses with symptoms including fever and headache. Blood donors with a potential WNV related illness will be deferred from giving blood until 28 days from the onset of symptoms or until 14 days after the symptoms have resolved. As of July 1, 2003, blood products will also be tested for WNV by an investigational nucleic acid amplification test (NAT). Blood components testing positive by NAT will be immediately quarantined. 

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► Bureau of Epidemiology Conference Call Scheduled for July 11th

The Bureau of Epidemiology began hosting bi-weekly county health department conference calls in March 2003. The purpose of the call is to update CHD staff on Bureau activities and to discuss issues of mutual interest. Each week’s agenda is determined by input from the CHDs and Bureau staff. While the majority of agenda topics is usually directed to surveillance and investigations, any other CHD/Epi topics are appropriate.

Any CHD staff are welcome to participate and staff conducting disease control activities are encouraged to attend. The calls will use the technology employed in the Bureau’s Grand Rounds, that is, any presentation material will be posted on the intranet the day before the call. The bi-weekly “epi-calls” begin at 10:00 AM and last no longer than an hour. The dial-in phone number, security code and the agenda will be emailed to CHD staff on Thursday, July 10, 2003. Please e-mail suggestions for agenda items and any presentation materials you may have to  Melanie_Black@doh.state.fl.us 

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► CDC Clarifies Recommendations for Vaccinations Regarding Influenza-like Illnesses

The CDC has announced that it does not recommend that influenza vaccination be considered as a way to avoid confusing influenza disease with an influenza-like illness caused by SARS. Influenza vaccination is the primary means of  preventing influenza and its severe complications, including pneumonia, hospitalization, and death. Complications from influenza infection most often occur among persons over 65 years of age, persons less than 65 years of age who have certain medical conditions, and children less than 2 years. Influenza vaccination is targeted toward these high-risk groups, all persons 50-64 years (because a high proportion of them have at least one high-risk condition), health care workers, and household contacts of high-risk persons.

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► Synthetic Anthrax Antibody on Short List for Approval 

A new drug on the fast track for approval by the FDA could be the first of its kind of provide immunity from exposure to anthrax, which became a household name in the aftermath of 9/11. The powder-like substance was used in the deaths of postal workers in other states and killed several persons in Florida. 

A synthetic antibody which blocks and prevents anthrax toxins from entering and killing cells, Abthrax, produced by a Rockville biotechnology firm called Human Genome Sciences Inc., has already tested successfully on animals. Because of ethical reservations regarding the testing of fatal rare diseases on humans, human test subjects cannot be exposed to anthrax spores, but the company has received a go-ahead from the FDA to proceed with human clinical trials to test for safety, tolerability and pharmacology. Following that testing phase, the company plans to consult with the government to ascertain its willingness to purchase the drug for stockpiling. Under the Bioterrorism Act of 2002 designed to eliminate delays in the interest of national security, certain drugs can win FDA approval based only on animal studies and human safety tests. 

It is feared that due to its portability and versatility, anthrax could be used as a biological weapon in a future mass terrorism attack. Since the events of 9/11, pharmaceutical firms have been in competition to produce a strain of anthrax which will resist the effects of the germ itself. Although antibiotics are already available to treat exposure, no company has yet produced an antibiotic injection which could impart immediate protection, with the potential to save thousands of lives.  Click on the Human Genome Sciences web site for more information at www.hgsi.com//products/request/html.

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► National Institute of General Medical Sciences Announces HIV Breakthrough 

According to the latest issue of Science Magazine, scientists have successfully isolated an antibody that can neutralize HIV, the virus that causes AIDS.  A team of scientists from Florida State University, the University of Oxford and the University of Agriculture in Vienna, led by Ian Wilson, D., Phil., and Dennis Burton, Ph.D., of the Scripps Research Institute, deduced the antibody structure by diffracting x-rays from crystals of 2G12. 

From these findings, the researchers were able to learn how the 2G12 antibody binds to sugars on the surface of the virus and provide immunity from the HIV virus. Since the sugars are made by human cells and attach to the virus, the immune system accepts them as part of the body and does not normally attack them. The team have theorized that if they were to were to design a template for an antigen based on the 2G12 antibody, it could help the body to produce its own 2G12, stimulating the immune system to produce sufficient antibodies to combat invading microbes.  

More detailed information about the project can be found at the National Institute of General Medical Sciences website at http://www.nigms.nih.gov/

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► Arboviral Disease Report  

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. 

EEE virus activity:  Eight seroconversions to EEE virus were confirmed in sentinel chickens from five mostly central counties. Fourteen horses were confirmed with EEE infections in eleven counties from central Florida to the panhandle. The first EEE positive mosquito pool was identified in Escambia County, bringing the total to 41 of Florida’s 67 counties reporting EEE activity, compared to 16 last year at this time. EEE activity is documented primarily in the central, northern and panhandle regions. 

WN virus activity:  Five seroconversions to WN virus were confirmed in sentinel chickens, for a YTD total of 51 WN seroconversions in 16 counties. No new WN activity has been reported in horses or birds. Twenty-three counties have reported WN activity this year, with sporadic distribution around the state, compared to 12 counties last year at this time. 

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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