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, Copy Editor/
Writer 

For Salmonella Outbreak Traced to Tampa BBQ Restaurant, David Atrubin, MPH, EIS Officer, Bureau of Epidemiology and Michael Friedman, MPD, Bureau of Community Environmental Health

For Trends in Tobacco Use Among New Mothers Unveiled, Marie A. Bailey, MA, MSW, BRFSS Coordinator and Curt Miller, BS, Epidemiologist, Bureau of Epidemiology

For Pre-Pregnancy Study Among Florida Women Finds Links Between BMI and Health, Curt Miller, BS, Epidemiologist and Youjie Huang, MD, DrPH, Bureau of Epidemiology

A R T I C L E S

Jerne Shapiro, MPH, Florida Epidemic Intelligence Service, Bureau of Epidemiology 

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

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

Kathryn Teates, MPH, Communicable Disease Surveillance & Reporting Manager, Bureau of Epidemiology

Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology

Pete Garner, Surveillance Systems Section Administrator, Bureau of Epidemiology

Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology

Kathryn Teates, MPH, Surveillance & Reporting Section Administrator, 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

► Viral Meningitis Outbreak Investigated in Alachua County
 
Investigators: Jerne Shapiro, MPH, Florida Epidemic Intelligence Service, Alachua County Health Department and Sally Bethart, RN, Epidemiology Nurse, Alachua County Health Department                       

Introduction: Non-polio enteroviruses are the second most common viral infections in humans, surpassed only by common cold viruses. Echovirus 9 is an identified serotype of enterovirus and known to be associated with high incidences of viral meningitis. Symptoms of viral meningitis include headache, fever, neck and back stiffness, photophobia, vomiting, nausea, and diarrhea. Symptoms usually last seven to ten days; however, the virus may present in the body for up to 7 days after symptoms have resolved. The incubation period is two to seven days. Less severe and asymptotic cases can occur. The virus is spread from an infected person via respiratory secretions (e.g., saliva, sputum, or nasal mucus) and stool. Enteroviruses are most likely to occur during summer and fall. Secondary spread often occurs in households, day care centers and group facilities. No vaccine is currently available. 

Background: On May 27, 2003, the Alachua County Health Department (ACHD), Department of Epidemiology received two reports from concerned schools of suspect viral meningitis, one high school student and one a kindergartener. The high school student’s date of onset was May 23, 2003. The following day (day 2), two cases from the same elementary school, one kindergartener (same classroom) and one first grader, were admitted to the hospital for suspect viral meningitis. On day 3 a first grader from a second elementary school was admitted. A sixth case from a third elementary school was added on day 4. The outbreak has continued to spread throughout day cares, households, and schools. The ACHD developed educational information for the families and schools and began implementing a policy not allowing students to return to school until 10 days after symptoms have resolved. 

Methods: The following case definition was established: Confirmed: A clinically compatible case (2 or more symptoms) from which Echovirus 9 or Enterovirus had been isolated either from CSF, stool, or respiratory samples. Probable: A clinically compatible case (2 or more symptoms) that had a lumbar puncture with a high WBC and no growth on the culture. Suspect: A clinically compatible case (2 or more symptoms) and was a resident of Alachua County or a clinically compatible case (2 or more symptoms) who was epidemiologically linked to a known probable or confirmed case. 

Signs and Symptoms:
Fever >100.5F or 38C
Headache
Stiff neck/back
Vomiting
Nausea
Diarrhea 

Each case was interviewed to establish epidemiological links, symptoms, date of onset and contacts. Information obtained from charts included lumbar puncture, CBC analysis and gram's stain. Isolates from CSF, stool, and respiratory samples were cultured and all labs testing positive for enterovirus were sent to the state lab for strain typing. Viral meningitis is not a reportable disease in the state of Florida; however, due to the outbreak nature of this organism the ACHD asked all local hospitals and physicians to report any suspected cases. To analyze the data a database was created in Epi Info 2002. 

To educate the community the ACHD mass mailed an information pamphlet on viral meningitis to all schools, churches, day cares, summer camps and pools in Alachua County. Daily updates were reported to the local press along with personal protection information. Each patient case was personally instructed on necessary hygiene practices for the protection of others. In addition, each patient case was mailed a personal letter reiterating necessary hygiene practices. All group activities the patient was involved with were subsequently contacted and sent an information pamphlet to pass out to all possibly exposed individuals. 

Results: Laboratory samples from cerebrospinal fluid (CSF), stool, or throat cultures were sent to the state lab and tested positive for Enterovirus Echo 9 as the causative organism. 

The ongoing investigation has revealed a total of 24 confirmed, 22 probable, and 1 suspect case since May 23, 2003 (See Table). All 47 cases were seen in local emergency rooms and 93.6% were admitted to the hospital. All cases have recovered fully with no sequela. A total 44.7% of the cases have been epidemiologically linked to each other with siblings, family members, and classmates subsequently becoming ill. The ages of cases range between 4 weeks to 41 years old with a total of 71.7% of the cases between ages 5-10yrs. A total of 58.7% are male and 73.9% black. 

Discussion: This outbreak is ongoing, thus the nature of the outbreak may change in the future. This outbreak of Echovirus 9 is following the known pattern occurring in the summer months and appears to be spread via contact with stool or respiratory secretion from infected individuals. The ACHD will continue to work with cases, contacts, schools, day cares, employers, media, laboratories and hospitals to provide the most up to date information and education. 

References:
Enterovirus Surveillance—United States, 1988. MMWR, August 26, 1988 / 37(33);516
Enterovirus Surveillance—United States, 2000-2001. MMWR, November 22, 2002 /51(46);1047-1049
Gerald L. Mandell, John E. Bennett, and Raphael Dolin. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases Fourth Edition Churchill Livingstone Inc. 1995; 1620-1633.
Outbreak of Aseptic Meningitis—Whiteside County, Illinois, 1995. MMWR, March 14, 1997/ 46(10); 221-224.
Respiratory and Enteric Viruses Branch, Non-Polio Enterovirus Infections. www.cdc.gov/ncidod/dvrd/entrvirs.htm  

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► Bioterrorism Surveillance to be Focus of July Grand Rounds

Grand Rounds: Bioterrorism Syndromic Surveillance:  A Dual-Use Approach with Direct Application to the Detection of Infectious Disease Outbreaks
Date:  Tuesday, July 29, 2003 from 11:00 a.m. - 12:00 p.m. EST
Dial in by 11:10 a.m. to 850.487.8587 or SunCom 277.8587
Moderator:  Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology
Presenter: Kristin Uhde, MPH, Surveillance Director, Center for Biological Defense, College of Public Health, University of South Florida

Abstract: The threat of bioterrorism forces the public health infrastructure to focus attention on overall issues related to challenges posed by emerging and re-emerging infectious diseases. There is a crucial need to strengthen existing surveillance systems and to validate real-time approaches to surveillance that can provide timely alerts of epidemics whether they occur naturally or through a bioterrorism attack. The purpose of this study is to implement and evaluate a bioterrorism syndromic surveillance system called BioDefend™, to determine whether the system could detect a potential epidemic/bioterrorism attack within 24-36 hours, more rapidly than it would be identified by routine health surveillance. This sentinel surveillance study was conducted in theme parks, theme park referral hospitals and clinics, and a military hospital and clinics in the Central Florida area. A six-month period of baseline data collection was completed at all surveillance sites for the purpose of serving as the comparison for the test period. The test period lasted five months and validated the system. The baseline was also used to identify normal illness trends and seasonality patterns so thresholds could be established to determine significant syndromic aberrations. The web-based reporting system enabled near real-time data entry. The syndromic and demographic information was then processed in an automated analysis system to provide a mechanism for alerting surveillance sites when significant rises in reported syndromes and/or clinic/hospital daily visits exceeded the established thresholds. A pocket PC/phone device enabled staff to receive notification of alerts 24/7.

The surveillance system was evaluated by comparing regional, state and national surveillance data to equivalent syndromic data reported from BioDefend™. After comparing these data, it was determined that the BioDefend™ system detected two epidemics of public health importance more than one month before they were identified through routine regional and state surveillance methods. The specific syndromes identified earlier than the State of Florida surveillance were “gastroenteritis” and “influenza-like illness.” This study has examined whether or not the BioDefend™ surveillance system is useful in the context of the above referenced surveillance sites, and whether it could serve as a national model for syndromic surveillance.   

Additional Information: Further details regarding the audio-conference call and the PowerPoint files will be posted on the Bureau of Epidemiology Intranet web site. CEUs 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 email Melanie Black (Melanie_Black@doh.state.fl.us) or telephone 850.245.4444 ext. 2448 (SunCom 205.4444 ext. 2448) to request presentation materials. 

Important:  While we realize you may not be able to call at precisely 11:10 a.m., it can be distracting to the speaker and others in the audience when participants dial in throughout the hour. Please try to call in on time, and remember to put your phone on mute so as not to disturb others. Thank you for your cooperation.

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 ► July 25th CHD Conference Call Set

The Bureau of Epidemiology will be hosting its bi-weekly conference call with county health department staff on Friday, July 25, 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 will be determined by input from the CHDs and Bureau staff. While the majority of agenda topics will probably be 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” will 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 Wednesday, July 23, 2003. Please e-mail suggestions for agenda items and any presentation materials you may have to Melanie Black at Melanie_black@doh.state.fl.us or Don Ward at donald_ward@doh.state.fl.us.  

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► Changes to Notifiable Disease Reporting in Florida

The administrative rule changes announced earlier were finalized this past month. The Bureau of Epidemiology recommends that you review the entire rule if possible, to familiarize yourself with all changes to the reporting of notifiable conditions. However, some of the more prominent changes to the rule specifically for diseases reported to the Bureau of Epidemiology are outlined below. Changes to the Merlin Reporting System are being implemented in the next two weeks to accommodate these new reporting changes. 

1. Animal bite – the case definition has been changed to include non-bite exposures.
2. Addition of Creutzfeldt-Jakob Disease (CJD) – CJD is now a reportable condition. Please review the case definition since the confirmatory laboratory tests can only be done post-mortem.
3. Addition of several bioterrorism agents – Several category B and C agents have been added including Glanders, Epsilon Toxin of Clostridium perfringens and Melioidosis.
4. Escherichia coli - Now has three codes to better accommodate and differentiate between the reportable E. coli conditions. These include a code for O157:H7 serogroup, shiga toxin + non-O157 serogroup and E. coli shiga toxin + not serogrouped. It is important to note that if the E. coli isolated is not at least positive for shiga-like toxins it is not a reportable condition.
5. Meningococcal Meningitis – The two previous codes for meningococcal meningitis and meningococcemia have been combined into a single code for meningococcal disease. The differentiation will be made from the laboratory test specimen site.
6. Saxitoxin Poisoning (Paralytic shellfish poisoning) – This is a new code added by the Division of Environmental Health.
7. Salmonellosis and Shigellosis – Both disease conditions no longer require additional clinical symptoms to be confirmed. A positive lab result alone indicates confirmed case.
8. Streptococcus pneumoniae invasive disease – Both drug resistant and susceptible cases are reportable in Merlin. Please make sure you mail a copy of the laboratory results to the Bureau of Epidemiology for ALL Strep pneumo cases. Case report forms are only needed for the drug resistant code.
9. Vaccinia disease - Now reportable for adverse events. VAERS form still same process, although the Bureau of Epidemiology is currently working with Bureau of Immunization and the Centers for Disease Control and Prevention (CDC) to streamline the electronic process.

The revised copy of the surveillance case definitions should be posted by July 18^th. The updated list of reportable conditions sent to community providers is already posted on the Epidemiology and Surveillance web site. Melanie Black in the Bureau of Epidemiology is currently working with the Public Information Office to get these lists printed and sent to each county health department. Updated alphabetic and numeric lists of Florida disease codes are already posted on the Web.  These lists are for epidemiology program internal use only; please do not send the disease code lists to community providers. The list of reportable laboratory findings is currently being revised for approval. Any questions regarding notifiable conditions in Florida should be directed to the Communicable Disease Surveillance and Reporting Section, Bureau of Epidemiology at 850-245-4401.

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► Conference Call Attendance on the Rise

With over 127 participants from 39 county health departments on the July 11th conference call, which included county health department directors/administrators, environmental epi staff, Florida EIS staff and communicable disease epi staff and a healthy amount of questions, the call lasted a little over an hour. Although this meant there was no time to discuss the database issue listed on the agenda, we’re confident the lively discussion was a positive signal that interest among county health departments is high and the bi-weekly conference calls are a viable method of exchanging ideas and information. The following is a summary of last week’s discussion:

Epi Update. Jaime Forth, editor of the weekly publication, affirmed that articles from all medical professionals are welcome for inclusion in the Epi Update. Writers might consider sending abstracts concerning unusual outbreaks or occurrences; interesting studies or activities in which individuals or their staff participated; information about noteworthy upcoming conferences; reports on new medical treatments or investigations [in] which the individual has been involved or has written. For information concerning submission guidelines, email Jaime, at jaime_forth@doh.state.fl.us. 

Case Definitions and Reportable Disease List. Kathryn Teates, surveillance and reporting section administrator, discussed pending changes to the Merlin reporting system. She outlined updated and completed lab findings and new codes which will go into effect next week. There will also be rule changes which necessitate a change to the reportable disease list. Be alert to other changes and email her or her staff with questions. Changes will also be listed on both our Internet and Intranet sites. There will be additional announcements in future editions of the Epi Update. Kathryn’s email address is kathryn_teates@doh.state.fl.us.

Chronic Disease Epi. Marie Bailey was introduced as the new BFRSS coordinator and announced that a working group will form to meet later this month. Information concerning the program is readily available and anyone seeking assistance can email her at marie_bailey@doh.state.fl.us.

BT Grant Spending 2003-04.  Don Ward, acting bureau chief, brought attendees up to date on approved budget figures for the next fiscal year. The $10 million bioterrorism grant funds for Epidemiology and Surveillance include new surveillance and epidemiology projects, training for 72 recently hired county health department epidemiologists, and quarterly regional training on preparedness on response. Don also elaborated on the type of surveillance activities for which the bureau is prepared to commit funding.

The next conference call is scheduled for July 25^th. Stay tuned for details or email Professional Training Coordinator Melanie Black at melanie_black@doh.state.fl.us

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► Merlin Frequency Reports Available to Public

For some time now, “de-identified” Merlin data in the form of Frequency Reports have been available to non-Merlin users and to the public through a data sharing initiative between the Bureau of Epidemiology and the Office of Planning, Evaluation, and Data Analysis.

Weekly, a sanitized extract of communicable disease case data is made from the Merlin Disease Reporting System and forwarded to the Planning and Evaluation internet web server where it can be queried through web forms to produce high-level reports.  Users can choose from selection criteria including ICD9 codes, County Name, and a range of dates from which to request reports.  The web site offers several subtotal “group by” options such as age groups, gender, and zip code.

These reports can be viewed by visiting the Florida Department of Health public website at http://www.doh.state.fl.us and clicking “Health Statistics” under the “Reports and Health Statistics heading.  Then select “Communicable Disease Frequency Reports”.

The development effort as well as the ongoing enhancement and maintenance of the data and reporting capabilities are credited to staff in both offices including Kathryn Teates and Xiaobing Zhang of the Bureau of Epidemiology and to Chris Keller and Ron Humphries of the Office of Planning, Evaluation, and Data Analysis.

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► Managing Public Health Threats Topic of Upcoming Conference 

The Florida Public Health Association and The Florida Association of Public Health Nurses will hold a joint educational conference at the PGA National Resort and Spa in Palm Beach Gardens entitled "Managing Public Health Threats: Present and Future" from August 5-8. Speakers will include our own Carina Blackmore, MS Vet Med, PhD, and Secretary of the Florida Department of Health Dr. John Agwunobi. Concurrent sessions will deal with issues such as The Salmonelle Seftenberg (ongoing) Outbreak, Perinatal Periods of Risk, a New Look at Infant Mortality, Public Health Laboratory Chemical Testing Capabilities, Role of PHNs in Bioterrorism and Epidemiology, and Norwalk Virus Outbreak on Cruise Ships Based in Florida, and much, much more. CEUs will be applicable and special group rates at the resort will be offered. For more information, call the FPHA office at 904.539.1401.  

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► New HIV Quick Test Available at Non-traditional Venues

A new FDA-approved test is available that can provide results within as little as 20 minutes showing whether an individual has been exposed to the HIV antibody. Although not yet marketed for over-the-counter retail sales, HIV tests have been available through health departments, clinics and in doctors offices for years. Until recently, the 7-14 day waiting period for outcomes has resulted in a large number of persons never returning to test sites to receive their results. 

There are high hopes, however, that the new rapid test, which boasts 99.6% accuracy, will bring changes to that scenario. OraQuick Rapid HIV-1 Antibody Test is a single-use qualitative immunoassay that detects antibodies to HIV-1 in a fingerstick sample of blood. Although the accuracy rate for positives is high and no false positives were found in clinical trials, follow-up confirmatory testing should still be completed, according to the FDA. 

In the interest of reducing the number of persons who don't return to receive their test results, the Department of Health and Human Services has granted a waiver for non-traditional venues to act as testing sites using OraQuick. Kits cost approximately $10-15 each. To find out more about the certificate of waiver program administered by the Centers for Medicare and Medicaid Services, go to the CMS CLIA website at http://www.cms.gov/clia/cliaapp.asp.

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► Influenza Season Summary Now on Web

The Bureau of Epidemiology and Bureau of Laboratories have completed the 2002-03 Influenza Season Summary. This final report is posted on the Internet under Diseases and Conditions, Influenza.

The summary report covers the Florida Sentinel Physician Reporting System, laboratory surveillance, results, and future plans for influenza surveillance in Florida. Recruitment plans and materials for the upcoming influenza season will be made available by September. Questions or comments can be directed to Melissa Covey, the influenza surveillance coordinator, at the Bureau of Epidemiology in Jacksonville. To reach Melissa, call at 904.791.1567.

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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 Eastern Equine Encephalitis (EEE) virus since mid-April. 

EEE virus activity: Eighteen horses were confirmed with EEE virus infections, bringing the YTD total for horses infected with EEE virus to 157 in 42 counties, with seven new counties added this week. This year so far, there are more than six times the number of horses which were reported with EEE in all of last year. Fourteen seroconversions to EEE virus were confirmed in sentinel chickens. No dead birds were reported positive with EEE. Six live wild birds were found EEE-positive, one juvenile in Walton County suggesting a recent infection. Of Florida’s 67 counties, 46 have reported EEE activity, compared to 16 this time last year. EEE activity appears to be spreading out from the central region.

West Nile (WN) virus activity: Three seroconversions to WN virus were confirmed in sentinel chickens, for a YTD total of 57 WN seroconversions in 17 counties. Nine dead birds were reported positive for WN virus. Twenty-nine counties have reported WN virus activity this year, with sporadic distribution around the state, compared to 18 at this time last year.

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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