Friday, July 23, 2004

         This Week in the News
 

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

►2004 Quality Showcase Selects Two Entries from Bureau of Epidemiology
EpiCom and Merlin netted places at the show scheduled for St. Petersburg in September.

►CHD Conference Call Provides News on County Outbreaks
A mysterious rash, nosocomial infection issues, and a hepatitis outbreak update. In addition, input from county health departments is being sought on a new plan for hazard surveillance.

A R T I C L E S

According to the abstract for the Merlin outbreak module, its success demonstrates the flexibility of the reporting system as a department-wide outbreak management tool. It will improve the ability to detect and respond to outbreaks in an efficient and timely manner. Karen Wheeler, MPH, Kim Wiley, Lalit Heda, Carmela Mancini, MPH and Ronee' Wilson, MPH, also worked on the module to bring it to fruition, as did Pete Garner, Kathryn Teates and Roberta Hammond.

The EpiCom communications system was developed to reduce the amount of time it took for public health practitioners in Florida to respond to suspected disease occurrences. It has filled a void in communication and provided a free service which also alerts users to epidemiological emergencies. Pete Garner and Karen Wheeler were also instrumental in development of this project.

Congratulations to these team members!  Their hard work represents our best in the spirit of  cooperation, innovation and inspiration, and we're proud of their achievements.
 

The Bureau of Epidemiology is proud to announce the publication of the 2001 & 2003 Florida Youth Risk Behavior Survey (YRBS). This report is available at the bureau’s Website at: http://www.doh.state.fl.us/disease_ctrl/epi/topics/pubs.htm. 

As a component of the Youth Risk Behavior Surveillance System developed by the CDC, the YRBS monitors health risk behaviors that contribute to disease morbidity and mortality, including tobacco use, nutrition, physical inactivity, alcohol and other drug use, sexual behavior, and unintentional injuries and violence. The YRBS is administered in Florida public high schools in the spring of odd-numbered years.  

• Findings from the 2001 and 2003 surveys show declines in the prevalence of tobacco use among Florida’s high school population, and indicate an increase in the number of high school students who are overweight:
• Percentage of Florida high school students who used any tobacco during the past 30 days decreased from 26.6 percent in 2001 to 22.7 percent in 2003.
• Percentage of Florida high school students who smoked cigarettes on one or more of the past 30 days decreased from 21.5 percent in 2001 to 18.1 percent in 2003. 
• Percentage of Florida high school students who smoked cigarettes on school property on one or more of the past 30 days decreased from 7.0 percent in 2001 to 5.2 percent in 2003.
• Percentage of Florida high school students who are overweight increased from 10.4 percent in 2001 to 12.4 percent in 2003.

In 2003, Florida’s high school population tobacco usage was below the national level. However, certain risk behaviors related to physical inactivity were higher than the national level. 

• Percentage of high school students who smoked cigarettes on one or more of the past 30 days (18.1 percent in Florida versus 21.9 percent in the U.S.)
• Percentage of high school students who used any tobacco during the past 30 days (22.7 percent in Florida versus 27.5 percent in the U.S.)
• Percentage of high school students who attended physical education class one or more days during an average school week (45.7 percent in Florida versus 55.7 percent in the U.S.)
• Percentage of high school students who watched three or more hours of TV per day on an average school day (42.7 percent versus 38.2 percent in the U.S.)

For more information on the YRBS, please contact Melissa Murray at 850.245.4444, ext. 2445, or at melissa_murray@doh.state.fl.us.  
 

The conference call between staff at health departments statewide and the staff at the Bureau of Epidemiology in Tallahassee which took place on Friday, July 16, 2004 is recounted here in brief for those who weren't able to participate.

Announcements. Don Ward reported that the All Hazards Surveillance and Epidemiology Plan will be ready for review by county health department personnel by the end of July. County health department staff wanting to be on the review team and haven't already contacted Don, please let him know via email. The plan encompasses all levels, from the CDC in Atlanta to Florida CHDs.

Merlin Outbreak Module Training. Angela Fix, MPH, reported that a training and demonstration session will be conducted on August 4. Ten counties will travel to Tallahassee to participate in an evaluation of the outbreak module.

Immune Globulin Supply. Bill Toth of Orange County offered vials of IG to any health department that may need them. There are approximately 150 extra vials of 2 cc prophylaxis for Hepatitis A due to expire in December 2004 and May 2005. Phone him at 407.623.1212 or email him. 

He also reported that one male adult who had received multiple immunizations and who had been on active duty in the military approximately 15 months ago, has since developed a rash. The incident has been placed on the VAERS report. The patient is being followed by the Orange County Health Department.

Nosocomial Infections - Putnam CHD. Joann Schulte reported that the team has finished examining hospital charts to review central line issues. Environmental controls were identified and discussed with hospital officials, who will address what was found.

Hepatitis A - Hillsborough CHD. Margaret Ewing provided an update, reporting that 69 contacts, mostly children, were made, and iG was administered. Although some of the children did not exhibit symptoms, their parents requested prophylaxis anyway as a preventative. No day care facilities were involved. One new case has been identified.

The next conference call will be held on Friday, July 30th at 10:00 a.m. If you have questions or would like to be placed on the agenda, contact Professional Training Coordinator Melanie Black, MSW at 245.4444, ext. 2448 or email her at melanie_black@doh.state.fl.us
 

The person most responsible for the proper training of new users on Merlin is Travis McLane, surveillance and reporting program specialist at the Bureau of Epidemiology in Tallahassee.

Travis is well acquainted with specialized software. Having worked for the Florida Department of Health since 1993, he's familiar with reporting systems used within health departments, as well as those in use by the Bureau of HIV/AIDS. Earlier in his career he was an office automation specialist, installing systems and providing technical assistance to users, conducting case surveillance and providing ad hoc data requests. Prior to concentrating on computer reporting systems, he worked as a statistician.

Travis currently enjoys writing music; he plays several instruments and has played with various bands throughout high school and college.

His work in Merlin encompasses testing the software, completing and submitting statewide  epidemiological data to the CDC, and assisting the over 700 registered users when contacted with questions. He travels frequently to conduct training sessions throughout the state, and also provides input on Merlin design issues.

To reach him, call Travis at 850.245.4444, ext. 2413 or email him at travis_mclane@doh.state.fl.us.
 

On February 19, 2004, the Brevard County Health Department was notified by Parrish Medical Center that a Brevard County resident had experienced neurological symptoms consistent with paralytic shellfish toxin or saxitoxin exposure. Prior to onset, the patient case was reported to have consumed a meal with two other people that consisted of pufferfish caught from an unknown location.   

The ingestion of saxitoxins produces symptoms of tingling and burning of the mouth and tongue, numbness, drowsiness, speech difficulties, ataxia, muscle weakness, and respiratory paralysis. Death can occur if respiratory support is not provided. Onset of symptoms can occur from 30 minutes to 2 hours after toxin ingestion (USFDA, 2004). Saxitoxin blocks ”neural transmission at the neuromuscular junction by binding to the surface of the sodium channels and interrupting the flow of the Na⁺ ions; atrioventricular nodal conduction may be suppressed, and there may be direct suppression of the respiratory center and progressive reduction of peripheral nerve excitability (Klaassen, 2001).”   

Methods
The Brevard County Health Department epidemiology team and the Bureau of Community Environmental Health conducted an investigation of these severe cases of foodborne illness. Additional surveillance was performed via Florida Poison Control Centers, active surveillance of hospital emergency departments and county health department foodborne illness logs. A case was defined as a person who experienced tingling or numbness in the mouth and/or lips following consumption of Florida pufferfish. A trained epidemiologist using a standardized questionnaire specific for this illness interviewed the three persons who were with the patient case on the day the pufferfish were caught and consumed. Urine samples were collected from two cases while they were still experiencing symptoms, and analyzed for the presence of saxitoxin by the Centers for Disease Control and Prevention. Four pufferfish filets associated with the ill persons were sent to the US Food and Drug Administration for laboratory analysis.   

Results
Three interviews were conducted using the standardized questionnaire. All three persons had eaten pufferfish with 2 reporting neurological symptoms consistent with the case definition. The only seafood eaten by all ill persons was pufferfish. The fish were consumed on February 18 and illness onset was 3.5 to 11.5 hours after consumption. The fish were prepared by pan-frying. Other meal items included hushpuppies, french fries, and various soft drinks. The patient cases were 43 and 50 years old. One was male and one was female. 

Predominant symptoms included tingling or numbness in lips (2), tingling or numbness in arms (1), tingling or numbness in face (1), tingling or numbness in leg (1), drowsiness (1), muscle aches (1), and headache (1). Neither person was placed on a respirator. The 43-year-old female went to the emergency room on February 19 and was hospitalized in intensive care until February 22. Patient cases consumed from 3-5 filets and the well person consumed 5 filets. No correlation appeared to exist between the quantity of fish eaten and latent period or whether or not illness occurred.  

All fish were caught recreationally from a boat in the Indian River Lagoon in Titusville, Florida, several miles north of Veteran’s Park. It is not known what species of pufferfish were consumed by the patients. Both well and ill persons in this investigation stated that they were not aware of the health risks associated with consumption of pufferfish, nor were they aware of the ban on possession of pufferfish, or that cooking and cleaning the fish “properly” did not reduce the health risk. The individuals believed that if the “bag” was removed and the fish were cooked “correctly” that pufferfish was safe to eat. The source of their information was reported to be television. Again, the Florida Department of Health published a press release detailing the hazards of consuming Indian River Lagoon pufferfish.   

Saxitoxin was present in the two collected urine samples ranging from 21.54 to 153.61 ng STX/mg creatinine. All four fried pufferfish filets tested positive for saxitoxin ranging from 3671 to 7480 mg STX 100g^-1 .   

Conclusions and Recommendations
This cluster of neurological illnesses is compatible with the known symptoms associated with paralytic shellfish poisoning. Each illness onset was preceded by the consumption of pufferfish harvested from the Indian River Lagoon in Brevard County. The presence of saxitoxin in the urine of two patient cases confirms the agent of this outbreak was severe neurological illness. The presence of saxitoxin in the four fried pufferfish filets confirms pufferfish as the vehicle of transmission.  

This is the third documented outbreak of saxitoxin poisoning associated with the consumption of pufferfish. The extent and cause of this phenomenon is still under investigation by marine scientists. Toxicological and ecological analyses of multiple aquatic life and microalgae are ongoing to determine the origins of this toxin that has not been documented in pufferfish or the Indian River Lagoon prior to this event. The connection between the health of the Indian River Lagoon ecosystem, other recent instances of aquatic mortality, and this event are being examined very closely. It is important to note that so far, saxitoxin has only been found in the Southern pufferfish in the Indian River Lagoon but not in any other fish or shellfish in those waters. The well-known Northern pufferfish ranges from North Florida to New York and has not been found to be toxic.   

Rapid identification of cases and the coordination of laboratory samples are critical in determining disease outbreaks and the extent of illnesses. The prompt reporting of neurological manifestations of exposure to foodborne toxins by attending physicians and poison information centers to the Department of Health is essential for implementing appropriate control measures and rendering prompt medical care with positive outcomes. 

Successful risk communication is another crucial element in preventing additional illnesses of saxitoxin poisoning from pufferfish. Despite many public warnings about the risks, this outbreak investigation and anecdotal evidence demonstrate continuing confusion among the public about the differences between saxitoxin and tetrodotoxin.   

In contrast to tetrodotoxin, pufferfish with saxitoxin cannot be cleaned, cooked or frozen to mitigate the effects of the toxin in the human body. Many consumers familiar with fugu poisoning and tetrodotoxin are confused on this critical point: Cleaning the pufferfish properly will not remove the saxitoxin. The only way to prevent illness from saxitoxin is to refrain from eating pufferfish altogether until more is learned of the origins and extent of the presence of the toxin. Communicating this message to the public is vital, and the use of news media, posters, information cards and other methods of communication is continuing in collaboration between the Brevard County Health Department, the Bureau of Community Environmental Health and the Fish and Wildlife Conservation Commission. 

References 

Florida Fish and Wildlife Conservation Commission, Florida Marine Institute. (2004) Website, www.floridamarine.org. 

Hammond, R. et al (2004). Update: Neurologic Illness Associated with Eating Florida Pufferfish, 2004. Morbidity and Mortality Weekly Report, Centers for Disease Control, May 17, 2004, 51(19) 414-6.

Klaasen, Curtis D., Ed.  Casarett and Doull’s Toxicology – The Basic Science of Poisons, 6^th Ed, 2001.  McGraw Hill, Medical Publishing Division, p. 1078.

Lalone, et al. (1963).  An assay of the toxicity of the Atlantic pufferfish, Spheroides maculatus. Toxicon, 1: 159-164.

Landsberg, J.H., et al (2004).  Pufferfish poisoning: Widespread Implications of Saxitoxin in Florida. Abstract for Xth International Conference on Harmful Algae, October 21-25, 2004, St. Petersburg, Florida.

Landsberg, J.H. (2004). Florida Fish and Wildlife Conservation Commission, Florida Marine Institute. Personal Communications, July 1, 2004 and October 3, 2004.

Sharifzadeh, K., et al (1991). Epidemiologic Notes and Reports Paralytic Shellfish Poisoning--Massachusetts and Alaska, 1990.  Morbidity and Mortality Weekly Report, Centers for Disease Control, March 15, 1991, 40(10) 157-161.

Marcus, S., et al (2004). Neurologic Illness Associated with Eating Florida Pufferfish, 2004. Morbidity and Mortality Weekly Report, Centers for Disease Control, February 19, 2004, 51(15) 321-3.

Rogers, H., (2004) Centers for Disease Control and Prevention, National Center for Environmental Health, Division of Environmental Hazards and Health Effects, Health Studies Branch, Personal Communications, August 23, 2004. 

U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. (2004). Foodborne Pathogenic Microorganisms and Natural Toxins Handbook. Website www.cfsan.fds.gov/~mow/chap37.html.

U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition. (2004). Foodborne Pathogenic Microorganisms and Natural Toxins Handbook. Website www.cfsan.fds.gov/~mow/chap39.html.
 

Who can access the Merlin system?  A Department of Health employee who is logged on the network with their DOH User_ID and Password. The Merlin system can be accessed via the Department of Health Intranet. There are several access levels which allow access to various screens and functions in Merlin.  Data Entry and Supervisor level users can record search, edit data, and run statistical reports and analysis.  Read Only level users can record, search, view data, and run statistical reports and analysis. Other access levels include Rabies Data Entry, Lab Data Entry, and Lab Administrator. 

What are the benefits and capabilities of Merlin? 

• Ability to electronically review and analyze county and statewide disease trends
• Ability to export disease information for sophisticated analysis

• Quick and easy data entry capabilities
• Availability of printable reports and documents
• Designed to receive and process electronic laboratory data
• Potential for increasing reporting timeliness
• Programmed to detect potential disease outbreaks and clusters
• GIS capabilities

• Availability of a Helpdesk for submitting questions and requesting assistance

• Ability to manage, investigate and analyze information from a variety of outbreak/cluster types, including:  reportable and non-reportable diseases, symptoms/syndromes and other events of public health importance.

Below, you will find a flow chart for entering and reporting a case in Merlin. If you have further questions, please feel free to contact the Merlin Helpdesk at Merlin_Helpdesk@doh.state.fl.us.  

Merlin Help:  Merlin_Helpdesk@doh.state.fl.us
 

Bureau of Epidemiology Grand Rounds Program
Tuesday, July 27, 2004 11:00 a.m. – 12:00 p.m. ET

      Varicella Has Been Breaking Out All Over:  Are We Chicken to Not Report It?

Presenters:
Joann Schulte DO, MPH, Medical Epidemiologist, Bureau of Epidemiology, Phyllis Yambor, RN, Bureau of Immunizations, Kendra Larry, MPH, Florida EIS Fellow, Bureau of Epidemiology

Abstract:
Varicella/chickenpox outbreaks have become more common in school settings in recent years. In 2004, two Florida counties (Flagler and Seminole) reported varicella outbreaks in elementary school settings. Such outbreaks are preventable because a varicella vaccine is now licensed and in use in the pediatric population. Control of varicella is important and persons who develop varicella as adults are much more likely to develop serious, life-threatening complications. The status of varicella as a reportable disease is evolving and some states have added it to the list of reportable diseases. This presentation will address the Florida outbreaks, explore the immunization requirements for varicella in the state and examine the pros and cons of whether it should be a reportable condition in Florida.

Additional Information:
The grand rounds presentation will begin promptly at 11:00 a.m. ET on Tuesday, July 27, 2004. The PowerPoint slides will be available on the Bureau of Epidemiology intranet Website on Wednesday, July 21. CEUs will be provided for nursing. Please remember you must complete the entire registration form including the evaluation and test questions. Registration for CEUs will be accepted June 27-June 29. Registrations received prior to the beginning of the program will not be accepted. If additional information is needed, contact Professional Training Coordinator Melanie Black, MSW, at 850.245.4444, ext. 2448, SunCom 205.4444 ext. 2448, or email Melanie_Black@doh.state.fl.us.
 

This Week on EpiCom

• 4 positive cases of West Nile virus in Miami-Dade
• 1 case of possible bacterial meningitis in child in SE Volusia County
• Palm Beach County female with Listeriosis
• Unusual rash seen in Orange County on former military servicemeber
• Rocky Mountain Spotted Fever in Sarasota County

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 four seroconversions to WN virus in sentinel chickens from Brevard (7/1) and Hillsborough (6/22 x3) counties. So far this year, 22 counties have reported WN activity. 

St. Louis Encephalitis (SLE) virus activity: None this week. To date, two counties have reported SLE activity. 

Eastern Equine Encephalomyelitis (EEE) virus activity: There were six seroconversions to EEE virus in sentinel chickens from Nassau (7/5), Orange (7/6 x3) and St. Johns (7/5 x2) counties. In addition, a live blue jay captured (6/23) in Santa Rosa County tested positive for EEE virus this week. So far this year, 20 counties have reported EEE activity. 

Highlands J (HJ) Virus activity: None this week. To date, eight counties have reported HJ activity.

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

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