Friday, July 23, 2004
Week in the News
"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."
Quality Showcase Selects Two Entries from Bureau of Epidemiology
Show Trends in Florida Youth Behavior
In two recently released reports on tobacco use and risk, youth behavior in Florida is measured against the national level.
Conference Call Provides News on County Outbreaks
Surveillance and Reporting Program Specialist|
Travis McLane travels a lot. It's because he conducts classes on the basics of Merlin, the reporting system used by the Bureau of Epi to track reportable diseases.
|Epi Update Managing Staff:||
Consumption Confirmed as Cause of Saxitoxin Poisoning Cases|
Pufferfish consumption isn't safe. Despite public warnings, some fishermen miss the alerts and end up in the emergency room.
MD, MBA, MPH,
Secretary, Department of Health
►How-to U - Merlin for Beginners
School is in! Here's a primer on the Merlin recording system, what it does, and how it works.
Division of Disease
Outbreaks Subject of July Grand Rounds|
Schools with increasing chickenpox outbreaks know these occurrences are preventable. This presentation will explore immunization requirements and other issues associated with the problem.
Acting Bureau Chief,
►This Week on EpiCom
Log on regularly to access information that could be vital to your organization if you're in the middle of an investigation. Someone else could be experiencing an outbreak that may be similar to yours.
Copy Editor / Writer
A report outlining activities for the week July 11 - 17, 2004 for confirmed cases.
A R T I C L E S
|Jaime Forth, Copy Editor / Writer, Bureau of Epidemiology||
2004 Quality Showcase Selects
Two Entries from Bureau of Epidemiology
Among the more than 58 applicants for this years' showcase were several entries from the Bureau of Epidemiology. However, Christie Luce's EpiCom submission and Don Ward's Merlin Outbreak Module were chosen to represent the Division of Disease Control at the exhibit, scheduled for September 14-15 at the Hilton Hotel in St. Petersburg.
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.
Melissa Murray, MS,
Coordinator of Statistical Research, Chronic Disease Surveillance and
Reports Show Trends in Florida Youth Behavior
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.
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.
information on the YRBS, please contact Melissa Murray at 850.245.4444,
ext. 2445, or at
|Jaime Forth, Copy Editor / Writer, Bureau of Epidemiology||
CHD Conference Call Provides News on County Outbreaks
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
|Jaime Forth, Copy Editor / Writer, Bureau of Epidemiology||
Surveillance and Reporting Program Specialist
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 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
|Dean Bodager, RS, MPA, DAAS, Bureau of Community Environmental Health; George Jackow, MED, Brevard CHD; Barry Inman, CIC, CHE, Brevard CHD; Saroj Aggarwal, MD, MBA||
Consumption Confirmed as Cause of Saxitoxin Poisoning Cases
Introduction and Background
During 2002 the Florida Department of Health reported 21 cases of saxitoxin poisoning as a result of consuming pufferfish obtained from the Indian River Lagoon. The 2002 outbreak was the first time southern pufferfish were associated with saxitoxin, the toxin that also causes paralytic shellfish poisoning in the United States. Two cases were reported during 2003. The Florida Wildlife Conservation Commission implemented a temporary ban during 2002 which was subsequently extended to October 22, 2004. On June 9, 2004, the ban was made a permanent rule with financial penalties.
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).”
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 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.
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, 6th 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.
|Travis McLane, Program Specialist, Surveillance and Reporting Section, Bureau of Epidemiology||
How-to U - Merlin for Beginners
What is Merlin? Merlin is Florida’s official web-based system for disease reporting, surveillance and analysis activities. Merlin is managed by the Bureau of Epidemiology, Florida Department of Health (FDOH), and is utilized by all county health departments and various bureaus and divisions within the FDOH.
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?
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.
|Joann Schulte, DO, MPH, Medical Epidemiologist, Bureau of Epidemiology||
July Grand Rounds
Explores Increasing Varicella Outbreaks
|Pete Garner, Surveillance Systems Manager, Bureau of Epidemiology||
The Bureau of Epidemiology encourages Epi
Update readers to not only register on the EpiCom system at
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
|Arbovirus Surveillance Team: Samantha Rivers, MS, Caroline Collins, Kristen Payne, Calvin DeSouza, and Carina Blackmore, MS Vet. Med., PhD., State Public Health Veterinarian||
Four residents of Miami-Dade County were confirmed with West Nile illness this week. The human cases were preceded by increased dead corvid (primarily blue jays) bird reporting in the county, which was placed under medical alert for mosquito-borne disease. Mosquito populations are present in many areas of the state. All are urged to take precautions against mosquito bites. Dead birds should be reported to www.wildflorida.org/bird/.
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.