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 

A R T I C L E S

Soni Schulze, MPH, Florida EIS Officer, Bureau of Epidemiology

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

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

►Broward County Study Shows Increase in Shigella Cases           

Nature of Outbreak: There has been an increase in the number of reported* shigella cases in Broward County beginning in June 2002. Since that time the county has been well above the anticipated 6.7 cases per month, based upon the three year average, 1999-2001. For the period June 2002 – May 2003, the average number of cases per month was approximately 17.7 cases, which is more than 2.6 times higher than the 1999-2001 three year average. It appears that this increase is attributable to separate outbreaks that are occurring simultaneously. The larger of the outbreaks is in children aged ten and under with 73 % (154/211) of the cases. Case reviews have not shown any particular day care center or elementary school linked to a high proportion of cases. In fact, there were 65 day care centers and elementary schools identified with shigellosis infections within their organization. On average, there have not been more than two cases reported at any one facility. In instances where an outbreak is identified, Broward County Health Department provides educational in-servicing and sends educational materials to the facility to control further spread of the illness.

The smaller outbreak appears to be among men who have sex with men. Communicable Disease Nursing has made possible links to circuit parties through case investigations. There were 2.25 times more reported shigella cases in men > 25 years than in women in the same age group. Additional educational outreach may be necessary among this population to identify cases and prevent further disease transmission.   

A new clinic is scheduled to open in August this year in the Wilton Manor area through grant funding, to deal specifically with the syphilis outbreak Broward County is experiencing. However, attempts are being made to coordinate other services such as hepatitis and HIV screening. Screening for enteric pathogens will be added for symptomatic cases.

Two zip codes (33311 and 33023) have been identified with a significant number of shigella cases. There appear to be two possible clusters and further investigations will continue, particularly in these areas. Contact has been made with Child Care Enforcement (regulatory agency for day care centers). A current list with mailing labels has been obtained from this agency. An updated Shigella Facts Sheet will be distributed to some (or possibly all) day care centers. 

Agent Identification: Of the cases reported between June 2002 – May 2003, 202 lab reports were received with the species identified. The species which predominates in Broward County is shigella sonnei with approximately 92.6% (187/202) of the cases with species identified, shigella flexneri with 6.4% (13/202) and shigella boydii with 1.0% (2/202) as identified by the Merlin reporting and analysis system, Case Management Reports.    

Symptoms: Watery or bloody diarrhea, abdominal pain, fever, and malaise are the common clinical features of shigellosis infection¹. Severe infection may occur in young children and the elderly, and seizures have been associated with infection in children under the age of two¹. Reiter’s syndrome can be a late complication of infection with shigella flexneri, especially in those who are genetically predisposed with the genetic marker HLA-B27¹. The following are identified risk groups according to the CDC; children in child-care centers, persons in custodial institutions where personal hygiene is difficult to maintain, international travelers, men who have sex with men, and those in homes with inadequate water for hand washing.

Transmission and Incubation: Transmission of shigella is mainly by direct or indirect fecal-oral contact. This may be through contaminated food or water, or person-to-person contact². Hand washing is the key to preventing the spread of shigellosis. As few as 10-100 organisms are needed to cause shigella infection. The incubation period is 12-96 hours with an average of 1-3 days². 

Preventive Measures: Broward epidemiology staff will continue to conduct case investigations and identify possible risk factors. Educational materials and outreach will be provided as appropriate. The goal will be to identify new cases and prevent further transmission of the disease to others. A copy of the Shigella Facts Sheet is available at the Broward County website, http://www.browardchd.org./

¹ http://www.cdc.gov/ncidod/dbmd/diseaseinfo/shigellosis_g.htm  
² Control of Communicable Diseases, James Chin, MD, MPH, Editor, 17th Edition, 2000.

* Data depicted for 2002 and 2003 are considered preliminary and reported cases are subject to change. Reported cases include both “reported” and “not yet reported” cases within the guidelines of the Merlin reporting system.

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► Bureau of Immunization Videoconference Offers CEUs 

The Department of Health, Bureau of Immunization, in conjunction with the Office of Performance Improvement, is making available the Immunization Update 2003 interactive satellite teleconference through the Department of Health Telnet Videoconference Sites. This broadcast will air on August 21, 2003 from 9:00 a.m. to 11:30 a.m. EDT. The teleconference will be re-broadcast from 12:00 noon to 2:30 p.m. that afternoon. Anticipated topics include influenza vaccine, including recommendations for the use of the new live attenuated intranasal vaccine; pneumococcal conjugate vaccine; hepatitis B vaccine; recommendations for the use of new pediatric combination vaccines; an update on the smallpox vaccination program, including recommendations for the use of smallpox vaccine for the prevention of monkeypox; and an update on global polio eradication. Continuing education credits will be offered for a variety of professions, based on 2.5 hours of instruction. Participants must register in order to receive continuing education credits for this broadcast at http://www.phppo.cdc.gov/phtonline/. For further information, please contact Tom Bendle of the Bureau of Immunization at (850) 245-4444, extension 2391 or SunCom 205-4444, extension 2391.

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► July 29th Grand Rounds to Feature Bioterrorism Study

The Grand Rounds scheduled for July 29th will commence at 11:00 a.m., with guest speaker Kristin Uhde, surveillance director at the Center for Biological Defense, College of Public Health at the University of South Florida presenting the outcome of a bioterrorism study which tested BioDefend^TM as a new method of syndromic surveillance. The call in number is 850.478.8587 or SunCom 277.8587. Please be sure to dial in by 11:10 a.m. and place your phone on mute so others will not be disturbed.  If you have questions, contact Melanie Black at melanie_black@doh.state.fl.us.

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► FDA Proposes Provisions to Enhance Bioterrorism Act of 2002

The FDA announced it has proposed four major provisions to the Bioterrorism Act signed by President Bush in June 2002, in an effort to provide additional safety measures to the protection of our food supply. The law gave the secretary of the Department of Health and Human Services authority to do whatever is necessary to protect the country’s consumables against acts of terrorism by foreign or domestic agents. The new measures would give the FDA, the regulatory branch of the department,  unprecedented authority to inspect, detect and monitor the nation's food supply. 

The four provisions would be contained in Title III, Subtitle A (Protection of the Food Supply). The  proposal includes registration of food facilities by December 12th of this year. This would be applicable to foreign or domestic facilities which manufacture, pack, process, distribute, hold or receive food for consumption by humans and animals in the U.S.

Beginning December 12^th, 2003, the FDA would receive advance notice of each shipment of food into the United States. The formal notice would include a description of all articles in the shipment including the manufacturer, shipper and grower, country of origin, anticipated port of entry and the country from which each article is shipped.

Another proposed stipulation would authorize the FDA to administratively detain food if the FDA holds credible information that the food poses a threat of serious adverse health to humans or animals in the U.S.

The fourth proposal would enable the FDA to investigate credible threats of serious health impacting humans or animals by tracing the food back to its source, by requiring persons that pack, transport, distribute, receive, hold, import and/or manufacture food to create and maintain records which clearly identify the immediate previous sources and immediate subsequent recipients of food.

Although these regulations have not yet been approved, they would apply to all facilities for all foods and animal feed products regulated by the FDA, including dietary supplements, infant formulas, beverages, including alcoholic beverages, and food additives. For more information or to track the progress of this proposal, log on to http://www.fda.gov/oc/bioterrorism/bioact.html.

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► Immunization Awareness Month Approaching

The National Partnership for Immunization has designated August as National Immunization Awareness Month (NIAM). Each year, this commemorative month increases awareness about immunization across the lifespan as parents and children prepare for the return to school, and the medical community begins preparations for the upcoming flu season. NIAM provides an opportunity to create positive messages for the media and to highlight local, grassroots immunization initiatives. County health departments are encouraged to participate in the observance of NIAM through press releases, media campaigns, health fairs and exhibits. For further information, please contact Tom Bendle of the Bureau of Immunization at (850) 245-4444, extension 2391 or SunCom 205-4444, extension 2391.

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► Arboviral Disease Report  

Two human cases of Eastern Equine Encephalomyelitis were confirmed this week in residents of Bay (onset 7/5) and Orange (onset 7/4) counties, which have been placed under medical alert for Eastern Equine Encephalitis (EEE), joining Gilchrist County which has been under medical alert since mid-April.  

EEE virus activity in animals: Ten horses were confirmed with EEE virus infections, bringing the YTD total for horses infected with EEE virus to 168 in 45 counties, with three new counties added this week. This year so far, there are nearly seven times the number of horses than were reported with EEE in all of last year. Seventeen seroconversions to EEE virus were confirmed in sentinel chickens. Two dead birds were reported positive with EEE (Alachua and Leon). Two live wild birds were found EEE-positive, both juveniles in Walton County suggesting recent infection. Of Florida’s 67 counties, 46 have reported EEE activity, compared to 19 last year by this time. EEE activity appears to be spreading out from the central region.

West Nile (WN) virus activity: Ten seroconversions to WN virus were confirmed in sentinel chickens, for a YTD total of 67 WN seroconversions in 20 counties (Martin, St. Lucie and Walton with new sentinel WN activity this week). Six dead birds were reported positive for WN virus. Thirty-three counties have reported WN virus activity this year, with sporadic distribution around the state, compared to 21 last year by this time.

The complete report can be viewed at: http://www.doh.state.fl.us/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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