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

Jaime Forth, Copy Editor/Writer, Bureau of  Epidemiology 

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

Curt Miller, BS, and Youjie Huang, MD, DrPH, Bureau of Epidemiology, Chronic Disease, Surveillance and Evaluation Section

David Atrubin, MPH, EIS Officer, Bureau of Epidemiology  and Michael Friedman, MPH, Bureau of Community Environmental Health

Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology

Marie A. Bailey, MA, MSW, BRFSS Coordinator and Curt Miller, BS, Epidemiologist, 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

► Polk County Health Department Increases Outreach
 
The Polk County Health Department has additional staff members and a further reaching mission, thanks to grants from the federal government and the vision of its director. 

County health departments use a variety of strategies to intervene in the disease transmission process, all of them dependent upon effective communication with constituents. However, during an outbreak of a serious disease, such as when typhoid fever spread throughout the Hispanic population in Polk County several years ago, it becomes apparent that immunizations are only one of an arsenal of preventive technologies available to medical practitioners, and that communication plays a more critical role in tracking and halting the spread of infections.  

According to Dr. Daniel Haight, director of the Polk County Health Department, some groups are difficult to reach with messages concerning infectious diseases. Migrant farm workers may have language or transportation problems preventing access to health care, while drug users may use poor hygiene or lack health insurance. Other hard-to-reach individuals are alien residents, runaway youths, or illiterates who can’t read the information handed out by health department workers.   

Jose Lojo, a Florida EIS Officer, was recently assigned to the health department after leaving the CDC in Atlanta. As an epidemiologist, he's interested in breaking down barriers that may exist between groups of people who “from our perspective, are under the public health radar.” He's now part of a team of health professionals whose mission it is to meet with members of the underserved community living in Polk County.  

To ensure future efforts will reach segments of the population that don’t speak English and to assist health department staff in gaining an understanding of the difficulties encountered by other cultures, the team of Spanish-speaking doctors, epidemiologists, disaster planners and others has been assembled to visit areas in which the underserved reside. There are also plans to produce a field manual which can help other health providers deal with hard-to-reach populations. 

The effort to reach out will involve building trust, making presentations on good health practices, and letting people know about the health department and what it can do for them. For more information about the Florida EIS or the Polk County programs, contact Alan Rowan at  850.245.4444, ext. 4404 concerning EIS, or Daniel Haight at  863.519.7900, ext. 1002 in Polk County.

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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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► Trends in Tobacco Use Among New Mothers Unveiled

Background:  Cigarette smoking during pregnancy is associated with adverse birth outcomes such as intrauterine growth retardation, low birth weight, and pre-term delivery. Maternal smoking and infant exposure to second-hand cigarette smoke have also been associated with Sudden Infant Death Syndrome (SIDS) and respiratory illnesses in children. This report provides a description of trends in smoking behavior before, during, and just after pregnancy from 1993 to 2000, among new mothers in Florida. These trends are compared to data from the Florida Youth Tobacco Survey (FYTS) for years 1998-2001 and from the Florida Behavioral Risk Factor Surveillance System (BRFSS) for years 1990-2000.  

Methods:  Analyses for this report are based on data from three sources: the Florida Pregnancy Risk Assessment Monitoring System (Florida PRAMS), for 1993 through 2000; the FYTS, for 1998 through 2001; and the Florida BRFSS, for 1990 through 2000. Florida PRAMS is a joint surveillance project between the Florida Department of Health and the CDC, designed to monitor the physical, economic, and social health of Florida’s mothers and newborns. The project was designed as a mail survey with telephone follow-up of a random sample of recent mothers of live-born infants, completed when the infant is approximately three to six months old.

The FYTS is a self-administered school-based survey of public middle school students (grades 6 through 8) and high school students (grades 9 through 12). The survey has been conducted by the Florida Department of Health since 1998. The FYTS data are weighted to reflect the grade and sex distribution of Florida’s in-school youth population. The FYTS tracks outcome indicators for use in monitoring and evaluating the progress of Florida’s youth-focused tobacco control program.  

The BRFSS is a state-based telephone survey of the civilian, non-institutionalized adult population with telephones. It was developed by the CDC and is designed to monitor trends in risk behaviors related to preventable chronic disease and conditions. With support from the CDC, the Florida Department of Health has conducted the Florida BRFSS annually since 1986. The Florida BRFSS data are weighted to reflect the age and sex distribution of Florida’s adult population, and to account for differences in the probability of selection and for non-response.

Results:  Among all new mothers in Florida, the prevalence of smoking during the last trimester of pregnancy decreased from 13.6% in 1993 to 9.1% in 2000 (p<0.01). For 20- to 34-year-old new mothers, smoking during the last trimester declined from 13.7% in 1993 to 12.9% in 2000 (p<0.01). Overall, among new mothers in Florida, the prevalence of smoking during the three months before pregnancy declined from 23.2% in 1993 to 17.2% in 2000 (p<0.01). The percentage of new mothers aged 20 to 34 who are current smokers decreased from 18.2% in 1993 to 13.8% in 2000 (p<0.05). The overall proportion of new mothers who report that they had had a discussion with a health care worker about the effects of smoking during pregnancy decreased from 76.9% in 1993 to 68.5% in 2000 (p<0.01). The overall trend of infant exposure to second-hand smoke (SHS) did not significantly change from 1996 to 2000. 

Conclusions:  Statistically significant declines from 1993 to 2000 in overall prevalence of smoking during the three months before pregnancy and during the last three months of pregnancy suggest that some tobacco control and reduction efforts might be having an impact on new mothers in Florida.

Programmatic efforts to prevent or reduce tobacco use of pregnant women and new mothers should be continued at the high school level, at programs for low-income women such as Women, Infants, and Children (WIC), and at primary physicians’ offices. Even in cases where a health care worker may be confident that the new mother-to-be does not smoke, counseling on how babies may be affected by second-hand smoke is still critical, especially given that Florida PRAMS data indicate a possible increase in infant exposure to second-hand smoke across all age groups. Infant exposure to second-hand smoke has been associated with SIDS and respiratory illnesses in children. When ascertaining the smoking status of a new mother-to-be, the physician, nurse, or health care worker should also inquire whether anyone in the household smokes.

The full report can be found at http://www9.myflorida.com/disease_ctrl/epi/prams/prams.htm.

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► Salmonella Outbreak Traced to Tampa BBQ Restaurant

Investigative Team:
David Atrubin, MPH, Florida EIS for Hillsborough County
Eliot Gregos, MPH, Environmental Manager, Environmental Health 
Michael Friedman, MPH, Bureau of Community Environmental Health
Paul Fiorella, PhD, Biological Scientist IV
Doug King, Environmental Specialist II
Xiomara Jeffrey-Hewitt, MPH, Epidemiologist
Jylmarie Kintz, MPH, Epidemiology Program Manager

Introduction and Background:  On June 25, 2003 the Hillsborough County Health Department was informed that two persons who had eaten lunch on June 20, 2003 at a local BBQ restaurant in Tampa experienced gastrointestinal illness approximately 24 hours after their meal. Reported symptoms included vomiting, abdominal cramps and diarrhea. One of the two affected persons was hospitalized and placed on kidney dialysis. Thirteen additional ill individuals, who all shared similar food histories involving the same BBQ restaurant, have been identified. All fifteen persons ate food from this restaurant during the period of June 18-21, 2003, with BBQ sauce being the only common food among them. Five of the fifteen illnesses were confirmed Salmonella group B cases (with matching strains identified by PFGE). Two of these five cases had not been previously linked to this BBQ restaurant, but were only done so after matching strains were identified by the Jacksonville DOH Laboratory. Upon re-interview, it was learned that these two persons did consume food from the implicated restaurant during the June 18-21 time period.

Methodology:  An investigation of this outbreak was performed by the Hillsborough County Health Department Environmental Health and Epidemiology Divisions and the Bureau of Environmental Epidemiology. A review of recently reported Salmonella cases and gastrointestinal illnesses was also conducted in order to identify additional cases. Isolates from recent Salmonella cases at local hospitals were also forwarded to the DOH Jacksonville Laboratory for PFGE analysis. An onsite investigation by the Environmental Health Division, in conjunction with an inspection by the Department of Business and Professional Regulation (DBPR), was performed on June 27, 2003, to assess employee illness, hygiene, and food handling and food chain procedures. A second field visit was planned; however, the apparent self-imposed closure of the restaurant prevented this from occurring.   

Results:  Fifteen persons (including one employee) were identified as either confirmed or probable Salmonella group-B cases associated with dining at the same BBQ restaurant during the period of June 18-21, 2003. All persons identified ate in the restaurant or consumed carryout food from the restaurant during the specified time period. At this point, extended data are available for 10 of the fifteen cases. The mean onset of the symptoms was 25.6 hours with a range of 15-36 hours.  Symptoms experienced by the ill restaurant patrons were diarrhea (100%) and vomiting (60%) being the predominant symptoms. Duration of illness ranged from a couple of days to over one week. 

An environmental field investigation was performed at the BBQ restaurant in Tampa on June 27, 2003. Preparation of all identified common foods consumed by the ill persons was reviewed and the kitchen facility was inspected by the DBPR representative. Large numbers of sanitation, employee hygiene and temperature control violations were identified. Some of the most significant problems identified included roast pork hot held at 95 degrees, roast chicken at 110 degrees, no hand wash sink in the kitchen area, inadequate sanitizing of work surfaces and equipment and live roaches observed in the kitchen. In addition, one food worker who had experienced gastrointestinal symptoms was identified. A warning was issued by the DBPR inspector to correct all violations. Repeat visits by the Health Department and DBPR were attempted; however, the restaurant facility had been vacated and the present location of the owners is not known. 
           
Analysis and Conclusion:  This outbreak of Salmonella group-B is strongly associated with the consumption of food from this BBQ restaurant in Tampa during the four-day period of July 18-21, 2003. The ill persons had no other epidemiological associations identified and the onsets of symptoms were chronologically clustered indicating a common source exposure. The identification of an ill food worker in the implicated food service facility may explain the four days of exposure associated with this outbreak. The wide variety of food consumed by ill individuals may be due to the ill food worker preparing multiple foods or cross-contamination among various food items. It should be noted that the investigation is ongoing, and Salmonella cases associated with food eaten from this restaurant continue to be identified.   

Recommendations:  It is recommended that before the implicated restaurant is allowed to re-open, another inspection of the facility be conducted, and educational food safety training be provided for existing staff involved in all aspects of food preparation and sanitation. All new kitchen staff should also undergo a similar training program. In addition, ongoing monitoring of the facility’s operation should be performed. 

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► Officials Say Japanese Encephalitis Epidemic in China Under Control 

The encephalitis outbreak that has caused at least 25 deaths and 287 cases in the Guangdong Province of China bordering Hong Kong is under control, according to China's Ministry of Health.  

Encephalitis B, the leading cause of viral encephalitis in Asia with 30-50,000 cases reported each year, usually occurs seasonally and peaks in August. Since a vaccine was developed in the mid 1970s; however, countries which have experienced major epidemics in the past have been able to control the disease. Another major factor in the decrease of cases is an intensified effort to control the mosquito population. 

The virus is transmitted by mosquitoes which breed in rice paddies, and can spread further through domesticated pigs and wild birds. Case fatality rates range from 0.3% to 60%, and it is known to kill over 10,000 people each year in rural Asia. Japanese encephalitis usually does not occur in urban settings.  

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► Pre-Pregnancy Study Among Florida Women Finds Links Between BMI and Health 

Background:  Pregnancy is a critical period when good health plays a vital role in the health of a mother and her baby. A healthy pregnancy is defined as being without health complications from the time of conception to the delivery of a healthy baby. According to the American Dietetic Association, women should establish a lifestyle for optimal health that reduces the chance of adverse pregnancy outcomes before becoming pregnant. Healthy pre-pregnancy weight is an essential element of such a lifestyle. 

The goal of this study was to document associations between pre-pregnancy BMI (Body Mass Index) and pregnancy outcomes and health factors among women in Florida. This report describes pre-pregnancy BMI and its relationship to pregnancy outcomes and health conditions. This is the first PRAMS report published nationally on pre-pregnancy weight. Other similar reports focus on maternal weight gain during pregnancy. We approached this study from quite a unique perspective, as we focused on pre-pregnancy BMI as a risk factor, and its associations with birth outcomes and adverse health conditions during prenancy. The report also describes the socio-demographics of women who were at risk of pre-pregnancy underweight, overweight, or obesity among Florida women in 2000.

Methods:  The data analyzed were from the 2000 Florida Pregnancy Risk Assessment Monitoring System (PRAMS). Maternal pre-pregnancy weight-for-height status was measured by BMI, which is weight in kilograms divided by height in meters squared (kg/m²). 

The following pregnancy outcomes were analyzed for this report: 1) preterm births, 2) delivery by Cesarean Section, 3) low birth-weight births, and 4) length of infant’s stay in hospital. The following health conditions were analyzed for the report: 1) diabetes, 2) hypertension, 3) urinary tract infection, and 4) premature rupture of membranes (PROM). 

Results:  The prevalence of pre-pregnancy underweight was highest among non-Hispanic White women aged 19 years and under. On the other hand, the prevalence of pre-pregnancy obesity was higher among non-Hispanic Black women and women aged 35 and older than among their counterparts. Non-Hispanic Black women had the highest prevalence of pre-pregnancy obesity (20.6%).  Pre-pregnancy weight was associated with health outcomes: The prevalence of Cesarean Section (30.9%), diabetes (20.3%) and hypertension (26.9%) during pregnancy was the highest among obese women. The prevalence of newborns who spent more than two nights in the hospital was significantly higher among those born to obese mothers than among those born to non-obese mothers. The prevalence of urinary tract infections during pregnancy was highest among underweight women (25.2%). Prevalence of low-birth-weight births (9.8%) was significantly higher among underweight women than among their normal-weight counterparts (6.8%). 

Conclusions:  Higher levels of poor birth outcomes and health conditions are present among women who are either underweight or obese prior to pregnancy. Underweight mothers had higher levels of preterm delivery, low birth-weight infants, and urinary tract infections. On the other hand, obese mothers had higher prevalence of other diseases and complications such as C-sections, diabetes, hypertension, PROM, and infants who had longer hospital stays.  

The full report can be found at http://www9.myflorida.com/disease_ctrl/epi/prams/prams.htm.

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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: Ten seroconversions to EEE virus were confirmed in sentinel chickens. Twenty-seven horses were confirmed with EEE virus infections in 16 counties, bringing the YTD total for horses infected with EEE virus to 140 in 35 counties. Two dead birds were reported positive with Highlands J virus, a close relative to EEE but not as pathogenic in humans. Five live wild birds in Santa Rosa County and three in Okaloosa County were found to be EEE-positive. Most of these birds were hatchling-year birds indicating a recent infection. Of Florida’s 67 counties, 42 have reported EEE activity, compared to 16 this time last year. EEE activity is documented primarily in the central, northern and panhandle regions.

WN virus activity: Three seroconversions to WN virus were confirmed in sentinel chickens, for a YTD total of 54 WN seroconversions in 16 counties. Seven dead birds were reported positive for WN virus. Twenty-six counties have reported WN virus activity this year, with sporadic distribution around the state, compared to 12 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 Weeks' Disease Table

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