Friday, August 8,
"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."
Foege WH et al.
International Journal of Epidemiology
Epi Update Managing Staff:
John Agwunobi, MD, MBA, Secretary, Department of Health
Landis Crockett, MD, MPH, Director, Division of Disease Control
Acting Bureau Chief,
Epi Update Managing Editor
Jaime Forth, Copy Editor/ Writer
| This Week in the News|
► Locally Acquired Malaria "Probable" in Palm Beach County
Two Palm Beach County men in same neighborhood are diagnosed with malaria, and local public health officials have ruled out travel as the source of infection.
► Vibrio Outbreak Discovered in Duval County
Reports of illness after consumption of garlic crabs resulted in the investigation of a seafood market in Duval County.
► Miami-Dade Survey Shows WNV Awareness Lacking
An award-winning poster entitled Current Knowledge, Practices and Attitudes of Miami-Dade Residents about West Nile Virus Disease and its Prevention, presented at the state epidemiology seminar this spring, outlines its findings confirming the need for public education.
► Merlin Development Assessment Scheduled
Merlin users will be asked to provide feedback in August and September using a variety of methods.
► This Week on EpiCom
If you haven't logged on, you may have missed an opportunity to compare notes on what's happening recently in your neck of the woods.
► Pediatric Preparedness for Disasters
Since children are not little adults, they have vulnerabilities worth noting in the event of natural disaster or terrorism. The American Academy of Pediatrics has prepared information for public health professionals.
► CDC Broadcasts Immunization Update 2003
The CDC will air a live broadcast on August 21 at 9:00 a.m. EST, with up-to-date information on topics including recommendations for the use of smallpox vaccine for prevention of monkeypox, an update on global polio eradication and more.
► Arboviral Disease Report
Statistics through the week ending August 4, 2003 for confirmed cases only.
► Weekly Disease Table
Florida Department of Health, Bureau of Epidemiology Weekly Morbidity Report for the current week only includes selected diseases and conditions for confirmed cases.
A R T I C L E S
Meghan M. Weems, MPH, Epidemiology Intelligence Service, Palm Beach County and Savita Kumar, MD, MSPH, Epidemiologist, Palm Beach County Health Department
Robyn Kay, MPH, Epidemiology Intelligence Service, Duval County, Bureau of Epidemiology
Dr. Fermin Leguen, Senior Physician, Miami-Dade County Health Department, Mary Jo Trepka, MD, MSPH, Zhang Gouyan, MD, MPH, Marie Etienne, RN, Office of Epidemiology & Disease Control
Kathryn S. Teates, MPH, Communicable Disease Surveillance & Reporting Manager, Bureau of Epidemiology
Pete Garner, Surveillance Systems Section Administrator, Bureau of Epidemiology
Malaria is a disease caused by one of four species of protozoan
parasites (Plasmodium) spread by the Anopheles mosquito. Symptoms include
headache, aching in the bones, anorexia, fever and chills in a repeating cycle.
The incubation period can be as short as seven days or as long as several months.
Although malaria disappeared as a significant problem in the U.S. by the
mid-1950’s, it is still one of the most important communicable diseases in the
world. Palm Beach County sees an average of 12 malaria cases per year, but most
have a history of international travel to a malarious area. The Palm Beach County
Health Department (PBCHD) was alerted on 7/25/03 of two cases of malaria in a
local hospital in Palm Beach County.
Case 1. On July 24th a 46-year-old man residing in
central Palm Beach County was admitted to a local hospital with a history of
fever, chills, anorexia, headache and vomiting. His admitting diagnosis was
pneumonia. On 7/25/03, a thick blood smear slide showed Plasmodium vivax
parasites. Those findings were confirmed at the state laboratory in Miami and at
CDC. The patient had no recent history of travel, blood transfusion, organ
transplant, or IV drug use. He did, however, indicate that he spends time
outdoors on a regular basis, especially at dusk. He was treated with antibiotics,
quinine and primaquin and discharged from the hospital on 7/27/03.
Case 2. On July 24th a 36-year-old man residing in
central Palm Beach County was admitted to the same local hospital complaining of
fever, headache, and vomiting. His admitting diagnosis was non-erosive gastritis.
His thick blood smear slide showed malaria parasites on 7/25/02. His species was
also identified as P. vivax. This patient had returned from the Bahamas on July 2
but it was decided that this travel was not his likely exposure due to the fact
that the Bahamas is not known as a malarious area. He had no history of blood
transfusion, organ transplant or IV drug use. He was treated with antibiotics,
quinine and primaquin and discharged on 7/27/03.
The two case patients live four houses apart on the same street in a
neighborhood in central Palm Beach County. They do not report spending much time
together, but both attended a block party on their street over the July 4th
weekend. The party lasted late into the evening. Both their careers led them to
spend a majority of time outdoors as construction worker and plumber.
Active Case Detection
An investigative team from PBCHD went on a neighborhood outreach
on 7/27/03, the Sunday after the case patients were announced to the public. They
operated in a four-block radius going door-to-door, handing out fact sheets and
administering surveys. The survey’s aim was to identify active cases by asking
about current mosquito exposure, symptoms, and travel history. The team visited
over 50 houses. If the homeowner was not home, information was left on the
premises. The team identified three people who had either matching risk factors
or symptoms. None of these suspect cases turned out to be cases of malaria.
Active case detection was hampered by the presence of TV cameras and reporters
who may have intimidated neighborhood residents, preventing them from being
interviewed by the investigators.
All local hospitals were notified of the two cases. They were
asked to test suspect cases for malaria and report results to the PBCHD.
A press conference was held on 7/27/03 to inform residents of the
situation and how to seek medical attention if needed. Ways to avoid mosquito
bites were also discussed during the press conference. A separate press
conference was held for Spanish-speaking media.
An alert for malaria was announced for the two-mile radius
surrounding the affected neighborhood. The Emergency Operations Center of PBC
instituted “reverse 911,” and over 35,000 area households were called.
Residents within a nine-square-mile radius heard a recorded message informing
them of the malaria cases and how to avoid mosquito bites.
A fax was sent to all area physicians within six zip code areas and
infection control practitioners at the 14 hospitals in Palm Beach County, asking
them to perform a "lookback" for cases of malaria or similar
constellation of symptoms as malaria since June 1, 2003. The same fax was sent to
all infectious disease specialists in the county.
Palm Beach County Mosquito Control performed mosquito trapping on
two occasions at two sites in the affected neighborhood. The first trapping
yielded a small population (4/10 trapped) of Anopheles quadrimaculatus
mosquitoes. The second trapping yielded none. Those mosquitoes are being sent to
CDC for further testing. No standing water or larvae were found at either
case’s home. Mosquito spraying was performed three times in a nine-square mile
area around the neighborhood.
The PBCHD is still searching for cases and trying to identify a
person or persons with malaria that might have been the source of the mosquito
infection. Gametocytemic persons (those with active malaria parasites in their
blood) are present in the United States and can serve as reservoirs of infection.
Palm Beach County is a haven for visitors who come from all over the world
including malarious areas. It is possible that a person could have come from abroad
with malaria and has treated symptoms with home remedies or inadequate treatment.
The individual may not be fully treated and is still circulating parasites,
allowing mosquitoes to become infected when they feed, thus spreading malaria
into the community. Relapse of P. vivax can occur up to four years after primary
infection. This is not likely a case of airport/baggage malaria since the airport
is much farther from the neighborhood than the two miles that most mosquitoes can
To protect oneself from mosquito borne illnesses, it is important
to remember the D’s:
International travelers to malarious areas should begin anti-malarial prophylaxis at least one week before travel and two weeks after their return to the United States.
Many thanks to the staff of the Bureau of Epidemiology and
Environmental Health, Miami State Laboratory, and Palm Beach County Health
Department Epidemiology and Environmental Health for their help in this
CDC. Probable locally acquired mosquito-transmitted Plasmodium
vivax infection---Suffolk County, New York, 1999.MMWR 2000; 49 (22); 495-8
CDC. Probably locally acquired mosquito-transmitted Plasmodium
vivax infection---Georgia, 1996. MMWR 1997; 46: 264-7
CDC. Local transmission of Plasmodium vivax malaria---
Virginia, 2002. MMWR 2002; 51 (41); 921-923
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On June 23,
2003, the Duval County Health Department (DCHD) Epidemiology Division received a
referral from the State of Florida Regional Epidemiologist for Food and
Waterborne Diseases regarding three people who had purchased garlic crabs, two of
whom became ill after eating the garlic crabs on June 21. On June 24 an
additional person contacted the DCHD to report becoming ill after consuming
garlic crabs on June 21 from the same seafood market.
the four individuals reported illness after consuming garlic crabs from the
seafood market. A case was defined as any person consuming garlic crabs at this
seafood market between June 21 and June 22, and exhibiting symptoms of diarrhea,
vomiting, and cramps. A DCHD epidemiology nurse conducted a case history for each
person. Common symptoms included: diarrhea, nausea, vomiting, fever/chills, and
cramps. None of the individuals sought medical attention from a health care
provider or were hospitalized. The onset of symptoms ranged from 2 to 12 hours
after eating the garlic crabs, with the duration of illness ranging from one to
seven days. All of the case patients purchased the garlic crabs as takeout, and ate them
within an hour of purchase.
common exposures existed between the three cases. No additional complaints by
other persons were made to DCHD or DBPR (Department of Business and Professional
food sample of the garlic crab was provided by one of the ill persons and was
submitted to the state lab on June 24 by the Regional Foodborne and Waterborne
Disease Epidemiologist. Stool specimens from two of the ill persons were
submitted on June 24 and June 26 for bacteria, enterovirus, norovirus, ova, and
On June 24,
2003, the DPBR inspected the facility providing the garlic crab meals and
reviewed food handing practices. In addition, the Regional Epidemiologist for
Foodborne and Waterborne Diseases and the Florida Epidemic Intelligence Service
officer from DCHD conducted an environmental epidemiological investigation to
determine the source of the pathogens, mode
of transmission, proliferation, and exposure. The seafood market sells packaged
meals of crabs, shrimp, corn, and potatoes.
cross contamination violations were observed in the facility including raw and
cooked food products placed next to and on top of each other in the display case.
Cooked food products were exposed to raw food products through contaminated food
preparation and handling surfaces, improper hand glove use, and unsuitable
storage of cooked food products in perforated metal containers on the floor.
abuse was another problem. The walk-in storage cooler in the back room was set at
50° F. Cooked crabs were inadequately cooled to 41° F prior to packaging in
styrofoam boxes. Cooked crabs were stored in a display case that was unable to
maintain a temperature of 41° F.
specimens were obtained from two of the ill individuals. Stool samples tested
negative for parasites and bacteria. The food sample yielded the following
results: Standard plate count/gm: 2,200,000/gm, Fecal Coliform MPN/gm: 40/gm, Vibrio
parahaemolyticus, and Vibrio alginolyticus.
issued two warnings and re-inspected the facility on July 10, 2003. In addition,
the Regional Epidemiologist for Foodborne and Waterborne diseases, the Reportable
Disease Program Manager from DCHD, the Florida Epidemic Intelligence Service
Officer from DCHD, and the sanitarian from DPBR revisited the facility on July
15, 2003 to discuss food handling and sanitation practices of the seafood market.
The owner was educated on food handling, temperature controls, and ways to
minimize cross contamination in order to ensure a safe food product is sold to
This was an
outbreak of Vibrio parahaemolyticus by consumption of garlic crabs.
Multiple cross contamination violations and temperature abuse by the seafood
market led to this outbreak.
food handlers on the proper ways to store, prepare, cook, and distribute food is
key in preventing foodborne outbreaks. It is therefore extremely important to
continue to educate and monitor those in the restaurant business on proper food
The following recommendations were made to the seafood market owner by the epidemiologists:
the month of March 2003, Miami-Dade County Health Department conducted a survey
among 451 Miami-Dade County residents aged 18 years and older.
survey was conducted by computer-assisted telephone interviewing using Computers
for Marketing Corporation’s computer-assisted telephone interviewing software
were selected randomly from all telephone-equipped dwelling units in Miami-Dade
eligible respondent was selected at random from each household included in the
survey instrument with versions in both English and Spanish was used to collect
data for this project.
survey collected data on knowledge, attitudes and practices related to West Nile
virus and other arboviruses.
percent of respondents reported having heard about WNV in the past, 40%
identified fever as a symptom related to WNV, 21% reported not knowing what the
symptoms of WNV are. Mosquitoes were identified as a WNV vector by 77% of
respondents; 20% also associated mosquitoes with HIV transmission.
percent of respondents keep mosquito repellents at home. Fifty-seven percent of
those respondents with history of recent travel reported using mosquito
repellents during the trip.
percent of respondents identified the television as their source of WNV and
mosquito-related information. Only 2.7% mentioned health department’s documents
as their source of information.
with personal protection against mosquito bites was as follows: 47% of
respondents reported use of repellents while outdoors, 8% reported use of screens
in doors and windows, 14% use of long-sleeves shirts and long pants while
outdoors, and 18% avoidance of outdoor activities after dusk or before dawn.
Twenty-two percent of respondents did not think that there was a serious risk of
WNV infection in the community, but 37% thought it was as extremely serious.
Infants (37%) and persons 50 years of age and older (41%) were identified as
those with the highest risk of developing a severe illness due to WNV.
County Health Department should implement an educational intervention among its
residents to encourage the use of personal protective measures against mosquito
development of partnerships with local media, especially Miami area TV stations
will be of paramount importance to the dissemination of educational information
about WNV and other arboviral diseases among Miami-Dade residents.
County Health Department should identify specific educational needs related to
arboviral diseases among communities with a higher risk of exposure to mosquito
bites due to travel or cultural issues.
1. Identification of symptoms
associated with WNV.
We would like to extend our appreciation to all staff members of the
Office of Epidemiology and Disease Control, Miami-Dade County Health Department
for their outstanding support and participation on multiples activities related
to the implementation of this project and the surveillance and control of
arboviral diseases in Miami-Dade County.
full text of this article, including complete charts and graphs, can be accessed
by clicking the link below:
The Merlin Development Team
will be conducting a series of meetings to discuss changes to the system by
assessing different areas of the application. All Merlin users will be included
in this assessment and will be encouraged to give feedback by email, survey or by
participating in a conference call. Existing change controls will automatically
be included in the assessment. To keep the assessment process more organized, the
system has been divided into the following sections:
Personal Profile, Basic Case Information, Unattached and Case
Related Laboratory Results
August 27th Task List and Electronic Laboratory Results and Processing
Section, Home Page and Resources
not covered by the four areas above, comments for the lead poisoning prevention
module, perinatal hepatitis B prevention module, rabies module, extended data and
any other section are needed as well.
will be two conference calls held for input on Thursday, August 21st
at 2:00 p.m. EST and Wednesday, September 10th at 10:00 a.m. EST. Each
call will cover different sections of the system and will be announced in the Epi
Update, by email and on the bi-weekly CHD conference call. Those not able to
attend the conference call should email comments to the Merlin Helpdesk
indicating the assessment in the subject line of the email.
The completed assessment and recommended changes will be published in summary form in the Epi Update.
Furthermore, it recommends:
Particularly in the case of bioterrorism, it is important to remember that children are more vulnerable to aerosolized agents than adults because they take more breaths per minute than adults; and since some agents, such as chlorine, are heavier than air, they accumulate closer to the ground, endangering more children than adults. In addition, because their skin is thinner, they may be more susceptible to skin-penetrating agents or toxic agents that cause vomiting and diarrhea. Last, toddlers are not able to flee an attack site as quickly as adults, placing them at higher risk of exposure. These facts and other relevant information can accessed at the AAP web site at http://www/aap.org/terrorism.index.html
Broadcasts Immunization Update 2003
The live satellite broadcast and webcast will be rebroadcast from noon until 2:30 p.m. the same day. If you have questions or need further information, contact the CDC at http://www.phppo.cdc.gov/PHTN/imm-up2003/default.asp
EEE virus activity in
animals: Eight horses were confirmed with EEE
virus infections, bringing the YTD total for horses infected with EEE virus to
183 in 47 counties. This year so far, there are seven times the number of horses
than were reported with EEE in all of last year. Twenty-one seroconversions to
EEE virus from 11 counties were confirmed in sentinel chickens. Of Florida’s 67
counties, 50 have reported EEE activity, compared to 20 last year by this time.
EEE activity appears to be spreading out from the central region.
WN virus activity: One WN virus infection in a horse from Marion County was reported this week, for a YTD total of two statewide. Twenty seroconversions to WN virus were confirmed in sentinel chickens, for a YTD total of 104 WN seroconversions in 24 counties. Twenty-nine dead birds were reported positive for WN virus, for a YTD total of 72. Forty-one counties have reported WN virus activity this year, with sporadic distribution around the state, compared to 27 last year by this time.
The complete report can be viewed at: http://www.doh.state.fl.us/Environment/hsee/arbo/weekly_summary2003.htm