An article in the most recent issue of Centers for Disease Control and Prevention's MMWR describes two cases of melioidosis reported by the Florida Department of Health in 2005. Both patient cases had visited Honduras prior to exhibiting symptoms.

Melioidosis is caused by the Burkholderia pseudomallei bacterium. Patients exhibit pneumonia-like symptoms, accompanied by septicemia in some. Both Florida cases were treated with antibiotics; one recovered and one expired.

Melioidosis is reportable in Florida. During the epidemiologic investigation, it was discovered that laboratorians at both treating hospitals might have been exposed to the bacteria when isolates were handled outside a biosafety cabinet. This occurred because B. pseudomallei went unrecognized as the source of Melioidosis, which resulted in a delay in notifying the local health department of the case. The article, written by Florida Department of Health personnel, discusses the case reports and presents further CDC editorial notes on the disease.

To access this article, go to:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5532a1.htm

Ciguatera Outbreak Associated with Consumption of Barracuda, August 2006
By Ryan M. Lowe

Background
Ciguatera is a naturally-occurring marine toxin found in large predatory reef fish such as black grouper, red snapper and barracuda. The occurrence of toxic fish is sporadic and not all fish of a given species or from a given locality will be toxic. Ingestion of contaminated fish can cause a combination of gastrointestinal, neurological, and cardiovascular disorders. Initial signs of poisoning occur within six hours after consumption and include perioral numbness and tingling (paresthesia) which may spread to the extremities, nausea, vomiting, and diarrhea. Neurological signs include intensified paresthesia, arthralgia, myalgia, headache, temperature sensory reversal and acute sensitivity to temperature extremes, vertigo, and muscular weakness to the point of prostration. Cardiovascular signs include arrhythmia, bradycardia or tachycardia, and reduced blood pressure. Ciguatera poisoning is usually self-limiting, and signs of poisoning often subside within several days from onset. However, in severe cases the neurological symptoms are known to persist from weeks to months. In a few isolated cases neurological symptoms have persisted for several years, and in other cases recovered patients have experienced recurrence of neurological symptoms months to years after recovery.¹ 

Introduction
On August 7, 2006, the Broward Regional Environmental Epidemiologist was notified of a possible case of ciguatera poisoning associated with consumption of barracuda that had been reported to Florida Poison Information Center Network on August 2, by a local emergency room physician at a hospital in Broward County. Upon notification of this report, the hospital’s infection control nurse was called to obtain contact information regarding the case. An interview with the initial patient case revealed an additional four related cases who had experienced similar symptoms including gastrointestinal symptoms of abdominal pain, vomiting, diarrhea within a couple of hours following ingestion. Following these initial symptoms, neurological symptoms were experienced: itching, reversal of hot/cold sensation, tingling/numbness sensations in the feet within the next 24 hours after ingesting flesh from the same barracuda. According to the initial case, all cases had visited the local hospital after becoming symptomatic. Based on this information, an outbreak investigation was initiated. 

Methods
All symptomatic persons were interviewed via telephone, using the Ciguafile, Record of Ciguatera Intoxication Form to compare the symptoms in the group and for reporting purposes. Medical records were obtained from the local Broward County hospital for review. No samples of the barracuda were available for analysis, as all leftovers had been discarded prior to the Department of Health being notified of the outbreak.  

Results
The barracuda was caught from Juno Pier in Juno Beach, Florida on July 31, 2006 by a relative. According to the patient who cooked the barracuda, the relative who caught the barracuda did not like to eat it and had planned to throw it out. However, the relative was asked to keep it so it could be eaten. The barracuda was approximately 24 inches in length and weighed approximately 5-6 pounds, according to the preparer.   

A total of five patient cases consumed the barracuda on August 1, 2006 for dinner. Three of the cases were adults and two were children. Their ages ranged from 6 to 39 years with a median age of 30. Four males and one female consumed the barracuda, which was fried. All became ill within one to six hours following ingestion with an average incubation period of 2.3 hours. As of August 21, three of the five persons were still sick. The two children only consumed ~2 oz portions and both experienced symptoms lasting ~1 day. The three adult cases who are still experiencing symptoms as of August 22 consumed 8 - 12 oz portions.  

Four of the five cases (two adults and two children) visited the same local Broward County hospital emergency room and were seen between 11:00 p.m., August 1 and 1:00 a.m., August 2, according to medical records obtained from the hospital. The two adults were diagnosed with ciguatera poisoning by two different ER physicians. The two children were diagnosed with acute gastroenteritis by a separate pediatric ER physician. Only one of the adult cases was treated with Mannitol. The final adult case was also seen at the same hospital; however, he did not visit the hospital until August 10. He was diagnosed with acute dysuria (painful or difficult urination). 

Three of the five cases reported having eaten barracuda in the past. They all stated they were unaware of the risks of consuming large reef fish such as barracuda, which may harbor ciguatoxin. All persons who consumed this particular barracuda became ill with ciguatera poisoning-like symptoms following ingestion. The relative who caught the barracuda, but did not eat it, did not become ill. Frequencies of symptoms are summarized in Table 1.

Table 1. Frequency of Symptoms for a Confirmed Ciguatera Outbreak Associated with
Barracuda Consumption, August 2006

         
Conclusions
This is a confirmed foodborne outbreak of ciguatera poisoning associated with consumption of a barracuda caught off of Juno Pier in Juno Beach, Florida. The outbreak is confirmed through diagnosis of ciguatera poisoning by two separate Broward County emergency room physicians within the same hospital for two of the cases, with a similar clinical syndrome consistent with ciguatera fish poisoning among all five persons who consumed the barracuda, a type of fish previously associated with ciguatera fish poisoning. 

Ciguatera is a reportable disease in Florida. Improper communication resulted in a delay of reporting this outbreak to the local county health department. There were several possible reasons for the delay in the outbreak investigation.  The initial complaint was reported to Florida Poison Information Center (FPICN) by an ER physician at a local hospital in Broward County on August 2, 2006. The hospital’s infection control practitioner was not notified of the two diagnosed cases of ciguatera poisoning that presented to the hospital that same day. The hospital, therefore, did not report the cases and outbreak to the Department of Health. When FPICN attempted to contact the local county health department, the e-mail addresses of the local contacts were incorrect, which also resulted in a delay in reporting of the outbreak.   

Recommendations
Persons should follow these general precautions to prevent ciguatera toxin poisoning: 1) avoid consuming large, predatory reef fish, including groupers, barracudas, snappers, jacks, mackerel, and triggerfish; 2) avoid eating the head, viscera, or roe of any reef fish; and 3) avoid eating fish caught at sites with known ciguatera toxins. 

Communication is an extremely important element during the investigation of an outbreak. Communication between  local department of health contacts and the local county hospitals, and their Florida Department of Health contacts and the Florida Poison Information Center needs to be improved. Interaction within local hospitals between  emergency room staff and infectious disease practitioners needs to be better defined and improved.   

¹ FDA's Bad Bug Book. Ciguatera.  http://www.cfsan.fda.gov/~mow/chap36.html

Ryan Lowe is a regional environmental epidemiologist in the Food and Waterborne Disease Program for the Bureau of Community Environmental Health assigned to Broward County. He can be reached at 954.467.4841.

Bureau of Epidemiology Anticipates Partnership
with US Virgin Islands 
by Jaime Forth

A recent visit to Tallahassee by health officials from the US Virgin Islands is bringing to fruition a concept that was set in motion over a year ago.

Kevin Hodge, communications coordinator at the Department of Health in St. Thomas and Julie Armstrong, MPH, a public health epidemiologist at the Department of Health in St. Croix traveled to Tallahassee in August to visit Christie Luce, administrator of the bureau's Surveillance Systems Section, prior to beginning design of a separate interface that will integrate their system and our EpiCom information and communication system.

There are five health clinics in the US Virgin Islands, and two hospitals. The facilities are funded through local agreements and the Centers for Disease Control and Prevention. With a fluctuating population that caters to a thriving tourism industry, this geographic archipelago has much in common with Florida; a transient pool of potential patient cases, and a tropical climate that plays host to similar diseases and environmental risks. 

The two entities have something else in common: CDC officer Mark Greene. When Greene was assigned to the Florida Department of Health a couple of years ago, he became acquainted with the EpiCom and Merlin systems through his work in public health preparedness. After his subsequent assignment to the Virgin Islands, he realized that limited resources were restricting efforts to create a better information-sharing network among healthcare workers there. He suggested officials at his new workplace contact technology staff at the Bureau of Epidemiology to explore ideas.

A series of discussions within both agencies during the past year led to the visit earlier this month from Kevin Hodge and Julie Armstrong. With health department leaders in the US Virgin Islands poised to sign on to EpiCom as a virtual 68th Florida county, several tasks remain to ensure a smooth integration. According to Armstrong, the ability to use the Bureau of Epidemiology system as an infection control tool will make it a valuable asset, and she plans to point that out to external partners in the islands. The opportunity to link with a wealth of resources here on the mainland, will be another. As the two meet with members of their healthcare community, they'll be using marketing and deployment strategies for coordinating use of the EpiCom system at their various locations. As Hodge said prior to departing Tallahassee, "I feel confident first responders and others will be excited to see a new and more sophisticated system in the Virgin Islands."

The Bureau of Epidemiology looks forward to welcoming its "68th" county to the state's EpiCom system, as well.

Jaime Forth is managing editor of Epi Update. To reach her, call her in Tallahassee at 850.245.4444, ext. 2440.  For answers to questions about the EpiCom system, phone Christie Luce at 850.245.4444, ext. 2450.



Mosquito-borne Disease Summary August 13 - 19, 2006
Rebecca Shultz, MPH, Caroline Collins, Daneshia Roberts, Calvin DeSouza, Carina Blackmore, PhD

During the period August 13 - 19, 2006, the following arboviral activity (St. Louis Encephalitis virus [SLEv], Eastern Equine Encephalitis virus [EEEv], Highlands J virus [HJv], West Nile virus [WNv], California Group virus [CEv]) was recorded in Florida: 

EEE virus activity There were seven seroconversions to EEEv reported in sentinel chickens from Alachua (5), Leon (1) and Nassau (1) counties. Two horses from Alachua and Madison counties were reported positive for EEEv infection this week. Of 15 sera samples collected from live wild birds, 2 were positive for antibodies to EEEv. A total of 21 counties have reported EEEv activity so far this year, compared to 46 at this time last year.  

WN virus activity Two live wild birds collected in Okaloosa and Santa Rosa counties tested positive for flavivirus antibodies. So far, 13 counties have reported WNv activity this year, compared to 19 at this time last year. 

No locally-acquired human cases of arboviral infection were reported yet this year.  A Palm Beach resident with travel history to Missouri and an Escambia County resident with travel history to Louisiana and Mississippi were confirmed with West Nile virus infections this week. They will be reported to CDC's ArboNET as Florida cases acquired out-of-state, but will appear as Florida cases on the CDC weekly maps.  A Hillsborough County resident with travel history to North Carolina was confirmed with LaCrosse encephalitis infection this week.  

Wild Live Birds Out of 15 sera samples collected from Okaloosa and Santa Rosa counties between August 8 and August 10, two tested positive for antibodies to EEE virus and one tested positive for flavivirus antibody. One of the Okaloosa birds was reactive to both EEE and flavivirus antibodies.

See the web page for more information: www.MyFloridaEH.com. The Disease Outbreak Information Hotline offers recorded updates on medical alert status and surveillance at 888.880.5782.  Dead birds should be reported to www.myfwc.com/bird/