Friday, September 3, 2004
This 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."
Foege, WH, et al.,
|►Bureau of Epidemiology Bi-weekly Conference Call Includes Morbidity Review|
Influenza and ER census updates were provided, and a presentation entitled Diabetes Among Adults in Florida was given.
►Infant Mortality Stratified by Maternal Age and Plurality in Florida: A comparative analysis of birth cohorts for 2000 and 2001
|►Minimizing Potential Vaccine Losses in Emergencies
Another how-to article instructs vaccine providers on storing and shipping vaccines when an emergency is imminent due to deteriorating weather conditions.
|Epi Update Managing Staff:||►Educational Opportunity for Bioterrorism Preparedness Announced
An online training module which offers continuing education credits is now available for healthcare professionals, including veterinarians, desiring further education in identification of, and response to, plague.
MD, MBA, MPH,
Secretary, Department of Health
►Satellite Broadcast and Grand Rounds Presented in August
A broadcast explaining the elements of the two programs aired on August 25th, with tapes of the broadcast available for future viewing. Grand Rounds exploring a rare Quinolone-resistant Salmonella was held August 31, with EIS Fellow Robyn Kay of Duval County presenting.
|Landis Crockett, MD,
Division of Disease
|►Mad Cow Disease Addressed
The disease which struck one cow in the U.S. in December 2003 reinforced citizen concerns about the safety of meat products in our country. The FDA and finally the World Health Organization have issued responses.
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.
|►Mosquito-borne Disease Update
A report outlining activities for the week August 22 - 28, 2004 for confirmed cases.
A R T I C L E S
|Maria N. Donnelly, MSPH, EIS Fellow, Bureau of Epidemiology
This article originally appeared in EpiWatch, a publication of the Pinellas County Health Department
Vibrio vulnificus Infections in Florida
Vibrio vulnificus is a bacterium commonly found in estuaries and warm coastal marine waters, such as the Gulf of Mexico. It is especially prolific when water temperatures increase during the months April through October. In the United States, V. vulnificus is the most common, and considered the most deadly, type of Vibrio infection. People with health conditions that make them particularly susceptible to V. vulnificus should be aware of the greater potential for infection associated with particular activities during these warmer months.
According to the Bureau of Environmental Epidemiology 1999 Annual Report on V. vulnificus in Florida, there were 12 deaths associated with the 36 total cases in 1998 and in the following year there were 13 deaths associated with the 22 total cases. From Merlin Registry System data for the years 2000 to 2003, there have been an average of 23 cases per year statewide. In 2000, each of the reporting counties had one case. In 2001, the greatest number of reported cases per county was two. These cases occurred in Dade, Duval, Lee, and Pinellas counties. Hillsborough (4 cases), St. Lucie (2 cases), and Pinellas (2 cases) led the state in reported cases in 2002. Last year, Okaloosa (5 cases) and Hillsborough (4 cases) had the most reported cases.
Individuals can become infected with V. vulnificus through an open wound or by eating contaminated shellfish, particularly raw oysters. The incubation period is typically 12 to 72 hours. Symptoms in healthy persons include vomiting, abdominal pain, and diarrhea. Those who have had gastric surgery, take prescribed stomach acid reducers, have any type of liver disease, hemochromatosis, diabetes mellitus, or are immuno-compromised may have more severe sequelae. These include septicemia, fever, chills, hypotension, and bullous skin lesions. Half of those with wound infections require surgical debridement or limb amputation. For patients with liver disease, there is a 50% fatality rate among those who develop septicemia, and a 90% fatality rate among those who become hypotensive. Standard treatment includes supportive care and antimicrobial therapy.
Tips to Prevent Infection:
Because of the potentially fatal nature of V. vulnificus infections in these high risk groups, patients presenting with compatible symptoms should be asked about possible exposures to raw/undercooked shellfish and coastal/brackish waters. Educate patients about the dangers of eating raw or undercooked shellfish and the importance of proper wound care. Please contact your local county health department with any questions or to request additional information regarding Vibrio vulnificus. Information can also be found on the CDC Website at www.cdc.gov and on the Interstate Shellfish Sanitation Conference Website at www.issc.org.
The natural beauty and abundance of our coast makes living and visiting Florida extremely enjoyable. Continuing education and a healthy respect for potential hazards help to ensure marine experiences in our state, and the memories which linger, will be happy ones.
|Jaime Forth, Epi Update Editor, Bureau of Epidemiology
|Bureau of Epidemiology Bi-weekly Conference Call Includes Morbidity Review
The latest conference call among Bureau of Epidemiology staff and health department personnel across the state occurred on August 13, 2004. A brief summary of the news and discussions is recounted here for those who were not present.
|Daniel Thompson, MPH, Melanie Simmons, PhD, Cheryl Clark, MPH, Carol Graham, PhD, Angel Watson, BS, Division of Family Health Services, Bureau of Family & Community Health
|Infant Mortality Stratified by Maternal Age and Plurality in Florida: A comparative analysis of birth cohorts for 2000 and 2001
The infant death rate in Florida reached an all-time low in 2000 with a rate of 7.0 infant deaths per 1,000 live births. In the following years, the rate increased to 7.3 in 2001 and to 7.5 in 2002. In comparison, the national infant death rate was 6.9 in 2000, 6.8 in 2001 and, based on preliminary data released February 2004, increased to 7.0 for 2002. In light of Florida?s increases in infant death rates, it has been suggested that increases in the proportion of multiple births (twins, triplets, etc.) and increases in the proportion of older women giving birth may have contributed to the increases in infant death rates.
The Infant, Maternal and Reproductive Health Evaluation Section, located in the Bureau of Family and Community Health, analyzed data related to multiple births and maternal age to assess the influence of these factors on infant death rates in Florida. They concluded that while increases in the proportion of multiple births and older maternal age contribute to increases in infant death rates, these factors do not account for all the increases in the death rates that occurred for births in 2001 compared to 2000.
This article is a summary of the full analysis which is available on the Department of Health Web site at http://www.doh.state.fl.us/family/mch/docs/pdf/InfantMortality_MaternalAge.pdf. In the analysis, data for Florida resident births and infant deaths were used to compare risk of death for infants born in 2000 and 2001. Birth records include the age of the mother and the plurality of the birth. A plurality of one indicates a single birth and a plurality of two or more indicates a multiple birth. For example, plurality of two indicates the birth of a twin. To analyze plurality and maternal age in relation to infant death, three categories were used for maternal age: 13 to 19, 20 to 35, and 36 to 50. Two categories were used for plurality: single births and multiple births. These categories were combined to create six mutually exclusive categories based on maternal age and plurality.
Infant death rates were calculated for each of the six maternal age/plurality categories for 2000 and 2001. Differences between the rates for 2000 and 2001 within each category were assumed to be independent of the influence of maternal age and plurality, since these factors remain constant within each age/plurality category.
In the paper referenced above, the influence of multiple births and older maternal age were quantified using direct, indirect and Kitagawa adjustment methods. With all three methods, the influence of increases in multiple births and older maternal ages was found to be small in comparison to the influence of increased risk for all maternal ages and pluralities. Refer to the full analysis at the link above for complete information regarding the methods.
The table below displays 2000 and 2001 infant death rates for each of the six maternal age/plurality categories. Overall, the infant death rate increased from 2000 to 2001. Specifically, the infant death rate increased five percent for mothers ages 36 to 50 with single births. The infant death rate for multiple births increased in all three age categories. The death rate increased by 78 percent for mothers ages 13 to 19 with multiple births, and 6 percent and 17 percent for mothers with multiple births ages 20 to 35 and 36 to 50 respectively.
The maternal age 20 to 35, singlet birth category, is especially relevant. Births in this category are not influenced by increased maternal age or multiple births, since none of them are born to older mothers and they are all single births. The infant death rate for this category increased from 5.26 per 1,000 live births in 2000 to 5.43 per 1,000 live births in 2001, which is an increase of 3%. It is important to note that 75 percent of the births were to mothers in this category.
In summary, increases in the proportion of older mothers and multiple births may have contributed to the increase in the infant death rate, but these factors do not account for the entire increase. In the paper referenced above, the influence of these factors was quantified and found to be small in comparison to the influence of increased risk for all maternal ages and pluralities.
|Bureau of Immunizations, Florida Department of Health
|Minimizing Potential Vaccine Losses In Emergencies|
To protect vaccines in storage and minimize potential monetary loss from a hurricane or other disaster, vaccine providers should have written emergency procedures. When state or local officials or the provider has reasonable cause to believe weather conditions have potential to disrupt power and/or flood any facility where vaccines are stored, the emergency procedures should be implemented.
a. Identify an alternative storage facility such as hospital, packing plant, or CHD with back-up power generator where the vaccines can be stored and monitored during the storm.
b. Ensure the availability of staff to pack and move the vaccines.
c. Ensure the availability of appropriate packing containers, cold packs, and dry ice for Varicella vaccine.
d. Ensure transport of the vaccines to the secure storage facility.
It?s appropriate for providers to suspend giving vaccinations before weather conditions deteriorate. Sufficient time must be allowed for packing and transporting the vaccine before the storm adversely affects local road conditions. There are other precautions and measures to take to protect vaccine inventories using the emergency procedures described below. These include helpful hints and reference information.
1. Emergency Procedures.
A. List emergency phone numbers, companies, and points of contact.
1. Electrical power company
2. Refrigeration repair company
3. Temperature alarm monitoring company
4. Perimeter alarm repair company
5. Perimeter alarm monitoring company
6. Back-up storage facility
7. Transportation to back-up storage
8. Dry ice vendor
9. Emergency generator repair company
10. National weather service
a. Merck: 800-672-6372
b. Aventis: 800-Vaccine (800-822-2463)
c. GlaxoSmith Kline: 800-366-8900
d. Wyeth: 800-666-7248
B. Provider/clinic assistance to providers in possession of vaccine.
1. Identify hospitals, health departments, or other facilities which could serve as emergency vaccine storage facilities and communicate this information. This might also be performed at the regional or county level and/or with the assistance of bioterrorism or emergency preparedness units.
2. Prioritize assistance and communication to target providers in areas at highest risk, e.g., low lying coastal or floodplain areas.
C. Entering vaccine spaces.
Describe when necessary how to enter the building and vaccine storage spaces in an emergency, if closed or after hours. Include a floor diagram and the locations.
2. Flash lights
3. Spare batteries
4. Light switches
8. Circuit breakers
9. Packing materials
D. Identify whom to call for
1. Equipment problems
2. Back-up storage
3. Back-up transportation
E. Identify which vaccines to pack first, while power is still operational.
1. Pack the refrigerated vaccines first, with an adequate supply of cold packs.
2. Remove and pack the Varicella vaccine using dry ice, immediately before it is to be transported.
F. Pack and transport all vaccines. If that isn?t possible, determine which types and amounts to save, e.g., only the most expensive vaccines to minimize dollar loss or some portion of all vaccines to ensure a short-term viability, versus a complete supply for resumption of the vaccination schedule. We suggest the first priority be given to vaccines which would be the most expensive to replace.
G. Follow vaccine packing procedures for transport to back-up storage.
1. Open refrigerated units only when absolutely necessary and only after you?ve made all preparations for packing and moving the vaccines to alternative storage sites.
2. Use properly insulated containers.
H. Move vaccines to back-up storage according to prearranged plans.
1. How to load transportation vehicle.
2. Routes to take.
3. Time enroute.
Two National Oceanic and Atmospheric Administration sites provide up-to-date information on hurricane activity:
Satellite tracking of significant weather is also on the Web at http://www.goes.noaa.gov/
|Educational Opportunity for Bioterrorism Preparedness Announced|
The CDC's National Center for Infectious Diseases Bioterrorism Preparedness and Response Program and Division of Vector-borne Infectious Diseases, along with PHPPO?s Division of Professional Development and Evaluation have developed a Web-based, on-line training module for healthcare professionals, including veterinarians, to learn important information about plague. The training module, available at http://www.bt.cdc.gov/agent/plague/trainingmodule/index.asp, provides a series of eight lessons describing the epidemiology of plague and how to manage it as both a naturally occurring disease and an intentional attack. Upon completion of the module, the participant will be able to
· Identify areas with naturally occurring plague in order to recognize possible acts of bioterrorism
· Identify patient symptoms indicating a diagnosis of bubonic, pneumonic or septicemic plague
· Describe how to rule out other diseases when diagnosing plague
· Identify the appropriate specimens to obtain in order to diagnose plague
· Describe the medical management of confirmed plague cases
· Describe the public health response for naturally occurring versus bioterrorist-associated plague
· Describe the diagnosis of plague in animals
Continuing education credits are available. CDs or videos of this training are not available.
|Robyn Kay, MPH, EIS Fellow, Bureau of Epidemiology,
|Satellite Broadcast and Grand Rounds Presented in August|
The Bureau of Epidemiology hosted a satellite broadcast on August 25. From 10:00 to 11:00 a.m. EDT, a discussion focusing on the EpiCom and ER Census features was hosted by Pete Garner, surveillance systems administrator at the Bureau of Epidemiology. Christie Luce, EpiCom consultant and Karen Wheeler, MPH, bioterrorism special surveillance projects coordinator described the significance of the EpiCom system to share disease outbreak information with associates and community partners, introduced the participants to the ER surveillance aspects of EpiCom, specifically the ER Census Program, and explained how county health departments can use ER Census data to monitor aberrations in emergency room numbers from hospitals in their counties. Tapes of the program will be mailed to county health departments and made available to other entities upon request.
Grand Rounds Aired on August 31. Beginning in fall of 1999, Northeast Florida experienced an increase in quinolone resistant salmonella in a local hospital. The Florida Bureau of Laboratories in Jacksonville identified the strain as multi-drug resistant Salmonella senftenberg. Nosocomial transmission of Salmonella senftenberg has been documented in neonatal wards, burn units, and adult intensive care units in India. This rare bacteria causes diarrhea and pneumonia, or may be asymptomatic. Salmonella senftenberg may also cause urinary tract, blood, and wound infections.
Salmonella senftenberg is an emerging infectious organism with significant public health implications to the state of Florida.
|Jaime Forth, Epi Update Editor, Bureau of Epidemiology||Mad Cow Disease Addressed
Just before Christmas 2003, the discovery through routine surveillance of a dairy cow diagnosed with bovine spongiform encephalopathy (BSE), or "Mad Cow disease," lead to an emergency investigation by the FDA and the USDA to track where the cow came from and ensure that, once the recall of its products was made, no infected portions of the cow would enter animal feed or FDA-regulated products used by humans.
The investigation took just two months and yielded no evidence of any other cows with BSE, thanks to safeguards which have been in place since 1989. The FDA and USDA work together to oversee a ban on the import of live ruminants imported from countries where BSE is considered to be a risk. The ongoing surveillance program which tests cows is another safeguard. A third safety feature is a rule which bans most forms of protein from mammals in ruminant animal feed. The most recent set of measures announced in January 2004 simply bolstered those already in effect, giving cosmetics and dietary supplements the same protection afforded food products.
For more in-depth reading on this topic, go to:
|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 https://www.epicomfl.net but to 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 situations.
|Arbovirus Surveillance Team: Samantha Rivers, MS, Caroline Collins, Kristen Payne, Calvin DeSouza, and Carina Blackmore, MS Vet. Med., PhD., State Public Health Veterinarian||Mosquito-Borne Disease Update|
West Nile (WN) virus activity: One resident of Gadsden County and one visitor of Broward County (out-of-state resident) were confirmed with WN illness this week, bringing the state-wide total to 20. There were 15 seroconversions to WN virus in sentinel chickens from Bay, Brevard, Hillsborough, Indian River, Palm Beach, Pinellas and St. Lucie counties. So far this year, 28 counties have reported WN activity. Broward, Duval, Gadsden, Hillsborough and Miami-Dade counties are under medical alerts for mosquito-borne disease.
Eastern Equine Encephalomyelitis (EEE) virus activity: There were 4 seroconversions to EEE virus in sentinel chickens from Madison, Nassau and St. Johns counties. So far this year, 31 counties have reported EEE activity.
St. Louis Encephalitis (SLE) virus activity: None this week. Two counties reported SLE this year.
Highlands J (HJ) Virus activity: None this week. Nine counties reported HJ this year
Mosquito populations are present in many areas of the state, especially in areas hard-hit by Hurricane Charley. All are urged to take precautions against mosquito bites. Dead birds should be reported to www.wildflorida.org/bird/.
See the Web for more information at www.MyFloridaEH.com.