Friday, September 3, 2004

         This Week in the News

Foege, WH, et al., 
International Journal of Epidemiology
1976; 5:29-37

►Vibrio vulnificus Infections in Florida
This reportable disease comes from bacterium which can be found in the warm waters surrounding our state.

►Infant Mortality Stratified by Maternal Age and Plurality in Florida: A comparative analysis of birth cohorts for 2000 and 2001
An examination of the infant mortality death rate in Florida was performed by members of the Division of Family Health Services. An executive summary is provided here, with a link to the full study.

A R T I C L E S

This article originally appeared in EpiWatch, a publication of the Pinellas County Health Department

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.

The laboratory to which the specimen is sent should be notified that a V. vulnificus infection is suspected so that the most effective growth medium can be used for the culture. Due to its virulence, all Vibrio infections are required to be reported to local county health departments, which in turn report cases to the CDC. If an infection is thought to be associated with the consumption of shellfish, the county health department should also notify the Florida Department of Agriculture and Consumer Services. 

Tips to Prevent Infection:

• Open wounds or broken skin should not be exposed to saltwater. If a wound is sustained while in the water, wash the area immediately with soap and water, apply an antibiotic ointment, and cover the area with a dry sterile bandage.
• Wear gloves when handling raw shellfish
• Do not eat raw or undercooked shellfish
• Practice good food hygiene by avoiding cross contamination, cooking foods for the correct length of time at the appropriate temperature, and eating or refrigerating foods promptly.

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.
 

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.

Announcements. Don Ward stated the bureau is actively seeking candidates for two new epidemiologist positions at the bureau in Tallahassee. One will be responsible for improving the laboratory/epidemiology interface and the other will coordinate the bureau's participation in infection control activities, conducting assessments and analysis. Formal recruiting announcements will appear soon.

Influenza Update. Angela Fix reported the work is nearly completed on the 60 packets for the 13 counties she has identified as needing to recruit sentinel providers.

In Vietnam, the first three cases of avian influenza have H5 subtypes. If confirmed as N1, they will be the first such cases since February and will also be the object of much concern, as they will indicate person to person transmission rather than zoonotic transmission.

ER Census Update. Karen Wheeler announced that four new hospitals have opted into the service. Monitors would be at county level; if they note a red flag, they'd call the hospital to find out the reason. In September, bureau staff will aggregate the accumulated data and have passive notification ability. (Ed note: An August 25 satellite broadcast introduced the system and provided a demonstration. An ER census brochure and online tutorial are being designed).

Morbidity Review - Diabetes Among Adults in Florida. Curt Miller, BS, provided a presentation which confirmed that diabetes is the sixth leading cause of death among adults in Florida. The prevalence since 1988 has climbed to 8.5, which is higher than the national level. Prevalence increases with age, although it develops earlier in life than cardiovascular diseases, and it appears in higher concentrations among lower income levels with more sedentary lifestyles. In Florida, the prevalence of diabetes is higher in rural counties and among non-Hispanic black females and non-Hispanic white males.

Bi-weekly conference calls are scheduled on alternating Fridays from 10:00 - 11:00 a.m. EDT. If you would like to appear on the agenda, contact Don Ward at Don_Ward@doh.state.fl.us or Jaime Forth at jaime_forth@doh.state.fl.us (who will be substituting for Melanie Black for the next several weeks).
 

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.

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

11.  Manufactures 

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. 

1.  Doors

2.  Flash lights

3.  Spare batteries

4.  Light switches

5.  Keys

6.  Locks

7.  Alarms

8.  Circuit breakers

9.  Packing materials 

D.  Identify whom to call for 

1.  Equipment problems

2.  Back-up storage

3.  Back-up transportation

4.  Security 

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: 

http://www.srh.noaa.gov/tlh/tropical/ and http://www.nhc.noaa.gov/ 

Satellite tracking of significant weather is also on the Web at http://www.goes.noaa.gov/
 

·         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.  
 

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. 

The presenter was Robyn Kay, MPH, an Epidemic Intelligence Service fellow working in Duval County. Follow-up questions concerning this topic can be emailed to her at robyn_kay@doh.state.fl.us.
 

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.

BSE is caused when a natural protein called a prion "folds" the wrong way and causes other prions to do the same. It has an incubation period of approximately five years and thus affects
only older cows. The disease was first recognized in cows in the U.K. in 1986 and reached epidemic proportions by 1992, when government-released figures showed 36,681 confirmed cases. By 1988, it was a notifiable disease in England. It is generally accepted that humans may develop variant Creutzfeldt-Jacob Disease (vCJD) by eating contaminated beef from cows with BSE. In contrast to classic CJD, vCJD primarily affects younger people; the illness has unique clinical features and a longer duration (at least 6 months) than classic CJD. The British government enacted 57 regulations in an effort to curb the spread of BSE. Those efforts appear to be working: By 1996, the estimated number of BSE cases in the U.K. was down to 8,000.

The cow found to have been infected with BSE here in the U.S. was born and bred in Canada, and imported here prior to a feed ban enacted in 1997. Despite protests from some groups, government officials assert their safeguards are scientifically based, and that they will continue to provide the best defense against a threat of BSE. Meanwhile, the World Health Organization has concluded that there is no direct evidence of a link between BSE and CJD.

For more in-depth reading on this topic, go to:

http://www.defra.gov.uk/animalh/bse/bse-publications/
http://www.fda.gov/fdac/features/2004/
http://www.shns.com/shns/g_index2.cfm?action=detail&pk=MADCOW-07-16-04
http://www.cfsan.fda.gov/~xomm/bsefaq.html
 

This Week on EpiCom

• Extensive use has been made of EpiCom during the ongoing Hurricane Charley disaster relief activities to report progress and communicate potential outbreaks and urgent care needs. Continue to monitor EpiCom for updates on volunteer efforts during this hurricane season or to share your own information.

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.

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/. 

 

Humans:
Onset Month	County	SLE	WN	EEE		Status
August	Broward		1			Deceased
August	Gadsden		1			Recovering
Sentinel Chickens:
Date of first positive bleed	County	SLE	WN	EEE	HJ	Seroconversion Rate
8/17(2)	Bay		2			11.8%
8/16, 8/17(5)	Brevard		6			15%
8/17	Hillsborough		1			2%
8/12	Indian River		1			2.08%
8/14	Madison			1		9.09%
8/15, 8/16	Nassau			2		19%
8/16(2)	Palm Beach		2			3.60%
8/16(2)	Pinellas		2			3.57%
8/16	St. Johns			1		1.75%
8/12	St. Lucie		1			2.78%
Dead Birds (collection date):	County	SLE	WN	EEE		MTD % Positive
Blue Jay (8/20)	Miami		1			16%
Horses:	None
Wild and Captive Birds:	County	Flavi	Alpha			Please Note:
Grackle 8/13(2), 8/14, Blue Jay (8/14), Cardinal (8/14)	Okaloosa	5				These are presumptive results and await confimatory testing.
Blue Jay 8/14 (2), Cardinal 8/14	Santa Rosa	3				?
Mosquito Pools:	None

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