On September 3 a Hong Kong man was admitted to a Singapore hospital with probable SARS, due, it is believed, to work-related exposure in his capacity as a laboratory researcher. As a consequence, Taiwan officials announced on September 11th that all visitors from Singapore would be required to take their temperature twice a day and maintain records of their health status for a full ten days. Passengers disembarking at international airports in three Chinese cities will have their temperatures checked by infrared cameras.

The Singapore man has been diagnosed with probable SARS because X-ray tests for atypical pneumonia were normal; however, blood tests were positive for SARS-CoV and he exhibits all other symptoms associated with the disease such as fever, joint pain, dry cough and muscle aches. Repeat blood tests verified by the CDC provided the same positive results. The man's identity has not been released and he has been placed in quarantine. None of his contacts have tested positive for SARS.

Authorities in Asia are on alert, but strict health measures enacted earlier this year and reassurances by health organizations appear to have kept the public mood calm. The new director general of the World Health Organization has warned that the illness could emerge again and has advised vigilance. "We have to prepare on the assumption that this will come back" said Lee Jong-wook. The organization has not, however, issued travel alerts since the case appears to be isolated.

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►School-based Syndromic Surveillance Pilot Test Pronounced Successful

Introduction
Duval County Health Department’s Epidemiology Division conducted school-based surveillance between February 1 and May 30, 2003. This syndromic surveillance established a pilot test to determine the feasibility and usefulness of development and maintenance of a school-based surveillance system. This system would also be capable of detecting increases in syndromes indicative of potential bioterrorism activity. 

Syndromic surveillance is the monitoring of a chosen population for symptoms of illness, to detect potential disease trends at the earliest possible stage. This is particularly important in the case of a bioterrorism event, where many symptoms may begin to surface shortly after exposure to a particular agent. The public health system would then be able to mobilize their resources in a timely manner, thus preventing or diminishing the effects of a potential public health disaster. 

Schools are a useful source of information for syndromic surveillance for several reasons: First, students provide a substantial and stable population for several hours per day, several days per week. Second, schools could be a potential bioterrorist target because children are a generally vulnerable population. Third, some schools maintain full-time nurses who see students in the school clinic every day.   

Materials and Methods - Data Collection
The Duval County Health Department (DCHD) Epidemiology Division conducted school-based syndromic surveillance between February 1 and May 30, 2003. The dates for this pilot study were based on the school calendar year. Four sentinel elementary schools in Duval County employing a full-time registered nurse on site were chosen for the data collection. The schools were not identified by name in order to protect the confidentiality of the participating schools. Schools were selected by convenience sample, as few schools employ a full-time school nurse.  

Data were collected by the school nurse based on visits by students to the school health clinic, and recorded on a form provided by the DCHD Epidemiology Division (refer to Appendix for form). The weekly report collected data regarding the following syndromes: a) diarrhea or vomiting, b) fever with cough or sore throat, and c) rash with fever. These syndromes were chosen because they represent symptoms that may be reported in relation to various biological agents used in bioterrorism attacks. The weekly report also collected daily attendance and school enrollment data. Weekly reports included a contact name and telephone number for the Epidemiology Division. 

The school health nurse submitted the completed form to the director of school health who then faxed it to the Epidemiology Division for review and analysis. The database for each school was contained in a separate Excel workbook. These workbooks were linked to a fifth workbook containing cumulative data for the four participating schools. 

The data gathered from the reports have been analyzed according to the individual schools and the cumulative schools, by month and by syndrome. 

Results of Schools by Month
These data were analyzed based on the number of cases per syndrome, the average daily population, and the total number of days of school each month. In February there were 19 days of school; 15 days in March; 20 days in April, and 17 days in May. 

School A: (Refer to Table A/Graph A)
School A had an average daily attendance of 473 to 484 students in all four months. The frequency of students complaining of diarrhea/vomiting increased during February and April. Fever with cough /sore throat increased in February and remained the same over the rest of the months. None of the students complained of rash and fever during this period. 

School B: (Refer to Table B/Graph B)
School B had an average daily attendance of 479 to 487 students. Students with diarrhea/vomiting and fever with cough/sore throat were high (11) in February. The rates remained low for rest of the months. None of the students presented for rash with fever during these months. 

School C: (Refer to Table C/Graph C)
There was an average daily population of 420 to 429 students. There were 11 cases of diarrhea/vomiting and five cases of fever with cough/sore throat. There were not many cases of the syndromes during the rest of the months. None of the students had rash with fever during this time.  

School D: (Refer to Table D/Graph D)
Average daily attendance for School D was 335 to 340 students. Twenty-nine students presented with fever and cough/sore throat, which remained the highest number of cases of fever with sore throat in any month. One student presented with rash with fever during February. 

Cumulative School Syndromic Data by Month (Refer to Table E/Graph E)
The mean population of all four schools was 430 students. Forty-five students presented with diarrhea/vomiting, 62 presented as fever with cough/sore throat, and one presented as rash with fever, with rates of 2.6%, 3.6% and 0.1% respectively. The frequencies remained higher in February and March and remained lower the rest of the months.  

There were many cases of diarrhea/vomiting throughout February in all four months in all schools. Schools A and had counts that were higher for these syndromes in the other months compared to the rest of the schools. The increase of fever with cough/sore throat cases in all schools may be attributable to seasonal allergies and flu which commonly occur during winter. The cases of nausea and vomiting could be attributed to the shigellosis in Duval county at that time. School D had the highest number (29) of cases for cough/sore throat. There was only one case of rash with fever in all schools during all four months.  

Discussion

The collected data will be distributed to The Board of Health for use in its annual report. At this point, the system will be evaluated to determine feasibility as a surveillance tool. The system is simple and acceptable and the time it took to fill out the form (attached) was minimal. The amount of time spent to design a form including time spent on transferring, entering, storing, and backing up data in the Excel database were also minimal. The system is flexible because categories on the form can be changed.

Limitations
This surveillance system did not represent a true picture of the whole population of Duval county schools. Since the data were from only four schools, the counts may not be sufficient to identify a problem. Surveillance was only for four months, which is a relatively short time to evaluate this as a possible surveillance tool. The four schools were chosen based on availability of school nurses in the north side, west side, south side, and Arlington area during this period. Schools were not equally represented as far as population and number of days off from school is concerned, which also adds bias to the analysis. No special follow-up laboratory tests to confirm the information were performed. Investigation of the cases, including telephone contact or a home visit by public health personnel to collect detailed information was not required by this surveillance system. The use of historical baseline information to gather point sources and clusters of different diseases will be helpful in future. The baseline of spatial clustering in real time could also be useful to locate changes in geographic distribution instead of historical baseline data.

To access the graphs mentioned in this article, click here:

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►News From the Front: County Health Department Bi-Weekly Conference Call Update

Conference call attendees, as always, are encouraged to play an active role in discussions and to ask questions. If you haven’t participated in this forum yet, you’ll find it an interesting and helpful way to stay on top of what’s going on in Florida epidemiology. Calls are scheduled on alternating Fridays at 10:00 a.m. EST. Here, then, are highlights of last week’s call:

Evaluation of Real Time Outbreak Disease Surveillance Project. The Bureau of Epidemiology's Karen Wheeler, MPH, described the newest addition to the project, the National Retail Data Monitor, which scrutinizes Over The Counter (OTC) health care products to track aberrations in sales. Currently, 32 states conduct this type of surveillance, which is provided free through University of Pittsburgh. Over 18,000 retail stores nationwide transmit their data via a secure Internet site, where the data is analyzed and manipulated using algorithms so the information can be viewed by zip code, product, and other formats. Wheeler explained the surveillance has great future potential combined with other methodologies; but, at present, its accuracy is affected by the fact there are not enough retail stores participating to portray an accurate representation of OTC sales spikes. Anyone interested in learning more or in forwarding the information to local drugstores should contact Karen at karen_wheeler@doh.state.fl.us. 

Pitfalls of Toxin Testing in Hospital Labs for Reportable E. coli.  Ron Baker of the Jacksonville Central Laboratory presented on toxin testing for reportable E. coli during the biweekly CHD conference call. The presentation clarified the difference between toxin testing in hospitals as a screening tool and a positive isolation of shiga-toxin positive E. coli, which is reportable. It is important to follow up on each hospital toxin positive test before reporting as E. coli since many of these hospital laboratories are not isolating the organism but merely reporting the detection of a toxin. Review of the case definition requirements included the necessary isolation of the organism and confirmation made by the state laboratory for E. coli O157:H7 and any E. coli that is shiga-toxin positive. Questions regarding reportable E. coli can be directed to the Communicable Disease Surveillance & Reporting section in the Bureau of Epidemiology. The power point presentation can be accessed from the following link: http://www.doh.state.fl.us/disease_ctrl/epi/conf/conf_call.html.  

Training Issues. Melanie Black announced that the Regional Epidemiology Seminar on October 29-30 will be held at the Volusia County Health Department in Daytona Beach. The seminar will focus on how to conduct an epidemiological investigation. Participation will be limited to 45, so registration should be completed quickly if you would like to attend. Participation will be limited to county health department staff who conduct epidemiologic investigations. Log on to the Bureau of Epidemiology Internet web site for further details.  

Grand Rounds on September 30^th will feature Dr. Savita Kumar presenting on the recent malaria outbreak in Palm Beach County. 

Continuing Education Credits have been updated. If you’re awaiting your certificate and need it promptly due to a licensing timeline but have not received it, please contact Melanie Black at melanie_black@doh.state.fl. 

Agendas for bi-weekly conference calls will no longer be emailed; instead, they will be posted on the Intranet web site. Be sure to make a note of this and check the web site regularly for information pertaining to the conference calls and Grand Rounds. Information on Regional Epidemiology Seminars, satellite broadcasts and other training can be found on the Bureau of Epidemiology Internet website at http://www.doh.state.fl.us/disease_ctrl/epi/conf/conf_call.html  

The next conference call is scheduled for September 19^th at 10:00 a.m. EST. If you have a suggestion for the agenda or you would like to be placed on the agenda, please email Don Ward donald_ward@doh.state.fl.us or Melanie Black at melanie_black@doh.state.fl.us.

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►Are We Ready for the Return of SARS? CDC Announces Preparedness Training

As temperatures begin to fall during the coming autumn months, health organizations worldwide are preparing to meet flu season, knowing that respiratory ailments could signal another SARS season as well. With that in mind, the CDC is acting to equip clinicians, laboratory workers and other public health personnel with the skills and knowledge to recognize and implement strategies for preventing the transmission of SARS.   

A course entitled Preparing for the Return of SARS: Are We Ready? will be presented as a two-part series on Tuesday, September 23, and Tuesday, September 30 from 2:00 – 4:00 p.m. Continuing credits will be offered based on two hours of instruction.   

For complete details concerning access, instructors and registration, log on to the CDC web page at http://www.phppo.cdc.gov/phtn/SARS-return/Default.asp 

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►Hepatitis Educational Materials Now Available in Spanish
 
Several of the Florida Hepatitis Program’s educational materials are now available in Spanish, including the Hepatitis ABC Chart, the Hepatitis C mini-placard, and the Improving Your Health - What You Need to Know if You Have Hepatitis C information sheet for clients. 

To order the charts and mini-placards - or any other hepatitis educational materials,  please contact April Crowley, Health Educator, at April_Crowley@doh.state.fl.us , SC 205-4444 extension 2580.

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►Adults With Asthma Encouraged to Obtain Flu Shots

Although approximately two-thirds of adults with asthma opt not to receive an annual flu shot, doctors are encouraging their patients to ensure they get vaccinated around October each year. 

Because symptoms of influenza such as coughing and fatigue can act as triggers to asthma, the belief that flu shots bring on asthma is a common misconception. But in a study conducted at the Indiana School of Medicine by the American Lung Association in 2001, it was proven that flu shots do not cause asthma attacks. According to Dr. John G. Mastronarde, Indiana University School of medicine researcher, “If everyone with asthma gets a flu shot ,,,we can potentially prevent millions of asthma attacks, many of which would have been severe and resulted in hospitalizations.” Being vaccinated can result in one less trigger for asthma, but hospitalization rates for asthma sufferers and other lung ailments increase two to five-fold during major flu outbreaks.  

With flu season in full swing from October to mid-May, it’s best to be vaccinated beforehand, allowing the immune system ample time to be stimulated so it can resist infection. And although immunization against influenza won’t prevent resistance to all viral infections, Dr. Stephen Wasserman, a fellow of the American Academy of Allergy, Asthma & Immunology and a professor of medicine at the University of California says, “Getting vaccinated can still be a great help to staying healthy.”  

For more information concerning the study, published in the November 22, 2001 issue of the New England Journal of Medicine, contact the IU School of Medicine at 317.274.7722 or visit the American Lung Association of Indiana web site at http://www.lungin.org/

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►Outbreak of Scombroid/Histamine Poisoning From Consumption of Marlin Spoils Film Crew Visit

Introduction
The Florida Department of Health investigated an outbreak of scombroid/histamine poisoning from the consumption of spoiled marlin in early May 2003. Two clusters were identified between May 5–9, 2003. The first cluster involved a film company that was filming on location in Miami Beach and the second cluster involved patients and staff at a drug rehabilitation/eating disorder treatment center in Collier County.  

Cluster 1 - Background
On May 5, 2003, the Office of Epidemiology and Disease Control of the Miami-Dade County Health Department (MDCHD) received an after-hours call from the owner of a catering service to report a group of persons with symptoms of rashes and allergic reactions after consuming marlin for lunch that day. This was followed by another call from a local hospital infection control department to report that these patients were received in their emergency room. The ill people were part of a film company that was filming on location in Miami Beach. Histamine poisoning from the marlin was suspected. 

Methods
On May 6, MDCHD sent an epidemiologist to interview the ill at the film site. Medical records of the ill seen at the emergency room were provided by the hospital infection control department. A case of histamine poisoning was defined as a person who consumed marlin at the catered lunch on May 5 and developed an allergic reaction with three or more of the following symptoms of histamine poisoning: nausea, vomiting, or diarrhea; itching, burning, or tingling sensations; rashes or flushing of the skin; headache; or a drop in blood pressure.   

The Florida Department of Agriculture and Consumer Services (DOACS) began a traceback investigation of the fish product on May 6. A sample of the fish from the previous day’s lunch was sent by the film company to a private laboratory for testing. A food service inspection of the catering service site was conducted by the Florida Department of Business and Professional Regulation (DBPR) on May 7. Although no major violations were observed during the inspection, the caterer did not have a license to operate in Florida, for which DBPR issued a warning. 

Results
About 90 people from the film company ate the catered lunch on May 5. Of these, 24 ate the marlin. Twenty of the 24 developed symptoms (attack rate = 96%), of whom 13 (57%) were treated at the ER and released the same day. A total of 15 symptomatic individuals were interviewed on May 6. Predominant symptoms reported include headache, nausea, diarrhea, flushing of the skin, and vomiting. Mean incubation time was 27 minutes (range 5–120 minutes). The duration of symptoms was up to 7 hours in those who delayed treatment, which included none for those with milder symptoms, to IV's, oxygen, Benadryl, steroids and painkillers.  Individuals who had eaten the other items on the menu reported no illnesses. On May 6, all the ill were eating normally at the catering site. 

Cluster 2 - Background
On May 9, four days after the Miami-Dade cluster, the Collier County Health Department (CHD) received a call from the county Emergency Medical Service about what appeared to be allergic reactions among several people at a drug rehabilitation/eating disorder treatment center. Twelve (12) people were transported to the ER where they were treated and released. Initially, it was unclear whether this was an act of intentional poisoning or a natural food-related illness. Based on the food consumed (Pacific marlin), signs and symptoms, the illness appeared to be food related and unintentional scombroid fish poisoning was suspected. 

Methods
On May 9, 2003, the Collier CHD conducted an onsite investigation at the treatment center. Interviews of patients and staff were conducted to obtain information about food consumption and illness. An inspection of the facility kitchen was performed and leftover food samples were collected and submitted to DOACS for laboratory analysis. On May 12, epidemiologists returned to the treatment center to complete the epidemiological investigation. An invoice for the Pacific marlin purchased by the treatment facility linked the fish consumed to a Miami distributor. The distributor was the same one identified by the DOACS traceback investigation earlier that week who had imported the marlin from Costa Rica. A case was thus defined as a person who experienced an allergic reaction of histamine poisoning after consuming Pacific marlin imported by this distributor. Resulting data were analyzed using Epi Info 2002 computer software. 

Results
A total of 70 people were interviewed in cluster 2. Of these, 21 ate the marlin. Fifteen of the 21 became ill (attack rate = 71%), 12 (80%) were treated at the ER and were released by that evening. Predominant symptoms reported include headache, dizziness, cramps, diarrhea, fatigue, nausea, rashes and weakness. Median incubation time was 30 minutes (range 1–180 minutes). Median duration of symptoms was 120 minutes (range 60–360 minutes). Patients and staff at the treatment center who did not consume the marlin reported no illnesses. No obvious food handling errors were discerned upon inquiring into the preparation of the marlin, which had previously been served for dinner at the facility on May 3. Treatment was documented for one patient who had an allergic reaction after consuming the marlin for dinner that evening.  

State-Level Traceback Investigation and Laboratory Results
The traceback investigation begun by DOACS after the Miami-Dade cluster (Cluster 1) revealed that the marlin originated from Costa Rica. A Miami distributor purchased 1,045 lbs and sold different quantities to secondary wholesalers and restaurants. On May 11, 2003, the Florida Department of Health issued a press release on the scombroid outbreak warning consumers in Collier and Miami-Dade counties to avoid eating marlin purchased from this distributor. By then, DOACS had accounted for 90% of the product and had issued stop sale orders. Raw fish product tested by DOACS at various points in the distribution chain to determine levels of histamine found a number of positive samples at levels as high as 5800 ppm. Two leftover samples collected on May 9 from the Collier cluster also contained similarly high levels of histamine: 5200 ppm and 3600 ppm. According to FDA guidelines, histamine levels of 50 ppm are considered poisonous. The sample tested at the private laboratory from the lunch consumed by the film crew on May 5 was found to have a histamine level of about 660 mg/100 g of fish.

Conclusion and Recommendations
The two clusters of scombroid fish poisoning that occurred in Miami-Dade and Collier counties in May were associated with the consumption of Pacific marlin originating from Costa Rica that had spoiled due to improper handling somewhere along the distribution chain. No additional cases or clusters have been reported since the Collier cluster. Significant economic losses were incurred by the film company, the distributors of the fish, and to a lesser extent, the restaurants that received the fish.

Scombroid fish poisoning occurs when certain kinds fish are consumed that have spoiled because of time or temperature abuse, which permits the growth of bacteria. These bacteria degrade substances in the muscle protein, leading to an elevation of histamine to toxic levels. Onset of intoxication symptoms is rapid, ranging from immediate to 30 minutes, and usually last several hours. Temperature controls are therefore essential to prevent histamine formation in susceptible fish. It is imperative that the fish be held below 41°F during all phases of handling, from the time of capture to preparation for consumption. Immediate freezing or irradiation are alternative ways to prevent this spoilage.

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►This Week on EpiCom

At about 8:00 p.m. on the evening of September 10, Deputy State Veterinarian Carina Blackmore, after consulting with officials from various state agencies, logged on to EpiCom and posted information regarding developments in the latest malaria case. When offered the option of notifying Bureau of Epidemiology personnel to review and approve her post immediately, she made the determination that this information was important enough to share even at this late hour and selected “Yes”. 

In less than a minute and a half, EpiCom had contacted both of the moderators assigned to Malaria, alerted them to the fact that an emergency post was awaiting their attention, registered their receipt of the message and then shut down the alert. 

The moderators, alerted at their homes, both responded, logged on to the EpiCom System and coordinated the posting of this emergency information as well as another later in the evening. Use of EpiCom provided almost instantaneous response to make information on this developing situation available to all EpiCom users who were monitoring the progress of the disease’s spread. 

It is this kind of remote capability to share vital information and to notify those who need to have it that the EpiCom system was designed to exploit. To reduce response times to breaking and changing data about emergency public health situations is the primary goal of the EpiCom team at the Bureau of Epidemiology. 

The Bureau acknowledges the timely and comprehensive contributions of Dr. Carina Blackmore, Dr. Joann Schulte and Dr. Lisa Conti in recognizing the potential of the EpiCom Exchange and EpiCom Alert system in combating emerging diseases, natural disease outbreaks, and potential bioterrorist attacks.

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►Arboviral Disease Report

Eastern Equine Encephalitis (EEE) activity appears to be on the decline as West Nile (WN) activity continues to rise throughout much of the state. 

Eleven WN virus cases were reported this week in residents of Duval (onset 8/22), Escambia (onset 8/16, 8/21), Lafayette (onset 8/16), Miami-Dade (onset 8/24), Okaloosa (onset 8/11, 8/24), Santa Rosa (onset 8/20), Sarasota (onset 8/29), Union (onset 8/24), and Volusia (onset 8/14) counties, bringing the number of cases reported this year in Florida to 28. The following 17 counties are under medical alert: Bay, Brevard, Broward, Collier, Duval, Escambia, Gilchrist, Lafayette, Lee, Miami-Dade, Nassau, Okaloosa, Orange, Palm Beach, Santa Rosa, St. Johns and Union.  Lafayette and Union were added this week. Malaria has been reported in seven Palm Beach County residents. The total number of EEE cases remains at two. 

EEE virus activity in animals: One new EEE virus infection was reported in a Leon County horse this week.  In sentinel chickens, 7 seroconversions to EEE virus were reported. To date, 52 of Florida’s 67 counties have reported EEE virus activity, compared to 23 counties reporting EEE last year at this time.  

WN virus activity in animals: Four WN virus infected horses were reported this week. In addition, 122 seroconversions to WN virus were confirmed in sentinel chickens from 24 of the 30 counties that collected samples. Seventy-five dead birds from 12 counties were reported positive for WN virus. Fifty-four counties have reported WN virus activity, compared to 48 at this time last year.   

The complete report can be viewed at:  http://www.doh.state.fl.us/Environment/hsee/arbo/weekly_summary2003.htm

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►Weekly Disease Table