Friday, September 17, 2004

         This Week in the News

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

►Respiratory Syncytial Virus Surveillance Season Starts
The program is already in place and recruiting is progressing. The benefits of RSV surveillance to public health efforts around the state are explained in this article by the respiratory disease epidemiologist heading up the effort.

►Information on National Bioterrorism Surveillance Systems
This two-part article explores various systems available for observing irregular activities. Next week, we'll look at the systems available within the state of Florida.

A R T I C L E S

These data are important to neonatologists, pediatricians, and other healthcare professionals working for the protection of infants and children against common childhood diseases. RSV surveillance data can help alert public health officials and physicians to the timing of seasonal and regional RSV activity within the state of Florida. Practitioners value the data because it provides them an indicator of when to initiate RSV prophylaxis to high-risk infants and children. Prophylaxis of high-risk infants and children has been shown to lessen the severity of disease and the likelihood of future sequellae, such as asthma and other severe pulmonary complications. Studies show that strategic planning of RSV prophylaxis is important to the efficacy of the vaccine. Surveillance of RSV also helps practitioners, hospitals, and health management organizations justify and measure the cost effectiveness of prophylaxis programs.

If you have questions about the RSV Surveillance Program or would like to recruit hospitals in your area, please feel free to contact Angela Fix, MPH, at 850.245.4444, ext. 2528 or by email at angela_fix@doh.state.fl.us.
 

The latest conference call among Bureau of Epidemiology staff and health department personnel across the state occurred on August 27, 2004. A brief summary of the  discussions is recounted here for parties who were not able to participate.

Announcements. Don Ward announced two job vacancies in the bureau; a laboratory liaison to improve lab reporting and craft protocols, and an infection control specialist to work on MRSA and related diseases and expand public awareness. Anyone interested in discussing either of these positions should telephone Don at 850.245.4405.

Review of EpiCom Satellite Broadcast. Pete Garner announced a tape of the broadcast which aired live on August 25th will be mailed to each CHD and also be made available to requestors.

A new forum has been created on EpiCom so members can post up-to-date information on hurricane-related activities. Over 50 messages have been shared so far on topics such as gasoline supplies, sun injuries, outbreaks and other news.

Hurricane Charley.  Dr. Schulte reported that hospitals and clinics in the affected areas set up an ad hoc surveillance system for admissions due to the large number of elderly patients in situ. They will transition the reporting into the Merlin system later. Health care practitioners have noted a need for better hand washing habits, as diarrhea has been a major problem for these patients.

The staging area at the Tampa fairgrounds is staffed by FEMA professionals. Sarasota is the jumping off point for volunteers who deploy to the affected areas. The duration of the response effort is unknown; however, anyone from DOH who wants to assist must sign up individually on the DOH Website provided in an earlier email from the Secretary.

The mortality rate is expected to rise as figures from the hardest-hit counties continue to arrive. In-depth studies on the mortality rate will be performed later.

Influenza News. Angela Fix and her staff have mailed sentinel information packets to the 83 providers who have enrolled in the program. If anyone would like assistance recruiting providers in their area, she will be happy to visit or send someone to provide the marketing expertise needed to bring more providers into the program.

The national pandemic plan is under review by DOH staff in Tallahassee. Anyone wishing to participate in the review should contact Angela at 850.245.4444, ext. 2528.  Comments are due to CDC within 60 days.

Discussion and Wrap-up. Sam Williamson, Santa Rosa CHD reported nine cases of pertussis in the county, with four confirmed. He has promulgated a memo to local physicians to be on the lookout for cases of pertussis, and will resubmit lab samples to the state laboratory for a culture confirmation.

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.
 

With so many bioterrorism surveillance programs and systems available, it becomes difficult to distinguish one system from another. This two-part article will provide descriptions and clarifications on popular national surveillance systems, as well as systems designed and/or used by the Florida Department of Health. This week's focus is on national systems.

BioSense is one of several national initiatives proposed by the Centers for Disease Control and Prevention and the Department of Health and Human Services to improve the nation’s preparedness for identifying and handling a bioterrorism event. The purpose of BioSense is to improve early detection of potential health emergencies through the implementation of near real-time reporting of health data, the implementation of enhanced connections between clinical care and public health, and the advancement of early detection analysis. BioSense will draw on several national data sources, such as requested lab tests, over-the-counter drug sales and managed care hot lines that patients call with questions or concerns. The system will also pull clinical data from the departments of Defense and Veterans Affairs. Much of these data are already collected on a regular basis and can be relayed to public health officials for analysis. http://www.cdc.gov/phin/04conference/05-26-04/Session_6C-David_Walker.ppt.

BioWatch is a federally initiated effort to conduct surveillance of environmental exposures caused by intentional release of biological agents. The Environmental Protection Agency (EPA) maintains a network of over 4000 air samplers nationwide for monitoring air pollutants. Approximately 10-20 air samplers in each of several cities (including cities in Florida) are equipped for 24 hours per day monitoring for selected agents. Filters from these samplers are removed at least once each day and transported to a designated local or state public health laboratory that participates in the Laboratory Response Network (LRN), where they are analyzed using PCR technology for six different agents (including anthrax, smallpox, plague, glanders, brucellosis, and tularemia) that might be used in acts of bioterrorism. Federal agencies, including the Department of Homeland Security (DHS), the EPA, and the Centers for Disease Control and Prevention (CDC) are collaborating with local and state health officials to implement this program. Various cities in Florida participate in the BioWatch program. More information on BioWatch can be found at
https://www.bids.tswg.gov/hsarpa/bids.nsf/F32FE3B1449E699D85256DC70065EB27/
$FILE/BioWatchFactSheetFINAL.pdf.

Autonomous Detection Systems (ADS) combine automated air sampling and testing to detect agents of biological and chemical terror in the environment and provides real-time alerts when an agent is present. An ADS continuously samples air and an automated detection assay (e.g., a real-time polymerase chain reaction [PCR] test or an immunoassay) analyzes the trapped material at a defined sampling interval (e.g., every 1.5 hours). All ADS under development are designed to alert authorities of a positive signal. The result is an approximate real-time detection and alerting system.

Biohazard Detection System (BDS) is one type of ADS developed by the U.S. Postal Service (USPS) to detect aerosolized Bacillus anthracis spores. USPS plans to install BDS in approximately 300 mail processing and distribution centers (PDCs) across the United States. PDCs have high-speed mail-handling equipment that can aerosolize B. anthracis spores sent through the mail, as demonstrated during the 2001 anthrax attacks. USPS will install BDS devices on or near key equipment that processes incoming mail. The immediate identification of aerosolized B. anthracis spores in an air sample allows for prompt on-site decontamination of workers and subsequent post exposure prophylaxis (PEP) before the onset of symptoms and to interrupt the flow of contaminated letters or packages into the postal stream. More information on ADS and BDS can be found at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr53e430-2a1.htm

Enhanced Surveillance Projects (ESP), also known as drop-in surveillance, is a CDC surveillance tool used during special events to monitor sentinel hospital emergency department visit data to establish syndrome baseline and threshold levels. CDC works with state and local health departments and information system contractors to develop real-time special event syndromic surveillance and analytical methods. Aberration detection models developed and evaluated at CDC identify deviations in visit data and report to state and local health departments for confirmation and appropriate epidemiological follow-up. ESP has been tested at the World Trade Organization in Seattle, the Republican and Democratic National Conventions held in Philadelphia and Los Angeles in 2000, the 2001 and 2004 Super Bowls in Tampa, Florida and Houston, and most recently, in July this year at the Democratic National Convention in Boston. CDC continuously develops and evaluates ESP to provide guidance and resources to state and local health departments for implementation of local real-time surveillance systems. More information on ESP can be found at http://www.bt.cdc.gov/episurv/ESP.asp

The Real-time Outbreak and Disease Surveillance (RODS) is an electronic public health surveillance system deployed in 1999 in Pennsylvania, in 2002 in Utah, and in 2003 in parts of Ohio, New Jersey, Michigan and Taiwan. RODS was developed by the RODS Laboratory within the Center for Biomedical Informatics of the University of Pittsburgh. RODS collects data from existing computer systems in clinical and other settings and displays them for public health departments through a secure web-based user interface. RODS monitors the health of the community for both culture proven cases of disease as well as for abnormal incidence of selected infectious disease syndromes by examining these data. RODS is also conducting research on other, non-traditional types of data to determine if outbreaks can be detected through analysis of these (anonymous) data, including daily sales volumes of different over-the-counter and prescription drugs, daily volumes of calls to 911 call centers and poison centers, animal health, absenteeism, insurance claim data, utility usage, etc. RODS provides tools that enable public health officials to detect the presence of a disease outbreak and support the characterization of that outbreak. These tools include case definitions, automatic detection algorithms that can be attached to specific data streams and tools that support temporal and spatial data analysis and visualization. More information on RODS can be found at http://rods.health.pitt.edu/default.htm.

The National Retail Data Monitor (NRDM) was built by the RODS Laboratory at the University of Pittsburgh in collaboration with the food and drug retail industry, state and local health departments and the Centers for Disease Control and Prevention (CDC). The NRDM monitors sales of over-the-counter (OTC) healthcare products to identify potential disease outbreaks as early as possible. In operation since December 2002, there are over 20,000 retail pharmacy, grocery, and mass merchandise stores that participate in the NRDM. There are over 400 public health officials across 46 states (including Florida), the District of Columbia, Puerto Rico, and the CDC with access to the system. Access to the NRDM is available free to public health officials through a secure web-based user interface. More information on the NRDM can be found at http://rods.health.pitt.edu/default.htm. To obtain a free user account for the NRDM contact nrdmaccounts@cbmi.pitt.edu.

Next week, Florida Department of Health, Bureau of Epidemiology systems programs will be highlighted. In the meantime, of you have questions pertaining to any of the already listed systems, contact Bioterrorism Surveillance Epidemiologist Karen Wheeler, MPH, at 850.245.4444, ext. 2401 or via email at karen_wheeler@doh.state.fl.us
 

Their plan is to provide communities and individuals a variety of ways in which become volunteers, receive first aid training, establish family emergency plans, procure emergency supply kits, and become more cognizant of threats which could impact their local area. Hosted events will be held throughout the month to promote preparedness around the country as Americans are encouraged to become more actively involved in learning and preparing for home and national emergencies.

The Department of Homeland Security can be contacted for more information. If you want to become involved in hosting an event or would like to receive more information, call Kristin Gossel or Lara Shane at 202.282.8010. To receive a Get Ready Now brochure, go to www.Ready.gov. To view the press release, go to http://www.dhs.gov/dhspublic/interapp/press_release/press_release_0481.xml
 

Translation of the VIS is underway, and the foreign language versions will be posted on the Immunization Action Coalition's Website at www.immunize.org when ready.

For more information regarding the new Hepatitis A VIS, contact Tom Bendle of the Bureau of Immunization at 850.245.4342 or at SunCom 205.4342.
 

Dr. Chertow is a board certified internist who graduated from the University of California at Berkeley with a masters degree in public health. He earned his medical degree from Northwestern University in Chicago. After interning and performing his residency at the University of California at San Diego, he worked for a private physicians group, providing at-home health care to a geriatric population. He worked as a hospitalist in intensive care and general medicine at Kaiser Permanente in Honolulu before his assignment to Tallahassee by the CDC.

His work on post-hurricane Charley has lead to an October 5 Grand Rounds discussion at the CDC pertaining to hurricane-associated morbidity. He'll present on implementation of the surveillance system used to gather data followed by a presentation of the team's findings. His long-term interests are clinical medicine and public health research and practice.

During the next two years Dr. Chertow's work will consist of consulting with CHDs throughout Florida, building consensus to address public health perceptions on issues such as community-acquired MRSA, and investigating outbreaks. And, taking advantage of the fact that Florida is one of the nation's top vacation spots, his peripheral time will be spent traveling, sailing and swimming. To reach him, call him at 850.245.4406 or email him at daniel_chertow@doh.state.fl.us.
 

Abstract: 
Clostridium difficile is the most commonly diagnosed cause of infectious diarrhea in hospitalized patients.  The clinical presentation of C. difficile associated disease (CDAD) varies from asymptomatic colonization to mild diarrhea to severe debilitation disease, which may include paralytic ileums, toxic megacolon, colonic perforation and death.  Risk factors include exposure to antimicrobials, health care, gastrointestinal surgery, feeding tubes, proton pump inhibitors, immunsuppression and older age.  CDAD can be associated with outbreaks in both hospitals and long-term care facilities.   As a spore-forming organism it presents unique challenges for infection control that are not found in the control of non-spore forming organism. 

Recent studies indicate that Clostridium difficile associated disease may be increasing both in disease incidence and disease associated mortality. In Florida there has been an increase in the number of patients discharged from acute care facilities with a diagnoses of Clostridium difficile enteritis over the last two years.  As a result of the increase in C. difficile the Bureau of Epidemiology conducted a surveyed acute care hospitals in January 2004.  This survey was divided into three major areas, laboratory testing, surveillance and infection control procedures. Preliminary results from this survey indicate there is a need for education concerning the disease and control methods.    

Additional Information: 
The grand rounds presentation will begin promptly at 11:00 a.m. EDT on Tuesday, September 28, 2004. The PowerPoint slides will be available on the Bureau of Epidemiology intranet Website on Friday, September 24. CEUs will be provided for nursing and environmental health professionals. Please remember you must complete the entire registration form including the evaluation and test questions. Registration for CEUs will be accepted September 28 - September 30. Registrations received prior to the beginning of the program will not be accepted. If additional information is needed, contact Karen Wheeler, MPH, bioterrorism special surveillance projects coordinator, at 850.245.4444 ext. 2401, SunCom 205.4444 ext. 2401 or email Karen_Wheeler@doh.state.fl.us
 

This Week on EpiCom

• Extensive use has been made of EpiCom during the ongoing Hurricane 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 three confirmed EEE horses this week, one each from Jackson, Leon and Liberty counties. There were two seroconversions to EEE virus in sentinel chickens from Alachua and Nassau counties. So far this year, 32 counties have reported EEE activity. 

St. Louis Encephalitis (SLE) virus activity: There were two seroconversions to SLE virus in sentinel chickens from Brevard and St. Lucie counties. So far this year, four counties have reported SLE activity. 

Highlands J (HJ) Virus activity: None this week. Eleven counties have 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
July	Miami-Dade		1			Recovering
Sentinel Chickens : (date of first positive bleed)	County	SLE	WN	EEE	HJ	Seroconversion Rate
(2) 8/30	Alachua		1	1		5.56%, 5.56%
8/24, 8/25, (6)8/26, 8/27, 8/30	Brevard	1	9			3.26%, 22.50%
8/27	Indian River		1			2.13%
8/30	Manatee		1			1.54%
8/30, 8/30	Nassau		1	1		2.63%, 2.56%
(4) 8/24	Osceola		4			15.38%
7/19, (4)8/30	Palm Beach		5			7.02%
(2) 8/30	Pinellas		2			3.64%
8/27	Seminole		1			3.57%
8/30	St. Johns		1			1.79%
8/26, 8/26	St. Lucie	1	1			2.86%, 2.86%
8/30	Volusia		1			2.38%
8/30	Walton		1			1.69%
Dead Birds : (dead date)	None
Horses : (onset date)	County	WN	EEE			Outcome
(8/19)	Jackson		1			Alive
(8/23)	Leon		1			Alive
(8/18)	Liberty		1			Alive
Wild and Captive Birds : (collection date)	None
Mosquito Pools : (collection date)	None

See the Web for more information at www.MyFloridaEH.com. 

Bureau of Epidemiology

 Epi Update Archives

Florida Department of Health

My Florida

Contact Us

CDC