Melanie Black, MSW, Professional Training Coordinator, Bureau of Epidemiology  

Local Transmission of Plasmodium vivax Malaria – Palm Beach County, Florida, 2003 

Savita Kumar, M.D., M.S.P.H., Palm Beach County Health Department, Division of Epidemiology & Disease Control 

The incidence of indigenous malaria in the USA has decreased since 1957 but may re-emerge due to the development of chloroquine resistance, changes in environmental conditions and increased international travel. 

Seven cases of introduced malaria were investigated in Palm Beach County during the months of July and August 2003. Six of the seven patients had no risk factors for malaria and denied any international travel. Patients 1 and 2 live four houses apart and both reported having attended the same 4^th of July block party that evening in their neighborhood. All of the patients denied previous history of malaria, blood transfusion, organ transplantations, or IV drug use. 

While the index case has not been identified, several possible sources were considered. Palm Beach County has a large immigrant population including many migrant farm laborers from Mexico and Central and South America. Returning international travelers were also considered.  

Notices were sent to all local physicians and hospitals, informing them of the presence of malaria in the area and requesting information and testing on anyone with a history of unexplained fever or other malaria symptoms.  

Surveillance and public education were implemented, such as door-to-door home visits and reverse 911 calls to residents in the targeted area. The public was educated through news media and postal mailings detailing the symptoms of malaria, modes of transmission and preventive measures. Mosquito traps were placed in the area around the homes of the patient cases. Larvicide and insecticide were applied in surrounding neighborhoods.  

With the increase in international travel, imported cases of malaria pose a threat, especially to those living in warmer climates. Medical providers should provide malaria chemoprophylaxis for travelers to countries where malaria is indigenous. They should also consider malaria a differential diagnosis for persons with unexplained fever, and perform a thick peripheral blood smear to diagnose malaria.

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►Campaign on Proper Use of Antibiotics Unveiled

The Department of Health and Human Services has a message for parents:  Lay off the Antibiotics! 

Referred to as antimicrobial drugs because they fight infections caused by bacteria, they revolutionized medical care after the 1940s and saved millions of lives. Everyone agrees antibiotics are a good thing but when, a decade ago, it was discovered that overuse was leading to a host of new resistant bacteria, health officials began warning physicians to be more firm with patients who expected to be issued antibiotics to treat common ailments such as sore throats and the flu.  

Physicians know that antibiotics are effective only against bacterial infections, but the pressure to yield to patient demands is one of the reasons frequently cited for over prescribing antibiotics.  Dr. Michael Fleming of Shreveport, LA and president-elect of the American Academy of Family Physicians said “You can’t imagine on a daily basis the pressure on a physician to write(a prescription for) that antibiotic.”  After an aggressive campaign by professional public health organizations, however, the trend has slowly begun to reverse, and physicians are beginning to counsel patients with a “wait and see” method of treatment for viral infections rather than reaching for the prescription pad.   

Curriculums at medical schools are under development to provide the new generation of physicians with the understanding of the relationships between antibiotic resistance, mechanisms of resistance, diagnosis judiciousness and techniques and prophylaxis. The next phase of the educational effort is a national media campaign directed towards parents with messages aired by the FDA, CDC and other health agencies. One Public Service Ad, released this month, reads, “Snort. Sniffle. Sneeze. No antibiotics, please.”  The intent of the ads is to make it clear to parents and others that antibiotics are powerful drugs intended for treatment of bacterial, not viral infections and, if overused, they may be unresponsive when needed for treatment of stronger infections that could develop in future.

The CDC has developed several programs to address the problem, and the information can be accessed at the following web sites: 

Active Bacterial Core Surveillance http://www.cdc.gov/abcs

Division of Healthcare Quality Promotion http://www.cdc.gov/ncidod/hip/Aresist/aresist.htm

National Antimicrobial Resistance Monitoring System for Enteric Bacteria http://www.cdc.gov/narms/what_is.htm

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►Cure for the Common Cold One Step Closer

The 43^rd Annual Interscience Conference on Antimicrobial Agents and Chemotherapy convened in Chicago this week, and one of the most talked-about topics at the conference was a research project which actually began two years ago.   

A new pneumovirus called human metapneumovirus (HMPV), a Paramyxovirus which may be the source of the common cold, has excited the scientific community because it could also be the cause of several severe respiratory illnesses affecting children and infants who are hospitalized each year.  

In 2001, a Dutch scientist named van den Hoogen cultured nasal swabs submitted during the winter season from young children with respiratory tract disease. His seroprevalence studies showed that 25% of the children aged 6-12 months had detectable antibodies to HMPV and that by age 5, every child showed indication of past infection. Subsequent studies by researchers in the U.S., Israel, England and Australia supported his initial findings and further implied that HMPV is capable of causing clinically important reinfection in late childhood or adult life.  

While discovery of the pathogen is still fairly recent, it is estimated that the virus has existed for centuries but has been difficult to find because it does not grow capably in cell cultures. And since the human body doesn’t remember the metapneumovirus after contracting an illness from the virus, it doesn’t develop immunity. The result, of course, has been miserable colds and those terrible tasting cold medicines ever since most of us can remember. However, those days may soon be behind us, now that scientists know which virus to attack in their war on the common cold.

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►Regional Training Set for Volusia County in October
 
The Bureau of Epidemiology is pleased to announce the next regional training for county health department staff members, which will be held in Daytona Beach at the Volusia County Health Department on Wednesday, October 29^th and Thursday, October 30^th, 2003. The target audiences for the regional training programs are county health department staff members and partner agencies who conduct epidemiologic investigations.  

This program will address public health surveillance and communicable disease outbreak investigations. Specific topics such as principles of public health surveillance, improving provider reporting, principles of field epidemiology, historical overview of emerging pathogens and an outbreak scenario will be covered in this training. On-line registration is now available through Friday, October 17, 2003 and can be accessed through the Bureau of Epidemiology Internet web site: http://www.doh.state.fl.us/disease_ctrl/epi/conf/conf_call.html. Space is limited to 45 participants, so register as soon as possible. 

Additional information will be provided in the Epi Update and on the Bureau of Epidemiology web page. We also intend to offer training programs in other regions of the state. If you are interested in hosting one of the training sessions or have questions related to this program, please feel free to contact Professional Training Coordinator Melanie Black, Bureau of Epidemiology at (850) 245-4444, ext.2448 or SunCom 205-4444,ext. 2448. 

We are truly excited about the potential this program offers for improving disease prevention in Florida and encourage you to pass this information along to colleagues who may be interested.

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►Agency for Healthcare Research and Quality Announces Bioterrorism Audioconference

The Agency for Healthcare Research and Quality will present the fourth event in its series of bioterrorism health system preparedness seminars on Tuesday, October 21 via audiocast.

The web-assisted audio conference, entitled, “The Role of Information/Communication Technology and Monitoring/Surveillance Systems in Bioterrorism Preparedness” will air from 2 – 3:30 p.m. EDT.  There is no charge for registration or participation, but registration is a must.  For detailed information, contact Cheryl Bell at cbell@hsrnet.com or phone her at 202.828.5100. 

Speakers will include John Loonsk, M.D., director of CDC’s Information Resources Management Office, U.S. Department of Health and Human Services. Dr. Loonsk will present strategies for improving coordination of activities between the systems and organizations involved in public health surveillance. Dr. Michael Wagner, Ph.D., assistant professor of medicine and intelligence systems at the Center for Biomedical Informatics at the University of Pittsburgh will discuss innovative surveillance systems and the information they can offer policymakers as well as public health providers. Chief of the Department of Emergency Services, Children’s Hospital, Harvard University Michael Shannon, M.D., M.P.H., will highlight the role played by information technology in improving syndromic surveillance and decision-making.

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►This Week on EpiCom

On the EpiCom web site this week:

• A suspect case of infant botulism in Broward County
• Two malaria outbreak conference calls among eight Florida counties were held

For further information regarding the EpiCom program, send an email to EpiCom_Administrator@doh.state.fl.us.

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►Mosquito-borne Disease Update

Three WN virus cases were reported this week in residents of Lee (onset 8/29), Santa Rosa (onset 8/20) and Washington (onset 8/6) counties, bringing the number of cases reported this year in Florida to 31. The following 18 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, Union and Washington.  Malaria has been reported in seven Palm Beach County residents. The total number of EEE cases remains at two. 

EEE virus activity in animals: Five new EEE virus infections were reported in horses this week. In sentinel chickens, 2 seroconversions to EEE virus were reported. One dead bird from Walton County was reported positive for EEE virus. 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: Seven WN virus infected horses were reported this week; one in Dixie County being the first WN report from that county this year. In addition, 45 seroconversions to WN virus were confirmed in sentinel chickens from 18 of the 33 counties that collected samples. Six dead birds were reported positive for WN virus. Fifty-six counties have reported WN virus activity, compared to 48 at this time last year.