Friday, September 24, 2004

         This Week in the News

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

►Beach Drowning Study Provides Clues to Panhandle Incidents
The study, conducted following a series of drownings which occurred in early summer 2003, demonstrates the importance of prevention.

►Fall Training Opportunities in Medical and Homeland Security
Combining medical and security training, courses scheduled this fall by the Institute of Homeland Security offer valuable information to first-responders and laboratorians.
 

A R T I C L E S

A study examined the drownings that took place during June through July 2003 in five Panhandle counties – Bay, Walton, Okaloosa, Santa Rosa, and Escambia. The study was divided into two parts: a descriptive analysis of the drownings and a survey of beachgoers designed to query respondents with respect to their knowledge of beach safety conditions and surf safety systems. 

The initial stage of the study, conducted from August 18-31, 2003, consisted of meetings with the stakeholders in each of the five counties to develop a descriptive summary of the drownings and identify any commonalities among the victims. The second stage of the study documented beachgoers’ understanding of beach safety conditions and evaluated their knowledge and behavior with respect to beach safety. The Beachgoers’ Survey was conducted from August 25 through Labor Day weekend in 2003. 

The descriptive study found that eight of 12 drowning victims were male, 10 of 12 were from out of state, and three of the 12 had detectable levels of alcohol.  The median age of the drowning victims was 46.5 years. The study also found that eight of the 12 who drowned were attempting to rescue someone else who was struggling in the water. Most of the persons being rescued eventually made it back to shore safely.  

Three of the 12 drownings occurred in the morning and nine occurred in the afternoon. Weather conditions for June 8 and 9 were examined because nine of the 12 drownings occurred during these two days. On both days, there were high waves offshore and large swells moving onshore over the entire northwest Florida coastline including the counties in our study. Although it is difficult to identify certain spots as being candidates for unsafe swimming conditions using weather reports, the entire northwest Florida coastline would have been affected. Red flags to warn swimmers to stay out of the water were flying over nearly the entire northwest Florida region. The distribution of Gulf drowning deaths by county during June and July 2003 shows the clustering of drowning fatalities. This occurrence is, at least in part, attributable to the adverse conditions present at a given place and time. The conditions during this two-day period were similar to those that occurred on Labor Day weekend (August 30-September 1, 2003), when four drownings occurred. The weather report for Labor Day was also similar; there were high waves over a large area of the Panhandle (Beeler, 2003).  

The study revealed that there are at least three different flag systems in place in Florida. At the time of the study, all five counties were using one of two different 3-flag warning systems (either a red-yellow-blue system or a red-yellow-green system).  A total of 69.4% of the respondents in the Beachgoers’ Survey correctly knew what color flag was flying at the time of the survey. And when given the three flag colors from which to choose, 98 percent of the public knew the red flag indicated the most dangerous conditions, yet 30 percent of the respondents said they would still enter the water even if the red flag were flying. 

The primary message of public health is prevention. Keeping people out of the water during dangerous conditions would be the easiest way to prevent drownings. Efforts should be made to discourage people from entering the water on red flag days. Additional Lifeguards would help in preventing people from entering the water and rescuing people that are in trouble. Better education would be useful in understanding the flag system and how to survive a rip current. A combination of these efforts would decrease the toll of Gulf drownings. 

The study in its entirety will be posted on the Department of Health intranet Website shortly. Questions can be directed to Dr. Alan Rowan at 850.245.4444, ext. 4404, or David Atrubin, MPH at 813.307.8015, ext. 6709.
 

With a plethora of bioterrorism surveillance programs and systems now available, it may be  difficult to distinguish one system from another. This two-part article provides 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 in-state systems.

Merlin is Florida’s official web-based system for the reporting, surveillance and analysis of diseases and outbreaks. Merlin is managed by the Bureau of Epidemiology, Florida Department of Health (FDOH), and is utilized by all county health departments and various bureaus and divisions within the FDOH. Merlin replaced the state’s previous paper-based reporting and surveillance system in January 2001. The Merlin system is designed to accomplish a variety of epidemiological tasks, including:

• Manage, report and analyze information from a variety of outbreak/cluster types, including: reportable and non-reportable diseases, symptoms/syndromes and other events of public health importance
• Real-time reporting of notifiable diseases
• Review and analyze county and statewide disease trends
• Export disease information for sophisticated analysis
• Quick and easy data entry capabilities
• Receive and process electronic laboratory data
• Detect potential disease outbreaks and clusters
• GIS capabilities

For additional information about Merlin please contact Travis McLane at Travis_McLane@doh.state.fl.us. 

EpiCom is an electronic system developed and maintained by the Florida Department of Health for health care practitioners and other partners to share and receive information related to disease outbreaks. EpiCom consists of two components: EpiCom Exchange for communicating messages related to potential or confirmed disease outbreaks, and EpiCom Alert which is employed once a threat is identified to issue an emergency notification to selected EpiCom users. Registered users post messages, which are approved by a moderator and categorized by topic. Users are notified of postings when they log on to EpiCom or via passive notification to their primary email address. Only a suspicion is necessary to post a message to EpiCom: Lab results and a case definition are not required. Users are encouraged to post messages at the first sign of an outbreak or interesting disease occurrence. EpiCom is equipped with state-of-the-art alert capabilities. If an immediate threat to public safety is identified, EpiCom administrators can issue alerts to some or all EpiCom users via landline, email, fax, pager, or cellular telephone. Anyone with an interest in disease outbreaks that could impact the public’s health and safety (e.g. doctors, nurses, infection control practitioners, veterinarians, medial examiners, public health workers, school nurse, etc.) can register to be an EpiCom user at https://www.epicomfl.net. For additional information on EpiCom, contact an EpiCom Administrator at EpiCom_Admin@doh.state.fl.us. 

Emergency Room Census (ERC) Early warning program maintained by the Bureau of Epidemiology to statistically analyze emergency department admissions data.  Registered users submit daily emergency department census data via the EpiCom system and receive reports based on the data. Statistical algorithms calculate several different threshold limits based on the ranges of average daily visitations. The system graphs the daily registrations comparing each daily count to the predicted upper threshold of emergency department activity. Daily emergency department counts above the upper threshold signal a potential abnormal community event. Aberrations show as one of three “flags,” each indicating a different level of change, which may be an early indication of a bioterrorism event or other public health emergency. Any hospital with an emergency department can register to be an ERC User (ability to input and access data). County health department staff can register to be ERC Monitors (access to data only). For additional information on ERC, contact Karen Wheeler at Karen_Wheeler@doh.state.fl.us. 

The Syndromic Tracking and Reporting System (STARS) is a Web-based database application operated by the Hillsborough County Health Department (HCHD) to conduct syndromic surveillance. The system was developed in 2003 to replace a previously contracted database service in use in Hillsborough since November 2001. Data collected from participating hospitals is analyzed on a regular basis using the CDC’s Early Aberration Reporting System (EARS) both by the Hillsborough County Emergency Dispatch Office and HCHD. Follow-up is completed with hospital infection control practitioners on identified spikes in syndromic activity meeting criteria of an established decision matrix. HCHD offers use of STARS free of charge to other interested Florida CHDs, and is currently utilized by both Pinellas and Collier counties. For additional information on STARS, contact Eliot Gregos at eliot_gregos@doh.state.fl.us.

If you have questions pertaining to any of the material from last week or this week's portion of the article, contact Bioterrorism Surveillance Epidemiologist Karen Wheeler at 850.245.4444, ext. 2401 or via email at karen_wheeler@doh.state.fl.us
 

Fall Training Opportunities in Medical and Homeland Security 

The Institute of Homeland Security continuously offers courses in preparedness, detection, disaster response, and a plethora of related issues. This fall, events targeting first responders and laboratory workers are scheduled for October and November. These events may provide valuable guidance to anyone interested in boosting his or her skills and knowledge in these areas:

Rural Homeland Security Technology Expo (21–22 October, Johnstown, PA) The event will demonstrate emerging technologies designed to improve rural America’s ability to prepare for and manage mass casualties resulting from a terrorist attack or weapons of mass destruction. The expo will provide emergency management officials working in public, private, and nonprofit entities a forum to discuss issues which will facilitate better communications and cooperation during emergencies. In addition, demonstrations will highlight technologies that may aid the participants in performing their professional duties.
http://www.cermusa.francis.edu/expo/

Contingency Planning & Management 2004 East (8–10 November, Washington, DC) The conference is facilitated by industry experts and includes sessions such as Public and Private Rules of Engagement, National Security--Fact or Fiction, a Disaster Simulation Exercise and more dynamic, interactive workshops. Additionally, industry experts will lead panel discussions, case studies, and lectures.
http://www.contingencyplanningexpo.com/EAST/overview.asp

Crossing Boundaries: Medical Biodefense and Civilian Medicine ( 21–23 November, Arlington, VA) This conference will explore novel approaches to fighting the diseases caused by biological weapons that could be released by terrorists. Research in the areas of host-pathogen interaction resulting from biological agents, of novel targets for therapeutic intervention, and of possible prophylactic efforts are among the topics to be discussed. Conference organizers will also showcase new candidate drug developments and combination treatments intended to increase the survival rate of infected people at different stages of these infections. Potential areas of promise include new antibacterial and antiviral substances, specific and nonspecific immunomodulators, and toxin blockers and inhibitors that could provide treatment for emerging diseases and infectious and non-infectious diseases, including cancer.
http://www.gmu.edu/centers/biodefense/about_events.html

Ed Note: The Florida Department of Health does not endorse products outside of the department, so always use your own best judgement in assessing which products are best suited for your needs.
 

West Nile virus (WNV) infections in blood donors may be identified in at least two ways: 

1)       A patient with WNV illness (“case”) may inform public health authorities that he or she donated blood in the 30 days prior to the onset of illness. Such cases should be reported to the blood bank. 

2)   A blood donor may be identified as a presumptively viremic donor (PVD) by nucleic acid-amplification test (NAT) screening of his or her donation by a blood collection agency.   

A PVD is a person associated with a blood donation that meets at least one of the following criteria:

a) One reactive NAT with a signal-to-cutoff (S/CO) ≥ 17
b) Two reactive NATs 

PVDs may or may not subsequently develop WNV illness.   

Consider the following examples.  

·         Blood Donor A: A patient diagnosed with WNV illness is interviewed by the County Health Department and responds positively to question #12, which asks if he or she donated blood in the 30 days prior to the onset of illness. This case (self-reported; symptomatic) must be reported to the patient’s specified blood bank and to the DOH (contact information below). 

·         Blood Donor B: A PVD is identified by blood donor screening but, upon follow-up, never develops WNV illness. The asymptomatic infection should be reported by blood collection agency to the DOH.   

·         Blood Donor C: A PVD is identified by blood donor screening and later develops WNV illness. This symptomatic case must be reported by the blood collection agency to the DOH.

Clinical Syndrome and Case Status: All PVDs should be reported to the state health office regardless of symptoms or not. Only enter “Cases” that have WNV related symptoms into Merlin. If WNV illness develops after the PVD is first reported, please contact the state health office and make the necessary documentation in Merlin. The DOH will be responsible for reporting PVDs to the CDC. 

For more information about screening blood components for WNV, go to www.cdc.gov/mmwr/preview/mmwrhtml/mm5232a3.htm, or contact Samantha Rivers, arbovirus surveillance coordinator at the Bureau of Community Environmental Health at
850.245.4444, ext. 2437 or email her at samantha_rivers@doh.state.fl.us.
 

Methodology
A food service inspection was conducted on August 10, 2004, by the Department of Business and Professional Regulation (DBPR) at the food service establishment in Bradenton (Note: Manatee Environmental Health was, at the time, assisting with Hurricane Charley recovery). Along with the routine inspection, a specific food hazard analysis was performed based on surveillance information provided by the Manatee County Health Department. Numerous food safety issues were identified including hot and cold food storage temperature problems, the walk-in cooler which was not maintaining proper temperature, dirty equipment in the kitchen area, and no sanitizer used with wiping cloths. Due to a major temperature problem with the BBQ pork, a “stop sale notice” was issued on this product. In addition, a warning was issued by DBPR due to the number of food safety violations identified. Food samples from the restaurant and from one attendee were collected and shipped to the Bureau of Laboratories, Tampa Branch for analysis.

Patient medical and food history questionnaires were developed and administered to the ill and non-ill attendees from the luncheon held on August 9, with the assistance of the school board. One ill attendee of the luncheon submitted stool specimens to the health department.

Results
A total of 21 (87.5%) people who attended the luncheon responded to the surveillance questions. Of these, 18 (85.7%) became ill following the suspected meal. The mean onset of the symptoms was 9.3 hours with a range of 3 – 15 hours. Predominant symptomatology included diarrhea (100%), abdominal pains (83%) and nausea (66%,  see Table 1).

Table 1 – Frequency of Symptoms
Luncheon Meal on August 9, 2004, Manatee County 

N=18

The reported duration of illness for acute symptoms ranged from 6 to 48 hours, with the average being 26 hours. None of the identified cases sought physician care.   

The case-control study showed that the BBQ pork had the highest food specific attack rate (85.7%) of the food served at the luncheon. No other items served had a high rate. Additional analysis with “Epi Info” software was done however; no significant food item was identified. The various soft drinks and desserts served were consumed evenly among ill and well attendees. Laboratory results on the BBQ pork from both the restaurant and one attendee tested presumptively positive for Clostridium perfringens. In addition, the stool specimen submitted from an ill attendee also tested positive for Clostridium perfringens. 

Analysis and Conclusions
This outbreak of gastroenteritis was confirmed to be associated with attendance at a local school board luncheon held on August 9, 2004. The group of attendees interviewed had no other common public gatherings identified or common food items consumed. The ill persons were also chronologically clustered, indicating a common source exposure. The pork that was implicated in this investigation tested positive for Clostridium perfringens, from food samples collected at the restaurant and from leftover foods taken home. In addition, both BBQ pork food samples had very high bacterial standard plate counts (140,000/gm & >300,000/gm). Documented temperature abuse of various food items at the restaurant (including the pork) and other sanitation problems further link the food vehicle to this foodborne outbreak. Results from the administered case-control study identified symptoms, onset times and durations of illness comparable with Clostridium perfringens. A positive stool specimen form one ill attendee also helped to confirm these findings. 

Clostridium perfringens is an anaerobic, spore-forming rod which is widely distributed in the environment and frequently occurs in the intestines of humans and many domestic and feral animals. Spores of the organism persist in soil, sediments, and areas subject to human or animal fecal pollution. The common form of perfringens poisoning is characterized by intense abdominal cramps and diarrhea which begin 8-22 hours after consumption of foods containing large numbers of those C. perfringens bacteria capable of producing the food poisoning toxin. The illness is usually over within 24 hours but less severe symptoms may persist in some individuals for 1 or 2 weeks. A few deaths have been reported as a result of dehydration and other complications. In most instances, the actual cause of poisoning by C. perfringens is temperature abuse of prepared foods. Small numbers of the organisms are often present after cooking and multiply to food poisoning levels during cooling and storage of prepared foods. Meats, meat products, and gravy are the foods most frequently implicated.
 

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 organisms. 

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 survey of 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 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

• Volusia County reports a case of Legionellosis
• Highlands County reports a Hepatitis A outbreak
• Continue to watch EpiCom for postings on the latest hurricane response news

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 Leon, Madison and Wakulla counties. There was one seroconversion to EEE virus in a sentinel chicken from Walton County. So far this year, 32 counties have reported EEE activity. 

St. Louis Encephalitis (SLE) virus activity: None this week. 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
Late August	Hillsborough		1			Recovering
July	Sarasota		1*			Recovering
Late August and Early September	Duval		3			Recovering
Sentinel Chickens : (date of first positive bleed)	County	SLE	WN	EEE	HJ	Seroconversion Rate
9/7	Bay		1			7.69%
2(8/23), 2(8/24)	Dade		4			14.81%
9/7	Osceola		1			2.50%
9/7	Pinellas		3			5.66%
8/11	Walton			1		2.22%
Dead Birds : (dead date)	County	SLE	WN	EEE		Species
9/9	Dade		1			Blue jay
Horses : (onset date)	County	WN	EEE			Outcome
8/1	Broward	1				Alive
8/19	Wakulla		1			Dead
8/28	Madison		1			Alive
9/4	Leon		1			Dead
Wild and Captive Birds : (collection date)	None
Mosquito Pools : (collection date)	County	SLE	WN	EEE		Species
8/18	Palm Beach		1			Cx. nigripalpus

* Patient had travel history during incubation period

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

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