Friday, September 24, 2004
This Week in the News
"The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow."
Drowning Study Provides Clues to Panhandle Incidents
►Bioterrorism Surveillance Systems
Last week in this two-part article, we described national systems. This week, we look at some systems available within the state of Florida.
Training Opportunities in Medical and Homeland Security
Nile Infection in Blood Donors: Arbovirus Reporting Guidelines Explained|
In another how-to article, the law requiring the reporting of encephalitis and meningitis cases to county health departments is explained and guidelines provided.
|Epi Update Managing Staff:||
perfringens Foodborne Outbreak at a Local School Board Luncheon -
Manatee County, August 9, 2004|
With 22 of the 24 attendees reportedly ill from the meal, a serious investigation was underway within hours.
MD, MBA, MPH,
Secretary, Department of Health
Grand Rounds on Clostridium difficile Associated Disease
in Hospitalized Patients|
Presented by Roger Sanderson, RN, MA, this live presentation offering CEUs will air on Tuesday, September 28 at 11:00 a.m. EDT.
Division of Disease
Week on EpiCom|
Log on regularly to access information that could be vital to your organization if you're in the middle of an investigation. Another entity may be experiencing an outbreak that could be linked to yours.
Acting Bureau Chief,
A report outlining confirmed cases and other activities for the week September 12 - 18, 2004.
Editor's Note: In the September 3, 2004 edition of Epi Update,
the article entitled "Vibrio vulnificus Infections on the Rise in
Florida" contained the following statement: "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." |
That statement was incorrect. Instead, the CHD should contact its local regional environmental epidemiologist.
A R T I C L E S
|Alan Rowan, DrPH, MPA; David Atrubin, MPH; Lisa VanderWerf-Hourigan, MS, Florida Department of Health||
Beach Drowning Study Provides Clues to Panhandle Incidents
The mission of the Florida Department of Health is to promote and protect the health and safety of all people in Florida. During the summer of 2003, the DOH became concerned when nine people drowned over a two-day period and a total of 12 drowned during a two-month period in the Gulf of Mexico along Florida’s Panhandle. The department believed there was a need to determine what factors may have been involved in these tragic events.
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.
Karen Wheeler, MPH,
Bioterrorism Surveillance Epidemiologist, Bureau of Epidemiology
Surveillance Systems Part II
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.
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 email@example.com.
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
Jaime Forth, Editor, Epi
Update, Bureau of Epidemiology
Opportunities in Medical and Homeland Security
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
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.
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.
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.
Samantha D. Rivers, MS,
Arbovirus Surveillance Coordinator, Bureau of Community Environmental
Infection in Blood Donors: Arbovirus Reporting Guidelines Explained
Human surveillance for arboviral encephalitis is extremely important for prevention and control of mosquito-borne viruses in Florida. Health care providers and laboratories in the state are required by law to report all suspect and confirmed cases of encephalitis and meningitis to their county health departments (Florida Statute 381). Another source of West Nile virus surveillance information is local blood banks. West Nile virus testing is performed on all blood products collected in the United States during arbovirus season. In 2003, more than 800 West Nile virus positive blood donors were reported to the Centers for Disease Control and Prevention (CDC). The Arbovirus Surveillance Program encourages local health departments to stay in contact with local blood collection agencies to facilitate blood donor reporting in Florida.
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:
reactive NAT with a signal-to-cutoff (S/CO) ≥ 17
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.
information about screening blood components for WNV, go to
contact Samantha Rivers, arbovirus surveillance coordinator at the Bureau
of Community Environmental Health at
|Mike Friedman, MPH, Regional Environmental Epidemiologist, Bureau of Community Environmental Health||
perfringens Foodborne Outbreak at a Local School Board Luncheon -
Manatee County, August 9, 2004
Joseph T. Busciglio, RS, Environmental Specialist II, Manatee County Health Department
Michael Friedman, MPH, Regional Environmental Epidemiologist, Bureau of Community Environmental Health
David Wingfield, Biological Scientist III, Bureau of Laboratories, Tampa
Introduction & Background
On August 10, 2004, the Manatee County Health Department was contacted by the local school board about members who attended a luncheon on August 9, 2004 who had become ill with gastrointestinal symptoms. Early information indicated that 22 of the 24 attendees had become ill approximately six hours after eating. Symptoms reported included diarrhea, nausea and abdominal pains. The food served at the luncheon had been purchased from a local BBQ restaurant. BBQ pork, cole slaw, baked beans, several desserts and soft drinks had been served at the luncheon. Some of the food items from the luncheon were available for laboratory testing.
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.
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.
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.
Roger Sanderson, RN,
MPH, Bureau of Epidemiology Investigation Section
Grand Rounds on Clostridium difficile Associated Disease in
Title: Clostridium difficile Associated Disease (CDAD) What is it and is it increasing in Florida?
Presenter: Roger Sanderson, RN, MA, Regional Epidemiologist, Bureau of Epidemiology, Florida Department of Health
Date: Tuesday, September 28, 2004 11:00 a.m.– 12:00 p.m. EDT
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.
|Pete Garner, Surveillance Systems Manager, Bureau of Epidemiology||
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.
|Arbovirus Surveillance Team: Samantha Rivers, MS, Caroline Collins, Kristen Payne, Calvin DeSouza, and Carina Blackmore, MS Vet. Med., PhD., State Public Health Veterinarian||
West Nile (WN) virus activity: Three Duval County residents, one Hillsborough County resident and one Sarasota County resident with travel history were confirmed with WN illness this week, bringing the state-wide total to 32. There were 9 seroconversions to WN virus in sentinel chickens from Bay, Dade, Osceola and Pinellas counties. There was one confirmed horse from Broward County and one confirmed dead bird from Dade County. A mosquito pool (Cx. nigripalpus) from Palm Beach County tested positive for West Nile virus. So far this year, 33 counties have reported WN activity. Brevard, Broward, Duval, Gadsden, Hillsborough and Miami-Dade counties are under medical alerts for mosquito-borne disease and Pinellas is under medical advisory for mosquito-borne diseases.
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/.
* Patient had travel history during incubation period
See the Web for more information at www.MyFloridaEH.com.