Zuber Mulla, MSPH, PhD, Assistant Professor of Epidemiology, University of Texas School of Public Health, formerly DOH Regional Epidemiologist,  Stephen Wiersma, MD, and Paul Leaverton, MD 

Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology

Sa'ad Zaheer, MD, MSPH, FRIPH, Duval County Health Department, Christine Cook, RN, BSN, MSH, Sandi Courson, Robyn Kay, MPH, EIS Fellow, Terry O'Reilly

Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology

Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology

April Crowley, Senior Health Educator, Bureau of HIV/AIDS

Angela Fix, MPH, Respiratory Disease Surveillance Epidemiologist,
Melissa Covey, Influenza Surveillance Coordinator

Pete Garner, Surveillance Systems Manager, Bureau of Epidemiology

Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology

Kathryn Teates, MPH, Surveillance & Reporting Section Administrator

Caroline Collins, Arbovirus Surveillance Coordinator and Carina Blackmore, DVM, Ph.D., Acting State Public Health Veterinarian, Bureau of Community Environmental Health

►Florida Group A. Streptoccocus Risk Factors Study Publishes Findings

A healthy 17-year-old boy is tackled during a high school football game. The team physician diagnoses a “bruise” on his thigh and he only misses two plays before returning to the game.  As the days go by the 17-year-old experiences more pain and swelling at the site of the injury. He develops a fever and begins to vomit. A few weeks later he dies in a hospital and group A Streptococcus is isolated from his muscle, a knee aspirate, and his blood. Fact or fiction? This unfortunate event happened several years ago in South Carolina¹. This case did not have any chronic illnesses but eventually succumbed to invasive group A streptococcal infection (IGASI). 

IGASI is a condition of major public health importance in the United States. Annually, over 9900 cases of IGASI are detected nationwide². This incidence is three times that of E. coli O157:H7 infections and four times the annual incidence of meningococcal disease². The popular press has dubbed the etiologic organism, Streptococcus pyogenes, the “flesh-eating” bacterium. The case-fatality rate of IGASI may be as high as 45%³. Group A streptococci are spread person to person by contact with infectious secretions⁴. 

According to the Centers for Disease Control and Prevention, there are several identified risk factors for IGASI including advanced age, a state of immunosuppression, chronic heart or lung disease, and diabetes⁴. Breaks in the skin, which may occur due to several reasons such as chicken pox or intravenous drug use, increase the risk of developing IGASI. The incidence of IGASI is higher among African-Americans and Native Americans than in whites. 

IGASI became a reportable condition in Florida in the summer of 1996^5. The crude incidence of IGASI steadily increased from 0.34 cases per 100,000 in 1997 to 0.97 cases per 100,000 in 2000⁶. This increase may be largely due to improved reporting by physicians and laboratories.
 
The Bureau of Epidemiology along with the University of South Florida College of Public Health recently conducted an epidemiologic study of patients hospitalized for IGASI. The results of this study were published in the October 2003 issue of the peer-reviewed Southern Medical Journal ⁷. The cases that were included in this retrospective cohort study were 257 patients who were hospitalized for IGASI throughout Florida between August of 1996 and August of 2000. Approximately 10% of these patients (25/257) were under the age of 18 years. This study examined risk factors for hospital mortality. One of the main objectives was to elucidate the optimum antibiotic treatment regimen for IGASI.   

The overall hospital mortality rate was 18% (41/228). This study found that after adjusting for several confounders including the use of beta-lactams, treatment with clindamycin reduced the odds of hospital mortality by 89% among patients with group A streptococcal necrotizing fasciitis; this result was statistically significant (Odds ratio=0.11, 95% confidence interval: 0.01 – 0.89).  Hospital mortality increased with age. Black patients appeared to have less severe disease than white patients ^6,7.

For more information on this study, please contact Zuber Mulla at (915) 747-8505, or zmulla@sph.uth.tmc.edu.

Acknowledgments

The authors acknowledge the data collection efforts of epidemiology and surveillance staff at all of the Florida county health departments. Special thanks are due to Don Ward, Bill Bigler, and Richard Hopkins for facilitating the execution of this study. Furthermore, we are grateful to the Orange County Health Department’s Office of Epidemiology for their clinical advice during the conduct of the study.

References

1. Hird B, Byrne K.  Gangrenous streptococcal myositis: case report. Journal of Trauma 1994; 36: 589-591.
2. Centers for Disease Control and Prevention. Summary of notifiable diseases – United States, 2001. Morbidity and Mortality Weekly Report. 2003;50:xxi, 2-3.
3. Passaro DJ, Smith DS, Hett EC, et al. Invasive group A streptococcal infections in the San Francisco Bay area, 1989-99. Epidemiology and Infection 2002; 129:471-478.
4. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/groupastreptococcal_g.htm
5. Florida Bureau of Epidemiology. Streptococcal disease, invasive group A, in Florida Morbidity Statistics 1996, Tallahassee, Florida, Florida Department of Health, Bureau of Epidemiology, p. 83.
6. Mulla ZD. Invasive group A streptococcal disease and intensive care unit admissions.  Intensive Care Medicine 2002; 28: 1822-1824.
7. Mulla ZD, Leaverton PE, Wiersma ST. Invasive group A streptococcal infections in Florida. Southern Medical Journal 2003; 96: 968-973.

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►Childhood Diseases Up in the U.K. During Past 18 Months

Statistics released last week by the National Health Service of Scotland have listed suspected or confirmed cases of mumps as having risen over the last 18 months by 27%, measles by 18% and rubella by 22% in children aged 15 and under. Chickenpox among children under 15 rose by a third.

The authors of an article published in the August 8, 2003 issue of Science Magazine entitled, "Measles Outbreaks in a Population with Declining Vaccine Uptake", have reported that the reproductive number of measles in the U.K., is increasing. The productive number is the average number of new infections that an infected person causes. According to the article, the reproductive number rose from a value of 0.47 for the years 1995-98 to a value of 0.82 for the years 1999-02. They drew this conclusion after comparing the distribution of outbreak sizes before 1999 to the distribution for the years 1999-02. Dr. Vincent Jansen, one of the authors and a researcher from the Wellcome Trust at the University of London, stated that "we reported a correlation between the drop in vaccinations and the increasing size of measles outbreaks."  They conclude that the reproductive number had increased and they quantified this increase, although they drew no conclusions from their data.

The MMR (measles, mumps and rubella) three-in-one jab is being blamed by health officials in the U.K. for keeping parents from seeking immunization, due to fears of adverse effects from the vaccine. Although government officials have insisted there is no proven link between the triple jab vaccine and autism, the public appears to believe otherwise due to several cases of autism that developed in children who received the vaccine. As a consequence, so many parents sought access to the single jab measles vaccine, supplies ran out even as health officials in London were confirming a new outbreak of measles in north London. 

Dr. Mac Armstrong, Scotland's Chief Medical Officer, is concerned that a fall in immunization levels "leaves unimmunized children and the population as a whole at risk." Seeking to reassure apprehensive parents, he also said that "research has shown that the MMR jab is the safest means of ensuring that young children are protected against all three diseases."

When the reproductive number increases beyond just one case, measles doesn't disappear; small outbreaks occur and people carry the disease into other countries as they travel.  Director of CDC's National Immunization Program Dr. Walter Orenstein said that "a resurgence of measles in the United Kingdom could translate to exposure here."  Because vaccination rates in this country have also dropped, an outbreak of measles could be sustained if a case occurred in a community where the vaccination rate happened to be low. The highly contagious nature of the disease has a death rate of 1-2 children for every 1,000 patients infected. Complications include seizures, swelling of the brain and pneumonia.

For further information concerning the National Health Service report, log on to BBC News at http://www.newsvote.bbc.co.uk/. To find out more about the article in Science Magazine, log on to its Web site at http://www.scienceonline.org/.

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►White Powder Investigation at Duval County Postal Facility Yields  Training Opportunity

Key Agencies:  Duval County Health Department (DCHD), Jacksonville Sheriff’s Office, Jacksonville Fire and Rescue Department, Florida Bureau of Laboratories, and the Federal Bureau of Investigations (FBI), Florida Epidemiologic Surveillance Program 

Background: Last month, the manager of a local postal facility activated EMS following discovery by postal workers of a white powder substance in a mail tray. In addition, the substance was found on an envelope addressed to the FBI. DCHD Epidemiology staff was activated and accompanied the DCHD director and Public Information Officer on-site. 

Investigation: Upon arrival, DCHD Epidemiology staff met with key agencies and were notified of least five postal workers who were exposed to the substance. Exposed individuals and the contaminated postal area were decontaminated. Epidemiology staff obtained contact information for all postal employees. Information regarding the originating source of the contaminated mail was requested from the postal inspectors, as well as a site map of the facility. In addition, the source area, a manual operation, was closed pending further investigation. In addition, FBI, Health Department and Postal Inspectors interviewed exposed individuals. Designated Health Department staff conducted briefings for postal employees and media to provide updates on the status of the investigation and appropriate health information.   

Samples of the white powder were collected and transported to the state lab. FBI requested sample testing for chemical and biological agents. FBI and Health Department recommended that the postal facility remain closed until preliminary results were available, at which time the decision to open the facility would be re-evaluated. Preliminary negative laboratory findings and lack of evidence of criminal intent resulted in the decision to re-open the facility the following day. 

Discussion: The incident served as a unique training opportunity for all agencies involved.  Positive outcomes included excellent communication, collaboration and cooperative practice for health and law enforcement. Future planning considerations include the need to isolate potentially exposed individuals immediately, obtaining contact information for prior exposed individuals who had left the scene, and tighter security of the “hot zone”.

A special thanks to Erica Boree, FBI, the Jacksonville Sherriff's Office, the Jacksonville Fire and Rescue, and the Office of Emergency Preparedness.

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►Bi-Weekly Conference Call Focuses on Funding, SARS Issues

Excerpted from the bi-weekly conference call conducted on October 31, 2003 are highlights of information exchanged between Bureau of Epidemiology staff and county health department participants. The next conference call will be held Friday, November 14th at 11:00 a.m. EST. To be included on the agenda, contact Melanie Black at melanie_black@doh.state.fl.us or Don Ward at donald_ward@doh.state.fl.us.

Bioterrorism Funding Issues. Don Ward emphasized that the bioterrorism grant does not allow  funding for OPS positions.  In Focus Area B, position descriptions will be needed, as well as certification from each health department showing that the person filling the position is engaged in bioterrorism-prevention activities 100% of the time. No surveillance projects will be funded except the Hillsborough County project, unless a project is initiated by the Bureau of Epidemiology. Likely projects would entail activities related to military bases.

Training Update. Melanie Black reported the two-day regional training course in Epidemiology 101 in Volusia County was very successful, and the next training opportunity will be held in the South Central Florida region. Grand Rounds presented by the Bureau are scheduled for Tuesday, November 25th.

SARS Update. Karen Eaton, director of the Office of Public Health, Nursing and leader of the SARS Incident Command Team said that the team this year is striving for more efficiency and to become more streamlined in its communications. This year, SARS tests will be available for persons meeting the clinical criteria, and our surveillance program will be working with the Bureau of Laboratories to rule out other diseases. We must also note that no community-associated SARS cases have been reported since July 2003. She reminded those with stocks of SARS tool kits to be sure to insert local county health department information in the kit.

Vibrio Illness Report Form. Dean Bodager advised Merlin users to refer to CDC Form 52.79 before reporting a vibrio illness on Merlin. Regional epidemiologists are also available for consultation.  Because state-level authorities and the federal government must have the report promptly, it's important to gather the information as quickly as possible.  To save time, the investigation may begin even before the test results are received.

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►FDA Announces New Restrictions on Importation of Animals into U.S.

In a move directly related to the outbreak of monkeypox earlier this year which resulted in 37 confirmed, 12 probable and 22 suspected cases of monkeypox in the United States, the FDA announced this week an interim rule designed to bolster existing regulations on the import, sale, exchange, capture and transport of certain animals within the country, including prairie dogs.

The CDC will work in conjunction with the FDA on the new rule, acting as the agent for restriction of the importation of the animals while the FDA will restrict interstate and intrastate movement of the animals. Special exemptions will be accommodated, although the nature of the exemptions were not noted in the official press release delivered to government agencies by the FDA Division of Federal-State Relations.

Questions and comments concerning the interim ruling can be directed to the Dockets Management Branch of the FDA in Rockville Maryland, at www.fda.gov/dockets/ecomments.

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►Hepatitis 101 Introductory Course to be Offered in December

The Florida Hepatitis and Liver Failure Prevention and Control Program will present a one-hour introductory training course titled "Hepatitis 101: For Counselors and Outreach Workers,” which will be offered three times in 2003: December 3, 2003, and December 10, 2003, from 2:00 – 3:00 p.m. The course will be presented by teleconference with a slideset available on the Web, and will provide an introduction to hepatitis A, hepatitis B, and hepatitis C. Continuing Education Credits will be available for laboratorians and nurses.   

To register for this course, please visit our web site at www.myflorida.com (Or,http://www.doh.state.fl.us/disease_ctrl/aids/hep/index.html) and indicate the date on which you would prefer to participate. Please register early, as each session will be limited to the first 50 registrants. We recommend that you allow 15 minutes during registration to take the mandatory pretest. 

Prior to the course date, a dial-in phone number will be emailed to all registrants. 

Learning Objectives: 

After participating in the introductory Hepatitis 101 Class, participants will have a basic understanding of the following: 

1. Hepatitis A, hepatitis B, and hepatitis C: clinical features, methods of transmission, and prevention messages. 

2. Patients/clients who should be referred for hepatitis vaccination and testing. 

3. How to use hepatitis information to counsel patients/clients about hepatitis A, hepatitis B, and hepatitis C. 

4. Test results for hepatitis A, hepatitis B, and hepatitis C. 

5. How HIV/AIDS affects the progression of hepatitis C.

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►Fall Influenza Report 2003

For Week 43, ending October 18, 2003

Summary. So far this season, Florida is experiencing low activity of influenza-like illness (ILI).  Indian River and Orange Counties had the highest percent ILI reported for Week 43. This data should be interpreted with caution since it cannot be compared to the national baseline and reporting practices have a large impact on the percentages. 

There were two positive specimens submitted to the state laboratories, both during Week 42.  These specimens were from Okaloosa County and were found positive for Influenza A (H3N2).  There have been a few other states in the US where influenza A (H3N2) has been isolated but overall the West South Central region of the United States continued to be the only region in the country that experienced a percent ILI above the national baseline. These regions include Texas, Oklahoma, Arkansas and Louisiana.

With the continued low activity of ILI, this is the time to think about getting a flu shot. October and November are the best months to get your flu shot if you are in a high-risk group. You should avoid getting a flu shot too early, because protection from flu can begin to decline within a few months after getting the shot. For more information about flu vaccine, please contact your primary care physician or your local county health department.

Florida Influenza-Like Illness (ILI). As of November 3, sixty-one sentinels from 54 public clinics and private offices submitted reports for the week ending October 18, 2003. Counties with the highest percentage of patients with ILI were Indian River County (4.54%, 6 of 8 sentinels reporting) and Orange County (4.32%, 5 of 8 sentinels reporting). Twelve counties reported a low percentage of patients with ILI, and 11 counties reported no cases of ILI. A breakdown of ILI% reported for Week 43 by county is listed in Table 1. 

Florida Specimen Testing for Week 43. Since September 28, 2003, only two specimens from Okaloosa County were found positive for Influenza A (H3N2). No new positive specimens have been reported from the state laboratories.

Florida Rapid Testing Performed by Private Laboratories. No new cases of influenza were reported during Week 43. Two cases of influenza were reported during late August in Sarasota County. An unsubtyped influenza A virus was found in Broward County during the Week 40.
.   

National Influenza Surveillance. This section summarizes the weekly influenza report from the Centers for Disease Control and Prevention.

Week 43:

Influenza-Like Illness Report. The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) was 1.8% nationwide.  This is less than the national baseline of 2.5%. On a regional level, the percentage of visits for ILI ranged from 0.7% to 6.6%. Due to wide variability in regional level data, it is not appropriate to apply the national baseline to regional level data. National percentage and regional percentages of patient visits for ILI are weighted on the basis of state population.

U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) Laboratories Report. Forty-eight (6.8%) of the 707 specimens tested for influenza viruses were positive during week 43. Thirty-two influenza A (H3N2) viruses, 15 unsubtyped influenza A viruses and 1 influenza B virus were identified. 

Since September 28, 2003, 121 (3.9%) of the 3,115 specimens tested for influenza viruses were positive.  Most (98%) of the viruses were influenza A. Forty-seven of these influenza A viruses have been subtyped and found positive for influenza A (H3N2) viruses.  Two of the 121 specimens were influenza B. Influenza A viruses have been identified in Arkansas, Colorado, Florida, Louisiana, New York, Okalahoma, Texas, and Washington. Influenza B virus have been identified in Hawaii and North Dakota. The majority of the isolates (91%) were reported from the West South Central region. 

State and Territorial Epidemiologists Report. Texas reported widespread influenza activity, and Alabama and Louisiana reported local influenza activity. Arkansas, Colorado, Florida, Hawaii, Massachusetts, New Hampshire, Vermont, and Rhode Island reported sporadic influenza activity.

2003-2004 National Summary By Region

*  Weekly ratios rather than proportions are presented in reporting ILI because specimens reported positive for influenza virus each week may include specimens submitted for testing during an earlier week.

 122 US Cities Vital Statistics Mortality Report. The percentage of all deaths due to pneumonia and influenza was 6.31. This percentage is below the epidemic threshold of 6.8% for week 43.

National Laboratory Surveillance. Laboratories other than those participating as U.S. WHO or NREVSS collaborating laboratories may submit influenza isolates to CDC for further testing. 

August: Influenza A(H3N2) viruses were reported from Alaska, Connecticut, the District of Columbia, Hawaii, New Hampshire, New York, and Wisconsin. An unsubtyped influenza A virus was reported from Louisiana. 

September: Influenza A(H3N2) viruses were identified in Alaska, Connecticut, Hawaii, and Texas, and unsubtyped influenza A viruses were identified in Louisiana, Texas, and Washington. 

October: Influenza A(H3N2) viruses collected in Texas have been submitted to CDC for further testing.

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►This Week on EpiCom

Undetermined meningitis has been diagnosed for three high school boys in Polk County affiliated with a football team.

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

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►People You Should Know

The autumn winds bring change, and two of those changes were new staff members to fill existing positions within the Bureau of Epidemiology in Tallahassee. We're delighted they've joined us.

Angela Fix, MPH, is a respiratory epidemiologist in the Surveillance and Reporting Section. She has a masters degree in public health and is newly arrived in Tallahassee from San Diego. Angela will have primary responsibility for developing a respiratory disease surveillance and response program for the state. Reach Angela at angela_fix@doh.state.fl.us.

Tara Hylton is a cancer epidemiologist in the Chronic Disease Surveillance and Epidemiology Section, working under the direction of Dr. Youjie Huang. Tara received her MPH from Emory University. She comes to us from Emory University's Rollins School of Public Health, where she was engaged in the Go Girls Program, teaching minority teens the importance of nutrition and physical activity to prevent chronic disease. Tara's work will focus on the Cancer Registry and on cancer clusters. You can reach her at tara_hylton@doh.state.fl.us.

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►New Sentinel Provider Update

Beginning November 1, new sentinel physician packets will be mailed from CDC only on Wednesdays; therefore, if you have new providers or need replacement packets, please get them to the Influenza Surveillance Coordinator by close of business on Mondays. New sentinel physician names received after this time will not be mailed packets until the following week. For additional information about recruiting sentinel physicians for Florida Influenza Surveillance, please call Melissa Covey at 904-791-1789.

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►Mosquito-Borne Disease Update

Six WN virus cases were reported this week in Florida residents from Alachua, Escambia (3), Gulf and Seminole counties, bringing the number of cases reported this year in Florida to 73. The following 29 counties are under medical alert (new ones bolded): Alachua, Bay, Brevard, Broward, Calhoun, Citrus, Collier, DeSoto, Duval, Escambia, Gilchrist, Gulf, Holmes, Jackson, Lafayette, Lee, Marion, Miami-Dade, Monroe, Nassau, Okaloosa, Orange, Palm Beach, Santa Rosa, Seminole, St. Johns, Union, Walton and Washington. Indian River County is under medical advisory. Malaria has been reported in eight Palm Beach County residents, with no new cases since mid-September. The total number of EEE cases remains at two. Last year by this date, there were 17 cases of WN, one case of EEE, and one case of St. Louis Encephalitis (SLE) infection. 

EEE virus activity in animals: There were no reports of EEE virus infection this week. To date, 52 of Florida’s 67 counties have reported EEE virus activity, compared to 24 counties reporting EEE last year at this time.  

WN virus activity in animals: Three WN virus infected horses were reported this week in Leon, Marion and Walton counties. In addition, 52 seroconversions to WN virus were confirmed in sentinel chickens from 24 of the 31 counties that collected samples. Two dead birds were reported positive for WN virus from Alachua and Escambia counties. Sixty counties have reported WN virus activity, compared to 53 at this time last year.   

See the Web page for maps and more information: http://www.doh.state.fl.us/Environment/hsee/arbo/index.htm

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

Click on the link below to access the latest data on Week 43 disease figures, provided by the Florida Department of Health, Bureau of Epidemiology.

Current week's disease table

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