Friday, November 12, 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."
of Epidemiology Welcomes New Chief
Outbreak of Bacillus cereus Gastroenteritis in a Stockade Facility, West
Palm Beach, Florida
A recent incident provides an excellent example of the need for adherence to mandated food preparation guidelines.
Management Behaviors for the Prevention of Diabetes Complications in
Florida: Data from Florida Behavior Risk Factor Surveillance System
DOH Staff Contribute to CDC Publications, Events|
Syndromic surveillance has long been on the minds of public health officials and now, after three national conferences on the topic, the merits of surveillance are being more thoroughly investigated. Two Department of Health staff members have been actively involved in the process.
|Epi Update Managing Staff:||
Ideas - Stretching the Vaccine Supply|
After two successful trials involving flu vaccines injected just beneath the skin's surface,
researchers are optimistic about using the method to extend the nation's supply of vaccines.
MD, MBA, MPH,
Secretary, Department of Health
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.
Division of Disease
►Mosquito-borne Disease Update
A report outlining confirmed cases and other activities for the week October 31 - November 6, 2004.
Dian K. Sharma,
MS, Ph.D., Bureau Chief,
The Florida Department of Health Bureau of Epidemiology Weekly Morbidity Report for the current week. The report contains diseases and conditions for confirmed cases.
|Ed Note: The November 5, 2004 article on a PRAMS report on domestic violence has been revised. A copy of the revised article is furnished at this link for clarification purposes.|
A R T I C L E S
|Jaime Forth, Managing Editor||
Bureau of Epidemiology Welcomes New Chief
The long wait over, Dian Sharma has finally moved into the office down the hall. All the names aren't memorized yet, but the meetings have begun and her familiarity with Tallahassee streets and landmarks is progressing.
Before taking over the reins at the Bureau of Epidemiology Dr. Sharma was senior epidemiologist and manager of Communicable Disease Control at the Tacoma-Pierce County Health Department in Tacoma, Washington. From 1995 until her departure last month, she developed and implemented a communicable disease program that became nationally recognized, transitioned clinical services to the private medical community, integrated STD, TB and HIV services, and coordinated marketing, funding and service for a countrywide family planning coalition. Concurrently, she was an adjunct professor at the Portland State University Department of Urban Affairs and Public Health, instructing in environmental and occupational health and safety.
Dr. Sharma was director of the Department of Health and Human Services in Washington County, Oregon and was Health Commissioner at the St. Louis City Health Division in Missouri before assuming her post in Tacoma.
Educated at York College in Pennsylvania,
Dian Sharma received her bachelor's degree in medical technology before
going on to Wagner University at Staten Island to receive a masters
degree in bacteriology. She earned a PhD in microbiology/immunology from
Rutgers University in 1978. Since then, she has been active in public
health management and human service, and has also been appointed to a
number of advisory boards and
panels from public relations to public health leadership.
M-Teresa Bonafonte, PhD,
MPH, MS, EIS Fellow, Palm Beach County
An Outbreak of
Bacillus cereus Gastroenteritis in a Stockade Facility, West Palm Beach,
The investigation was carried out by the Palm Beach County Department of Health, Division of Epidemiology. A control/case study of 113 inmates who ate lunch on Wednesday, September 15 was carried out to determine the cause and extent of the outbreak. Questionnaires were distributed to randomly selected inmates to collect demographic information, data of onset, duration, and nature of symptoms and the foods eaten on September 13, 14 and 15. The case definition was gastrointestinal disease with at least two of the following symptoms: nausea, vomiting or diarrhea among inmates who ate at the stockade facility between September 13, 14 and 15.
Laboratory and environmental investigation
An inspection by the Division of Environmental Health found out that Sunday, September 12, one pan of leftover beans had been thrown away, but three other pans were mixed with a new batch which contaminated the food served on Wednesday, September 15.
Samples of leftover cold baked beans, turkey bologna and pudding, served on September 1, were taken by the Division of Environmental Health and analyzed at the Bureau of Laboratories in Tampa for the presence of Staphylococcus aureus (S. aureus) and Bacillus cereus (B. cereus). No inmate’s stools, vomitus, or blood specimens were obtained.
thirteen inmates were interviewed (16% of a total of 700), 56 of whom
met the case definition (attack rate 49.6%). Based on the frequency of
symptoms after consuming lunch, a case was defined as the presence of
two or three of the following symptoms within the afternoon/evening of
Wednesday, September 15 after consumption of foods or beverages: 1)
nausea, 2) vomiting, or 3) diarrhea.
The odds of exposure (eating cold baked beans and/or turkey) were greater for the group that was ill than for the group that was well, and the cold baked beans and turkey bologna were likely to be the etiologic agents. Inmates who reported that they ate cold-baked beans were almost 9 times as likely to be ill as those who did not consume them (OR = 8.8, CI = 2.8 – 27.7); those who ate turkey bologna were almost 4 times as likely to be ill as those who did not eat the bologna (OR = 4.22, CI = 1-16). Seventy one percent (71.7%) of inmates had eaten both cold baked beans and turkey. Eating pudding was not statistically significant (OR = 0.55, CI = 0.25 - 1.22).
Symptoms were characterized by a short onset; 52 of the 56 cases (92.9%) whose time of onset was available had become ill within minutes of exposure to the suspected vehicle of infection. The mean time between lunch and onset of symptoms was 1½ h (range 15 min - 4½ h), median 1½ h. The first cases developed symptoms between 1:15 and 1:30 p.m. on September 15.
The mean duration of onset for the 39 cases available was 10 h (range 30 min - 48 h), median 12½ h. Patients made a complete recovery within two days. No hospitalization or fatalities among inmates were reported.
The mean age for cases was 30 years old (range 18-63), median 28.5, and for the controls mean age was 31 years old (range 17-66), median 30.
Fifty (89.3%) of the 56 cases reported nausea, 49 (87.5%) vomiting, 40 (71.4%) diarrhea, and 44 (78.6%) abdominal pain.
Laboratory and environmental
B. cereus was isolated from samples of leftover cold baked beans, turkey bologna and pudding. A leftover sample of cold baked beans grew a B. cereus isolate ³ 2,5 x 105, turkey bologna grew 420/gm and the pudding 70/gm. All cultures were negative for S. aureus.
The shape of the epidemic curve is consistent with a point source outbreak rather than a continuing source of infection.
Seventy, 420 and up to 2,5 x 105 colonies of B. cereus per gram were isolated in several foods. In this outbreak, bacterial multiplication was facilitated at several points in the interval between preparation and consumption of the meal. Inmates complained about food being served frozen or cold, expired milk and bread with mold growth. Other comments were that sugar was added when a food was spoiled, such as the BBQ. beans served on Wednesday, September 15.
The environmental health report suggested that several food-handling risks might have contributed to the outbreak:
1) contaminated raw ingredients (beans), 2) insufficient cooking or reheating of turkey, 3) cross-contamination, and 5) preparation of large amounts of food several hours before consumption combined with its storage at temperatures that favor the growth of pathogenic bacteria.
Previous inspections of the stockade kitchen found violations in food temperatures, food expiration dates (milk), sinks lacking sanitizer, dirty floors, and flies in the kitchen.
Finally, this outbreak could have been prevented if measures had been taken to ensure reliable food sources, adequate heat treatment, and adequate temperature control.
Marie Bailey, MA, MSW,
BFRSS Coordinator; Regan Glover, Bureau of Epidemiology
Management Behaviors for the Prevention of Diabetes Complications in
Florida: Data from the Florida Behavioral Risk Factor Surveillance
Approximately 40% of non-Hispanic Blacks reported having been told by their doctor that diabetes has affected their eyes, compared to 24% of non-Hispanic Whites. Finally, older Hispanics with diabetes were less likely than their White and Black counterparts to report having taken courses or classes on diabetes self-management (34.6% vs. 51.4% and 57%, respectively).
Jaime Forth, Managing
Staff Contribute to CDC Publications, Events
Before the U.S. was attacked by terrorists on September 11, 2001, syndromic surveillance was a term familiar to public health officials at the CDC and in many other parts of the country. Afterward, syndromic surveillance became almost synonymous with biologic terrorism surveillance.
The original objective of syndromic surveillance was to provide early identification of large quantities of biological and chemical agents. As early as 1998, the CDC was planning programs for early warning systems for outbreaks of suspicious events. But the scope of the project stretched beyond biological and chemical awareness, and today certain surveillance programs monitor a variety of data sources such as over-the-counter drug sales, public school attendance and emergency room visitation.
Syndromic surveillance offers many attractive features such as the ability to monitor disease trends and follow the extent and breadth of an occurrence. It can also provide reassurance to a frightened public that an outbreak has not occurred. It cannot, however, make the same kind of intelligence observations made by physicians or public health officials.
At a 2003 conference entitled Lessons Learned and Questions to Be Answered regarding national syndromic surveillance, attendees representing the fields of epidemiology, informatics, health care and statistics discussed various data sources and analytic methods, and evaluated various new syndromic surveillance systems. Richard S. Hopkins, MD, MSPH, now assistant chief of science at the Bureau of Epidemiology in Tallahassee, was then director of the Division of Public Health Surveillance and Informatics at the CDC Epidemiology Program Office, and played a key role in the conference as a member of the Editorial Committee and in authorship of the follow-up publication in 2004 entitled Framework for Evaluating Public Health Surveillance Systems for Early Detection of Outbreaks. http://www.cdc.gov/mmwr/preview/su5301toc.htm
JoEllen DeThomasis, formerly of the Division of Applied Public Health Training and Division of Public Health Surveillance and Informatics, Epidemiology Program Office at the CDC and currently a public health prevention specialist in Environmental Health, was a member of conference planning committee and coordinated editorial, scientific and other tasks needed to bring the MMWR publication to fruition.
Further information on syndromatic surveillance can be found at the CDC MMWR site at http://www.cdc.gov/mmwr/preview/se5301toc.htm.
Other information on
syndromic surveillance is at
|Jaime Forth, Managing Editor||
Ideas - Stretching the Vaccine Supply
In two separate studies on the effectiveness of intradermal shots, the outcomes showed intradermal vaccinations containing smaller dosages provided coverage that was just as good as vaccines administered intramuscularly.
One study was conducted by a Maryland company developing vaccine skin patches. Using healthy young adults randomly assigned, the participants were given either the standard intramuscular dose of trivalent flu vaccine or a single intradermal dose at approximately 20% strength. After 21 days, the increases in hemugglutination-inhibition titers were measured and showed the immune response in the intradermal group was close to or better than the other group. Any reactions to the shot were mild and lasted only briefly.
The second study was conducted by researchers from Saint Louis University, the University of Rochester and GlaxoSmithKline, which divided groups by age and administered either an intradermal shot containing 6 mcg of hemagglutinin for each flu strain, or an intramuscular shot containing 15 mcg for each strain.
In the 18-60 age group the shots did not produce significantly different reactions. The age group comprised of persons over 60 years had a more pronounced response to both vaccinations, with a slightly better response for those receiving the intramuscular shots. There was a significant difference for only the H3N2 strain.
These reports, published in the latest issue of the New England Journal of Medicine, imply that an innovative solution to limited flu supplies may be just what the doctor ordered. Clinical trials involving a wide range of populations would come first, however. In the meantime, FluMist nasal spray is recommended by physicians for healthy adults who have been unable to obtain a flu shot, and Florida Secretary of Health John Agwunobi has encouraged others to seek out anti viral medications requiring a prescription.
Florida has just received 300,000 doses of
the vaccine it ordered this year, but the manufacturer responsible for
producing the shots is unable come up with additional supplies due to
|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
use the link to sign up for features such as automatic
notification for certain events.
|D'Juan Harris, MSP, GIS Specialist, Surveillance Systems Section, Bureau of Epidemiology||
Weekly Disease Table
Click on the highlighted link to review the most recent disease figures provided by the Florida Department of Health Bureau of Epidemiology.
Click here for this week's Disease Table
|Arbovirus Surveillance Team: Samantha Rivers, MS, Caroline Collins, Kristen Payne, Calvin DeSouza, and Carina Blackmore, MS Vet. Med., PhD., State Public Health Veterinarian||
Eastern Equine Encephalomyelitis (EEE) virus activity: Two wild birds captured in Okaloosa and Walton counties were reported to be infected with EEE virus. There were 3 seroconversions to EEE virus in sentinel chickens from Leon County. So far this year, 33 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: There were 2 seroconversions to HJ virus in sentinel chickens from Leon County. Twelve counties have reported HJ this year.
Mosquito populations are still present in many areas of the state, although cooler temperatures are expected to reduce their numbers. All are urged to maintain preventive actions against mosquito bites. Dead birds should be reported to www.wildflorida.org/bird/.
See the Web for more information at www.MyFloridaEH.com.