Friday, November 12, 2004

         This Week in the News

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

►Bureau of Epidemiology Welcomes New Chief
With an extensive background in management and environmental public health, Dr. Dian Sharma brings a wealth of expertise to Tallahassee.

►Health Management Behaviors for the Prevention of Diabetes Complications in Florida: Data from Florida Behavior Risk Factor Surveillance System (BRFSS)
An abstract on the results of a survey conducted in Florida between 2000 and 2002.
 

A R T I C L E S

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.
 

Background
On September 15, 2004, the Palm Beach County Health Department was notified of a presumptive foodborne outbreak among inmates of a county stockade facility in West Palm Beach. The stockade kitchen delivers three meals a day to approximately 700 inmates. Early reports suggested that the first cases had become ill after eating lunch on September 15. The illness was characterized by nausea and vomiting.

Methods

Epidemiological investigation

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. 

Results

Epidemiological investigation

One hundred 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. 

Conclusions
The epidemiological investigation and the laboratory results suggest that at least two food items (cold baked beans and turkey bologna) were implicated in the outbreak. A strong epidemiological association between gastroenteritis and eating cold baked beans and/or turkey bologna was found. The symptoms reported (nausea, vomiting, diarrhea) and the incubation period (mean 1.5 h, range 15 minutes - 4 ½ h) were compatible with infection with B. cereus (the incubation period for B. cereus is usually between ½ h and 5 h). 

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.

Health Management Behaviors for the Prevention of Diabetes Complications in Florida: Data from the Florida Behavioral Risk Factor Surveillance System (BRFSS)

Background
Diabetes-related complications are serious health burdens, in addition to increasing the  mortality rate. The onset of diabetes-related complications may be delayed by maintaining health behaviors such as eating healthfully, exercising, and using proper diabetes self-management practices such as monitoring blood glucose levels. In this study, we describe the health management behaviors of those diagnosed with diabetes among Florida's population of adults 45 years old and older (referred to as older adults).

Methods
Data from the 2000 through 2002 Florida BRFSS were combined to generate reliable estimates for the specific population of older adults with diabetes. Combining the datasets gave us a sample of 8,941 older adults, including 1,087 older adults with diabetes. Bivariate analysis was conducted for health status such as being overweight or obese; health behaviors such as current smoking and exercise; and diabetes self-management practices, as in regularly checking blood glucose levels.

Results
Among the subpopulation of older adults overall, no significant differences were found in smoking status or being overweight or obese between those with and those without diabetes. Older adults with diabetes, however, were generally less likely to report engaging in leisure time physical activity and more likely to report being in fair or poor health than older adults who were not diabetic. More older adults with diabetes reported taking diabetes pills than reported taking insulin (68.2% vs. 27.1%). Older Hispanics with diabetes were less likely to report taking insulin (19.9%) than were their Black counterparts (38.5%). Just under half (49.8%) of older Hispanics were less likely to report checking their feet for sores at least once a day, compared to their White and Black counterparts (72.2% and 70.5%, respectively).

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).

Conclusions
Diabetes self management is key to delaying the onset of life-threatening complications due to the disease. These data highlight areas of unhealthy behaviors and inadequate diabetes self-management that can be targeted by health education programs. Also, the apparent differences by race/ethnicity in diabetes self-management suggest that culturally specific education programs may need to be developed or implemented.
 

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 http://www.cdc.gov/epo/dphsi/syndromic.htm
 

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 quality issues.
 

This Week on EpiCom

The Bureau of Epidemiology encourages Epi Update readers to not only register on the EpiCom system at https://www.epicomfl.net  but to use the link to sign up for features such as automatic notification for certain events.

Registered users should 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.
 

Mosquito-Borne Disease Update

West Nile (WN) virus activity: No new human cases of WN illness this week, leaving the state-wide total at 40.  There were 9 seroconversions to WN virus in sentinel chickens from Brevard, Duval, Hillsborough, Orange, Pasco and Pinellas counties. A dead bird in Orange County was confirmed with WN virus this week. So far this year, 34 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: 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. 

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