| Friday, November 21, 2003
"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."
Foege WH et al.
International Journal of Epidemiology
Epi Update Managing Staff:
John Agwunobi, MD, MBA, Secretary, Department of Health
Landis Crockett, MD, MPH, Director, Division of Disease Control
Acting Bureau Chief,
Epi Update Managing Editor
Jaime Forth, Copy Editor/ Writer
| This Week in the
►Influenza Report 2003
State, national and worldwide influenza data are reviewed for Week 45, with graphics provided to keep you up to date on what's going on this flu season.
►November Grand Rounds Will Focus on Governor's Task
Care Access a Challenge For Some Florida Residents
|A R T I C L E S|
Kathryn Teates, MPH, Surveillance & Reporting Section Administrator and Melissa Covey, Influenza Surveillance Coordinator
Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology
Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology
Jaime Forth, Copy Editor/Writer, Bureau of Epidemiology
Marie Bailey, MSW, Program Evaluation Specialist, Chronic Disease Surveillance & Epidemiology Section
Pete Garner, Surveillance Systems Manager, Bureau of Epidemiology
Caroline Collins, Arbovirus Surveillance Coordinator and Carina Blackmore, DVM, Ph.D., Acting State Public Health Veterinarian, Bureau of Community Environmental Health
Florida influenza-like illness (ILI) activity this week has been relatively quiet. Although 7 counties are reported below as having the highest ILI% last week, only Indian River, Palm Beach and Polk Counties had increased percentages from the previous week. Significance testing is not done for these percentages but Palm Beach was the only county with more than a full point change in their ILI%. Specimen submissions and positive laboratory results are increasing and two specimens submitted by Okaloosa County providers were positive for influenza A/Fujian/411/2002 (H3N2). The Okaloosa County Health Department is currently investigating whether these two patients represent a cluster. This new influenza A drift variant has potential to cause more widespread infection in Florida as it has done in Texas and Colorado. The Bureau of Epidemiology is encouraging the county influenza coordinators to contact their sentinel providers to promote submission of laboratory specimens. With a new variant circulating it is increasingly more important to subtype any influenza A isolates. While the current vaccine is expected to provide some cross-protection against this drift variant, the level of protection is not known. The CDC encourages vaccination because the current vaccine continues to protect against other types of influenza.
Influenza-Like Illness (ILI) Florida Summary
Sixty-five sentinels from 59 public clinics and private offices submitted reports for 28 counties during the week ending November 8, 2003 (Week 45). Counties with the highest percentage of patients with ILI were Broward, Indian River, Monroe, Okaloosa, Palm Beach, Polk, and Seminole. Thirteen counties reported a low percentage of patients with ILI, and 8 counties reported no cases of ILI. A breakdown of ILI% reported for week ending November 8, 2003 by county is listed in Table 1.
Laboratory Specimen Testing in Florida
Four of the 15 specimens received by the Jacksonville Central and Tampa Branch laboratories for influenza isolate testing during the week ending November 8, 2003 (Week 200345) were found positive for influenza A (H3N2). Three of these viruses came from Alachua County and 1 came from Leon County.
From September 28, 2003
to November 8, 2003, the Florida laboratories tested a total of 41
specimens and found 7 positive for influenza A (H3N2). The remaining
specimens were negative for influenza. Table 2 details isolates found
since September 28, 2003 by county.
No new cases of influenza were reported during the week ending November 8, 2003.
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 ending September 4, 2003.
National Influenza Surveillance
This section summarizes the weekly influenza report from the Centers for Disease Control and Prevention. More detailed information can be found at their website: http://www.cdc.gov/ncidod/diseases/flu/weekly.htm
Influenza-Like Illness Report for the Week ending November 8, 2003.
The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) was 3.2% nationwide. This is above the national baseline of 2.5%. On a regional level, the percentage of visits for ILI for most regions was below 4%. The West South Central region, however, continues to have a higher ILI (14.2%). 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.
Influenza Drift Variant, A/Fujian/411/2002 (H3N2), Found in the United States and Europe.
The influenza A drift variant, A/Fujian/411/2002 (H3N2) predominated the Australian and New Zealand outbreaks that peaked in mid-to-late August 2003. This influenza A (H3N2) drift variant has been found in 46 of the 55 influenza A (H3N2) viruses that have been antigenically characterized by the CDC to date. Two of the influenza A (H3N2) viruses submitted to the CDC from Florida in mid-October were A/Fujian/411/2002 (H3N2). The CDC expects the current U.S. vaccine will offer some protective immunity against the A/Fujian/411/2002-like viruses because these viruses are related to the vaccine strain, A/Panama/2007/99. Antibodies produced against the vaccine virus cross-react with A/Fujian/411/2002-like viruses, but at a lower level. A/Fuijan/411/2002 (H3N2)-like isolates have also been identified in Denmark (4), England (6), Ireland (8), Northern Ireland (1), Norway (5), Portugal (3), Spain (13) and Switzerland (1).
U.S. World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) Laboratories Report. Two hundred three (19.2%) of the 1,056 specimens submitted during the week ending November 8, 2003 tested for influenza viruses were positive. Thirty influenza A (H3N2), 170 unsubtyped influenza A viruses, and 3 influenza B viruses were identified.
Since September 28, 2003, 443 (7.4%) of the 6,024 specimens tested for influenza viruses were positive. One hundred ten influenza A (H3N2) viruses and 6 influenza B viruses have been identified. Of the 443 specimens submitted to date, 285 (64%) were reported from the West South Central region and 23% (102) were from the Mountain region.
State and Territorial Epidemiologists Report Texas reported widespread influenza activity, Colorado reported regional influenza activity, Arkansas, Louisiana, Montana, Nevada, New Mexico, Tennessee, Utah, and West Virginia reported local influenza activity, and Alabama, Alaska, Arizona, Connecticut, Florida, Georgia, Hawaii, Idaho, Kansas, Minnesota, Mississippi, Missouri, Nebraska, New York, North Carolina, North Dakota, Oklahoma, South Carolina, Virginia, Washington, Wisconsin, and Wyoming, New York City, Guam, and Puerto Rico reported sporadic influenza activity. Eighteen states and the District of Columbia reported no influenza activity.
Click here for the 2003-2004 Summary By Region
122 US Cities Vital Statistics Mortality Report. The percentage of all deaths due to pneumonia and influenza was 6.2%. This percentage is below the epidemic threshold of 7.1% for the week ending November 8, 2003.
International Influenza Activity
WHO Collaborating Centre for Reference and Research on Influenza, Melbourne Australia
Australia’s winter months are from May to October. One of Australia’s biggest influenza seasons since 1998 peaked from mid to late August 2003, and by October cases of influenza had generally subsided. Influenza A (H3) viruses were cited as the primary cause of outbreaks, with little A (H1) or B viruses isolated during the season. For more information about Australian influenza, please visit the Melbourne, Australia Branch website at http://www.influenzacentre.org/ (specific article can be found at http://www.influenzacentre.org/flunews.htm#subsiding).
FluWatch Report from the Canadian Centre for Infectious Disease Prevention and Control
For the week ending November 8, 2003, widespread influenza activity was reported in all regions in Saskatchewan, localized influenza activity was reported in all parts of Alberta and the Northwest Territories, 2 regions of Ontario, and 1 region of British Columbia, and sporadic influenza activity was reported 2 regions in British Columbia, 1 region in Nova Scotia, and 1region in Manitoba. For more information about the FluWatch report, please visit their website at http://www.hc-sc.gc.ca/pphb-dgspsp/fluwatch/index.html
Report from the European Influenza Surveillance Scheme (EISS)
Of the 22 European countries that are members of the EISS, widespread influenza activity was reported in Scotland and Spain, Northern Ireland and Norway reported local activity, and Belgium, England, France, and Portugal reported sporadic activity for the week ending November 1, 2003. For more information about the EISS report, please visit their website at http://www.eiss.org/index.
2002-2003 Influenza Surveillance Summaries
An international summary of the 2002-2003 influenza surveillance season (October-September) can be found on page 303 in the November 7, 2003 edition of the WHO’s Weekly Epidemiological Record (Vol. 78) at http://www.who.int/wer/2003/wer7845/en/. WHO recommended composition of influenza virus vaccines for use in the 2004 influenza season. http://www.who.int/csr/disease/influenza/recommendations2004/en/
* Reporting is incomplete for this week. Numbers may change as more reports are received.
Grand Rounds Will Focus on Governor's Task Force Issues
Topic: Recent Data on Overweight and Obesity In Florida
Presenter: Youjie Huang, MD, MPH, Administrator,
Chronic Disease Section, Bureau of Epidemiology, Florida Department of
Additional Information: The grand rounds presentation will begin promptly at 11:00 a.m. EST on Tuesday, October 28, 2003. PowerPoint slides and the dial-in number will be available on the Bureau of Epidemiology Intranet website on Monday, October 27th. If additional information is needed, contact Melanie Black, MSW, Professional Training Coordinator at (850) 245-4444 ext. 2448, SunCom 205-4444 ext. 2448 or email Melanie_Black@doh.state.fl.us.
Since the beginning of October 2003, several counties in Florida have observed an increase in the number of cases of viral meningitis. Further investigation of these cases has revealed clusters of viral meningitis in Indian River, Polk, and Brevard Counties. Echovirus 30, an enterovirus serotype known to be associated with high incidence levels of viral meningitis, has been isolated from specimens in all three counties. However, an epidemiological link between the counties has not been established at this time, suggesting that the outbreaks are independent of one another.
As of November 19th, Indian River County Health Department officials reported 71 persons with diagnoses clinically compatible with viral meningitis. However, notifications of additional probable cases have been received daily since that time. Approximately 22 clusters have been identified, consisting of cases linked through familial or other household contacts. Thirty-four cerebral spinal fluid (CSF) specimens have tested positive for enterovirus and echovirus 30 specifically has been isolated in 11 (32%) of those specimens. Other lab results are pending.
Two clusters of viral meningitis have been identified by Polk County Health Department officials; a cluster of five football players from a local high school and a cluster of three children from a local elementary school. Four of the five CSF specimens obtained from the football team cluster were positive for enterovirus and echovirus 30 has been isolated in two of those specimens. Cerebral spinal fluid specimens from all three cases of the elementary school children were positive for enterovirus.
Additionally, staff at Brevard County Health Department have identified a cluster of nine students from a local high school. Four cases are members of the football team and three cases are close contacts with those four identified football team members. The remaining two cases have not been identified as close contacts of any of the cases. Echovirus 30 has been isolated in three of the four CSF specimens from this cluster.
Since viral meningitis is most often transmitted through direct contact with respiratory secretions or stools of infected individuals, health education messages emphasizing the importance of good hygiene practices has been the primary prevention method employed by Indian River, Polk, and Brevard Counties. Furthermore, county health department officials are recommending those persons diagnosed with viral meningitis stay home for seven to ten days after symptoms end to prevent spread to others. No specific treatment for viral meningitis exists at this time.
Although viral meningitis is not a reportable disease, any outbreak or clustering of patients with similar disease symptoms or syndromes is reportable and should be reported to the Bureau of Epidemiology, Surveillance and Reporting Section through the local county health department.
Many thanks to Jean
Kline of the Indian River County Health Department, Barry Inman and Dr.
Saroj Aggarwal of the Brevard County Health Department, Colleen Sullivan
and Cynthia Goldstein-Hart of the Polk County Health Department, and
Regional Epidemiologist Roger Sanderson for providing ongoing information
on viral meningitis activity.
The resulting 35-page report also traces the epidemiology of the disease at each of the main outbreak sites and provides specific points in a bulleted format dealing with seven topics:
The report found no evidence that SARS is an airborne disease, which differs from droplet transmission spread through the air. Researchers found health care workers were at special risk, but they also found children were rarely affected by the disease and, in fact, were not at risk from transmission in schools or from mother to infant. They did find risk of transmission is greatest around the 10th day of illness but after fever had resolved, risk was negligible.
For a thorough review of the document, view their site at http://www.who.int/entity/csr/sars/em/WHOconsensus.pdf
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Every four years the CDC Division of Reproductive Health/PRAMS team revises the PRAMS questionnaire to better reflect current health trends in postpartum women and children. New questions include those about new methods of birth control, fertility treatments, mental health, co-sleeping, infections, health problems, and depression. Continuing questions are on child health care, multivitamins, Medicaid, prenatal healthcare, HIV, childcare, pregnancy intendedness, birth control, folate, tobacco and alcohol use, pregnancy risk factors, domestic violence, breastfeeding and income.
The Phase 5 questionnaire will be implemented with January 2004 births.
Health departments or other entities desiring to access this information
should contact Helen Marshall at
firstname.lastname@example.org. or access the Department of Health
to read PRAMS reports.
Announcements. Don Ward announced that he has begun actively recruiting for the manager of the surveillance section opening left by the departing Kathryn Teates. Qualified individuals with an interest in the position should contact Don at email@example.com or call him at 850.245.4405.
Merlin. Travis McLane, technical manager for Merlin training and reporting, emphasized that paper meningitis report forms should not be sent to Tallahassee; CRFs should be input only on Merlin. If there are questions, help is available on our Intranet website, or contact Travis at firstname.lastname@example.org.
Viral Meningitis Outbreaks. Karen Wheeler, MPH, bioterrorism special surveillance coordinator, presented a brief overview of the number of cases of meningitis in Florida. Although not reportable on a case-by-case basis, the CHDs and the bureau are tracking outbreaks. Polk, Brevard and Indian River Counties are reporting outbreaks, primarily among teenagers, with 61 cases in Indian River so far. Polk County has 13 cases and Brevard has 11. Karen advised staff at county health departments noticing outbreaks to start line lists and develop a list of links. They should also send tests to the state lab and begin to document intervention efforts immediately.
PRAMS Reports. Dr. Youjie Huang and Curt Miller announced the PRAMS report is now available on the Intranet website. This report, and other summary reports, uses 2001 data sets, which is the most recent data available. Reports on folic acid use by pregnant women, smoking, domestic abuse, prepregnancy weight, breastfeeding and other chronic disease reports will soon be posted on the website.
Flu Surveillance. Angela Fix, MPH, respiratory disease epidemiologist, will be working on a protocol for testing people with severe respiratory diseases through state laboratories during the next several months. She also noted that over 70 sentinel providers representing 30 counties are currently reporting sporadic flu activity in the state of Florida.
Training. Melanie Black, MSW, announced new training dates for the
On December 16th from 11:00 a.m. - 12:00 p.m., Dr. JoAnn Schulte, Carol Graham and Anne Cope will present on Investigation of Increase of Infant Mortality in Brevard County.
On January 27th, David Atrubin, MPH, will present on Inspiratory Stridor in Female Students at a High School in Tampa, Florida.
The next regional training seminar will be held in south central Florida at the end of January or beginning of February. Anyone interested in hosting the event should contact Melanie at email@example.com or by phone at 850.245.4444, ext. 2448.
Due to the Thanksgiving holiday the next CHD conference call will be held on December 5th. Look for postings concerning the date and time on our Intranet site and in future Epi Updates.
TB Course to Occur in December
Topics will include the legalities associate with the disease, hospital admission policies, infection control, pharmacology, radiologic interpretation of the disease, skin testing, risk management and other important issues.
Tuition is $300. For more information,
contact Melody McIntosh at 561.540.3364 or Suzy Peters at 850.245.4350. Deadline for registration is November 21st.
The reports are based on Behavioral Risk Factor Surveillance System data from the 2002 survey. The survey, covering a four-month period, asked over 34,000 adults about their general health and their ability to access health care. Although a majority of respondents had access to health care when they were sick or needed medical advice, it was found that Hispanics and non-Hispanic Blacks were less likely to have health care coverage than non-Hispanic Whites; this was the case more often for non-Hispanic Blacks in urban areas and Hispanics in rural areas. Emergency rooms, public health centers and outpatient departments were more often used by non-Hispanic Blacks and Hispanics than non-Hispanic Whites. Within the non-Hispanic Black and Hispanic populations, factors such as age, marital status, education and household income were also associated with access to health care.
The reports were produced by the Chronic Disease Surveillance and Epidemiology Section within the Bureau of Epidemiology and are posted on the Intranet website at http://www.doh.state.fl.us/disease_ctrl/epi/brfss/reports.htm, under the heading “2002 County BRFSS Special Reports.” For more information on these and other Florida BRFSS reports, please contact Marie Bailey at 850.245.4444, ext. 2434, or at firstname.lastname@example.org
Week on EpiCom
This represents the first use of EpiCom by a medical examiner to report a death from an infectious disease and illustrates a number of the key characteristics of the EpiCom outbreak communication and emergency notification system.
First, EpiCom is intended to provide rapid information sharing between public and private health officials and practitioners from both inside and outside the Department of Health. The information the medical examiner was reading in EpiCom had, up to that point, all been provided by DOH and CHD EpiCom users. His was the first post from an EpiCom user outside the Department of Health and his information was available statewide within an hour.
Second, EpiCom is not limited to reportable diseases. Not only is the meningitis not reportable, but the cases discussed in Brevard and Polk counties did not have to be clinically confirmed before they were shared on the EpiCom system for officials and practitioners to be made aware of situations forming in nearby or in distant parts of the state.
EpiCom is intended to spark the collective memories and to trigger recognition on the part of its readers and contributors of similar episodes and trends that they may be aware, or to help condition observers to be more keenly aware of symptoms and situations they observe later on. This medical examiner’s recollection and contribution, while referring to a “closed case,” reflects an incident very close in time to the onset dates in some of the clusters the Bureau and the County Health Departments involved are currently investigating.
Finally, the EpiCom Alert system, while not directly involved in this incident, is always a mouse-click away for either the contributor or the Bureau moderator to instantly notify as few or as many of the over 300 registered EpiCom users as may be necessary to initiate the appropriate response to an emergency.
The Bureau of Epidemiology once again encourages all Epi Update readers not only to register with the EpiCom system at https://www.epicomfl.net but to browse EpiCom often and to contribute public health observations related to any suspicious or unusual situations or circumstances as appropriate.
EEE virus activity in animals: There was no EEE virus activity reported 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: Seven dead birds were reported positive for WN virus from Leon (2), Levy (1) and Okaloosa (4) counties. In addition, 67 seroconversions to WN virus were confirmed in sentinel chickens from 25 of the 28 counties that collected samples. One WN virus infected horse was reported this week in Jackson County. Sixty counties have reported WN virus activity, compared to 54 at this time last year.
See the web page
for maps and more information: