Friday, November 19, 2004

         This Week in the News

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

►Enhanced Surveillance for Superbowl XXXIX
With the game just weeks away, preparations are in the final stages. This year, one of our own staff is involved in the disease control effort.

►Overweight and Related Behavioral Factors Among Florida High School Youth
A study pointing to a dramatic rise in obesity among Florida's youth also shows differences in the way males and females approach weight loss.
 

A R T I C L E S

The enhanced surveillance project will involve a partnership between the Duval County, St. Johns County, Nassau County and Clay County Health Departments, the Florida Department of Health, and the U.S. Centers for Disease Control and Prevention. It will also involve close collaboration with hospitals and cruise lines throughout the region.   

Participating hospitals will send chief complaint data plus limited patient geographic, demographic and clinical information electronically via an FTP file to the department of health’s secure server. The data will be electronically imported and stored in the Merlin Outbreak Module where it will be coded into syndromes and analyzed using CDC’s EARS (Early Aberration Reporting System) algorithms to generate a set of charts and graphs. The charts and graphs will be exported and posted to EpiCom.   

Cruise ships will use a separate surveillance system from the hospital-based system. Participating cruise ships will report those patients that fall into a specific syndrome category. Medical personnel on the ship will determine what syndrome the patient belongs to. The completed form will be faxed or emailed to the appropriate health department and the information will be manually entered into the Merlin Outbreak module. Data analysis and dissemination methods will be the same as utilized in the hospital-based surveillance system. 

The development and implementation of this surveillance system will allow for a sustainable, enhanced disease detection capability for the region, and allow the Florida Department of Health the ability to evaluate the need and utility of expanding syndromic surveillance to other areas of the state.
 

Hemolytic Uremic Syndrome (HUS) is a reportable medical condition in the State of Florida. Clinical characteristics of HUS include hemolytic anemia, renal injury, and low platelet count. HUS primarily occurs following a gastrointestinal illness and is most commonly associated with shiga-like toxin-producing Escherichia coli (SLTEC), including Escherichia coli 0157:H71,2,3 In addition, HUS may be related to other types of bacteria, viruses and fungi 4,5   

Hemolytic Uremic Syndrome primarily affects children < 5 years of age and elderly persons6. The red blood cells are destroyed and the kidneys fail. According to the Centers for Disease Control and Prevention, approximately 2%-7% of E. coli O157:H7 infections lead to HUS.  

Four cases of Hemolytic Uremic Syndrome in children have been reported in the Northeast Florida region between April and August 2004. These children were all administered antibiotics prior to specimen collection and no bacterial, viral or parasitic organisms have been isolated with three of the four cases. Only one of these cases has been associated with E. coli O157:H7. All cases are recovering. No epidemiological link has been established among any of the cases. 

A confirmed case is defined as an acute illness diagnosed with HUS or Thrombotic thrombocytopenic purpura (TPP) in the presence of 1) anemia with microangiopathic changes on a peripheral blood smear AND 2)  renal injury, evidenced by either hematuria, proteinuria, or elevated creatinine level AND 3) began within 3 weeks after onset of an episode of acute or bloody diarrhea.  

A probable case is defined as an acute illness diagnosed as HUS or TPP in the presence of 1) anemia with microangiopathic changes on a peripheral blood smear AND 2) renal injury, evidenced by either hematuria, proteinuria, or elevated creatinine level in a patient who does not have a clear history of acute or bloody diarrhea in the preceding 3 weeks. A probable case is also defined as an acute illness diagnosed as HUS or TPP in the presence of 1) anemia with microangiopathic changes that have not been confirmed AND 2)  renal injury, evidenced by either hematuria, proteinuria, or elevated creatinine level AND 3) began within 3 weeks after onset of an acute or bloody diarrhea. 

Medical management for HUS includes IV fluids to maintain hydration, blood transfusion, or dialysis7.  Severe cases of HUS may require a renal transplant. Treating an Escherichia coli 0157:H7 with antibiotics or antimotility agents has been widely debated by researchers. Some studies have suggested that antibiotics or antimotility agents increase the risk of HUS in children with an Escherichia coli 0157:H7 infection 8.  

Please remember:

• Physicians should refrain from administering antibiotics to any person that presents with diarrhea (particularly bloody diarrhea) until a stool specimen may be obtained for culture.

• If an individual presents with bloody diarrhea, specimens should be specifically tested for Salmonella, Shigella, and Campylobacter, and additionally E. coli 0157:H7.
• All E. coli 0157:H7 positive laboratory specimens should be sent to the State Laboratory in Jacksonville for confirmation.

If you suspect that a patient has HUS or an enterohemorrhagic E. coli infection and the reference laboratory does not have the ability to test for shiga toxins, please contact your health department’s epidemiology division so testing may be arranged through the state laboratory.

If you have any questions regarding the submission of laboratory specimens to the state laboratory or how to report a case of HUS or E. coli contact the Florida Department of Health Bureau of Epidemiology at 850.245.4401 for assistance. 

1  CDC. Community Outbreak of Hemolytic Uremic Syndrome Attributable to Escherichia coli 0111:NM—South Australia, 1995. MMWR 1995; 44: 550-551, 557-558.
2  CDC. Epidemiologic Notes and Report Hemolytic-Uremic Syndrome associated with Escherichia coli 0157:H7 Enteric infections - United States, 1984. MMWR  1985; 34:20-21
3  Paton AW, Ratcliff RM, Doyle R, Seymour Murray J, Davos D, Lasner JA, and Paton JC. Molecular Microbiological Investigation of an Outbreak of Hemolytic Uremic Syndrome caused by Dry Fermented Sausage Contaminated with Shiga-like Toxin-Producing Escherichia coli.  J Clin Micro 1996;34: 1622-1627
4  Small G, Watson AR, Evans JHC, and Gallagher J.  Hemolytic uremic syndrome: defining the need for long-term follow-up.  Clinical Nephrology  1999:52 (6); 352-356.
5  Parmar MS. Emedicine. Hemolytic Uremic Syndrome  http://www.emedicine.com/med/topic980.htm Accessed August 20, 2004.
6  http://www.cdc.gov/ncidod/dbmd/diseaseinfo/escherichiacoli_g.htm
7  National Kidney Foundation Kidney Learning System (KLSTM) http://www.kidney.org/kls/factsheets/printFS.cfm?id=72  Accessed August 20, 2004.
8  Bell BP, Griffin PM, Lozano P, Christie DL, Kobayahi JM, and Tarr PI. Predictors of Hemolytic Uremic Syndrome in Children During a Large Outbreak of Escherichia coli 0157: H7 Infections, PEDIATRICS Vol. 100 No. 1 July 1997, p. e12.

A special thank you to Roberta Hammond, PhD, Kathleen Ward, RS MSEH, Carmela Mancini, MPH, Angela Morgan, RN, BSN, Rebecca Crouse, RN, BSN, Christine Bailey, RN, BSN, MSH, and Jerne Shapiro, MPH.                               

Overweight and Related Behavioral Factors Among Florida High School Youth

Background
Chronic diseases - such as heart disease, cancer and diabetes - are the leading cause of death and disability in the United States. Overweight and obese individuals are at increased risk for these chronic health problems. Many adverse health effects associated with being overweight are observed in children and adolescents, which is related to increased morbidity and mortality in later life. This study focuses on overweight Florida high school students and addresses behavior factors that may contribute to their overweight status.

Methods
Florida Youth Tobacco Survey data were included. Youth Risk Behavior Survey data were used to address behavioral factors related to overweight teens. Data were weighted and analyzed by gender, race/ethnicity and body weight status to represent prevalence at state level.

Results
Prevalence of the overweight population among Florida high school students increased by 44.2%; from 8.6% in 2000 to 12.4% in 2003. Boys had a significantly higher prevalence of overweight numbers than girls; Non-Hispanic Black students had higher prevalence of overweight than students in other racial/ethnic groups. Students who were overweight were less likely to participate in moderate or vigorous physical activity than students with normal weight. Although the data show that more boys (23.8%) than girls (18.1%) consumed five or more servings of fruits and vegetables a day and more boys (70.9%) than girls (50.6%) were physically active, girls were much more likely than boys to maintain or lose weight by many means: taking diet pills, powders or liquids without a doctor's advice (22.1% vs. 6.1%); vomiting or abusing laxatives (11.0% vs. 2.7%); eating less food, fewer calories or foods low in fat (76.7% vs. 57.2%); or going without eating for 24 hours or more (25.1% vs. 11.5%).

Conclusion
The prevalence of overweight among high school youth increased dramatically in the past four years. This study shows important sex differences in behaviors related to overweight and obesity. Efforts to reverse this trend should focus on healthy nutrition and physical activity as well as avoidance of unsafe ways to lose weight among girls.
 

The Renaissance Resort at World Golf Village at St. Augustine, Florida will host the First Coast Infectious Disease Clinical Microbiology Symposium scheduled for February 18 - 19, 2005. Some oaf the confirmed speakers are Susan Sharp, PhD, from Kaiser Permanente at Portland, Oregon; Peter Gilligan, PhD, University of North Carolina at Chapel Hill; John Wingard, MD, University of Florida College of Medicine and Michael Miller, PhD, The Centers for Disease Control & Prevention in Atlanta.  Abstracts are currently being accepted for work presented within the February 2004 - January 2005 timeframe. The conference is co-sponsored by Baptist Health, Jacksonville and the First Coast Infectious Disease/Clinical Microbiology Symposium. For details, log on to http://www.firstcoastidem.com or call Dr. Diane Halstead at 904.202.2166.

The Department of Health Bureau of Epidemiology does not specifically endorse trainings or products highlighted in this journal. To determine whether these services are suitable for your particular needs, we encourage to you investigate and use your own best judgment.
 

Abstract:
Between August 13 and September 25th, 2004, four hurricanes made landfall in the state of Florida. Over 5 million people were evacuated, greater than 3.5 million customers lost power, and more than 70 deaths occurred. Given the multiple public health implications following this natural disaster, the Florida Department of Health implemented an illness and injury surveillance system.

Following hurricane Charley (8/13 to 8/31), 13,465 medical visits were recorded from the majority of hospitals, clinics, and DMATs (disaster medical assistance teams) in Charlotte, Desoto, and Hardee counties. Data were also collected from Sarasota and Lee counties. A summary of demographic and clinical data from these visits is as follows: 53% of patients were female, 78% white, and 76% non-Hispanic. The majority of visits (30%) were for reasons other than those under surveillance. Twenty-three percent of visits were for injuries, 7 % for GI illness, 7% for respiratory conditions, 6% for skin conditions, 6% for an exacerbation of a chronic illness, and 5% for chest pain. Less common were visits for fever (3%), heat illness (2%), stress (1%), dehydration (1%) and poisoning (1%). A peak in poisoning was noted early in surveillance. This peak was thought secondary to carbon monoxide. No outbreaks of infectious disease were detected. Findings from this surveillance system helped guide prevention messages and public health interventions. 

With the rush of hurricanes following hurricane Charley, the original surveillance system was modified for hurricanes Frances, Ivan, and Jeanne so that data could be collected, transferred, and analyzed electronically. EARS (the early aberration detection system) was applied for the purpose of detecting outbreaks. This application of EARS was the first ever in a natural disaster setting. Although no outbreaks of infectious disease were detected, the application of EARS allowed for specificity in describing illness and injury, as well as a timely and acceptable approach to natural disaster surveillance. 

Additional Information: 
The grand rounds presentation will begin promptly at 11:00 a.m. EDT on Tuesday, November 30, 2004. The PowerPoint slides will be on the Bureau of Epidemiology intranet Website on Wednesday, November 24. If additional information is needed, contact Melanie Black, MSW, professional training coordinator, at 850.245.4444 ext. 2448,  or email Melanie_Black@doh.state.fl.us.
 

This Week on EpiCom

• Creutzfeld Jacob (Prion) Disease reported in Lee County female
• Vibrio vulnificus cases and deaths related to consumption of oysters reported in  Hillsborough County

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 4 seroconversions to WN virus in sentinel chickens from Hillsborough (3) and Pinellas (1) counties.    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 Washington County were reported to be infected with EEE virus.  There were 4 seroconversions to EEE virus in sentinel chickens from Leon (3) and Walton (1) counties.  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: None this week. 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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