December 5, 2004

Epi Update Managing Staff:

John A. Agwunobi, MD, MBA, MPH, Secretary, Florida Department of Health
Landis Crockett, MD, MPH, Director, Division of Disease Control
Dian K. Sharma, MS, PhD, Bureau Chief, Bureau of Epidemiology, Editor-in-Chief
Jaime Forth, Managing Editor

"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., International Journal of Epidemiology 1976; 5:29-37

 

National Program of Cancer Registries' Audit Findings Prove Completeness and Quality of Florida's Cancer Registry Data
by Tara Hylton, MPH and Youjie Huang, MD, Dr.PH, MPH

The National Program of Cancer Registries (NPCR) examined the data collection procedures of the Florida Cancer Data System (FCDS) by conducting a data audit in March 2004. The audit found that both completeness and accuracy of Florida cancer registry data reached 95 percent. The results of the audit indicate that the FCDS is the leading nation’s central cancer registry by the volume of case reports and by the quality of data.    

The Technical Assistance and Audit Program (TAA), a contractor of the NPCR, conducted the audit from March 14^th through March 26^th 2004. The TAA auditors conducted case-finding and re-abstraction to check case completeness and data quality. The audit focused on the reporting of four major cancer sites (female breast, colon and rectum, lung and bronchus, and prostate) diagnosed in hospitals during 2001. Military and Veterans Administration hospitals were not included in this audit as they are not subject to State Laws. Children hospitals were excluded from this audit as well. Nine hospitals were randomly selected from 231 hospitals reporting cancer incidence to the FCDS. These nine selected hospitals were categorized based on caseload into low (25 to 565 cases), medium (566 to 1,131 cases), and high (1,132 to 1,697 of cases).   

For case-finding, six months of records were examined in the low-caseload facilities, four months of records were examined in the medium-caseload facilities, and three months of records were examined in the high-caseload facilities. The level of case completeness during a selected period was assessed by independently case-finding cancer cases in the sample facilities utilizing various sources of medical information. These sources of medical information included the medical records disease indices (MRDI), pathology reports, cytology reports, surgical logbooks and same-day-surgery logbooks, outpatient clinic records, radiation therapy clinic logs, nuclear-medicine logs, and any other hospital source providing cancer diagnosis and treatment information. Any incident case identified during the audit, which was not collected by the FCDS, was considered a missed case. 

The TAA auditors identified from the various case-finding sources in these hospitals that 2,167 cases should have been reported to the FCDS as a cancer case. Of the 2,167 cases, only 91 cases were “missed”. Of the 91 missed cases, there were 27 missed colon and rectum cases, 25 missed female breast cancer cases, 21 missed lung and bronchus cases, and 18 missed prostate cancer cases. The majority of missed cases were found in the low-caseload facilities (48) and the medium-caseload facilities (41). Only two cases were missed in the high-caseload hospitals. 

The overall FCDS case completeness was 95.8 percent, which exceeds the standard set by the Centers for Disease Control and Prevention, which states “ninety-five percent of unduplicated, expected malignant cases of reportable cancer occurring in State residents should be reported within 24 months of the close of each diagnosis year.”   

To assess the data quality of collected cancer incidence by the FCDS, the auditors randomly selected 33 record from each of the nine hospitals. A total of 13 critical data elements were examined for each record. Out of a total of 3,861 possible data elements examined, 195 data elements (5.1 percent) were found to have discrepancies. The TAA auditors further classified these discrepancies as major (errors in the critical data elements that affect the incidence rate) and minor (errors in the critical data elements that may not directly affect the incidence rate). The majority of discrepancies found by the auditors were minor (59.5 percent).  The overall data accuracy rate for the FCDS was estimated at 94.9 percent, comparable to the NPCR (1993-1999) mean rate of 94.8 percent (the NPCR mean rate is calculated for all state central cancer registries within the NPCR program).

Table 1.  Case Completeness

Table 2.  Data Quality

Tara Hylton is a cancer epidemiologist in the Chronic Disease Epidemiology Evaluation and
Surveillance Section. Dr. Huang is section administrator. Tara can be reached at 850.245.4444,
ext. 2441.

Emergency Room Census
Surveillance System
Improvements
   by Karen Wheeler, MPH

Emergency Room Census (ERC) is an early warning program maintained
by the Bureau of Epidemiology that analyzes emergency room admissions
data using three CDC developed statistical algorithms. The algorithms calculate different threshold limits based
on the range of average daily visitation. Aberrations show up as “flags” indicating different levels of change that
could be an early indication of a bioterrorism event or other public health emergency. ERC allows practitioners
and epidemiologists to readily identify and quantify variations in the expected distribution of census numbers
and respond accordingly. Additionally, ERC creates a strong network between Florida hospitals and the Florida Department of Health.   

When ERC was implemented in December 2000, hospitals reported their daily census numbers either by email
or a 24-hour, toll free, touch tone telephone reporting system. Graphical reports were produced manually by the
Bureau of Epidemiology and disseminated to the respective hospitals via email. Recently, the Bureau of
Epidemiology has improved ERC by implementing a web-based system of reporting via EpiCom (https://www.epicomfl.net). The enhancement allows users to enter daily census counts and immediately
generate real-time reports.   

Within ERC, there are three types of users: ER User, ER Monitor and ER Super User. An ER User (hospital staff) enters emergency department census data for a specific hospital and views reports for that hospital only. ER Monitors (county health department staff) are able to view regional, county, and hospital data, for any county,
region or hospital, but they cannot enter emergency room census data. ER Super Users (ERC program staff
or EpiCom Administrators) have the same options as ER Monitors but are also able to enter census data.   

Three types of reports, described below, can be generated using the ERC Surveillance System. 

Regional Report (chart): Lists only those hospitals in the region that participate in ERC. This report provides
census numbers. The regions used include the Regional Domestic Security Task Force (RDSTF) regions
(North East, North Central, North West, Central East, Central West, South East, and South West).  ER
Monitors and ER Super Users can view this report.  

County Report (graph and chart): The graph displays the census number for participating hospitals. The chart
provides the census number, moving average, standard deviation, and any aberrations detected. ER Monitors
and ER Super Users can view this report.  

Hospital Report (graph and chart): The graph displays the census number, the moving average and the standard deviation. The chart provides the census number, moving average, standard deviation, and any aberrations
detected. All ERC users have access to this report; however, ER Users can only view data from their assigned hospital.  

If you are interested in becoming an ER User or ER Monitor and are already an EpiCom user, please contact an EpiCom Administrator at 850-245-4401 or by email at: EpiCom_Administrator@doh.state.fl.us. If you are not an EpiCom user, log on to https://www.epicomfl.net and choose the “click here if you are not a registered user” link.
Fill out the registration form and make sure to choose “ER Census” system access. ER Users will need their
hospital’s FRAES number to register. If you need assistance identifying your hospital’s FRAES number, an
EpiCom Administrator can help. 

For additional information about the ERC Surveillance System please contact Karen Wheeler at 850-245-4401
or Karen_Wheeler@doh.state.fl.us.

Karen Wheeler is a bioterrorism and special projects epidemiologist at the Bureau of Epidemiology
in Tallahassee.

Risk Factors for Diabetes Among Adults in Florida
                               by Curt Miller, BS; Youjie Huang, MD, Dr.PH, MPH; Marie Bailey, MSW


Diabetes is a major chronic disease among adults. People with diabetes suffer with
other health problems, such as hypertension and high cholesterol, both of which
increase the risk for heart attack and stroke. Our study shows that the prevalence
of diabetes among Florida’s adult population has remained consistently higher than
that of the national rate of diabetes, since 1994. 

This study identifies socio-demographical disparities relating to diabetes among
adults in Florida, examines risk factors that are associated with diabetes, and looks
at the prevalence of other health concerns, such as hypertension and high
cholesterol among adults in Florida with diabetes. 

The prevalence of diabetes and related factors were analyzed using the 2003 Florida Behavioral Risk Factor Surveillance System (BRFSS) data. 

According to our data, the prevalence of diabetes among adults in Florida has increased by 77 percent from
4.8 percent in 1994 to 8.5 percent in 2003. The prevalence of diabetes is the highest among non-Hispanic
Black women (13.0 percent), next among non-Hispanic White men (10.3 percent). The prevalence of diabetes
among adults age 45 and older is over five times greater (13.5 percent) than that among adults between the
ages 18 and 44 (2.6 percent). 

The prevalence of diabetes among adults who engage in no physical activity outside of work (11.1 percent) is
higher than among those who are physically active (7.4 percent).  Further, the prevalence of diabetes among
adults who are obese (18.9 percent) is four times that among those who are either normal weight or
underweight (4.8 percent). 

Nearly 12 percent of adults in Florida who have diabetes are not receiving annual medical check-ups,
specifically for diabetes. 

Additionally, adults with diabetes have much higher rates of hypertension (59.4 percent) and high cholesterol
(54.8 percent) than those without diabetes (26.5 percent and 33.0 percent, respectively).  Because these
particular adverse health conditions increase a person’s risk for heart attack and stroke, it is important for
adults with diabetes to see a doctor on a regular basis. 

People with diabetes who get the flu are at a high risk for developing flu-related complications. The prevalence
of getting a flu vaccination among Florida adults with diabetes (53.0 percent) is higher than among those
without diabetes (29.9 percent); thus 47% of adults with diabetes are at risk for flu-related complications.  

One out of every five (20.2 percent) adults in Florida over the age of 18 who have diabetes also smokes
cigarettes.

Since cigarette smoking is also a risk factor for cardiovascular disease and cerebral-vascular disease,
adults with diabetes who smoke are at increased risk for these diseases.  

This study identifies significant risk factors for diabetes among adults in Florida. The data indicate that diabetes
is more likely to occur among adults who are non-Hispanic Black females, non-Hispanic White males, are age
45 and older, are obese, and/or engage in no leisure-time physical activity.  Further, the data show an association between having diabetes and having hypertension and/or high cholesterol, both of which increase the risk for
developing cardiovascular disease and cerebral-vascular disease. Results of this study could be used to reduce the prevalence of diabetes among adults in Florida.

Curt Miller is a data analyst in the Bureau of Epidemiology Chronic Disease Epidemiology Evaluation and Surveillance Section. Dr. Youjie Huang is section administrator, and Marie Bailey is BRFSS
coordinator. Curt can be reached at 850.245.4444, ext. 2407.

                        New Look, Same Publication
                                                                        by Jaime Forth                        

Epi Update is sporting a brand new look with this issue. Change is inevitable in life although
for us it has been a gradual process, coming to fruition just this month. Our main goal has been twofold: To enhance the look of articles with appealing graphics, and present the publication
within a simpler format while still providing the good information our readers have come to
expect. We hope you'll like the new style of the journal and that you'll continue to find the
material helpful and stimulating. 

At the same time, some reprinted guidelines should answer any questions you may have concerning correct
formatting, timelines and other details related to article submissions. And while I'm on the topic of submissions,
I encourage you to contribute to Epi Update if you haven't ever done so. Each of us has a unique perspective that
our colleagues may not have considered, and your experiences could be helpful to other practitioners who are determining a course of action. Sharing our skills through the written word is a wonderful way to extend knowledge. Sample topics could include abstracts, investigations, how-to articles and research trips. Anything with
epidemiological impact would be welcomed. Here, then, are your guidelines:

1.  Articles must be between 250 and 2,000 words in length.
2.  Use MS Word format for all articles.
3.  Font should be 11-point Arial with no centering, boxes or other elements added to the text.
4.  Charts, graphs, tables and other data should be e-mailed as a separate attachment to the main document.
Other graphics should be attached as a gif file.
5.  Include the author's name, title and professional designations for the byline, plus the bureau or business name
and telephone/email for contact purposes.
6.  Only final documents (not drafts) will be accepted. Please ensure the piece is proofread for accuracy prior to submission.
7.  All articles will be subject to editing.
8.  The deadline for submissions is each Tuesday at 5:00 p.m. Email all submissions to
jaime_forth@doh.state.fl.us.

Jaime Forth is managing editor of, and a contributing writer to, Epi Update.

        Salmonella Shown to use Hydrogen to Grow
                                                                                                                   by Jaime Forth

In a breakthrough finding headed by microbiologist Rob Maier, researchers at the University of Georgia have shown
that Salmonella use molecular hydrogen as a source of energy from which to initiate and nurture disease. 

Maier, a Georgia Research Alliance Eminent Scholar and Ramsey Professor of Microbiology at the University of Georgia in Athens,  Adriana Olczak and Susan Maier, also of UGA, and Shilpa Sonia and John Gunn from Ohio State University authored a paper published in the November issue of Infection and Immunity entitled Respiratory Hydrogen Use by Salmonella enterica Serovar Typhimurium is Essential for Virulence. In 2002, Maier published similar research showing that Helicobacter pylori, the gastric bacterium which cause ulcers and some forms of gastric cancers, also derive energy from hydrogen.

His latest research is based on our knowledge of genome sequencing of enteric pathogen Salmonella, which
contain three putative membrane-associated hydrogen-using hydrogenase enzymes. These enzymes split
molecular hydrogen with a metal center made of iron, nickel, carbon monoxide and cyanide. The research team
coupled each of the membranes to a respiratory pathway that used oxygen as the terminal electron acceptor,
and the pathogen subsequently developed.

Dr. Maier, whose project was funded through the Georgia Research Foundation, suspected that hydrogen-
using enzymes could allow bacteria to obtain energy from the splitting of the molecular hydrogen, and sought
to demonstrate it by measuring the gas produced by reactions of normal flora bacteria in the intestinal tract.
He and his team achieved this using mice as a model system.

The full abstract can be accessed at http://iai.asm.org/

Jaime Forth is managing editor of Epi Update and a freelance writer for other professional publications.
She can be reached at 850.245.4444, ext. 2440.

       This Week on EpiCom
                                                    by Pete Garner
                                

• Botulism in Broward County being investigated by the FDA
• Pinellas County investigating report of Vibrio vulnificus
• Bacterial Meningitis identified in male in Hendry County
• Cluster of botulism in Broward and Palm Beach Counties
• Measles in an unimmunized child from Hillsborough County who had recently traveled to India

Pete Garner is administrator of the Bureau of Epidemiology Surveillance Systems Section in
Tallahassee.  He can be reached at 850.245.4444, ext. 2481.

Mosquito-borne Disease Update     November 21-27, 2004
       Samantha Rivers, MS; Caroline Collins; Kristen Payne;
       Calvin DeSouza; Carina Blackmore, DVM, PhD

West Nile (WN) virus activity: No new human cases of WN illness this week, leaving the statewide total at 41. There were four seroconversions to WN virus in sentinel chickens from Hillsborough (1) and Pinellas (3) 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: There were two seroconversions to EEE virus in sentinel chickens from Leon and Walton counties. Three horses in Clay, Leon and Madison counties were reported with EEE virus infections. 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 this year. 

Highlands J (HJ) Virus activity: None this week. Twelve counties have reported HJ this year. 

Cooler weather in many parts of the state is helping to reduce mosquito populations. Where they are still
present, people are urged to take precautions against getting bitten. Dead birds should be reported to
 www.wildflorida.org/bird/.  See the Web page for more information: www.MyFloridaEH.com.   

Samantha Rivers, Caroline Collins, Kristen Payne and Calvin DeSouza are the arbovirus surveillance
team at the Bureau of Community Environmental Health in Tallahassee and can be reached at
850.245.2437. Dr. Carina Blackmore is the state public health veterinarian and can be reached at
850.245.4444, ext. 4732.

                         Weekly Disease Table
                                                                           D'Juan Harris, MSP

Click here to review the most recent disease figures provided by the Florida Department of Health Bureau of Epidemiology.

D'Juan Harris is a GIS specialist in the Surveillance Systems Section of the Bureau of Epidemiology.
He can be reached at 850.245.4444, ext. 2435.

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