December 17, 2002

"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. 
Int. J of Epidemiology
1976; 5:29-37

Epi Update Managing Staff
John Agwunobi, MD, MBA,
Secretary, Department of Health 

Landis Crockett, MD, MPH, 
Director, 
Division of Disease Control 

Steven T. Wiersma, MD, MPH,
Bureau Chief, 
State Epidemiologist 

Don Ward, 
Deputy Bureau Chief 
Epi Update Managing Editor 

Catherine Richards, 
Editorial Assistant 

Elizabeth Woodsmall,
Web Page Designer

A r t i c l e s:

 
Rob Hayes,
Director of Communication



Dr. Agwunobi
has designated
Dr. Bill Tynan, Deputy State Epidemiologist, as coordinator of Operation Vaccinate Florida.

Rob Hayes,
Director of Communication



The Florida
 Department of Health
 has confirmed the
 27th and 28th
human cases of
West Nile (WN) virus
 encephalitis in Florida
 this year.  Both cases
 resulted in death considered to be
WN virus-related.

Note:
“norovirus” was recently approved as the official genus name assigned to the group of viruses provisionally described as "Norwalk-like viruses".

Carina Blackmore,
M.S. Vet. Med., Ph.D.



Higher flu activity
than expected for this
time of year (>2%)
was reported by
physicians in Duval,
Okaloosa and Polk counties

Caroline Collins,
Arbovirus Surveillance Coordinator

Lisa Conti, DVM, MPH
State Public Health Veterinarian

and D’Juan Harris,
GIS Coordinator

Disclaimer:
Please note that
numbers are subject
to change with
confirmatory information.

To report dead birds use: 
http://wildflorida.org/bird/ 
http://wld.fwc.state.fl.us/bird/ 
or call toll free 1-800-871-9703

► Governor and Secretary of Health Commend
President Bush's Decision To Vaccinate Volunteer 
Response Teams Against Smallpox
Governor Jeb Bush and Florida Department of Health (DOH) Secretary Dr. John Agwunobi commend President Bush's decision to vaccinate volunteer response teams against the smallpox disease. Florida, as part of an ongoing collaboration with the Centers for Disease Control and Prevention (CDC), the Florida health care provider community and Florida's Domestic Security leadership in the area of public health preparedness, recently submitted updated plans to the federal government for the vaccination of hospital and public health professionals.

Dr. Agwunobi has designated Dr. Bill Tynan, Deputy State Epidemiologist, as coordinator of Operation Vaccinate Florida.

"The President has accepted the challenge and made a difficult decision. I know he put a great deal of time and thought into this, and in the end decided it was imperative that we protect our protectors - medical response teams and military personnel," said Governor Bush. "Although we have no current information indicating a smallpox attack is imminent, we continue to believe it is wise to aggressively prepare to ensure the safety of our state and nation."

"I praise President Bush for the leadership he has displayed in making this decision, and for the efforts he made to ensure there is enough vaccine available for the entire population, if needed," said Dr. Agwunobi. "Through the guidance he has already provided us through our collaboration with the CDC, we have developed plans to protect Floridians against the potential threat of smallpox and mitigate the consequences that could result from an intentional release of this disease."

Agwunobi said Department of Health officials at the state and local level have worked closely with federal, state and local agencies, public and private representatives, legislators and other elected officials in its pursuit of preparedness. The planning was based upon the framework for collaboration provided by Governor Jeb Bush through his Domestic Security Task Forces at the state and regional levels.

The Department of Health has submitted two plans to the federal government: an implementation plan to make smallpox vaccine available to Florida's citizen's prior to the identification of a first smallpox case (a pre-event smallpox vaccination plan); and a plan to respond to an actual smallpox case or outbreak (a post-event plan). Additionally, a detailed implementation plan for Stage I of the pre-event plan (Operation Vaccinate Florida) has been submitted to the federal government for review and input. 

Operation Vaccinate Florida involves the voluntary immunization of Florida residents in three phases, with varying time between each phase

The first stage, which is estimated to last 30 days, is expected to include the vaccination of hospital response teams and county health department personnel. DOH estimates that approximately 35,000 to 40,000 doses will be provided to protect these health care professionals and ensure a core group of trained and protected health professionals will be available to help conduct future phases of Operation Vaccinate Florida;

The second stage is expected to include the vaccination of first responders such as law enforcement officers, firemen, emergency medical crews, etc. as well as other health care professionals. DOH estimates that during the second phase, approximately 300,000 to 400,000 doses will be provided to protect and prepare these individuals; and

The third and final stage, should the federal government determine the need to proceed, would include the voluntary vaccination of the general public. DOH estimates that up to 10 million individuals might be eligible in Florida for phase III vaccination against smallpox. An as yet undetermined number of the population will be ineligible to receive the vaccine due to pregnancy, eczema, and various other contraindications.

The post-event plan, outlining Florida's response to the identification of a smallpox case, would be conducted as an emergency, using all the resources included in the state's emergency operations, domestic security, and Department of Health structure. The response would also involve mobilization of many of the resources available in the non-state government domestic security community. The response would include both "ring vaccination" of all contacts of cases as well as statewide voluntary mass vaccination for citizens and visitors. The plan also includes DOH's existing national pharmaceutical stockpile distribution plan, as well as the state's "All Hazard" response plan used effectively in hurricane response, many of the components of its pandemic influenza plan, surveillance and isolation considerations, and a host of other important strategies.

Smallpox Training
Drs. Steven Wiersma and Fermin Arguello conducted smallpox vaccination training in Orlando on Saturday, December 7, 2002. This training was conducted for over 350 Disaster Medical Assistance Team (DMAT) members and County Health Department employees in vaccination against smallpox and issues associated with adverse events as part of pre-event vaccination efforts.
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► Two West Nile Virus-Related Deaths Confirmed 
in Marion and Sarasota Counties
The Florida Department of Health (DOH) has confirmed the 27th and 28th human cases of West Nile (WN) virus encephalitis in Florida this year—in a 74-year-old Marion County resident and in a 71-year-old Sarasota County resident. Both cases resulted in death considered to be WN virus-related. Marion County has been under medical alert for WN virus since August 13. This is the second case of WN virus in Sarasota County this year, which has been under medical alert for the virus since September 9.

“Due to Florida’s warm climate, the potential for exposure to the West Nile virus is a year round issue,” said DOH Secretary John O. Agwunobi, M.D., M.B.A. “Unfortunately, it appears that this individual has succumbed to complications resulting from West Nile virus encephalitis. This tragedy reminds us of the ongoing importance of the precautions we all must take to avoid being bitten by mosquitoes.”

The following 39 counties are now under medical alert for WN virus and other mosquito-borne diseases: Alachua, Brevard, Charlotte, Citrus, Clay, Collier, DeSoto, Duval, Escambia, Flagler, Glades, Hardee, Hendry, Hernando, Highlands, Hillsborough, Indian River, Jackson, Lake, Lee, Levy, Manatee, Marion, Martin, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Putnam, Santa Rosa, Sarasota, Seminole, St. Johns, St. Lucie, Sumter and Volusia counties. 

Agwunobi recommends people take the following precautionary measures to avoid being bitten by mosquitoes:

• Avoid outdoor activities when mosquitoes are active, especially at dusk and dawn; 
  

• If you must be outdoors when mosquitoes are active, cover up by wearing shoes, socks, long pants and a long-sleeved shirt. Additional protection can be obtained by applying permethrin repellent directly to clothing;
  

• For adults and children older than two months of age, the best protection is achieved by using mosquito repellent containing 30 percent DEET (N,N-Diethyl-meta-toluamide also called N,N-diethyl-3- methylbenzamide) according to manufacturer’s directions. Greater concentrations provide no additional benefits and risk increased incidence of side effects. For children younger than two months of age DEET is not recommended; use protective clothing and cover with mosquito netting;
  

• Eliminate stagnant water in birdbaths, ponds and other receptacles in which mosquitoes might breed by emptying or changing.

The Department of Health laboratories provide testing services for physicians treating patients with clinical signs of mosquito-borne (arboviral) disease. These signs may include headache, fever, fatigue, dizziness, weakness and confusion. Physicians should submit serum and, if available, cerebrospinal fluid samples to either the Tampa or Jacksonville Department of Health laboratories. People over the age of 50 are at the greatest risk of having severe disease from an arbovirus infection.

DOH continues to conduct statewide surveillance for arboviruses, including West Nile (WN) virus, Eastern Equine Encephalomyelitis (EEE) and St. Louis Encephalitis (SLE). Residents of Florida are encouraged to report dead birds by calling the West Nile Virus Hotline at 1-800-871-9703, or via the Web site www.wildflorida.org/bird. For more information on WN virus, visit the DOH Bureau of Epidemiology’s Web site at www.doh.state.fl.us (click on Epidemiology, then Health Topics), call the Bureau’s hotline at 1-888-880-5782 for recorded information, or call your local county health department.
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► Outbreaks of Norovirus Gastroenteritis On Cruise 
Excerpted from http://www.cdc.gov/travel/other/gastro_illness_cruiseships.htm (12/06/02) and Epi-X

Since January 2002, the Vessel Sanitation Program of the Centers for Disease Control and Prevention has received 21 reports of outbreaks of acute gastroenteritis on cruise ships, compared with 7 outbreaks reported in 2001. Nine of the 21 were confirmed as caused by noroviruses by laboratory analysis of stool specimens, using RT-PCR. Note: “norovirus” was recently approved as the official genus name assigned to the group of viruses provisionally described as "Norwalk-like viruses". 

The Vessel Sanitation Program, in partnership with the cruise line industry, recently investigated several outbreaks of gastrointestinal illness aboard cruise ships. On November 21, 2002, 64 passengers and 18 crew aboard the Amsterdam (Holland America Cruise Lines) developed gastrointestinal illness, later confirmed to be Norwalk virus. Holland America voluntarily took the ship out of service to avert further illness and conduct cleaning and disinfection of the vessel. The Amsterdam returned to service on December 1, and its staff is providing daily reports to CDC. As of December 4, 2 passengers and 1 crew have had gastrointestinal illness.

Norwalk virus has also been confirmed as the cause of a recent outbreak of gastrointestinal illness aboard the Magic (Disney Cruise Line), in which 163 passengers and 12 crew became ill. The ship remains in port for cleaning and disinfection, monitored by the Vessel Sanitation Program. Gastrointestinal illness has also been reported among 189 passengers and 13 crew on the cruise ship Fascination (Carnival Cruise Lines) that returned to port on December 2 following a 3-day cruise.

On December 4 the Oceana (P&O Cruises, UK) on a 14-day Caribbean cruise, reported gastrointestinal illness among 114 passengers and 3 crew. All passengers were British nationals, most had traveled together by air from the United Kingdom to Fort Lauderdale, the city of embarkation. 

Cruise ship travelers are reminded that basic hygienic practices, such as frequent and thorough hand washing and avoiding contact with other passengers when ill, are important measures to prevent the spread of disease.

Outbreaks Associated with a Predominant Strain
CDC has been confirming outbreak strains of noroviruses since January 2002. The strains of noroviruses detected from passengers on 4 different ships (Dawn Princess, Ryndaam, Amsterdam, and Magic) were genetically indistinguishable, based on a 172-bp fragment of the RNA polymerase gene. In addition, of the 29 non-cruise ship, norovirus-associated outbreaks for which CDC provided lab confirmation, five were caused by strains that were genetically identical to those detected during the 4 recent cruise ship outbreaks. These 5 outbreaks occurred in North Carolina, Kentucky, Alaska, Georgia, and Utah. An additional 5 outbreaks caused by this strain were reported from Michigan. 

There may be a predominant norovirus strain associated with the majority of recent outbreaks. Further genetic characterization of a 277-bp fragment of the capsid protein gene from strains detected in seven of the outbreaks has identified four slightly different sequence variants among those with identical RNA polymerase sequences. The lack of routine norovirus surveillance in the US, and the scarcity of data on circulating strain types in the general population, limit our ability to assess the significance of finding strains with identical sequences in multiple outbreaks and define the extent of circulation of the predominant strain. 

The Viral Gastroenteritis Section (VGS), REVB, DVRD, NCID, CDC, encourages local and state health departments to send specimens to state public health laboratories or the CDC to test for norovirus when investigating outbreaks of suspected viral gastroenteritis. For health department laboratories currently testing for noroviruses, we request that aliquots of all positive samples be sent to VGS for further strain characterization. Laboratory and/or epidemiologic assistance is available from VGS by contacting Ms. Sandra Bulens (epi) at 404-639-1159, sbulens@cdc.gov; Ms. Suzanne Beard (lab) at 404-639-1923, sbeard@cdc.gov; or our epidemiologist-on-call, 404-639-3607.

For more information on recent cruise ship outbreaks and CDC’s Vessel Sanitation Program, see: http://www.cdc.gov/nceh/vsp/outbreak/2002/amsterdam.htm http://www.cdc.gov/nceh/vsp/outbreak/2002/ryndam.htm 

For information on gastrointestinal viruses, including Norwalk-like virus, see: http://www.cdc.gov/od/oc/media/fact/norwalkv.htm http://www.cdc.gov/ncidod/dvrd/gastro.htm 

Additional information about CDC’s Vessel Sanitation Program available at http://www.cdc.gov/nceh/vsp
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► Influenza Virus Surveillance Summary Update
Week ending November 30, 2002-Week 48
Florida: During week 48 (November 24-30, 2002) influenza activity, calculated based on the proportion of patients with influenza-like illness (ILI) seeking care by physicians participating in the Florida Sentinel Physicians Surveillance Network was 1.6%. Although the activity is increasing over time it is below the national baseline of 1.9%. Higher flu activity than expected for this time of year (>2%) was reported by physicians in Broward, Duval, Leon, Orange, Palm Beach, Polk and Sarasota counties. Two influenza isolates (influenza A (H1N1) from Leon County and influenza A (H3N2) from Indian River county) were reported this week. Influenza cases confirmed by rapid tests were also reported from Miami-Dade County. Earlier this season, influenza viruses (Influenza A (H1N1)) were detected in Broward and Holmes counties.  

National Report: Seven isolates (3 influenza A and 4 influenza B viruses) were made from 519 specimens tested by the World Health Organization (WHO) and National Respiratory and Enteric Virus Surveillance System (NREVSS) collaborating laboratories this week. Since September 29, 0.5% (n=55) of the 10,691 specimens tested nationwide have been positive. Eight (35%) of the 24 influenza A viruses have been subtyped; 7 were influenza A H1 viruses and 1 was an influenza A (H3N2). 

Influenza A activity has been detected in Florida, Hawaii, Louisiana, Nebraska, New York, North Carolina, Oregon, South Carolina, Texas and Virginia. Influenza B isolates have been identified in Louisiana, New York, Oklahoma, South Carolina and Texas. CDC has characterized three influenza A (H1N1), one influenza A (H1N2), one influenza A (H3N2) and five influenza B isolates antigenically. All strains were similar antigenically to corresponding vaccine strains. The proportion of patient visits to sentinel physicians for influenza-like illness (ILI) was 1.4% nationwide. 

Outbreaks were reported from Colorado, Tennessee and Texas. Sporadic influenza activity was reported from 18 states (Alabama, Florida, Georgia, Indiana, Kansas, Louisiana, Maine, Michigan, Missouri, Nebraska, Nevada, New Mexico, New York, Oklahoma, Oregon, Utah, Vermont and West Virginia). The proportion of deaths attributed to pneumonia and influenza as reported by the vital statistics offices of 122 U.S. cities was 7.1% during week 47. This percentage is below the epidemic threshold of 7.4% for this time. 
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► Arboviral Activity Summary Week Ending 12/16/02

During the period of December 10, 2002 through December 16, 2002, the following arbovirus activity (St. Louis encephalitis [SLE] virus, eastern equine encephalomyelitis [EEE] virus, West Nile [WN] virus and dengue virus) was recorded for Florida:

Human:  Two cases of  West Nile Virus were reported this week, a 74 year-old resident of Marion County (Marion’s third case this year), and a 71 year-old resident of Sarasota County (Sarasota’s second case this year). These cases were the state’s first fatalities.

Sentinel Chickens:  Twenty-two WN seroconversions were confirmed in Charlotte (1), Citrus (1), Flagler (1), Hillsborough (3), Indian River (1), Leon (1), Martin (1), Okeechobee (1), Palm Beach (4), Pinellas (2), Sarasota (4) and St. Lucie (2) counties.   Two EEE seroconversions  were confirmed in Walton County.  This week,  635 samples were tested from 20 counties. 
Equine*:  Twenty WN cases were reported from the following counties: Holmes (3), Levy (6), Marion (8), Martin (1), Palm Beach (1) and  St. Johns (1).
Bird Mortality:  Three dead birds were reported with WN from Dixie (1) and Jackson (2) counties, representing the first WN activity for Dixie County.   More than 2,300 birds were tested and an additional 407 were too decomposed to be tested.  To date, 9,758 bird reports were logged representing 11,347 dead birds; 1,225 (11%) were crows; 1,334 (12%) were blue jays and 305 (3%) were raptors.

To report dead birds use http://wildflorida.org/bird/.  Online bird identification: http://www.mbr-pwrc.usgs.gov/id/framlst/framlst.html or http://data.acnatsci.org/ornithology/vireo.php 

Mosquito Pools:  No new mosquito pools were reported WN positive this week.  A  total of 4,209 mosquito pools collected during 2002 have been submitted for testing at the DOH Tampa Laboratory.  At least 982 additional pools have been tested by mosquito control agencies and 298 pools have been tested by Department of Defense installations in the state.

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► Welcome Dr. Alan D. Rowan
We welcome Alan D. Rowan, Dr.P.H., to the Bureau of Epidemiology. Dr. Rowan comes to us with over ten years experience in the field of environmental epidemiology with the Florida Department of Health, specializing in lead poisoning, pesticide exposure, and aquatic toxins. He is currently the Florida Birth Defects Registry Coordinator and supervisor of the Surveillance Section in the Bureau of Environmental Epidemiology. He has published more than 25 scientific publications and presentations. Dr. Rowan began work here on December 16 and will supervise six staff.

Dr. Rowan will be the Program Administrator for the Florida Epidemic Intelligence Service (FL EIS), a unique one-year and two-year, post-graduate program of service and on-the-job training for health professionals in epidemiology. The program was founded in 2001 as part of the state’s response to terrorism and will train epidemiologists to assist county health departments in identifying and resolving disease outbreaks.

The Bureau of Epidemiology has a long history of training CDC EIS officers who have gone on to hold senior positions in public health and other areas. The long-term goal of this program is to increase the capacity of the Department of Health to respond to new challenges in disease control and prevention.

When not at work, Dr. Rowan enjoys camping and running (he is planning to run a marathon in February). He and his wife Karen have two girls, six and eight.
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► Weekly Disease Table : Week 50
Florida Department of Health, Bureau of Epidemiology
Weekly Morbidity Report, Week 50, ending December 14, 2002
Selected Diseases and Conditions (Confirmed Cases Only)

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