December 16, 2005
Epi Update Managing Staff:
"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
A total of nineteen health care workers attended the dinner. The food choices were limited to three appetizers, salad, three entrees and three desserts. One attendee kept the menu, aiding our ability to obtain food histories. Also, because a pharmaceutical company funded the dinner, a sign-in sheet was available to us. All but one person was contacted, and a complete line list was created from responses of eighteen individuals. Only one person had taken food home and not yet eaten it. She provided her slice of cheesecake to us for testing.
Five people reported illness within twelve hours of dinner. Symptoms included abdominal pain/cramping, diarrhea, nausea, and generalized malaise. After follow-up with cases on Monday, all reported symptoms had resolved during the weekend. No secondary cases were reported and the restaurant involved did not report any other complaints of illness nor any employees with gastrointestinal symptoms.
Upon analysis of the line list, cheesecake (Attack rate=75%, RR=4.9), potatoes (Attack rate=66.7%, RR=3.1), or green beans/carrots (Attack rate=66.7%, RR=3.1) were the most likely culprits. Unfortunately, the sample size and number ill were too small to reach significance for any of the food items with a chi-squared test at a=0.05. The p-value for cheesecake was p=0.0525.
Analysis of the cheesecake by the state laboratory revealed Bacillus cereus at 32 cfu/gram.
Symptoms caused by the diarrheal toxin of B. cereus are consistent with those present in our cases, namely cramping abdominal pain and watery diarrhea beginning 8-16 hours after eating with resolution within 12-24 hours. Since B. cereus can be found in the stool of up to 14% of people in the general population, stool samples were not useful in this investigation.
The cases in our investigation most likely became ill after eating cheesecake held at an improper temperature (between 40ºF and 140ºF) for too long either before or after cooking, allowing the B. cereus spores to multiply and produce a sufficient amount of toxin to cause symptoms. The restaurant has been notified of the causative agent and measures necessary to prevent a similar incident in the future. The restaurant received several unsatisfactory marks from DBPR, but none were critical violations. At the time of inspection, the refrigerator holding the cheesecake was at 40F and all aspects relating to cheesecake preparation and storage were appropriate.
Erin DeFries is an intern in epidemiology at the Alachua County Health Department and an MPH candidate in epidemiology at the University of Florida. Jerne Shapiro is an epidemiologist at the Alachua County Health Department and can be contacted via telephone at 352.334.8827.
Special thanks to Don Windham, Regional Environmental Epidemiologist and Ron Baker, Microbiology, Jacksonville state laboratory.
The Bureau of Epidemiology December Grand Rounds will be held on December 27 at 11:00 a.m. and presenters will be Joann Schulte, DO, MPH, medical epidemiologist and CDC Assignee to the Bureau of Epidemiology, and Phyllis Yambor, RN, Bureau of Immunizations, Florida Department of Health.
Field Trip Outbreak at
Indian River Lagoon
One of the children presented with fever of 102 degrees, nausea, vomiting and red, swollen, tender feet. There was no rash and lesions or open wounds on feet or legs. She was hospitalized with the diagnosis of cellulites secondary to r/o vibrio/staph infection and treated with a broad spectrum antibiotics ((Doxycycline and fortaz). Blood cultures were negative. She responded well and was discharged in good condition. Another child presented at the same time at the same physician’s office and was treated with antibiotics and sent home, as the parents did not agree to hospitalization.
Most children visited physicians and received antibiotics. All children showed improvement after 4-5 days. No marked improvement was noticed after initiating treatment. There were three adults, interviewed amongst these individuals, who accompanied children. They had similar symptoms.
Description of the field trip activities: All persons met at a pavilion at one of the two sites, Long Point or Sandler, and chosen for activities, where they were given instructions for the day. Everyone removed their shoes and put on the boots supplied by the Brevard Zoo before going in the river. The water was knee deep. The activities performed were scooping river material, critters and such from the river for study. A long net was held on each end by children to scoop the material. After about an hour and a half, the groups walked back to the pavilion, removed the boots, and rinsed their feet. Everyone was supposed to rinse their feet but whether everyone did is not certain. The boots were dipped in a pail of water, hosed down with tap water, and left in the sun to dry. No chemicals were used to clean or disinfect the boots. The process was repeated with another group of children the next day.
The educational program has been in place for past nine years. There have not been any such illnesses in the past. This year, however, new boots were bought and used by everyone who went in the water. The boots, including the soles, are made of 90% Neoprene and 10% nylon. There is a flap on the upper part that helps to trap the water, which then stays in the boot around the foot to keep it warm. There are two different styles of boots, but both are made of the same material. One has slightly heavier material than the other. Visitors noticed that the boots were not completely dry when they began to put them on..
The boot vendor received no previous reports of illness although the boots have been on sale for five years. Many people use Indian River Lagoon for activities. No such illness in other members of the community has been reported. It was reported that there were burning bushes in the area and possible use of chemicals, but the environmental division investigated and found no evidence of such activities. The Environmental Health Division also visited the area and noticed no unusual circumstances.
Analysis and Conclusion
The illness does not appear to be of infectious etiology, the reasons being:
The clinical picture does not resemble an illness such as sea lice or sea
eruption, i.e., no itching/red marks/bites.
Note, however, that if there could have been an underlying pathology such as fungal infection of the foot, an activity in the water could aggravate it.
The possibility of a chemical reaction fits into the time of onset, and perhaps the clinical picture. However, it would have been much more widespread than 4%. Secondly, no chemicals were used to clean the boots and no other reports in the community.
At this time it is recommended that boots either not be used, or used on a selective basis. If used, they should be properly cleaned and dried between usages. The proper fit should also be assured, considering physical factors adding to an underlying etiology.
Further studies could include testing the affected persons for neoprene allergy, doing a case control study by allowing persons to continue the activities in different groups with one group using the boots and the other not using boots. In addition, the boots could be numbered, tagged, and isolated to determine if it is only certain boots causing the problem. The study performed could address any underlying problems.
Dr. Aggarwal is senior physician at the Brevard County Health Department and can be reached at 321.454.7101.
Environmental Health Seeks
The position will be
under direct supervision of the Florida Childhood Lead Poisoning
Prevention Program coordinator.
If you have questions, contact Julie Kurlfink, program coordinator for the Lead Poisoning Prevention and Control Program at 850.245.4444 ext. 2869. This job has been posted on the University of Florida job site at http://jobs.ufl.edu/ under requisition number 034938, and an application deadline of 12/21/05 has been established.
The January program will specifically address public health surveillance and communicable disease outbreak investigations as well as epidemiologic response to natural disasters. Topics will include carbon monoxide poisoning surveillance, poison control, ESF 8 operations, arboviral surveillance, the medical examiner mortality system and an outbreak scenario. On-line registration is now available and can be accessed through the Bureau of Epidemiology Internet web site: http://www.doh.state.fl.us/disease_ctrl/epi/conf/training/agenda.htm The class will be limited to 45 participants. CEUs will be offered to nursing, environmental health professionals and laboratorians.
Accommodations have been arranged at the Hampton Inn Daytona Beach Speedway. To receive the government rate of $99 you must mention DOH, Confirmation #858-800-28. Be sure to present your tax exemption paperwork to the hotel staff to ensure proper billing. In addition, remember to book your room by Friday, December 23, 2005 to ensure your reservation.
Additional information will be provided in Epi Update and on the Bureau of Epidemiology web page. We intend to offer future training programs in other regions of the state. If you're interested in hosting one of these training sessions or have questions related to the program, please feel free to contact Linea Sundbye, assistant training coordinator at the Bureau of Epidemiology at 850.245.4444, ext. 2436 or SunCom 205.4444,ext. 2436.
We're truly excited about the potential this program offers for improving disease prevention in Florida, and encourage you not to delay in signing up!
Alachua, Hillsborough, Nassau, Brevard and Walton counties are currently under medical advisory for mosquito-borne illness. Pinellas, Pasco, Duval and Marion Counties are currently under a medical alert.
Dead birds should be reported to www.myfwc.com/bird/
See the web page for more information at www.MyFloridaEH.com. The Disease Outbreak Information Hotline offers recorded updates on medical alerts status and surveillance at 888.880.5782.
The Bureau of Epidemiology encourages
Epi Update readers to not only register on the EpiCom system at
https://www.epicomfl.net but to sign up for features such as automatic
notification of certain events
contribute appropriate public health observations related
any suspicious or unusual occurrences or circumstances. EpiCom is the primary method of communication
between the Bureau of Epidemiology and other state medical agencies during emergency situations.
Christie Luce is administrator
of the Surveillance Systems Section in the Bureau of
Epidemiology. She can be reached at 850.245.4444, ext. 2450.
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
Copyright©2005 State of Florida