August 25, 2006
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
On July 21, 2006, the Bureau of Epidemiology hosted the second of its four-part series of disease-specific conference calls. This was an introduction to Hepatitis A virus morphology, symptoms and transmission, case surveillance definition, and serological tests. There was an analysis of the distribution of Hepatitis A globally, in the United States, and Florida. In addition, there was a review of current guidelines in the prevention and control of Hepatitis A in a variety of settings.
The source of Hepatitis A is infected feces and the infection is primarily spread by the fecal-oral route. An infected individual may transmit the virus through close personal contact, contaminated food or water or, rarely, by blood exposure. Unlike Hepatitis B and Hepatitis C, no chronic carrier state exists for the Hepatitis A. Once infected with Hepatitis A, an individual develops antibodies which provide lifelong immunity.
Individuals infected with Hepatitis A may be symptomatic or asymptomatic. Symptoms include fever, malaise, anorexia, nausea, abdominal pain, and jaundice. It is important to note that the severity of illness increases with age. The incubation period of Hepatitis A is on average 30 days, with a range of 15-50 days. The concentration of virus in the stool is highest the week or more before the onset of recognizable hepatitis symptoms (Figure 1).
In the United States, the rate of Hepatitis A among all age groups began to decline after the recommendations by the Advisory Committee on Immunization Practice (ACIP) to prevent Hepatitis A through immunization in 1996 and 1999 (Figure 2). As depicted in the Florida Hepatitis Program 20-year Surveillance Report—February 2006, Florida had a lower incidence of Hepatitis A than the United States except for 2001-2002 (Figure 3). An investigation started in 2001 after an increase in the number of reported hepatitis A cases from Polk County. Cases were identified as young adults with a history of methamphetamine use, and their contacts.
An analysis of the reportable disease data in MERLIN for confirmed and probable Hepatitis A cases (N=289) for 2005 showed that 57% were males and 42% were females. In 2005, 52% were of Hispanic origin and 47% were of Non-Hispanic origin. Data from 2000-2005 also showed a higher percentage of males with Hepatitis A infection, but more Non-Hispanic individuals with Hepatitis A. Using MERLIN data and population estimates from Florida’s CHARTS, the highest rate of infection was in the 5-9 yr old age group (Figure 4). The lowest rate of infection is among those <1 year, which is most likely due to those in this age group being asymptomatic.
An analysis of reported risk factors among cases of Hepatitis A in 2005 depicted:
Using MERLIN’s Data Quality Report, there were 83 cases reported with unknown or blank values. Of these 83 cases with unknown or blank values, 45 cases had the outbreak variable reported as unknown. In 2005, the reason for testing these individuals, as indicated on the extended data form, were most likely due to acute symptoms of viral illness.
Prophylaxis against Hepatitis A Infection may include administration of Immune Globulin (IG) or Hepatitis A Vaccine ( HAVRIX®-GlaxoSmithKine, VAQTA® Merck&Co) or Hepatitis A and B Vaccine TWINRIX® (GlaxoSmithKline).
The discussion also included a comprehensive review of the most current guidelines for the prevention and control of Hepatitis A in a variety of settings from:
MMWR Recommendations and Reports for the Prevention of Hepatitis A through active or Passive Immunizations. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm
Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. 9th ed. Washington DC: Public Health Foundation, 2006 -Chapter 14. Available at http://www.cdc.gov/nip/publications/pink/hepa.pdf
* Florida Hepatitis Program 20-year Surveillance Report—February 2006 is available at http://www.doh.state.fl.us/Disease_ctrl/aids/hep/TwentyYearHepSurvReport1-Nov2005-final.pdf
Robyn Kay is an epidemiologist in the Bureau of Epidemiology Investigation Section, assigned to Jacksonville. She can be reached at 904.791.1747.
Acknowledgements: The author would like to thank and acknowledge the assistance of Richard S. Hopkins, MD, Joann Schulte, DO, Roger Sanderson, Jodi Baldy, and April Crowley.
Florida Melioidosis Cases Reported
An article in the most recent issue of Centers for Disease Control and Prevention's MMWR describes two cases of melioidosis reported by the Florida Department of Health in 2005. Both patient cases had visited Honduras prior to exhibiting symptoms.
Melioidosis is caused by the Burkholderia pseudomallei bacterium. Patients exhibit pneumonia-like symptoms, accompanied by septicemia in some. Both Florida cases were treated with antibiotics; one recovered and one expired.
Melioidosis is reportable in Florida. During the epidemiologic investigation, it was discovered that laboratorians at both treating hospitals might have been exposed to the bacteria when isolates were handled outside a biosafety cabinet. This occurred because B. pseudomallei went unrecognized as the source of Melioidosis, which resulted in a delay in notifying the local health department of the case. The article, written by Florida Department of Health personnel, discusses the case reports and presents further CDC editorial notes on the disease.
To access this article, go to:
Ciguatera Outbreak Associated with Consumption of Barracuda, August 2006
A total of five patient cases consumed the barracuda on August 1, 2006 for dinner. Three of the cases were adults and two were children. Their ages ranged from 6 to 39 years with a median age of 30. Four males and one female consumed the barracuda, which was fried. All became ill within one to six hours following ingestion with an average incubation period of 2.3 hours. As of August 21, three of the five persons were still sick. The two children only consumed ~2 oz portions and both experienced symptoms lasting ~1 day. The three adult cases who are still experiencing symptoms as of August 22 consumed 8 - 12 oz portions.
Four of the five cases (two adults and two children) visited the same local Broward County hospital emergency room and were seen between 11:00 p.m., August 1 and 1:00 a.m., August 2, according to medical records obtained from the hospital. The two adults were diagnosed with ciguatera poisoning by two different ER physicians. The two children were diagnosed with acute gastroenteritis by a separate pediatric ER physician. Only one of the adult cases was treated with Mannitol. The final adult case was also seen at the same hospital; however, he did not visit the hospital until August 10. He was diagnosed with acute dysuria (painful or difficult urination).
Three of the five cases reported having eaten barracuda in the past. They all stated they were unaware of the risks of consuming large reef fish such as barracuda, which may harbor ciguatoxin. All persons who consumed this particular barracuda became ill with ciguatera poisoning-like symptoms following ingestion. The relative who caught the barracuda, but did not eat it, did not become ill. Frequencies of symptoms are summarized in Table 1.
Ciguatera is a reportable disease in Florida. Improper communication resulted in a delay of reporting this outbreak to the local county health department. There were several possible reasons for the delay in the outbreak investigation. The initial complaint was reported to Florida Poison Information Center (FPICN) by an ER physician at a local hospital in Broward County on August 2, 2006. The hospital’s infection control practitioner was not notified of the two diagnosed cases of ciguatera poisoning that presented to the hospital that same day. The hospital, therefore, did not report the cases and outbreak to the Department of Health. When FPICN attempted to contact the local county health department, the e-mail addresses of the local contacts were incorrect, which also resulted in a delay in reporting of the outbreak.
Communication is an extremely important element during the investigation of an outbreak. Communication between local department of health contacts and the local county hospitals, and their Florida Department of Health contacts and the Florida Poison Information Center needs to be improved. Interaction within local hospitals between emergency room staff and infectious disease practitioners needs to be better defined and improved.
1 FDA's Bad Bug Book. Ciguatera. http://www.cfsan.fda.gov/~mow/chap36.html
Ryan Lowe is a regional environmental epidemiologist in the Food and Waterborne Disease Program for the Bureau of Community Environmental Health assigned to Broward County. He can be reached at 954.467.4841.
Bureau of Epidemiology Anticipates
Kevin Hodge, communications coordinator at the Department of Health in St. Thomas and Julie Armstrong, MPH, a public health epidemiologist at the Department of Health in St. Croix traveled to Tallahassee in August to visit Christie Luce, administrator of the bureau's Surveillance Systems Section, prior to beginning design of a separate interface that will integrate their system and our EpiCom information and communication system.
There are five health clinics in the US Virgin Islands, and two hospitals. The facilities are funded through local agreements and the Centers for Disease Control and Prevention. With a fluctuating population that caters to a thriving tourism industry, this geographic archipelago has much in common with Florida; a transient pool of potential patient cases, and a tropical climate that plays host to similar diseases and environmental risks.
The two entities have something else in common: CDC officer Mark Greene. When Greene was assigned to the Florida Department of Health a couple of years ago, he became acquainted with the EpiCom and Merlin systems through his work in public health preparedness. After his subsequent assignment to the Virgin Islands, he realized that limited resources were restricting efforts to create a better information-sharing network among healthcare workers there. He suggested officials at his new workplace contact technology staff at the Bureau of Epidemiology to explore ideas.
A series of discussions within both agencies during the past year led to the visit earlier this month from Kevin Hodge and Julie Armstrong. With health department leaders in the US Virgin Islands poised to sign on to EpiCom as a virtual 68th Florida county, several tasks remain to ensure a smooth integration. According to Armstrong, the ability to use the Bureau of Epidemiology system as an infection control tool will make it a valuable asset, and she plans to point that out to external partners in the islands. The opportunity to link with a wealth of resources here on the mainland, will be another. As the two meet with members of their healthcare community, they'll be using marketing and deployment strategies for coordinating use of the EpiCom system at their various locations. As Hodge said prior to departing Tallahassee, "I feel confident first responders and others will be excited to see a new and more sophisticated system in the Virgin Islands."
The Bureau of Epidemiology looks forward to welcoming its "68th" county to the state's EpiCom system, as well.
Jaime Forth is managing
editor of Epi Update. To reach her, call her in Tallahassee at
850.245.4444, ext. 2440. For answers to questions about the EpiCom
system, phone Christie Luce at 850.245.4444, ext. 2450.
Mosquito-borne Disease Summary August 13 - 19, 2006
Rebecca Shultz, MPH, Caroline Collins, Daneshia Roberts, Calvin DeSouza, Carina Blackmore, PhD
During the period August 13 - 19, 2006, the following arboviral activity (St. Louis Encephalitis virus [SLEv], Eastern Equine Encephalitis virus [EEEv], Highlands J virus [HJv], West Nile virus [WNv], California Group virus [CEv]) was recorded in Florida:
EEE virus activity There were seven seroconversions to EEEv reported in sentinel chickens from Alachua (5), Leon (1) and Nassau (1) counties. Two horses from Alachua and Madison counties were reported positive for EEEv infection this week. Of 15 sera samples collected from live wild birds, 2 were positive for antibodies to EEEv. A total of 21 counties have reported EEEv activity so far this year, compared to 46 at this time last year.
WN virus activity Two live wild birds collected in Okaloosa and Santa Rosa counties tested positive for flavivirus antibodies. So far, 13 counties have reported WNv activity this year, compared to 19 at this time last year.
No locally-acquired human cases of arboviral infection were reported yet this year. A Palm Beach resident with travel history to Missouri and an Escambia County resident with travel history to Louisiana and Mississippi were confirmed with West Nile virus infections this week. They will be reported to CDC's ArboNET as Florida cases acquired out-of-state, but will appear as Florida cases on the CDC weekly maps. A Hillsborough County resident with travel history to North Carolina was confirmed with LaCrosse encephalitis infection this week.
Wild Live Birds Out of 15 sera samples collected from Okaloosa and Santa Rosa counties between August 8 and August 10, two tested positive for antibodies to EEE virus and one tested positive for flavivirus antibody. One of the Okaloosa birds was reactive to both EEE and flavivirus antibodies.
See the web page for more information: www.MyFloridaEH.com. The Disease Outbreak Information Hotline offers recorded updates on medical alert status and surveillance at 888.880.5782. Dead birds should be reported to www.myfwc.com/bird/
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 Systems Project Analyst in the Surveillance Systems Section of the Bureau of Epidemiology. He can be reached at 850.245.4444, ext. 2435.
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