Florida Morbidity Statistics Report

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Florida Department of Health Bureau of Epidemiology Florida Morbidity Statistics Report

2008

Florida Department of Health Division of Disease Control Bureau of Epidemiology 4052 Bald Cypress Way, Bin # A-12 Tallahassee, Florida 32399-1720 850-245-4401

http://www.doh.state.fl.us/

Florida Morbidity Statistics Report 2008: http://www.doh.state.fl.us/disease_ctrl/epi/Morbidity_Report/amr_2008.pdf

Published August 2009 Table of Contents

Acknowledgments...... v

Introduction...... ix Purpose...... ix Report Format...... ix Data Sources...... ix Interpreting the Data...... x Florida County Boundaries...... xii Population Estimates...... xiii Table A: Florida Population by Year and County, 1999-2008...... xiii Table B: Florida Population by Age Group, 2008...... xv Table C: Florida Population by Gender, 2008...... xv Table D: Florida Population by Race Aggregated to White and Non-White, 2008...... xv List of Reportable Diseases/Conditions in Florida, 2008...... xvi Selected Florida Department of Health Contacts...... xvii Vaccine-Preventable Diseases in Florida...... xviii

Section 1: Summary of Selected Notifiable Diseases and Conditions...... 27 Table 1.1: Reported Confirmed and Probable Cases and Incidence Rate per 100,000 Population for Selected Notifiable Diseases, Florida, 1999-2008...... 29 Table 1.2: Reported Confirmed and Probable Cases of Notifiable Diseases of Infrequent Occurrence, Florida, 1999-2008...... 30 Table 1.3: Reported Confirmed and Probable Cases and Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008...... 32 Table 1.4: Reported Confirmed and Probable Cases and Incidence Rate per 100,000 Population for Selected Notifiable Diseases by Age Group, Florida, 2008...... 42 Table 1.5: Top 10 Reported Confirmed and Probable Cases of Disease by Age Group, Florida, 2008.... 43 Table 1.6: Reported Confirmed and Probable Cases and Incidence Rate per 100,000 Population for Selected Notifiable Diseases by Gender, Florida, 2008 ...... 44 Table 1.7: Reported Confirmed and Probable Cases of Selected Notifiable Diseases by Month of Onset, Florida, 2008...... 45

Section 2: Selected Notifiable Diseases and Conditions...... 47 Acquired Immune Deficiency Syndrome/Human Immunodeficiency Virus...... 48 Brucellosis...... 58 Campylobacteriosis...... 60 Chlamydia...... 62 Ciguatera Fish Poisoning...... 65 Cryptosporidiosis...... 67 Cyclosporiasis...... 70 Dengue Fever...... 72 Eastern Equine Encephalitis...... 75 Ehrlichiosis/Anaplasmosis...... 77 Escherichia coli, Shiga Toxin Producing...... 79 Giardiasis...... 82 Gonorrhea...... 85 Haemophilus influenzae, Invasive Disease...... 88 Hepatitis A...... 91 Hepatitis B (+HBsAg in Pregnant Women)...... 94 ii Hepatitis B, Acute...... 95 Hepatitis C, Acute...... 99 Lead Poisoning...... 101 Legionellosis...... 103 Listeriosis...... 105 Lyme Disease...... 108 Malaria...... 111 Measles...... 114 Meningitis, Other (Bacterial, Cryptococcal, Mycotic)...... 115 Meningococcal Disease...... 117 Mumps...... 120 Neonatal Infections...... 121 Pertussis...... 123 Rabies, Animal...... 125 Rabies, Possible Exposure...... 127 Rocky Mountain Spotted Fever...... 131 Salmonellosis...... 134 Shigellosis...... 136 Streptococcal Disease, Invasive Group A...... 139 Streptococcus pneumoniae, Invasive Disease, Drug-Resistant...... 141 Streptococcus pneumoniae, Invasive Disease, Drug-Susceptible...... 145 Syphilis...... 147 Tetanus...... 149 Toxoplasmosis...... 150 Tuberculosis...... 153 Typhoid Fever...... 158 Varicella...... 160 Vibrio Infections...... 163 West Nile Virus...... 166

Section 3: Summary of Foodborne Diseases...... 169

Section 4: Summary of Antimicrobial Resistance Surveillance...... 177

Section 5: Summary of Enhanced Surveillance for Influenza and Community Associated MRSA Deaths...... 191

Section 6: Summary of Notable Outbreaks and Case Investigations...... 193

Section 7: Recently Published Papers and Reports...... 221

Section 8: Summary of Cancer Data, 2006...... 235

Section 9: Summary of Revisions to Florida’s Notifiable Disease Reporting Rule (Chapter 64D-3, F.A.C.)...... 244

iii iv Acknowledgements

Disease control and prevention is one of the core functions of any city, county, local, or state public health agency. Indeed, the mission of the Florida Department of Health is “to promote, protect and improve the health of all Floridians.” With this in mind, there has been a worrisome trend in the re-emergence of diseases that were considered rare even just a decade ago. Many of these re-emerging diseases are vaccine-preventable and have seen a resurgence in parts of the state, country, and world where immunization coverage rates have slipped. There have been reports of measles outbreaks in many European countries as well as internationally imported cases in Australia and New Zealand. The ease of international travel and the popularity of Florida as a destination make cases of infectious disease in foreign countries a real threat to the health of Floridians. Additionally, the decrease in immunization rates in the U.S. puts many more people at risk and increases the possibility of endemic transmission of many of these diseases.

Protection of the public’s health from these emerging and re-emerging diseases is a collaborative effort by many within and outside the Florida Department of Health and requires diligence in all areas. Our most important partners facing this emerging trend are the physicians, nurses, laboratorians, hospital infection control practitioners and other health care professionals who participate in reportable disease surveillance. Without their participation, our ability to recognize and intervene in emerging public health issues would be impeded.

The Bureau of Epidemiology would like to thank the other program areas within the Florida Department of Health that contributed information to this report including the Bureau of Immunization, Bureau of HIV/AIDS, Bureau of Sexually Transmitted Diseases Prevention and Control, Bureau of Tuberculosis and Refugee Health, and Bureau of Environmental Public Health Medicine. Finally, many thanks are extended to the County Health Department staff and other public health professionals who are involved in reportable disease surveillance, either through disease control activities, case investigations, data collection, or other essential functions.

We hope readers will find this document useful when setting priorities and directions for action at the individual and community levels to improve the health of all Floridians.

Julia Gill, Ph.D., M.P.H. Chief, Bureau of Epidemiology

v vi Florida Morbidity Statistics Report Staff

Editors

Kate Goodin, M.P.H. Bureau of Epidemiology Aaron Kite-Powell, M.S. Bureau of Epidemiology Janet J. Hamilton, M.P.H. Bureau of Epidemiology Richard S. Hopkins, M.D., M.S.P.H. Bureau of Epidemiology Leesa Gibson , M.S. Bureau of Epidemiology

Contributors

Rebecca Alcantara, R. N. Duval County Health Department Margie Alderman Hendry County Health Department Isabel Anasco, R.N., B.S.N. Alachua County Health Department David Atrubin, M.P.H. Hillsborough County Health Department Taj Azarian, M.P.H. Duval County Health Department Lauren Ball, D.O., M.P.H. Bureau of Epidemiology Rosanna Barrett, M.P.H. Bureau of Environmental Public Health Medicine Mary Beverly, R.S. Escambia County Health Department Carina Blackmore, D.V.M., Ph.D. Bureau of Environmental Public Health Medicine Dean Bodager, R.S., M.P.A., D.A.A.S Bureau of Environmental Public Health Medicine Tracinda Bush Bureau of HIV/AIDS Pedro Castellon, M.P.H. Collier County Health Department Adrian Cooksey, M.P.H. Bureau of Sexually Transmitted Diseases Prevention and Control Virginia Crandall, R.N., B.S.N., M.P.H. Citrus County Health Department John DePasquale, M.D., M.P.H. Bureau of Epidemiology Timothy Doyle, M.P.H. Bureau of Epidemiology Russell Eggert, M.D., M.P.H. Division of Disease Control Leah Eisenstein, M.P.H. Bureau of Epidemiology Brian Fox, M.A. Bureau of Epidemiology Kimberly Fraser, M.P.H. Osceola County Health Department Mike Friedman, M.P.H. Bureau of Environmental Public Health Medicine Kate Goodin, M.P.H. Bureau of Epidemiology Roberta Hammond, Ph.D., R.S. Bureau of Environmental Public Health Medicine Janet J. Hamilton, M.P.H. Bureau of Epidemiology Terri Harder, B.S.N., R.N. Collier County Health Department Richard Hutchinson Bureau of Environmental Public Health Medicine Diane King, R.N., M.S.P.H. Palm Beach County Health Department Marjorie Kirsch, M.D. Leon County Health Department Aaron Kite-Powell, M.S. Bureau of Epidemiology Catherine Kroll, M.P.H. Leon County Health Department Richard S. Hopkins, M.D., M.S.P.H. Bureau of Epidemiology Tara Hylton, M.P.H. Bureau of Epidemiology Robyn Kay, M.P.H. Bureau of Epidemiology

vii Becky Lazensky, M.P.H. Bureau of Environmental Public Health Medicine Ryan M. Lowe, M.P.H. Bureau of Environmental Public Health Medicine Yvonne Luster-Harvey, M.P.H. Bureau of Tuberculosis and Refugee Health Lorene Maddox, M.P.H. Bureau of HIV/AIDS Sarah D. Matthews, M.P.H. Lake County Health Department Kateesha McConnell, M.P.H. Bureau of Epidemiology Travis McLane Bureau of Epidemiology Catheryn Mellinger, R.N., B.C. Bureau of Immunization Lisa Palmatier, R.N., N.P.S. Volusia County Health Department Scott Pritchard, M.P.H. Sarasota County Health Department Patricia Ragan, Ph.D., M.P.H. Bureau of Epidemiology Edhelene Rico, M.P.H. Miami-Dade County Health Department Samantha Rivers, M.S., M.P.H. Santa Rosa County Health Department Laura Rutledge, R.N., B.S.N. Bureau of Immunization Roger Sanderson, M.A., B.S.N. Bureau of Epidemiology Cindy Siegenthaler, R.N. Lake County Health Department J. Robert South, Ph.D., M.P.H., P.A. Lee County Health Department Danielle Stanek, D.V.M. Bureau of Environmental Public Health Medicine Juan Suarez Bureau of Environmental Public Health Medicine Holli M. Tietjen, M.S. Palm Beach County Health Department Sharleen Traynor, M.P.H. Charlotte County Health Department Kathleen Van Zile, R.S., M.P.H. Bureau of Environmental Public Health Medicine Donna J. Walsh, M.P.A., R.N., B.S.N. Orange County Health Department Janet Wamnes, M.S. Bureau of Environmental Public Health Medicine Connie Wolfe, R.N., B.S.N. Clay County Health Department Phyllis Yambor, R.N. Bureau of Immunization

viii Introduction

Purpose

The Florida Morbidity Statistics Report is compiled to: 1. Summarize annual morbidity from notifiable acute communicable and environmental diseases, and cancer in Florida; 2. Describe patterns of disease as an aid in directing future disease prevention and control efforts; and, 3. Provide a resource to medical and public health authorities at county, state, and national levels.

Report Format

This report is divided into 10 sections: Section 1: Summary of Selected Notifiable Diseases and Conditions Section 2: Selected Notifiable Diseases and Conditions Section 3: Summary of Foodborne Diseases Section 4: Summary of Antimicrobial Resistance Surveillance Section 5: Summary of Enhanced Surveillance for Influenza and Community Associated MRSA Deaths Section 6: Summary of Notable Outbreaks and Case Investigations Section 7: Recently Published Papers and Reports Section 8: Summary of Cancer Data, 2006 Section 9: Summary of Revisions to Florida’s Notifiable Disease Reporting Rule (Chapter 64D-3, F.A.C.)

Data Sources

Data presented in this report are based on reportable disease information received by county and state health department staff from physicians, hospitals, and laboratories. Data on occurrence of reportable diseases in Florida were obtained through passive and sometimes active surveillance. Reporting suspect and confirmed notifiable diseases or conditions in the State of Florida is mandated under Florida Statute 381.0031, Chapter 64D-3, Florida Administrative Code (F.A.C.). People in charge of laboratories, practitioners, hospitals, medical facilities, or other locations providing health services (can include schools, nursing homes, and state institutions) are required to report diseases or conditions and the associated laboratory test results listed in the Table of Notifiable Diseases or Conditions, Chapter 64D-3 F.A.C. Reporting test results by a laboratory does not nullify the practitioner’s obligation to also report the disease or condition. These data are the basis for providing useful information on reportable diseases and conditions in Florida to healthcare workers and policymakers, and would not be possible without the cooperation of the extensive network involving both private and public sector participants. 1. Passive surveillance relies on physicians, laboratories, and other healthcare providers to report diseases to the Florida Department of Health (FDOH) using a confidential morbidity report form, electronically, by telephone, or by facsimile. 2. Active surveillance entails FDOH staff regularly contacting hospitals, laboratories, and physicians in an effort to identify all cases of a given disease. 3. Increasingly, information about cases of reportable diseases is passed from providers, especially laboratories, to the FDOH as electronic records, which occurs automatically.

ix Interpreting the Data

This report should be interpreted in light of the following limitations:

1. Under-reporting Evaluations of infectious disease reporting systems have, in general, indicated that the completeness of reporting varies by disease. The less common, more severe reportable diseases such as bacterial meningitis, diphtheria, polio, botulism, anthrax, tuberculosis, and congenital syphilis are more completely reported than the more common but (individually) less severe diseases such as hepatitis A or campylobacteriosis. Variation in reported disease incidence at the local level reflects, to varying degrees, both differences in the true incidence of disease and differences in the vigor with which surveillance is performed.

2. Reliability of Rates All incidence rates in this report are expressed as the number of reported cases of a disease per 100,000 population unless otherwise specified. Animal rabies is only reported as the number of cases, because no reliable denominators exist for animal populations. Rates for diseases with only a few cases reported per year can be unstable and should be interpreted with caution. The observation of zero events is especially difficult to interpret. All rates in the report based on fewer than 19 events should be considered unreliable. This translates into a relative standard error of the rate of 23% or more, which is the cut-off for rate reliability used by the National Center for Health Statistics.

3. Reporting Period The data in this report are aggregated by the date the case was reported to the Bureau of Epidemiology for each of the years presented, beginning January 1 and ending December 31. Frequency counts included only cases reported during this time. In some cases, diseases reported in 2008 may have onset or diagnosis dates in 2007.

4. Case Definition Cases are classified as confirmed, probable, or suspected at the local level, using a published set of surveillance case definitions (Surveillance Case Definitions for Select Reportable Diseases in Florida, available at http://www.doh.state.fl.us/disease_ctrl/epi/surv/CaseDefinitions.html). For cases of selected diseases, these classifications are reviewed at the state level. In this report confirmed and probable cases have been included for all diseases, but no suspected cases have been included.

5. Place of Acquisition of Disease or Condition The distribution of cases among Florida counties is determined by the patient’s reported county of residence. Cases are allocated to their county of residence regardless of where they became ill or are/ were hospitalized, diagnosed, or exposed. Cases in people whose official residence is outside the state of Florida, but who became ill or are/were hospitalized or diagnosed in Florida, are not included. These cases are referred through an interstate reciprocal notification system to the state where the patient resides.

6. Population Estimates All population estimates are from the Community Health Assessment Resource Tool Set (CHARTS). The CHARTS system receives its estimates from the Florida Legislature’s Office of Economic and Demographic Research (EDR). Estimates are updated once per year in the CHARTS system. Note that previous editions of this report may show somewhat different populations and rates for a given year than the ones shown here, as these estimates are revised periodically.

x 7. Incomplete Case Information Certain analyses may not include all reportable cases of a specific disease due to incomplete case information. For graphs denoting month of onset, it is important to note that only those cases of disease for which an onset date could be determined are included.

xi Florida County Boundaries

xii 9,710 9,871 9,974 10,250 10,530 10,682 10,909 12,082 12,257 12,286 46,050 46,998 47,534 47,963 49,218 48,891 49,883 50,286 50,482 51,106 18,371 18,620 18,713 18,746 18,983 19,027 19,189 19,525 19,432 19,406 85,892 87,676 88,373 89,343 90,770 92,456 93,807 97,336 98,987 99,760 35,608 36,300 36,256 36,174 36,739 37,800 38,610 38,870 39,846 40,295 26,543 26,952 27,021 27,474 27,434 27,898 27,277 27,240 27,574 27,650 12,831 13,457 13,792 13,952 14,039 14,346 14,319 14,571 14,725 14,763 13,559 14,785 15,101 15,290 15,691 16,235 16,543 16,565 16,875 17,001 10,407 10,595 10,624 10,675 10,759 10,763 10,743 10,849 11,113 11,301 13,980 14,533 14,759 15,140 15,637 16,016 16,303 16,812 17,171 17,375 45,312 45,070 45,419 46,073 46,600 46,965 47,883 48,380 49,630 50,152 47,559 50,620 53,881 58,004 62,511 71,004 80,559 90,663 94,199 96,912 13,559 13,883 14,154 14,530 14,768 15,054 15,482 15,715 15,826 15,927 31,436 32,404 32,741 32,959 33,912 34,220 32,391 33,353 34,086 34,294 55,446 56,683 57,354 58,537 59,218 60,821 61,744 64,052 65,658 66,429 12,863 13,038 13,101 13,286 13,491 13,636 14,011 14,192 14,545 14,688 25,767 26,110 26,136 26,649 27,084 27,865 28,195 28,685 29,131 29,304 21,498 22,388 22,641 23,105 23,472 24,069 23,980 25,216 25,692 25,905 116,208 118,689 121,078 123,704 126,475 129,822 133,472 137,690 140,652 142,143 128,733 131,298 133,497 137,613 141,574 146,118 152,049 158,441 163,035 165,329 292,937 294,911 297,321 300,421 304,165 308,068 303,240 310,617 311,701 311,924 767,860 782,691 797,566 813,817 829,937 843,772 865,965 883,875 900,608 908,378 242,408 254,571 267,632 281,148 295,848 309,369 320,859 327,945 335,235 340,589 137,357 141,331 144,161 151,746 157,325 164,868 171,118 178,922 186,014 189,667 139,032 142,357 145,481 149,486 152,865 158,006 153,788 161,731 165,061 166,473 469,515 478,541 487,131 497,429 510,622 524,046 534,596 545,460 553,481 557,741 147,075 148,692 150,748 152,818 155,414 159,108 162,499 166,160 167,881 168,817 213,346 219,239 224,397 229,524 232,110 237,374 241,858 244,648 248,183 249,788 2,219,329 2,262,902 2,292,316 2,320,465 2,354,404 2,388,138 2,432,276 2,442,170 2,466,645 2,478,585 Jackson Indian River 110,142 113,755 116,291 118,884 121,887 127,831 130,849 136,546 140,469 142,452 Holmes Hillsborough 978,079 1,005,808 1,034,164 1,062,140 1,085,318 1,114,774 1,137,583 1,171,585 1,197,312 1,209,978 Highlands Hernando Hendry Hardee Hamilton Gulf Glades Gilchrist Gadsden Franklin Flagler Escambia Duval Dixie Desoto Dade Columbia Collier Clay Citrus Charlotte Calhoun Broward 1,590,361 1,631,445 1,654,923 1,673,972 1,706,363 1,730,580 1,746,603 1,755,392 1,767,538 1,775,101 Brevard Bradford Bay Baker Alachua Table A. Florida Population by Year and County, 1999-2008. (Source – Florida CHARTS; accessed February 2009) 1999-2008. (Source – Florida CHARTS; and County, Year A. Florida Population by Table CountyTotalState 15,679,606 1999 16,074,896 16,412,296 2000 16,772,201 17,164,199 2001 17,613,368 18,018,497 18,440,700 2002 18,731,287 18,896,559 2003 2004 2005 2006 2007 2008 xiii 430,644 444,151 459,278 481,014 499,387 526,157 555,874 594,219 620,778 634,660 475,268 487,183 498,011 504,381 514,247 531,472 545,064 570,067 583,315 589,784 CountyJefferson 1999 13,307 2000 12,874 2001 13,107 2002 13,329 2003 13,618 2004 14,110 2005 14,265 2006 14,390 14,513 2007 14,562 2008 Lafayette 6,703 7,061 7,076 7,245 7,394 7,559 8,064 8,092 8,273 8,571 Lake 204,152 212,823 222,988 233,622 242,919 254,246 265,716 279,583 288,078 293,216 Lee Leon 236,658 240,631 245,070 249,744 256,921 265,258 272,749 272,573 272,938 273,741 Levy 33,759 34,626 35,325 36,197 36,856 37,691 38,136 39,277 40,219 40,677 Liberty 6,967 7,045 7,145 7,165 7,248 7,372 7,623 7,784 7,763 7,767 Madison 18,596 18,775 18,878 18,974 19,183 19,564 19,738 19,846 19,960 20,018 Manatee 259,039 265,701 272,342 279,366 288,888 297,037 306,557 309,952 317,395 321,323 Marion 253,235 260,407 265,629 273,602 284,232 295,550 307,646 317,755 326,791 331,843 Martin 124,952 127,430 129,415 132,009 135,280 138,329 141,871 142,859 143,914 144,736 Monroe 79,875 79,721 80,850 81,030 80,473 81,336 82,628 80,055 78,729 78,157 Nassau 56,022 58,037 59,452 61,643 63,523 65,478 66,019 68,662 69,745 70,447 Okaloosa 167,880 171,264 174,228 178,036 182,020 186,744 189,766 193,668 197,164 198,884 Okeechobee 35,452 35,998 36,211 36,715 37,377 38,153 37,752 38,821 39,038 39,116 Orange 864,197 906,000 936,749 962,531 989,962 1,021,215 1,050,939 1,087,172 1,109,714 1,123,324 Osceola 166,024 174,107 182,202 197,901 213,723 228,755 237,659 259,521 267,510 273,266 Palm Beach 1,107,053 1,137,532 1,160,977 1,190,653 1,218,508 1,249,598 1,272,335 1,290,600 1,295,586 1,302,077 Pasco 337,348 346,882 354,196 364,900 378,085 392,507 410,758 427,594 435,913 441,188 Pinellas 917,331 923,308 930,602 935,274 941,435 944,966 948,925 947,122 942,911 940,645 Polk Putnam 70,029 70,532 70,929 71,481 72,114 73,435 73,897 74,549 74,816 74,903 Saint Johns 118,249 124,613 129,880 135,467 141,216 151,114 159,168 167,553 175,521 179,857 Saint Lucie 189,330 194,062 199,390 205,396 213,614 228,480 243,061 263,319 273,868 279,469 Santa Rosa 115,333 118,605 122,252 125,947 129,842 134,761 137,245 142,004 142,094 142,991 Sarasota 319,980 328,135 335,428 341,784 350,664 360,214 370,123 381,828 388,641 392,262 Seminole 357,714 368,231 380,763 389,549 396,934 405,565 413,937 422,288 426,364 429,244 Sumter 50,539 54,203 58,083 61,979 63,522 67,221 75,660 84,687 90,996 94,125 Suwannee 34,226 35,091 35,744 35,815 37,479 37,863 38,319 39,008 39,816 40,773 Taylor 19,264 19,297 19,594 19,878 20,794 20,977 21,395 21,696 22,721 23,062 Union 13,335 13,473 13,660 13,786 13,793 14,752 15,135 15,160 15,865 16,112 Volusia 436,218 445,676 453,840 462,377 473,185 486,874 497,224 505,317 508,468 511,094 Wakulla 21,917 23,150 23,936 24,340 25,141 25,692 27,193 28,727 29,632 30,575 Walton 39,387 40,990 43,270 46,052 47,472 51,167 54,218 56,199 57,318 58,264 Washington 20,850 21,069 21,516 21,702 21,987 22,534 23,255 23,179 23,876 24,307 xiv Table B. Florida Population by Age Group, Table C. Florida Population by Gender, 2008 2008 Sex 2008 Age Group 2008 Male 9,255,976 < 1 224,519 Female 9,640,583 1-4 898,077 Total 18,896,559 5-9 1,153,024 10-14 1,175,813 15-17 738,078 18-19 481,775 Table D. Florida Population by Race, 20-24 1,219,961 Aggregated to White and Non-White, 2008 25-29 1,162,368 30-34 1,138,562 Race 2008 35-39 1,209,419 White 15,208,029 40-44 1,306,416 Black 3,147,900 45-49 1,373,927 Other Non-white 540,630 50-54 1,304,080 Total 18,896,559 55-59 1,194,616 60-64 1,055,689 65-69 866,658 70-74 739,132 75-79 652,268 80-84 523,055 85+ 479,122 Total 18,896,559

xv List of Reportable Diseases/Conditions in Florida, 2008

Section 381.0031 (1,2), Florida Statutes, provides that “Any practitioner, licensed in Florida to practice medicine, osteopathic medicine, chiropractic, naturopathy, or veterinary medicine, who diagnoses or suspects the existence of a disease of public health significance shall immediately report the fact to the Department of Health.” County health departments serve as the Department’s representative in this reporting requirement. Furthermore, this Section provides that “Periodically the Department shall issue a list of diseases determined by it to be of public health significance…and shall furnish a copy of said list to the practitioners…”. This list reflects diseases and conditions that were reportable in 2008. However, additional updates were made in November, 2008; Annual Morbidity Reports for subsequent years will reflect changes in the list.

Acquired Immune Deficiency Syndrome (AIDS) Lyme Disease Anthrax Lymphogranuloma Venereum (LGV) Botulism Malaria Brucellosis Measles (Rubeola) California Serogroup Virus (neuroinvasive and non- Melioidosis neuroinvasive) Meningitis (bacterial, cryptococcal, mycotic) Campylobacteriosis Meningococcal Disease (includes meningitis and Cancer (except non-melanoma skin cancer, and including meningococcemia) benign and borderline intracranial and CNS tumors) Mercury Poisoning Chancroid Mumps Chlamydia Neurotoxic Shellfish Poisoning Ciguatera Fish Poisoning (Ciguatera) Pertussis Clostridium perfringens, Epsilon Toxin (disease due to) Pesticide-Related Illness and Injury Congenital Anomalies Plague Conjunctivitis (in neonates < 14 days old) Poliomyelitis Creutzfeldt-Jakob Disease (CJD) Psittacosis (Ornithosis) Cryptosporidiosis Q Fever Cyclosporiasis Rabies (human, animal) Dengue Rabies (possible exposure) Diphtheria Ricin Toxicity Eastern Equine Encephalitis Virus Disease (neuroinvasive and Rocky Mountain Spotted Fever non-neuroinvasive) Rubella (including congenital) Ehrlichiosis/Anaplasmosis [human granulocytic (HGA), human St. Louis Encephalitis (SLE) Virus Disease (neuroinvasive and monocytic (HME), human other or unspecified agent] non-neuroinvasive) Encephalitis, Other (non-arboviral) Salmonellosis Enteric diseases due to: Saxitoxin Poisoning (including paralytic shellfish poisoning) Escherichia coli, O157:H7 Severe Acute Respiratory Syndrome-associated Coronavirus Escherichia coli, Other (known serotypes) (SARS-CoV) Disease Giardiasis (acute) Shigellosis Glanders Smallpox Gonorrhea Staphylococcus aureus (with intermediate or full resistance to Granuloma Inguinale vancomycin, VISA, VRSA) Haemophilus influenzae (meningitis and invasive disease) Staphylococcus Enterotoxin B Hansen’s Disease (Leprosy) Streptococcal Disease (invasive, Group A) Hantavirus Infection Streptococcus pneumoniae (invasive disease) Hemolytic Uremic Syndrome Syphilis Hepatitis A Tetanus Hepatitis B, C, D, E, and G Toxoplasmosis (acute) Hepatitis B Surface Antigen (HBsAg) Positive in a Pregnant Trichinosis Woman or a Child < 24 months of age Tuberculosis Herpes Simplex Virus (HSV) [in Infants to 6 months of age; Tularemia anogenital in children < 12 yrs] Typhoid Fever Human Immunodeficiency Virus (HIV) Typhus Fever (epidemic and endemic) Human Papillomavirus (HPV) [in children < 6 years; anogenital Vaccinia Disease in children < 12 yrs, cancer associated strains] Varicella Mortality Influenza Due to Novel or Pandemic Strains Venezuelan Equine Encephalitis Virus Disease (neuroinvasive Influenza-associated Pediatric Mortality (in persons aged < 18 and non-neuroinvasive) yrs) Vibriosis (Vibrio infections) Lead Poisoning Viral Hemorrhagic Fevers (Ebola, Marburg, Lassa, Machupo) Legionellosis West Nile Virus Disease (neuroinvasive and non-neuroinvasive) Leptospirosis Western Equine Encephalitis Virus Disease (neuroinvasive and Listeriosis non-neuroinvasive) Yellow Fever Any disease outbreak Any grouping or clustering xvi Selected Florida Department of Health Contacts

Division of Disease Control

Bureau of Epidemiology (850) 245-4401 (accessible 24/7/365) Bureau of Immunization (850) 245-4342 Bureau of HIV/AIDS (850) 245-4334 Bureau of Sexually Transmitted Disease (850) 245-4303 Prevention and Control Bureau of Tuberculosis and Refugee Health (850) 245-4350

Division of Environmental Health

Bureau of Environmental Public Health Medicine (850) 245-4277

xvii Vaccine-Preventable Diseases in Florida

Millions of people have benefited from vaccines for more than two centuries. The history of vaccines and immunization began in the 1790s with Edward Jenner’s creation of the world’s first vaccine for smallpox. Before the existence of vaccines, diseases such as smallpox, measles, rubella, diphtheria, polio, and pertussis (whooping cough) were common childhood killers and left many survivors disabled for life. Fortunately, in Florida and the United States these devastating diseases have been almost eliminated due to the widespread use of safe, effective, and affordable vaccines. In fact, smallpox, a disease that has caused countless suffering and death for centuries, was eradicated worldwide through vigorous vaccination programs. There is little else in medicine that can compare to this achievement. With concerted effort, other diseases, such as polio and measles (a disease that infects approximately thirty million children per year, killing approximately 750,000 of them), can similarly be eradicated.

Public health professionals and the World Health Organization (WHO) rank immunizations in the top ten health achievements of the past century. Immunization is as important as the development of safe drinking water and public sanitation practices. Vaccines protect infants, children, and adults from the unnecessary harm and premature death caused by a number of severe communicable diseases. Vaccination is the single most effective communicable disease prevention strategy. Vaccines are also among the most cost-effective medical interventions available, providing huge savings in direct medical care costs, as well as indirect costs such as lost time from work and school. Unlike other areas of healthcare, widespread immunization has effectively leveled racial-ethnic disparities in this country.

Florida’s childcare and school entry immunization requirements ensure that students are protected against communicable diseases in settings where such diseases are easily transmitted. When most children in a community are immunized, vulnerable children who are not able to be immunized due to medical reasons are also protected. This concept, known as “herd immunity,” is the key to the low levels of vaccine-preventable diseases in Florida, nationally, and in most developed countries. Herd immunity occurs when a large portion of the population (85%–98% depending on the disease) receives vaccine against a disease. Such high immunization coverage rates protect susceptible individuals in a group because, due to immunity in most of the group, transmission of disease cannot be sustained.

An important reason for vaccines’ effectiveness in reducing the spread of communicable diseases is the fact that early childhood immunization and childcare/school entry immunization requirements lead to herd immunity. The huge reductions now seen in most of the vaccine-preventable diseases did not occur until states implemented school and childcare immunization entry requirements. Without herd immunity, those who are too young to be immunized, and/or have medical or religious contraindications to immunization, and/or have diseases that cause immunodeficiency, would all be at much greater risk for infections and their sequelae. That is, when fewer children are immunized, then children who cannot be immunized are much more vulnerable to getting infected with a disease.

Section 1003.22 of the Florida Statutes requires immunization for school entry and attendance, and allows for medical (temporary and permanent) or religious exemption from immunizations. The Florida childcare and school entry immunization requirements cover public and private schools, childcare facilities, and family childcare homes. They are in accordance with the recommendations from the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association. These organizations set the standard of care and practice that healthcare providers, health plans, and insurance companies follow with respect to providing immunizations.

Florida Statutes require specific immunizations for infants and children who attend childcare, family childcare homes, pre-kindergarten and school. Immunization entry requirements for school and childcare settings relate to factors such as whether the disease is communicable in childcare and school settings, xviii whether the vaccine has been on the market long enough to assess for previously undetected side effects, and whether the vaccine is covered by insurance and health plans.

Immunization safety is of utmost concern to parents, healthcare providers, the public health community, legislators and vaccine manufacturers. Vaccines undergo rigorous and lengthy testing for both safety and efficacy prior to approval by the Food and Drug Administration (FDA). Today’s vaccines are much more pure than those produced decades ago. This increased purity has the effect that the total number of antigens (from the vaccines themselves and from other substances in the vaccine preparation) introduced to the body is much less, even as the number of recommended vaccines has increased.

Concerns about vaccine safety have been addressed since the time when vaccines were first introduced. Public health authorities and governmental bodies must balance the right to immunize for the “common good” with individual rights and concerns. The U.S. Supreme Court, in 1905, ruled in Jacobson v. Massachusetts that the need to protect the public health through compulsory smallpox vaccination outweighed the individual’s right to privacy. This justification is consistently applied to childcare and school entry immunization requirements, with allowances for religious beliefs and medical conditions.

A robust immunization program has tremendous benefit to individual and public health. Calls for opposing immunizations and/or school entry vaccination requirements, or for providing easier and more numerous ways to obtain exemptions for required vaccinations, are resulting in growing numbers of individuals not fully immunized. This, in turn, is leading to increases in outbreaks of vaccine-preventable disease such as measles and pertussis. This is occurring not just in the United States but in a number of developed countries such as the Netherlands, Great Britain, Switzerland, France, and Israel. In fact, Great Britain has recently had to rescind its 1980’s declaration that measles was no longer endemic (that is, children in Great Britain can now contract measles even if no new cases are brought in from the outside). Thus, children and adults in developed nations are increasingly suffering from significant illness, disability, and death due to vaccine-preventable diseases. With the ease and volume of international travel today, Florida is highly vulnerable to the importation of such diseases, especially if the number of children immunized and herd immunity levels decline.

Epidemiology in Florida

The following tables and charts have been compiled from surveillance data collected in Florida over the past seventy years to quantify and visually assess the impact that vaccination practices have had on the burden of disease in this state. Table 1 depicts the precipitous decline in the number of vaccine- preventable disease cases and deaths after widespread use of vaccination. While comparing the number of vaccine-preventable disease cases in 2007 to the number of cases in 1934 is certainly meaningful, this may not be a fair comparison due to the drastic change in Florida’s population over time. Florida’s population has grown from just under 1.6 million residents in 1934 to over 18.5 million in 2005; a larger population would be expected to have a larger number of cases, all else being equal. To address this, the 2007 population (18,762,014 residents) was used to estimate the number of cases that would have been reported for each year, had the population size been comparable to the 2007 population. This standardized estimate was calculated by dividing the 2007 population by the population for a given historical year to get a population ratio. The number of cases reported for that given year was multiplied by the population ratio. For example, the 2007 population (18,762,014 residents) was 10.1 times the population in 1939 (1,853,660 residents). The number of cases reported in 1939 was multiplied by 10.1 to estimate the number of cases that would have been reported in 1939 if the 1939 population was equal to the 2007 population. Table 2 presents a summary of these standardized estimates of select vaccine- preventable disease cases occurring in census years for 1940 to 2000. These standardized estimations are represented in Charts 1-11 as a dashed line. The actual number of cases reported for each year is represented in the charts as a solid line. Note that as the population size approaches the 2007 population, the dashed line and the solid line converge.

xix Table 1: Average Vaccine-Preventable Disease Cases and Deaths Pre-Vaccine Compared to Post-Vaccine (2007) in Florida Year Disease Pre-Vaccine Post-Vaccine (2007) Cases/ Deaths/ Vaccine in (Pre-Vaccine Years Averaged) Cases Deaths Year Year Wide Use Diphtheria 319 36 1943 0 0 (1936-1945) Measles 5,723 11 1968 5 0 (1953-1962) Mumps 3,732 1 1967 21 0 (1963-1968) Pertussis 723 58 1941 211 0 (1934-1943) Polio (acute and paralytic) 416 24†† 1955 0 0 (1941-1954) Rubella* 1,580 1 1969 0 0 (1966-1969) Smallpox 442 N/A N/A 0 0 (1934-1944) Tetanus 57 37 1949 5 1 (1947-1949) Hepatitis A 816 6 1995 171 2 (1986-1995) Acute hepatitis B 1,364 44 1986 368 38 (1982-1991) H. influenzae meningitis 378 9 1990 10 0 (1980-1989) Total 20,322 32 2,112 41 *Congenital Rubella Syndrome cases are not included. †† Deaths include only those attributable to acute Polio.

Table 2. Summary of Standardized Cases* of Selected Vaccine-Preventable Disease Cases Occurring in Census Years 1940 through 2000 Year Diphtheria Measles Mumps Pertussis Polio Rubella Smallpox Tetanus 1940 2,185 22,581 2,596 3,752 323 1,479 69 167 1950 645 16,620 9,657 3,133 3,133 299 0 286 1960 274 15,362 16,476 1,587 244 3,130 0 105 1970 38 4,160 8,309 260 0 9,829 0 44 1980 0 826 373 130 0 208 0 8 1990 1 855 281 84 0 24 0 9 2000 0 2 8 78 0 2 0 1 *Number of cases that would have occurred in Florida each year if Florida had a population of 18,762,014 (see text for further explanation).

xx Table 2. Summary of Standardized Cases* of Selected Vaccine-Preventable Disease Cases Occurring in Census Years 1940 through 2000 Year Diphtheria Measles Mumps Pertussis Polio Rubella Smallpox Tetanus 1940 2,185 22,581 2,596 3,752 323 1,479 69 167 1950 645 16,620 9,657 3,133 3133 299 0 286 1960 274 15,362 16,476 1,587 244 3,130 0 105 1970 38 4,160 8,309 260 0 9,829 0 44 1980 0 826 373 130 0 208 0 8 1990 1 855 281 84 0 24 0 9 2000 0 2 8 78 0 2 0 1 *Number of cases that would have occurred in Florida each year if Florida had a population of 18,762,014 (see text for further explanation).

Reported and Standardized* Diphtheria Cases in Florida, 1934-2007 Reported and Standardized* Diphtheria Cases in Florida, 1934-2007 8,000 Actual Cases Standardized* Cases 7,000

6,000 Vaccine in wide use by 1943 5,000

4,000

3,000 Numberof Cases 2,000

1,000

4 3 2 1 0 9 8 7 6 37 40 46 49 55 58 64 67 73 82 91 00 9 9 9 9 9 9 9 9 9 9 9 0 193 1 1 194 1 1 195 1 1 196 1 1 197 1 1976 197 1 1985 198 1 1994 199 2 2003 200 Year *Number of cases that would have occurred in Florida each year if Florida had a population of 18,762,014. See the paragraph preceding these charts for a more detailed description of these calculations.

Reported and Standardized* H. influenzae Meningitis in Florida, 1982-2007

800 Actual Cases Standardized* Cases 700 Vaccine in wide use by 1990 600

500

400

300 Number of Cases of Number 200

100

Reported and Standardized* Hepatitis A Cases in Florida, 1970-2007 10,000 Actual Cases Standardized* Cases

8,000 xxi

6,000

Vaccine in w ide use by 1995 4,000 Number Number of Cases

2,000

2 4 2 0 2 0 2 80 98 970 978 986 988 996 004 006 1 197 197 1976 1 19 198 1984 1 1 199 199 1994 1 19 200 200 2 2 Year *Number of cases that would have occurred in Florida each year if Florida had a population of 18,762,014. See the paragraph preceding these charts for a more detailed description of these calculations.

Reported and Standardized* H. influenzae Meningitis in Florida, 1982-2007 800 Actual Cases Standardized* Cases 700 Vaccine in wide use by 1990 600

500

400

300 Number of Cases of Number 200

100

2 3 4 5 6 7 9 0 1 2 3 4 5 6 7 8 9 0 1 2 4 5 6 7 8 9 0 198 198 198 198 198 198 1988 19 199 199 199 199 199 199 19 199 199 199 200 200 200 2003 20 200 200 200 Year *Number of cases that would have occurred in Florida each year if Florida had a population of 18,762,014. See the paragraph preceding these charts for a more detailed description of these calculations. Reported and Standardized* Hepatitis A Cases in Florida, 1970-2007 Reported and Standardized* Hepatitis A Cases in Florida, 1970-2007 10,000 Actual Cases Standardized* Cases

8,000

6,000

Vaccine in w ide use by 1995 4,000 Number Number of Cases

2,000

Reported and Standardized* Hepatitis B (Acute) Cases in Florida, 1970-2007 Reported and Standardized* Hepatitis B (Acute) Cases in Florida, 1970-2007 4,000 Actual Cases Vaccine in wide use by 1986 Standardized* Cases

3,000

2,000 Numberof Cases 1,000

0 8 6 4 2 74 76 82 84 90 92 98 00 06 9 9 9 9 9 9 9 0 0 197 1972 1 1 197 1980 1 1 198 1988 1 1 199 1996 1 2 200 2004 2 Year *Number of cases that would have occurred in Florida each year if Florida had a population of 18,762,014. See the paragraph preceding these charts for a more detailed description of these calculations.

Reported and Standardized* Measles Cases in Florida, 1934-2007 120,000 Actual Cases Standardized* Cases xxii 100,000

80,000

Vaccine in wide use by 1968 60,000

40,000 Numberof Cases

20,000

7 6 8 7 6 5 4 6 34 40 43 49 52 61 70 79 82 88 91 97 00 9 9 9 9 9 9 9 9 9 9 9 9 0 1 193 1 1 194 1 1 1955 195 1 1964 196 1 1973 197 1 1 198 1 1 199 1 2 2003 200 Year *Number of cases that would have occurred in Florida each year if Florida had a population of 18,762,014. See the paragraph preceding these charts for a more detailed description of these calculations.

Reported and Standardized* Hepatitis B (Acute) Cases in Florida, 1970-2007 4,000 Actual Cases Vaccine in wide use by 1986 Standardized* Cases

3,000

2,000 Numberof Cases 1,000

Reported and Standardized* Measles Cases in Florida, 1934-2007 120,000 Actual Cases Standardized* Cases 100,000

80,000

Vaccine in wide use by 1968 60,000

40,000 Numberof Cases

20,000

Reported and Standardized* Mumps Cases in Florida, 1935-2007 25,000 Vaccine in w ide use by 1967 Actual Cases Standardized* Cases

20,000

15,000

10,000 Number of Cases

5,000

5 8 1 4 7 0 3 6 9 2 5 8 1 4 7 0 3 6 9 2 5 8 1 4 7 3 3 4 4 4 5 5 5 5 6 6 6 7 7 7 8 8 8 8 9 9 9 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 Year *Number of cases that would have occurred in Florida each year if Florida had a population of 18,762,014. See the paragraph preceding these charts for a more detailed description of these calculations.

xxiii Reported and Standardized* Pertussis Cases in Florida, 1934-2007 16,000 Vaccine in w ide use by 1941 Actual Cases Standardized* Cases 14,000

12,000

10,000

8,000

6,000 Number of Cases 4,000

2,000

4 7 0 3 6 9 2 5 8 1 4 7 0 3 6 9 2 5 8 1 4 7 0 3 6 3 3 4 4 4 4 5 5 5 6 6 6 7 7 7 7 8 8 8 9 9 9 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 Year *Number of cases that would have occurred in Florida each year if Florida had a population of 18,762,014. See the paragraph preceding these charts for a more detailed description of these calculations.

Reported and Standardized* Polio Cases in Florida, 1934-2007 12,000 Vaccine in w ide use by 1955 Actual Cases Standardized* Cases 10,000

8,000

6,000

Number of Cases 4,000

2,000

xxiv Reported and Standardized* Rubella Cases in Florida, 1937-2007 30,000 Actual Cases Standardized* Cases 25,000

20,000 Vaccine in w ide use by 1969

15,000

Number of Cases 10,000

5,000

7 0 3 6 9 2 5 8 1 4 7 0 3 6 9 2 5 8 1 4 7 0 3 6 3 4 4 4 4 5 5 5 6 6 6 7 7 7 7 8 8 8 9 9 9 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 Year *Number of cases that would have occurred in Florida each year if Florida had a population of 18,762,014. See the paragraph preceding these charts for a more detailed description of these calculations.

Reported and Standardized* Smallpox Cases in Florida, 1934-2007 200 Actual Cases Standardized* Cases

160

120

80 Number of Cases

xxv Reported and Standardized* Tetanus Cases in Florida, 1935-2007 600 Vaccine in w ide use by 1949 Actual Cases Standardized* Cases 500

400

300

Number of Cases 200

100

xxvi Summary of Selected Notifiable Diseases and Conditions

Section 1

Table 1.1: Reported Confirmed and Probable Cases and Incidence Rate per 100,000 Population for Selected Notifiable Diseases, Florida, 1999-2008

Table 1.2: Reported Confirmed and Probable Cases of Notifiable Diseases of Infrequent Occurrence, Florida, 1999-2008

Table 1.3: Reported Confirmed and Probable Cases and Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008

Table 1.4: Reported Confirmed and Probable Cases and Incidence Rate per 100,000 Population for Selected Notifiable Diseases by Age Group, Florida, 2008

Table 1.5: Top 10 Reported Confirmed and Probable Cases of Disease by Age Group, Florida, 2008

Table 1.6: Reported Confirmed and Probable Cases and Incidence Rate per 100,000 Population for Selected Notifiable Diseases by Gender, Florida, 2008

Table 1.7: Reported Confirmed and Probable Cases of Select Notifiable Diseases by Month of Onset, Florida, 2008

27 2008 Florida Morbidity Statistics

28 Summary of Selected Notifiable Diseases and Conditions 1.12 314 1.66 211 0.63 380.65 0.21 142 47 0.77 0.25 127 65 0.680.66 0.34 162 167 0.86 0.91 153 0.82 148 0.78 114 117 119 other. 0.66 132 0.75 208 1.15 228 1.24 0.67 107 0.61 103 0.57 99 0.54 97 0.52 94 0.49 113 115 0.67 131 0.78 158 0.92 128 0.73 127 0.70 162 0.88 135 0.72 199 1.05 0.07 36 0.21 93 0.54 45 0.26 22 0.12 3 0.02 3 0.02 3 0.02 11 110 0.70 52 0.32 66 0.39 57 0.33 56 0.32 58 0.32 73 0.40 67 0.36 41 0.22 0.70 66 0.40 89 0.53 72 0.42 78 0.44 113 112 0.71 67 0.42 304.53 0.18 1,162 7.23 53 799 0.32 4.87 610 3.64 606 3.53 581 3.30 614 3.41 774 4.20 725 3.86 792 4.19 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 1086 0.06 0.55 949 0.06 0.31 48 72 0.2955 0.45 0.35 3229 70 4750 0.19 0.18 0.4360 0.32 0.29 14 5497 82 0.38 4064 43 0.08 0.62 0.34 0.49 57 0.41 0.25 0.26 90 9 97 99 0.35 109 19 76 0.56 0.59 0.05 0.58 57 0.68 0.12 0.45 61 524 85 99 0.35 28 69 2.91 0.37 0.51 0.56 77 0.17 0.40 31 147 76 0.46 37 53 0.86 0.17 0.45 43 0.2294 0.30 141 32 92 0.25 0.60 0.80 28 39 0.17 0.5418 46 149 0.16 0.22 0.11 59 9385 0.26 0.93 61 49 0.31 14 0.53 0.54 159 47 0.34 0.27 0.09 68 61 0.97 0.26 47 46 35 0.38 0.38 201 34 0.26 0.25 0.21 61 1.20 55 0.18 34 53 45 229 0.33 0.34 30 0.18 0.28 1.33 0.27 56 87 0.16 49 219 31 0.30 0.52 88 1.24 0.26 0.18 65 0.47 260 24 0.34 1.44 0.14 312 2 1.69 0.01 309 1.65 4 275 0.02 1.46 9 0.05 14 0.07 NR - NR -NR NR - - NR NR - - 201 1.17 606 3.44 598 3.32 620 3.37 622 3.32 704 3.73 112 711 189 1.21 241 1.50 89855252 0.54 5.45551 7.45 106 657 3.51 512 0.63 4.09 610 14.83 128 847 3.79 437 0.75 5.16 12.53 502 1,056 149 631 3.06 6.30 0.85100 17.93 543 399138 350 0.64 555 3.24 2.32 0.88 15.39 1.94186 631 295 136 599155 717 NA 3.68 1.67 0.85 16.35 0.99 3.89 161 527 530 289 124 475 738 2.99 NA 14.16 1.60 0.76 2.95 3.93 510 448 157 1,100 233 128 549 11.78 2.83 6.70 NA 1.26 0.76 2.91 644 1,082 446 171 106 181 16.85 6.45 2.42 0.91 0.62 NA 599 1,051 366 165 107 6.12 15.69 188 1.95 0.87 0.61 1,128 NA 358 6.40 84 205 1.89 1,215 0.47 NA 6.74 79 1,244 201 6.75 0.43 NA 1,474 67 176 7.86 0.36 1,618 NA 8.56 51 128 0.27 NA 144 NA 4,969 31.691,034 4,609 6.59 28.67 1,051 4,620 6.54 28.15 8951,360 4,675 8.67 27.87 5.45 1,532 4,429 995 25.80 9.53 5.93 5,421 1,150 1,056 30.78 7.01 6.15 4,7556,539 1,318 26.39 1,009 41.70 7.86 4,960 5.73 5,788 1,132 26.92 36.01 894 6.60 3,896 5,917 4.96 20.77 1,126 36.05 4,957 6.39 6,602 941 26.23 39.36 987 5.11 6,198 1,017 5.48 36.11 5.42 1,165 5,9873,144 1,118 6.32 33.99 20.051,709 5.92 5,514 1,268 10.90 2,830 30.60 6.76 1,522 17.61 5,224 1,391 3,104 9.47 28.36 7.36 18.91 1,052 6,2352,660 4,651 6.41 33.23 16.96 27.73 2,538 7,588 2,7281,281 4,669 15.13 40.16 16.97 8.17 27.20 2,845 2,877 1,171 4,276 16.58 17.53 7.28 24.28 3,251 965 5,552 1,145 19.38 30.81 5.48 6.98 3,256 4,928 1,270 1,086 18.97 26.75 7.05 6.47 2,948 5,022 1,646 16.74 1,046 26.77 8.93 2,872 6.09 5,312 15.94 2,288 1,076 28.11 2,924 12.19 6.11 15.87 801 1,094 3,928 4.24 6.07 20.94 1,038 4,578 5.63 24.23 989 5.27 953 5.04 31,410 200.32 33,390 207.72 37,625 229.25 42,05822,797 250.76 145.39 42,381 22,781 246.92 141.72 42,554 21,531 241.60 131.19 43,372 21,348 240.71 127.28 48,955 18,974 265.74 110.54 57,580 18,580 306.90 105.49 70,751 20,225 374.41 112.25 23,976 130.15 23,308 124.23 23,237 122.97 Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate 1 2 4 5 3 Includes reported cases of Hemophilus influenzae presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. Includes reported cases of listeriosis and meningitis caused by Listeria monocytogenes. Includes reported cases of meningococcal meningitis, pneumonia caused by Neisseria meningitidis , disease, and meningococcemia disseminated. V. vulnificus, and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, cholerae non-O1 , V. alginolyticus, V. Includes reported cases of V. Includes reported cases of E. coli , O157:H7, serogrpouped non-O157, and shiga toxin producing. NA - Not applicable NA 1 2 3 4 5 Selected Notifiable Diseases Acquired Immune Deficiency Syndrome Campylobacteriosis Chlamydia Cryptosporidiosis Cyclosporiasis Producing Toxin Escherichia coli , Shiga Giardiasis Gonorrhea Hemophilus influenzae, Invasive A Hepatitis Hepatitis B (+HBsAg in Pregnant Women) Acute Hepatitis B, Acute Hepatitis C, Virus Human Immunodeficiency Legionellosis Listeriosis Disease Lyme Malaria Meningitis, Other Meningitis, Streptococcus pneumoniae Meningococcal Disease Pertussis Animal Rabies, Rabies, Possible Exposure Salmonellosis Shigellosis Streptococcus pneumoniae, Invasive Disease, Drug-Resistant Streptococcus pneumoniae, Invasive Disease, Drug-Susceptible A Streptococcal Disease, Invasive Group Syphilis Toxoplasmosis Tuberculosis Infections Vibrio Nile Virus West Table 1.1: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases, Florida, 1999-2008 Table

29 2008 Florida Morbidity Statistics

Table 1.2: Reported Confirmed and Probable Cases of Notifiable Diseases of Infrequent Occurrence, Florida, 1999-2008

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Anaplasmosis, Human Granulocytic NR NR - 1 5 3 1 1 3 2

Anthrax - - 2 ------

Botulism, Foodborne 4 ------1 --

Botulism, Infant - - - - - 1 1 - 1 1

Botulism, Other - - - - - 2 - - --

Botulism, Wound ------

Brucellosis 3 6 5 6 10 8 3 5 10 10

California Serogroup Virus - - - - - 4 - 1 1 1

Chancroid 2 - 2 7 2 1 1 1 3 -

Ciguatera 2 14 13 7 7 4 10 32 29 53

Creutzfeldt-Jakob Disease (CJD) NR NR NR NR 4 14 17 14 12 23

Dengue Fever 5 13 12 21 16 13 19 20 46 33

Diphtheria ------

Escherichia coli Shiga Toxin + (not serogrouped) - - - - 7 6 16 22 109 57

Eastern Equine Encephalitis 3 - 3 1 2 1 5 - - 1

Ehrlichiosis, Human1 8 - NR NR NR NR NR NR --

Ehrlichiosis, Human Monocytic NR 10 8 4 8 4 4 5 18 10

Encephalitis, Other 19 19 12 20 10 8 8 5 18 5 Epsilon Toxin of Clostridium perfringnes 2 NR NR NR NR ------

Glanders NR NR NR NR ------

Granuloma Inguinale ------

Hantavirus Infection ------

Hemolytic Uremic Syndrome 8 20 5 5 6 6 20 5 6 5 Hemorrhagic Fever ------

Hepatitis B, Perinatal 2 2 7 6 2 - 2 6 2 3 Hepatitis Non-A or B 12 6 6 8 4 8 5 36 NR NR

Hepatitis Unspecified, Acute 19 7 6 1 3 - 2 2 NR NR

Hepatitis D NR NR NR NR NR NR NR NR 1 -

Hepatitis E NR NR NR NR NR NR NR NR 1 -

Hepatitis G NR NR NR NR NR NR NR NR - -

Leprosy (Hansen’s disease) 3 4 1 4 9 5 2 7 10 10 Leptospirosis 1 3 1 - 1 1 2 2 1 - 1 Includes codes for human ehrlichiosis (NR after 1999), ehrlichiosis caused by E. ewingii, and ehrlichiosis unspecified 2 Epsilon toxin of Clostridium perfringens was no longer reportable after August of 2008 NR - Not Reportable

30 Summary of Selected Notifiable Diseases and Conditions

Table 1.2: Continued

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Lymphogranuloma venereum - 1 2 4 2 - 3 - - -

Measles 2 2 - 3 - 1 - 4 5 1 Melioidosis NR NR NR NR - - 1 1 - -

Meningitis, Group B Streptococcus 14 21 18 19 15 15 23 23 30 11

Mumps 17 7 8 7 7 9 8 15 21 16 Neurotoxic Shellfish Poisoning ------4 16 1 -

Plague ------

Poliomyelitis ------

Psittacosis 1 4 1 3 3 1 - 1 - 2

Q Fever - - 1 2 6 2 1 8 2 1 Rabies, Human - - - - - 1 - - - -

Ricin Toxin NR NR NR NR ------

Rocky Mountain Spotted Fever 7 12 8 15 17 22 14 21 19 19

Rubella 1 2 3 5 - - - 1 - 3 Rubella, Congenital - 1 ------

Saxitoxin Poisoning - - - - - 1 - - - -

Smallpox ------

St. Louis Encephalitis 4 - - 1 ------

Staphylococcus aureus (GISA/VISA) ------1 3

Staphylococcus aureus (GRSA/VRSA) ------

Staphylococcus Enterotoxin B NR NR NR NR - - - - - 2

Tetanus 3 1 3 3 3 4 3 2 5 2 Trichinosis 1 1 - - - - 1 1 - 1

Tularemia ------1 - - -

Typhoid Fever 24 12 12 19 15 10 11 16 15 18

Typhus Fever - - - - - 1 - 2 1 -

Vaccinia Disease - - - - 1 - - - - -

Venezuelan Equine Encephalitis ------

Vibrio cholerae Type O1 ------

Western Equine Encephalitis ------

Yellow Fever ------NR - Not Reportable

31 2008 Florida Morbidity Statistics ------2 0.11 - 5 0.28 - - - - - 3.23 93 5.24 1 6.81 - - - 6 1.08 15 0.85 - 1 0.18 1 0.06 - 2 0.36 12 0.68 - 5 0.90 21 1.18 - 2 0.36 42 2.37 1 6.81 3 0.54 1 0.06 - 4 0.72 6 0.34 - 1 0.18 7 0.391 - 0.18 6 0.34 - 6 1.08 2 0.11 - 7 1.26 21 1.18 - 5 0.90 1 0.06 - - - 18 ------37 6.63 106 5.97 ------other. ------1 3.41 ------6.52 1 3.41 27 4.84 78 4.39 - 6.52 1 3.41 14 2.51 120 6.76 ------9 5.33 2 6.83 10 1.79 85 4.79 1 6.81 1 0.59 - 2 1.18 - 5 2.96 2 6.83 6 1.08 25 1.41 - 2 1.18 - 8 4.74 4 13.65 7 1.26 55 3.10 - 2 1.18 - 1 0.59 - 6 3.55 1 3.41 7 1.26 36 2.03 - 2 1.18 1 3.41 5 0.90 14 0.79 - 4 2.37 - 11 11 , meningococcal disease, and meningococcemia disseminated. . ------E. coli , shiga toxin producing. ------Neisseria meningitidis Listeria monocytogenes ------4.40 ------1 0.40 - 1 0.40 - 1 0.40 - 3 1.20 - 3 1.20 - 8 3.20 - 3 1.20 - 7 2.80 - 1 0.40 - 2 0.80 1 3.86 - V. fluvialis, V. hollisae, V. mimicus, V. parahaemolyticus, V. vulnificus , and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, non-O1, V. 11 57 22.82 31 119.67 4 2.37 3 10.24 20 3.59 49 2.76 - 10 4.00 24 9.61 2 7.72 10 5.92 2 6.83 22 3.94 767 43.21 2 13.62 71 28.42 4 15.44 30 17.77 3 10.24 58 10.40 1,403 79.04 1 6.81 84 33.63 13 50.18 91 53.90 18 61.43 226 40.52 416 23.44 1 6.81 13 5.20 - 33 13.21 13 50.18 27 15.99 3 10.24 82 14.70 24 1.35 - 16 6.41 2 7.72 10 5.92 2 6.83 28 5.02 62 3.49 1 6.81 14 5.60 5 19.30 10 5.92 - 30 12.01 2 7.72 43 17.21 2 7.72 16 9.48 3 10.24 46 8.25 895 50.42 - 559 223.79 13 50.18 251 148.68 37 126.26 398 71.36 2,316 130.47 40 272.33 1,750 700.59 88 339.70 561 332.31 101 344.66 1,549 277.73 6,963 392.26 63 428.92 Alachua County Baker County Bay County Bradford County Brevard County Broward County Calhoun County Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. A 1 2 Invasive Disease, Invasive Disease, E. coli , O157:H7; serogrpouped non-O157; and Hemophilus influenzae cholerae alginolyticus, V. V. 4 Invasive 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Selected Notifiable Diseases Includes reported cases of Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Vibrio Infections Vibrio Varicella Tuberculosis Toxoplasmosis Legionellosis Listeriosis Shigellosis Syphilis Escherichia coli Hemophilus influenzae, Streptococcal Disease, Invasive Group Human Immunodeficiency Virus Human Immunodeficiency Cyclosporiasis Meningococcal Disease Salmonellosis Hepatitis C, Acute Hepatitis C, Cryptosporidiosis Meningitis, Other (bacterial, cryptococcal, mycotic) 2 0.80 - Meningitis, Hepatitis B, Acute Hepatitis B, Gonorrhea Malaria Rabies, Possible Exposure Hepatitis B (+HBsAg in Pregnant Women) Streptococcus pneumoniae, Drug-Susceptible Giardiasis disease Lyme Pertussis Hepatitis A Hepatitis Streptococcus pneumoniae, Drug-Resistant Chlamydia West Nile Virus West 1 2 3 4 5 Campylobacteriosis Acquired Immune Deficiency Syndrome Table 1.3: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008 Table

32 Summary of Selected Notifiable Diseases and Conditions ------2 12.56 ------1 2.92 - 1 2.92 - 1 2.92 - 1 2.92 1 6.28 ------16.56 ------11 ------2 0.59 1 1.51 - 2 0.59 1 1.51 1 2.92 ------1 0.53 6 1.76 - 1 0.53 - 2 1.05 7 2.06 - 2 1.05 - 1 0.53 1 0.29 - 1 0.53 10 2.94 1 1.51 ------. ------1 0.70 29 15.29 7 2.06 9 13.55 2 5.83 - 2 1.41 - 1 0.70 1 0.53 3 0.88 1 1.51 - 5 3.52 8 4.22 9 2.64 - 1 0.70 - 1 0.70 - 1 0.70 1 0.53 4 1.17 - E. coli , shiga toxin producing. ------Neisseria meningitidis , meningococcal disease, and meningococcemia disseminated. Listeria monocytogenes ------6 3.60 3 2.11 2 1.05 26 7.63 4 6.02 3 8.75 - 2 1.20 - 1 0.60 - 1 0.60 - 9 5.41 1 0.70 9 4.75 66 19.38 7 10.54 4 11.66 1 6.28 1 0.60 - 1 0.60 2 1.41 4 2.11 16 4.70 2 3.01 1 2.92 - 3 1.80 5 3.52 10 5.27 58 17.03 7 10.54 3 8.75 5 31.39 3 1.80 11 0.70 0.60 10 2 5.27 1.41 12 10 3.52 5.27 3 7 4.52 2.06 - 5 7.53 - 2 1.20 7 4.92 16 8.44 16 4.70 9 13.55 1 2.92 4 25.11 2 1.20 4 2.81 11 0.53 0.60 2 - 0.59 - 2 1.20 9 6.33 12 6.33 10 2.94 2 3.01 - 44 26.43 33 23.22 25 13.18 48 14.09 5 7.53 19 55.40 - 27 16.22 18 12.66 25 13.18 57 16.74 12 18.06 10 29.16 2 12.56 34 20.42 39 27.44 108 56.94 83 24.37 36 54.19 10 29.16 2 12.56 33 19.82 48 33.77 23 12.13 52 15.27 46 27.63 45 31.66 158 83.30 94 27.60 65 97.85 32 93.31 19 119.29 18 10.81 5 3.52 12 6.33 44 12.92 10 15.05 8 23.33 3 18.84 227 136.36 278 195.58 574 302.64 763 224.02 200 301.07 142 414.07 51 320.21 Charlotte County Citrus County Clay County Collier County Columbia County DeSoto County Dixie County Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate other. V. vulnificus , and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, non-O1, V. presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. A 1 2 Invasive Disease, Invasive Disease, Hemophilus influenzae E. coli , O157:H7; serogrpouped non-O157; and cholerae alginolyticus, V. V. 4 Invasive 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Selected Notifiable Diseases Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Vibrio Infections Vibrio Varicella Escherichia coli Listeriosis Tuberculosis Legionellosis Meningococcal Disease Cyclosporiasis Human Immunodeficiency Virus Human Immunodeficiency Shigellosis Toxoplasmosis Meningitis, Hepatitis C, Acute Hepatitis C, Cryptosporidiosis Hepatitis B, Acute Hepatitis B, Salmonellosis Syphilis Hemophilus influenzae, Meningitis, Other (bacterial, cryptococcal, mycotic)cryptococcal, (bacterial, Other Meningitis, - Chlamydia Malaria Hepatitis B (+HBsAg in Pregnant Women) Rabies, Possible Exposure Streptococcal Disease, Invasive Group Gonorrhea Campylobacteriosis Lyme disease Lyme Nile Virus West Hepatitis A Hepatitis Pertussis Streptococcus pneumoniae, Drug-Susceptible Giardiasis Streptococcus pneumoniae, Drug-Resistant Acquired Immune Deficiency Syndrome 1 2 3 4 5 Cont’d Table 1.3: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008 Cont’d Table

33 2008 Florida Morbidity Statistics ------1 8.85 1 8.85 ------1.51 1 8.85 ------1 5.76 - 3 17.27 - 1 5.76 - 1 5.76 - 1 5.76 ------1.99 0 0.00 - 21.93 1 5.76 4 35.40 ------1 1.99 - 3 5.98 1 5.76 2 17.70 1 1 1.99 1 5.76 1 8.85 1 1.99 - 2 3.99 - 4 7.98 4 23.02 - 2 3.99 2 1 2 3.99 4 23.02 1 8.85 1 1.99 - 11 ------15 29.91 ------1 8.14 - 3 24.42 5 9.97 6 34.53 ------11.35 1 8.14 2 3.99 - 11.35 2 16.28 27 53.84 2 11.51 1 8.85 ------11 11 ------. - - - - 2 0.64 - E. coli , shiga toxin producing. - - - - - Neisseria meningitidis , meningococcal disease, and meningococcemia disseminated. Listeria monocytogenes - - - - - 6 0.66 - 2 0.22 3 0.96 - 3 0.33 - 3 0.33 3 0.96 3 3.10 1 8.14 - 7 0.779 1 0.99 0.32 61 - 1.92 0.11 12 - 1.03 0.22 - 1 0.32 - 3 0.33 2 0.64 1 1.03 - 47 5.17 192 61.55 38 4.18 144 46.17 1 1.03 - 28 3.08 3 0.96 - 68 7.49 3 0.96 1 1.03 1 8.14 - 58 6.39 18 5.77 1 1.03 - 25 2.75 7 2.24 2 2.06 - 55 6.05 9 2.89 - 70 7.71 3 0.96 1 1.03 - 40 4.40 40 12.82 2 2.06 - 77 8.48 24 7.69 2 2.06 - 48 5.28 25 8.01 4 4.13 - Duval County Escambia County Flagler County Franklin County Gadsden County Gilchrist County Glades County 113 12.44 43 13.79 8 8.25 - 102 11.23 10 3.21 1 1.03 - 375 41.28 72 23.08 280 30.82 38 12.18 3 3.10 1 8.14 530 58.35 83 26.61 12 12.38 2 16.28 20 39.88 6 34.53 3 26.55 284 31.26 73 23.40 4 4.13 - 2,655 292.28 721 231.15 46 47.47 25 203.48 262 522.41 7 40.29 9 79.64 6,124 674.17 1,834 587.96 227 234.23 58 472.08 548 1,092.68 32 184.17 25 221.22 Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate other. V. vulnificus , and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, non-O1, V. presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. 1 2 Invasive Disease, Invasive Disease, E. coli , O157:H7; serogrpouped non-O157; and Hemophilus influenzae cholerae alginolyticus, V. V. 4 Invasive 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Selected Notifiable Diseases Includes reported cases of Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Listeriosis Vibrio Infections Vibrio Legionellosis Meningococcal Disease Varicella Tuberculosis Escherichia coli Meningitis, Human Immunodeficiency Virus Human Immunodeficiency Hepatitis C, Acute Hepatitis C, Toxoplasmosis Cyclosporiasis Hemophilus influenzae, Shigellosis Hepatitis B, Acute Hepatitis B, Meningitis, Other (bacterial, cryptococcal, mycotic) 13 1.43 13 4.17 - Cryptosporidiosis Hepatitis B (+HBsAg in Pregnant Women) Malaria Syphilis Gonorrhea Salmonellosis Streptococcal Disease, Invasive Group A Streptococcal Disease, Invasive Group Giardiasis A Hepatitis disease Lyme Rabies, Possible Exposure Chlamydia Pertussis West Nile Virus West Streptococcus pneumoniae, Drug-Susceptible Campylobacteriosis Acquired Immune Deficiency Syndrome 1 2 3 4 5 Streptococcus pneumoniae, Drug-Resistant Cont’d Table 1.3: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008 Cont’d Table

34 Summary of Selected Notifiable Diseases and Conditions - 0.91 - 7 0.58 1 0.08 4 0.33 4 0.33 2 0.17 2 0.17 1 0.08 2 0.17 11 - - - 33 2.73 - - - - 82 6.78 - 15 1.24 - - - - - 30 2.48 ------1 1.00 2 0.17 1 1.00 3 3.01 38 3.14 1 1.00 21 1.74 3 3.01 57 4.71 2 2.00 2 0.17 ------0.60 ------1 0.60 - 1 2 1.21 - 1 0.602 - 1.21 - 3 1.81 1 1.00 14 1.16 ------13 7.86- 6 6.01 28 2.31 - - - 14 8.47 19 19.05 15 1.24 ------27.30 22 13.31 25 25.06 455 37.60 ------1 2.48 1 0.60 2 2.00 10 0.83 2 4.96 - 1 2.48 1 0.60 1 1.00 28 2.31 11 ------39.78 16 39.71 14 8.47 16 16.04 62 5.12 ------3 10.85 6 14.89 4 2.42 3 3.01 69 5.70 1 3.62 2 4.96 - 1 3.62 - 1 3.62 - 2 7.23 - 1 3.62 - 5 18.08 8 19.85 8 4.84 23 23.06 324 26.78 11 ------74.51 8 28.93 5 12.41 8 4.84 5 5.01 503 41.57 . ------1 6.77 2 7.23 1 2.48 4 2.42 - 6 40.64 7 25.32 1 6.77 1 3.62 - 6 40.64 6 21.70 - 1 6.77 - 1 6.77 2 7.23 1 2.48 10 6.05 4 4.01 55 4.55 11 E. coli , shiga toxin producing. ------Neisseria meningitidis , meningococcal disease, and meningococcemia disseminated. Listeria monocytogenes ------3 17.65 4 27.09 3 17.65 8 47.06 6 40.64 15 54.25 18 44.67 32 19.36 26 26.06 242 20.00 1 5.88 5 33.87 13 47.02 2 4.96 4 2.42 1 1.00 90 7.44 3 17.65 2 13.55 - 2 11.76 1 6.77 2 7.23 2 4.96 5 3.02 - Gulf County Hamilton County Hardee County Hendry County Hernando County Highlands County Hillsborough County 10 58.82 17 115.15 17 61.48 35 86.86 62 37.50 73 73.18 2,088 172.57 41 241.16 86 582.54 114 412.30 187 464.08 289 174.80 318 318.77 6,250 516.54 Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate other. V. vulnificus , and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, non-O1, V. presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. A 1 2 Invasive Disease, Invasive Disease, E. coli , O157:H7; serogrpouped non-O157; and Hemophilus influenzae cholerae alginolyticus, V. V. 4 Invasive 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Selected Notifiable Diseases Includes reported cases of Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Vibrio Infections Vibrio Varicella Tuberculosis Listeriosis Escherichia coli Toxoplasmosis Hemophilus influenzae, Legionellosis Meningococcal Disease Cyclosporiasis Cryptosporidiosis Shigellosis Human Immunodeficiency Virus Human Immunodeficiency Syphilis Gonorrhea Hepatitis C, Acute Hepatitis C, Meningitis, Hepatitis B, Acute Hepatitis B, Streptococcal Disease, Invasive Group Meningitis, Other (bacterial, cryptococcal, mycotic) - Chlamydia Hepatitis B (+HBsAg in Pregnant Women) Salmonellosis Giardiasis Rabies, Possible Exposure Streptococcus pneumoniae, Drug-Susceptible Nile Virus West Malaria Campylobacteriosis Hepatitis A Hepatitis Lyme disease Lyme Pertussis Streptococcus pneumoniae, Drug-Resistant Acquired Immune Deficiency Syndrome 1 2 3 4 5 Cont’d Table 1.3: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008 Cont’d Table

35 2008 Florida Morbidity Statistics ------1 0.16 1 0.16 4 0.63 3 0.47 5 0.79 2 0.32 ------3.75 25 3.94 ------1 0.34 32 5.04 3 1.02 9 1.42 3 1.02 18 2.84 1 0.34 3 0.47 7 2.39 8 1.26 1 0.34 7 1.10 4 1.36 19 2.99 3 1.02 6 0.95 2 0.68 6 0.95 8 2.73 75 11.82 2 0.68 31 0.47 0.34 4 0.63 1 0.34 6 0.95 11 ------90 30.69 233 36.71 ------18 6.14 22 3.47 - 34 11.60 104 16.39 - - 10 3.41 24 3.78 1.67 ------25 291.68 35 11.94 15 2.36 ------1 0.69 ------3 5.87 2 1.37 ------. ------2 1.40 1 1.96 1 0.69 - 1 0.70 - 1 0.70 - 1 0.70 - 1 0.70 - 1 0.70 - 3 2.11 - 3 2.11 - E. coli , shiga toxin producing. - - - - 24 16.85 1 1.96 1 0.69 ------15 10.53 5 9.78 2 1.37 1 11.67 33 11.25 90 14.18 ------10 7.02 4 7.83 4 2.75 - Neisseria meningitidis , meningococcal disease, and meningococcemia disseminated. Listeria monocytogenes ------2 10.31 9 6.32 1 1.96 - 5 25.77 20 14.04 15 29.35 3 2.06 3 35.00 36 12.28 159 25.05 2 10.31 20 14.04 10 19.57 1 0.69 2 23.33 25 8.53 82 12.92 8 41.22 42 29.48 7 13.70 5 3.43 - 1 5.15 6 4.21 2 3.91 1 0.69 - 1 5.15 1 0.70 - 1 5.15 1 0.70 - 2 10.31 14 9.83 1 1.961 3 5.15 2.06 - 1 11.67 22 7.50 41 6.46 1 5.15 2 1.40 7 13.70 1 0.69 1 1 1 5.15 3 2.11 1 1.96 1 0.69 - 12 61.84 222 155.84 113 221.11 22 15.11 3 35.00 251 85.60 474 74.69 46 237.04 473 332.04 205 401.13 91 62.49 15 175.01 743 253.40 2,022 318.60 Holmes County Indian River County Jackson County Jefferson County Lafayette County Lake County Lee County Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate other. V. vulnificus , and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, non-O1, V. presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. 1 2 Invasive Disease, Invasive Disease, E. coli , O157:H7, serogrpouped non-O157, and Hemophilus influenzae cholerae alginolyticus, V. V. 4 Invasive 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Selected Notifiable Diseases Includes reported cases of Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Vibrio Infections Vibrio Varicella Listeriosis Tuberculosis Legionellosis Toxoplasmosis Meningococcal Disease Escherichia coli Hemophilus influenzae, Shigellosis Cyclosporiasis Human Immunodeficiency Virus Human Immunodeficiency Syphilis Salmonellosis Hepatitis C, Acute Hepatitis C, Meningitis, Cryptosporidiosis Gonorrhea Meningitis, Other (bacterial, cryptococcal, mycotic) - Streptococcal Disease, Invasive Group A Streptococcal Disease, Invasive Group Hepatitis B, Acute Hepatitis B, Rabies, Possible Exposure Hepatitis B (+HBsAg in Pregnant Women) Malaria Chlamydia Giardiasis A Hepatitis disease Lyme Pertussis Streptococcus pneumoniae, Drug-Susceptible Campylobacteriosis West Nile Virus West Streptococcus pneumoniae, Drug-Resistant 2 3 Acquired Immune Deficiency Syndrome 1 4 5 Cont’d Table 1.3: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008 Cont’d Table

36 Summary of Selected Notifiable Diseases and Conditions ------7.60 - - - - - 1 0.69 1 0.69 11 ------2 0.60 3 2.07 ------4.36 5 1.51 2 1.38 ------3 0.93 2 0.60 1 0.69 1 0.31 - 1 0.31 1 0.30 - 4 1.24 3 0.90 3 2.07 5 1.56 5 1.51 1 0.69 6 1.87 3 0.90 - 9 2.80 5 1.51 5 3.45 1 0.31 1 0.30 - 3 0.93 5 1.51 2 1.38 8 2.49 13 3.92 4 2.76 1 0.31 - 38 0.93 2.49 5 4 1.51 1.21 - 4 2.76 5 1.56 3 0.90 1 0.69 - 17 5.29 14 4.22 20 13.82 ------14 - 84 26.14 75 22.60 33 22.80 - - - - 13 4.05 5 1.51 2 1.38 - - - 37 11.51 70 21.09 - - - 10 3.11 16 4.82 6 4.15 - - - 12 3.73 16 4.82 2 1.38 ------3 14.99 14 4.36 10 3.01 7 4.84 1 5.00 15 4.67 16 4.82 4 2.76 ------27.04 - . ------11 E. coli , shiga toxin producing. ------Neisseria meningitidis , meningococcal disease, and meningococcemia disseminated. Listeria monocytogenes ------2 0.73 1 0.37 1 2.46 - 9 3.29 4 9.83 - 1 0.37 - 6 2.19 1 2.46 - 8 2.92 1 2.46 - 2 0.73 - 4 1.46 - 3 1.10 - 4 1.46 - 9 3.29 - 5 1.83 - 6 2.19 - 1 0.371 - 0.37 - 2 0.73 - 1 0.37 - 89 32.51 3 7.38 1 12.87 4 19.98 64 19.92 62 18.68 24 16.58 40 14.61 1 2.46 4 51.50 5 24.98 31 9.65 34 10.25 12 8.29 17 6.21 3 7.38 - 43 15.71 3 7.38 - 33 12.06 1 2.46 1 12.87 - 59 21.55 1 2.46 1 12.87 7 34.97 45 14.00 57 17.18 14 9.67 Leon County Levy County Liberty County Madison County Manatee County Marion County Martin County 117 42.74 13 31.96 - 2,827 1,032.73 167 410.55 36 463.50 123 614.45 1,102 342.96 1,203 362.52 266 183.78 1,050 383.57 57 140.13 12 154.50 23 114.90 454 141.29 381 114.81 43 29.71 Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate other. V. vulnificus , and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, non-O1, V. presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. A 1 2 Invasive Disease, Invasive Disease, E. coli , O157:H7; serogrpouped non-O157; and Hemophilus influenzae cholerae alginolyticus, V. V. 4 Invasive 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Selected Notifiable Diseases Includes reported cases of Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Vibrio Infections Vibrio Listeriosis Varicella Legionellosis Meningococcal Disease Tuberculosis Cyclosporiasis Escherichia coli Meningitis, Human Immunodeficiency Virus Human Immunodeficiency Cryptosporidiosis Toxoplasmosis Hemophilus influenzae, Shigellosis Meningitis, Other (bacterial, cryptococcal, mycotic) - Hepatitis C, Acute Hepatitis C, Chlamydia Salmonellosis Malaria Streptococcal Disease, Invasive Group Syphilis Hepatitis B, Acute Hepatitis B, Gonorrhea Campylobacteriosis Pertussis Rabies, Possible Exposure Streptococcus pneumoniae, Drug-Susceptible Hepatitis B (+HBsAg in Pregnant Women) Nile Virus West Giardiasis Lyme disease Lyme Streptococcus pneumoniae, Drug-Resistant Hepatitis A Hepatitis Acquired Immune Deficiency Syndrome 1 2 3 4 5 Cont’d Table 1.3: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008 Cont’d Table

37 2008 Florida Morbidity Statistics ------4 0.36 - 1 0.09 1 0.37 7 0.62 1 0.37 3 0.27 - 3 0.273 - 0.27 - 8 0.71 - 6 0.53 3 1.10 1 0.09 - 8 0.71 2 0.73 1 31 2.76 2 0.73 - -- 28 2.49 4 1.46 - 15 1.34 1 0.37 ------42 3.74 5 1.83 - - 29 2.58 1 0.37 - - - - 5.11 71 6.32 10 3.66 ------1 0.50 - 1 0.50 - 6 3.02 2 1 0.50 - 2 1.01 1 2.561 3 0.50 0.27 - - 1 0.50 ------2 2.84 - 3 4.26 3 1.51 3 7.67 12 1.07 1 0.37 2 2.84 - 2 2.84 1 0.50 ------. - - E. coli , shiga toxin producing. - - 0.44 - Neisseria meningitidis , meningococcal disease, and meningococcemia disseminated. Listeria monocytogenes - - 2 0.08 - 3 0.12 - 7 0.28 - 7 0.289 - 0.36 - 8 0.32 - 7 0.28 1 1.28 - 11 82 3.31 0 0.00 18 25.55 35 17.60 3 7.67 63 5.61 65 23.79 10 0.40 - 67 2.70 3 3.84 5 7.10 3 1.51 - 78 3.15 1 1.28 - 25 1.01 2 2.56 1 1.42 4 2.01 1 2.56 16 1.42 - 17 0.69 3 3.84 2 2.84 1 0.50 1 2.56 42 3.74 7 2.56 73 2.95 2 2.56 6 8.52 7 3.52 2 5.1 13 0.5232 - 1.29 - 26 1.05 4 5.12 2 2.84 1 0.50 1 2.56 78 6.94 15 5.49 16 0.65 - 29 1.17 1 1.28 - 199 8.03 6 7.68 2 2.84 4 2.01 5 12.78 90 8.01 6 2.20 551 22.23 15 19.19 31 44.00 68 34.19 13 33.23 224 19.94 45 16.47 154 6.21 2 2.56 9 12.78 7 3.52 5 12.78 42 3.74 12 4.39 108 4.36 3 3.84 7 9.94 33 16.59 3 7.67 92 8.19 16 5.86 312 12.59 14 17.91 8 11.36 8 4.02 5 12.78 90 8.01 9 3.29 134 5.41 3 3.84 5 7.10 9 4.53 - 2,112 85.21 15 19.19 70 99.37 197 99.05 15 38.35 2,069 184.19 162 59.28 1,380 55.68 19 24.31 14 19.87 10 5.03 5 12.78 338 30.09 40 14.64 1,587 64.03 30 38.38 8 11.36 22 11.06 8 20.45 585 52.08 82 30.01 7,547 304.49 107 136.90 217 308.03 705 354.48 159 406.48 5,744 511.34 1,074 393.02 1,097 44.26 40 51.18 4 5.68 17 8.55 4 10.23 259 23.06 38 13.91 Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Miami-Dade County Monroe County Nassau County Okaloosa County Okeechobee County Orange County Osceola County other. V. vulnificus , and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, non-O1, V. presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. 1 2 Invasive Disease, Invasive Disease, E. coli , O157:H7; serogrpouped non-O157; and Hemophilus influenzae cholerae alginolyticus, V. V. 4 Invasive 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Selected Notifiable Diseases Includes reported cases of Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Vibrio Infections Vibrio Varicella Tuberculosis Toxoplasmosis Cyclosporiasis Escherichia coli Legionellosis Listeriosis Cryptosporidiosis Shigellosis Syphilis Hemophilus influenzae, Hepatitis C, Acute Hepatitis C, Human Immunodeficiency Virus Human Immunodeficiency Chlamydia Salmonellosis Streptococcal Disease, Invasive Group A Streptococcal Disease, Invasive Group Gonorrhea Hepatitis B, Acute Hepatitis B, Campylobacteriosis Rabies, Possible Exposure Meningococcal Disease Giardiasis Streptococcus pneumoniae, Drug-Susceptible Nile Virus West Malaria Pertussis Meningitis, Other (bacterial, cryptococcal, mycotic)Meningitis, 20 0.81 - Hepatitis B (+HBsAg in Pregnant Women) Acquired Immune Deficiency Syndrome 1 2 3 4 5 Lyme disease Lyme Streptococcus pneumoniae, Drug-Resistant Hepatitis A Hepatitis Cont’d Table 1.3: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008 Cont’d Table

38 Summary of Selected Notifiable Diseases and Conditions - - - 3.57 3.82 4.33 3.57 1.27 0.51 1.02 4.33 2.80 2.80 4.59 9.43 0.76 0.51 0.25 0.76 2.80 0.51 0.25 1.02 0.76 1.27 0.25 0.25 14.28 77.50 18.10 17.59 13.77 265.13 - - - 5 2 4 3 2 1 3 2 1 4 3 5 1 1 11 11 11 14 15 17 14 17 56 71 18 69 37 54 304 1,040 ------4.90 1.40 0.70 4.90 1.40 2.10 1.40 1.40 1.40 4.90 8.39 9.09 2.10 8.39 1.40 0.70 3.50 3.50 1.40 0.70 0.70 0.70 12.59 53.15 32.87 208.40 ------7 2 1 7 2 3 2 2 2 7 3 2 1 5 5 2 1 1 1 18 76 12 13 47 12 298 ------2.67 4.01 1.34 5.34 6.68 1.34 1.34 2.671.34 185.34 12.59 10 2.55 9.35 6.68 5.34 13.35 30.71 52.07 415.20 242.98 ------2 3 1 4 5 1 1 2 1 4 7 5 4 10 23 39 311 182 - - - - 0.51 0.68 0.85 0.34 6.44 4.92 6.61 3.22 0.17 2.03 0.85 4.75 1.70 0.85 0.17 0.85 2.54 2.71 3.56 1.87 6.44 1.02 22.55 28.32 24.42 12.55 395.57 129.20 - - - - 3 4 5 2 1 5 5 1 5 6 11 38 29 39 19 12 28 10 15 16 21 38 74 133 167 144 762 2,333 - 0.11 0.32 0.96 0.85 0.32 0.53 0.85 1.81 3.61 3.83 1.38 0.64 0.43 0.32 3.72 2.34 0.96 0.32 0.74 1.17 0.96 3.19 7.44 5.10 0.21 21.90 34.55 22.54 15.84 416.20 158.72 - 3 9 8 3 5 8 6 4 3 9 3 7 9 2 1 11 17 34 36 13 35 22 30 70 48 206 325 212 149 3,915 1,493 - - - 0.23 0.45 0.00 0.23 0.23 0.23 1.36 5.44 2.49 0.23 0.23 1.59 2.04 3.17 0.00 0.45 0.23 0.68 2.27 1.81 8.16 3.63 7.25 10.20 15.41 16.09 43.75 28.79 164.56 - - - 1 2 0 1 1 1 6 1 1 7 9 0 2 1 3 8 11 45 24 14 10 36 68 71 16 32 726 193 127 . - E. coli , shiga toxin producing. 0.54 0.08 0.61 0.31 0.31 0.31 0.46 0.08 0.23 9.06 6.60 2.84 0.92 1.00 1.31 4.53 1.31 1.38 0.77 0.92 5.84 1.92 4.99 7.83 26.04 78.49 40.47 27.26 19.97 12.60 273.64 Neisseria meningitidis , meningococcal disease, and meningococcemia disseminated. Listeria monocytogenes - 7 1 8 4 4 4 6 1 3 86 37 12 13 17 59 17 18 10 12 76 4847 3.6925 3.61 1365 20 2.95 4.53 28 27 2.98 2.87 39 34 6.61 5.76 118 339 527 102 355 260 164 3,563 1,022 Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Palm Beach County Pasco County Pinellas County Polk County Putnam County Santa Rosa County Sarasota County other. V. vulnificus , and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, non-O1, V. presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. 1 2 Invasive Disease, Invasive Disease, 4 Invasive E. coli , O157:H7; serogrpouped non-O157; and Hemophilus influenzae cholerae alginolyticus, V. V. 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Selected Notifiable Diseases Includes reported cases of Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Acquired Immune Deficiency Syndrome Campylobacteriosis Chlamydia Cryptosporidiosis Cyclosporiasis Escherichia coli Giardiasis Gonorrhea Hemophilus influenzae, A Hepatitis Hepatitis B (+HBsAg in Pregnant Women) Acute Hepatitis B, Acute Hepatitis C, Virus Human Immunodeficiency Legionellosis Listeriosis disease Lyme Malaria Meningitis, Other (bacterial, cryptococcal, mycotic) Meningitis, Meningococcal Disease Pertussis Rabies, Possible Exposure Salmonellosis Shigellosis Streptococcus pneumoniae, Streptococcus pneumoniae, A Streptococcal Disease, Invasive Group Syphilis Toxoplasmosis Tuberculosis Varicella Infections Vibrio Nile Virus West 1 2 3 4 5 Drug-Resistant Drug-Susceptible Cont’d Table 1.3: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008 Cont’d Table

39 2008 Florida Morbidity Statistics ------68.27 ------1 6.21 5 31.03 1 6.21 1 6.21 2 12.41 3 18.62 1 6.21 11 ------2 8.67 ------3 7.36 - 1 2.45 ------1 1.06 - 2 2.12 - 1 1.06 ------1 0.36 1 1.06 - 5 1.79 - 3 1.07 1 1.06 - 3 1.07 - 1 16 5.73 4 4.25 ------6.12 16 5.73 6 6.37 2 4.91 2 8.67 2 12.41 6.12 78 27.91 14 14.87 8 19.62 3 13.01 - . - - - - 3 1.67 9 3.22 - 5 2.78 - 1 0.56 - 11 11 E. coli , shiga toxin producing. ------2.56 1 0.56 17 6.08 2 2.12 - 2.56 17 9.45 9 3.22 6 6.37 4 9.81 - Neisseria meningitidis , meningococcal disease, and meningococcemia disseminated. Listeria monocytogenes ------6 1.40 - 9 2.10 1 0.56 13 4.65 1 1.06 3 7.36 - 1 0.23 5 2.78 - 1 0.23 - 1 0.23 - 8 1.86 8 4.45 2 0.72 3 3.19 2 4.91 - 8 1.86 4 2.22 9 3.22 4 4.25 1 2.45 - 5 1.16 29 16.12 54 19.32 6 6.37 1 2.45 1 4.34 6 37.24 5 1.16 1 0.56 2 0.72 - 4 0.93 4 2.22 2 0.72 3 3.19 - 1 0.23 - 1 0.23 2 1.11 6 2.15 - 1 0.231 3 0.23 1.67 - - 11 11 31 7.22 26 14.46 16 5.73 1 1.06 6 14.72 - 89 20.73 18 10.01 84 30.06 17 18.06 3 7.36 4 17.34 89 20.73 90 50.04 82 29.34 20 21.25 23 56.41 5 21.68 2 12.41 53 12.35 369 205.16 212 75.86 61 64.81 34 83.39 51 221.14 18 111.72 14 3.26 5 2.78 12 4.29 - 24 5.59 13 7.23 23 8.23 3 3.19 7 17.17 3 13.01 - 31 7.22 16 3.73 2 1.1 42 9.78 306 71.29 919 510.96 700 250.48 210 223.11 154 377.70 106 459.63 61 378.60 Seminole County St. Johns County St. Lucie County Sumter County Suwannee County County Taylor Union County Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate other. V. vulnificus , and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, non-O1, V. presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. 1 2 Invasive Disease, Invasive Disease, E. coli , O157:H7; serogrpouped non-O157; and Hemophilus influenzae cholerae alginolyticus, V. V. 4 Invasive 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Selected Notifiable Diseases Includes reported cases of Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Listeriosis Vibrio Infections Vibrio Legionellosis Varicella Escherichia coli Tuberculosis Human Immunodeficiency Virus Human Immunodeficiency Cyclosporiasis Hepatitis C, Acute Hepatitis C, Toxoplasmosis Meningococcal Disease Shigellosis Meningitis, Cryptosporidiosis Hemophilus influenzae, Hepatitis B, Acute Hepatitis B, Syphilis Meningitis, Other (bacterial, cryptococcal, mycotic) 3 0.70 - Streptococcal Disease, Invasive Group A Streptococcal Disease, Invasive Group Salmonellosis Chlamydia Gonorrhea Hepatitis B (+HBsAg in Pregnant Women) Streptococcus pneumoniae, Drug-Susceptible Malaria Campylobacteriosis Pertussis Nile Virus West Rabies, Possible Exposure Giardiasis A Hepatitis Lyme disease Lyme Streptococcus pneumoniae, Drug-Resistant Acquired Immune Deficiency Syndrome 1 2 3 4 5 Cont’d Table 1.3: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008 Cont’d Table

40 Summary of Selected Notifiable Diseases and Conditions ------4.11 4.11 4.11 8.23 8.23 8.23 8.23 32.91 24.68 49.37 16.46 226.27 ------2 2 2 2 8 6 4 1 1 1 55 12 ------5.15 5.15 1.72 3.43 8.58 1.72 6.87 3.43 1.72 1.72 1.72 1.72 1.72 1.72 12.01 27.46 39.48 27.46 267.75 ------7 3 3 1 2 5 1 4 2 1 1 1 1 1 1 16 23 16 156 ------3.27 9.81 3.27 3.27 3.27 0.00 3.27 13.08 19.62 29.44 16.35 291.09 104.66 ------1 3 4 6 1 1 1 1 9 5 89 32 - - - - 2.15 0.20 1.17 0.39 1.37 0.59 0.59 0.59 0.20 0.78 0.39 0.39 0.39 0.39 3.72 2.35 6.65 3.72 4.89 1.96 8.02 2.35 11.35 19.37 19.17 96.66 26.22 28.57 27.78 291.92 - - - - 1 6 2 7 3 3 3 1 4 2 2 2 2 11 99 19 12 34 98 58 19 25 10 41 12 494 134 146 142 1,492 Volusia CountyVolusia County Wakulla County Walton County Washington Number Rate Number Rate Number Rate Number Rate other. . E. coli , shiga toxin producing. Neisseria meningitidis, meningococcal disease, and meningococcemia disseminated. Listeria monocytogenes V. fluvialis, V. hollisae, V. mimicus, V. parahaemolyticus, V. vulnificus , and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, non-O1, V. Selected Notifiable Diseases presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. 1 2 Invasive Disease, Drug-Resistant Invasive Disease, Drug-Susceptible 4 Invasive Hemophilus influenzae E. coli , O157:H7; serogrpouped non-O157; and cholerae alginolyticus, V. V. 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Acquired Immune Deficiency Syndrome Campylobacteriosis Chlamydia Cryptosporidiosis Cyclosporiasis Escherichia coli Giardiasis Gonorrhea Hemophilus influenzae, A Hepatitis Hepatitis B (+HBsAg in Pregnant Women) Acute Hepatitis B, Acute Hepatitis C, Virus Human Immunodeficiency Legionellosis Listeriosis disease Lyme Malaria Meningitis, Other (bacterial, cryptococcal, mycotic) Meningitis, Meningococcal Disease Pertussis Rabies, Possible Exposure Salmonellosis Shigellosis Streptococcus pneumoniae, Streptococcus pneumoniae, A Streptococcal Disease, Invasive Group Syphilis Toxoplasmosis Tuberculosis Varicella Infections Vibrio Nile Virus West 1 2 3 4 5 Cont’d Table 1.3: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by County of Residence, Florida, 2008 Cont’d Table

41 2008 Florida Morbidity Statistics 3.34 1.46 2.30 7 11 16 0.94 5 1.04 1.36 4.42 11 16 52 6.91 48 4.08 12 2.50 0.69 12 1.02 2 0.42 0.69 10 0.85 4 0.83 1.56 4.55 19 7.41 40 3.40 13 2.71 11 11 25 73 111 11.19 72.71 34 2.12 14 1.19 8 1.67 45.54 28 114 182 - - - 1 0.06 1 0.09 - - 0.11 1 0.40 3 0.19 - - 1 0.21 0.34 7 2.80 3 0.19 1 0.09 - - 9.93 157 62.72 1.12 28 11.19 0.07 4 1.60 5 0.31 - - - - 3.21 320.37 12.78 5 15 2.00 0.93 3 6 0.19 0.51 - 1 0.21 - - - 1.27 20 7.99 22 1.37 19 1.62 5 1.04 8.66 140 55.93 79 4.92 63 5.36 20 4.17 0.67 8 3.20 4 0.25 - - - - 0.75 20 7.99 16 1.00 0.07 2 0.80 1 0.06 - - - - 0.26 4 1.60 6 0.37 3 0.26 - - 0.22 ------0.71 17 6.79 23 1.43 27 2.30 26 5.43 0.41 17 6.79 0.22 10 4.00 12 0.75 6 0.51 - - 1.27 57 22.77 42 2.62 29 2.47 25 5.22 5.64 99 39.55 64 3.99 36 3.06 15 3.13 2.05 4.82 0.34 13 5.19 13 0.81 5 0.43 - - 0.71 35 13.98 32 1.99 30 2.55 14.56 335 133.84 311 19.37 210 17.87 94 19.62 31.70 326 130.24 1 29.87 31.33 219 87.49 48 2.99 9 0.77 3 0.63 66.02 578 230.92 136 8.47 22 1.87 3 0.63 - 9 2 2 7 3 6 3 9 11 34 30 86 10 34 18 20 19 55 19 390 266 232 849 800 839 151 129 1,768 - 0.12 0.76 1.15 0.60 4.45 0.60 2.46 5.72 0.44 0.95 0.20 0.20 8.40 0.16 0.48 0.36 7.59 0.16 2.90 4.41 0.040.44 - - 7 2.80 13 0.81 10 0.85 8 1.67 0.52 14.43 10.02 50.44 76.24 88.64 122.31 - 3 5 5 4 9 4 1 11 11 19 29 15 15 62 24 12 73 13 111 112 363 252 144 105 191 1,269 3,077 1,918 2,230 - 0.09 0.83 1.09 0.61 0.22 4.00 3.39 5.82 0.35 0.96 0.13 0.09 0.39 0.43 0.52 0.26 5.78 3.30 4.52 0.30 0.17 13.60 10.13 47.29 29.22 75.62 678.86 248.90 - 2 5 8 3 2 9 6 7 4 19 25 14 92 78 22 10 12 76 313 233 134 329 133 104 1,088 5,727 1,740 15,620 Age Group - 0.74 0.41 0.41 1.07 0.90 2.71 5.49 0.57 0.57 0.08 0.33 0.57 0.25 0.08 0.25 4.51 2.54 3.93 0.080.41 - - 0.33 13.12 10.49 47.71 20.98 63.03 614.94 2168.59 - 9 5 5 7 7 1 4 7 3 1 3 1 5 4 11 13 33 67 55 31 48 160 128 582 125 769 7,502 26,456 - 0.33 0.90 5 0.41 43 1.87 71 2.82 139 5.19 109 43.55 32 1.99 79 6.72 61 12.73 0.57 0.08 - - 1.23 0.08 0.25 2.13 0.33 0.49 0.41 6.03 0.16 0.49 0.08 0.82 4.02 2.62 4.84 0.41 11.97 11.97 10.74 22.13 20.25 548.34 1946.05 - 4 7 1 1 3 4 6 5 2 6 1 5 11 15 26 36 10 49 32 59 146 131 146 270 247 6,689 23,739 - 8.67 0.77 3.83 0.60 0.17 0.34 0.09 0.34 0.09 1.19 0.17 0.85 7.14 0.09 2.30 0.26 0.60 3.06 6.04 0.17 - - 0.77 17.43 32.66 62.51 21.52 - 9 7 2 4 1 4 1 1 1 3 7 2 9 , meningococcal disease, and meningococcemia disseminated. 45 14 10 84 27 36 71 205 102 384 735 253 ------8.67 0.61 5.12 0.35 0.35 0.43 0.26 0.26 1.04 0.61 1.04 0.69 0.26 1.47 0.09 0.09 0.09 - - 5.29 7.46 0.52 39.55 60.02 15.96 - - - - E. coli , shiga toxin producing. 7 4 4 5 3 3 7 8 3 1 1 1 6 59 12 12 17 61 86 456 100 692 184 Neisseria meningitidis - - - - 0.11 0.11 8.02 1.78 6.24 0.56 0.22 2.56 1.67 0.89 2.78 0.78 1.56 0.22 - - 0.89 2.00 1.34 0.22 0.56 Listeria monocytogenes. 11.13 20.38 20.49 35.63 139.85 - - - - 5 2 8 7 2 8 1 2 1 5 72 16 56 23 15 25 14 18 12 183 100 184 320 1,256 - - - - - 2.67 2.23 3.12 7.13 0.89 0.89 1.34 5.34 4.01 4.90 14.70 15.14 25.39 41.42 31.62 477.91 <1 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. ------6 5 7 4 1.78 3 0.33 3 0.26 13 1.11 66 5.41 227 18.61 915 39.77 1,677 66.66 1,410 52.65 479 191.37 132 8.22 27 2.30 1 0.21 2 2 3 9 11 33 26 11.58 22447 24.94 20.93 207 11421 17.95 12.69 9.35 61 26 49 5.19 2.25 5.46 26 3 20 2.13 0.26 1.73 42 7 4 3.44 0.57 0.34 86 9 3.74 0.74 50 1.99 42 30 1.83 1.12 68 18 2.70 7.19 125 4.67 14 124 0.87 49.54 15 87 1.28 5.42 2 92 0.42 7.83 48 10.02 34 57 16 93 12 71 NR NR NR 1,073 Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate Number Rate 1 2 Invasive Invasive E. coli , O157:H7; serogrpouped non-O157; and Hemophilus influenzae V. other. V. vulnificus, and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, cholerae non-O1, V. alginolyticus, V. V. 4 Invasive 5 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 3 Selected Notifiable Diseases Includes reported cases of Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Includes reported cases of meningococcal meningitis, pneumonia caused by Includes reported cases of Meningococcal Disease Salmonellosis Rabies, Possible Exposure Human Immunodeficiency Virus Human Immunodeficiency Shigellosis Streptococcus pneumoniae, Disease, Drug-Resistant Streptococcus pneumoniae, Disease, Drug-Susceptible A Streptococcal Disease, Invasive Group Meningitis, Other Meningitis, Varicella Tuberculosis Pertussis Hepatitis B, Acute Hepatitis B, Acute Hepatitis C, Vibrio Infections Vibrio Toxoplasmosis Escherichia coli Hepatitis A Hepatitis Hepatitis B (+HBsAg in Pregnant Women) NR-Not reported Acquired Immune Deficiency Syndrome 1 2 3 4 5 Syphilis Gonorrhea Malaria West Nile Virus West Cryptosporidiosis Chlamydia Campylobacteriosis Hemophilus influenzae, Giardiasis Legionellosis Cyclosporiasis Lyme Disease Lyme Listeriosis Table 1.4: Reported Confirmed and Probable Cases and Incidence Rate per 100,000 Population for Selected Notifiable Diseases by Age Group, Florida, 2008 1.4: Reported Confirmed and Probable Cases Incidence Rate per 100,000 Population for Selected Notifiable Diseases by Table

42 Summary of Selected Notifiable Diseases and Conditions

, 85+ (12) (15) (25) (13) (26) (94) (16) (48) (61) (20) Syphilis Syphilis Exposure Exposure Giardiasis Giardiasis influenzae Tuberculosis Tuberculosis pneumoniae, pneumoniae, Haemophilus Salmonellosis Salmonellosis Streptococcus Streptococcus Drug-Sensitive Drug-Sensitive Drug-Resistant Drug-Resistant Rabies, Possible Invasive Disease Invasive Disease Invasive Group A A Invasive Group Invasive Disease, Invasive Disease, Campylobacteriosis Streptococcal Disease, Streptococcal

(29) (36) (52) (30) (63) (79) (92) (40) (48) (210) 75-84 Syphilis Syphilis Exposure Exposure Giardiasis Giardiasis Tuberculosis Tuberculosis pneumoniae, pneumoniae, Legionellosis Legionellosis Salmonellosis Salmonellosis Streptococcus Streptococcus Drug-Sensitive Drug-Sensitive Drug-Resistant Drug-Resistant Rabies, Possible Invasive Group A A Invasive Group Invasive Disease, Invasive Disease, Campylobacteriosis Streptococcal Disease, Streptococcal

HIV HIV (79) (73) (64) (87) (92) (111) (119) (311) AIDS AIDS (132) (136) 65-74 Syphilis Syphilis Exposure Exposure Giardiasis Giardiasis Tuberculosis Tuberculosis pneumoniae, pneumoniae, Salmonellosis Salmonellosis Streptococcus Streptococcus Drug-Sensitive Drug-Sensitive Drug-Resistant Drug-Resistant Rabies, Possible Invasive Disease, Invasive Disease, Campylobacteriosis

HIV HIV (114) (335) (140) AIDS AIDS (479) (219) (326) (157) (124) (182) (578) 55-64 Syphilis Syphilis Exposure Exposure Chlamydia Chlamydia Gonorrhea Gonorrhea Tuberculosis Tuberculosis pneumoniae, Salmonellosis Salmonellosis Streptococcus Drug-Resistant Drug-Resistant Rabies, Possible Invasive Disease, Campylobacteriosis

HIV HIV (849) (232) AIDS AIDS (600) (151) (839) (266) (390) (139) 45-54 (1,410) (1,768) Syphilis Syphilis Exposure Exposure Giardiasis Giardiasis Chlamydia Chlamydia Gonorrhea Gonorrhea Tuberculosis Tuberculosis pneumoniae, Salmonellosis Salmonellosis Streptococcus Drug-Sensitive Drug-Sensitive Rabies, Possible Invasive Disease, HIV HIV (112) (191) (144) AIDS AIDS (252) (363) 35-44 (1,918) (2,230) (1,269) (1,677) (3,077) Syphilis Syphilis Exposure Exposure Giardiasis Giardiasis Chlamydia Chlamydia Gonorrhea Gonorrhea Tuberculosis Tuberculosis Salmonellosis Salmonellosis Rabies, Possible Hepatitis B, Acute Hepatitis B, HIV HIV (233) (134) AIDS AIDS (915) (313) (133) (329) 25-34 (1,740) (5,727) (1,088) Syphilis Syphilis (15,620) Exposure Exposure Giardiasis Giardiasis Chlamydia Chlamydia Gonorrhea Gonorrhea Tuberculosis Tuberculosis Salmonellosis Salmonellosis Rabies, Possible Age Group Hepatitis B (+HBsAg in Pregnant Woman) in Pregnant Woman) HIV HIV (67) (55) (769) (125) AIDS AIDS (227) (582) (128) (160) 20-24 (7,502) Syphilis Syphilis (26,456) Exposure Exposure Giardiasis Giardiasis Chlamydia Chlamydia Gonorrhea Gonorrhea Tuberculosis Tuberculosis Salmonellosis Salmonellosis Rabies, Possible Hepatitis B (+HBsAg in Pregnant Woman) in Pregnant Woman) HIV HIV (66) (59) (49) (270) AIDS AIDS (146) (247) (131) (146) 15-19 (6,689) Syphilis Syphilis (23,739) Varicella Varicella Exposure Exposure Giardiasis Giardiasis Chlamydia Chlamydia Gonorrhea Gonorrhea Salmonellosis Salmonellosis Rabies, Possible Campylobacteriosis (61) (61) (71) (45) (84) (253) (384) (102) (205) (735) 10-14 Varicella Varicella Pertussis Pertussis Exposure Exposure Giardiasis Giardiasis Chlamydia Chlamydia Gonorrhea Gonorrhea Shigellosis Shigellosis Salmonellosis Lead Poisoning Lead Poisoning Rabies, Possible Campylobacteriosis

5-9 (61) (59) (86) (26) (92) (207) (456) (100) (184) (692) Varicella Varicella Pertussis Pertussis Exposure Exposure Giardiasis Giardiasis Shigellosis Shigellosis pneumoniae, Salmonellosis Streptococcus Drug-Resistant Drug-Resistant Lead Poisoning Lead Poisoning Rabies, Possible Cryptosporidiosis Invasive Disease, Campylobacteriosis 1-4 (56) (72) (114) (224) (320) (184) (217) (100) (183) (1,256) Varicella Varicella Pertussis Pertussis exposure exposure Giardiasis Giardiasis Shigellosis Shigellosis pneumoniae, Salmonellosis Streptococcus Drug-Resistant Drug-Resistant Lead Poisoning Rabies, possible Cryptosporidiosis Invasive Disease, Campylobacteriosis Campylobacteriosis <1 HIV HIV (71) (18) (26) (93) (21) (47) (34) (57) (33) (1,073) Syphilis Syphilis Varicella Varicella Pertussis Pertussis Shigellosis Shigellosis pneumoniae, pneumoniae, Salmonellosis Salmonellosis Streptococcus Streptococcus Drug-Resistant Drug-Resistant Meningitis, Other Meningitis, Other Drug-Susceptible Drug-Susceptible Invasive Disease, Invasive Disease, Campylobacteriosis 1 2 3 4 5 6 7 8 9 10 Rank Table 1.5: Top 10 Reported Confirmed and Probable Cases of Disease by Age Group, Florida, 2008 10 Reported Confirmed and Probable Cases of Disease by 1.5: Top Table For contextual understanding of the distribution an individual disease listed in this table, please refer to Section 2: Select Notifiable Diseases and Conditions.

43 2008 Florida Morbidity Statistics

Table 1.6: Reported Confirmed and Probable Cases and Incidence Rate per 100,000 Population for Selected Notifiable Diseases by Gender, Florida, 2008 Male Female Selected Notifiable Diseases Number Rate Number Rate Acquired Immune Deficiency Syndrome 3,420 36.95 1,537 15.94 Campylobacteriosis 618 6.68 499 5.18 Chlamydia 18,519 200.08 52,014 539.53 Cryptosporidiosis 274 2.96 273 2.83 Cyclosporiasis 36 0.39 23 0.24 Escherichia coli, Shiga Toxin Producing 1 37 0.40 28 0.29 Giardiasis 794 8.58 596 6.18 Gonorrhea 10,964 118.45 12,221 126.77 Hemophilus influenzae, Invasive Disease2 70 0.76 92 0.95 Hepatitis A 92 0.99 73 0.76 Hepatitis B (+HBsAg in Pregnant Women) - - 600 6.22 Hepatitis B, Acute 234 2.53 123 1.28 Hepatitis C, Acute 27 0.29 26 0.27 Human Immunodeficiency Virus 5,578 60.26 2,010 20.85 Legionellosis 80 0.86 68 0.71 Listeriosis3 31 0.33 19 0.20 Lyme Disease 53 0.57 35 0.36 Malaria 45 0.49 20 0.21 Meningitis, Other (bacterial, cryptococcal, mycotic) 130 1.40 69 0.72 Meningitis, Streptococcus pneumoniae 25 0.27 16 0.17 Meningococcal Disease4 23 0.25 28 0.29 Pertussis 160 1.73 154 1.60 Rabies, Possible Exposure 758 8.19 859 8.91 Salmonellosis 2,601 28.10 2,704 28.05 Shigellosis 385 4.16 416 4.32 Streptococcus pneumoniae, Invasive Disease, Drug-Resistant 393 4.25 399 4.14 Streptococcus pneumoniae, Invasive Disease, Drug-Susceptible 351 3.79 353 3.66 Streptococcal disease, Invasive Group A 157 1.70 118 1.22 Syphilis 3,262 35.24 1,306 13.55 Toxoplasmosis 8 0.09 6 0.06 Tuberculosis 615 6.64 338 3.51 Varicella 893 9.65 842 8.73 Vibrio Infections5 66 0.70 27 0.28 West Nile Virus 3 0.03 0 0.00 1 Includes reported cases of E. coli, O157:H7; E. coli, serogrpouped non-O157; and E. coli, shiga toxin producing. 2 Includes reported cases of Hemophilus influenzae presenting as cellulitis, epiglottitis, meningitis, bacterimia, and septic arthritis. 3 Includes reported cases of listeriosis and cases of meningitis caused by Listeria monocytogenes. 4 Includes reported cases of meningococcal meningitis, pneumonia caused by Neisseria meningitidis, meningococcal disease, and meningococcemia disseminated. 5 Includes reported cases of V. alginolyticus, V. cholerae non-O1, V. fluvialis, V. hollisae, V. mimicus, V. parahaemolyticus, V. vulnificus, and V. other.

44 Summary of Selected Notifiable Diseases and Conditions 11 1 4 11 8 5 6 4 7 9 7 13 13 11 , Florida, 2008 15 25 21 18 17 14 1 11 11 11 5 6 12 11 74 2 3 0 5461292234235 3 0 16372242543048 18 5245233376632 4 61 10 1 1 5 0764446400013 1 4 2696643342104 3 0 4 2 15 24 15 12000100212301 30 3000001020000 4 1 2 10 5 14 10 13 7 10 2 4 7021 77 24 58 23 7664 3012 44 7613 103 14 20 65 117 14 33 73 7 10123 62 7 107 87 26 6 12313 17 77 82 21 12 88 14 70 96 29 8 37 101 75 712 21 103 8 1816 20 8 97 20 2 26 29 16 10 71 1 33 14 1510 70 4 3283 17 10 17 104 16 12 2 17 10 11380 29 12 16 117 561 9 75 141 31 2053 19 59 3 1386524 56 32 132 50 9 64 20 140 47 38 45 12 59 106 20 45 44 154 47 77 22 34 120 42 33 61 17 31 20 98 23 51 15 17 23 26 38 21 23 23 56 17 26 49 41 15 36 72 62 22 50 78 12 78 26 267 163 182 267 302 485 558105 526 228 573 200 547 180 410 168 318 53 42 36 81 95 115 169 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec , meningococcal disease, and meningococcemia disseminated. 3 2 presenting as cellulitis, epiglottitis, meningitis, bacteremia, and septic arthritis. , Invasive Disease, Drug-Resistant , Invasive Disease, Drug-Susceptible , Invasive Disease 5 E. coli , O157:H7; serogrpouped non-O157; and E. coli , shiga toxin producing. H. influenzae V. other. V. vulnificus, and V. parahaemolyticus, V. mimicus, V. hollisae, fluvialis, cholerae non-O1, V. alginolyticus, V. V. 6 , Shiga Toxin Producing Toxin , Shiga Streptococcus pneumoniae 4 Infections Includes reported cases of Includes reported cases of Includes reported cases of listeriosis and meningitis caused by Listeria monocytogenes. Includes reported cases of meningococcal meningitis, pneumonia caused by Neisseria meningitidis Includes reported cases of Only cases of diseases with known dates onset are included in this table. Table 1.7: Reported Confirmed and Probable Cases of Selected Notifiable Diseases by Month Onset Table Disease Campylobacteriosis Cryptosporidiosis Cyclosporiasis Escherichia coli Giardiasis Haemophilus influenzae A Hepatitis Hepatitis B (+HBsAg in a Pregnant Woman) Acute Hepatitis B, Acute Hepatitis C, Legionellosis Listeriosis Disease Lyme Malaria Meningitis, Other (bacterial, cryptococcal, mycotic) Meningitis, Meningococcal Disease Pertussis Rabies, Possible Exposure Salmonellosis Shigellosis Streptococcus pneumoniae Streptococcus pneumoniae A Streptococcal Disease, Invasive Group Toxoplasmosis Varicella Vibrio Nile Virus West 1 2 3 4 5 6

45 2008 Florida Morbidity Statistics

46 Summary of Selected Notifiable Diseases and Conditions

Section 2

List of Notifiable Diseases and Conditions Included

Acquired Immune Deficiency Syndrome/ Syphilis Human Immunodeficiency Virus Tetanus Brucellosis Tuberculosis Campylobacteriosis Toxoplasmosis Chlamydia Typhoid Fever Ciguatera Fish Poisoning Varicella Cryptosporidiosis Vibrio Infections Cyclosporiasis West Nile Virus Dengue Fever Eastern Equine Encephalitis Ehrlichiosis/Anaplasmosis Escherichia coli, Shiga Toxin Producing Giardiasis Gonorrhea Haemophilus influenzae, Invasive Disease Hepatitis A Hepatitis B (+HBsAg in Pregnant Women) Hepatitis B, Acute Hepatitis C, Acute Lead Poisoning Legionellosis Listeriosis Lyme Disease Malaria Measles Meningitis, Other (Bacterial, Cryptococcal, Mycotic) Meningococcal Disease Mumps Neonatal Infections Pertussis Rabies, Animal Rabies, Possible Exposure Rocky Mountain Spotted Fever Salmonellosis Shigellosis Streptococcal Disease, Invasive Group A Streptococcus pneumoniae, Invasive Disease, Drug-Resistant Streptococcus pneumoniae, Invasive Disease, Drug-Susceptible

47 2008 Florida Morbidity Statistics

Acquired Immune Deficiency Syndrome/ Human Immunodeficiency Virus

In 2008, Florida ranked third among states in the number of reported acquired immune deficiency syndrome (AIDS) cases. California reported 4,952 (13%), followed by New York with 4,810 cases (13%), then Florida with 3,960 cases (10%), and Texas with 2,964 cases (8%). Florida ranked third among the 38 states that reported human immunodeficiency virus (HIV) cases in 2008. California reported 17,588 cases (28%), followed by New York with 5,197 cases (8%), then Florida with 5,165 cases (8%), and Pennsylvania with 3,694 cases (6%).

In 2008, Florida reported a higher percentage of adult AIDS cases among heterosexuals (33%) than the U.S. reported in 2007 (20%) (Note: U.S. data not available for 2008). Florida reported a lower percentage of adult AIDS cases among men who had sex with men (MSM) (34%) than the U.S. (38%) and among injection drug users (IDU) (8%) than the U.S. (12%). MSM/IDU cases accounted for 3% of total reported cases in Florida and 4% in the U.S. A lower proportion of cases with no identified risk (NIR) were reported in Florida (22%) than in the U.S. (26%). Florida reported a higher percentage of adult AIDS cases among blacks (53%) compared with the U.S. (41%). Florida also reported a higher percentage of cases among women (31%) compared with the U.S. (27%).

As with reported AIDS cases in 2008, Florida reported a higher percentage of cases of HIV among heterosexuals (23%) compared to reported cases in the U.S. (16%). Florida reported a lower percentage of adult HIV cases among MSM (42% vs. 47%) and among IDU (4% vs. 9%) than the U.S. MSM/IDU cases accounted for 2% of total reported cases in Florida and 4% in the U.S. A higher proportion of cases with no identified risk (NIR) were reported in Florida (29%) than in the U.S. (24%). Florida reported a higher percentage of adult HIV cases among blacks (46%) compared with the U.S. (34%). Florida reported the same percentage of cases among women (26%) as the U.S.

48 Summary of Selected Notifiable Diseases and Conditions

Figure 1. AIDS Cases and Rates per 100,000 Population, by County of Residence*, Florida, 2008 Figure 1. AIDS Cases and Rates per 100,000 Population, by County of Residence*, Florida, 2008

73 0 7 17 7 4 2 15 4 59 4 7 0 0 2 284 16 1 1 8 10 16 3 0 12 0 0 0 3 11 0 43 3 10 4 1 57 99 N= 4,701 5 14 34 42 8 259 Case Rate per 100,000 36 46 133 38 324 206 0 10 45 5 0.1 to 15.0 23 4 78 8 15.1 to 30.0 56 14 18 1 > 30.0 339 104 8 44 895

Based on 2008 statewide population estimates, the 2008 state rate is 31.1 40 1097 per 100,000 population.

*County totals exclude Department of Corrections cases (N=256). Numbers on counties are cases reported.

In 2008, at least one AIDS case was reported in all but eight counties (Figure 1). Although the AIDS epidemic is widespread throughout Florida, the majority of cases were reported from nine counties: Broward, Duval, Hillsborough, Lee, Miami-Dade, Orange, Palm Beach, Pinellas, and Polk. These seven In 2008, at least one HIV case was reported in all but one county, and ten counties reported 100 countiesor reportedmore cases a combined (Figure 2). total These of ten3,641 counties cases, included or 77% the of same Florida’s nine countiestotal reported that reported cases thein 2008. The greatestmajority numbers of AIDS of AIDS cases cases plus Volusiawere reported County. fromThese three ten counties counties reported located a incombined the southeastern total of part of the state;5,717 Broward, cases, orMiami-Dade, 80% of Florida’s and totalPalm reported Beach. HIV These cases three in 2008. counties The greatest reported numbers a combined of HIV total of 2,331 casescases inwere 2008, reported or 49% from of Miami-Dade, the statewide Broward, total. and Orange Counties. These three counties reported a combined total of 3,575 cases in 2008, or 50% of the statewide total. Analysis of county-specific AIDS case rates per 100,000 population for 2008 in counties with 20 or more reported cases, indicate that Monroe County ranked the highest with a rate of 51.2, followed by Broward (50.4), Miami-Dade (44.3), and Duval (31.3) counties.

49 2008 Florida Morbidity Statistics

FigureFigure 2. HIV2. HIV cases, cases, by by County County ofof Residence*, Florida, Florida, 2008 2008

5 72 15 12 22 4 6 27 8 89 3 4 6 30 1 4 375 1 1 3 12 30 4 11 25 0 2 3 3 18 2 71 2 23 11 3 62 134 18 N= 7,111 17 36 89 22 585 Case Rate per 100,000 68 82 58 167 455 325 0 20 64 7 25 8 84 10 0.1 to 15.0 71 24 1 15.1 to 30.0 27 527 159 > 30.0 11 57 1403

1587 Based on 2008 statewide population estimates, the 2008 state 30 rate is 47.1 per 100,000 population.

*County totals exclude Department of Corrections cases (N=477). This map does not reflect HIV incidence. Numbers on counties are cases reported.

In 2008, at least one HIV case was reported in all but one county, and ten counties reported 100 or more cases (Figure 2). These ten counties included the same nine counties that reported the majority of AIDS casesGenerally, plus Volusia reported County. numbers These of HIV ten cases counties remained reported fairly stablea combined from 1999 total to of2006. 5,717 The cases, slight or 80% of Florida’sincrease total reported in 2002 wasHIV duecases to increased in 2008. HIVThe testing greatest statewide numbers as part of HIV of the cases “Get towere Know reported Your from Status” campaign. Since that time, newly reported HIV cases have decreased each year until Miami-Dade,2006. Broward, Enhanced and reporting Orange lawsCounties. were implemented These three in Novembercounties reported 2006, leading a combined to an increase total of 3,575 cases in 2008,in reported or 50% cases of the of HIV statewide in 2007 total.and 2008 (Figure 3). This change in reporting laws allowed more people to meet the case definition for newly diagnosed HIV and therefore the increase Generally,observed reported is numbers not a true of increase HIV cases in incidence remained of HIV fairly infection stable but from rather 1999 an toincrease 2006. inThe reported slight increase in 2002 wascases. due to increased HIV testing statewide as part of the “Get to Know Your Status” campaign. Since that time, newly reported HIV cases have decreased each year until 2006. Enhanced reporting

laws were implemented in November 2006, leading to an increase in reported cases of HIV in 2007 and 2008 (Figure 3). This change in reporting laws allowed more people to meet the case definition for newly diagnosed HIV and therefore the increase observed is not a true increase in incidence of HIV infection but rather an increase in reported cases.

50 Summary of Selected Notifiable Diseases and Conditions

Figure 3. HIV Cases and Case Rates per 100,000 Population*, Figure 3. HIV Cases and Case Rates per 100,000 Population*, by Year of Report, Florida, 1999-2008 by Year of Report, Florida, 1999-2008

Year Rate 7,588 1999 14.5 6,505 2000 16.2 6,553 6,285 2001 15.9 7,000 6,145 17.8 5,748 5,877 5,943 2002 5,158 2003 16.9 6,000 5,467 2004 13.3 2005 10.5 2006 14.0 5,000 2007 16.8 2008 40.2 4,000

3,000

Number of Cases 2,000

1,000

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year of Report *Rates are expressed as deaths per 100,000 population based on 2006 Population Estimates, DOH, Office of Planning, Evaluation and Data Analysis In 1999, 28% of the adult AIDS cases reported in Florida were women (Figure 4). Over the past In 1999,ten years, 28% theof the proportion adult AIDS of AIDS cases cases reported among in Florida women were has womenincreased (Figure slightly. 4). OverThis hasthe past ten years,resulted the proportion in a decline of AIDSof the casesmale-to-female among women ratio, fromhas increased 2.5:1 in 1999 slightly. to 2.2:1 This in has 2008. resulted In 2008, in a decline of thethe male-to-female case rate per 100,000 ratio, from population 2.5:1 in was1999 33.5 to 2.2:1 among in 2008. adult malesIn 2008, and the 16.2 case among rate peradult 100,000 populationfemales, was indicating 33.5 among that AIDS adult cases males in and this 16.2 period among were adult still more females, likely indicating to be reported that AIDS among cases in this timemales period than were females still more in Florida. likely to be reported among males than females in Florida.

Figure 4. Percent of Adult AIDS Cases by Sex and Figure 4. YearPercent of Report, of Adult Florida, AIDS Cases 1999-2008 by Sex and YearYear of of Report, Report, Florida, Florida, 1999-2008 1999-2008 Males 80 100% 90% 70 80% M:F Ratio 60 70% M:F Ratio 1999 1999 2.5:1 2.5:1 60% Females 50 2008 2008 2.2:1 2.2:1 50% 40 40% 30%

30 Percent of Cases 20% Percent of Cases 20 10% 10 0% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 0 1999 2000 2001 2002 2003 200Year4 of200 Report5 2006 2007 2008 Year of ReportMale Female

Figure 5. Percent of Adult HIV Cases by Sex and Year of Report, Florida, 1999-2008 51 100% 90% 80% M:F Ratio 70% 1999 1.6:1 60% 2008 2.8:1 50% 40% 30% Percent of Cases 20% 10% 0% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year of Report

Male Female Figure 4. Percent of Adult AIDS Cases by Sex and Year of Report, Florida, 1999-2008

100% 90% 80% 70% M:F Ratio 1999 2.5:1 60% 2008 2.2:1 50% 40% 30% Percent of Cases 20% 2008 Florida Morbidity Statistics 10% 0% In 1999, 38% of the1999 HIV cases 2000 reported 2001 2002 in Florida 2003 2004were female 2005 2006(Figure 2007 5). The 2008 proportion of HIV cases among women has decreased steadily over the past ten years. The result is an increase of the male-to- femaleIn 1999, ratio, 38% from of 1.6:1 the HIVin 1999 cases to reported2.8:1 in 2008.Year in Florida of This Report were increase female in the(Figure male-to-female 5). The proportion ratio differs of from the patternHIV casesseen for among AIDS womencases during has decreased the same steadilytime period. over the past ten years. The result is an increase of the male-to-female ratio, fromMale 1.6:1 Femalein 1999 to 2.8:1 in 2008. This increase in the male-to-female ratio differs from the pattern seen for AIDS cases during the same time period. Figure 5.Figure Percent 5. Percent of Adult of HIV Adult Cases HIV byCases Sex byand Sex and Year of YearReport, of Report, Florida, Florida, 1999-2008 1999-2008 Figure 5. Percent of Adult HIV Cases by Sex and Year of Report, Florida, 1999-2008 100% Males 90% 80 80% M:F Ratio 7070% 1999 1.6:1 6060% 2008M:F Ratio 2.8:1 50% 50 FemalesFemalesFemales 1999 1.6:1 40% 2008 2.8:1 4030% Percent of Cases 3020%

Percent of Cases 10% 20 0% 10 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 0 Year of Report 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Male Female Year of Report

In 2008, a total of 3,415 men and 1,529 women were reported with AIDS, representing 69% and 31% of In 2008, a total of 3,415 men and 1,529 women were reported with AIDS, representing 69% and cases, respectively (Figure 6). Also in 2008, a total of 5,532 men and 1,966 women were reported with 31% of cases, respectively (Figure 6). Also in 2008, a total of 5,532 men and 1,966 women HIV infection, representing 74% and 26% of cases, respectively. were reported with HIV infection, representing 74% and 26% of cases, respectively.

Figure 6. Percentage of Adult AIDS Cases by Sex, Florida, Compared with Figure 6. Percentage of Adult AIDS Cases by Sex, Florida, Compared with Percentage of Adult HIV Cases by Sex, Florida, 2008 Percentage of Adult HIV Cases by Sex, Florida, 2008

Total Adult AIDS Cases Total Adult HIV Cases by Gender by Gender 2008, (N=4,944) 2008, (N=7,498) 31% 26%

69% 74% Males Females

HIV case reporting, implemented in July 1997, tends to indicate newer infections than are reflected by AIDS case data, although we do not know the proportion of diagnosed HIV cases that were recently

HIV case reporting, implemented in July 1997, tends to indicate newer infections than are Summaryreflected of bySelected AIDS Notifiable case data, Diseases although and Conditionswe do not know the proportion of diagnosed HIV cases that were recently acquired. HIV case reports augment AIDS case data and provide good information by age, sex and race/ethnicity on persons who have been tested confidentially. acquired.Twenty-eight HIV case percent reports of the augment adult AIDS AIDS cases case reporteddata and inprovide Florida good in 1998 information were white, by age, compared sex and race/ ethnicitywith 55% on personsblack and who 15% have Hispanic been tested(Figure confidentially. 7). Over the past Twenty-eight ten years thepercent proportion of the adultof AIDS AIDS cases reportedcases amongin Florida whites, in 1999 blacks were and white, Hispanics compared has withremained 55% black fairly andstable. 15% Hispanic (Figure 7). Over the past ten years the proportion of AIDS cases among whites, blacks and Hispanics has remained fairly stable.

FigureFigure 7. Percent7. Percent of Adultof Adult AIDS AIDS Cases Cases by by Race/Ethnicity Race/Ethnicity and and Figure 7. Percent of AdultYear AIDSYear of CasesofReport, Report, by Florida, Race/Ethnicity Florida, 1999-2008 1999-2008 and Year of Report, Florida, 1999-2008 Black Factors Affecting 100%60 Disparities 90% -Late diagnosis of 80%50 HIV. 70% White Access to/acceptance Figure 7. Percent of Adult AIDS Cases by Race/Ethnicity and - 60%40 of care. 50% Year of Report, Florida, 1999-2008 -Delayed prevention 40%30 messages. 100% 30% Hispanic Percent of Cases of Percent -Stigma. 20%20 90%

Percent of Cases 80% 10% -Non-HIV STDs in the 70% community. 100% Other* 60% -Prevalence of injection 1999 200050% 2001 2002 2003 2004 2005 2006 2007 2008 drug use. 0 40% Year of Report -Complex matrix of 1999 200030% 2001 2002 2003 2004 2005 2006 2007 2008 factors related to Other*Cases of Percent 20%Hispanic White, Non-Hispanic Black, Non-Hispanic socioeconomic status.. Year of Report *Other*Other includes includes American American Indian/Alaska Indian/Alaska10% Native, Native, Asian/Pacific Asian/Pacific Islander, Islander, and Multi-racial and Multi-racial *Other includes American Indian/Alaska0% Native, Asian/Pacific Islander, and Multi-racial 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Twenty-three percent of the adult HIV cases reported in Florida in 1999 were white, compared with 62% Year of Report black (Figure 8).Figure By 8. 2008, Percent the of percentage Adult HIV Cases of HIV by Race/Ethnicity* cases increased and for whites (34%) and decreased among blacks to 46%. TheYear percentage of Report,Other* Florida, Hispanicof HIV 1999-2008 casesWhite, among Non-Hispanic HispanicsBlack, had Non-Hispanic a slight but steady increase sinceTwenty-three 1999. *Other percent includes Americanof the adultIndian/Alaska HIV Native,cases Asian/Pacific reported Islander, in Florida and Multi-racial in 1999 were white, compared with100% 62% black (Figure 8). By 2008, the percentage of HIV cases increased for whites (34%) and decreased90% among blacks to 46%. The percentage of HIV cases among Hispanics had a slight80% but steady increaseFigure since 8. Percent1999. of Adult HIV Cases by Race/Ethnicity* and 70% Figure 8. PercentYear of ofReport, Adult HIV Florida, Cases 1999-2008 by Race/Ethnicity* and Year of Report, Florida, 1999-2008 60% 50% 100% 40% 90% 80%

PercentCasesof 30% 70% 20% 60% 10% 50% 0% 40% 1999 2000 2001 2002 2003 20042005 2006 2007 2008

PercentCasesof 30%

20% Year of Report Hispanic10% White, Non-Hispanic Black, Non-Hispanic

*Other races represent less than 1% of0% the cases and are not included 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year of Report

Hispanic White, Non-Hispanic Black, Non-Hispanic

*Other races represent*Other less races than represent 1% of theless cases than 1% and of arethe casesnot included and are not included

53 Figure 8. Percent of Adult HIV Cases by Race/Ethnicity* and Year of Report, Florida, 1999-2008 70 Black, Non-Hispanic 60

50 White, Non-Hispanic 40

Percent of Cases 20

10 Hispanic

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year of Report 2008 Florida Morbidity Statistics *Other races represent less than 1% of the cases and are not included

BlacksBlacks comprise comprise only only 15% 15% of of the the adult adult population, population, but but represent represent 53% 53% of of the the AIDS AIDS cases cases and and 46% of the46% HIV of casesthe HIV reported cases reportedin 2008 (Figure in 2008 9). (Figure Hispanics 9). Hispanics comprise comprise 20% of Florida’s 20% of Florida’sadult population, adult and accountpopulation, for 18% and ofaccount the AIDS for cases18% of and the 19%AIDS of cases the HIV and cases. 19% of the HIV cases.

FigureFigure 9. Percentage 9. Percentage of Adult of Adult AIDS AIDS Cases Cases by Race/Ethnicity, by Race/Ethnicity, Florida, Florida, Compared Compared with with PercentagePercentage of Adult of Adult HIV HIVCases Cases by Race/Ethnicity, by Race/Ethnicity, Florida, Florida, 2008 2008

2008 Florida AIDS (N=4,944) Population Estimates* HIV (N=7,498) (N=15,915,453) 18% 20% 19% 2% 2% 1%

15% 34% 27%

53% 63% 46%

White Black Hispanic Other**

*2008 Florida Population Estimates, Adults (Ages 13+), DOH, Office of Planning, Evaluation and Data Analysis **Other includes Asian/Pacific Islanders, Native Alaskans/American Indians and people of mixed race.

Black men and, to an even greater extent, black women are over-represented in the HIV epidemic (Figure 10). The HIV case rate for 2008 is four times higher among black men than among white men. Among black women, the HIV case rate is 15 times higher than among white women. Hispanic male and Hispanic female rates are double the rates among their white counterparts.

HIV (N=7,498) Figure 8. Percent of Adult HIV Cases by Race/Ethnicity* and Year of Report, Florida, 1999-2008 70 Black, Non-Hispanic 60

50 White, Non-Hispanic 40

Percent of Cases 20

10 Hispanic

0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year of Report Black men and, to an even greater extent, black women are over-represented in the HIV epidemic (Figure 10). The HIV case rate for 2008 is four times higher among black men than Summary of Selected Notifiable Diseases and Conditions *Other races represent less than 1% of the cases and are not included among white men. Among black women, the HIV case rate is 15 times higher than among white women. Hispanic male and Hispanic female rates are double the rates among their white counterparts. BlacksBlacks comprise comprise only only 15% 15% of of the the adult adult population, population, but but represent represent 53% 53% of of the the AIDS AIDS cases cases and and 46% of Figure 10. Adult HIV Cases and Case Rates per 100,000 Population the HIV cases reported in 2008 (Figure 9). Hispanics comprise 20% of Florida’s adult population, and Figure 10. Adultby Sex HIV andCases Race/Ethnicity, and Case Rates Florida,per 100,000 2008 Population 46% of the HIV cases reported in 2008 (Figure 9). Hispanics comprise 20% of Florida’s adult by Sex and Race/Ethnicity, Florida, 2008 accountpopulation, for 18% and ofaccount the AIDS for cases18% of and the 19%AIDS of cases the HIV and cases. 19% of the HIV cases. MALES Rate ratios Figure 9. Percentage of Adult AIDS Cases by Race/Ethnicity, Florida, Compared with 200 187.9 Blacks:Whites, 4.1:1 Figure 9. Percentage of Adult AIDS Cases by Race/Ethnicity, Florida, Compared with Hispanics:Whites, 1.6:1 Percentage of Adult HIV Cases by Race/Ethnicity, Florida, 2008 Percentage of Adult HIV Cases by Race/Ethnicity, Florida, 2008 180 FEMALES 2008 Florida 160 Rate ratios Black:Whites, 15.4:1 AIDS (N=4,944) Population Estimates* HIV (N=7,498) 140 Hispanics:Whites, 2.6:1 (N=15,915,453) 18% 120 106.6 20% 19% 2% 2% 1% 100 80 72.8 15% 34% Rate per 100,000 60 45.4 27% 40 17.8 20 6.9 53% 0 63% 46% Male Female White Black Hispanic

White Black Hispanic Other** As in previous years, the greatest proportion of AIDS cases reported in 2008 was among As in previous years, the greatest proportion of AIDS cases reported in 2008 was among persons 40 to *2008 Florida Population Estimates, Adults (Ages 13+), DOH, Office of Planning, Evaluation and Data Analysis persons 40 to 49 years old (35%) but this age group only accounts for 16% of the total **Other includes Asian/Pacific Islanders, Native Alaskans/American Indians and people of mixed race. 49 years oldpopulation (35%) but (Figure this 11).age Thegroup 30-39 only age accounts group was forsecond, 16% with of the26% total of the population reported AIDS (Figure 11). The 30- 39 age groupcases. was Thesecond, 20-29 agewith group 26% accounted of the reported for 12% ofAIDS the cases, cases. and The the 5020-29 and older age agegroup group accounted for 12% of the cases,accounted and for the25%. 50 and older age group accounted for 25%.

Compared with AIDS cases, a greater proportion of HIV cases in 2008 was reported among Black men and, to an even greater extent, black women are over-represented in the HIV epidemic Compared withthose AIDS aged 20-29cases, (22%), a greater those aged proportion 30-39 (25%), of HIV and cases those agedin 2008 40-49 was (30%). reported There wasamong a those aged (Figure 10). The HIV case rate for 2008 is four times higher among black men than among white men. 20-29 (22%),lower those proportion aged 30-39among those(25%), aged and 13-19 those (3%) aged and a40-49 higher (30%).proportion There among was those a agedlower 20- proportion Among black women, the HIV case rate is 15 times higher than among white women. Hispanic male and among those29 aged years (22%),13-19 but(3%) a lower and proportiona higher forproportion those aged among 50 and olderthose (19%), aged all 20-29 of which years is (22%), but a Hispanic female rates are double the rates among their white counterparts. consistent with earlier detection of HIV cases. lower proportion for those aged 50 and older (19%), all of which is consistent with earlier detection of HIV cases.

FigureFigure 11. 11. AgeAge DistributionDistribution ofof Florida’sFlorida’s AdultAdult AIDS Cases Compared with the AgeAge DistributionDistribution ofof Florida’sFlorida’s AdultAdult HIVHIV Cases,Cases, 20082008

AIDS HIV (N=7,498) 40 35 40

35 35 30 30 26 30 25 22 25 25 25 19 20 20

Percent 12 Percent 15 15 10 10 5 2 5 3 0 0 13-19 20-29 30-39 40-49 50+ 13-19 20-29 30-39 40-49 50+

HIV/AIDS by Mode of Exposure The dynamics of the HIV epidemic are different in each population; so multiple data sets must be used to compile a representative epidemiologic profile for HIV prevention, planning, and targeting of resources and outreach. The following data represent HIV and AIDS cases by mode of exposure. Cases reported with no identified risks (NIRs) have been redistributed into HIV (N=7,498) known risk categories, based on previous patterns of re-classification for NRIs once a risk has been identified.

2008 Florida Morbidity Statistics

HIV/AIDS by Mode of Exposure The dynamics of the HIV epidemic are different in each population; so multiple data sets must be used to compile a representative epidemiologic profile for HIV prevention, planning, and targeting of resources and outreach. The following data represent HIV and AIDS cases by mode of exposure. Cases reported with no identified risks (NIRs) have been redistributed into known risk categories, based on previous patterns of re-classification for NRIs once a risk has been identified.

Males Among the male AIDS and HIV cases reported for 2008, MSM was the most common risk factor (60% and 71%, respectively) followed by cases with a heterosexual risk factor (27% for AIDS and 18% for HIV) (Figure 12). People with an IDU risk factor are similar among AIDS cases (8%) and HIV cases (7%). Figure 12. Adult Male AIDS and HIV Cases by Mode of Exposure, Florida, 2008 AIDS HIV Figure 12. Adult Male AIDS and Note:HIV Cases NIRs redistributed. by Mode of Exposure, Florida, 2008 Figure 12. Adult Male AIDS and HIV Cases by Mode of Exposure, Florida, 2008 MSM 18% 27%AIDS 4% HIV Note: NIRs redistributed. IDU 7% 1% MSM 18% <1% 27% MSM/IDU 4% 5% HeteroIDU 7% <1% 1% MSM/IDU 5% Other 8% Hetero Other 8%

60% 71%

FemalesFemales

AmongAmong the female the female AIDS andAIDS HIV and cases HIV casesreported reported for 2008, for 2008,heterosexual heterosexual contact contact was the was highest the highest risk

factor risk(Figure factor 13). (Figure 13). Females

Among the female AIDS and HIV cases reported for 2008, heterosexual contact was the highest

risk factorFigure Figure(Figure 13. 13. 13). Adult Adult Female Female AIDS AIDS and and HIV HIV Cases Cases by by Mode Mode of of Exposure, Exposure, Florida, Florida, 2008 2008

AIDS HIV Figure 13. Adult Female AIDS Note:and HIV NIRs Cases redistributed. by Mode of Exposure, Florida, 2008

IDU AIDS HIV 2% Note: NIRs redistributed. Hetero IDU 10% 14% 2% Other Hetero 10% 14% Other

84% 90%

56 Prevalence Estimates of HIV/AIDS Assessment of the extent of the HIV epidemic is an important step in community planning for HIV prevention and HIV/AIDS patient care. The HIV prevalence estimate, the estimated numberPrevalence of persons Estimates living of with HIV/AIDS HIV infection, includes those living with a diagnosis of HIV or Assessment of the extent of the HIV epidemic is an important step in communityNote: NIRs redistributed. planning for AIDS and those who may be infected but are unaware of their serostatus. Approximately HIV prevention and HIV/AIDS patient care.AIDS The N=(3,415) HIV prevalence estimate, the estimated HIV N=(5,532) number of persons living with HIV infection, includes those living with a diagnosis of HIV or AIDS and those who may be infected but are unaware of their serostatus. Approximately

Summary of Selected Notifiable Diseases and Conditions

HIV/AIDS by Mode of Exposure Prevalence Estimates of HIV/AIDS The dynamics of the HIV epidemic are different in each population; so multiple data sets must be used Assessment of the extent of the HIV epidemic is an important step in community planning for HIV to compile a representative epidemiologic profile for HIV prevention, planning, and targeting of resources prevention and HIV/AIDS patient care. The HIV prevalence estimate, the estimated number of and outreach. The following data represent HIV and AIDS cases by mode of exposure. Cases reported persons living with HIV infection, includes those living with a diagnosis of HIV or AIDS and those who with no identified risks (NIRs) have been redistributed into known risk categories, based on previous may be infected but are unaware of their serostatus. Approximately 1,039,000 to 1,185,000 persons patterns of re-classification for NRIs once a risk has been identified. are currently1,039,000 living to with 1,185,000 HIV infection persons in arethe U.S.currently Florida living has with consistently HIV infection reported in the 10%-12%U.S. Florida of the has nationalconsistently AIDS morbidity reported and 10%-12%currently accounts of the national for 11% AIDS of all morbidity persons andliving currently with AIDS accounts in the U.S.for The Males Florida11% Department of all persons of Health living now with estimates AIDS in thatthe U.S.approximately The Florida 125,000 Department persons, of Health or roughly now 11.7% Among the male AIDS and HIV cases reported for 2008, MSM was the most common risk factor (60% of the nationalestimates total that of approximately persons living 125,000with HIV persons, infection, or are roughly currently 11.7% living of inthe Florida national as totalof the of end of and 71%, respectively) followed by cases with a heterosexual risk factor (27% for AIDS and 18% for HIV) 2007. persons living with HIV infection, are currently living in Florida as of the end of 2007. (Figure 12). People with an IDU risk factor are similar among AIDS cases (8%) and HIV cases (7%). Figure 12. Adult Male AIDS and HIV Cases by Mode of Exposure, Florida, 2008 ImpactImpact of HIV-related of HIV-related Deaths Deaths AIDS HIV As of DecemberAs of December 31, 2008 31, a 2008 total ofa total114,057 of 114,057 AIDS cases AIDS hadcases been had reported been reported in Florida. in Florida. Of these Of these Figure 12. Adult Male AIDS and Note:HIV Cases NIRs redistributed. by Mode of Exposure, Florida, 2008 cumulativecumulative cases, cases,62,565 62,565 (55%) were(55%) known were knownto have to died. have died. Figure 12. Adult Male AIDS and HIV Cases by Mode of Exposure, Florida, 2008 MSM 18% 27%AIDS 4% HIV Annual numbers of HIV/AIDS deaths decreased markedly from 1995 to 1998, associated with Note: NIRs redistributed. Annual numbers of HIV/AIDS deaths decreased markedly from 1995 to 1998, associated with the advent IDU of highlythe active advent anti-retroviral of highly active therapy anti-retroviral (HAART) intherapy 1996. (HAART) A leveling in of 1996. the trend A leveling since 1998of the may trend reflect since 7% 1% MSM 18% <1% 27% MSM/IDU 4% factors 1998such mayas viral reflect resistance, factors suchlate diagnosisas viral resistance, of HIV, adherence late diagnosis problems, of HIV, and adherence lack of access problems, to or 5% acceptanceand lack of care of access (Figure to 14). or acceptance In 2007, the of number care (Figure of HIV/AIDS 14). In deaths2007, the decreased number ofby HIV/AIDS 13% from the HeteroIDU 7% <1% previousdeaths year, decreasedwhich is a 65%by 13% decrease from the since previous the peak year, year which in 1995. is a 65% Decreases decrease among since malesthe peak and year 1% MSM/IDU 5% Other femalesin were 1995. observed Decreases in all among racial/ethnic males andgroups, females except were white observed females in where all racial/ethnic there was groups, no change except at 8% Hetero all. Racial/ethnicwhite females disparities where thereare evident was no in change the death at all.rate Racial/ethnic data. disparities are evident in the death rate data. Other 8% Figure 14. Resident HIV deaths, by Year of Death, Florida, 1994–2007 Figure 14. Resident HIV deaths, by Year of Death, Florida, 1994–2007

Race/Ethnicity 2007 60% 71% No. rate * White Male 31 1 5.6 White Female 78 1.3 60% 71% 5,000 Black Male 52 6 38.1 4,142 4,336 Black Female 39 1 26.3 Hispanic Male 16 1 8.8 Hispanic Female 41 2.2 FemalesFemales 4,000 Other** 18 3.9 AmongAmong the female the female AIDS andAIDS HIV and cases HIV casesreported reported for 2008, for 2008,heterosexual heterosexual contact contact was the was highest the highest risk TOTAL 1,526 8.3 3,093 factor risk(Figure factor 13). (Figure 13). Females 3,000 Among the female AIDS and HIV cases reported for 2008, heterosexual contact was the highest 29% 1,879 risk factor (Figure 13). 1,809 FigureFigure 13. 13. Adult Adult Female Female AIDS AIDS and and HIV HIV Cases Cases by by Mode Mode of of Exposure, Exposure, Florida, Florida, 2008 2008 1,651 1,658 1,714 1,742 1,714 1,706 1,746 2,000 1,547 1,526

AIDS HIV Figure 13. Adult Female AIDS Note:and HIV NIRs Cases redistributed. by Mode of Exposure, Florida, 2008 Number of Deaths 39% 18% 1,000 IDU AIDS HIV 2% Note: NIRs redistributed. Hetero 0 IDU 10% 14% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2% Other Year of Death Hetero 10% *Rates are expressed as deaths per 100,000 population based on 2006 Population Estimates, DOH, Office of Planning, Evaluation and Data 14% Analysis *Rates are expressed as deaths per 100,000 population based on 2006 Population Estimates, DOH, Office of Planning, Evaluation Other and Data Analysis

84% 90%

57 Prevalence Estimates of HIV/AIDS Assessment of the extent of the HIV epidemic is an important step in community planning for HIV prevention and HIV/AIDS patient care. The HIV prevalence estimate, the estimated numberPrevalence of persons Estimates living of with HIV/AIDS HIV infection, includes those living with a diagnosis of HIV or Assessment of the extent of the HIV epidemic is an important step in communityNote: NIRs redistributed. planning for AIDS and those who may be infected but are unaware of their serostatus. Approximately HIV prevention and HIV/AIDS patient care.AIDS The N=(3,415) HIV prevalence estimate, the estimated HIV N=(5,532) number of persons living with HIV infection, includes those living with a diagnosis of HIV or AIDS and those who may be infected but are unaware of their serostatus. Approximately

2008 Florida Morbidity Statistics

Brucellosis Brucellosis

Figure 1. Brucellosis:Brucellosis: Crude Data Crude Data Brucellosis Cases by Year Reported, Florida, 1999- Number of CasesNumber of Cases 10 10 2008 2008 incidence2008 rate incidence per rate per 12 100,000 100,000 0.05 0.05 10 % change from% change average from average 5- 5-year (2003-2007)year (2003-2007) reported reported 8 cases 38.89 cases 38.89 6 Age (yrs) Age (yrs) Mean 49 4 Number Number of Cases Mean Median 49 50.5 2 Median Min-Max 50.5 36 - 69 Min-Max 36 - 69 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year Disease AbstractDisease Abstract A total of 76A casestotal of of 76 human cases brucellosisof human brucellosis were reported were in reported Florida infrom Florida 1999 from to 2008, 1999 ofto 2008,which of67 which (88%) 67 were classified(88%) as were confirmed. classified asThere confirmed. were 10 Therecases werereported 10 casesin 2008, reported nine inconfirmed 2008, nine and confirmed one probable, and compared withone probable,a 10 year comparedannual average with a of10 6.3.year Speciationannual average was providedof 6.3. There in nine were cases; also sevenat least Brucella eight suis and twolaboratory B. melitensis workers infections in private were laboratories identified. that Site were of exposedexposure to wasBrucella determined cultures for while all ofworking the cases from 2008, withwith diagnostic eight reported specimens as being in 2008.acquired Speciation in Florida was and provided both B. in melitensis nine cases; cases seven being Brucella acquired suis in Mexico. andMen two accounted B. melitensis for all infections cases except were identified.for one infection Site of acquired exposure outside was determined the U.S. (90%for all male).of the Affected peoplecases ranged from 2008, from with 36-69 eight years reported old. Incidenceas being acquired was highest in Florida in those and aged both 35-44B. melitensis and 45-54, cases representingbeing eight acquired of the ten in Mexico.cases. RiskMen factorsaccounted identified for all cases in the exceptnine of for the one ten infection cases include: acquired hunting feral pigs and/oroutside handling the U.S. carcasses (90% male). with Affected open cuts people while ranged not using from appropriate 36-69 years personal old. Incidence protective was equipment highest(six cases); in those consuming aged 35-44 unpasteurized and 45-54, milkrepresentin productsg eight (two, of both the tenimported); cases. andRisk eating factors meat from wild animalsidentified including in the nine pigs of (one). the ten The cases tenth include: case (culturehunting feralpositive pigs for and/or B. suis handling) denied carcasses pertinent with exposure historyopen cuts other while than not eating using semi-soft appropriate cheese personal made protective from cow’ equipments milk acquired (six cases); from U.S.consuming states reported tounpasteurized be free of B. suis, milk andproducts also (two,had immigrated both imported); 15 years and eatingpreviously meat from from awild country animals (Cuba) including with a high prevalencepigs (one). of B. suis The. tenth case (culture positive for B. suis) denied pertinent exposure history other than eating semi-soft cheese made from cow’s milk acquired from U.S. states reported to be Hog huntingfree was of aB. significant suis, and also risk hadfactor, immigrated with six 15of ten years cases previously identified from in a 2008country as (Cuba)being associatedwith a high with that activity.prevalence A seventh of B. suis case. was associated with preparing or eating meat from wild pigs or other wild animals. Cases acquired outside Florida and the U.S.Figure were2. most likely to be associated with eating unpasteurized milk products. In addition,Brucellosis Cases cultures by Month from of Onset, patients Florida, with 2008 Brucella infections posed a significant exposure risk for laboratory3.50 personnel. There were at least eight laboratory workers in private laboratories that were exposed 3.00to Brucella cultures while working with diagnostic specimens in 2008. 2.50

Brucella has potential for relapse2.00 or chronic infection, particularly for patients who do not receive complete and appropriate treatment, patients who delay treatment, and patients with underlying disease 1.50 conditions. A hog hunter who was in remission for cancer had been diagnosed with brucellosis infection in 2007 and initially respondedCases Numberof well1.00 to six weeks of antibiotic treatment following primary diagnosis. In the spring of 2008, when the patient’s0.50 cancer went out of remission, a relapse of Brucella symptoms occurred and Brucella suis was0.00 isolated from his blood (not included in the 2008 case count). Two additional patients reported to have B.Jan suis Feb infections Mar Apr Mayin 2008 Jun were Jul Aug still Sepsymptomatic Oct Nov Dec and culture-positive several months following primary diagnosis. Month 5yr average 2008

58 Brucellosis

Figure 1. Brucellosis: Crude Data Brucellosis Cases by Year Reported, Florida, 1999- Number of Cases 10 2008 2008 incidence rate per 12 100,000 0.05 10 % change from average 5- year (2003-2007) reported 8 cases 38.89 6 Age (yrs) Mean 49 4 Number Number of Cases Median 50.5 2 Min-Max 36 - 69 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year Disease Abstract A total of 76 cases of human brucellosis were reported in Florida from 1999 to 2008, of which 67 (88%) were classified as confirmed. There were 10 cases reported in 2008, nine confirmed and one probable, compared with a 10 year annual average of 6.3. There were also at least eight laboratory workers in private laboratories that were exposed to Brucella cultures while working with diagnostic specimens in 2008. Speciation was provided in nine cases; seven Brucella suis and two B. melitensis infections were identified. Site of exposure was determined for all of the cases from 2008, with eight reported as being acquired in Florida and both B. melitensis cases being acquired in Mexico. Men accounted for all cases except for one infection acquired outside the U.S. (90% male). Affected people ranged from 36-69 years old. Incidence was highest in those aged 35-44 and 45-54, representing eight of the ten cases. Risk factors identified in the nine of the ten cases include: hunting feral pigs and/or handling carcasses with open cuts while not using appropriate personal protective equipment (six cases); consuming unpasteurized milk products (two, both imported); and eating meat from wild animals including pigs (one). The tenth case (culture positive for B. suis) denied pertinent exposure history other Summarythan eating of Selected semi-soft Notifiable cheese Diseases made and fromConditions cow’s milk acquired from U.S. states reported to be free of B. suis, and also had immigrated 15 years previously from a country (Cuba) with a high prevalence of B. suis.

Figure 2. Brucellosis Brucellosis Cases by Month of Onset, Florida, 2008

Figure 1. 3.50 Brucellosis: Crude Data Brucellosis Cases by Year Reported, Florida, 1999- 3.00 Number of Cases 10 2008 2.50 2008 incidence rate per 12 2.00 100,000 0.05 10 % change from average 5- 1.50 year (2003-2007) reported 8 Number of Cases Numberof 1.00 cases 38.89 6 0.50 Age (yrs) Mean 49 4 0.00 Number Number of Cases Median 50.5 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2 Min-Max 36 - 69 Month 5yr average 2008 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year Prevention Disease Abstract Prevention can best be accomplished through education of animal workers and hunters on proper A total of 76 cases of human brucellosis were reported in Florida from 1999 to 2008, of which 67 handling techniques: wearing gloves and protective clothing; working in properly ventilated areas; proper (88%) were classified as confirmed. There were 10 cases reported in 2008, nine confirmed and carcass and tissue disposal; disinfection of contaminated areas; and proper handling of modified live one probable, compared with a 10 year annual average of 6.3. There were also at least eight vaccines. Also important is requiring pasteurization of milk. Education should be provided to travelers laboratory workers in private laboratories that were exposed to Brucella cultures while working and the general public on the risks of drinking or eating unpasteurized dairy products, especially products with diagnostic specimens in 2008. Speciation was provided in nine cases; seven Brucella suis originating in countries where brucellosis is endemic in livestock. Outreach should be done for laboratory and two B. melitensis infections were identified. Site of exposure was determined for all of the personnel to ensure knowledge of appropriate specimen handling (aerosol protection), and clinicians cases from 2008, with eight reported as being acquired in Florida and both B. melitensis cases being acquired in Mexico. Men accounted for all cases except for one infection acquired should be reminded to always forewarn laboratories working with patient culture samples if Brucella is in outside the U.S. (90% male). Affected people ranged from 36-69 years old. Incidence was the differential diagnosis. Laboratories should be periodically reminded of state and federal confirmation highest in those aged 35-44 and 45-54, representing eight of the ten cases. Risk factors and reporting requirements for this select agent. Continued surveillance and management programs for identified in the nine of the ten cases include: hunting feral pigs and/or handling carcasses with Brucella sp. in domestic livestock will keep exposure risk low in Florida. Surveillance is also important open cuts while not using appropriate personal protective equipment (six cases); consuming because Brucella has the potential for use as a bioterrorist agent. unpasteurized milk products (two, both imported); and eating meat from wild animals including pigs (one). The tenth case (culture positive for B. suis) denied pertinent exposure history other References th than eating semi-soft cheese made from cow’s milk acquired from U.S. states reported to be David L. Heymann (ed.), Control of Communicable Diseases Manual, 19 ed., American Public Health free of B. suis, and also had immigrated 15 years previously from a country (Cuba) with a high Association Press, Washington, District of Columbia, 2008. prevalence of B. suis. Lt. Col. Jon B. Woods (ed.), USAMRIID, Medical Management of Biological Casualties Handbook, 6th ed., Figure 2. Brucellosis Cases by Month of Onset, Florida, 2008 U.S. Army Medical Research Institute of Infectious Diseases, 2005. 3.50

3.00 M.J. Corbel. 2006. Brucellosis in humans and animals. World Health Organization Press. Geneva, Switzerland. 2.50 2.00 Additional Resources 1.50 Information on human brucellosis in Florida can be obtained at the Florida Department of Health website

Number of Cases Numberof 1.00 at http://www.doh.state.fl.us/Environment/medicine/arboviral/Zoonoses/Zoonotic-brucellosis.html

0.50 Additional information can also be found at the United States Department of Agriculture, Animal and 0.00 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Plant Health Inspection Services website at http://www.aphis.usda.gov/animal_health/animal_diseases/ Month brucellosis/ 5yr average 2008 As well as the Centers for Disease Control and Prevention website at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/brucellosis_g.htm

59 2008 Florida Morbidity Statistics

CampylobacteriosisCampylobacteriosis

Campylobacteriosis

Campylobacteriosis: Crude Data Figure 1. Campylobacteriosis: Crude Data Campylobacteriosis Incidence Rate by Year Reported, Florida, Number of Cases 1,118 1999-2008Figure 1. Campylobacteriosis: Crude Data Campylobacteriosis Incidence Rate by Year Reported, Florida, Number of Cases 1,118 8 2008 incidence rate per 1999-2008 2008100,000 incidenceNumber of rateCases per 5.92 1,118 8 100,000 5.92 6 % change2008 incidence from average rate per % change100,000 from average 5- 5.92 6 5-year (2003-2007) incidence 4 year (2003-2007)% change from incidence average 5- rate 8.25 4 rate year (2003-2007) incidence 8.25

Cases per 100,000 Cases 2 Agerate (yrs) 8.25

Age (yrs) per 100,000 Cases 2 Age (yrs) Mean 31.38 MeanMedian 31.3828 0 Mean 31.38 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 MedianMin-Max <1 28 - 93 Median 28 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max <1 - 93 Year Min-Max <1 - 93 Year

DiseaseDisease Abstract Abstract TheDisease incidence Abstract rate for campylobacteriosis had declined slightly from 1999 through 2005, but has been The incidenceThe incidence rate ratefor campylobacteriosis for campylobacteriosis had had declined declined slightly slightly from from 19991999 through 2005,2005, but but has has beenincreasing increasing since since 2005 2005 (Figure (Figure 1). In 1). 2008, In 2008,there was there an was 8.25% an increase8.25% increase in comparison in comparison to the average to incidencebeen increasing from 2003-2007. since 2005 A total (Figure of 1,118 1). In cases 2008, were there reported was an in8.25% 2008, increase of which in 95.89% comparison were classifiedto the average incidence from 2003-2007. A total of 1,118 cases were reported in 2008, of which as theconfirmed. average incidenceThe number from of 2003-2007.cases reported A total tends of to1,118 increase cases in were the summerreported monthsin 2008, but of there which were a 95.89%high95.89% number were were classified of cases classified reportedas confirmed. as confirmed. in the fall The ofThe 2008number number compared of of cases cases to reportedthe reported previous tendstends 5-year to increaseincrease average. in in Inthe the 2008, the summernumbersummer months of cases months but exceeded therebut there were the were aprevious high a high number 5-year number averageof ofcases cases in reported allreported months in in theofthe the fallfall year of 2008 except comparedcompared March and to to May the(Figure previousthe previous 2). 5-year The 5-yearhighest average. average. incidence In 2008, In occurs 2008, the amongthe number number infants of of cases cases<1 year exceeded exceeded old and children thethe previous aged 5-year1-45-year years (Figure average3). average Overall, in all inmonths5.72% all months of of the the ofcampylobacteriosis theyear year except except March March cases and and were May May classified (Figure (Figure 2). 2).as TheTheoutbreak-related highest incidenceincidence as compared to occurs7.2%occurs among in 2007. among infants infants <1 year <1 year old oldand and children children aged aged 1-4 1-4 years years (Figure (Figure 3).3). Overall, 5.72%5.72% of of the the campylobacteriosiscampylobacteriosis cases cases were were classified classified as asoutbreak-related outbreak-related as as compared compared to 7.2%7.2% in in 2007. 2007.

Figure 2. Figure 2. Campylobacteriosis Cases by Month of Onset, Florida, 2008 Campylobacteriosis Cases by Month of Onset, Florida, 2008 140 140 120 120 100 100 80 80 60 60

Number of CasesNumber of 40

Number of CasesNumber of 40 20

20 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 0 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 5yr average 2008 Month 5yr average 2008 Campylobacteriosis was reported in 60 of the 67 counties in Florida. Counties in north-central Campylobacteriosis was reported in 60 of the 67 counties in Florida. Counties in north-central and southwesternand southwestern Florida Floridareported reported the highest the highestincidence incidence rates. rates. Campylobacteriosis was reported in 60 of the 67 counties in Florida. Counties in north-central and southwestern Florida reported the highest incidence rates.

60 Summary of Selected Notifiable Diseases and Conditions

Figure 3. Campylobacteriosis Incidence Rate by Age Group, Florida, 2008

10 Cases per 100,000 per Cases 5

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

PreventionPrevention TheThe likelihood of of contracting contracting campylobacteriosis campylobacteriosi cans becan reduced be reduced by cooking by cooking all meat all products meat products thoroughly, thoroughly,particularly poultry. particularly Avoid poultry. cross-contamination Avoid cross-cont by makingamination sure utensils, by making counter sure tops, utensils, cutting counter boards and tops,sponges cutting are cleanedboards orand do spongesnot come arein contact cleaned with or raw do poultrynot come or other in contact meat. withWash raw hands poultry thoroughly or otherbefore, meat. during, Wash and after hands food thoroughly preparation. before, Do not during, allow fluids and after from foodraw poultrypreparation. or meat Doto drip not onallow or touch fluidsother foods.from raw Consume poultry only or meat pasteurized to drip milk, on or milk touch products, other orfoods. juices. Consume Additionally, only it ispasteurized important to milk, wash hands after coming into contact with any animals or their environment. milk products, or juices. Additionally, it is important to wash hands after coming into contact with any animals or their environment.

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004. 61

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/campylobacter_g.htm

2008 Florida Morbidity Statistics

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/ncidod/dbmd/diseaseinfo/campylobacter_g.htm

ChlamydiaChlamydia

DiseaseDisease Abstract Abstract ChlamydiaChlamydia remains remains the the most most commonly commonly reported reported sexually sexually transmitted transmitted infection infection in Floridain Florida and and the most prevalentthe most sexually prevalent transmitted sexually bacterialtransmitted infection bacterial reported infection among reported 15-24 among year olds. 15-24 Reported year olds. chlamydia casesReported in Florida chlamydia have increased cases in 66%Florida since have 2004 increased (Figure 66% 1). Insince 2008, 2004 there (Figure were 1).70,751 In 2008, chlamydia there cases reportedwere 70,751 in Florida, chlamydia or 374.4 cases cases reported per 100,000 in Florida, population. or 374.4 Although cases per the 100,000 prevalence population. of chlamydia is the highestAlthough among the those prevalence under of25 chlamydia years of age, is the specific highest populations, among those i.e. under females 25 andyears minorities, of age, bear a huge burdenspecific of this populations, infection. i.e. The females vast differences and minorities, in adverse bear aoutcomes, huge burden higher of thissusceptibility infection. to The infection vast with STDs,differences and a combination in adverse outcomes,of other factors higher leave susceptibility adolescents to infection and young with adults STDs, disproportionately and a combination affected withof chlamydia other factors compared leave adolescents to older populations; and young however, adults disproportionately chlamydia continues affected to increase with chlamydia in all age groups.compared to older populations; however, chlamydia continues to increase in all age groups.

Figure 1. Reported Cases of Chlamydia by Year, Florida, 2004-2008

80,000 374.4 400.0

306.9 70,000 350.0 265.7 60,000 300.0 241.6 240.7 50,000 250.0

Cases 40,000 200.0

30,000 150.0 Rate/100,000

20,000 100.0 10,000 50.0 0 0.0 2004 2005 2006 2007 2008 Year

Cases Rate/100,000

Persons between the ages of 15-24 only represented 12% of Florida’s population in 2008, yet account for Persons71% of all between reported the chlamydia ages of 15-24 cases only in Florida. repres ented In this 12% age of cohort, Florida’s over population 50,000 cases in 2008, were yet reported in 2008account (Table for 71%1). From of all 2007reported to 2008, chlamydia reported cases cases in Florida. in this population In this age increased cohort, over by 21.8%. 50,000 These Florida-specificcases were reported trends inparallel 2008 (Tablenational 1). data From which 2007 also to indicate 2008, reported infection cases is most in thisprevalent population in women underincreased the age by of 21.8%. 25. In 2008These and Florida-specific preceding years, trends the parallel highest national number data of cases which in also females indicate was reported in theinfection 15-24 is age most group. prevalent When in that women age undergroup theis broken age of down 25. In further, 2008 andthe highestpreceding rate years, is among the females 15-19highest (3,280.0 number per of100,000 cases population),in females was which reported is the inhighest the 15-24 rate agefor any group. gender/age When that grouping. age group The rate for iswomen broken in down the 20-24 further, age the group highest was rate slightly is among lower femalesat 3,238.7 15-19 per 100,000(3,280.0 population.per 100,000 population), which is the highest rate for any gender/age grouping. The rate for women in the 20-24 age group was slightly lower at 3,238.7 per 100,000 population.

Table 1. Rate/100,000 For Select Age Groups, 2008 Age Groups Cases Reported Rate/100,000 62 15-19 23,739 1,946.1 20-24 26,456 2,168.6 25-29 11,305 972.6 30-34 4,315 379.0 35-39 2,050 169.5 40-44 1,027 78.6 Summary of Selected Notifiable Diseases and Conditions

Table 1. Rate/100,000 For Select Age Groups, 2008 Age Groups Cases Reported Rate/100,000 15-19 23,739 1,946.1 20-24 26,456 2,168.6 25-29 11,305 972.6 30-34 4,315 379.0 35-39 2,050 169.5 40-44 1,027 78.6

Much of the difference between the rates by gender is due to the strong clinical Much of therecommendations difference between for women the rates and by the gender lack ofis duescreening to the instrong men. clinical Although recommendations the rate of chlamydia for women andin menthe lack is lower of screening overall than in men. it is in Although women, the similar rate ageof chlamydia distributions in men are seenis lower within overall each than gender it is in women,(Figure similar 2). age Men distributions 15 to 24 yearsare seen old withinhad almost each doublegender the(Figure number 2). Menof reported 15 to 24 cases years compared old had almost doubleto those the overnumber 25, ofwhich reported is similar cases to comparedwhat is seen to thosein women. over 25, However, which is when similar that to age what group is seen is in women.broken However, down when further, that the age incidence group is isbroken flipped down from further, what it theis in incidence women. isIn reversed2008, 20 fromto 24 what year it is in women.old men In 2008, had the20 tohighest 24 year rate old among men had male the age highest groups rate (1,136.9 among permale 100,000 age groups population). (1,136.9 This per 100,000 population).rate was trailed This by rate a rate was of trailed 654.5 by per a 100,000rate of 654.5 population per 100,000 for males population between for the males ages between of 15-19. the ages ofThe 15-19. most Theimportant most importantrisk factor riskfor chlamydialfactor for chlamydial infection is infection age. When is age. data When is examined data is examinedby age in by age in singlesingle years,years, ratherrather thanthan asas ageage groups,groups, reportedreported casescases peakedpeaked atat thethe ageage ofof 1919 withwith aa gradualgradual decline indecline number in of number cases asof casesage in asyears age increased in years increased above that above age. that age.

DisparitiesDisparities among racial among and racial ethnic and groups ethnic exist groups in the exist number in the of number cases reportedof cases annually.reported annually.Non-Hispanic black femaleNon-Hispanic adolescents black and female young adolescentsadults have higherand young rates adults compared have tohigher non-Hispanic rates compared white and to non- Hispanic populationsHispanic white in Florida. and Hispanic Among populations women, the in caseFlorida. rate Among for non-Hispanic women, the black case 15 rate to 24-year-for non- olds is nearlyHispanic five timesblack 15higher to 24-year-olds than the second is nearly highest five rate,times whichhigher is thanin non-Hispanic the second highestwhites 15-24rate, which (733.68 peris in100,000 non-Hispanic population). whites In 15-24 all cases (733.68 reported, per 100,000 non-Hispanic population). blacks In accounted all cases reported,for 47.1% non- of the Hispanic blacks accounted for 47.1% of the chlamydia cases in 2008, non-Hispanic whites chlamydia cases in 2008, non-Hispanic whites accounted for 22.6% of cases, Hispanics (white or black) accounted for 22.6% of cases, Hispanics (white or black) accounted for 10.4% of cases, and accounted for 10.4% of cases, and people in other or unidentified racial-ethnic groups accounted for people in other or unidentified racial-ethnic groups accounted for 19.9% of cases. 19.9% of cases.

Figure 2. Reported Cases of Chlamydia by Race/Ethnicity, Gender, Age, 2008 45,000 40,000

35,000 30,000 25,000 20,000 15,000 Number of Cases Number 10,000 5,000 0 Female (15-24) Male (15-24) Female (25 +) Male (25 +) Gender (Age) White Black Hispanic Other

Prevention The Centers for Disease Control and Prevention (CDC) recommends annual chlamydia screening for all sexually active women under age 26, as well as older women with risk factors 63 such as new or multiple sex partners. Routine screening is necessary for these populations because approximately three quarters of infected women and greater than half of infected men have no symptoms. If untreated, chlamydia may lead to complications including infertility and ectopic pregnancy.

2008 Florida Morbidity Statistics

Prevention The Centers for Disease Control and Prevention (CDC) recommends annual chlamydia screening for all sexually active women under age 26, as well as older women with risk factors such as new or multiple sex partners. Routine screening is necessary for these populations because approximately three quarters of infected women and greater than half of infected men have no symptoms. If untreated, chlamydia may lead to complications including infertility and ectopic pregnancy.

Treating infected patients prevents transmission to sex partners. In addition, treating pregnant women usually prevents transmission of C. trachomatis to infants during birth. Treatment of sex partners helps to prevent reinfection of the index patient and infection of other partners. Co-infection with C. trachomatis frequently occurs among patients who have gonorrhea; therefore, presumptive treatment of those patients for chlamydia is recommended. Main treatment options include azithromycin (1 g orally in a single dose) or doxycycline (100 mg orally twice a day for seven days). Recent studies show that azithromycin and doxycycline were equally effective in treating chlamydia with microbial cure rates of 97% and 98%, respectively. Doxycycline costs less than azithromycin and has no higher risk for adverse events; however, if it is not likely that a patient will comply with the multi-day dosing schedule for doxycycline, azithromycin should be prescribed. Erythromycin, ofloxacin, and levofloxacin are all effective in treating chlamydia infection but have disadvantages such as more severe side effects or cost. Other quinolones either are not reliably effective against chlamydia infection or have not been evaluated adequately.

The CDC recommends that to maximize compliance with recommended therapies, medications for chlamydia infections should be dispensed on site, and the first dose should be directly observed. Additionally, people being treated for chlamydia should abstain from sexual intercourse for seven days after their single dose of azithromycin or until completion of the 7-day regimen for one of the other recommended medications. To minimize the risk for re-infection, patients should abstain from sexual intercourse until all of their sex partners are treated.

References American Social Health Association, “Chlamydia Questions & Answers.” Published online at http://www. ashastd.org/learn/learn_chlamydia.cfm, July 30, 2007.

Centers for Disease Control and Prevention. “Sexually Transmitted Diseases Treatment Guidelines, 2006.” MMWR, 2006, Vol. 55, No. RR-11, pp. 38-42.

Lau C-Y, Qureshi AK. “Azithromycin versus doxycycline for genital chlamydial infections: a meta-analysis of randomized clinical trials.” Sexually Transmitted Disisease, 2002, Vol. 29, pp. 497–502.

64 Summary of Selected Notifiable Diseases and Conditions

Ciguatera Fish Poisoning Ciguatera Fish Poisoning

Ciguatera: Crude Data Figure 1. Ciguatera: Crude Data Ciguatera Cases by Year Reported, Florida, 1999-2008 Number of Cases 53 Number of Cases 53 60 2008 incidence rate per 50 2008100,000 incidence rate per 0.28 100,000 0.28 % change from average 5 40 % change from average 5 year (2003-2007) incidence year (2003-2007) incidence 30 rate 207.73207.73 rate 20 AgeAge (yrs) (yrs) Number of Cases MeanMean 4646 10 MedianMedian 4848 0 Min-MaxMin-Max 5 -5 94 - 94 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Disease Abstract TheDisease epidemiology Abstract of ciguatera fish poisoning in the U.S. is not known. This may be due to lack ofThe recognition epidemiology among of the ciguatera medical fish community, poisoning the in non-fatalthe U.S. is nature not known. of the This disease, may and be duethe shortto lack of duration.recognition However, among thethe epidemiologymedical community, in Florida the is non-fatal more complete, nature of although the disease, it is likely and thethat short there duration. isHowever, significant the under-reporting. epidemiology in In Florida 2008, ais totalmore of complete, 11 ciguatera although outbreaks it is likely were that reported there inis Floridasignificant betweenunder-reporting. January-July In 2008, 2008, a resulting total of 11 in ciguatera51 cases. outbreaks In comparison, were reported from January-July in Florida betweenof 2007, January- sixJuly ciguatera 2008, resulting outbreaks in were51 cases. reported In comparison, and seven were from reportedJanuary-July in 2006. of 2007, The sixstate’s ciguatera 10 year outbreaks averagewere reported during 1998-2007and seven waswere 3.1 reported outbreaks in 2006. during The this state’s same 10 time year period. average In six during of 2008’s 1998-2007 11 was ciguatera3.1 outbreaks outbreaks, during ciguatoxin this same was time laboratory period. In confirmed. six of 2008’s Species 11 ciguatera of fish implicatedoutbreaks, in ciguatoxin these was outbreakslaboratory include: confirmed. grouper Species (7), barracuda of fish implicated(2), eel (1), in andthese mahi-mahi outbreaks (1). include: The Food grouper and (7), Drug barracuda Administration(2), eel (1), and (FDA) mahi-mahi product (1). trace-back The Food identified and Drug a common Administration seafood (FDA) distributor product in trace-backtwo of the identified sevena common grouper seafood outbreaks. distributor Grouper in two sold of bythe that seven implicated grouper vendor outbreaks. was of Grouper Bahamian sold origin. by that The implicated FDOHvendor Aquatic was of Toxin Bahamian and Food origin. and The Waterborne FDOH Aquatic Disease Toxin Programs and Food are and working Waterborne on an Disease Programs educationalare working campaign on an educational to target this campaign difficult-to-reach to target this audience difficult-to-reach of recreational audience fishers. of recreationalNote: the fishers. numberNote: the of outbreak-relatednumber of outbreak-related cases may casesnot match may Merlin not match case Merlin report casenumbers report due numbers to the fact due to the fact thatthat outbreaks outbreaks often often include include ill illpeople people who who are are not not residents residents of of the the State State of of Florida Florida (i.e., (i.e., visitors visitors who were who were exposed and got sick while in Florida), or ill people were not available for interview, exposed and got sick while in Florida), or ill people were not available for interview, and were therefore and were therefore not posted in Merlin. Also, outbreak cases may not match with Merlin not posted in Merlin. Also, outbreak cases may not match with Merlin across counties (often people across counties (often people cross county boundaries to eat in other counties). Outbreaks are cross county boundaries to eat in other counties). Outbreaks are generally reported by county/state of generally reported by county/state of exposure; individual reportable diseases are generally reportedexposure; by county/stateindividual reportable of residence. diseases are generally reported by county/state of residence.

65 2008 Florida Morbidity Statistics

References WalderhaugReferences M, “Ciguatera,” Foodborne Pathogenic Microorganisms and Natural Toxins Handbook, U.S. WalderhaugFood and M, Drug“Ciguatera,” Administration, Foodborne 1992, Pathogenicavailable at http://www.cfsan.fda.gov/~mow/chap36.html.Microorganisms and Natural Toxins Handbook, U.S. Food and Drug Administration, 1992, available at http://www.cfsan.fda.gov/~mow/chap36.html.

66 Summary of Selected Notifiable Diseases and Conditions

Cryptosporidiosis Cryptosporidiosis

Cryptosporidiosis: Crude Data Figure 1. Cryptosporidiosis Incidence Rate by Year Reported, Florida, NumberCryptosporidiosis: of Cases Crude 549 Data 1999-2008 5 2008Number incidence of Cases rate per 549 100,000 2008 incidence rate per 2.91 4 100,000 2.91 % change from average 3 5-year% change (2003-2007) from average incidence 5- rateyear (2003-2007) incidence 25.54 2 25.54

rate Cases100,000per Age (yrs) Age (yrs) 1 Mean 27.86 Mean 27.86 Median 25 0 Min-MaxMedian <1 - 2592 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max <1 - 92 Year

DiseaseDisease Abstract Abstract A totalA total of of549 549 cases cases of ofcryptosporidiosis cryptosporidiosis were were reported reported in 2008,in 2008, of ofwhich which 88.52% 88.52% were were classified classified as confirmed.as confirmed. Thirteen Thirteen percent percent of all of reported all reported cases cases were were classified classified as asoutbreak-related, outbreak-related, which which is a decreaseis a decrease from 16% from the 16% previous the previous year; 5% year; of 5%cases of caseswere acquired were acquired outside outside the U.S. the Since U.S. 2001,Since the incidence2001, the rate incidence for cryptosporidiosis rate for cryptosporidiosis has increased, has with increased, a sharp withincrease a sharp observed increase since observed 2004 (Figure 1). Thesince incidence 2004 (Figure rate in 1).2007 The was incidence 138% higher rate inthan 2007 the was average 138% incidence higher than from the 2002-2006 average incidence but only slightly higherfrom than2002-2006 the previous but only year slightly (2006: higher 717 cases;than the 3.89 previous cases/100,000 year (2006: population). 717 cases; However, 3.89 in 2008 there wascases/100,000 a decrease in population). the incidence However, rate (2.91 in cases/100,0002008 there was population) a decrease below in the thatincidence in 2006. rate Seasonal (2.91 increasescases/100,000 in cryptosporidiosis population) below are commonly that in 2006. observed Seasonal during increases the summer in cryptosporidiosis months when exposure are to recreationalcommonly water observed settings during is more the summer common. months In 2008, when the exposure number ofto casesrecreational exceeded water the settings previous is 5-year averagemore common. in all months In 2008, but three, the number though ofthe cases increase exceeded was particularly the previous great 5-year in the average summer in monthsall (Figure 2).months The overall but three, increase though in cryptosporidiosis the increase was over particula the pastrly great decade in the is consistentsummer months with national (Figure trends 2). and is Thelikely overall due to increase a combination in cryptosporidiosis of actual increased over the disease past decade incidence, is consistent increased with clinical national recognition, trends and increasedand is likely diagnostic due to testing.a combination Increased of actual use of in creasedrecreational disease water incidence, settings by increased young children clinical may account forrecognition, increases in and disease increased incidence. diagnostic The testing.recent introduction Increased useof nitazoxanide, of recreational the water first licensedsettings bytreatment foryoung the disease, children may may have account influenced for increases clinical in practice disease because incidence. diagnostic The recent testing introduction for Cryptosporidium of now cannitazoxanide, lead to specific the firsttreatment. licensed Testing treatment may for also the lead disease, to case may reporting have influenced which would clinical explain practice the increase in becausecases seen diagnostic between testing 2004 andfor Cryptosporidium 2007. now can lead to specific treatment. Testing may also lead to case reporting which would explain the increase in cases seen between 2004 and

2007. Figure 2. Cryptosporidiosis Cases by Month of Onset, Florida, 2008 140

120

100

Number of Cases Numberof 40

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008

Rates are higher among children <10 years old, with the highest rates occurring in the 1-4 age group (20.43 per 100,000) (Figure 3). However, there has been a significant increase in 67 incidence among those aged 10-24 years above the previous 5-year average. In 2008, approximately 29% of reported cases less than five years old attended day care centers. The smaller second peak in incidence among adults 20 to 44 years old may be attributed to family contact with infected children (Figure 3).

Cases of cryptosporidiosis were reported in 51 of the 67 counties in Florida. The county with the highest incidence, Clay, reported 24.1% of their cases as being outbreak-associated. Sarasota County had a lower incidence rate, but reported 76.5% of their cases as being associated with a single outbreak among swim team participants. Wakulla County reported all four of their cases as outbreak associated and they were all linked to a single daycare that has “waterplay”. The children were allowed access to a small waterslide and play pool at the daycare location. Additional counties with a high proportion of outbreak associated cases include Duval (41.2%) and Broward (12.7%).

Figure 3. Cryptosporidiosis Incidence Rate by Age Group, Florida, 2008

4 Cases per 100,000 per Cases 2

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

Figure 2. Cryptosporidiosis Cases by Month of Onset, Florida, 2008 140

120

100

Number of Cases Numberof 40

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008

2008 Florida Morbidity Statistics Rates are higher among children <10 years old, with the highest rates occurring in the 1-4 age group (20.43 per 100,000) (Figure 3). However, there has been a significant increase in Ratesincidence are higher among among those children aged <10 10-24 years years old, above with the the highest previous rates 5-year occurring average. in the In 1-42008, age group (20.43approximately per 100,000) 29%(Figure of reported3). However, cases there less thanhas been five years a significant old attended increase day incare incidence centers. among The those aged smaller10-24 years second above peak the in previousincidence 5-year among average. adults 20 In to 2008, 44 years approximately old may be 29% attributed of reported to family cases amongcontact those withless infectedthan five children years old(Figure attended 3). day care centers. The smaller second peak in incidence among adults 20 to 44 years old may be attributed to family contact with infected children (Figure 3). Cases of cryptosporidiosis were reported in 51 of the 67 counties in Florida. The county with the highest incidence, Clay, reported 24.1% of their cases as being outbreak-associated. Cases of cryptosporidiosis were reported in 51 of the 67 counties in Florida. The county with the highest Sarasota County had a lower incidence rate, but reported 76.5% of their cases as being incidence, Clay, reported 24.1% of their cases as being outbreak-associated. Sarasota County had a associated with a single outbreak among swim team participants. Wakulla County reported all lower incidence rate, but reported 76.5% of their cases as being associated with a single outbreak among four of their cases as outbreak associated and they were all linked to a single daycare that has swim team participants. Wakulla County reported all four of their cases as outbreak associated and they “waterplay”. The children were allowed access to a small waterslide and play pool at the were all linked to a single daycare that has “waterplay”. The children were allowed access to a small daycare location. Additional counties with a high proportion of outbreak associated cases waterslide and play pool at the daycare location. Additional counties with a high proportion of outbreak include Duval (41.2%) and Broward (12.7%). associated cases include Duval (41.2%) and Broward (12.7%).

Figure 3. Cryptosporidiosis Incidence Rate by Age Group, Florida, 2008

4 Cases per 100,000 per Cases 2

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

Prevention The likelihood of contracting cryptosporidiosis can be reduced by practicing good hand hygiene, such as washing hands before handling or eating food and after diaper changing. Water in recreational settings, such as swimming pools or water parks, should not be ingested or swallowed. Outbreaks associated with recreational water, especially water parks and interactive fountains, can be prevented by following established guidelines for management of these facilities. The likelihood of contracting cryptosporidiosis in a recreational water setting can be reduced by practicing healthy swimming behaviors. Avoid swallowing pool water or even getting it in your mouth. Shower before swimming and wash your hands after using the toilet or changing diapers. Take children on bathroom breaks or check diapers often. Change diapers in a bathroom and not at poolside and thoroughly clean the diaper changing area. Protect others by not swimming if you are experiencing diarrhea (this is essential for children in diapers). Swimming is not recommended for at least two weeks after diarrhea stops.

68 Prevention The likelihood of contracting cryptosporidiosis can be reduced by practicing good hand hygiene, such as washing hands before handling or eating food and after diaper changing. Water in recreational settings, such as swimming pools or water parks, should not be ingested or swallowed. Outbreaks associated with recreational water, especially water parks and interactive fountains, can be prevented by following established guidelines for management of these facilities. The likelihood of contracting cryptosporidiosis in a recreational water setting can be reduced by practicing healthy swimming behaviors. Avoid swallowing pool water or even getting it in your mouth. Shower before swimming and wash your hands after using the toilet or changing diapers. Take children on bathroom breaks or check diapers often. Change diapers in a bathroom and not at poolside and thoroughly clean the diaper changing area. Protect others by not swimming if you are experiencing diarrhea (this is essential for children in diapers). Swimming is not recommended for at least two weeks after diarrhea stops.

Summary of Selected Notifiable Diseases and Conditions

References th ReferencesDavid L. Heymann (ed.), Control of Communicable Diseases Manual, 18 ed., American Public Health th David L. HeymannAssociation (ed.), Press, Control Washington, of Communicable District of DiseasesColumbia, Manual 2004. , 18 ed., American Public Health Association Press, Washington, District of Columbia, 2004. Centers for Disease Control and Prevention, “Outbreak of gastroenteritis associated with an interactive water fountain at a beachside park – Florida, 1999,” Morbidity and Mortality Weekly Report, Vol. 49, No. 25, 2000, pp. 565-8.

Centers for Disease Control and Prevention, “Summary of notifiable diseases – United States, 2006,” Morbidity and Mortality Weekly Report, Vol. 55, No. 53, 2006.

Centers for Disease Control and Prevention, “Surveillance for Waterborne Disease and Outbreaks Associated with Recreational Water Use and Other Aquatic Facility-Associated Health Events - United States, 2005—2006,” Morbidity and Mortality Weekly Report, Vol. 57, No. SS-9, 2009.

L.M. Fox, et al., “Nitazoxanide: a new thiazolide antiparasitic agent.” Clinical Infectious Diseases, Vol. 40, 2005, pp. 1173-80.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/ncidod/dpd/parasites/cryptosporidiosis/factsht_cryptosporidiosis.htm.

69 2008 Florida Morbidity Statistics

Cyclosporiasis

Figure 1. Cyclosporiasis: Crude Data Cyclosporiasis Incidence Rate by Year Reported, Cyclosporiasis: Crude Data Number of Cases 59 Florida, 1999-2008 3.5 2008Number incidence of rateCases per 59 3.0 100,0002008 incidence rate per 0.31 2.5 100,000 0.31 % change from median 5 year 2.0 (2003-2007)% change reported from median cases 5 year 81.23 1.5 (2003-2007) reported cases 81.23 Age (yrs) 1.0 Age (yrs) per 100,000 Cases Mean 49.75 0.5 MedianMean 49 49.75 Median 49 0.0 Min-Max 3 - 83 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 3 - 83 Year

DiseaseDisease Abstract Abstract With Withthe exception the exception of a largeof a large outbreak outbreak of cyclosporiasis of cyclosporiasis in 2005 in 2005 (493 (493cases cases from fromFlorida; Florida; see thesee notable outbreaksthe notable section outbreaks of the 1997-2006 section of Annual the 1997-2006 Morbidity Ann Statisticsual Morbidity Report Statisticsfor more details),Report for the more incidence rate fordetails), cyclosporiasis the incidence has remainedrate for cyclosporiasis stable in recent has years remained (Figure stable 1). Inin recentcomparison years to (Figure the median 1). In incidencecomparison for the tolast the five median years, incidence the incidence for the in last 2008 five has years, increased the incidence by 81.23%, in 2008 with hasa total increased of 59 cases reported.by 81.23%, Thirteen with percent a total of of the 59 cases reportedreported. in Thirteen 2008 were percent considered of the casesoutbreak-associated. reported in 2008 In 2008, the numberwere considered of cases by outbreak-associated. month of disease onset In 2008, met orthe exceeded number ofthe cases previous by month 5-year of median disease during onset all monthsmet of or the exceeded year when the cases previous were 5-year reported median (Figure during 2). all The months peak ofin latethe yearspring when and casesearly summerwere may reflectreported the seasonal (Figure variation2). The peakof endemic in late cyclosporiasisspring and early in summercountries may who reflect export the fruits seasonal and vegetables to the U.S.variation However, of endemic the large cyclosporiasis increase in incases countries occurring who inexport May fruitsand June and vegetablesof 2008 prompted to the U.S.the Food and WaterborneHowever, the Disease large increase Program in within cases the occurring Florida inDepartment May and June of Health of 2008 to launchprompted a case-control the Food studyand aimed Waterborne at discovering Disease if there Program was awithin common the Florida source Department for these cases. of Health No definitiveto launch aconclusion case- was reachedcontrol regarding study aimed these atcases discovering and the ifcase there numbers was a common returned source to their for expected these cases. levels shortlyNo definitive after. Pleaseconclusion see the “Summarywas reached of Notableregarding Outbreaks these cases and and Case the Investigations” case numbers section returned for to further their details. expected levels shortly after. Please see the “Summary of Notable Outbreaks and Case Investigations” section for further details. Figure 2. Cyclosporiasis Cases by Month of Onset, Florida, 2008 20 18 16 14 12 10 8 6 Number of CasesNumber of 4 2 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr median 2008

In 2008,In 2008, 93% 93% of the of casesthe cases were were reported reported in those in those who who were were between between the agesthe ages of 25 of and 25 and84, with84, the largestwith increase the largest occurring increase in occurringthe 25-34 inage the group 25-34 (Figure age group 3). (Figure 3).

Figure 3. Cyclosporiasis Cases by Age Group, Florida, 2008

70 14

4 Number of Cases of Number 2

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr median 2008

Cyclosporiasis was reported in 21 of the 67 counties in Florida, with the largest number of cases occurring in Palm Beach County.

Figure 2. Cyclosporiasis Cases by Month of Onset, Florida, 2008 20 18 16 14 12 10 8 6 Number of CasesNumber of 4 2 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr median 2008

Summary of Selected Notifiable Diseases and Conditions In 2008, 93% of the cases were reported in those who were between the ages of 25 and 84, with the largest increase occurring in the 25-34 age group (Figure 3).

Figure 3. Cyclosporiasis Cases by Age Group, Florida, 2008

4 Number of Cases of Number 2

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr median 2008

CyclosporiasisCyclosporiasis was reportedwas reported in 21 inof 21 the of 67 the counties 67 counties in Florida, in Florida, with thewith largest the largest number number of cases of cases occurringoccurring in Palm in Palm Beach Beach County. County.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// Additionalwww.cdc.gov/ncidod/dpd/parasites/cyclospora/default.htm Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at th http://www.cdc.gov/ncidod/dpd/parasites/cyclospora/default.htmDavid L. Heymann (ed.), Control of Communicable Diseases Manual , 18 ed., American Public Health Association Press, Washington, District of Columbia, 2004. David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004. 71

2008 Florida Morbidity Statistics

Dengue DengueDengue

Figure 1. DengueDengue Fever: Fever: Crude Crude Data Data Dengue Fever Cases by FigureYear Reported, 1. Florida, 1999-2008 Dengue Fever: Crude Data Dengue Fever Cases by Year Reported, Florida, 1999-2008 NumberNumber of Cases of Cases 33 33 50 Number of Cases 33 50 20082008 incidence incidence rate perrate per 2008 incidence rate per 40 100,000100,000 0.17 40 100,000 0.170.17 % change from average 5- % change% change from from average average 5- 30 year (2003-2007) incidence 30 5-yearyear (2003-2007) (2003-2007) incidence incidence rate 37.82 20 raterate 37.8237.82 20

Age (yrs) Number of Cases Age (yrs) Number of Cases Age (yrs) Mean 43.85 10 Mean 43.85 10 MeanMedian 43.85 40 MedianMedian 40 40 0 Min-Max <1 - 80 0 Min-Max <1 - 80 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max <1 - 80 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Year Disease Abstract Disease Abstract DiseasePrior Abstract to 1998, dengue virus (DENV) infection was not often considered among diagnoses for ill Prior to 1998, dengue virus (DENV) infection was not often considered among diagnoses for ill Priortravelers to 1998, returningdengue virus from (DENV) areas where infection dengue was isnot endemic. often considered A 1998 study among on diagnoses an active for ill travelers travelers returning from areas where dengue is endemic. A 1998 study on an active returningsurveillance from areas program where for dengue recent isdengue endemic. infections A 1998 in study Florida on led an toactive an increase surveillance in awareness program foras surveillance program for recent dengue infections in Florida led to an increase in awareness as recentwell dengue as enhanced infections laboratory in Florida capacity led to an to increasetest for the in viruses.awareness Since as well1998, as dengue enhanced cases laboratory have well as enhanced laboratory capacity to test for the viruses. Since 1998, dengue cases have capacitybeen to reported test for thein Florida viruses. each Since year 1998, (Figure dengue 1). The cases number have ofbeen imported reported cases in Florida reported each typically year been reported in Florida each year (Figure 1). The number of imported cases reported typically (Figureranged 1). Thefrom number 10-20 per of importedyear until cases 2007 reportedwhen 46 typicallycases were ranged reported; from 10-2033 cases per wereyear untilreported 2007 in ranged from 10-20 per year until 2007 when 46 cases were reported; 33 cases were reported in when2008. 46 cases This wereincrease reported; may be33 duecases to epidemicswere reported outside in 2008. the continental This increase U.S., may including be due Puerto to epidemics 2008. This increase may be due to epidemics outside the continental U.S., including Puerto outsideRico, the the continental Dominican U.S., Republic, including Central Puerto and Rico, South the America, Dominican and Republic, Asia, which Central began and in South2007 andAmerica, Rico, the Dominican Republic, Central and South America, and Asia, which began in 2007 and and Asia,are ongoing which began in many in instances.2007 and are Increased ongoing activity in many in instances.Puerto Rico Increased and the Caribbean activity in Puertois Rico are ongoing in many instances. Increased activity in Puerto Rico and the Caribbean is and especiallythe Caribbean concerning is especially for Florida concerning given thefor Floridamany Floridians given the thatmany travel Floridians to the area.that travel Though to the local area. especially concerning for Florida given the many Floridians that travel to the area. Though local Thoughtransmission local transmission has not been has notreported been inreported recent inyears, recent the years, disease the was disease previously was previously endemic endemicto to transmission has not been reported in recent years, the disease was previously endemic to FloridaFlorida and andcompetent competent mosquito mosquito vectors vectors are stillare present.still present. Typically, Typically, disease disease onset onset for travelers for travelers returning Florida and competent mosquito vectors are still present. Typically, disease onset for travelers to Floridareturning peaks to Floridaduring mid-summerpeaks during and mid-summer fall, though and cases fall, thoughare reported cases year-round are reported (Figure year-round 2). There returning to Florida peaks during mid-summer and fall, though cases are reported year-round were(Figure a large 2). number There of were cases a largereported number in January; of cases this reported may have in January; been due this to mayholiday have travel been as due well to as (Figure 2). There were a large number of cases reported in January; this may have been due to late reportingholiday travel as several as well cases as late who reporting had onset as several dates in cases 2007. who had onset dates in 2007. holiday travel as well as late reporting as several cases who had onset dates in 2007. Figure 2. Figure 2. Dengue Fever Cases by Month of Onset, Florida, 2008 Dengue Fever Cases by Month of Onset, Florida, 2008 8 8 7 7 6 6 5 5 4 4 3 3

Number of CasesNumber of 2 Number of CasesNumber of 2 1 1 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Month 5yr average 2008 5yr average 2008

In 2008, 57% percent of cases were male, and 27% occurred among those 55-64 years of age. In 2008, 57% percent of cases were male, and 27% occurred among those 55-64 years of age.

72 Summary of Selected Notifiable Diseases and Conditions

In 2008, 57% percent of cases were male, and 27% occurred among those 55-64 years of age. In 2008, In 2008, 28% of dengue cases reported travel history to Puerto Rico, 15% traveled to the 28% of dengue cases reported travel history to Puerto Rico, 15% traveled to the Dominican Republic, Dominican Republic, 24% traveled to other countries in the Caribbean, 18% traveled to South or 24% traveled to other countries in the Caribbean, 18% traveled to South or Central America, and 9% Central America, and 9% traveled to Asia. The remaining 6% were listed as unknown. traveled to Asia. The remaining 6% were listed as unknown.

Figure 3. Dengue Fever Cases by Age Group, Florida, 2008

10 9 8 7 6 5 4 3 Number of Cases of Number 2 1 0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

Prevention TherePrevention is currently no vaccine available against DENV infection. Travelers to dengue-endemic countries shouldThere be warned is currently of the no risk vaccine of disease available and instructedagainst DENV to avoid infection. mosquito Travelers bites. toUse dengue-endemic insect repellents that containcountries DEET orshould other beEPA-approved warned of the ingredients risk of disease such andas Picaridin, instructed oil to of avoid lemon mosquito eucalyptus, bites. or UseIR3535. Avoidinsect spending repellents time outdoors that contain during DEET daytime or other hours EPA-approved when disease-carrying ingredients mosquitoes such as Picaridin, are most oil likely of to be lemonseeking eucalyptus, a blood meal, or IR3535. and drain Avoid any spendingstanding watertime outdoors in containers during around daytime the hours home. when Dress in long sleevesdisease-carrying and long pants mosquitoes to protect your are mostskin from likely mosquitoes. to be seeking Also, a blood try to meal, remain and in drain well-screened any standing or air- conditionedwater in areas. containers around the home. Dress in long sleeves and long pants to protect your skin from mosquitoes. Also, try to remain in well-screened or air-conditioned areas.

73 2008 Florida Morbidity Statistics

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 19th ed., American Public Health References Association Press, Washington, District of Columbia, 2008. David L. Heymann (ed.), Control of Communicable Diseases Manual, 19th ed., American Public J. Gill, L.M. Stark, G.G. Clark. “Dengue Surveillance in Florida, 1997-1998.” Emerging Infectious HealthDiseases Association, Vol. 1, Press,2000, pp.30-35. Washington, District of Columbia, 2008.

J. Gill, L.M.Additional Stark, Resources G.G. Clark. “Dengue Surveillance in Florida, 1997-1998.” Emerging Infectious AdditionalDiseases information, Vol. 1, 2000,on DENV pp.30-35. and other mosquito-borne diseases can be found in the Surveillance and Control of Arthropod-borne Diseases in Florida Guidebook, online at http://www.doh.state.fl.us/ environment/medicine/arboviral/pdf_files/2009MosquitoGuide.pdf. AdditionalDisease Resources information is also available from the Centers for Disease Control and Prevention (CDC) website Additionalat http://wwwn.cdc.gov/travel/yellowBookCh4-DengueFever.aspx. information on DENV and other mosquito-borne diseases can be found in the Surveillance and Control of Arthropod-borne Diseases in Florida Guidebook, online at http://www.doh.state.fl.us/environment/medicine/arboviral/pdf_files/2009MosquitoGuide.pdf. Disease information is also available from the Centers for Disease Control and Prevention (CDC) website at http://wwwn.cdc.gov/travel/yellowBookCh4-DengueFever.aspx.

74 Summary of Selected Notifiable Diseases and Conditions

Eastern Equine Encephalitis Eastern Equine Encephalitis

Eastern Equine Encephalitis: Figure 1. Eastern Equine Encephalitis: Eastern Equine Encephalitis Cases by Year Reported, Florida, Crude Data 1999-2008 Crude Data Number of Cases 1 Number of Cases 1 6

20082008 incidence incidence rate rate per per 5 100,000 100,000 0.010.01 4 % %change change from from average average 5 year 5 year 3 (2003-2007) reported cases -40.49 (2003-2007) reported cases -40.49 2 Age (yrs) Number of Cases Age (yrs) 1 MeanMean N/A N/A 0 MedianMedian N/A N/A Min-Max N/A 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max N/A Year

DiseaseDisease Abstract Abstract EasternEastern equine equine encephalitis encephalitis virus virus (EEEV) (EEEV) is a mosquito-borneis a mosquito-borne alphavirus alphavirus that was that first was identified first identified in the 1930s.in the EEEV1930s. occurs EEEV in occursnatural incycles natural involving cycles birds involving and Culiseta birds and melanura Culiseta in melanurafreshwater in swampy freshwater areas,swampy with areas,a peak withof activity a peak occurring of activity between occurring May between and August. May In and this August. usual cycle In this of transmission usual cycle of (enzootictransmission cycle), (enzootic the EEEV cycle), remains the in EEEVthe swampy remains areas, in the as swampythe mosquito areas, involved as the prefers mosquito to feed upon birds,involved and does prefers not tousually feed uponbite humans birds, andor other does mammals. not usually Most bite human humans cases or other are thought mammals. to occur Most whenhuman the viruscases occasionally are thought moves to occur into when other themosquito virus occasionallyspecies that aremoves more into likely other to bite mosquito people and act asspecies bridge vectors. that are more likely to bite people and act as bridge vectors.

AllAll evidence evidence indicates indicates that that human human eastern eastern equine equine encephalitis encephalitis (EEE) (EEE) does notdoes have not epidemichave epidemic potential in potentialFlorida, but in Florida,can cause but severe can cause disease severe in those disease infected. in those Continuous infected. surveillance Continuous since surveillance 1957 has documentedsince 1957 only has 78 documented human cases only (average 78 human 1.5 casescases per (average year, range: 1.5 cases 0-5), perincluding year, onerange: in 2008. 0-5), The casesincluding reported one each in 2008. year fromThe 1999cases to reported 2008 suggest each yearthat it from remains 1999 infrequent to 2008 suggest(Figure 1). that The it remains peak illnessinfrequent onset period(Figure for 1). human The peakcases illness is from onset June perto Augustiod for (Figurehuman 2),cases though is from transmission June to Augustcan occur year-round.(Figure 2), Unlike though some transmission other mosquito-borne can occur year-round. diseases, which Unlike typically some afotherfect themosquito-borne elderly, EEE tends to affectdiseases, individuals which in typicallyyounger ageaffect groups the elderly, (Figure EEE 3). In tends fact, toof affectthe cases individuals reported in since younger 1998, age 63% were in groupsthose <15 (Figure years 3). of age.In fact, Of ofthe the 13 casescases reportedreported betweensince 1998, 2001 63% and were 2008, in four those (31%) <15 resulted years of in death.age. ThisOf the is consistent13 cases reportedwith the known between case 2001 fatality and rate 2008, for EEEfour (31%)(approximately resulted 1in death/3 death. cases), This is with anotherconsistent 1/3 of with patients the known suffering case permanent fatality rate brain for damage EEE (approximately requiring long-term 1 death/3 medical cases), care. with Between 2001another and 2008, 1/3 of 62% patients of cases suffering were reportedpermanent in individuals brain damage residing requiring in counties long-term in the medical panhandle care. or northernBetween region 2001 of andthe state.2008, Thirty-two62% of cases percent were of reportedcases were in individualsreported from residing the central in counties region. in One the non- fatalpanhandle case involving or northern a child region was reported of the state.from Leon Thirty-two County percent in 2008. of cases were reported from the central region. One non-fatal case involving a child was reported from Leon County in 2008.

75 2008 Florida Morbidity Statistics

Figure 2. Eastern Equine EncephalitisFigure Cases 2. by Month of Onset, Florida, 2008 1.4Eastern Equine Encephalitis Cases by Month of Onset, Florida, 2008

1.4 1.2

1.2 1

1 0.8

0.8 0.6

0.6 0.4 Numberof Cases

0.4 Numberof Cases 0.2

0.2 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 0 Jan Feb Mar Apr May JunMonth Jul Aug Sep Oct Nov Dec 5yr averageMonth 2008

5yr average 2008 Prevention PreventionPreventionPrevention of the disease is a necessity, as there is no cure for EEE; only supportive care is PreventionPreventionavailable. of the of disease Measuresthe disease is acan necessity, is bea necessity, taken as to there avoid as there is bei nong iscure nobitten forcure EEE;by for mosquitoes. EEE; only supportiveonly supportive Drain care any iscareareas available. is of Measuresavailable.standing can be Measures water taken from to canavoid around be being taken the bitten hometo avoid by to mosquitoes.eliminatebeing bitten mosquito by Drain mosquitoes. anybreeding areas sites.Drain of standing anyUse areas insect water of from aroundstanding repellentsthe home water tothat fromeliminate contain around mosquitoDEET the homeor otherbreeding to EPA-approvedeliminate sites. mosquitoUse insectingredients breeding repellents such sites. thatas PicaridinUse contain insect DEETor oil ofor other EPA-approvedrepellentslemon eucalyptus. ingredientsthat contain suchAvoid DEET as spending or Picaridin other EPA-approvedtime or oil ou oftdoors lemon duringingredients eucalyptus. dusk suchand Avoid dawn, as Picaridinspending the time ortime whenoil outdoorsof duringlemon duskdisease-carrying eucalyptus. and dawn, the Avoidmosquitoes time spending when are disease-carrying timemost ou likelytdoors to be duringmosquitoes seeking dusk a and areblood mostdawn, meal. likely the Dress timeto be when in seeking long sleeves a blood meal.disease-carrying Dressand long in long pants sleeves mosquitoes to protect and skinlong are frompantsmost mosquitoes. likelyto protect to be skinseeking In addition,from a mosquitoes. blood inspect meal. screens In Dress addition, onin longdoors inspect sleeves and screens on doorsandwindows longand windowspants for holesto protectfor toholes make skin to suremakefrom mosquitoesmosquitoes. sure mosquitoes cannot In addition, cannot enter theinspectenter home. the screens home. Horses on Horses aredoors also areand quite also quite susceptiblewindowssusceptible to forthis holes virus to this toand makevirus vaccination and sure vaccination mosquitoes is strongly is cannot strongly recommended. enter recommended. the home. Horses are also quite susceptible to this virus and vaccination is stronglyFigure recommended. 3. Eastern Equine EncephalitisFigure Cases 3. by Age Group, Florida, 2008 Eastern Equine Encephalitis Cases by Age Group, Florida, 2008 1.2

1.2 1.0

1.0 0.8

0.8 0.6

0.6 0.4

0.4Numberof Cases 0.2

Numberof Cases 0.2 0.0 <1 1-4 5-9

0.0 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 <1 1-4 5-9 85+

10-14 15-19 20-24 Age25-34 Group35-44 45-54 55-64 65-74 75-84

PreviousAge 5yrGroup average 2008

Previous 5yr average 2008 References ReferencesDavid L. Heyman (ed.), Control of Communicable Diseases Manual, 19th ed., American Public ReferencesDavid L. HeymanHealth Association (ed.), Control Press, of Communicable Washington, DistrictDiseases of Columbia,Manual, 19th 2008. ed., American Public David L. HeymanHealth (ed.), Association Control Press,of Communicable Washington, Diseases District ofManual Columbia,, 19th 2008. ed., American Public Health AssociationAdditional ResourcesPress, Washington, District of Columbia, 2008. AdditionalAdditional Resources information on EEE and other mosquito-borne diseases can be found in the Surveillance and Control of Arthropod-borne Diseases in Florida Guidebook, online at AdditionalAdditional Resources information on EEE and other mosquito-borne diseases can be found in the http://www.doh.state.fl.us/environment/medicine/arboviral/pdf_files/2009MosquitoGuide.pdf. AdditionalSurveillance information and Controlon EEE ofand Arthropod-borne other mosquito-borne Diseases diseases in Florida can Guidebook, be found in online the Surveillance at and Controlhttp://www.doh.state.fl.us/environment/medicine/arboviral/pdf_files/2009MosquitoGuide.pdf. of Arthropod-borne Diseases in Florida Guidebook, online at http://www.doh.state.fl.us/ environment/medicine/arboviral/pdf_files/2009MosquitoGuide.pdf. Disease information is also available from the Centers for Disease Control and Prevention (CDC) website http://www.cdc.gov/ncidod/dvbid/arbor/eeefact.htm.

76 Summary of Selected Notifiable Diseases and Conditions

Ehrlichiosis/AnaplasmosisEhrlichiosis/Anaplasmosis

Figure 1. EhrlichiosisEhrlichiosis (all (all codes): codes): Crude Crude Ehrlichiosis/Anaplasmosis (combined) Cases by Year Reported, Florida, 1999-2008 DataData 24 NumberNumber of ofCases Cases 12 12 21 20082008 incidence incidence rate rate per per 18 100,000100,000 0.060.06 15 12 % change from average 5-year % change from average 5-year 9 (2003-2007)(2003-2007) reported reported cases cases 15.38 15.38 Number of Cases 6 AgeAge (yrs) (yrs) 3 MeanMean 51.92 51.92 0 MedianMedian 58.5 58.5 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-MaxMin-Max 4 - 489 - 89 Year

Disease Abstract DiseaseEhrlichia Abstract chaffeensis , discovered in 1987, causes human monocytic ehrlichiosis (HME), which is Ehrlichianationally chaffeensis notifiable., discovered Ehrlichia ewingiiin 1987, is causes indistinguishable human monocytic from E. ehrlichiosis chaffeensis (HME), using serologicwhich is nationallytesting andnotifiable. is present Ehrlichia in Florida, ewingii therefore is indistinguishable some cases from classified E. chaffeensis as HME mayusing actually serologic be testing due andto isE. present ewingii .in TheFlorida, principal therefore vector some for bothcases agents classified is the as Lone HME Star may Tick, actually Amblyomma be due to E. ewingii. Theamericanum principal vector. Due for to both testing agents limitations, is the Lone E. ewingii Star Tick, is not Amblyomma as well characterized americanum as. E.Due chaffeensis to testing ; limitations,however E.it hasewingii most is frequentlynot as well been characterized identified asin immunocompromisedE. chaffeensis; however patients. it has most Human frequently been identified in immunocompromised patients. Human granulocytic ehrlichiosis (HGE) was originally thought granulocytic ehrlichiosis (HGE) was originally thought to be caused by another species of to be caused by another species of Ehrlichia, but was later reclassified as Anaplasma phagocytophilum, Ehrlichia, but was later reclassified as Anaplasma phagocytophilum, with the associated illness with the associated illness renamed to human granulocytic anaplasmosis (HGA). The principal vector for renamed to human granulocytic anaplasmosis (HGA). The principal vector for A. A. phagocytophilum is Ixodes scapularis. HGA became nationally notifiable in1999. phagocytophilum is Ixodes scapularis. HGA became nationally notifiable in1999.

Between 1998 and 2006 the total number of combined cases of HME and HGA reported ranged from Between 1998 and 2006 the total number of combined cases of HME and HGA reported ranged two to thirteen cases per year, but in 2007 there were 21 cases reported (18 HME and 3 HGA). This from two to thirteen cases per year, but in 2007 there were 21 cases reported (18 HME and 3 number decreased to more typical levels in 2008 (Figure 1), with 10 cases of HME and two cases of HGA). This number decreased to more typical levels in 2008 (Figure 1), with 10 cases of HME HGA reported. Increased educational efforts and awareness may have contributed to the increase in and two cases of HGA reported. Increased educational efforts and awareness may have reported cases in 2007. White-tailed deer are an important reservoir species for E. chaffeensis. Less is knowncontributed regarding to theother increase potential in wildlifereported reservoirs. cases in 2007. In addition, White-tailed there is deer no standardized are an important tick surveillance programreservoir in Florida.species Thesefor E. chaffeensisgaps in knowledge. Less is make known it difficult regarding to otherascertain potential why case wildlife numbers reservoirs. might fluctuateIn addition, from there year tois noyear. standardized Since HGA tick was surveillance recognized programas a separate in Florida. reportable These disease gaps inin 1999, there haveknowledge been consistently make it difficult more HMEto ascertain cases than why HGAcase cases numbers reported might in fluctuate Florida. from In 2008, year 58% to year. of HME andSince HGA HGA cases was were recognized men. The as majority a separate of HME reportable cases (70%) disease are in reported 1999, there as being have acquired been in Florida, primarilyconsistently in the morenorth HMEand central cases partsthan HGAof the cases state. re HGAported is more in Florida. likely to In be 2008, acquired 58% ofoutside HME Floridaand and is moreHGA casesprevalent were in men.the northeast The majority United of States. HME cases One locally-acquired(70%) are reported case as of being HGA wasacquired reported in from DadeFlorida, County primarily in 2008. in the Though north cases and central of both parts HME of and the HGA state. are HGA reported is more year-round, likely to bepeak acquired transmission occursoutside during Florida the lateand springis more and prevalent summer in months the northeast (Figure United2). Sixty States. percent One of reportedlocally-acquired cases in case 2008 wereof HGAover thewas age reported of 50. from No deaths Dade Countywere reported in 2008. in Though2008. cases of both HME and HGA are reported year-round, peak transmission occurs during the late spring and summer months (Figure 2). Sixty percent of reported cases in 2008 were over the age of 50. No deaths were reported in 2008.

77 2008 Florida Morbidity Statistics

Figure 2. Ehrlichiosis (all codes) Cases by Month of Onset, Florida, 2008 6

2 Number of Cases Numberof

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008

PreventionPrevention BothBoth HME HME and andHGA HGA can canbe treated be treated with withdoxycycline, doxycycline, though though prevention prevention of tick of bitestick bites is the is bestthe best way to avoidway disease. to avoid Wear disease. light-colored Wear light-colored clothing so clothingthat ticks so crawling that ticks on crawling clothing onare clothing visible. are Tuck visible. pants legsTuck into sockspants solegs that into ticks socks cannot so that crawl ticks inside cannot clothing. crawl insideApply clothing.repellent toApply discourage repellent tick to attachment. Repellentsdiscourage containing tick attachment. permethrin Repellents can be sprayed containing on boots permethrin and clothing, can be and sprayed will last on for boots several and days. Repellentsclothing, containing and will last DEET for severalcan be applieddays. Repellents to the skin, containing but will last DEET only acan few be hours applied before to the reapplication skin, is necessary.but will last Search only a thefew body hours for before ticks frequentlyreapplication when is necessary. spending time Search in potentially the body tick-infested for ticks areas. If a tickfrequently is found, when it should spending be removed time in potentially as soon as tick-infested possible. Controlling areas. If a tick tick populations is found, it shouldin the yard be and on petsremoved can also as soonreduce as thepossible. risk of diseaseControlling transmission. tick populations in the yard and on pets can also reduce the risk of disease transmission.

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 19th ed., American Public Health Association Press, Washington, District of Columbia, 2008.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) http:// www.cdc.gov/ncidod/dvrd/ehrlichia/Index.htm.

Disease information is also available from the Florida Department of Health at http://www.doh.state.fl.us/Environment/medicine/arboviral/Tick_Borne_Diseases/Tick_Index.htm

Summary of Selected Notifiable Diseases and Conditions

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 19th ed., American Public Health Association Press, Washington, District of Columbia, 2008.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) http:// www. cdc.gov/ncidod/dvrd/ehrlichia/Index.htm.

Disease information is also available from the Florida Department of Health at http://www.doh.state.fl.us/ Environment/medicine/arboviral/Tick_Borne_Diseases/Tick_Index.htm

Escherichia coli, Shiga Toxin Producing Escherichia coli, Shiga Toxin Producing

Figure 1. EscherichiaEscherichia coli, coli, S Shigahiga Toxin Toxin Escherichia coli , Shiga Toxin Producing Incidence Rate by Year Reported, Florida, 1999-2008 ProducingProducing 1.0 NumberNumber of of Cases Cases 6565 0.8 20082008 incidence incidence rate rate per per 100,000100,000 0.34 0.34 0.6 %% change change from from average average 5- year5-year (2003-2007) (2003-2007) incidence 0.4 -11.33 rateincidence rate -11.33 per 100,000 Cases Age (yrs) 0.2 Age (yrs) Mean 19.42 MedianMean 19.42 14 Median 14 0.0 Min-Max <1 - 85 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max <1 - 85 Year

Description TheDescription most commonly identified Shiga toxin producing Escherichia coli (STEC) in the U.S. is E. coliThe serogroup most commonly O157:H7; identified however, Shiga there toxin are producingmany other Escherichia serogroups coli that (STEC) cause in disease the U.S. due is E. to coli Shigaserogroup toxin. O157:H7; Serogroups however, O26, O111,there areand many O103 other are the serogroups non-O157 that serogroups cause disease that most due oftento Shiga toxin. causeSerogroups illness O26, in people O111, in and the O103U.S. Asare a the whole, non-O157 the non-O157 serogroups serogroups that most are often less cause likely illnessthan E. in people coliin the O157:H7 U.S. As to a cause whole, severe the non-O157 illness; however, serogroups some are non-O157 less likely STEC than E. serogroups coli O157:H7 can to cause cause severe theillness; most however, severe manifestations some non-O157 of STECSTEC illness.serogroups can cause the most severe manifestations of STEC illness. Prior to 2008, STEC was reported under multiple disease codes, depending on the serogroup. One reporting code captured only serogroup O157:H7. Another reporting code captured known Prior to 2008, STEC was reported under multiple disease codes, depending on the serogroup. One serogroups other than O157:H7. Previous Florida Morbidity Statistics Reports included only the diseasereporting code code for captured E. coli O157:H7. only serogroup However, O157:H7. in 2008, Another these reporting codescode captured were combined known serogroupsinto oneother and than E. O157:H7.coli O157:H7 Previous is no longer Florida separated Morbidity from Statistics the non-O157 Reports included strains. only the disease code for E. coli O157:H7. However, in 2008, these reporting codes were combined into one and E. coli O157:H7 is Theno longer figures separated in this report from reflect the non-O157 all STEC strains.serogroups reported over the past 10 years, not just serogroup O157:H7, and therefore cannot be compared to previous years’ reports. The figures in this report reflect all STEC serogroups reported over the past 10 years, not just serogroup O157:H7, and therefore cannot be compared to previous years’ reports.

79 2008 Florida Morbidity Statistics

Figure 2. Escherichia coli , Shiga Toxin Producing, Cases by Month of Onset, 18 Florida, 2008 16 14 12 10 8 6 Number of Cases Numberof 4 2 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008

DiseaseDisease Abstract Abstract A totalA total of 65 of cases 65 cases were were reported reported in 2008, in 2008, of which of which 59 were 59 were confirmed. confirmed. Eleven Eleven were were classified classified as outbreak-associated.as outbreak-associated. Four cases Four werecases acquired were acquired in states in otherstates than other Florida than Florida and three and were three acquired were outsideacquired the U.S. outside Most the of U.S.the confirmed Most of the cases confirmed were casescaused were by serogroup caused by O157:H7serogroup (49) O157:H7 and a few were caused(49) byand O157:non-motile a few were caused (2). byNon-O157 O157:non-motile serogroups (2). included Non-O157 O103:H2 serogroups (3), O111:H8 included (1), O103:H2 O26:H11 (1), (3), O111:H8 (1), O26:H11 (1), O73:H18 (1), O45:unknown H (1) and O rough:H18 (1). O73:H18 (1), O45:unknown H (1) and O rough:H18 (1).

The incidence rate for STEC has varied over the last ten years (Figure 1). One source of The incidence rate for STEC has varied over the last ten years (Figure 1). One source of variation variation is large outbreaks involving food products distributed across multiple states or other is largecommon outbreaks source involving exposures. food Inproducts 2008, theredistributed was an across 11% decreasemultiple states in incidence or other of common new cases source in exposures.comparison In 2008, to the there average was incidencean 11% decrease from 2003 in incidenceto 2007, likely of new due cases to the in absence comparison of large to the average incidenceoutbreaks from tied 2003 to toa common2007, likely source. due to However, the absence the 65of largecases outbreaks in 2008 represent tied to a commona substantial source. However,increase the over 65 cases the 47 in cases 2008 reportedrepresent in a 2007. substantial increase over the 47 cases reported in 2007.

Figure 3. Escherichia coli , Shiga Toxin Producing, Incidence Rate by Age Group, Florida, 2008 2.0

1.5

1.0

0.5 Cases per 100,000 per Cases

0.0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

In 2008, no clear seasonal patterns were observed (Figure 2). Incidence was greatest among children and teenagers (Figure 3). Incidence was lower than the previous 5-year average in those aged 45 and older, but higher in those aged 10-19 and less than one (Figure 3).

80 STEC cases were reported in 25 of the 67 counties in Florida.

Prevention To reduce the likelihood of becoming infected with STEC, all meat products should be cooked thoroughly, particularly ground beef. Cross-contamination may be avoided by making sure utensils, counter tops, cutting boards, and sponges are cleaned, or do not come in contact with raw meat. Hands should be thoroughly washed before, during, and after food preparation and after toilet use. The fluids from raw meat should not be allowed to come in contact with other foods. Additionally, it is important to wash hands after coming into contact with any animals or their environment. Particular care should be taken with young children in the settings of petting zoos or when they come in contact with farm animals which harbor the organism.

Summary of Selected Notifiable Diseases and Conditions

STEC cases were reported in 25 of the 67 counties in Florida.

Escherichia coli, Shiga Toxin Producing, Incidence Rate* by County, Florida, 2008

References th David L. Heymann (ed.), Control of Communicable Diseases Manual, 18 ed., American Public Health Association Press, Washington, District of Columbia, 2004. References th DavidAdditional L. Heymann Resources (ed.), Control of Communicable Diseases Manual, 18 ed., American Public DiseaseHealth information Association is available Press, from Washington, the Centers District for Disease of Columbia, Control 2004. and Prevention (CDC) at http:// www.cdc.gov/nczved/dfbmd/disease_listing/stec_gi.html Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/nczved/dfbmd/disease_listing/stec_gi.html

81 Giardiasis

Figure 1. Giardiasis Incidence Rate by Year Reported, Florida, Giardiasis: Crude Data 1999-2008 2008 Florida Morbidity Statistics 12 Number of Cases 1,391 10 2008 incidence rate per GiardiasisGiardiasis 100,000 7.36 8 % change from average 5 Figure 1. year (2003-2007) reported Giardiasis6 Incidence Rate by Year Reported, Florida, Giardiasis:Giardiasis: Crude Crude Data Data 1999-2008 16.64 casesNumber of Cases 1,391 12 Number of Cases 1,391 4 Age (yrs) 100,000 Casesper 20082008 incidence incidence rate rate per per 10 Mean 27.56 2 100,000100,000 7.367.36 Median 24 8 % %change change from from average average 5 5 0 year (2003-2007) reported 6 year (2003-2007)Min-Max reported <1 - 93 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 casescases 16.6416.64 4 Age (yrs) 100,000 Casesper Year Age (yrs) Mean 27.56 2 Mean 27.56 Disease AbstractMedian 24 The incidence rateMedian for giardiasis 24 has declined by 0about half over the nine years from 1999-2008 Min-MaxMin-Max <1 <1 - 93 - 93 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 but increased slightly starting in 2006 (Figure 1). In 2008, there was a 16.64% increase in Year comparison to the 5-year average incidence from 2003 to 2007. A total of 1,391 cases were Disease Abstract reportedDiseaseThe inincidence Abstract2008, rateslightly for giardiasis higher thanhas declined the number by about reported half over thein 2007 nine years (1,268 from cases). 1999-2008 Of the 1,391 casesThebut reported incidence increased inrate slightly 2008, for giardiasis starting 98% were inhas 2006 declined classified (Figure by 1). about as In c2008, halfonfirmed. over there the was nineThe a 16.64%years number from increase 1999-2008of cases in increasesbut in increasedcomparison slightly to the starting 5-year in average2006 (Figure incidence 1). In from 2008, 2003 there to was2007. a 16.64%A total of increase 1,391 cases in comparison were to the summerthe 5-year averageand early incidence fall months from 2003 (Figure to 2007. 2). A Thetotal ofmonth 1,391 casesof July were historically reported in has 2008, the slightly largest numberreported of reported in 2008, casesslightly higher(2003-2007: than the number5-year reportedaverage in 200795.2 (1,268cases cases). per 100,000), Of the 1,391 but in 2008, highercases than reported the number in 2008, reported 98% were in 2007 classified (1,268 as cases). confirmed. Of the The 1,391 number cases of reported cases increases in 2008, 98%in were the largestclassifiedthe summer number as confirmed. and ofearly cases fall The months occurred number (Figure of incases 2).Septem Theincreases monthber in (103of the July summercases) historically andand hasearly July the fall hadlargest months the (Figurefourth 2).highest caseThe count.number month of Inof reported July2008, historically allcases months (2003-2007: has the of largestexcept 5-year number for average January of reported 95.2 andcases cases February per (2003-2007: 100,000), exceeded but 5-year in 2008, average the previous 95.2 5- casesthe largestper 100,000), number but of incases 2008, occurred the largest in September number of (103 cases cases) occurred and inJuly September had the fourth (103 cases)highest and yearJuly average had the numberfourth highest of cases. case count. Among In 2008, the all1, months391 giardiasis of except forcases January reported and February in 2008, exceeded 82, or 5.89%,case were count. reported In 2008, as all outbreakmonths of exceptassociated. for January Over and 70%February of all exceeded reported the casesprevious indicated 5- theyear previous average 5-year number average of cases. number Among of cases. the 1,391 Among giardiasis the 1,391 cases giardiasis reported cases in 2008, reported 82, inor 2008, 82, infectionor 5.89%,5.89%, had werewere been reportedreported acquired asas outbreakoutbreak in Florida. associated.associated. There OverOver were 70%70% 290 ofof allall cases reportedreported that casescases were indicatedindicated reported infection as acquired had outsidebeeninfection ofacquired the had U.S. in been Florida. with acquired 155 There of in wereFlorida.these 290 cases, Therecases were thator 53.8%, were290 casesreported indicating that as were acquired infectionreported outside as was acquired of the acquired U.S. with in Cuba. 155outside of these of thecases, U.S. or with 53.8%, 155 indicatingof these cases, infection or 53.8%, was acquired indicating in Cuba. infection was acquired in Cuba.

Figure 2. Giardiasis CasesFigure by Month 2. of Onset, Florida, 2008 Giardiasis Cases by Month of Onset, Florida, 2008 120 120

100100

8080

60 60 40 Number of Cases Numberof 40

Number of Cases Numberof 20

20 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 0 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 5yr average 2008 Month The highest reported incidence rates continue to 5yroccur average among2008 in children aged 1-4 years (35.63 cases per 100,000) and 5-9 years (15.96 cases per 100,000) (Figure 3). There were a total of TheThe highest313 highest cases reported reported reported incidence incidenceamong children rates rates continue aged continue 1-4 to years. occur to amongApproximatelyoccur inamong children forty in aged percentchildren 1-4 yearsof agedthe (35.63313 1-4 cases years (35.63 casesper per100,000) 100,000) and 5-9 and years 5-9 (15.96 years cases (15.96 per 100,000) cases per(Figure 100,000) 3). There (Figure were a total3). Thereof 313 cases were a total of reported among children aged 1-4 years. Approximately forty percent of the 313 cases aged 1-4 years 313attended cases reporteddaycare. among children aged 1-4 years. Approximately forty percent of the 313

82 Summary of Selected Notifiable Diseases and Conditions cases aged 1-4 years attended daycare.

Figure 3. Giardiasis Incidence Rate by Age Group, Florida, 2008

40 35 30 25 20 15 10 Cases per 100,000 per Cases 5 0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

Overall,Overall, males males continue continue to to have have a higher a higher reported reported incidence incidence than females than (8.58 females and 6.18 (8.58 per 100,000,and 6.18 per 100,000,respectively). respectively). Following previousFollowing annual previous trends, annualincidence trends, rates in incidencewhites are greater rates thanin whites those in are non- greater thanwhites. those in non-whites. In 2008, giardiasis was reported in 61 of the 67 counties in Florida. In 2008, giardiasis was reported in 61 of the 67 counties in Florida. Prevention PreventionMost Giaridia infections can be avoided or reduced by practicing good hand hygiene. This is particularly important in child care centers and after toilet use, before handling food, and before eating. Avoid food Mostand Giaridia swallowing infections water that can might be be avoided contaminated or reduced such as recreationalby practicing water good (ponds, hand lakes, hygiene. etc.) and This is particularlydrinking untreated important water in childfrom shallow care centers wells, lakes, and rivers, after springs, toilet use,ponds, before streams, handling or untreated food, ice. and before eating.Avoid Avoid drinking food tap water and whenswallowing traveling waterin countries that wheremight the be water contaminated may not be adequately such as recreationalfiltered and watertreated. (ponds, Boiling lakes, water etc.) is the and most drinking reliable way untreated to make waterwater safe from for shallowdrinking. Filterswells, and lakes, chemical rivers, springs, disinfection can be effective against Giardia, but the effectiveness of chlorine is dependent on several ponds,factors, streams, including: or pH, untreated temperature, ice. and Avoid organic drinking content tapof the water water. when People traveling with diarrhea in countries caused by where the waterGiardia mayshould not avoid be use adequately of recreational filtered water and venues treated. for two weeksBoiling after water symptoms is the resolve. most reliable way to make water safe for drinking. Filters and chemical disinfection can be effective against Giardia, but the effectiveness of chlorine is dependent on several factors, including: pH, temperature, and organic content of the water. People with diarrhea caused by Giardia should avoid use of recreational water venues for two weeks after symptoms resolve.

83 2008 Florida Morbidity Statistics

References ReferencesDavid L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health David L. HeymannAssociation (ed.), Press, Control Washington, of Communicable District of Columbia, Diseases 2004. Manual , 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004. L.K. Pickering, C.J. Baker, S.S. Long, and J.A. McMillan (eds.), Red Book: 2006 Report of the Committee th L.K. Pickering,on Infectious C.J. Baker, Diseases S.S., 27 Long, ed., andAmerican J.A. McMillan Academy (eds.),of Pediatrics Red Book:Press, 20062006. Report of the Committee on Infectious Diseases, 27th ed., American Academy of Pediatrics Press, Additional Resources Disease2006. information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/ncidod/dpd/parasites/giardiasis/default.htm. Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncidod/dpd/parasites/giardiasis/default.htm.

84 Summary of Selected Notifiable Diseases and Conditions

GonorrheaGonorrhea

DiseaseDisease Abstract Abstract In 2008,In 2008, there there were were 23,237 23,237 gonorrhea gonorrhea cases cases reported reported among among both both males males and andfemales females in Florida, in or a rateFlorida, of 122.9 or cases a rate per of 122.9100,000 cases population. per 100,000 Overall population. cases decreased Overall cases by 8.2% decreased from 2007. by 8.2% Over 48% of allfrom gonorrhea 2007. Overcases 48% are ofreported all gonorrhea from the cases larger, are more reported populous from countiesthe larger, (Duval, more Broward,populous Dade, Hillsborough,counties (Duval, Orange) Broward, and although Dade, certain Hillsborough, counties Orange) bear a andlarger although proportion certain of disease, counties smaller bear a counties absorblarger higher proportion rates (Table of disease, 1). smaller counties absorb higher rates (Table 1).

Figure 1. Reported Cases of Gonorrhea by Year, Florida, 2004-2008

130.15 30,000 124.23 122.9 140 112.25 25,000 105.49 120 100 20,000 80 15,000

Cases 60

10,000 Rate/100,000 40

5,000 20

0 0 2004 2005 2006 2007 2008 Year

Cases Rate/100,000

TableTable 1. 1. Counties Counties with with the the Highest Highest Rate/100,000 Rate/100,000 of of Gonorrhea, Gonorrhea, Florida, Florida, 2008 2008 CountyCounty RankRank PopulationPopulation Cases Cases RateRate per per 100,000 100,000 GadsdenGadsden 11 50,15250,152 262 262 522.4522.4 LeonLeon 22 273,741273,741 1,0501,050 383.6383.6 DuvalDuval 33 908,378908,378 2,6552,655 292.3292.3 Calhoun 4 14,688 40 272.3 Calhoun 4 14,688 40 272.3 Putnam 5 74,903 182 243.0 Putnam 5 74,903 182 243.0

In the urban environment of the U.S. disease incidence can be 20 to 30 times that of In the urban environment of the U.S. disease incidence can be 20 to 30 times that of surrounding areas. surrounding areas. However, in Florida rates of infection are highest in the panhandle and the However,northern in Floridaportion ratesof the of state infection which are are highest some ofin the leastpanhandle populated and theand northern most rural portion portions of the of state whichthe are state some (Figure of the 2). least populated and most rural portions of the state (Figure 2).

MuchMuch like likechlamydia chlamydia trends, trends, gonorrhea gonorrhea cases cases disproportionately disproportionately affect affect those those under under the agethe ageof 25. of Close examination25. Close of examinationthe disease distributionof the disease reveals distribution that over reveals 75% ofthat all over reported 75% casesof all reported of gonorrhea cases are of reportedgonorrhea in populations are reported under in thepopulations age of 30; under further, the gonorrheaage of 30; isfurther, the second gonorrhea most isprevalent the second sexually transmittedmost prevalent bacterial sexually infection transmitted reported among bacterial 15 infectionto 24-year-olds reported in amongFlorida. 15 More to 24-year-olds cases have in been reportedFlorida. in the More 20-24 cases age have group been for gonorrheareported in consistently the 20-24 age since group 1998; for further, gonorrhea 15- toconsistently 24-year-olds accountedsince 1998; for 61% further, of infections 15- to 24-year-olds reported in accounted2008. The forage 61% specific of infections case rate reported for 15- into 2008. 24-year-olds The was 581.6age per specific 100,000 case population. rate for 15- The to mean24-year-olds age of allwas reported 581.6 per gonorrhea 100,000 cases population. was 24.9 The years. mean However,age whenof dataall reported is examined gonorrhea by age cases in single was years24.9 years. for those However, 15-24, ratherwhen datathan isas examined an age group, by age reported in casessingle peaked years at forthe those age of 15-24, 19 with rather a gradual than as decline an age in group,number reported of cases cases as age peaked in years at the increased. age of 19 with a gradual decline in number of cases as age in years increased.

85 2008 Florida Morbidity Statistics

Figure 2. Gonorrhea Rates/100,000, 2008

When comparing gender-specific data in populations under 25, females under the age of 25 accounted for the largest proportion of cases reported (52.6%) (Figure 3). Among females, the highest number of cases was reported in 15- to 19-year-olds (4,546 cases) with a rate of 761.8 per 100,000 population. The second highest rate among females was in 20- to 24-year-olds (690.8 per 100,000 population). Among males, the highest numbers of cases was reported in the 20-24 age group (3,370 cases) with a rate of 539.9 cases per 100,000 population. Men 25-29 had the second highest rate (348.9 per 100,000 population). Unlike chlamydia trends, men aged 25 and over had higher rates compared to women of the same age group. Nevertheless, all cases reported, regardless of gender, occur disproportionately in populations under 25 years of age. One explanation for the higher rates of gonorrhea among men as compared to chlamydia is that a majority of urethral infections with N. gonorrheae cause symptoms that prompt the patient to seek care. This could lead to greater detection of gonorrhea cases among men, not necessarily reflect higher incidence of infection.

In 2008, the distribution of gonorrhea by race/ethnicity disproportionately affected non-Hispanic blacks (Figure 3). Non-Hispanic black adolescents and young adults (15-24) had the highest rates by race/ ethnicity and age group in Florida. In 2008, non-Hispanic blacks age 15-24 had a case rate of 1,833.1 per 100,000 population. This rate was 11 times higher than the second highest rate in non-Hispanic whites 15-24 (163.2 per 100,000 population).

86 Summary of Selected Notifiable Diseases and Conditions

Figure 3. Reported Cases of Gonorrhea by Race/Ethnicity, Gender, Age, 2008

10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 Number of Cases Number 2,000 1,000 0 Female (15-24) Male (15-24) Female (25 +) Male (25 +)

Gender (Age) White Black Hispanic Other

Prevention STD infections in women can lead to complications such as pelvic inflammatory disease (PID). Both symptomaticPrevention and asymptomatic cases of PID can result in tubal scarring that can lead to infertility or ectopicMany pregnancy. infections Because in women gonococcal can lead toinfections complications among such women as pelvicare frequently inflammatory asymptomatic, disease (PID). an essentialBoth component symptomatic of gonorrheaand asymptomatic control in cases the U.S. of PID is screening can result of in women tubal scarring at high thatrisk forcan STDs. lead to The U.S. Preventiveinfertility or Services ectopic pregnancy.Task Force (USPSTF)Because gonococcal recommends infections screening among all sexually women activeare frequently women, includingasymptomatic, those who arean essentialpregnant, component for gonorrhea of gonorrhea infection if control they are in atthe increased U.S. is screening risk. Risk of factors women includeat agehigh <25 risk years,for STDs. a previous The U.S. gonorrhea Preventive infection, Services other Task sexually Force transmitted(USPSTF) recommendsinfections, new or multiplescreening sex partners, all sexually inconsistent active women,condom includinguse, commercial those who sex are work, pregnant, and drug for use.gonorrhea The USPSTF infection does if not recommendthey are at screening increased for risk. men Risk or womenfactors includewho are age at low <25 risk years, for infection.a previous gonorrhea infection, other sexually transmitted infections, new or multiple sex partners, inconsistent condom use, Patientscommercial infected withsex N.work, gonorrhoeae and drug use. are frequently The USPSTF co-infected does not with recommend C. trachomatis screening which for has men led or to the womenrecommendation who are at that low patients risk for infection.treated for gonococcal infection also be treated routinely with a regimen that is effective against Chlamydia. Because the majority of gonococci in the United States Patients infected with N. gonorrhoeae are frequently co-infected with C. trachomatis which has are susceptible to doxycycline and azithromycin (used to treat chlamydia), routine co-treatment might led to the recommendation that patients treated for gonococcal infection also be treated also hinder the development of antimicrobial-resistant N. gonorrhoeae. Due to the prevalence of routinely with a regimen that is effective against Chlamydia. Because the majority of gonococci antimicrobial-resistant N. gonorrhoeae in the U.S. and globally, the treatment recommendations for in the United States are susceptible to doxycycline and azithromycin (used to treat chlamydia), patientsroutine are specific co-treatment to the might site ofalso the hinderinfection, the thedevelopment geographical of antimicrobial-resistant area of exposure, patient N. health status, and othergonorrhoeae factors. .The Due most to the current prevalence treatment of antimicrobial-resistant guidelines can be accessed N. gonorrhoeae from the CDCin the at U.S. http://www. and cdc.gov/std/treatment/default.htm.globally, the treatment recommendations for patients are specific to the site of the infection, the geographical area of exposure, patient health status, and other factors. The most current Gonorrheatreatment cases guidelines continue canto decrease be accessed overall. from However, the CDC someat of the core risk factors for infection correlatehttp://www.cdc.gov/std/treatment/default.htm. to socioeconomic indicators that are often unrecognized in data reporting. Gonorrhea continues to disproportionately impact minority populations and is increasing among MSM (men who have sex with men) Gonorrheapopulations. cases This continuedata suggests to decrease the need overall. for specialized However, interventions some of the coreand resourcesrisk factors for for these populations.infection Additionally, correlate to the socioeconomic sustained number indicators of cases that arein youth often andunrecognized young adult in populationsdata reporting. indicates that theseGonorrhea populations continues are participating to disproportionately in behaviors impact that minority put them populations at risk for STDsand is in increasing general, includingamong HIV. ToMSM further (men understand who have thesex contributorywith men) populations. causes and Thisrisk factorsdata suggests for acquisition the need of disease,for specialized accurate, timely,interventions and comprehensive and resources reporting for andthese disease populations. investigation Additionally, must continue. the sustained Additionally, number clusters of cases of infection must be understood.

87 2008 Florida Morbidity Statistics

References Centers for Disease Control and Prevention. “Gonorrhea- CDC Fact Sheet.” Atlanta, GA: U.S. Department of Health and Human Services, April 2006.

Nelson KE, Williams CM, Graham NMH (Eds.). Infectious Disease Epidemiology: Theory and Practice. Gaithersburg, Md, Aspen Publishers, 2001.

Centers for Disease Control and Prevention. “Sexually Transmitted Diseases Treatment Guidelines, 2006.” MMWR, 2006, Vol. 55, No. RR-11, pp. 42-49.

HaemophilusHaemophilus influenzae influenzae (Invasive (Invasive Disease)Disease) Haemophilus influenzae (Invasive Disease)Figure 1. Haemophilus influenzae , Invasive Disease, Incidence Haemophilus influenzae Figure 1. Rate by Year Reported, Florida, 1999-2008 (InvasiveHaemophilusHaemophilus Disease): influenzae influenzae Crude Data 1.0 Haemophilus influenzae , Invasive Disease, Incidence Rate by Year Reported, Florida, 1999-2008 Number(Invasive(Invasive of Cases Disease): Disease): Crude Crude Data 162Data 1.0 Number of Cases 162 0.8 2008Number incidence of Cases rate per 162 0.8 2008100,0002008 incidence incidence rate rate per per 0.86 0.6 100,000 %100,000 change from average 5- 0.860.86 0.6 %year change% change(2003-2007) from from average average incidence 5- 0.4

31.62 100,000 per Cases 5-yearrateyear (2003-2007) (2003-2007) incidence incidence 0.4

rate 31.62 100,000 per Cases rateAge (yrs) 31.62 0.2 Age (yrs) Mean 54.06 0.2 Age (yrs) Mean 54.06 MeanMedian 54.06 62 0.0 Median 62 0.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 MedianMin-Max <162 - 100 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max <1 - 100 Year Min-Max <1 - 100 Year Disease Abstract TheDisease incidence Abstract rate for all invasive diseases caused by Haemophilus influenzae has gradually DiseaseincreasedThe incidence Abstract over therate past for all ten in yearsvasive (Figure diseases 1). caused In 2008, by Haemophilusthere was a 31.62% influenzae increase has gradually compared increased over the past ten years (Figure 1). In 2008, there was a 31.62% increase compared Theto theincidence average rate incidence for all invasive from 2003 diseases to 2007. caused A totalby Haemophilus of 162 cases influenzae were reported has gradually in 2008, increased all of to the average incidence from 2003 to 2007. A total of 162 cases were reported in 2008, all of overwhich the were past tenclassified years (Figureas confirmed. 1). In 2008, The therenumbe wasr of a cases 31.62% reported increase is comparedhighest in tothe the winter, average which were classified as confirmed. The number of cases reported is highest in the winter, incidenceduring the from months 2003 toof 2007.December A total through of 162 Februarycases were (Figure reported 2). in In 2008, 2008, all the of numberwhich were of cases classified during the months of December through February (Figure 2). In 2008, the number of cases assignificantly confirmed. exceeded The number the ofprevious cases reported 5-year averageis highest in in most the monthswinter, during of the the year. months Nearly of Decemberall cases throughsignificantly February exceeded (Figure 2).the Inprevious 2008, the5-year number average of cases in most significantly months of exceededthe year. theNearly previous all cases 5-year ofof invasive invasive disease disease caused caused by by Haemophilus Haemophilus influenzae areare sporadicsporadic in in nature. nature. average in most months of the year. Nearly all cases of invasive disease caused by Haemophilus influenzae are sporadic in nature. Figure 2. HaemophilusHaemophilus influenzaeinfluenzae,, Invasive Disease,Disease, CasesCases by by Month Month of of Onset, Florida, 2008 1616 Onset, Florida, 2008

1414

1212

1010

8 8

6 6 Number of CasesNumber of Number of CasesNumber of 4 4

2 2

0 0 JanJan Feb Feb Mar Mar Apr Apr May Jun Jul Jul Aug Aug Sep Sep Oct Oct Nov Nov Dec Dec Month 5yr average 2008 5yr average 2008

The highest reported incidence rates occur in those aged <1 year or in those >85 years (Figure 88 The highest reported incidence rates occur in those aged <1 year or in those >85 years (Figure 3).3). In In 2008, 2008, the the incidence incidence rates rates werewere higherhigher than the previousprevious 5-year 5-year average average in in all all age age groups groups except those 5-9, 15-19, and 35-44 years. The incidence of disease in males and females does except those 5-9, 15-19, and 35-44 years. The incidence of disease in males and females does not differ significantly (0.76 per 100,000 and 0.95 per 100,000 respectively). As in the past, not differ significantly (0.76 per 100,000 and 0.95 per 100,000 respectively). As in the past, incidence rates in non-whites are greater than those in whites with the highest incidence being incidence rates in non-whites are greater than those in whites with the highest incidence being in non-white males (1.24 per 100,000). in non-white males (1.24 per 100,000).

Summary of Selected Notifiable Diseases and Conditions

The highest reported incidence rates occur in those aged <1 year or in those >85 years (Figure 3). In 2008, the incidence rates were higher than the previous 5-year average in all age groups except those 5-9, 15-19, and 35-44 years. The incidence of disease in males and females does not differ significantly (0.76 per 100,000 and 0.95 per 100,000 respectively). As in the past, incidence rates in non-whites are greater than those in whites with the highest incidence being in non-white males (1.24 per 100,000).

Figure 3. Haemophilus influenzae , Invasive Disease, Incidence Rate by Age Group, Florida, 2008 6

2 Cases per 100,000 per Cases

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

InvasiveInvasive disease disease causedcaused by by Haemophilus Haemophilus influenzae influenzae was reported was inreported half (33) ofin thehalf 67 (33) counties of the in 67 counties in Florida.Florida. Overall, Overall, counties counties in central in central and southwestern and southwestern Florida reported Florida the highestreported incidence the highest rates. incidence rates.Invasive disease caused by Haemophilus influenzae b in those under age five: In 2008, there was one case of invasive disease (meningitis) caused by Haemophilus influenzae serotype Invasiveb in a child disease under age caused 5 that resulted by Haemophilus in death. influenzae b in those under age five: In 2008, there was one case of invasive disease (meningitis) caused by Haemophilus influenzae Prevention serotypeA conjugate b in vaccinea child series under against age 5Haemophilus that resulted influenzae in death. type B (Hib) is recommended by the Advisory Committee on Immunization Practices for infants and children, birth to five years of age. A Preventionfull series is four doses, but the recommended number of doses varies by age and immunization Conjugatehistory. As vaccines of January against 2009, the Haemophilus age-appropriate influenzae number of doses, type orb (Hib)valid exemption, for infants is requiredand children for are recommendedentry and attendance by the at Advisory childcare facilities.Committee Additional on Immunization information may Practices. be found at http://www.cdc.gov/Additional information mmwr/preview/mmwrhtml/rr4805a1.htm and http://www.cdc.gov/vaccines/ recs/schedules/downloads/ maychild/2007/child-schedule-color-print.pdf be found at http://www.cdc.gov/mmw r/preview/mmwrhtml/rr4805a1.htm and http://www.cdc.gov/vaccines/ recs/schedules/downloads/child/2007/child-schedule-color- print.pdf

89 2008 Florida Morbidity Statistics

Haemophilus influenzae Invasive Disease Incidence Rate* by County, Florida, 2008

References DavidReferences L. Heyman (Ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health DavidAssociation L. Heyman Press, (Ed.), Washington, Control of District Communicable of Columbia, Diseases2004, p. 366. Manual , 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004, p. 366. Additional Resources Additional information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/ncidod/dbmd/diseaseinfo/haeminfluserob_t.htmAdditional Resources and http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr4805a1.htmAdditional information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/haeminfluserob_t.htm and Immunizationhttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr4805a1.htm Recommendations are available from: Centers for Disease Control and Prevention, “Haemophilus b Conjugate Vaccines for Prevention of ImmunizationHaemophilus Recommendations influenzae Type b Disease are available Among Infantsfrom: and Children Two Months of Age and CentersOlder. for Recommendations Disease Control of and the Prevention,ACIP,” Morbidity “Haemophilus and Mortality Weeklyb Conjugate Report ,Vaccines Vol. 40, (RR01); for pp.1-7. http://www.cdc.gov/mmwr/preview/mmwrhtml/00041736.htm. Prevention of Haemophilus influenzae Type b Disease Among Infants and Children Two Months of Age and Older. Recommendations of the ACIP,” Morbidity and Mortality Weekly Report, Vol. 40, (RR01); pp.1-7. http://www.cdc.gov/mmwr/preview/mmwrhtml/00041736.htm.

90 Hepatitis A Figure 1. Hepatitis A Incidence Rate by Year Reported, Florida, 1999- Hepatitis A: Crude Data Summary of Selected Notifiable Diseases and Conditions 2008

Number of Cases 165 7 2008 incidence rate per Hepatitis6 A Hepatitis A 100,000 0.87 5

% change from average 5-year Figure 1. Hepatitis4 A Incidence Rate by Year Reported, Florida, 1999- Hepatitis A: Crude Data (2003-2007)Hepatitis incidence A: Crude rate Data -43.36 3 2008 AgeNumber (yrs) of Cases 165 Number of Cases 165 7 2 2008 incidence rateMean per 40.82 Cases per 100,000 2008 incidence rate per 6 1 100,000 100,000 Median 0.870.87 41 5 0 % change from average 5-year % change from averageMin-Max 5-year 1 - 88 4 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 (2003-2007) incidence rate -43.36 (2003-2007) incidence rate -43.36 3 Year AgeAge (yrs)(yrs) 2 Disease AbstractMeanMean 40.8240.82 Cases per 100,000 1 A total of 165 casesMedianMedian of hepatitis 41A41 were reported in 2008, of which 88.48% were classified as Min-Max 1 - 88 0 confirmed. ApproximatelyMin-Max 38.8% 1 - 88 of hepatitis A1999 cases 2000 were 2001 2002hospitalized. 2003 2004 2005 Approximately 2006 2007 2008 11% of cases were classified as outbreak-related and only 15% reported contactYear with a person with confirmedDiseaseDisease Abstract or suspected hepatitis A infection in the 2-6 weeks prior to their illness. ApproximatelyAA total ofof 165165 casescases 35% of of ofhepatitis hepatitis cases A Awerereported were reported report a traveled in 2008,in 2008, history of whichof which outside 88.48% 88.48% thewere wereU.S. classified classified and Canadaas confirmed.as in the 2-6 weeksconfirmed.Approximately prior Approximately to 38.8% their ofillness; hepatitis 38.8% additionally, A ofcases hepatitis were 23%Ahospitalized. cases of werecases Approximately hospitalized. reported that 11%Approximately ofsom caseseone were 11% in classifiedtheir of household hadcasesas outbreak-relatedtraveled were classified outside and as of only outbreak-related the 15% U.S. reported or Canada. contactand only with Four15% a person reported cases with werecontact confirmed associated with aor personsuspected with with daycare hepatitis Acenters confirmedinfection in orthe suspected 2-6 weeks hepatitis prior to their A infection illness. inApproximately the 2-6 weeks 35% prior of casesto their reported illness. a travel history outside andApproximatelythe twoU.S. casesand Canada 35% were of in reportedcases the 2-6 reported weeks in food-handlers. prior a travel to their history illness; outside The additionally, incidence the U.S. 23% and rate of Canada cases for hepatitis reported in the 2-6 that A insomeone Florida has declinedweeksin their priorhousehold markedly to their had illness; since traveled additionally,2002, outside which of 23%the mirrors U.S. of cases or Canada.a similarreported Four decline that cases someone observedwere associatedin their nationally household with daycare (Figure 1). Thehadcenters annual traveled and twoincidence outside cases of were the in FloridaU.S.reported or Canada. fromin food-handlers. 2004 Four to cases 2008 The were incidencewas associated around rate for 1-2with hepatitis cases daycare A perin centers Florida 100,000. has This is a substantialanddeclined two casesmarkedly decrease were since reported from2002, theinwhich food-handlers. annual mirrors incidence a similar The declineincidence of 4-6 observed casesrate for nationally perhepatitis 100,000 (Figure A in Florida observed 1). The has annual between 1998declinedincidence and markedly in2002. Florida The sincefrom decrease 20042002, to which 2008 in mirrorswasFlorida, around a similar and 1-2 natiocases declinenally, per observed 100,000. is likely nationally This due is a to substantial (Figure increased 1). decrease use of The annual incidence in Florida from 2004 to 2008 was around 1-2 cases per 100,000. This is a vaccinesfrom the annualto protect incidence against of 4-6 hepatitis cases per A100,000 virus, observed which first between became 1998 commerciallyand 2002. The decrease available in in 1995. substantialFlorida, and decrease nationally, from is likely the dueannual to increased incidence use of 4-6of vaccines cases per to protect100,000 against observed hepatitis between A virus, which first 1998became and commercially 2002. The decreaseavailable inin 1995. Florida, and nationally, is likely due to increased use of vaccines to protect against hepatitis A virus, which firstFigure became 2. commercially available in 1995. Hepatitis A Cases by Month of Onset, Florida, 2008 45 Figure 2. Hepatitis A Cases by Month of Onset, Florida, 2008 40 45 35 40 35 30

30 25 25 20 20 15

15CasesNumber of

Number of CasesNumber of 10 10 5 5 0 0 JanJan Feb Feb Mar Mar Apr May Apr Jun May Jul Jun Aug Jul Sep Aug Oct SepNov Dec Oct Nov Dec Month Month 5yr average 2008 5yr average 2008

Hepatitis A occurs throughout the year (Figure 2). In 2008, incidence rates were lower than the previous Hepatitis A occurs throughout the year (Figure 2). In 2008, incidence rates were lower than the Hepatitis5-year average A occurs in all throughout age groups (Figurethe year 3). (FigureThe largest 2). decrease In 2008, in incidence incidence was rates observed were loweramong than the previouschildren 55-year to 9 years average old andin all adults age groups 20 to 24 (Figur yearse 3). old. The The largest incidence decrease in 2008 in incidencewas lowest was among non- previouswhite females 5-year (0.21 average per 100,000) in all andage highest groups among (Figure white 3). males The (0.96 largest per decrease100,000). in incidence was

During 2008, hepatitis A was reported in 31 of the 67 counties in Florida.

91 observed among children 5 to 9 years old and adults 20 to 24 years old. The incidence in 2008 was lowest among non-white females (0.21 per 100,000) and highest among white males (0.96 per 100,000).

During 2008, hepatitis A was reported in 31 of the 67 counties in 2008Florida. Florida Morbidity Statistics

Figure 3. Hepatitis A Incidence Rate by Age Group, Florida, 2008

Cases per 100,000 per Cases 1

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

PreventionPrevention Currently,Currently, the the single antigen, antigen, two-dose two-dose hepatitis hepatitis A vaccine A isvaccine recommended is recommended as part of the routine as part of the immunization schedule for all children, starting at age one. However, this is not a requirement for routinechildcare immunization or school entry schedule in Florida. for The all doses children, should starting be spaced at at age least one. six months However, apart. thisA combined is not a requirementhepatitis A and for hepatitis childcare B vaccine or school is available entry forin adultsFlorida. >18 Theyears doses old, and should is administered be spaced in three at least six monthsdoses. apart. In addition A combined to routine childhood hepatitis immunization, A and hepatitis hepatitis B A vaccine vaccine isis also available recommended for adults for those >18 years old,at andincreased is administered risk of infection, in includingthree doses. those traveling In addition to developing to routine countries, childhood men who immunization, have sex with hepatitis A vaccinemen (MSM), is also injection recommended and non-injection for drug those users, at increasedand persons riskwith ofa clotting infection, factor including disorder. those traveling to developingOther efforts to countries, prevent hepatitis men Awho infection have should sex wifocusth menon disrupting (MSM), transmission injection andthrough non-injection good drug users,personal and hygiene, persons hand with washing, a clotting and washingfactor disorder.fruits and vegetables before eating. Illness among food- handlers or persons in a childcare setting should be promptly identified and reported to prevent further Otherspread efforts of the to disease prevent in those hepatitis settings. A infection In outbreak should settings, focus immune-globulin on disrupting may betransmission administered tothrough at-risk contacts of infected individuals, particularly children <1 year and adults over age 40. Recently goodupdated personal guidelines hygiene, based handon results washing, from a clinical and washing trial, recommend fruits andvaccine vegetables for post-exposure before eating. Illness amongprophylaxis food-handlers in healthy individuals or persons between in a 1childcare and 40 years setting old. Allshould post-exposure be promptly prophylaxis identified should and be reportedadministered to prevent within two further weeks spread of exposure. of the disease in those settings. In outbreak settings, immune-globulin may be administered to at-risk contacts of infected individuals, particularly children <1 year and adults over age 40. Recently updated guidelines based on results from a clinical trial, recommend vaccine for post-exposure prophylaxis in healthy individuals between 1 and 40 years old. All post-exposure prophylaxis should be administered within two weeks of exposure.

92 Summary of Selected Notifiable Diseases and Conditions

References CentersReferences for Disease Control and Prevention, “Prevention of Hepatitis A through Active or Passive CentersImmunization: for Disease Recommendations Control and Prevention, of the “PreventionAdvisory Committee of Hepatitis on AImmunization through Active Practices or (ACIP),” MMWRPassive 2006; Immunization: 55(RR07); pp1-23. Recommendations of the Advisory Committee on Immunization Practices (ACIP),” MMWR 2006; 55(RR07); pp1-23.

Centers for Disease Control and Prevention, “Update: Prevention of hepatitis A after exposure to hepatitis Centers for Disease Control and Prevention, “Update: Prevention of hepatitis A after exposure A virus and in international travelers. Updated recommendations of the Advisory Committee on to hepatitis A virus and in international travelers. Updated recommendations of the Immunization Practices (ACIP),” MMWR 2007; 56(41); pp1080-84. Advisory Committee on Immunization Practices (ACIP),” MMWR 2007; 56(41); pp1080- 84. Centers for Disease Control and Prevention, “Summary of Notifiable Diseases-United States, 2006,”

MMWR 2006; 55(53). Centers for Disease Control and Prevention, “Summary of Notifiable Diseases-United States, 2006,” MMWR 2006; 55(53). Additional Resources DiseaseAdditional information Resources is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/NCIDOD/diseases/hepatitis/a/index.htm.Disease information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/NCIDOD/diseases/hepatitis/a/index.htm.

93 2008 Florida Morbidity Statistics

Hepatitis B (HBsAg + Pregnant Women) Hepatitis B (HBsAg + Pregnant Women)

Hepatitis B (HBsAg + Pregnant Figure 1. Hepatitis B (HBsAg + Pregnant Hepatitis B (HBsAg + Pregnant Women) Incidence Rate by Year Women): Crude Data 20 Reported, Florida, 1999-2008 Number of CasesWomen): Crude Data599 Number of Cases 599 2008 incidence rate per 15 2008 incidence rate per 100,000 15.69 100,000 15.69 10 % change% change from from average average 5- 5-yearyear (2003-2007) (2003-2007) incidence incidence raterate 5.325.32 Cases per 100,000 5 Age Age(yrs) (yrs) MeanMean 28.64 28.64 0 MedianMedian 29 29 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Min-MaxMin-Max 14 - 1451 - 51

Disease Abstract DiseaseThere Abstract were 599 pregnant women that tested positive for the hepatitis B surface antigen There(HBsAg+) were 599 in pregnant2008, which women is a decreasethat tested from positive 644 womenfor the hepatitis in 2007. B In surface 2008, oneantigen Florida-born (HBsAg+) in 2008,infant which was is identifieda decrease as from a perinatal 644 women case ofin hepatitis2007. In B2008, (disease one Florida-borncode 07744) infantand was was identified identified as a perinatalby post-vaccination case of hepatitis blood B (disease testing. code This 07744)is a de creaseand was from identified the two infantsby post-vaccination identified as perinatalblood testing. Thishepatitis is a decrease B cases from in 2007.the two infants identified as perinatal hepatitis B cases in 2007.

PreventionPrevention HepatitisHepatitis B immune B immune globulin globulin (HBIG) (HBIG) is prepared is prepared from from human human plasma plasma known known to contain to contain a high a high titer of antibodytiter of to antibody HBsAg (anti-HBs). to HBsAg (anti-HBs). A regimen combiningA regimen HBIGcombining and hepatitisHBIG and B hepatitisvaccine is B 85%-95%vaccine is effective in preventing85%-95% HBV effective infection in preventing when administered HBV infection at birth when to administeredinfants born to at HBsAg+ birth to infantsmothers. born HBIG to and the firstHBsAg+ dose mothers. of hepatitis HBIG B vaccine and the shouldfirst dose be ofadministered hepatitis B vaccinewithin 12 shouldhours beof birth.administered The second within dose should12 hoursbe given of birth.at one The month second of age dose and should the third be dosegiven at at six one months month ofof age.age and Dose the three third of dose hepatitis at B vaccinesix months should ofnot age. be given Dose before three ofsix hepatitis months Bof vaccineage. These should infants not be should given have before serologic six months testing of at 9-15age. months These of age infants to determine should have if a serologicprotective testing antibody at 9-15response months developed of age to after determine vaccination. if a Infants whoprotective do not respond antibody to theresponse primary developed vaccination after series vacc shouldination. be Infants given threewho do additional not respond doses to ofthe hepatitis B vaccineprimary in vaccination a 0, 1-2, 4-6 series month should schedule, be given and threehave theadditional HBsAg doses and anti-HBs of hepatitis blood B vaccinetests repeated in a 0, to determine1-2, 4-6 response. month schedule, Vaccine and for childrenhave the and HBsAg adults and is anti-HBsavailable bloodin combination tests repeated vaccines. to determine response. Vaccine for children and adults is available in combination vaccines. References CentersReferences for Disease Control and Prevention, Manual for the Surveillance of Vaccine-Preventable CentersDiseases for Disease, 4th ed., Control 2008, Chapter and Prevention, 4. Manual for the Surveillance of Vaccine- Preventable Diseases, 4th ed., 2008, Chapter 4. Centers for Disease Control and Prevention, “A comprehensive immunization strategy to eliminate Centerstransmission for Disease of hepatitis Control Band virus Prevention, infection in“A thecomprehensive United States: immunization recommendations strategy of tothe Advisory Committeeeliminate on transmissionImmunization of Practices hepatitis (ACIP);B virus infectionPart 1: Immunization in the United of States: Infants, Children, and Adolescents,”recommendations Morbidity of and the MortalityAdvisory WeeklyCommittee Report on ,Immunization Vol. 54, No. RR-16, Practices 2005. (ACIP); Part 1: Immunization of Infants, Children, and Adolescents,” Morbidity and Mortality Weekly Centers for ReportDisease, Vol. Control 54, No. and RR-16, Prevention, 2005. “A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States Recommendations of the Advisory CentersCommittee for Disease on Immunization Control and Practices Prevention, (ACIP) “A Comprehensive Part II: Immunization Immunization of Adults,” Strategy Morbidity to and MortalityEliminate Weekly Transmission Report, Vol. of 55, Hepatitis No. RR-16, B Virus 2006. Infection in the United States Recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II:

94 Summary of Selected Notifiable Diseases and Conditions

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/vaccines/vpd-vac/hepatitis/default.htmHepatitis B, Acute

Recommended immunization schedule is available at: http://www.cdc.gov/vaccines/recs/ schedules/ default.htm. Figure 1. Hepatitis B, Acute Incidence Rate by Year Reported, Hepatitis B, Acute: Crude Data Florida, 1999-2008 Hepatitis B,4.0 Acute Number of Cases 358 Hepatitis3.5 B, Acute

2008 incidence rate per 3.0 Figure 1. 100,000Hepatitis B, Acute: Crude Data1.89 Hepatitis B, Acute Incidence Rate by Year Reported, Hepatitis B, Acute: Crude Data 2.5 Florida, 1999-2008 % changeNumber from of Cases average 5- 358 4.0 Number of Cases 358 3.52.0 year 2008(2003-2007) incidence incidence rate per rate 2008 incidence rate per -31.27 3.0 100,000 1.89 1.5 100,000 1.89 100,000 per Cases Age (yrs) 2.5 %% changechange fromfrom averageaverage 5- 1.0 Mean 42.34 2.0 5-yearyear (2003-2007) (2003-2007) incidence incidence 0.5 raterate Median -31.27-31.27 41 1.5

Cases per 100,000 per Cases 0.0 AgeAge (yrs)(yrs) Min-Max 18 - 85 1.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 MeanMean 42.34 42.34 0.5 Year MedianMedian 41 41 Min-MaxMin-Max 18 18 -- 8585 0.0 Disease Abstract 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

The incidence rate for acute Hepatitis B has declined gradually over theYear last ten years (Figure

1). TheDiseaseDisease 2008 AbstractAbstract rate was 31.27% lower than the average from 2003-2007. A total of 358 cases wereTheThe reported incidenceincidence in 2008, raterate forfor of acuteacute which HepatitisHepatitis 96.09% BB hashas were declineddeclined classified graduallygradually as confirmed. overover thethe lastlast tenThereten yearsyears is (Figureno(Figure seasonal 1). The trend20081). for The acuterate 2008 was hepatitis rate31.27% was Blower 31.27% infection than lower the (Figure averagethan the 2). fromaverage Overall, 2003-2007. from 91.89% 2003-2007. A total of theof A358 acutetotal cases of hepatitis358 were cases reported B cases in were2008,were classified reportedof which as in96.09% sporadic. 2008, wereof which classified 96.09% as were confirmed. classified Thereas confirmed. is no seasonal There trend is no forseasonal acute hepatitis B infectiontrend for (Figureacute hepatitis 2). Overall, B infection 91.89% (Figure of the 2).acute Overall, hepatitis 91.89% B cases of the were acute classified hepatitis as B sporadic. cases were classified as sporadic. Figure 2. Hepatitis B, Acute Cases by Month of Onset, Florida, 2008 Figure 2. 50 Hepatitis B, Acute Cases by Month of Onset, Florida, 2008 45 50 40 45 35 40 30 35 30 25 25 20 20

Number of CasesNumber of 15

Number of CasesNumber of 15 10 10 5 5 0 0 JanJan Feb Feb Mar Mar Apr Apr May May Jun Jun Jul Jul Aug Aug Sep Sep Oct OctNov Dec Nov Dec Month Month 5yr average 2008 5yr average 2008

The highest historical incidence rates occurred in the 25 to 34-year-old age group, and for 2008 the The highest historical incidence rates occurred in the 25 to 34-year-old age group, and for 2008 incidence rate in this group was high, but the highest incidence was among those aged 35-44 which was The highestthe incidence historical rate in incidence this group wasrates high, occurred but the inhighest the 25 incidence to 34-year-old was among age those group, aged and 35- for 2008 the same for 2007. In 2008, the incidence rates were lower than the previous 5-year average in all age the incidence44 which was rate the in samethis group for 2007. was In high, 2008, but the theincidence highest rates incidence were lower was than among the previous those 5-aged 35- groups (Figure 3). The incidence of Hepatitis B is lowest in people <19 years of age. Rates have always year average in all age groups (Figure 3). The incidence of Hepatitis B is lowest in people <19 44 whichbeen lowwas in the children, same and for are 2007. even Inlower 2008, with the widespread incidence immunization. rates were Maleslower continuethan the to previous have a higher 5- years of age. Rates have always been low in children, and are even lower with widespread yearincidence average thanin all females age groups (2.53 per (Figure 100,000 3). and The 1.28 incidence per 100,000, of Hepatitis respectively). B is lowest in people <19 yearsimmunization. of age. Rates Males have continue always to beenhave a low higher in children,incidence andthan arefemales even (2.53 lower per with100,000 widespread and 1.28 per 100,000, respectively). immunization. Males continue to have a higher incidence than females (2.53 per 100,000 and 1.28 per 100,000, respectively). 95 2008 Florida Morbidity Statistics

Figure 3. Hepatitis B, Acute Incidence Rate by Age Group, Florida, 2008

Cases per 100,000 per Cases 2

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

HepatitisHepatitis B Bis is a a vaccine-preventable vaccine-preventable disease. disease. Among Among the 358 the people 358 diagnosed people diagnosed with acute hepatitis with acute B, hepatitis68.2 % B,never 68.2 received % never the vaccinereceived and the 26.26% vaccine have and unknown 26.26% vaccine have status. unknown This demonstrates vaccine status. the This demonstratesimportance of the vaccination importance campaigns of vaccination to eliminate campaignhepatitis B ins tothe eliminate U.S. The symptomshepatitis ofB acutein the viral U.S. The hepatic illness may prompt individuals to seek immediate medical attention. Approximately 56.7% of symptomsthose diagnosed of acute with viral acute hepatic hepatitis illness B were may hospitalized. prompt individualsIn 2008, death to occurred seek immediate in one of the medical 358 attention.people with Approximately acute hepatitis 56.7%B infection. of those Twenty-nine diagnosed of the 368with people acute with hepatitis acute hepatitis B were B hospitalized.reported In 2008,having death had occurredcontact with in someone one of theconfirmed 358 people or suspected with acute of having hepatitis a hepatitis B infection. B infection, Twenty-nineand of these, of the 76%368 reported people thewith ill personacute washepatitis a sexual B reportedpartner. Drug having use has had also contact been associated with someone with hepatitis confirmed B or suspectedinfection. of Of having the 358 aacute hepatitis hepatitis B Binfection, cases, 9.5% and reported of these, injection 76% drug reported use and the 19.6% ill person reported was using a street drugs but not injection drug use. Hepatitis B infection has also been associated with improper sexualsterilization partner. or sharing Drug useof needles has also to create been tattoos. associated In 2008, with 9.5% hepatitis of those withB infection. an acute hepatitis Of the B358 acute hepatitisinfection B hadcases, recently 9.5% received reported a tattoo. injection drug use and 19.6% reported using street drugs but not injection drug use. Hepatitis B infection has also been associated with improper sterilization or sharingSexual behavior of needles may placeto create an individual tattoos. at riskIn 2008,for hepatitis 9.5% B ofinfection. those withHowever, an acute individuals hepatitis may often B infectiondecline had to comment recently on received the frequency a tattoo. of sexual partners and/or their sexual preference. For 2008, sexual preference and frequency of sexual partnerships are summarized in Table 2. People’s risk factors may change over time. Sexual behavior may place an individual at risk for hepatitis B infection. However, individuals mayAcute often hepatitis decline B wasto comment reported in on47 ofthe the frequency 67 counties of in sexualFlorida. partners A cluster of and/or high-rate their counties sexual can be preference.seen in the Forcenter 2008, of the sexual state and preference along the northern and frequency border. of sexual partnerships are summarized in Table 2. People’s risk factors may change over time.

Acute hepatitis B was reported in 47 of the 67 counties in Florida. A cluster of high-rate counties can be seen in the center of the state and along the northern border.

Summary of Selected Notifiable Diseases and Conditions

Table 2. Distribution of the Number of Sexual Partners in the Six Months Prior to Symptoms in Four Table 2. DistributionSexual Preference of the Number Groups, of forSexual People Partners with Acute in the Hepatitis Six Months B Reported Prior to Symptomsin 2008. in Four Sexual Sexual Behavior RiskPreference Groups,Men having for People Men with having Acute sex Hepatitis Women B Reported having in 2008.Women having FactorsSexual Behavior Risk sex withMen men* having withMen women* having sexsex Womenwith men* having sex withWomen women* having 1 SexualFactors Partner sex with4% men* with29% women* sex with42% men* sex with 2%women* 2-5 Sexual1 Sexual Partners Partner 6% 4% 16% 29% 19% 42% 0% 2% 2-5 Sexual Partners 6% 16% 19% 0% More than 5 Sexual Partners 3% 3% 3% 0% More than 5 Sexual Partners 3% 3% 3% 0% No Reported Sexual 55% 23% 13% 74% PartnersNo Reported Sexual 55% 23% 13% 74% Not AnsweredPartners 3% 1% 2% 4% UnknownNot Answered 29% 3% 28% 1% 21% 2% 20% 4% Total 100% 100% 100% 100% Unknown 29% 28% 21% 20% % of Cases in Each Sexual 12% 48% 64% 2% PreferenceTotal Group† 100% 100% 100% 100% * Total% number of Cases of acute in hepatitisEach Sexual B positive males is 234 and12% females is 123. One48% person identified themselves64% as unknown. In 2% 2008,Preference all 358 acute Group cases †of hepatitis B occurred in individuals 18 years of age and older. † Sexual history is collected by asking about the number of sexual partnerships in the last 6 months prior to having symptoms, * Totalregardless number of gender.acute hepatitis B positive males is 234 and females is 123. One person identified themselves as unknown. In 2008, all 358 acute cases of hepatitis B occurred in individuals 18 years of age and older. † Sexual history is collected by asking about the number of sexual partnerships in the last 6 months prior to having symptoms, regardless of gender.

Prevention Hepatitis B vaccines are available to protect against hepatitis B virus infection. In addition, in health care settings, universal precautions should be implemented for individuals in contact with body fluids. High- risk groups for infection include drug users who share needles, healthcare workers who have contact with infected blood, MSM (men who have sex with men), people who have multiple sexual partners, household contacts of infected persons, and infants born to mothers who are hepatitis B carriers.

97 2008 Florida Morbidity Statistics

References Centers for Disease Control and Prevention, “A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States,” Morbidity and Mortality Weekly Report, Vol. 55, No. RR16, pp. 1-25.

Centers for Disease Control and Prevention, “Incidence of Acute Hepatitis B-United States, 1990-2002,” Morbidity and Mortality Weekly Report, Vol. 52, 2004, pp. 1252-1254.

Centers for Disease Control and Prevention, “Surveillance for Acute Viral Hepatitis-United States, 2005,” Morbidity and Mortality Weekly Report, Vol. 56, No. SS03, 2007, pp. 1-24.

Centers for Disease Control and Prevention, “Update: Recommendations to Prevent Hepatitis B Virus Transmission-United States,” Morbidity and Mortality Weekly Report, Vol. 48, 1999, pp. 33-34.

Centers for Disease Control and Prevention, “Hepatitis B Vaccination-United States, 1982-2002,” Morbidity and Mortality Weekly Report, Vol. 51, 2002, pp. 549-52, 563.

J.T. Redd, J. Baumbach, W. Kohn, et al, “Patient-to Patient Transmission of Hepatitis B virus Associated with Oral Surgery,” Journal of Infectious Diseases, Vol. 195, 2007, pp. 1311-1314.

American Academy of Pediatrics, Red Book 2003: Report of the Committee on Infectious Diseases, 26th ed., American Academy of Pediatrics Press, Elk Grove Village, Illinois, 2003.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) website at http://www.cdc.gov/ncidod/diseases/hepatitis/b/index.htm and http://www.cdc.gov/ncidod/diseases/ hepatitis/recs/index.htm

Disease information is also available from the World Health Organization (WHO) website at http://www. who.int/mediacentre/factsheets/fs204/en/

98 Hepatitis C, Acute

Summary of Selected Notifiable Diseases and Conditions Figure 1. Hepatitis C, Acute Incidence Rate by Year Reported, Hepatitis C, Acute: Crude Data 0.6 Florida, 1999-2008 Hepatitis C, Acute Number of Cases 53 Hepatitis C, Acute 2008 incidence rate per 0.4 Figure 1. 100,000Hepatitis C, Acute: Crude Data0.28 Hepatitis C, Acute Incidence Rate by Year Reported, Hepatitis C, Acute: Crude Data Florida, 1999-2008 % changeNumber from of Cases average 5- 53 0.6 year (2003-2007)Number of incidence Cases 53 2008 incidence rate per 0.2 rate 2008 incidence rate per -1.43 100,000 per Cases 100,000 0.28 0.4 Age (yrs) 100,000 0.28 % change% change from averagefrom average 5- 5-year (2003-2007)Mean incidence 39.13 year (2003-2007) incidence 0.0 rate Median -1.43 41 0.2 rate -1.43 100,000 per Cases 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Age (yrs)Min-Max 14 - 72 Age (yrs) Year MeanMean 39.13 39.13 MedianMedian 41 41 0.0 Disease Abstract 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-MaxMin-Max 14 - 72 14 - 72 The incidence rate for acute hepatitis C has been variable over the lastYear eight years, but has been increasingDisease Abstractsince 2005 (Figure 1). In 2008, there was a 1.43% decrease in comparison to the averageDiseaseThe Abstractincidence rate from for acute2003-2007. hepatitis CA hastotal been of 53variable cases over were the lastreported eight years, in 2008, but has of which 60.38%The wereincidencebeen increasingclassified rate for since acuteas confirmed 2005 hepatitis (Figure C cases. has 1). been In 2008, It variable is importantthere over was the a to1.43% last note eight decrease that years, the inbut hepatitis comparison has been C toacute increasingthe average since 2005 incidence (Figure from 1). 2003-2007. In 2008, there A total was ofa 1.43%53 cases decrease were reported in comparison in 2008, to of the which average surveillanceincidence case from 2003-2007.definition changedA total of 53 in cases 2008, were ther reportedefore more in 2008, cases of which may 60.38% have werebeen classified classified as as confirmed60.38% compared were classified to previous as confirmed reporting cases. years It is(2006:36%, important to note2007:34.7%, that the hepatitis 2008:60.4%). C acute There confirmedsurveillance cases. case It is importantdefinition changedto note that in 2008, the hepatitis therefore C moreacute casessurveillance may have case been definition classified changed as in is no2008, seasonalconfirmed therefore trend comparedmore for cases acute to may previous hepatitis have reportingbeen C classifiedinfection years (2006:36%, (Figureas confirmed 2). 2007:34.7%, Therecompared were 2008:60.4%).to previousno acute reporting There hepatitis years C cases(2006:36%, classifiedis no seasonal 2007:34.7%, as outbreak-related. trend 2008:60.4%).for acute hepatitis There C isinfection no seasonal (Figure trend 2). Therefor acute were hepatitis no acute C infectionhepatitis (FigureC 2). Therecases were classified no acute as outbreak-related.hepatitis C cases classified as outbreak-related.

Figure 2. Hepatitis C, Acute Cases byFigure Month 2. of Onset, Florida, 2008 Hepatitis C, Acute Cases by Month of Onset, Florida, 2008 9 9

8 8 7 7 6 6 5 5 4 4 3 Number of CasesNumber of 3 2 Number of CasesNumber of 2 1 1 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 0 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 5yr average 2008 Month

5yr average 2008 The highest incidence rates for 2008 occurred among those 20 to 24 years old which is a change from historical trends where the highest rates occurred among those in the 35 to 44- The highestThe highestyear-old incidence incidence age group, rates rates where for 2008the2008 incidence occurred occurred actuallyamong among thosedecreased those 20 to in24 20 2008. years to 24 Inold years2008, which the oldis incidencea whichchange is from a changehistorical fromrates trends historicalwere higherwhere trends thethan highest the where previous rates the occurred 5-year highest average among rates inthose occurredthose in 10the to 35among 14, to 2044 to yearthose 24, old 55 in ageto the64, group, and35 to 65where 44- to 74 years old (Figure 3). year-oldthe incidence age group, actually where decreased the incidence in 2008. In actually 2008, the decreased incidence rates in 2008. were higher In 2008, than the previous incidence 5-year average in those 10 to 14, 20 to 24, 55 to 64, and 65 to 74 years old (Figure 3). rates were higher than the previous 5-year average in those 10 to 14, 20 to 24, 55 to 64, and 65 to 74 years old (Figure 3).

99 2008 Florida Morbidity Statistics

Figure 3. Hepatitis C, Acute Incidence Rate by Age Group, Florida, 2008

1.2

1.0

0.8

0.6

0.4 Cases per 100,000 per Cases 0.2

0.0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

The passive transfer of maternal HCV antibodies may be present in infants up to 18 months of age. A Thepositive passive Anti-HCV transfer result of in maternal an infant <18HCV months antibodies is a not may a true be indicator present of in hepatitis infants C up infection to 18 inmonths an of age.infant. A positiveIn 2008, menAnti-HCV and women result had in similaran infant incidence <18 months of acute is hepatitis a not a C true (0.29 indicator per 100,000 of hepatitisand 0.27 C per 100,000 respectively). The incidence rates in whites are greater than those in non-whites. infection in an infant. In 2008, men and women had similar incidence of acute hepatitis C (0.29 perAcute 100,000 Hepatitis and C 0.27was reported per 100,000 in 21 of respectively). the 67 counties The in Florida. incidence rates in whites are greater than those in non-whites. Prevention AcuteUniversal Hepatitis precautions C was should reported be implemented in 21 of the for 67 individuals counties in in contact Florida. with body fluids in health care settings. High-risk groups for infection include drug abusers who share needles, healthcare workers who have contact with infected blood, MSM, people who have multiple sexual partners, household contacts of Preventioninfected persons, and infants born to mothers who are hepatitis C carriers. Universal precautions should be implemented for individuals in contact with body fluids in health care settings. High-risk groups for infection include drug abusers who share needles, healthcare workers who have contact with infected blood, MSM, people who have multiple sexual partners, household contacts of infected persons, and infants born to mothers who are hepatitis C carriers.

100

References Centers for Disease Control and Prevention, “Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease,” Morbidity and Mortality Weekly Report, Vol. 47, No. RR-19, 1998, pp. 1-39.

Centers for Disease Control and Prevention, “Sexually Transmitted Diseases Treatment Guidelines, 2006,” Morbidity and Mortality Weekly Report, Vol. 55, No. RR-11, 2006, pp. 1-101.

J.L. Dienstag, “Sexual and perinatal transmission of hepatitis C,” Hepatology, Vol. 26, No. 66S- 70S, 1997.

Centers for Disease Control and Prevention, “Guidelines for Laboratory Testing and Result Reporting of Antibody to Hepatitis C Virus,” Morbidity and Mortality Weekly Report, Vol. 52, No. RR-03, 2003, pp. 1-16.

American Academy of Pediatrics, Red Book 2003: Report of the Committee on Infectious Diseases, 26th ed., Elk Grove Village, IL, American Academy of Pediatrics Press, 2003.

Centers for Disease Control and Prevention, Frequently Asked Questions About Hepatitis C, Summary of Selected Notifiable Diseases and Conditions

Centers for Disease Control and Prevention, “Sexually Transmitted Diseases Treatment Guidelines, 2006,” Morbidity and Mortality Weekly Report, Vol. 55, No. RR-11, 2006, pp. 1-101.

J.L. Dienstag, “Sexual and perinatal transmission of hepatitis C,” Hepatology, Vol. 26, No. 66S-70S, 1997.

American Academy of Pediatrics, Red Book 2003: Report of the Committee on Infectious Diseases, 26th ed., Elk Grove Village, IL, American Academy of Pediatrics Press, 2003.

Centers for Disease Control and Prevention, Frequently Asked Questions About Hepatitis C, accessed at: http://www.cdc.gov/ncidod/diseases/hepatitis/c/faq.htm#1a.

M.I Gismondi, E.I. Turazza, S. Grinstein, et al., “Hepatitic C Virus Infection in Infants and Children from Argentina,” Journal of Clinical Microbiology, Vol. 42, 2004, pp. 1199-1202.

J.A. Hochman, W.F. Balistreri, “Chronic Viral Hepatitis: Always Be Current!,” Pediatrics in Review, Vol. 24, 2003, pp. 399-410.

S. Kamili, et al., “Infectivity of Hepatitis C Virus in Plasma After Drying and Storage at Room Temperature,” Infection Control and Hospital Epidemiology, Vol. 28, 2007, pp. 519-524.

Lead Poisoning

Disease Abstract The Florida Childhood Lead Poisoning Prevention Program (FL CLPPP) monitors all reported blood lead levels in children less than 72 months of age. The program documents the reported number of children per year who meet the case definition of lead poisoning (≥ 10 ug/dL) and the reported number of children screened. Although some children are tested multiple times in a single year, only the first test per year is considered a screening test, all subsequent tests are considered follow-up tests.

The total number of new cases reported to FL CLPPP increased from 304 in 2005 to 389 in 2006. Additionally, an overall increase in lead screening was observed during that same time period. The 2007 and 2008 FL CLPPP laboratory data is not yet available due to data system limitations. A comprehensive review of that data will be completed in the future. The observed increase in cases of lead poisoning is likely explained by increased outreach and education in targeted counties and a subsequent increase in the reporting of blood lead data by physicians and laboratories. Additional efforts are underway to ensure that the laboratory data collected by FL CLPPP is available to the county health departments for timely follow-up on cases.

Currently, county health departments receive reports of lead poisoning cases from local physicians and local laboratories. These cases are entered into the State’s notifiable disease reporting surveillance

101 Lead Poisoning

Disease Abstract The Florida Childhood Lead Poisoning Prevention Program (FL CLPPP) monitors all reported blood lead levels in children less than 72 months of age. The program documents the reported number of children per year who meet the case definition of lead poisoning ( 10 ug/dL) and the reported number of children screened. Although some children are tested multiple times in a single year, only the first test per year is considered a screening test, all subsequent tests are considered follow-up tests.

The total number of new cases reported to FL CLPPP increased from 304 in 2005 to 389 in 2006. Additionally, an overall increase in lead screening was observed during that same time period. The 2007 FL CLPPP laboratory data is not yet available due to data system limitations. A comprehensive review of that data will be completed in the future. The observed increase in cases of lead poisoning is likely explained by increased outreach and education in targeted counties and a subsequent increase in the reporting of blood lead data by physicians and laboratories. Additional efforts are underway to ensure that the laboratory data collected by FL CLPPP is available to the county health departments for timely follow-up on cases.

Currently, county health departments receive reports of lead poisoning2008 cases Florida from Morbidity local Statistics physicians and local laboratories. These cases are entered into the State’s notifiable disease reporting surveillance system, Merlin. Figure 1 shows that the number of confirmed lead system,poisoning Merlin. casesFigure in 1 Floridashows thatfor 2005 the number to 2007 of as confirmed reported through lead poisoning Merlin. Thecases data in Floridashows fora 2005 to 2007steady as reported decline throughin the number Merlin. of The confirmed data shows cases a reportedsteady decline from 2005 in the to number 2007. Theof confirmed number of casesreported reported cases from 2005decreased to 2007. from The 353 number in 2005 of to reported 227 in 2007. cases Twodecreased hundred from and 353 seventy-six in 2005 to 227 incases 2007. were Two reported hundred inand 2006. seventy-six It should cases be noted were that reported the number in 2006. of confirmedIt should be cases noted reported that the in Merlin each year from 2005 to 2007 is not reflective of the total number of confirmed cases number of confirmed cases reported in Merlin each year from 2005 to 2007 is not reflective of the total reported to the FL CLPPP surveillance system on an annual basis. Access to test result data number of confirmed cases reported to the FL CLPPP surveillance system on an annual basis. Access from FL CLPPP at the county health department level would supplement the current reporting to test result data from FL CLPPP at the county health department level would supplement the current procedures of having physicians and local labs report to their respective counties. This will reportingallow procedures for consistency of having in the physicians reporting andof confirmed local labs cases report between to their respective FL CLPPP counties. and Merlin This will allow surveillancefor consistency data in systems.the reporting of confirmed cases between FL CLPPP and Merlin surveillance data systems. Figure 1: Confirmed Cases of Lead Poisoning Among Children Less Than 72 Figure 1: ConfirmedMonths of Age Cases as Reportedof Lead Poisoning in Merlin, AmongFlorida, Children2005 to 2007Less Than 72 Months of Age as Reported in Merlin, Florida, 2005 to 2007 400 353 s 350 276 300 227 250 200 150 100

Number of Confirmed Case Confirmed of Number 50 0 2005 2006 2007 Year

The discordance between the number of confirmed cases of lead poisoning reported in the two systems (FL CLPPP and Merlin) is a result of the way the data is initially collected. The FL CLPPP surveillance system collects all blood lead test results electronically from laboratories regardless of test result. County health departments rely on physicians and local laboratories to report cases with elevated blood lead levels. This system relies on the physician or laboratorian to know when and how to report the case and to whom to report it. Automated laboratory reporting is more complete and the number of cases reported to the FL CLPPP database is therefore expected to be larger than the number of cases reported in Merlin. That trend has been observed over the previous two years when comparing the available data.

Prevention According to the CDC, Florida ranks eighth in the nation for the number of estimated children with lead poisoning. The CDC further estimates that 7,400 children with elevated blood lead levels live in nine Florida cities with populations of 100,000 or greater. In total, the CDC estimates that 22,000 children may suffer from lead poisoning in the state (CDC 2003 Program Announcement 03007, Appendix III). Lead poisoning is completely preventable. Prevention efforts of the FL CLPPP include ensuring parents, property owners, healthcare professionals, and those who work with young children are informed about the risks of lead poisoning and how to prevent it. Other prevention efforts have been initiated through the “Healthy Home” component of the program.

Additional Resources Florida Department of Health FL CLPPP website can be accessed at http://www.doh.state.fl.us/environment/medicine/lead/index.html.

Centers for Disease Control and Prevention (CDC) Lead Program website can be accessed at http://www.cdc.gov/nceh/lead/faq/about.htm.

102 Legionellosis

Summary of Selected Notifiable Diseases and Conditions Figure 1. Legionellosis Incidence Rate by Year Reported, Florida, 1999- Legionellosis: Crude Data 2008 Legionellosis1.2 Number of Cases 148 Legionellosis1.0 2008 incidence rate per 0.8 Figure 1. 100,000 Legionellosis: Crude Data0.78 Legionellosis Incidence Rate by Year Reported, Florida, 1999- Legionellosis: Crude Data 0.6 2008 % changeNumber from of Cases average 5- 148 year (2003-2007) incidence 1.2 0.4

Cases per 100,000 Number2008 of incidence Cases rate per 148-3.08 rate 1.0 0.2 2008 100,000incidence rate per 0.78 Age (yrs) 0.8 100,000% change from average 0.78 0.0 Mean 63.25 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 % change5-year from (2003-2007) average incidence 5- 0.6 rate Median -3.08 64 year (2003-2007) incidence 0.4 Year Min-Max -3.08 22 - 92 Cases per 100,000 rate Age (yrs) 0.2 Age (yrs) Mean 63.25 0.0 Median 64 Disease AbstractMean 63.25 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 MedianMin-Max 22 64 - 92 The Florida incidence rate for legionellosis has steadily increased overYear the last ten years (Figure 1). In 2008, thereMin-Max was an 3.08% 22 - decrease92 in comparison to the average incidence from 2003- 2007.Disease A total Abstract of 148 cases were reported in 2008, of which 100% were classified as confirmed DiseasecasesThe and FloridaAbstract 7.43% incidence were rate acquired for legionellosis outside has of Floriincreasedda. overThe thenumber last ten of years cases (Figure reported 1). In 2008,tends to Theincrease Floridathere wasin incidence the a 3.08% summer decreaserate months.for legionellosis in comparison In 2008, has to thethe steadily averagenumber increased incidence of cases over from exceeded the2003-2007. last tenthe Ayears previous total of(Figure 148 5-year cases were reported in 2008, of which 100% were classified as confirmed cases and 7.43% were 1).average In 2008, for thereJanuary, was anFebruary, 3.08% decrease June, July, in comparison October, and to the December average incidence(Figure 2). from Three 2003- of the 2007.acquired A total outside of 148 of cases Florida. were The reported number ofin cases2008, reported of which tends 100% to increasewere classified in the summer as confirmed months. In legionellosis cases were classified as outbreak-related. cases2008, and the 7.43% number were of casesacquired exceeded outside the of previous Florida. 5-year The averagenumber forof January,cases reported February, tends June, to July, October, and December (Figure 2). Three of the legionellosis cases were classified as outbreak-related. increase in the summer months. In 2008, the number of cases exceeded the previous 5-year average for January, February, June, July, October,Figure and 2. December (Figure 2). Three of the legionellosis cases were classifiedLegionellosis as outbreak-related. Cases by Month of Onset, Florida, 2008 25

20 Figure 2. Legionellosis Cases by Month of Onset, Florida, 2008 25 15

20 10

15Cases Numberof 5

10 0 Number of Cases Numberof 5 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 0 5yr average 2008 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec The highest incidence rates continue to occur among adults 45 years of age and older with incidence Month rates ranging from 0.71 per 100,000 in the 45-545yr average age group2008 to 2.55 per 100,000 in the 75-84 age group. The Inhighest 2008, the incidence incidence ratesrates were continue higher to than oc thecur previous among 5-year adults average 45 years in those of age 35-44 and and older those with 85 incidenceand older; rates there ranging was also from a very 0.71 interesting per 100,000 increase in in the incidence 45-54 among age group those 20to to2.55 24 yearsper 100,000 old. There in the The75-84 highestwere age four group.incidence cases reported In rates2008, in continue thethis ageincidence groupto occur for rates 2008among werecompared adults higher 45to onlyyears than two theof cases age previous andin 2007. older 5-year Incidence with average of in incidencethosedisease 35-44 rates is andminimal ranging those in individualsfrom 85 and0.71 older; <19per years100,000 there of age, wasin the with also 45-54 no a cases very age reported interestinggroup to in 2.55the increase last per 10 100,000 years in incidence in ininfants the 75-84amongand age thosechildren group. 20 ages toIn 2008,1-924 years(Figure the incidenceold.3). Males There continuerates were were tofour have higher cases a slightly than reported thehigher previous inincidence this 5-year age than group averagefemales for (0.86 in2008 thosecomparedand 35-44 0.71 to andper only 100,000,those two 85 cases respectively). and older;in 2007. there Incidence was also aof very disease interesting is minimal increase in individuals in incidence <19 years of amongage, with those no 20cases to 24 reported years old. in theThere last were 10 yearsfour cases in infants reported and in children this age agesgroup 1-9 for 2008(Figure 3). comparedMales continue to only to two have cases a slightly in 2007. higher Incidence incidence of disease than is females minimal (0.86 in individuals and 0.71 <19 per years 100,000, of age,respectively). with no cases reported in the last 10 years in infants and children ages 1-9 (Figure 3). Males continue to have a slightly higher incidence than females (0.86 and 0.71 per 100,000, respectively). 103 2008 Florida Morbidity Statistics

Figure 3. Legionellosis Incidence Rate by Age Group, Florida, 2008

3.0

2.5

2.0

1.5

1.0 Cases per 100,000 per Cases 0.5

0.0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

LegionellosisLegionellosis was reported reported in 30in 30of the of 67the counties 67 counties in Florida. in Florida. Counties inCounties the central, in southwestern,the central, and southwestern,southeastern regions and southeastern Florida reported regions the highest Florida incidence reported rates. the highest incidence rates. Prevention PreventionCooling towers should be drained when not in use, and mechanically cleaned periodically to remove Coolingscale and towers sediment. should Appropriate be drained biocides when should not bein use,used toand limit mechanically the growth of slime-forming cleaned periodically organisms. to removeTap water scale should and not sediment. be used in respiratoryAppropriate therapy biocides devices. should Maintaining be used hot towater limit system the growth temperatures of slime- formingat 50°C organisms. (122°F) or higher Tap as water well as should proper nothot tub/spabe used maintenance in respiratory may reducetherapy the devices. risk of transmission. Maintaining hot water system temperatures at 50°C (122°F) or higher as well as proper hot tub/spa maintenance may reduce the risk of transmission.

104

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/legionellosis_g.htm. Summary of Selected Notifiable Diseases and Conditions

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

Additional Resources Disease information is available from the CentersListeriosis for Disease Control and Prevention (CDC) at http:// www.cdc.gov/ncidod/dbmd/diseaseinfo/legionellosis_g.htm.

Figure 1. Listeriosis Incidence Rate by Year Reported, Florida, 1999-2008 Listeriosis: Crude Data ListeriosisListeriosis 0.4 Number of Cases 49

2008 incidence rate per 0.3 Figure 1. Listeriosis: Crude Data Listeriosis Incidence Rate by Year Reported, Florida, 1999-2008 100,000Listeriosis: Crude Data 0.26 Number of Cases 49 0.4 % change from average 5- 0.2 yearNumber2008 (2003-2007) incidence of Cases rate incidence per 49 rate2008100,000 incidence rate per 11.62 0.3

0.26 100,000 per Cases 100,000 0.26 Age% (yrs)change from average 0.1 % change from average 5- 5-year (2003-2007) incidence 0.2 year (2003-2007)Mean incidence 62.04 raterate Median 11.6211.62 70.5 Cases per 100,000 per Cases 0.0 AgeAge (yrs)(yrs) Min-Max <1 - 99 0.1 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Mean 62.04 Year Mean 62.04 MedianMedian 70.570.5 0.0 Min-MaxMin-Max <1<1 -- 9999 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Disease Abstract Year

The reported incidence rate for listeriosis has been variable over the last ten years with no clear trendDiseaseDisease (Figure Abstract 1). In 2008, there was an 11.62% increase in comparison to the previous 5-year averageTheThe reportedreported incidence. incidenceincidence A totalraterate for of listeriosis49 cases has were been reported vavariableriable overoverin 2008. thethe lastlast All tenten of yearsyears the 2008withwith nono cases clearclear trendwere trend(Figure (Figure 1). In 1). 2008, In 2008, there therewas an was 11.62% an 11.62% increase increase in comparison in comparison to the toprevious the previous 5-year 5-year average sporadicincidence. and A nottotal outbreak-related. of 49 cases were reported Historically, in 2008. the All ofnumber the 2008 of cases cases were reported sporadic tends and notto increase slightlyaverage in incidence.the late summer A total of months 49 cases with were a reportedhigh number in 2008. of Allcases of the in 2008 July, cases August, were and September. sporadicoutbreak-related. and not outbreak-related. Historically, the number Historically, of cases the numberreported of tends cases to reportedincrease tendsslightly to inincrease the late summer In slightly2008,months ina with similarthe a late high summertrend number was months of observedcases with in aJuly, highwith August, number the number and of casesSeptember. of in cases July, In August, exceeding 2008, aand similar September. the trend previous was 5-year averageInobserved 2008, during a withsimilar the seven trend number monthswas of observed cases of theexceeding with year, the numberthemost previous notably of cases 5-year in exceeding August average throughthe during previous seven October 5-year months (Figure of the 2). averageyear, most during notably seven in August months through of the year, October most (Figure notably 2). in August through October (Figure 2).

Figure 2. Listeriosis CasesFigure by 2.Month of Onset, Florida, 2008 Listeriosis Cases by Month of Onset, Florida, 2008 8 8 7 7

44 3 3 Number of CasesNumber of 2 Number of CasesNumber of 2 1 1 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr MayMonth Jun Jul Aug Sep Oct Nov Dec 5yr average 2008 Month 5yr average 2008 The very young and the elderly are at increased risk of infection in comparison to other age groups (Figure 3). In 2007, the incidence rate was higher than the previous 5-year average for 105 Themost very age young groups and except the those elderly 15-19, are 35-44, at increased 45-54, and risk 75-84. of infection The incidence in comparison rate in males to other age groupswas higher (Figure than 3). in females In 2007, (0.33 the and incidence 0.20 per rate100,000, was respectively) higher than for the 2008 previous which is 5-year different average for mostfrom age the groupshistorical except trend. Historically,those 15-19, incidence 35-44, rates 45-54, in whites and are75-84. greater The than incidence those in non- rate in males waswhites, higher and than this wasin females seen in 2008(0.33 as and well, 0.20 with whiteper 100,000, males having respectively) the highest forincidence. 2008 which is different from the historical trend. Historically, incidence rates in whites are greater than those in non- whites, and this was seen in 2008 as well, with white males having the highest incidence. 2008 Florida Morbidity Statistics

The very young and the elderly are at increased risk of infection in comparison to other age groups (Figure 3). In 2007, the incidence rate was higher than the previous 5-year average for most age groups except those 15-19, 35-44, 45-54, and 75-84. The incidence rate in males was higher than in females (0.33 and 0.20 per 100,000, respectively) for 2008 which is different from the historical trend. Historically, incidence rates in whites are greater than those in non-whites, and this was seen in 2008 as well, with white males having the highest incidence.

Figure 3. Listeriosis Incidence Rate by Age Group, Florida, 2008

2.0

1.5

1.0

Cases per 100,000 per Cases 0.5

0.0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

ListeriosisListeriosis was was reported in in21 21 of theof the67 counties 67 counties in Florida. in Florida.

Prevention PreventionGenerally, listeriosis may be prevented by: thoroughly cooking raw food from animal sources, such as Generally,beef, pork, listeriosis or poultry; washingmay be raw prevented vegetables by: before thoroughly eating; and cooking keeping raw uncooked food from meats animal separate sources, suchfrom as vegetables, beef, pork, cooked or poultry; foods, and washing ready-to-eat raw foods.vegetables Avoiding before unpasteurized eating; andmilk orkeeping foods made uncooked from meatsunpasteurized separate milk, from and vegetables, washing hands, cooked knives, foods, and cutting and boardsready-to-eat after handling foods. uncooked Avoiding foods may unpasteurizedalso prevent listeriosis. milk or foodsThose atmade high riskfrom for unpasteurized listeriosis (the elderly, milk, pregnant and washing women, hands, those with knives, cancer, and HIV, diabetes, or weakened immune systems) should follow additional recommendations: avoid soft cuttingcheeses boards such asafter feta, handling brie, camembert, uncooked blue-veined, foods may and Mexican-stylealso prevent cheese. listeriosis. Leftover Those foods at or highready- risk for listeriosisto-eat foods, (the such elderly, as hot pregnant dogs or cold women, cuts, should those be with cooked cancer, until steaming HIV, diabetes, hot before or eating. weakened immune systems) should follow additional recommendations: avoid soft cheeses such as feta, brie, camembert, blue-veined, and Mexican-style cheese. Leftover foods or ready-to-eat foods, such as hot dogs or cold cuts, should be cooked until steaming hot before eating.

106 Summary of Selected Notifiable Diseases and Conditions

References References th David L. Heymann (ed.), Control of Communicable Diseases Manual, 18 ed., thAmerican Public Health AssociationDavid Press,L. Heymann Washington, (ed.), Control District of Communicable of Columbia, Diseases 2004. Manual, 18 ed., American Public Health Association Press, Washington, District of Columbia, 2004.

Additional ResourcesAdditional Resources Disease informationDisease is information available fromis available the Centers from the for Centers Disease for Disease Control Control and Prevention and Prevention (CDC) (CDC) at http:// at www.cdc.gov/ncidod/dbmd/diseaseinfo/listeriosis_g.htm.http://www.cdc.gov/ncidod/dbmd/diseaseinfo/listeriosis_g.htm.

107 Lyme Disease

2008Figure Florida 1. Morbidity Statistics Lyme Disease Incidence Rate by Year Reported, Florida, 1999- Lyme Disease: Crude Data 2008 Lyme0.5 Disease Lyme Disease Number of Cases 88 0.4

2008 incidence rate per Figure 1. 100,000Lyme Disease: Crude Data0.47 0.3Lyme Disease Incidence Rate by Year Reported, Florida, 1999- NumberLyme of Cases Disease: Crude Data88 2008 % change from average 5- 0.5 0.2 year2008 (2003-2007)Number incidence of Cases rateincidence per 88 rate 100,000 109.49 per 100,000 Cases 0.4 2008 incidence rate per 0.47 0.1 Age %(yrs)100,000 change from average 0.47 0.3 5-year% change (2003-2007) fromMean average incidence 5- 39.56 0.0 rateyear (2003-2007)Median incidence 109.49 40.5 0.2 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

rate 109.49 per 100,000 Cases Year Age (yrs) Min-Max 1 - 84 0.1 Age (yrs) Mean 39.56 Mean 39.56 Median 40.5 0.0 Disease AbstractMedian 40.5 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 1 - 84 Year The reported incidenceMin-Max rate for Lyme 1 - 84 disease in Florida has dropped steeply over the past ten years, but there was a very sharp increase in incidence between 2007 and 2008 (Figure 1). In 2007,Disease there was Abstract a 43.03% decrease in comparison to the average incidence from 2002-2006. ChangesDiseaseThe reportedin Abstracttesting incidence procedures rate for by Lyme private disease laboratories in Florida has may dropped have steeplycontributed over the to pastthis tendecline. In Theyears, reported but there incidence was a rate very for sharp Lyme increase disease in caused incidence by Borreliabetween burgdorferi 2007 and 2008in Florida (Figure has 1). dropped In 2007,steeply2007, a positive overthere the was ELISA past a 43.03% ten test years, followeddecrease but there inby comparison wasa Western a very sharpto blot the increaseaveragewas required incidencein incidence to frommeet between 2002-2006. surveillance 2007 and criteria for case2008Changes confirmation.(Figure in 1).testing In 2007, procedures Some there laboratories had by privatebeen a laboratories 43.03%provided decrease onlymay haveEIA in comparison testicontributedng which to to the this did average decline. not allow incidence In cases to meetfrom 2007,the 2002-2006. case a positive definition, ChangesELISA ortest indid followedtesting not reportprocedures by a Western the resultsby privateblot was of laboratoriesthe required Western to maymeet Blot have surveillance testing contributed along criteria to withthis the initialdecline. forEIA case result. Prior confirmation. to These 2008, a practicesSome positive laboratories ELISA could test have provided followed resulted only by a EIA Westernin recognitiontesting blot which was ofdid required fewer not allow tocases meet cases andsurveillance to a declinecriteriameet in thefor casecase reported confirmation.definition, incidence. or did Some not However, report laboratories the resultsin provided2008 of thethere only Western wasEIA testing aBlot sharp testingwhich increase didalong not with allow in thereported cases to initial EIA result. These practices could have resulted in recognition of fewer cases and a casesmeet that the was case a definition, 109% increase or did not over report the the previous results of 5-year the Western average Blot testingwhich alongmay bewith partly the initial EIA result.decline These in the practices reported could incidence. have resultedHowever, in inrecognition 2008 there of was fewer a sharpcases increaseand a decline in reported in the reported attributedincidence.cases to that a However, changewas a 109% inin 2008 the increase casethere overwasdefinition thea 109% previous and increase possibly 5-year in averagereported to increased whichcases mayover public bethe partly previous awareness 5-year and mediaaverageattributed attention. which to a can Inchange Florida, be partly in the theattributed case increase definition to a changewas and primarily possibly in the case to observed increased definition inpublic andcases awarenesspossibly imported to increased and from outpublic of state,awarenessmedia particularly attention. and mediafrom In Florida, theattention. northeast the Inincrease Florida, United was the States. primarilyincrease observedTherewas primarily are in casesgaps observed inimported knowledge in cases from importedout regarding of from otherout state,Borrelia of state, particularly speciesparticularly from that fromthe might northeast the northeast be presentUnited United States. in States.Florida. There There are gaps are gaps in knowledge in knowledge regarding regarding other Borreliaother Borrelia species species that might that be might present be present in Florida. in Florida.

Figure 2. Figure 2. LymeLyme Disease Disease Cases Cases by by Month Month of Onset, of Onset, Florida, Florida, 2008 2008 30 30

25 25

20 20

15 15 10 Number of CasesNumber of 10

Number of CasesNumber of 5

5 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 0 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 5yr average 2008 Month

5yr average 2008 A total of 88 cases were reported in 2008, 82% were classified as confirmed cases. A smaller

A total of 88 cases were reported in 2008, 82% were classified as confirmed cases. A smaller

108 proportion of cases were acquired in the state of Florida for 2008 (11 cases, 13%) as compared to 2007Summary (9 cases,of Selected 30%) Notifiable but Diseasesthe majority and Conditions of cases (71 cases, 81% in 2008) were acquired outside of the state for both years. Most imported cases were acquired in the northeast United States, particularlyA total of 88 New cases York, were Massachusetts,reported in 2008, of and which Connec 82% wereticut. classified Highest as caseconfirmed incidence cases. was A smaller in the summer,proportion with of casespeak wereincidence acquired in in July, the state but ofcases Florida occurred for 2008 (1year1 cases, round. 13%) In as 2008, compared the numberto 2007 of cases(9 cases, exceeded 30%) but the the previous majority of 5-year cases (71average cases, in81% all in months 2008) were except acquired January, outside February, of the state andfor both years. Most imported cases were acquired in the northeast United States, particularly New York, December,Massachusetts, which and are Connecticut. low periods Highest of tick case activity incidence (Figure was in 2). the Twosummer, of the with 2008 peak incidenceimported cases fromin July, Minnesota but cases were occurred classified year round. as outbreak In 2008, the related. number of cases exceeded the previous 5-year average in all months except January, February, and December, which are low periods of tick activity The(Figure highest 2). Twoincidence of the 2008 in 2008 imported was cases in 65- from to Minnesota74-year-olds were whichclassified is consistentas outbreak withrelated. the previous 5-year average for age. Three of the four highest age group incidences were in older patients The highest incidence in 2008 was in 65- to 74-year-olds which is consistent with the previous 5-year (65-74,average 75-84, for age. and Three those of the85 fourand highest over) agecompared group incidences to the nationally were in older reported patients peak(65-74, incidence 75- group84, and of 45-54.those 85 Moreand over) consistent compared with to the national nationally trends reported is thepeak peak incidence in children group of aged45-54. five More to nine yearsconsistent old and with those national 10-14 trends (Figure is the peak 3). inIncidence children aged rates five in to whites nine years continue old and to those be higher10-14 than in non-whites(Figure 3). with Incidence the highest rates in whitesincidence continue occurring to be higher among than whitein non-whites males with (0.64 the perhighest 100,000) incidence and the secondoccurring highest among incidence white males occurring (0.64 per 100,000)among whiteand the females second highest (0.41 incidenceper 100,000). occurring among white females (0.41 per 100,000).

Figure 3. Lyme Disease Incidence Rate by Age Group, Florida, 2008

1.0

0.8

0.6

0.4

Cases per 100,000 per Cases 0.2

0.0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

LymeLyme disease disease was reported reported in 24in of24 67 of Florida 67 Florida counties. count Mosties. cases Most were cases reported were from reported central and from central south Florida, with four cases reported from the Panhandle. and south Florida, with four cases reported from the Panhandle. Prevention PreventionThe most effective prevention is avoiding human and pet exposure to ticks including: avoiding tick Theinfested most areas;effective covering prevention exposed isskin avoiding as much human as possible; and wearing pet exposure light colored to ticks clothing including: to better seeavoiding tickticks; infested tucking areas; in pant coveringlegs and buttoning exposed sleeves; skin as appropriate much as application possible; of wearing permethrin light to clothing colored and clothing to DEET to skin (per CDC recommendations); inspecting children, pets, and adults for ticks immediately betterfollowing see likelyticks; exposure; tucking andin pant using legs appropriate and buttoning veterinary sleeves; products asappropriate recommended application by a veterinarian of to permethrinprevent tick to exposure. clothing Landscapingand DEET measuresto skin (per around CDC the recommendations); home to reduce ground inspecting cover can also children, reduce pets, andcontact adults with for ticks. ticks Any immediately ticks found attached following to children,likely exposure; adults, or petsand should using be appropriate removed promptly. veterinary productsUsing fine as tweezersrecommended or a tissue by to a protectveterinarian fingers, to grasp prevent the tick tick close exposure. to the skin Landscapingand gently pull straightmeasures aroundout without the home twisting. to Doreduce not use ground bare fingers cover to can crush also ticks. reduce ashW handscontact following with ticks. tick removal. Any ticks Most found Florida cases are acquired in Lyme-endemic areas of the northeastern U.S.; these prevention measures attachedare especially to children, important adults, while visitingor pets those should areas. be removed promptly. Using fine tweezers or a tissue to protect fingers, grasp the tick close to the skin and gently pull straight out without twisting. Do not use bare fingers to crush ticks. Wash hands following tick removal. Most Florida cases are acquired in Lyme-endemic areas of the northeastern U.S.; these prevention measures are especially important while visiting those areas. 109 2008 Florida Morbidity Statistics

References th ReferencesDavid L. Heymann (ed.), Control of Communicable Diseases Manual, 19 ed., American Public Health David L. HeymannAssociation (ed.), Press, Control Washington, of Communicable District of Diseases Columbia, Manual 2008., 19th ed., American Public Health Association Press, Washington, District of Columbia, 2008. L.K. Pickering, C.J. Baker, S.S. Long, and J.A. McMillan (eds.), Red Book: 2006 Report of the Committee L.K. Pickering,on Infectious C.J. Baker, Diseases S.S. Long,, 27th anded., AmericanJ.A. McMillan Academy (eds.), of Red Pediatrics Book: 2006 Press, Report 2006. of the Committee on Infectious Diseases, 27th ed., American Academy of Pediatrics Press, Additional2006. Resources Disease information is available from the Centers for Disease Control and Prevention at http://www.cdc. Additionalgov/ncidod/dvbid/lyme/ Resources and http://www.cdc.gov/healthypets/diseases/lyme.htm. Disease information is available from the Centers for Disease Control and Prevention at http://www.cdc.gov/ncidod/dvbid/lyme/Disease information is available from and the http://wFloridaww.cdc.gov/healthypets/diseases/lyme.htm. Department of Health at http://www.doh.state. fl.us/Environment/medicine/arboviral/Tick_Borne_Diseases/Tick_Index.htm. Disease information is available from the Florida Department of Health at http://www.doh.state. fl.us/Environment/medicine/arboviral/Tick_Borne_Diseases/Tick_Index.htm.

110 Summary of Selected Notifiable Diseases and Conditions

Malaria Malaria

Malaria: Crude Data Figure 1. Malaria: Crude Data Malaria Incidence Rate by Year Reported, Florida, 1999-2008 NumberNumber of Cases of Cases 65 65 2008 incidence rate per 0.8 2008 incidence rate per 100,000 0.34 100,000 % change from average 5- 0.34 0.6 % changeyear from(2003-2007) average incidence 5-yearrate (2003-2007) incidence -16.37 0.4 rate Age (yrs) -16.37 Mean 39.43 0.2

Age (yrs) Cases per 100,000 Median 43 Mean 39.43 0.0 MedianMin-Max 43 4 - 74 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 4 - 74 Year Disease Abstract Human malaria is caused by four species of protozoan parasites of the genus Plasmodium: P. Diseasevivax, Abstract P. falciparum, P. malariae, and P. ovale. All four are transmitted from person to person Humanvia malaria the bite is and caused blood-feeding by four species behavior of protozoan of mosquitoes parasites of the of genus the genus Anopheles Plasmodium. Malaria: P. wasvivax, P. falciparum,endemic P. malariae, in Florida and up untilP. ovale the .1940s. All four Currently, are transmitted nearly toall people cases arevia thetravelers bite and returning blood-feeding to the behaviorstate of frommosquitoes malaria ofendemic the genus regions Anopheles of the .world, Malaria though was competentendemic in vectorsFlorida doup existuntil thein the 1940s. state, Currently,providing nearly the all possibilitycases are foramong local travelerstransmission. returning The to incidence the state rate from for malaria malaria endemic in Florida regions has of the world,declined though competent over the last vectors 10 years do exist (Figure in the 1) withstate, 65 providing cases reported the possibility in 2008. for In local 2008, transmission. there was a The incidence16% rate decrease for malaria in comparison in Florida tohas the declined average over incidence the last from 10 years 2003 (Figureto 2007. 1) More with 65cases cases are reported in 2008.reported In 2008, during there the was summer a 16% and decrease early fall in monthscomparison, but tocases the averageare reported incidence year-round from 2003 (Figure to 2007.2). More casesThe highest are reported historical during incidence the summer rates occur and early among fall those months, in the but 20-34 cases age are groupreported but year-round there was (Figurea second2). The peakhighest in 2008historical in those incidence 45-54 rates(Figure occur 3). amongThe average those agein the of 20-34 reported age malaria group butcases there in was aFlorida second is peak 39.43 in years2008 in(range: those 4-74). 45-54 (FigureIn 2008, 3). 86% The of averagethe 65 reported age of reported malaria casesmalaria were cases in Floridadiagnosed is 39.4 years with (range:P. falciparum 4-74). andIn 2008, 11% 86%were ofdiagnosed the 65 reported with P. malariavivax. Onecases case were was diagnosed diagnosed with with P. ovale and species was unable to be determined for one case. Sixty-nine percent of P. falciparum and 11% were diagnosed with P. vivax. One case was diagnosed with P. ovale and species cases were non-white, 28% were white, and the remaining were of unknown race. was unable to be determined for one case. Sixty-nine percent of cases were non-white, 28% were white, and the remaining were of unknown race. Thirty-eight percent of cases had recent travel history to Haiti, 26% traveled to Nigeria, 23% traveled to another African country, 9% traveled to Central or South America, and the remaining Thirty-eight3% traveled percent to of countries cases had in Asia.recent Of travel those history for whom to Haiti, additional 26% traveled data was to Nigeria,available 23% (39/65), traveled the to anotherlargest African proportion country, (49%) 9% traveledacquired to malaria Central while or South visiting America, relatives and or thefriends. remaining Persons 3% “visitingtraveled to countriesfriends in Asia. and relatives” Of those orfor VFRs whom are additional considered data a was high-risk available group (39/65), since theprior largest immunity proportion they may (49%) acquiredhave malaria had has while waned visiting and relatives they tend or tofriends. not take Persons proper “visitingmalaria preventionfriends and precautions. relatives” are Other considered a high-riskreasons group for sincetravel priorto malaria immunity endemic they mayareas have were had missionary/volunteer has waned and they work tend (33%) to not and take tourism proper malaria(8%). prevention Malaria precautions. was also identified Other reasonsin new immigrants for travel to or malaria students endemic studying areas in the were United missionary/ States. volunteer work (33%) and tourism (8%). Malaria was also identified in new immigrants or students studying in the United States.

111 2008 Florida Morbidity Statistics

Figure 2. Malaria Cases by FigureMonth 2.of Onset, Florida, 2008 Malaria Cases by Month of Onset, Florida, 2008 14 14 12 12 10 10 8 8 6 6

Number of CasesNumber of 4

Number of CasesNumber of 4 2 2 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Month 5yr average 2008 5yr average 2008

PreventionPrevention Prevention No vaccineNo vaccine is currently is currently available. available. Travelers Travelers to malaria-endemic to malaria-endemic countries countries should should consult consult with their with No vaccine is currently available. Travelers to malaria-endemic countries should consult with doctortheir to make doctor sure to makethey receive sure they an receiveappropriate an appropriate preventative preventative chemoprophylactic chemoprophylactic regimen and regimen should their doctor to make sure they receive an appropriate preventative chemoprophylactic regimen and should also take the full course of chemoprophylaxis as prescribed. A number of factors alsoand take should the full also course take of the chemoprophylaxis full course of chemoprophylaxis as prescribed. Aas number prescribed. of factors A number should of be factors taken into should be taken into consideration prior to prescribing chemoprophylaxis including, but not considerationshould be priortaken to into prescribing consideration chemoprophylaxis prior to prescribing including, chemoprophylaxis but not limited to,including, risk, the but species not of limited to, risk, the species of malaria present, drug resistance, and how well the drug is malarialimited present, to, risk, drug the resistance, species of andmalaria how present, well the drugdrug resistance,is tolerated. and Personal how well protection the drug measures is can tolerated. Personal protection measures can also help prevent malaria infection. Avoid contact alsotolerated. help prevent Personal malaria protection infection. measures Avoid contact can alsowith helpmosquitoes prevent bymalaria using infection.an insect repellentAvoid contact containing with mosquitoes by using an insect repellent containing DEET or other EPA-approved DEETwith or mosquitoesother EPA-approved by using aningredient, insect repellent remaining containing in well-screened DEET or areas,other EPA-approved keeping skin covered in ingredient, remaining in well-screened areas, keeping skin covered in clothing, and using clothing,ingredient, and using remaining insecticide-treated in well-screened bed areas,nets. keeping skin covered in clothing, and using insecticide-treated bed nets. insecticide-treated bed nets. Figure 3. Figure 3. Malaria Incidence Rate by Age Group, Florida, 2008 Malaria Incidence Rate by Age Group, Florida, 2008 0.8 0.8

0.6 0.6

0.4 0.4

Cases per 100,000 per Cases 0.2

0.0 0.0 <1 1-4 5-9 85+ <1 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 Age Group Age Group Previous 5yr average 2008 Previous 5yr average 2008

112 Summary of Selected Notifiable Diseases and Conditions

References Centers for Disease Control and Prevention, Traveler’s Health: Yellow Book, Health Information for ReferencesInternational Travel, 2008, 22 June 2007, http://wwwn.cdc.gov/travel/contentYellowBook.aspx. Centers for Disease Control and Prevention, “Traveler’s Health: Yellow Book, Health AdditionalInformation Resources for International Travel, 2008,” 22 June 2007, A table http://wwwn.cdc.gov/travel/contentYellowBook.aspx.containing drugs used in malaria prophylaxis can be found in the CDC Yellow Book, online http:// wwwn.cdc.gov/travel/yellowBookCh4-Malaria.aspx#404. Additional Resources AAdditional table containing information drugs on malariaused in andmalaria other pr mosquito-borneophylaxis can bediseases found incan the be CDC found Yellow in the Book,Surveillance onlineand Control http://wwwn.cdc.gov/travel/yellowBookCh4-Malaria.aspx#404. of Arthropod-borne Diseases in Florida Guidebook, online at http://www.doh.state.fl.us/ environment/medicine/arboviral/pdf_files/2009MosquitoGuide.pdf. Additional information on malaria and other mosquito-borne diseases can be found in the Surveillance and Control of Arthropod-borne Diseases in Florida Guidebook, online at http://www.doh.state.fl.us/environment/medicine/arboviral/pdf_files/2009MosquitoGuide.pdf.

113 2008 Florida Morbidity Statistics

Measles

Disease Abstract In 2008, one laboratory-confirmed case of measles was reported for a statewide incidence rate of 0.005 cases per 100,000 population. This is a significant decrease from the five cases reported in 2007 and the four cases reported in 2006. The 2008 case was imported from England where there has been an increase in measles activity over the past few years due to decreased vaccination rates. England currently has endemic transmission of measles. A case is officially classified as internationally imported when it has its source outside the country, with rash onset within 21 days after entering the country, and is not linked to local transmission.

Measles is a disease of urgent public health importance, so even one case requires tracking of all contacts and conducting interviews to assess susceptibility. Florida has many possible sources of infection due to the many foreign visitors each year, ease of international travel, and increasing incidence of measles in the U.S. and abroad. When a case is identified in another state or country, all possible contacts in Florida must be tracked in order to identify other potential cases and prevent continued transmission.

Prevention Vaccination against measles is recommended for all children after their first birthday. Two doses of measles vaccine (preferably MMR) are required for entry and attendance in kindergarten through twelfth grade. All children attending or entering childcare facilities or family daycare must be age-appropriately vaccinated with one or two doses of measles vaccine.

References Centers for Disease Control and Prevention, Manual for the Surveillance of Vaccine-Preventable Diseases, 4th ed., 2008, Chapter 7.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at www.cdc. gov/vaccines/vpd-vac/measles/default.htm.

Recommended immunization schedule is available at: http://www.cdc.gov/vaccines/recs/ schedules/ default.htm.

114 Summary of Selected Notifiable Diseases andMeningitis, Conditions Other Figure 1. Meningitis, Other (bacterial, Meningitis, OtherMeningitis, Other (bacterial, cryptococcal, mycotic) Incidence cryptococcal, mycotic): Rate by Year Reported, Florida, 1999-2008 Meningitis, 1.2Other Crude Data 1.0 Figure 1. NumberMeningitis, ofMeningitis, Cases Other Other (bacterial, (bacterial, 199 Meningitis, Other (bacterial, cryptococcal, mycotic) Incidence Rate by Year Reported, Florida, 1999-2008 cryptococcal, mycotic): 0.8 2008 incidencecryptococcal, rate per mycotic): 1.2 Crude Data 100,000 Crude Data 1.05 Number of Cases 199 1.00.6 % changeNumber from of average Cases 5 199 0.80.4 year2008 (2003-2007)2008 incidence incidence rate incidence rateper per 100,000 per Cases 100,000100,000 1.05 rate 1.0533.44 0.6 % change from average 5 0.2 % change from average 5 0.4 Age (yrs)year (2003-2007) incidence 100,000 per Cases year (2003-2007) incidence rate Mean 36.7533.44 0.0 rate 33.44 0.2 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Age (yrs) Median 41 Age (yrs) Mean 36.75 0.0 Year Min-Max <1 - 93 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 MeanMedian 36.75 41 Year MedianMin-Max 41 <1 - 93 Disease AbstractMin-Max <1 - 93

The “meningitis,Disease Abstract other” category includes any meningitis due to any bacterial or fungal species The “meningitis, other” category includes any meningitis due to any bacterial or fungal species otherDisease than NeisseriaAbstract meningitidis or Haemophilus influenzae, with an isolate from the blood or cerebralThe other“meningitis, spinal than fluid. Neisseria other” Incategory 2008,meningitidis includes some or anycommon Haemophilus meningitis pathogens dueinfluenzae to any isolated,bacterial with an orisolate were fungal fromCryptococcus species the blood other orthan Neisseriacerebral meningitidis spinal fluid. or Haemophilus In 2008, some influenzae common, with pathogens an isolate isolated from the were blood Cryptococcus or cerebral spinal fluid. In neoformansneoformans, Escherichia, Escherichia coli coli, Pseudomonas, Pseudomonas species, species, Klebsiella Klebsiella pneumoniae pneumoniae, Staphylococcal, Staphylococcal species,2008, someand commonStreptococcal pathogens species. isolated were Cryptococcus species (61), Staphylococcal species (40), Streptococcalspecies, andspecies Streptococcal (27), Klebsiella species. pneumoniae (6), Escherichia coli (5), and Pseudomonas species (5).

FigureFigure 2. 2. Meningitis, Other (bacterial, cryptococcal, mycotic) Cases by Month Meningitis, Other (bacterial, cryptococcal, mycotic) Cases by Month of Onset, Florida, 2008 30 of Onset, Florida, 2008 30

25 25 20

20 15

15 10 Numberof Cases

10 5 Numberof Cases

0 5 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 0 5yr average 2008 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month The incidence rate of “meningitis, other” has increased5yr average gradually2008 over the previous 10 years and in 2008 there was a 33.44% increase in the incidence rate as compared to the previous 5-year average (Figure 1). A total of 199 cases were reported in 2008, all confirmed. The number of TheThe incidence casesincidence of “meningitis,rate rate of “meningitis,“meningitis, other” shows other” other” little has difference hasincreased increased by gradually season gradually overwhen the averaged previousover the over 10 previous yearsseveral and years 10 in 2008years and in 2008therebut therewas there a 33.44%was did seema 33.44%increase to be increased inincrease the incidence incidence in the rate incidence in as the compared fall and rate winterto asthe comparedpreviousof 2008 (Figure 5-year to the 2).average previousThere (Figure 5-year were no “meningitis, other” outbreaks in 2008. average1). A total (Figure of 199 1). cases A total were of reported 199 cases in 2008, were all confirmed. reported inThe 2008, number all ofconfirmed. cases of “meningitis, The number other” of shows little difference by season when averaged over several years but there did seem to be increased casesincidence of “meningitis, in the fall and other” winter shows of 2008 little (Figure difference 2). There by were season no “meningitis, when averaged other” outbreaks over several in 2008. years but there did seem to be increased incidence in the fall and winter of 2008 (Figure 2). There were no “meningitis, other” outbreaks in 2008.

115 2008 Florida Morbidity Statistics

Figure 3. Meningitis, Other (bacterial, cryptococcal, mycotic) Disease Incidence Rate by Age Group, Florida, 2008 16

Cases per 100,000 per Cases 4

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

The highestThe highest incidence incidence rates rates continue continue to occur to occur in infants in infants <1 year <1 year(Figure (Figure 3). Immunosuppressed 3). Immunosuppressed or immunocompromisedor immunocompromised people inpeople the older in the age older groups age maygroups also may be alsoat risk be for at infection.risk for infection. Males continue Males to havecontinue a higher toincidence have a higherthan females incidence (1.40 than per females 100,000 (1.40 and per0.72 100,000 per 100,000 and 0.72 respectively). per 100,000 Incidence ratesrespectively). in non-white males Incidence are more rates than in non-white double the males incidence are more rates than in whitedouble males. the incidence rates in white males. “Meningitis, other” was reported by 32 of the 67 counties in Florida. Counties with the highest incidence rates“Meningitis, were widely other” scattered. was reported by 32 of the 67 counties in Florida. Counties with the highest incidence rates were widely scattered. Prevention PracticingPrevention good personal hygiene will reduce the chances of a fungal or bacterial infection. Practicing good personal hygiene will reduce the chances of a fungal or bacterial infection.

116

References American Academy of Pediatrics. Red Book 2003: Report of the Committee on Infectious Diseases, 26th ed., Elk Grove Village, Illinois, American Academy of Pediatrics Press, 2003.

N. Jabbour, J. Reyes, S. Kusne, M. Martin, J. Fung, “Cryptococcal meningitis after liver transplantation,” Transplantation, Vol. 61, 1996, pp. 146-167.

J.H. Price, J. de Louvois, M. R. Workman, “Antibiotics for Salmonella meningitis in children,” Journal of Antimicrobial Chemotherapy, Vol. 46, 2000, pp. 653-655.

A. Varaiya, K. Saraswathi, U. Tendolkar, A. De, S. Shah, M. Mathur, “Salmonella enteritidis meningitis – A case report,” Indian Journal of Medical Microbiology, Vol. 19. 2001, pp. 151-152.

A. Zuger, E. Louie, R.S. Holzman, M.S. Simberkoff, J.J. Rahal, “Cryptococcal disease in patients with the acquired immunodeficiency syndrome. Diagnostic features and outcome of treatment,” Annals of Internal Medicine, Vol. 104, 1986, pp. 234-40.

A. Lerche, N. Rasmussen, J.H. Wandall, V.A. Bohr, “Staphylococcus aureus meningitis: a Summary of Selected Notifiable Diseases and Conditions

References American Academy of Pediatrics. Red Book 2003: Report of the Committee on Infectious Diseases, 26th ed., Elk Grove Village, Illinois, American Academy of Pediatrics Press, 2003.

N. Jabbour, J. Reyes, S. Kusne, M. Martin, J. Fung, “Cryptococcal meningitis after liver transplantation,” Transplantation, Vol. 61, 1996, pp. 146-167.

J.H. Price, J. de Louvois, M. R. Workman, “Antibiotics for Salmonella meningitis in children,” Journal of Antimicrobial Chemotherapy, Vol. 46, 2000, pp. 653-655.

A. Varaiya, K. Saraswathi, U. Tendolkar, A. De, S. Shah, M. Mathur, “Salmonella enteritidis meningitis – A case report,” Indian Journal of Medical Microbiology, Vol. 19. 2001, pp. 151-152.

A. Lerche, N. Rasmussen, J.H. Wandall, V.A. Bohr, “Staphylococcus aureus meningitis: a review of 28 community acquired cases,” Scandinavian Journal of Infectious Diseases, Vol. 27, No. 6, 1995, pp. 569-573.

Meningococcal Disease Meningococcal Disease

Meningococcal Disease: Figure 1. Meningococcal Disease: Meningococcal Disease Incidence Rate by Year Reported, Florida, Crude Data 1999-2008 Number of CasesCrude Data 51 1.0 Number of Cases 51 2008 incidence rate per 0.8 100,0002008 incidence rate per 0.27 100,000 0.27 0.6 % change from average 5- 5-year (2003-2007) incidence year (2003-2007) incidence 0.4 raterate -45.19-45.19 Cases per 100,000 Cases Age (yrs) 0.2 Mean 33.45 0.0 Median 30 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max <1 - 83 Year

Disease Abstract DiseaseMeningococcal Abstract disease includes both meningitis and septicemia due to the bacteria Neisseria Meningococcalmengitidis. There disease are many includes different both serogroupsmeningitis and of Neisseria septicemia menigitidis due to the around bacteria the Neisseria world. The mengitidis . Therecommon are ones many in different the United serogroups States include of Neisseria A, B, C, menigitidis W-135, and around Y. The the reportedworld. The incidence common rate ones in thefor meningococcalUnited States include disease A, hasB, C, declined W-135, gradually and Y. The over reported the previous incidence 10 years, rate for and meningococcal in 2008 was disease hasless declined than half gradually of what it over was the10 yearsprevious ago 10 (Figur years,e 1). and In in 2008, 2008 therewas lesswas thana 45.19% half of decrease what it was in 10 years agocomparison (Figure 1).to the In 2008,average there incidence was a 45.19% from 2003-2007. decrease inA comparisontotal of 51 cases to the were average reported incidence in from 2003-2007.2008, of which A total 96% of were 51 cases classified were as reported confirmed in 2008, cases. of whichThere 96%is a general were classified increase inas casesconfirmed in cases. Thereearly winteris a general and late increase spring in(Figure cases 2). in earlyThis maywinter be and due late in part spring to social(Figure gatherings 2). This mayas well be dueas in part to socialstaying gatherings indoors in as the well fall as and staying winter indoors months. in Therethe fall were and winterfour cases months. reported There as were outbreak- four cases reported asrelated outbreak-related in 2008 due into 2008a primary due toand a primarysecondary and case secondary among case family among members. family There members. were There were sevenseven casescases thatthat resultedresulted inin death.death.

Figure 2. Meningococcal Disease Cases by Month of Onset, Florida, 2008 117 12

4 Number of Cases Numberof

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008

The highest incidence rates continue to occur in infants <1 year. There are no vaccines approved for use in those less than two years old. In 2007, the incidence rates were lower than or equal to the previous 5-year average in all age groups (Figure 3). In 2008, the incidence rate in white females was greater than that in non-white females (0.32 and 0.05 per 100,000, respectively). Forty-five of the 51 cases had specimens submitted to the Bureau of Laboratories Meningococcal Disease

Figure 1. Meningococcal Disease: Meningococcal Disease Incidence Rate by Year Reported, Florida, 1999-2008 Crude Data 1.0 Number of Cases 51 2008 incidence rate per 0.8 100,000 0.27 0.6 % change from average 5- year (2003-2007) incidence 0.4 rate -45.19 Cases per 100,000 Cases Age (yrs) 0.2 Mean 33.45 0.0 Median 30 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max <1 - 83 Year

Disease Abstract Meningococcal disease includes both meningitis and septicemia due to the bacteria Neisseria mengitidis. There are many different serogroups of Neisseria menigitidis around the world. The common ones in the United States include A, B, C, W-135, and Y. The reported incidence rate for meningococcal disease has declined gradually over the previous 10 years, and in 2008 was less than half of what it was 10 years ago (Figure 1). In 2008, there was a 45.19% decrease in comparison to the average incidence from 2003-2007. A total of 51 cases were reported in 2008, of which 96% were classified as confirmed cases. There is a general increase in cases in early winter and late spring (Figure 2). This may be due in part to social gatherings as well as staying indoors in the fall and winter months. There were four cases reported as outbreak- related in 2008 due to a primary and secondary case among family members. There were 2008 Florida Morbidity Statistics seven cases that resulted in death.

Figure 2. Meningococcal Disease Cases by Month of Onset, Florida, 2008 12

4 Number of Cases Numberof

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008

The highest incidence rates continue to occur in infants <1 year. There are no vaccines approved for use Thein highest those less incidence than two yearsrates old. continue In 2008, to the occur incidence in infants rates were<1 year. lower thanThere or equalare no to thevaccines previous approved5-year averagefor use in in all those age groups less than(Figure two 3). years In 2008, old. the Inincidence 2007, therate incidencein white females rates was were greater lower than orfor equal serogroupingthan that to thein non-white previous (Table females 1).5-year (0.32 average and 0.05 in perall 100,000,age groups respectively). (Figure 3).Forty-five In 2008, of the the 51 incidencecases had rate in whitespecimens females submitted was greaterto the Bureau than ofthat Laboratories in non-white for serogrouping females (0.32 (Table and 1). 0.05 per 100,000, respectively). Forty-five of the 51 cases had specimensFigure 3. submitted to the Bureau of Laboratories Meningococcal Disease Incidence Rate by Age Group, Florida, 2008

Cases per 100,000 per Cases 1

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

Meningococcal disease was reported in 21 of the 67 counties in Florida. Counties in central and Meningococcalnortheastern Florida disease reported was thereported highest inincidence 21 of the rates. 67 counties in Florida. Counties in central and northeastern Florida reported the highest incidence rates.

Table 1. Cases of Meningococcal Disease, by Serogroup, Florida, 2008 Serogroup Number of Cases

Group A 0 Group B 17 Group C 7 118 Group Y 13 Group W-135 5 Non-Groupable 1 Not Answered 7 Unknown 1 Total 51

Prevention Meningococcal vaccines are available to reduce the likelihood of contracting Neisseria meningitidis. Two vaccines, licensed in 1978 and 2005, each provide protection against four serogroups (A, C, Y, and W-135). In addition, droplet precautions should be implemented if the individual is hospitalized. Anyone who has close contact with an infected person’s respiratory or oral secretions (i.e., kissing, sharing utensils or drinks, exposure to respiratory secretions during health care or resuscitation, or close household or social contact) should receive antibiotic prophylaxis with an approved regimen (most often used are ciprofloxacin and rifampin).

Please see “Section 4: Summary of Antimicrobial Resistance Surveillance” for additional information on MeningNet, an enhanced meningococcal surveillance system used to monitor antimicrobial susceptibility.

Summary of Selected Notifiable Diseases and Conditions

Table 1. Cases of Meningococcal Disease, by Serogroup, Florida, 2008 Serogroup Number of Cases Group A 0 Group B 17 Group C 7 Group Y 13 Group W-135 5 Non-Groupable 1 Not Answered 7 Unknown 1 Total 51 Prevention Meningococcal vaccines are available to reduce the likelihood of contracting Neisseria meningitidis. Two vaccines, licensed in 1978 and 2005, each provide protection against four serogroups (A, C, Y, and W-135) and are recommended for selected populations at increased risk of meningococcal disease. In addition, droplet precautions should be implemented if the individual is hospitalized. Anyone who has close contact with an infected person’s respiratory or oral secretions (i.e., kissing, sharing utensils or drinks, exposure to respiratory secretions during health care or resuscitation, or close household or social contact) should receive antibiotic prophylaxis with an approved regimen (most often used are ciprofloxacin and rifampin).

119 References American Academy of Pediatrics, Red Book 2003: Report of the Committee on Infectious Diseases, 26th ed., American Academy of Pediatrics Press, Elk Grove Village, Illinois, 2003.

Centers for Disease Control and Prevention, “Prevention and Control of Meningococcal Disease,” Morbidity and Mortality Weekly Report, Vol. 54, No. RR07, 2005, pp.1-21.

Centers for Disease Control and Prevention, “Control and prevention of meningococcal disease and control and prevention of serogroup C meningococcal disease: evaluation and management of suspected outbreaks; recommendations of the Advisory Committee on Immunization Practices (ACIP),” Morbidity and Mortality Weekly Report, Vol. 46, No. RR- 5, 1997, pp. 1-21.

Centers for Disease Control and Prevention, “Meningococcal disease and college students: recommendations of the Advisory Committee on Immunization Practices (ACIP),” Morbidity and Mortality Weekly Report, Vol. 49, No. RR-7, 2000, pp. 11-20.

2008 Florida Morbidity Statistics

References American Academy of Pediatrics, Red Book 2003: Report of the Committee on Infectious Diseases, 26th ed., American Academy of Pediatrics Press, Elk Grove Village, Illinois, 2003.

Centers for Disease Control and Prevention, “Prevention and Control of Meningococcal Disease,” Morbidity and Mortality Weekly Report, Vol. 54, No. RR07, 2005, pp.1-21.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) website at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/meningococcal_g.htm and http://www.cdc.gov/vaccines/ pubs/pinkbook/downloads/mening.pdf.

MumpsMumps

Figure 1. Mumps: Crude Data Mumps Cases by Year Reported, Florida, 1999-2008 Mumps: Crude Data Number of Cases 16 25 2008Number incidence of Cases rate per 16 20 100,0002008 incidence rate per 0.08 % 100,000change from average 5-year 0.08 15 (2003-2007)% change reportedfrom average cases 5-year 33.33 10 (2003-2007) reported cases 33.33 Age (yrs) CasesNumber of Age (yrs) Mean 23.5 5 MedianMean 23 23.5 Median 23 0 Min-Max 1 - 54 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 1 - 54 Year

Disease Abstract The statewide incidence rate for confirmed and probable cases of mumps for all ages was 0.08 per 100,000Disease population. Abstract The ages ranged from 1-54 years. There were 12 confirmed cases and four probableThe statewide cases of incidence mumps reported rate for confirmedin 2008, of and which probable one was cases acquired of mumps in a state for all other ages than was Florida 0.08 and fourper were 100,000 acquired population. outside ofThe the ages U.S. ranged Three fromof the 1-54 cases years were of hospitalized.age. There were Seven 12 ofconfirmed the 16 total cases hadcases received and fourvaccine, probable two had cases no ofhistory mumps of vaccine,reported andin 2008, seven of hadwhich unknown one was immunization acquired in astatus. state other than Florida and four were acquired outside of the U.S. Three of the cases were Thehospitalized. twelve confirmed Seven ofcases the representcases had areceived slight increase vaccine, from two the had ten no confirmedhistory of vaccine, cases in and 2007 even thoughseven the had total unknown number immunization of cases (confirmed status. plus probable) declined in 2008. Incidence of mumps was relatively unchanged from 2000 to 2005. However, in 2006 there was a significant increase in cases in theThe U.S., twelve especially confirmed in the cases college-age represent population. a slight increase This trend from continued the ten confirmed in 2007 with cases an increasein 2007 of 128% overeven the though average the number total number of cases of reportedcases (confirmed in the previous plus probable) five years, declined but slowed in 2008. for Incidence2008 when of there wasmumps an increase was relatively of 33% overunchanged the previous from 2000 5-year to average.2005. However, in 2006 there was a significant increase in cases in the U.S., especially in the college-age population. This trend continued in 2007 with an increase of 128.26% over the average number of cases reported in the previous 120 five years, but slowed for 2008 when there was an increase of 33.33% over the previous 5-year average.

Figure 3. Mumps Cases by Age Group, Florida, 2008

Numberof Cases 1

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

Mumps

Figure 1. Mumps Cases by Year Reported, Florida, 1999-2008 Mumps: Crude Data 25 Number of Cases 16 20 2008 incidence rate per 100,000 0.08 15 % change from average 5-year 10 (2003-2007) reported cases 33.33 Number of CasesNumber of Age (yrs) 5 Mean 23.5 Median 23 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 1 - 54 Year

Disease Abstract The statewide incidence rate for confirmed and probable cases of mumps for all ages was 0.08 per 100,000 population. The ages ranged from 1-54 years of age. There were 12 confirmed cases and four probable cases of mumps reported in 2008, of which one was acquired in a state other than Florida and four were acquired outside of the U.S. Three of the cases were hospitalized. Seven of the cases had received vaccine, two had no history of vaccine, and seven had unknown immunization status.

The twelve confirmed cases represent a slight increase from the ten confirmed cases in 2007 even though the total number of cases (confirmed plus probable) declined in 2008. Incidence of mumps was relatively unchanged from 2000 to 2005. However, in 2006 there was a significant increase in cases in the U.S., especially in the college-age population. This trend continued in 2007 with an increase of 128.26% over the average number of cases reported in the previous Summaryfive years, of Selected but slowedNotifiable for Diseases2008 when and Conditions there was an increase of 33.33% over the previous 5-year average.

Figure 3. Mumps Cases by Age Group, Florida, 2008

Numberof Cases 1

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

Prevention Vaccination with two doses of mumps (preferably MMR) vaccine is recommended. The first dose of MMR should be given at 12 months of age and the second dose at kindergarten entrance. Proof of MMR is required for entry and attendance in childcare facilities, family day care homes, and kindergarten through twelfth grade. Many colleges in Florida also require mumps vaccination for entry. After the 2006 multi-state mumps outbreak in young adults, two doses of mumps vaccine are now recommended for all children and young adults.

References Centers for Disease Control and Prevention, Manual for the Surveillance of Vaccine-Preventable Diseases, 4th ed., 2008, Chapter 9.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/vaccines/vpd-vac/mumps/default.htm#clinical.

Recommended immunization schedule is available at: http://www.cdc.gov/vaccines/recs/ schedules/ default.htm.

Neonatal Infections

Description The term “neonatal infections” includes reported cases of chlamydia, gonorrhea, syphilis, herpes simplex virus (HSV), and human papillomavirus (HPV) diagnosed in infants up to six months of age. This extended age range is used in order to capture delayed identification of chlamydial pneumonia and human papillomavirus infections that are not readily identifiable upon birth. Reporting parameters for neonatal infections were updated in November 2008 in F.A.C. 64D-3.

Disease Abstract In 2008, 11,150 pregnant women were infected with a sexually transmitted disease (STD). During the same time period, thirty-seven infants were diagnosed with an STD-related neonatal infection.

121 Neonatal Infections

Disease Abstract In 2008, 11,150 females were pregnant and also infected with a sexually transmitted2008 Florida disease Morbidity Statistics (STD). During the same time period, thirty-seven infants were diagnosed with an STD-related neonatal infection. The 2008 distribution of neonatal infections by disease is displayed in Figure The1. During 2008 distribution 2008, chlamydia of these and 37 syphilis neonatal accounted infections for by nearly disease 95% is displayedof all neonatal in Figure infections 1. During and 2008, chlamydiathere were and no casessyphilis of accounted HPV reported for nearly among 95% neonates. of these Fourteen neonatal countiesinfections. reported There neonatalwere no cases of HPVinfections reported in 2008 among with neonates. the highest Fourteen number counties of neonatal reported infections neonatal occurring infections in Dade in 2008 (12) withfollowed the highest numberby Broward of neonatal (5) and infectionsDuval (4). occurring in Dade (12) followed by Broward (5) and Duval (4).

Figure 1. Reported Cases of Neonatal Infections, 2008

Chlamydia, 17, 46% Gonorrhea, 1, 3%

HSV, 1, 3%

Syphilis, 18, 48% The racial/ethnic distribution of neonatal infections is reflective of trends seen in all reported STD

cases,The racial/ethnic with an excess distribution in minority of neonatal populations. infections Non-Hispanic is reflective black of trends neonates seen accounted in all reported for 54.1% of theSTD neonatal cases and infections; disproportionately whereas non-Hispanic affects minority whites populations. accounted Non-Hispanicfor 21.8%. The black remaining neonates cases were reportedaccounted in Hispanicsfor 54.1% (8.1%)of the neonatal or the other/unknown infections; whereas category non-Hispanic (12.0%). There whites were accounted no significant for racial/ ethnic21.8%. differences The remaining among cases disease were categories. reported in Hispanics (8.1%) or the other/unknown category (12.0%). There were no significant racial/ethnic differences among disease categories. Prevention InadequatePrevention or no prenatal care is the primary risk factor for neonatal infections. Untreated STD infections inInadequate pregnancy or can no haveprenatal adverse care effectsis the primary on the babyrisk factor before, for during, neonatal or infections.after the baby’s Untreated birth. STDThese infectionsinfections remain in pregnancy a leading can cause have ofadverse preventable effects morbidity on the baby among before, newborns. during, orAdverse after the outcomes baby’s include: lowbirth. birth These weight, infections eye infections, remain aneurological leading cause damage, of preventable and death. morbidity However among, the frequencynewborns. and severity ofAdverse complications outcomes related include: to STD low infectionsbirth weight, in neonates eye infections, are underestimated, neurological damage, as is the and true death. burden of diseaseHowever, in Florida.the frequency It is imperative and severity that of women complications be routinely related screened to STD for infections STDs during in neonates pregnancy are and be appropriatelyunderestimated treated. and do not describe the true burden of disease in Florida. It is imperative that women are routinely screened for STDs during pregnancy and are appropriately treated. References Florida Administrative Code, Chapter 64D-3. Florida Department of State. November 24, 2008. Available online at https://www.flrules.org/gateway/ChapterHome.asp?Chapter=64D-3.

Schrag SJ, Arnold KE, Mohle-Boetanie JC, et. al., “Prenatal Screening for Infectious Diseases and Opportunities for Prevention.” Obstetrics and Gynecology, 2003, Vol. 102, pp. 753-760.

122 Pertussis

Figure 1. Summary of Selected Notifiable Diseases and Conditions Pertussis Incidence Rate by Year Reported, Florida, 1999-2008 Pertussis: Crude Data 1.8 Pertussis1.6 Number of Cases 314 Pertussis 1.4

2008 incidence rate per 1.2 Figure 1. Pertussis Incidence Rate by Year Reported, Florida, 1999-2008 100,000 Pertussis: Crude Data 1.66 1.0 % changePertussis: from average Crude 5- Data 1.8 Number of Cases 314 0.8 year (2003-2007) incidence 1.6 Number of Cases 314 100,000 per Cases rate 2008 incidence rate per 67.60 1.4 0.6 2008 incidence rate per 100,000 1.66 1.2 0.4 Age 100,000(yrs) 1.66 % change from average 1.0 % change fromMean average 5- 9.97 0.2 5-year (2003-2007) incidence 0.8 year (2003-2007) incidence 0.0 rate Median 67.60 5 100,000 per Cases 0.6 rate 67.60 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max <1 - 73 0.4 AgeAge (yrs)(yrs) Year MeanMean 9.979.97 0.2 MedianMedian 55 0.0 Disease Abstract 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-MaxMin-Max <1<1 -- 7373 Disease trends in Florida, and nationwide, indicate that pertussis casesYear have increased significantly since 2001 (Figure 1). Case numbers went from 30 cases in 2001 (22 confirmed Disease Abstract casesDiseaseDisease and 8 trendsAbstract probable in Florida, cases) and tonationwide, a peak ofindicate 314 casesthat pertussis in 2008 cases (239 have confirmed increased cases and 75 Disease trends in Florida, and nationwide, indicate that pertussis cases have increased significantly probablesignificantly cases). since In 2001 the (Figureprevious 1). fiveCase years, numbers most went cases from 30 occurred cases in 2001during (22 the confirmed summer months, since 2001 (Figure 1). Case numbers went from 30 in 2001 (22 confirmed and 8 probable) to a high of but manycases andcases 8 probable occurred cases) in theto a fallpeak and of 314 winter cases months in 2008 in(239 2008 confirmed (Figure cases 2). and In the75 previous five 314 cases in 2008 (239 confirmed cases and 75 probable cases). In the previous five years, most cases probable cases). In the previous five years, most cases occurred during the summer months, years,occurred pertussis during cases the summer were months,consistent but manybetween cases gender occurred and in the race. fall and In winter2008, months however, of 2008 white but many cases occurred in the fall and winter months in 2008 (Figure 2). In the previous five males(Figure and 2).females In the previoushad significantly five years, higherpertussis rates. rates were similar by gender and race. In 2008, however, years, pertussis cases were consistent between gender and race. In 2008, however, white white males and females had significantly higher rates. males and females had significantly higher rates. Figure 2. Pertussis CasesFigure by Month 2. of Onset, Florida, 2008 50 Pertussis Cases by Month of Onset, Florida, 2008 4550 45 40 40 3535 3030 2525 2020

Number of Cases Numberof 15

Number of Cases Numberof 15 10 10 5 50 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr MayMonth Jun Jul Aug Sep Oct Nov Dec 5yr average 2008 Month 5yr average 2008

AsAs inin thethe previousprevious fivefive years, years, most most pertussis pertussis cases cases were were identified identified in ininfants infants and and young young children. children. Of Of the 314 reported cases in 2008, 93 were reported in infants less than 12 months of age; too As inthe the 314 previous reported fivecases years, in 2008, most 93 were pertussis reported cases in infants were less identified than 12 months in infants of age, and too youngyoung to children. younghave completed to have completed the vaccination the vaccination series (Figure series 3). (Figure Of the 3). 2008 Of thecases, 2008 208 cases, were 208 in children were in under nine Of thechildrenyears 314 old, reportedunder and nine96 were casesyears hospitalized. old. in 2008, Of the One93reported were death cases, reported occurred 96 were in in a infants two-week-oldhospitalized. less thanHispanicOne death 12 infant;months the of mother age; too youngoccurredalso to had have ain cougha completed two-week-old illness that the Hispanic was vaccination undiagnosed. infant; the series mother Another (Figure also two-week-old had 3). a cough Of theHispanic illness 2008 that infant cases, was with 208 pertussis were in childrenundiagnosed.developed under acute nine Another encephalopathy years two-week-old old. Of with the Hispanic severe reported sequela.infant cases, with Case pertussis 96 reports were developed show hospitalized. that acute 139 cases One did death not receive encephalopathyvaccine; of these, with 41 severe(30%) hadsequela. refused Case vaccination. information reflects 139 did not receive vaccine; of occurredthese, in41 a (30%) two-week-old had refused Hispanic vaccination. infant; the mother also had a cough illness that was undiagnosed. Another two-week-old Hispanic infant with pertussis developed acute encephalopathy with severe sequela. Case information reflects 139 did not receive vaccine; of these, 41 (30%) had refused vaccination.

123 2008 Florida Morbidity Statistics

Figure 3. Pertussis Incidence Rate by Age Group, Florida, 2008

45 40 35 30 25 20 15

Cases per 100,000 per Cases 10 5 0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

Pertussis was reported in 41 of the 67 counties in Florida. Counties in the northeast, northwest, and central regions of Florida reported the highest incidence rates. Pertussis was reported in 41 of the 67 counties in Florida. Counties in the northeast, northwest, andPrevention southeast regions of Florida reported the highest incidence rates. Currently, only acellular pertussis vaccines combined with diphtheria and tetanus toxoids (DTaP and PreventionTdap) are available in the U.S. The five DTaP doses should be administered to children at two months, Currently,four months, only six acellularmonths, 15–18 pertussis months, vaccines and 4–6 combined years of age. with This diphtheria vaccine is and also tetanus available toxoids in (DTaP andcombination Tdap) are with available other childhood in the vaccines.U.S. The The five increase DTaP dosesin disease should in the be early administered teenage years to indicateschildren at that immunity decreases over time. Vaccine recommendations now include one dose of Tdap vaccine twoto be months, given between four months, 10 and 64six years months, of age. 15–18 As of months, school year and 2009-2010, 4–6 years Tdap of age. vaccine This is requiredvaccine to is alsomeet available the seventh in combinationgrade vaccination with requirement. other childhood Post-exposure vaccines. antibiotic The increase and vaccine in diseaseprophylaxis in theof earlyclose teenage contacts ofyears a case indicates are the major that immunityoutbreak control decreases measures over to time. stop pertussis Vaccine transmission. recommendations now include one dose of Tdap vaccine to be given between 10 and 64 years of age. As of school year 2009-2010, Tdap vaccine is required to meet the seventh grade vaccination requirement. Post-exposure antibiotic and vaccine prophylaxis of close contacts of a case are the major outbreak control measures to stop pertussis transmission.

124

References Centers for Disease Control and Prevention, Manual for the Surveillance of Vaccine- Preventable Diseases, 4th ed., 2008, Chapter 10.

Centers for Disease Control and Prevention, Guidelines for the Control of Pertussis Outbreaks. Centers for Disease Control and Prevention: Atlanta, GA, 2000. Web site: http://www.cdc.gov/vaccines/pubs/pertussis-guide/guide.htm

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at www.cdc. gov/vaccines/vpd-vac/pertussis/default.htm.

Recommended immunization schedule is available at: http://www.cdc.gov/vaccines/recs/ schedules/default.htm.

Summary of Selected Notifiable Diseases and Conditions

References Centers for Disease Control and Prevention, Manual for the Surveillance of Vaccine-Preventable Diseases, 4th ed., 2008, Chapter 10.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at www.cdc. gov/vaccines/vpd-vac/pertussis/default.htm.

Recommended immunization schedule is available at: http://www.cdc.gov/vaccines/recs/ schedules/ default.htm.

Rabies, Animal Rabies, Animal

Figure 1. Rabies, Animal: Crude Data Animal Rabies by Year Reported, Florida, 1999-2008 Rabies, Animal: Crude Data Number of Cases 144 250 2008Number incidence of Cases rate per 144 200 100,0002008 incidence rate per NA 100,000 NA % change from average 150 5-year% change (2003-2007) from average reported 5- year (2003-2007) reported cases -19.82 100 cases -19.82 Age (yrs) Number of Cases Age (yrs) 50 MeanMean NA NA MedianMedian NA NA 0 Min-Max NA Min-Max NA 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Disease Abstract FromDisease 1999 Abstract through 2008, there was one human rabies case in Florida. The person was bitten by a dog inFrom Haiti 1999in 2004 through and became 2008, there ill after was returning one human to Florida. rabies caseA canine in Florida. variant Thestrain person of rabies was then bitten circulating inby Haiti a dog was in isolatedHaiti in 2004from theand patient. became In ill 2008,after return post-exposureing to Florida. treatment A canine was variantrecommended strain of for 1,618 peoplerabies inthen Florida; circulating there inwere Haiti no was human isolated cases from reported the patient. in 2008. In 2008, post-exposure treatment was recommended for 1,618 people in Florida; there were no human cases reported in 2008. Rabies is endemic in the raccoon and bat populations of Florida, and frequently spills out from raccoons intoRabies other is animal endemic populations. in the raccoon Laboratory and bat testing populations for animal of Florida, rabies and is only frequently done when spills animals out from are involvedraccoons in intoexposures other animal to humans populations. or domestic Laboratory animals, testing and the for dataanimal do rabiesnot necessarily is only done correlate when with the trueanimals prevalence are involved of rabies in exposures in Florida. to Of humans the 3,598 or domesticanimals tested animals, at the and Bureau the data of doLaboratories not (BOL) innecessarily 2008, there correlate were 144 with confirmed the true prevalencerabid animals, of rabies representing in Florida. a 19.8% Of the decrease 3,598 animals from the tested previous 5-yearat the averageBureau ofbut Laboratories a 10% increase (BOL) from in 20 2007.08, there After were a trough 144 confirmedin reported rabid cases animals, in 2007 suspected to berepresenting associated awith 19.8% raccoon decrease distemper from theoutbreaks previous statewide, 5-year average overall butcase a numbers10% increase seem from to be increasing to2007. more Aftertypical a troughlevels (20-yearin reported avg. cases 186 cases/yr).in 2007 suspected No cases to werebe associated identified with as beingraccoon associated with outbreaks.distemper outbreaksIn 2008, rabid statewide, animals overall were foundcase numbers in 42 of 67seem counties to be inincreasing Florida, withto more highest typical activity in thelevels central (20-year part of avg. the 186state. cases/yr). Three counties No cases reported were identified more than as 10 being cases: associated Leon (15); with Marion (19); and Orangeoutbreaks. (10) (seeIn 2008, map). rabid Cases animals were were reported found in in each 42 of month 67 counties of the year,in Florida, with peakswith highest in July (17), June (15),activity and concentrated February (14). in theCase central numbers part ofpeaked the state. slightly Three earlier counties in 2008 reported as August more is thanhistorically 10 the peak monthcases: for Leon rabies (15); activity Marion in (19);Florida, and and Orange March (10) rather (see than map). February Cases is were often reported a peak inmonth each in month the early part ofof the the year. year, Highestwith peaks numbers in July of (17), positive June raccoon (15), and cases February were (14).reported Case in February,numbers peakedMarch, June, slightly earlier in 2008 as August is historically the peak month for rabies activity in Florida, and March rather than February is often a peak month in the early part of the year. Highest numbers of positive raccoon cases were reported in February, March, June, and July with nine 125 cases each. September and April had the most rabid fox reports, with five and four cases respectively. Although rabid bat cases typically peak in August, in 2008 the most rabid bat cases were reported in October (4), followed by June (3) and July (3).

and July with nine cases each. September and April had the most rabid fox reports, with five and four cases respectively. Although rabid bat cases typically peak in August, in 2008 the most rabid bat cases were reported in October (4), followed by June (3) and July (3).

Raccoons once again accounted for the majority of cases (88, 61%), followed by foxes (20, 14%), bats (20, 14%), and cats (9, 6%). Two rabid raccoons that had been “adopted” as pets each exposed multiple people including children (see Section 6). There were no dogs found to be rabid in 2008, although over 1,000 were tested. Since 1997, rabid cats have continued to outnumber rabid dogs, though rabies vaccination is compulsory for both. All positive cats were either not vaccinated for rabies or had unknown rabies vaccination history. All positive cats were feral or primarily resided outdoors. Two of the cats that tested positive for rabies in 2008 each exposed 15 or more people (see Section 6). One horse and one mule were found to be rabid, and three bobcats and two skunks were also positive for rabies. Testing at the BOL demonstrates that terrestrial rabies in Florida is primarily due to the raccoon variant.

Prevention During 2008, the Florida Rabies Advisory Committee revised the rabies guidebook to provide information for county health departments and others involved in rabies control and prevention. Other preventive measures include: vaccination of pets and at-risk livestock; avoiding direct human and domestic animal contact with wild animals; educating the public to reduce contact with stray and feral animals; supporting animal control in efforts to reduce feral and stray animal populations; bat-proofing homes; and providing pre-exposure prophylaxis for people in high risk professions, such as animal control and veterinary personnel, laboratory workers, and those working with wildlife. Pre-exposure prophylaxis should also be considered for those traveling extensively where rabies is common in domestic animals. Oral bait vaccination programs for wildlife are possible in some situations. These programs can be effective but require careful advance planning and substantial time and financial commitments.

Animal Rabies Cases by County, Florida, 2008

126 Summary of Selected Notifiable Diseases and Conditions

References Florida Rabies Advisory Committee, Rabies Prevention and Control in Florida, 2007, Florida Department of Health, Bureau of Community Environmental Health, 2006.

David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

L.K. Pickering, C.J. Baker, S.S. Long, and J.A. McMillan (eds.), Red Book: 2006 Report of the Committee on Infectious Diseases, 27th ed., American Academy of Pediatrics Press, 2006.

Additional Resources Information is available from the Florida Department of Health website at http://www.doh.state.fl.us/ environment/medicine/rabies/rabies-index.html

Disease information is also available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncidod/dvrd/rabies/introduction/intro.htm.

Rabies,Rabies, PossiblePossible ExposureExposure

Rabies, Possible Exposure: Figure 1. Rabies, Possible Exposure: Rabies, Possible Exposure Incidence Rate by Year Reported, Crude Data Crude Data Florida, 2000-2008 Number of Cases 1618 Number of Cases 1618 10 2008 incidence rate per 2008 incidence rate per 100,000 8 100,000 8.56 8.56 % change% change from averagefrom average 5- 6 5-yearyear (2003-2007) (2003-2007) incidence 4 incidencerate rate 26.0426.04 Cases per 100,000 2 Age (yrs)Age (yrs) MeanMean 36.53 36.53 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 MedianMedian 36 36 Min-MaxMin-Max <1 - 108 <1 - 108 Year

Disease Abstract DiseaseElectronic Abstract reporting through the Merlin system of animal encounters (bites, scratches, etc.) for Electronicwhich reporting rabies post-exposure through the Merlin prophylaxis system (PEP) of animal is recommended encounters (bites, was initiated scratches, in 2001. etc.) for Rabies which rabiesPEP post-exposure is recommended prophylaxis when an(PEP) individual is recommended is bitten, scratched, was initiated or has in 2001. mucous Rabies membrane PEP is or recommendedfresh wound when contact an individual with the issaliva bitten, or scratched,nervous tissue or has of amucous laboratory membrane confirmed or fleshor suspected wound contact with therabid saliva animal or nervous that is not tissue available of a laboratory for testing. confirmed rabid animal or a suspected rabid animal that is not available for testing.

Figure 2. Rabies, Possible Exposure Cases by Month of Onset, Florida, 2008 180 160 140 120 100 80 60

Number of Cases 40 20 0 127 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008

The annual incidence of cases for which PEP is recommended has increased since electronic reporting was initiated (Figure 1). In 2008, the incidence rate was up 26.04% over the previous 5-year average. This increase is thought to be largely due to the rabies vaccine shortage experienced throughout most of 2008. During much of this time, healthcare providers were required to contact local and state health officials on a case by case basis in order to obtain rabies post-exposure vaccines, which led to more cases being reported.

PEP is recommended year round in Florida, though the number of treatment incidents increases somewhat during the summer months (Figure 2). Treatment information was provided in 91% Rabies, Possible Exposure

Figure 1. Rabies, Possible Exposure: Rabies, Possible Exposure Incidence Rate by Year Reported, Crude Data Florida, 2000-2008

Number of Cases 1618 10

2008 incidence rate per 8 100,000 8.56 % change from average 5- 6 year (2003-2007) incidence 4 rate 26.04 Cases per 100,000 2 Age (yrs) Mean 36.53 0 Median 36 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max <1 - 108 Year

Disease Abstract Electronic reporting through the Merlin system of animal encounters (bites, scratches, etc.) for which rabies post-exposure prophylaxis (PEP) is recommended was initiated in 2001. Rabies PEP is recommended when an individual is bitten, scratched, or has mucous membrane or fresh wound contact with the saliva or nervous tissue of a laboratory confirmed2008 Florida or suspected Morbidity Statistics rabid animal that is not available for testing.

Figure 2. Rabies, Possible Exposure Cases by Month of Onset, Florida, 2008 180 160 140 120 100 80 60

Number of Cases 40 20 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008

The Theannual annual incidence incidence of cases of cases for which for which PEP PEP is recommended is recommended has increasedhas increased since since electronic electronic reporting was reportinginitiated (Figure was initiated 1). In (Figure2008, the 1). incidence In 2008, therate incidence was up 26.04% rate was over up the26.04% previous over 5-year the previous average. This5-year increase average. is thought This to increase be largely is duethought to the to rabiesbe largely vaccine due toshortage the rabies experienced vaccine shortage throughout most of 2008.experienced During muchthroughout of this most time, of healthcare 2008. During providers much were of this required time, healthcare to contact providers local and werestate health officialsrequired on ato case contact by case local basisand statein order health to obtainofficials rabies on a post-exposurecase by case basisvaccines, in order which to ledobtain to more casesrabies being post-exposure reported. vaccines, which led to more cases being reported.

ofPEP cases.PEP is recommended is Ofrecommended these reports, year year round 86%round in Florida, of in casesFlorida, though rece though theived numberthe at number least of treatmentone of treatment dose incidents of incidentsPEP, increases 8% increases refused PEP, somewhat during the summer months (Figure 2). Treatment information was provided in 91% 5%somewhat were lostduring to thefollow-up, summer andmonths 1% (Figure were 2).determined Treatment not information to need was PEP provided after the in 91% animal of cases. tested Of these reports, 86% of cases received at least one dose of PEP, 8% refused PEP, 5% were lost to negative or was well at the end of the observation period. follow-up, and 1% were determined not to need PEP after the animal tested negative or was well at the end of the observation period. The average age of the victim for the 1,618 cases reported in 2008 was 36.53 years, with a rangeThe average of <1 ageto 108 of the years victim of for age. the 1,618 In 2008, cases the reported highest in 2008incidence was 36.5 was years, seen with in individualsa range of between<1 to 108 years15 and of age.19 years In 2008, of age,the highest but incidence incidence waswas seensimilar in individualsfrom ages between 15 to 54 15 (Figureand 19 3). The incidenceyears of age, rate but forincidence males wasis approximately similar from ages the 15 same to 54 (Figureas that 3). for The females, incidence but rate the for incidence males is rate amongapproximately white the males same is as almost that for double females, that but ofthe non-white incidence ratemales. among white males is almost double that of non-white males.

Figure 3. Rabies, Possible Exposure Incidence Rate by Age Group, Florida, 2008 12

Cases100,000per 2

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group Previous 5yr average 2008

The type of animal involved in the exposures was available for 97% of cases. Of these, 40% of 128exposures involved a dog, 27% a cat, 18% a raccoon, 9% a bat, 1% a fox, and the remaining 5% of exposures were other animals. Victims exposed to rabid or suspected rabid cats were 65% female and, although 35% of all exposures occurred in children under the age of 15, only 10% of all cat exposures occurred in that age group. Children less than 15 years of age were also involved in only 14% of all wild animal exposures. Exposure type was available for 54% of all reported cases. Of these, 80% of exposures involved bites, 6% involved scratches, and 14% involved saliva or other non-bite/non-scratch exposures. Among bite exposures, 54% had an exposure site listed. The most common exposure sites were the hand (49%), leg/foot (24%), and the arm (18%). Only 14% of the bites occurred from the neck and above. The majority of these injuries occurred among children under 10 years of age (54%) and involved a dog (75%).

Emergency department utilization and hospital discharge data are useful for demonstrating the magnitude of animal bites in general. Rates of hospitalization and emergency department visits related to dog bites among children far exceed rates among older age groups (Figures 4 and 5).

Summary of Selected Notifiable Diseases and Conditions

The type of animal involved in the exposures was available for 97% of cases. Of these, 40% involved a dog, 27% a cat, 18% a raccoon, 9% a bat, 1% a fox, and the remaining 5% of exposures were other animals. Victims exposed to rabid or suspected rabid dogs were 55% male. Approximately 26% of all dog exposures occurred in children less than 15 years of age, and of these, 60% of exposures were in boys. Victims exposed to rabid or suspected rabid cats were 65% female and, although 35% of all exposures occurred in children under the age of 15, only 10% of all cat exposures occurred in that age group. Children less than 15 years of age were also involved in only 14% of all wild animal exposures. Exposure type was available for 54% of all reported cases. Of these, 80% of exposures involved bites, 6% involved scratches, and 14% involved saliva or other non-bite/non-scratch exposures. Among bite exposures, 54% had an exposure site listed. The most common exposure sites were the hand (49%), leg/foot (24%), and the arm (18%). Only 14% of the bites occurred above the neck. The majority of these injuries occurred among children under 10 years of age (54%) and involved a dog (75%).

Prevention Contact with wildlife and unfamiliar domestic animals should be limited. It is especially important that children be educated on appropriate interactions with animals. If bitten, it is important to wash the area thoroughly with soap and water, seek medical attention, and report the bite to the local county health department. Figure 4. Non-Fatal Dog Bite-Related Hospitalization Rates by Age, Figure 4. Florida Residents, 1999-2007 7 Non-Fatal Dog Bite-Related Hospitalization Rates by Age, 67 Florida Residents, 1999-2007 56 45 34 23 HospRate/100,000 12 HospRate/100,000 01 <1

0 1-4 85+ 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 <1 1-4 85+ 5-14 Age 15-24 25-34 35-44 45-54 55-64 65-74 75-84 Age

Figure 5. Non-Fatal Dog Bite-Related Emergency Department Visit Rates Figure 5. by Age, Florida Residents, 2005-2007 Non-Fatal Dog Bite-Related Emergency Department Visit Rates 200 by Age, Florida Residents, 2005-2007 180 200 160 180 140 160 120 140 100120 80 100 60 80 Visit Rate/100,000 Visit 40 60

Visit Rate/100,000 Visit 20 40 0 20 <1 1-4

0 85+ 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 <1 1-4 85+ 5-14 Age 15-24 25-34 35-44 45-54 55-64 65-74 75-84 Age Data Source: Hospital and Emergency Department Discharge Data, Agency for Health Care AdministrationData Source:Data Hospital Source: Hospital and Emergency and Emergency Department Department DischargeDischarge Data, Data, Agency Agency for Health for CareHealth Administration Care Administration

129

2008 Florida Morbidity Statistics

Additional Resources AdditionalAdditional Resources information on animal bites and PEP can be found in the Rabies Prevention and Control Additionalin Florida, information 2008 Guidebookon animal ,bites online and at PEPhttp://www.doh.state.fl.us/environment/community/arboviral/ can be found in the Rabies Prevention and ControlZoonoses/Rabiesguide2008.pdf in Florida, 2008 Guidebook, online or http://www.doh.state.fl.us/environment/medicine/rabies/Documents/ at http://www.doh.state.fl.us/environment/community/arboviral/Zoonoses/Rabiesguide2008.pdf.Rabiesguide2008.pdf.

Dog biteDog prevention bite prevention and rabies and rabies information information can also can be also found be found on the on Department the Department of Health of Health website at websitewww.MyFloridaEH.com at www.MyFloridaEH.com and http://www.doh.state.fl.us/environment/community/rabies/rabies-index.html and or http://www.doh.state.fl.us/environment/community/rabies/rabies-index.html.http://www.doh.state.fl.us/environment/medicine/rabies/rabies-index.html.

130 Summary of Selected NotifiableRocky Diseases Mountainand Conditions Spotted Fever

Rocky Mountain Spotted Fever Rocky Mountain Spotted Fever Figure 1. Rocky Mountain Spotted Fever: Rocky Mountain Spotted Fever Cases by Year Reported, Florida, 1999-2008 Crude Data 25 Rocky Mountain Spotted Fever: Figure 1. Number ofRocky Cases MountainCrude Data Spotted 19 Fever: Rocky Mountain Spotted Fever Cases by Year Reported, 20 Florida, 1999-2008 2008 incidenceNumber of Casesrate perCrude Data 19 25 Number of Cases 19 100,0002008 incidence rate per 0.10 1520

% change100,0002008 from incidence average rate 5- per 0.10 100,000 0.10 year (2003-2007) reported 1015 % change% change from from average average 5-

cases 2.15 Number of Cases 5-yearyear (2003-2007) (2003-2007) reported reported 10 cases 2.15 5 Age (yrs) cases 2.15 Number of Cases AgeAge (yrs) (yrs)Mean 47.29 5 MeanMean 47.29 47.29 0 Median 47 0 MedianMedian 47 47 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 12 - 86 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-MaxMin-Max 12 - 1286 - 86 Year Year

Disease DiseaseAbstract Abstract The numberDiseaseThe number ofAbstract Rocky of Rocky Mountain Mountain spotted spotted fever fever (RMSF) (RMSF) casescases reported reported annually annually has increased has increased The number of Rocky Mountain spotted fever (RMSF) cases reported annually has increased markedly markedlymarkedly since 1999 since (Figure1999 (Figure 1). 1).The The disease disease tends tends to affectaffect adults adults more more than than other otherage groups, age groups, sincealthough 1999 (Figure in 2008, 1). there The weredisease more tends cases to affectreported adults in those more agethan 10-14 other thanage groups,the previous although 5-year in 2008, althoughthereaverage in were 2008, more (Figure there cases 3). were reportedThe moreelderly, in thosecases males, age reported those 10-14 of thanblack in thosethe race, previous thoseage 10-14 5-yearwith glucose-6-phosphate- averagethan the (Figure previous 3). The 5-year averageelderly, dehydrogenase(Figure males, 3). those The (G6PD) of elderly,black deficiency, race, males, those and withthose those glucose-6-phosphate-dehydrogenase of with black a history race, of thosealcohol with abuse glucose-6-phosphate- are (G6PD) at greatest deficiency, risk dehydrogenaseandfor those severe with (G6PD) disease. a history deficiency, Approximatelyof alcohol abuse and 12% arethose of at bla greatest withck males a riskhistory in for the severe U.S.of alcohol are disease. G6PD abuse Approximatelydeficient. are at greatest 12% of risk black males in the U.S. are G6PD deficient. for severe disease. Approximately 12% of blackFigure males 2. in the U.S. are G6PD deficient. Rocky Mountain Spotted Fever Cases by Month of Onset, Florida, 3.50 Figure2008 2. Rocky Mountain Spotted Fever Cases by Month of Onset, Florida, 3.00 3.50 2008 2.50 3.00 2.00

2.50 1.50

2.00 Cases Numberof 1.00

1.50 0.50 0.00 Number of Cases Numberof 1.00 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 0.50 5yr average 2008 0.00 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec In Florida, cases of RMSF are reported year-round, though peak transmission occurs during the Month summer months (Figure 2). Of the 19 cases reported in 2008, 13 (68.4%) acquired the disease 5yr average 2008 in Florida, five (26%) acquired the disease in another U.S. state; travel history for the remaining cases is unknown. Most cases were reported from the Panhandle and central areas of the In Florida,In Florida,state. cases Fifteencases of RMSFof patients RMSF are (83%)are reportedreported in 2008 year-round, year-round,were over 30though yearsthough peak old, peak transmissionwith the transmission highest occurs proportion during occurs thein duringsummer the months (Figure 2). Of the 19 cases reported in 2008, 13 (68.4%) acquired the disease in Florida, five summer thosemonths over (Figure 60. Males 2). accounted Of the 19 for cases 11 cases reported (61%). Noin 2008,deaths 13were (68.4%) reported acquired in 2008, but the at disease (26%)least acquired six patients the disease (32%) werein another hospitalized. U.S. state; The travel national history case for fatality the remaining rate for treatedcase is casesunknown. is Most in Florida,casesapproximately fivewere (26%) reported 5%acquired from and theup toPanhandlethe 20% disease in untreated and in central anot cases. herareas U.S.Antibodies of the state; state. for travel otherFifteen rickettsialhistory patients for species,(83%) the inremaining 2008 caseswere is suchunknown. over as 30 Rickettsia years Most old, parkeri caseswith the and were highest Rickettsia reported proportion amblyommii, from in those the cross-react Panhandleover 60. Males with and tests accounted central for the forRMSFareas 11 cases of the state. (61%). Fifteenagent, No patientsRickettsia deaths were (83%)rickettsii reported in, which 2008 in 2008, may were explainbut over at least changes 30 six years patients in national old, (32%) with disease werethe highesthospitalized.prevalence proportion and The national in those caseovergeographic fatality 60. Malesrate distribution for accountedtreated in cases recent for is years. approximately11 cases The (61%).American 5% and No dog is updeaths tick, to 20%Dermacentor were in untreated reported variabilis cases. in, 2008,is Antibodies the but at for other rickettsial species, such as Rickettsia parkeri and Rickettsia amblyommii, cross-react with tests least sixfor thepatients RMSF agent,(32%) Rickettsia were hospitalized. rickettsii, which The may national explain changes case fatality in national rate disease for treated incidence cases and is approximately 5% and up to 20% in untreated cases. Antibodies for other rickettsial species, such as Rickettsia parkeri and Rickettsia amblyommii, cross-react with tests for the RMSF agent, Rickettsia rickettsii, which may explain changes in national disease prevalence and 131 geographic distribution in recent years. The American dog tick, Dermacentor variabilis, is the 2008 Florida Morbidity Statistics principle RMSF vector in Florida, the primary vector for R. parkeri is the Gulf Coast Tick, Amblyommageographic distributionmaculatum, in recent and years.the primary The American vector dogfor tick,R. amblyomma Dermacentor variabilis is believed, is the to principal be the Lone RMSF vector in Florida, the primary vector for R. parkeri is the Gulf Coast Tick, Amblyomma maculatum, Starand Tick, the primaryAmblyomma vector for americanum R. amblyomma. is Eschars believed toat be the the site Lone of Star the Tick, tick Amblyomma bite are associated americanum with. R. parkeriEschars infections, at the site butof the uncommonly tick bite are associated reported with in R.cases parkeri of infections, RMSF. but uncommonly reported in cases of RMSF.

Figure 3. Rocky Mountain Spotted Fever Cases by Age Group, Florida, 2008

2 Numberof Cases 1

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

PreventionPrevention Prevention of tick bites is the best way to avoid disease. Wear light-colored clothing so that ticks crawling Preventionon clothing of are tick visible. bites Tuck is the pants best legs way into tosocks avoid so that disease. ticks cannot Wear crawl light-colored inside clothing. clothing Apply so that ticksrepellent crawling to discourage on clothing tick attachment.are visible. Repellents Tuck pants containing legs permethrininto socks can so be that sprayed ticks on cannot boots crawl insideand clothing.clothing, and Apply will last repellent for several to days. discourage Repellents tick containing attachment. DEET can Repellents be applied containingto the skin, but permethrin canwill be last sprayed only a few on hours boots before and reapplication clothing, and is necessary. will last for Search several the body days. for ticks Repellents frequently containing when spending time in potentially tick-infested areas. If a tick is found, it should be removed as soon as DEETpossible. can beUsing applied fine tweezers to the skin,or a tissue but willto protect last onlyfingers, a few grasp hours the tick before close reapplicationto the skin and gentlyis necessary. pull Searchstraight the out body without for twisting. ticks frequently Do not use barewhen fingers spending to crush time ticks. in potentiallyashW hands following tick-infested tick removal. areas. If a tickControlling is found, tick it should populations be removedin the yard andas soonon pets as can possible. also reduce Using the risk fine of diseasetweezers transmission. or a tissue to protect fingers, grasp the tick close to the skin and gently pull straight out without twisting. Do not use bare fingers to crush ticks. Wash hands following tick removal. Controlling tick populations in the yard and on pets can also reduce the risk of disease transmission.

132 Summary of Selected Notifiable Diseases and Conditions

References DavidReferences L. Heymann (ed.), Control of Communicable Diseases Manual, 19th ed., American Public Health David L. Heymann (ed.), Control of Communicable Diseases Manual, 19th ed., American Public Association Press, Washington, District of Columbia, 2008. Health Association Press, Washington, District of Columbia, 2008.

Additional Resources DiseaseAdditional information Resources is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/ncidod/dvrd/rmsf/index.htm.Disease information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncidod/dvrd/rmsf/index.htm.

Disease information is also available from the Florida Department of Health at http://www.doh.state.fl.us/ Disease information is also available from the Florida Department of Health at Environment/medicine/arboviral/Tick_Borne_Diseases/Tick_Index.htm.http://www.doh.state.fl.us/Environment/medicine/arboviral/Tick_Borne_Diseases/Tick_Index.htm

133 Salmonellosis Figure 1. Salmonellosis Incidence Rate by Year Reported, Florida, Salmonellosis: Crude Data 2008 Florida1999-2008 Morbidity Statistics 35

Number of Cases 5,312 30 Salmonellosis 2008 incidence rate per Salmonellosis25 100,000 28.11 Figure 1. % change from average 5 Salmonellosis20 Incidence Rate by Year Reported, Florida, Salmonellosis:Salmonellosis: Crude Crude Data Data 1999-2008 year (2003-2007) incidence 35 15 rateNumber Number of of Cases Cases 5,3125,3123.45 30 100,000 per Cases 10 Age 2008(yrs) incidence rate per 2008 incidence rate per 25 100,000100,000 Mean 28.1128.11 23.15 5 % change from average 5 20 % change fromMedian average 5 8 yearyear (2003-2007) (2003-2007) incidence incidence 0 15 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 raterate Min-Max 3.45 <13.45 - 106 Cases per 100,000 per Cases 10 Year AgeAge (yrs) (yrs) MeanMean 23.1523.15 5 Disease AbstractMedian 8 The incidence rateMedian for salmonellosis 8 has increased0 gradually over the last ten years (Figure 1). Min-MaxMin-Max <1<1 - -106 106 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 In 2008, the incidence was 28.11 cases/100,000, a decrease from Yearthe 2005 peak of 30.8 Abstract cases/100,000.Disease Abstract A total of 5,312 cases were reported in 2008, of which 95.73% were classified The incidence rate for salmonellosis has increased gradually over the last ten years (Figure 1). In 2008, as confirmed.The incidence The rate fornumber salmonellosis of cases has reported increased increasesgradually over in the last summer ten years and (Figure early 1). fall. In 2008, the incidence was 28.11 cases/100,000, a decrease from the 2005 peak of 30.8 cases/100,000. A total of In 2008, the incidence was 28.11 cases/100,000, a decrease from the 2005 peak of 30.8 the 5,312number cases of werecases reported exceeded in 2008, the of previous which 95.73% 5-year were average classified in as all confirmed. months The except number March of cases which cases/100,000. A total of 5,312 cases were reported in 2008, of which 95.73% were classified wasreported only slightly increases lower in the (Figure summer 2). and Overall, early fall. 7.7% In 2008, of thethe numbersalmonellosis of cases casesexceeded were the previousclassified as as confirmed. The number of cases reported increases in the summer and early fall. In 2008, 5-year average in all months except March which was only slightly lower (Figure 2). Overall, 7.7% of the outbreak-relatedthe number of cases in 2008. exceeded the previous 5-year average in all months except March which salmonellosis cases were classified as outbreak-related in 2008. was only slightly lower (Figure 2). Overall, 7.7% of the salmonellosis cases were classified as outbreak-related in 2008. Figure 2. Salmonellosis Cases by Month of Onset, Florida, 2008 700 Figure 2. Salmonellosis Cases by Month of Onset, Florida, 2008 600 700

600500

500400

400 300 300

Number of Cases Numberof 200

100100

0 0 JanJan Feb Feb Mar Mar Apr MayApr Jun May Jul Jun Aug Jul Sep Aug Oct Sep Nov Dec Oct Nov Dec Month Month 5yr average 2008 5yr average 2008

TheThe highest highest incidence incidence rates rates continue continue to to occur occur among among infants infants <1 <1 year year old old and and children children 1-4 1-4 years years old. In Theold.2008, highest In the2008, incidenceincidence the incidence rates rates were rates continue slightly were slightly higher to occur higherthan amongthe than previous the infants previous 5-year <1 5-yearaverage year average old in those and in children <1those and the 1-4 years old.<1 incidence In and 2008, the ratesincidence the wereincidence ratessimilar were inrates the similar others were in (Figuretheslightly others 3). higher (Figure Males thanand3). Malesfemales the previousand have females almost 5-year have identical average incidence in those <1 almostandrates the (28.10 identical incidence and incidence 28.05 rates per rates 100,000, were (28.10 similar respectively). and 28.05in the per othersThe 100,000, incidence (Figure respectively). rate 3). among Males The non-white andincidence females females have(11.06 rateper among100,000) non-white is less than females half of (11.06 that of per any 100,000) other gender-race is less than group. half of that of any other gender- almostrace identicalgroup. incidence rates (28.10 and 28.05 per 100,000, respectively). The incidence rate among non-white females (11.06 per 100,000) is less than half of that of any other gender- race group.

134 Summary of Selected Notifiable Diseases and Conditions

Figure 3. Salmonellosis Incidence Rate by Age Group, Florida, 2008

500 450 400 350 300 250 200 150 Cases per 100,000 Cases 100 50 0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008 Salmonellosis was reported in 64 of the 67 counties in Florida. Rates vary across the state, but appear to Salmonellosisbe higher in the was western reported panhandle in 64 ofand the the 67 northeastern counties portionin Florida. of the Rates state. vary across the state, but appear to be higher in the western panhandle and the northeastern portion of the state. Prevention To reduce the likelihood of contracting salmonellosis, cook all meat products and eggs thoroughly, Preventionparticularly poultry. Avoid cross-contamination by making sure utensils, counter tops, cutting boards, and To spongesreduce theare cleanedlikelihood or do of notcontracting come in contact salmonellosis, with raw poultry cook or all other meat meat. products Wash handsand eggs thoroughly thoroughly,before, during, particularly and after poultry. food preparation. Avoid cross-contamination Do not allow the fluids by from making raw poultry sure orutensils, meat to counterdrip onto tops,other cutting foods. boards, Consume and only sponges pasteurized are milk,cleaned milk products, or do not or comejuices. in Additionally, contact with it is rawimportant poultry to wash or hands after coming into contact with any animals or their environment. other meat. Wash hands thoroughly before, during, and after food preparation. Do not allow the fluids from raw poultry or meat to drip onto other foods. Consume only pasteurized milk, milk products, or juices. Additionally, it is important to wash hands after coming into contact with any animals or their environment.

135

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

L. Pickering (ed.), 2006 Red Book: Report of the Committee on Infectious Diseases, 27th ed., American Academy of Pediatrics, Elk Grove Village, IL, 2006, pp. 992.

Florida Department of Health -Guidelines for Control of Outbreaks of Enteric Disease in Child Care Settings http://www.doh.state.fl.us/disease_ctrl/epi/surv/enteric.pdf

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/salmonella/

Additional information is available from the U.S Food and Drug Administration – Bad Bug book at http://www.cfsan.fda.gov/~mow/chap1.html. 2008 Florida Morbidity Statistics

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

L. Pickering (ed.), 2006 Red Book: Report of the Committee on Infectious Diseases, 27th ed., American Academy of Pediatrics, Elk Grove Village, IL, 2006, pp. 992.

Florida Department of Health -Guidelines for Control of Outbreaks of Enteric Disease in Child Care Settings http://www.doh.state.fl.us/disease_ctrl/epi/surv/enteric.pdf

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/salmonella/

Additional information is available from the U.S Food and Drug Administration – Bad Bug book at http:// www.cfsan.fda.gov/~mow/chap1.html.

R. Baker, et al., “Outbreak of Salmonella Serotype Javiana Infections-Orlando, Florida, June 2002,” Morbidity and Mortality Weekly Report, Vol. 51, No. MM31, p. 683.

ShigellosisShigellosis

Figure 1. Shigellosis: Crude Data Shigellosis Incidence Rate by Year Reported, Florida, 1999- Shigellosis: Crude Data 2008 18 Number of CasesNumber of Cases 801 801 16

2008 incidence2008 rate incidence per rate per 14 100,000 100,000 4.24 4.24 12

% change from% change average from 5 average 5 10 year (2003-2007)year (2003-2007) incidence incidence 8 rate rate -57.69 -57.69 6 Cases per 100,000 Cases Age (yrs) Age (yrs) 4 Mean 16.71 Mean 16.71 2 Median Median 8 8 Min-Max <1 - 88 0 Min-Max <1 - 88 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Disease Abstract Disease AbstractThe incidence rate for shigellosis has varied over the last ten years (Figure 1). Periodic community The incidenceoutbreaks rate forinvolving shigellosis childcare has centers varied account over the for mostlast ten of the years observed (Figure variability. 1). Periodic Over 20% of the communitycases outbreaks reported involving in 2008 werechildcare in children centers who aattendccount daycare for most or staff of thewho observedwork at affected variability. daycares. This Over 20% numberof the cases does not reported take into in account 2008 werethe proportion children of that cases attend that are daycare secondary or staff to the that initial work daycare- at associated case. In 2008, there was a 57.69% decrease in comparison to the average incidence from affected daycares.2003-2007. This A total number of 801 doescases notwere take reported into accountin 2008 (2007= the proportion 2,288 cases), of casesof which that 79.53% are were secondary classifiedto the initial as confirmed.daycare-associated Historically, case.the number In 2008, of cases there reported was atends 57.69% to increase decrease in late in summer comparisonand to thethe fall average months. incidence However, infrom 2008, 2003-2007. the number ofA casestotal of was 801 highest cases at werethe beginning reported of inthe year, 2008 (2007=in January 2,288 cases),and February, of which and steadily79.53% decreased were classified through asthe confirmed.year (Figure 2).Historically, Overall, 32.21% the of the number of shigellosiscases reported cases weretends classified to increase as outbreak-related in late summer and and 19.23% the fallof the months. shigellosis However, cases were in daycare 2008, the numberattendees. of cases was highest at the beginning of the year in January and February and steadily decreased through the year (Figure 2). Overall, 32.21% of the shigellosis cases were classified136 as outbreak-related and 19.23% of the shigellosis cases were daycare attendees.

Figure 2. Shigellosis Cases by Month of Onset, Florida, 2008 180

160 140

120 100

80 60 Number of Cases Numberof 40 20

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008

The highest incidence rates continue to occur among children aged 1 to 4 years old. In 2008, the incidence rates were similar in trend to the 5-year average but were at much lower levels (Figure 3). Incidence rates were higher among females than males (4.32 and 4.16 per 100,000 respectively) and higher in non-whites than whites, with the highest incidence being among non- Shigellosis

Figure 1. Shigellosis: Crude Data Shigellosis Incidence Rate by Year Reported, Florida, 1999- 2008 18 Number of Cases 801 16

2008 incidence rate per 14

100,000 4.24 12

% change from average 5 10 year (2003-2007) incidence 8 rate -57.69 6 Cases per 100,000 Cases Age (yrs) 4

Mean 16.71 2

Median 8 0 Min-Max <1 - 88 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

Disease Abstract The incidence rate for shigellosis has varied over the last ten years (Figure 1). Periodic community outbreaks involving childcare centers account for most of the observed variability. Over 20% of the cases reported in 2008 were children that attend daycare or staff that work at affected daycares. This number does not take into account the proportion of cases that are secondary to the initial daycare-associated case. In 2008, there was a 57.69% decrease in comparison to the average incidence from 2003-2007. A total of 801 cases were reported in 2008 (2007= 2,288 cases), of which 79.53% were classified as confirmed. Historically, the number of cases reported tends to increase in late summer and the fall months. However, in 2008, the number of cases was highest at the beginning of the year in January and February and steadily decreased through the year (Figure 2). Overall, 32.21% of the shigellosis cases were classifiedSummary of Selected as outbreak-related Notifiable Diseases and Conditions 19.23% of the shigellosis cases were daycare attendees.

Figure 2. Shigellosis Cases by Month of Onset, Florida, 2008 180

160 140

120 100

80 60 Number of Cases Numberof 40 20

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008

The highestThe highest incidence incidence rates rates continue to tooccur occur among among children children aged 1 agedto 4 years 1 to old. 4 years In 2008, old. the In 2008, incidence rates were similar in trend to the 5-year average but were at much lower levels (Figure 3). the incidenceIncidence rates rates were were higher similar among in femalestrend to than the males 5-year (4.32 average and 4.16 but per were 100,000 at muchrespectively) lower and levels (Figurewhitehigher 3).males in Incidence non (7.97-whites per thanrates 100,000). whites, were withhigher the highestamong incidence females being than among males non-white (4.32 and males 4.16 (7.97 per per 100,000 respectively) 100,000). and higher in non-whites than whites, with the highest incidence being among non-

Figure 3. Shigellosis Incidence Rate by Age Group, Florida, 2008

100

40 Cases per 100,000 Cases 20

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group Previous 5yr average 2008 Shigellosis was reported in 45 of the 67 counties in Florida. There were no distinct geographic patterns Shigellosisin the distribution was reported of shigellosis in 45 cases of the throughout 67 counties the state. in Florida. There were no distinct geographic patterns in the distribution of shigellosis cases throughout the state. Prevention PreventionTo reduce the likelihood of contracting shigellosis, it is important to practice good hand hygiene. Outbreaks in daycare centers are common and control may be difficult. The Department of Health has Topublished reduce theoutbreak likelihood control ofmeasures contracting for childcare shigellosis, settings it (seeis important references). to practice good hand hygiene. Outbreaks in daycare centers are common and control may be difficult. The Department of Health has published outbreak control measures for childcare settings (see references).

137 2008 Florida Morbidity Statistics

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health

Association Press, Washington, District of Columbia, 2004.

References th L.David Pickering L. Heymann (ed.), 2006 (ed.), Red Control Book: of Report Communicable of the Committee Diseases on InfectiousManual, 18 Diseasesth ed., American, 27 ed., Public American Academy of Pediatrics, Elk Grove Village, IL, 2006, pp. 992. Health Association Press, Washington, District of Columbia, 2004.

Florida Department of Health -Guidelines for Control of Outbreaks of Enteric Disease in Child Care L. Pickering (ed.), 2006 Red Book: Report of the Committee on Infectious Diseases, 27th ed., Settings http://www.doh.state.fl.us/disease_ctrl/epi/surv/enteric.pdf. American Academy of Pediatrics, Elk Grove Village, IL, 2006, pp. 992. Additional Resources DiseaseFlorida Department information isof availableHealth -Guidelines from the Centers for Control for Disease of Outbreaks Control of and Enteric Prevention Disease (CDC) in Child at http:// www.cdc.gov/ncidod/dbmd/diseaseinfo/shigellosis_g.htm.Care Settings http://www.doh.state.fl.us/disease_ctrl/epi/surv/enteric.pdf.

Additional information Resources is available from the U.S Food and Drug Administration – Bad Bug book at http:// www.cfsan.fda.gov/~mow/chap19.html.Disease information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/shigellosis_g.htm. Centers for Disease Control and Prevention, “Outbreak of Gastroenteritis Associated With an Interactive AdditionalWater information Fountain isat availablea Beachside from Park the -U.S Florida, Food 1999,” and Drug Morbidity Administration and Mortality – Bad Weekly Bug Report book , Vol. at http://www.cfsan.fda.gov/~mow/chap19.html.49, No. 25, 2000, pp. 565-8.

Centers for Disease Control and Prevention, “Outbreak of Gastroenteritis Associated With an Interactive Water Fountain at a Beachside Park - Florida, 1999,” Morbidity and Mortality Weekly Report, Vol. 49, No. 25, 2000, pp. 565-8.

138 Streptococcal Disease, Invasive, Group A Summary of Selected Notifiable Diseases and Conditions Streptococcal Disease, Invasive Figure 1. Streptococcal Disease, Invasive Group A Incidence Rate by Year Reported, Florida, Group A: CrudeStreptococcal Data Disease, Invasive, Group 1999-2008A Number of Cases 275 Streptococcal Disease, Invasive,2.0 Group A 2008 incidence rate per Streptococcal Disease, Invasive 1.5 100,000 1.46 Figure 1. StreptococcalGroup A: Crude Disease, Data Invasive % change from average 5- Streptococcal Disease, Invasive Group A Incidence Rate by Year Reported, Florida, Number ofGroup Cases A: Crude Data275 1999-2008 year (2003-2007) incidence 1.0 Number of Cases 275 2.0 rate2008 incidence rate per -1.48 0.5 100,0002008 incidence rate per 1.46 Cases per 100,000 Age100,000 (yrs) 1.46 1.5 % change from average Mean 52.29 0.0 5-year% change (2003-2007) from average 5- 1.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 incidenceyear (2003-2007) rateMedian incidence -1.48 57 rate -1.48 Year 0.5 Min-Max <1 - 100 Cases per 100,000 AgeAge (yrs) (yrs) Mean 52.29 Mean 52.29 0.0 Median 57 Disease AbstractMedian 57 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max <1 - 100 Year The incidence rateMin-Max for reported <1 invasive - 100 group A streptococcal disease in Florida has gradually increased over the past 10 years, with a more than four-fold cumulative increase since 1997 (FigureDiseaseDisease 1). Abstract InAbstract 2008, there was a 1.48% decrease compared to the average incidence for 2003- 2007TheThe (Table incidence incidence 1). rate rateA fortotal for reported reportedof 275 invasive cases invasive group were group A reportedstreptococcal A streptococcal in 2008, disease disease of in which Florida in Florida 100% has gradually has were gradually classifiedincreased as confirmed.overincreased the past Cases over 10 years, the occur past with 10throughout a years,more than with allfour-fold a moremonths cumulativethan of four-fold the increaseyear cumulative with since no 1997clearincrease (Figure seasonal since 1). 1997 In pattern. 2008, there(Figure was 1). a 1.48% In 2008, decrease there wascompared a 1.48% to the decrease average compared incidence tofor the 2003-2007 average (Table incidence 1). A for total 2003- of 275 Compared to the previous 5-year average, the number of cases reported in 2008 was higher in cases2007 were (Table reported 1). A totalin 2008, of 275 of which cases 100% were were reported classified in 2008, as ofconfirmed. which 100% Cases were occur classified throughout as all allmonthsconfirmed. months except of theCases year for occur withFebruary, no throughout clear March,seasonal all months Ju pattern.ne, ofand theCompared November, year with to nothe with clearprevious theseasonal 5-yeargreatest pattern. average, number the occurringnumberCompared ofin cases January, to the reported previous October, in 20085-year andwas average, higherDecember in the all number months (Figur ofexcepte cases2). forNo reported February, cases inwere March, 2008 reported was June, higher and as in outbreak- associatedNovember,all months in with except2008. the greatest for February, number March, occurring June, in andJanuary, November, October, with and the December greatest (Figure number 2). No cases wereoccurring reported in January,as outbreak-associated October, and Decemberin 2008. (Figure 2). No cases were reported as outbreak- associated in 2008. Figure 2. Streptococcal Disease, Invasive Group A, Cases by Month of Onset, 30 FigureFlorida, 2. 2008 Streptococcal Disease, Invasive Group A, Cases by Month of Onset, 2530 Florida, 2008

25 20

20 15 15 10 Number of Cases Numberof 10 Number of Cases Numberof 5 5

0 0 JanJan Feb Mar Mar Apr Apr May May Jun Jun Jul Jul Aug Aug Sep SepOct Nov Oct Dec Nov Dec MonthMonth

5yr average 2008 5yr average 2008 The highest incidence rate for 2008 occurred in those 85 and older, which is in line with historical trends The(FigureThe highest highest 3). Inincidence 2008,incidence incidence rate rate forfor increased 2008 occurred occurred in about inhalf inthose ofthose the 85 age and85 groups, andolder, older, whichmost whichnotably is in line isthose within line over with 85. Maleshistorical continue trends to have(Figure a higher 3). In incidence 2008, incidence than females increased (1.70 inand about 1.22 half per of100,000 the age respectively). groups, most In historical2007,notably the trends thoseincidence over(Figure rate 85. for Males3). white In continue 2008,males surpassedincidenc to have aethat higherincreased for non-white incidence in about males. than females half of the (1.70 age and groups, 1.22 most notablyper 100,000 those over respectively). 85. Males In 2007,continue the incidence to have arate higher for white incidence males surpassed than females that for (1.70 non- and 1.22 per white100,000 males. respectively). In 2007, the incidence rate for white males surpassed that for non- white males.

139 2008 Florida Morbidity Statistics

Figure 3. Streptococcal Disease, Invasive Group A Incidence Rate by Age Group, Florida, 2008 6

2 Cases per 100,000 per Cases 1

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

InvasiveInvasive group group A A streptococcal streptococcal disease disease cases cases were were reported reported in 41 of inthe 41 67 of counties the 67 in counties Florida. The in Florida.five The countiesfive counties reporting reporting the highest the number highest of casesnumber were of primarily cases inwere the central primarily and southernin the central part of andthe state with relatively few cases occurring in the panhandle region. However, the counties with the highest rates southernof disease part were of the in thestate northern with relativelypart of the state.few cases occurring in the panhandle region. However, the counties with the highest rates of disease were in the northern part of the state. Prevention PreventionPrevention is through education about modes of transmission, prompt and effective treatment of Preventioninfections, is andthrough appropriate education drainage about and secretionmodes ofprecautions transmission, for infection prompt sites and and effectivewound care. treatment of infections, and appropriate drainage and secretion precautions for infection sites and wound care.

140

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/groupastreptococcal_g.htm

Summary of Selected Notifiable Diseases and Conditions

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

AdditionalStreptococcus Resources pneumoniae, Invasive Disease, Drug-Resistant Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/ncidod/dbmd/diseaseinfo/groupastreptococcal_g.htm Figure 1. Streptococcus pneumoniae, Invasive Streptococcus pneumoniae Invasive Disease, Drug-Resistant Incidence Rate by Year Reported, Florida, 1999-2008 Disease, Drug-Resistant: Crude Data 8 Streptococcus pneumoniae, Invasive Disease, Drug-Resistant NumberStreptococcus of Cases pneumoniae 792 , Invasive Disease, Drug-Resistant 2008 incidence rate per 6 Figure 1. 100,000StreptococcusStreptococcus pneumoniaepneumoniae , , InvasiveInvasive4.19 Streptococcus pneumoniae Invasive Disease, Drug-Resistant % changeDisease, from Drug-Resistant: average 5 Crude Data Incidence Rate by Year Reported, Florida, 1999-2008 Disease, Drug-Resistant: Crude Data 8 4 year (2003-2007) incidence NumberNumber of of CasesCases 792 792 14.27 rate per 100,000 Cases

20082008 incidence incidence raterate per 6 2 Age100,000100,000 (yrs) 4.194.19 Mean 45.36 %% change change fromfrom averageaverage 5 4 yearyear (2003-2007) (2003-2007)Median incidenceincidence 51 0 14.27 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 raterate Min-Max 14.27 <1 - 102 per 100,000 Cases Age (yrs) 2 Year Age (yrs) Mean 45.36 Mean 45.36 Median 51 0 Disease AbstractMedian 51 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-MaxMin-Max <1 <1 -- 102102 Drug-resistant S. pneumoniae (DRSP) invasive disease, for reportingYear purposes, includes cultures Disease obtained Abstract from a normally sterile site, such as blood or CSF, which are either intermediateDiseaseDrug-resistant Abstract resistant S. pneumoniae or fully (DRSP) resistant invasive to one disease, or more for reportingcommonly purposes, used includesantibiotics. cultures The incidenceDrug-resistantobtained rate from for aS. normally pneumoniaeDRSP sterilepeaked (DRSP) site, in such 2000 invasive as andblood disease, gradually or CSF, for which reportingdeclined are either purposes, until intermediate 2005 includes when resistant it started or fully to increaseculturesresistant again obtained to one (Figure or from more a1). commonly normally There sterile used was antibiotics. site,an in suchcrease as The blood from incidence or 3.86 CSF, rate cases/100,000 which for DRSP are either peaked in 2007in 2000 to and 4.19 intermediategradually declined resistant until or 2005 fully when resistant it started to one to orincrease more commonly again (Figure used 1). antibiotics. There was Thean increase from cases/100,000incidence3.86 cases/100,000 rate infor 2008. DRSP in 2007 peaked to 4.19 in cases/100,0002000 and gradual in 2008.ly declined until 2005 when it started to increase again (Figure 1). There was an increase from 3.86 cases/100,000 in 2007 to 4.19 cases/100,000 in 2008. Figure 2. Streptococcus pneumoniae , Invasive Disease, Drug-Resistant 90 Cases by MonthFigure 2.of Onset, Florida, 2008 80 Streptococcus pneumoniae , Invasive Disease, Drug-Resistant 90 Cases by Month of Onset, Florida, 2008 70 80 60 70

6050

5040

4030 Number of Cases Numberof 30

Number of Cases Numberof 20 20 10 10 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Month 5yr average 2008 5yr average 2008

TheThe highest highest incidence incidence ratesrates continue continue to occurto occur among among infants infants <1 year <1 old, year children old, children1-4 years, 1-4 years, andand those those over over 85. 85. In 2008,2008, the the incidence incidence rates rates were were higher higher than the than previous the previous 5-year average 5-year average in most age groups, except those over 85 (Figure 3). Males have a slightly higher incidence in most age groups, except those over 85 (Figure 3). Males have a slightly higher incidence than females (4.25 per 100,000 and 4.14 per 100,000, respectively). The highest incidence is 141 thanamong females non-white (4.25 males per 100,000 (6.96 per and100,000) 4.14 and per lowest 100,000, among respectively). non-white females The (0.52highest per incidence is among100,000). non-white males (6.96 per 100,000) and lowest among non-white females (0.52 per 100,000).

2008 Florida Morbidity Statistics

The highest incidence rates continue to occur among infants <1 year old, children 1-4 years, and those over 85. In 2008, the incidence rates were higher than the previous 5-year average in most age groups, except those over 85 (Figure 3). Males have a slightly higher incidence than females (4.25 per 100,000 and 4.14 per 100,000, respectively). The highest incidence is among non-white males (6.96 per 100,000) and lowest among non-white females (0.52 per 100,000).

Figure 3. Figure 3. Streptococcus pneumoniae , Invasive Disease, Drug-Resistant StreptococcusIncide pneunce Ratemoniae by Age, Invasive Group, Florida Disease,, 2008 Drug-Resistant 25 Incidence Rate by Age Group, Florida, 2008 25 20

20 15

15 10 Cases100,000per 10 5

Cases100,000per 0 5 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

0 Age Group <1 1-4 5-9

Previous 5yr average 2008 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 Age Group The data from both the drug-resistant and drug-sensitive S. pneumoniae isolates reported were Previous 5yr average 2008 used to calculate resistance rates of common antibiotics for 2008 (Figure 4 and Table 1). A The datatotal from of 1,483 both casesthe drug-resistant had one or more and drug-sensitive antibiograms, S.and pneumoniae the earliest isolatespattern forreported each casewere wasused to Thecalculate dataused from resistance in these both calculations. ratesthe drug-resistant of common The sensitivityantibiotics and drug-sensitiveratefor 2008 varies (Figure by the 4S. class and pneumoniae Tableof antibiotic. 1). A total isolates Erythromycin of 1,483 reported cases were had oneand or penicillin more antibiograms, had the greatest and thepercentage earliest pattern of intermediate for each andcase resistant was used isolates in these (47.0% calculations. and usedThe to sensitivity40.8% calculate respectively). rate resistance varies by the rates class ofof antibiotic.common Erythromycinantibiotics for and 2008 penicillin (Figure had the 4 andgreatest Table 1). A totalpercentage of 1,483 of cases intermediate had one and resistantor more isolates antibiograms, (47.0% and and 40.8% the respectively).earliest pattern for each case was used inPlease these see calculations. “Section 4: Summary The sensitivity of Antimicrobial rate varies Resistance by the Surveillance” class of antibiotic. for additional Erythromycin andPlease penicillininformation see “Section had on the antimicrobial4: Summarygreatest ofresistancepercentage Antimicrobial surveillance of Resistance intermediate in Florida Surveillance” andincluding resistant for MeningNet, additional isolates informationan (47.0% and on antimicrobialenhanced meningococcalresistance surveillance surveillance in Florida system including used to MeningNet, monitor antimicrobial an enhanced susceptibility. meningococcal 40.8%surveillance respectively). system used to monitor antimicrobial susceptibility.

Figure 4. Please see “Section 4: SummaryStreptoco of Antimicrobialccus pneumoniae Resistance, Invasive Disease, Surveillance” for additional information on antimicrobial resistanceAntibiotic surveillance Resistance, Florida, in Florida 2008 including MeningNet, an enhanced meningococcal1,600 surveillance system used to monitor antimicrobial susceptibility.

1,400 Figure 4. 1,200 Streptococcus pneumoniae, Invasive Disease, 1,000 Antibiotic Resistance, Florida, 2008 1,600 800 Number 1,400 600

1,200 400

200 1,000 0 l e e n in in m e 800 ico ci c lin in ycin im on xetil yc icil ep a my my f iax o pene en ifampin oxazol Number om r phen ft me dam hro P R comyc thr Ce lin Imi Ofloxacin zi CefotaximeCe oxi C an 600 A r larithr Eryt Tetracycline V C efu Chloram ulfameth C Antibiotic 400 prim/S

Susceptible Intermediate Resistant rimetho T 142 200

0 l e e n in in m e ico ci c lin in ycin im on xetil yc icil fep ax a my my pene om ri phen o en ifampin oxazol ft me dam hro P R comyc thr Ce lin Imi Ofloxacin zi CefotaximeCe oxi C an A r larithr Eryt Tetracycline V C efu Chloram ulfameth C Antibiotic prim/S

Susceptible Intermediate Resistant rimetho T Summary of Selected Notifiable Diseases and Conditions

Table1. Streptococcus pneumoniae, Invasive Disease, Antibiotic Resistance, Florida 2008 Number of Cases Antibiotic name Susceptible Intermediate Resistant Tested Azithromycin 265 61.9% 3.0% 35.1% Cefepime 140 93.6% 6.4% 0.0% Cefotaxime 935 88.6% 6.5% 4.9% Ceftriaxone 1220 89.7% 7.0% 3.3% Cefuroxime axetil 272 70.2% 4.0% 25.7% Chloramphenicol 441 96.4% 0.2% 3.4% Clarithromycin 110 60.9% 4.5% 34.5% Clindamycin 434 75.1% 3.9% 21.0% Erythromycin 991 53.0% 1.4% 45.6% Imipenem 104 78.8% 18.3% 2.9% Ofloxacin 299 96.3% 2.7% 1.0% Penicillin 1384 59.2% 22.1% 18.7% Rifampin 107 99.1% 0.0% 0.9% Tetracycline 753 74.4% 0.7% 25.0% Trimethoprim/Sulfamethoxazole 947 62.3% 7.5% 30.1% Vancomycin 1364 99.9% 0.0% 0.1%

Drug-resistant S. pneumoniae was reported in 49 of the 67 counties in Florida.

Streptococcus pneumoniae, Invasive Disease, Drug-Resistant, Incidence Rate* by County, Florida, 2008

Prevention The most effective way of preventing pneumococcal infections, including DRSP infections, is through vaccination. Currently, there are two vaccines available. A conjugate vaccine is 143 recommended for all children <24 months, and children age 24–59 months with a high-risk medical condition. The older pneumococcal polysaccharide vaccine should be administered routinely to all adults over 65 years old. The vaccine is also indicated for people >2 with a normal immune system who have chronic illnesses. Additionally, it is important to practice good hand hygiene, to take antibiotics only when necessary, and to finish the entire course of treatment.

References David L. Heymann, Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

American Academy of Pediatrics, Red Book 2003: Report of the Committee on Infectious 2008 Florida Morbidity Statistics

Prevention The most effective way of preventing pneumococcal infections, including DRSP infections, is through vaccination. Currently, there are two vaccines available. A conjugate vaccine is recommended for all children <24 months, and children age 24–59 months with a high-risk medical condition. The other pneumococcal polysaccharide vaccine should be administered routinely to all adults over 65 years old. Vaccine is also indicated for people >2 with a normal immune system who have chronic illnesses. Additionally, it is important to practice good hand hygiene, to take antibiotics only when necessary, and to finish the entire course of treatment.

References David L. Heymann, Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

American Academy of Pediatrics, Red Book 2003: Report of the Committee on Infectious Diseases, 26th ed., American Academy of Pediatrics Press, Elk Grove Village, Illinois, 2003.

William Atkinson (ed.) et al., Epidemiology and Prevention of Vaccine-Preventable Diseases, 10th ed., Public Health Foundation, Washington, District of Columbia, 2007.

Michael T. Drennon, “Drug Resistant Patterns of Invasive Streptococcus pneumoniae Infections in the State of Florida in 2003,” Master’s Thesis, University of South Florida, Tampa, 2006.

The following reports are available on the Department of Health web site: 1999 Streptococcus pneumoniae Surveillance Report, 2000 Streptococcus pneumoniae Surveillance Report, and 1997-1999, Surveillance of SP in Central FL, at http://www.doh.state.fl.us/disease_ctrl/epi/topics/popups/anti_res.htm.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at: http:// www.cdc.gov//ncidod/dbmd/diseaseinfo/drugresisstreppneum_t.htm.

Centers for Disease Control and Prevention, “Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP),” Morbidity and Mortality Weekly Report, Vol. 49, No. RR-9, 2000, pp. 1-35.

144 Streptococcus pneumoniae, Invasive Disease, Drug-Susceptible

Summary of Selected Notifiable Diseases and Conditions Streptococcus pneumoniae, Invasive Figure 1. Streptococcus pneumoniae , Invasive Disease, Drug-Susceptible Disease, Drug-Susceptible: Crude Data Incidence Rate by Year Reported, Florida, 2003-2008 StreptococcusStreptococcus pneumoniae pneumoniae, Invasive, Invasive4 Disease, Disease, Drug-Susceptible Drug-Susceptible Number of Cases 704 2008 incidence rate per StreptococcusStreptococcus pneumoniae pneumoniae,, InvasiveInvasive 3 Figure 1. 100,000 3.73 Streptococcus pneumoniae , Invasive Disease, Drug-Susceptible Disease,Disease, Drug-Susceptible: Drug-Susceptible: Crude Crude Data Incidence Rate by Year Reported, Florida, 2003-2008 % change from average 5- 4 NumberNumber of ofCases Cases 704 2 year (2003-2007) incidence 20082008 incidence incidence rate rate per per rate 3.7326.63 3 100,000100,000 3.73 100,000 per Cases 1 Age (yrs) % change from average 5- % change from averageMean 51.32 2 year5-year (2003-2007) (2003-2007) incidence incidence 26.63 0 rate rate Median 26.63 53.5 2003 2004 2005 2006 2007 2008 Cases per 100,000 per Cases 1 Age (yrs) Year Age (yrs) Min-Max <1 - 97 Mean 51.32 Mean 51.32 0 Median 53.5 Disease AbstractMedian 53.5 2003 2004 2005 2006 2007 2008 Min-Max <1 - 97 Year Drug-sensitive Min-Max Streptococcus <1 pneumoniae - 97 (DSSP) invasive disease, for reporting purposes,

includes cultures obtained from a normally sterile site, such as blood or CSF, that are sensitive DiseaseDisease Abstract Abstract Drug-sensitivetoDrug-sensitive all of the commonly Streptococcus Streptococcus used pneumoniae antibiotics. (DSSP) (DSSP) Data invasive oninvasive drug-susceptible disease, disease, for forreporting reporting S. pneumoniae purposes, purposes, includes has been cultures obtained from a normally sterile site, such as blood or CSF, that are sensitive to all of the includesavailable cultures for the obtained last six from years. a normally Since thesterile sec site,ond such year as of blood reporting, or CSF, in that 2004, are thesensitive incidence of DSSPcommonly has usedconsistently antibiotics. been Data about on drug-susceptible 3.43 per 100,000. S. pneumoniae A total has of been704 availablecases were for the reported last six in to years.all of the Since commonly the second used year antibiotics. of reporting, Data in 2004, on drug-susceptible the incidence of DSSPS. pneumoniae has consistently has been been about available2008.3.43 per This for 100,000. the is thelast A highestsix total years. of 704 reported Since cases the wereincidence sec reportedond year in in the 2008.of reporting,six Thisyears is inthe that 2004, highest the the disease reported incidence hasincidence of been in DSSPreportable.the six has years consistently The that thenumber disease been of about has cases been 3.43 reported reportable. per 100,000. tends The Anumber to total increase of of 704 cases casesin reportedthe werewinter tends reported months. to increase in In in2008, the 2008.numberthe winter This of is months.cases the highest exceeded In 2008, reported the the number incidence previous of cases in 5-year the exceeded six average years the that previous in the all diseasemonths 5-year average has (Figure been in all2). months reportable. (Figure 2). The number of cases reported tends to increase in the winter months. In 2008, the number of cases exceeded the previous 5-year average in all months (Figure 2). Figure 2. Streptococcus pneumoniae, Invasive Disease, Drug-Susceptible 90 Cases byFigure Month 2. of Onset, Florida, 2008 Streptococcus pneumoniae, Invasive Disease, Drug-Susceptible 80 90 Cases by Month of Onset, Florida, 2008

80 70

70 60

60 50 50 40

40 30 Number of CasesNumber of 30

Number of CasesNumber of 20 20 10 10 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Month 5yr average 2008 5yr average 2008

TheThe highest highest incidence incidence rates rates continuecontinue toto occuroccu ramong among infants infants <1, <1, children children aged aged 1-4 1-4years, years, and thoseand over The85. highest In 2008, incidencethe incidence rates rates continue were higher to than occur or theamong same infantsas the previous <1, children 5-year averageaged 1-4 in allyears, age and those over 85. In 2008, the incidence rates were higher than or the same as the previous 5- thosegroups over except 85. those In 2008, 10-14 andthe 20-24,incidence in which rates the wererates decreasedhigher than (Figure or the 3). sameMales continueas the previousto have a 5- yearyearslightly average average higher in incidenceinall allage age groups than groups females except except (3.79those andthose 10-14 3.66 10-14 and per 20-24,100,000, and 20-24,in respectively).which in the which rates The the decreased highest rates incidence decreased (Figure(Figureis among 3). 3). non-whiteMales Males continue continuemales (4.32to have to per have a 100,000) slightly a slightly higherand lowest higher incidence among incidence than non-white females than females females(3.79 (0.47 and (3.79 per3.66 100,000). perand 3.66 per 100,000, respectively). The highest incidence is among non-white males (4.32 per 100,000) and100,000, lowest respectively).among non-white The females highest (0.47 incidence per 100,000). is among non-white males (4.32 per 100,000) and lowest among non-white females (0.47 per 100,000).

145 2008 Florida Morbidity Statistics

Figure 3. Streptococcus pneumoniae, Invasive Disease, Drug-Susceptible Incidence Rate by Age Group, Florida, 2008 14

4 Cases per 100,000 per Cases

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

DSSP was reported in 58 of the 67 counties in Florida. DSSP was reported in 58 of the 67 counties in Florida. Prevention The most effective way of preventing pneumococcal infections including DRSP is through vaccination. PreventionCurrently, there are two vaccines available. A conjugate vaccine is recommended for all children The<24 mostmonths effective of age, and way children of preventing age 24–59 pneumocmonths withoccal a high-risk infections medical including condition. DRSP The other is through vaccination.pneumococcal Currently,polysaccharide there vaccine are twoshould vaccines be administered available. routinely A conjugate to all adults vaccine 65+ years. is recommendedVaccine foris alsoall children indicated <24for persons months >2 ofwith age, a normal and childrenimmune system age 24–59 with chronic months illnesses. with aAdditionally, high-risk itmedical condition.is important Theto practice older good pneumococcal hand hygiene, polysaccharide take antibiotics only vaccine when necessary should be, and administered finish the entire routinely to course of treatment. all adults 65+ years. The vaccine is also indicated for persons >2 with a normal immune system with chronic illnesses. Additionally, it is important to practice good hand hygiene, take antibiotics only whenStreptococcus necessary, pneumoniae and finish Invasive the entire Disease, course Drug-Susceptible, of treatment. Incidence Rate* by County, Florida, 2008

146

References David L. Heymann, Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

American Academy of Pediatrics, Red Book 2003: Report of the Committee on Infectious Diseases, 26th ed., American Academy of Pediatrics Press, Elk Grove Village, Illinois, 2003.

William Atkinson (ed.) et al., Epidemiology and Prevention of Vaccine-Preventable Diseases, 10th ed., Public Health Foundation, Washington, District of Columbia, 2007.

Michael T. Drennon, “Drug Resistant Patterns of Invasive Streptococcus pneumoniae Infections in the State of Florida in 2003,” Master’s Thesis, University of South Florida, Tampa, 2006.

The following reports are available on the Department of Health web site: 1999 Streptococcus pneumoniae Surveillance Report, 2000 Streptococcus pneumoniae Surveillance Report, 1997- 1999 Surveillance of SP in Central FL, at http://www.doh.state.fl.us/disease_ctrl/epi/topics/popups/anti_res.htm

Summary of Selected Notifiable Diseases and Conditions

References David L. Heymann, Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

American Academy of Pediatrics, Red Book 2003: Report of the Committee on Infectious Diseases, 26th ed., American Academy of Pediatrics Press, Elk Grove Village, Illinois, 2003.

William Atkinson (ed.) et al., Epidemiology and Prevention of Vaccine-Preventable Diseases, 10th ed., Public Health Foundation, Washington, District of Columbia, 2007.

Michael T. Drennon, “Drug Resistant Patterns of Invasive Streptococcus pneumoniae Infections in the State of Florida in 2003,” Master’s Thesis, University of South Florida, Tampa, 2006.

The following reports are available on the Department of Health web site: 1999 Streptococcus pneumoniae Surveillance Report, 2000 Streptococcus pneumoniae Surveillance Report, 1997-1999 Surveillance of SP in Central FL, at http://www.doh.state.fl.us/disease_ctrl/epi/topics/popups/anti_res.htm

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at: http:// www.cdc.gov//ncidod/dbmd/diseaseinfo/drugresisstreppneum_t.htm.

Syphilis

Disease Abstract Of the 4,578 syphilis cases reported in 2008, 50% were diagnosed as primary, secondary, or early latent infection. Early (primary, secondary, and early latent) syphilis includes all cases where initial infection has occurred within the previous 12 months. In 2008, there were 2,290 early syphilis cases reported in Florida; a 10.6% increase from 2007. Infectious syphilis (primary and secondary stages) increased 14% from 2007; whereas early latent cases increased 7.9% in the same period. The incidence rate for early syphilis in 2008 was 12.1 per 100,000 population, compared to 11.1 per 100,000 population in 2007. Of the 2,290 early syphilis cases reported in 2008, nearly 70% were reported from five counties: Miami-Dade (569/2,290), Broward (386/2,290), Hillsborough (327/2,290), Orange (184/2,290), and Palm Beach (139/2,290). Fourteen counties reported no cases of early syphilis (Figure 1).

Overall, men accounted for 77% of the early syphilis cases among those over 14 years of age (Table 1). The greatest number of cases among men occurred in the 40 to 44 year old age group, with a second peak among those 20-24. Provisional risk factor data indicate 60% of primary and secondary syphilis cases were reported in men who have sex with men (MSM) populations in 2008. Trends since 1999 support the hypothesis that syphilis cases among MSM are a driving force behind increases in early syphilis, particularly the primary and secondary stages.

The greatest proportion of early syphilis cases for women was reported in the 15-24 age group, which accounted for 43% of cases. Nearly 60% of female cases were under 30 years of age, compared to 35% among males of the same age cohort. Age differences in males and females can be attributed to several factors: health seeking behavior, prenatal recommendations, and partner dynamics which all indicate that females are more likely to be screened and/or tested at an earlier age than males. Secondly, risk behaviors in older MSM populations contribute heavily to the distribution of disease among males.

147 2008 Florida Morbidity Statistics

Table 1. Reported Early Syphilis Cases by Age and Gender, Florida, 2007 Total Males Females Age # % # % # % 15 – 19 190 8.3 95 5.4 95 18.0 20 – 24 404 17.7 274 15.6 130 24.6 25 – 29 326 14.2 240 13.6 86 16.3 30 – 34 288 12.6 234 13.3 54 10.2 35 – 39 287 12.5 228 13.0 59 11.2 40 – 44 335 14.6 289 16.4 46 8.7 45 – 49 225 9.8 196 11.1 29 5.5 50 – 54 113 4.9 100 5.7 13 2.5 55 -59 61 2.7 54 3.1 7 1.3 60+ 55 2.4 50 2.8 5 0.9 Total 2,288 100.0 1,760 100.0 528 100.0

In 2008, the number of early syphilis cases increased 10.2% from 2007 among males and 11.5% among females. In 2008, the rate of early syphilis was highest among women in the 20-24 age group (21.8 cases per 100,000 population) and among men between the ages of 40-44 (44.3 cases per 100,000 population). The ratio of male to female rates of early syphilis was 3.3 to 1 overall but differed significantly among racial/ethnic groups. The male to female (M:F) rate ratio among non-Hispanic blacks was 2:1, Hispanics 5:1, and non-hispanic whites 7:1. The varying differences in male to female rate ratios indicate that early syphilis cases in non-Hispanic black populations are more sustained in heterosexual populations and early syphilis among Hispanic and non-Hispanic white populations continue to indicate stronger distribution among MSMs.

Figure 1: Early Syphilis Rates/100,000, 2008

When looking at case counts, persons who self reported as non-Hispanic black accounted for 44.6% of the syphilis cases in 2008. Persons who self reported as non-Hispanic white accounted for 29.4% of the

148 Summary of Selected Notifiable Diseases and Conditions

cases. Persons who self reported as Hispanic (regardless of race) accounted for 18.2% of the cases. Persons who self reported in other or unidentified racial and ethnic groups accounted for 1.3%1 of the cases. The rate per 100,000 for non-Hispanic blacks was 34.3 per 100,000 population. This rate was six times greater than the second highest rate, in non-Hispanic whites (5.9/100,000).

Prevention Regardless of stage, cases reported in 2008 reflect an upward trend among both male and female populations. Community prevalence and higher risk-taking behaviors associated with certain populations continue to contribute to morbidity. Although syphilis is preventable, and infection can be diagnosed and cured with simple, inexpensive, and widely available tests, syphilis has remained endemic in Florida communities. The sequelae of untreated syphilis can result in neurological damage, paralysis, blindness, increased risk of HIV, and death. Untreated syphilis in pregnancy can lead to stillbirth, spontaneous abortion, and preterm delivery, and cause serious complications for neonates. The American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention recommend that women be screened for syphilis as early as possible in their pregnancies. F.A.C. 64D-3.019 and Florida Statute 384.31 requires that all women receive two tests during prenatal care. Syphilis in pregnant women and neonates is considered a notifiable condition of urgent public health importance. Reports should be made to the local county health department immediately.

Tetanus Tetanus

Figure 1. Tetanus: Crude Data Tetanus Cases by Year Reported, Florida, 1999-2008 NumberTetanus: of Cases Crude Data 2 6 2008 incidence rate per Number of Cases 2 5 100,000 0.01 2008 incidence rate per 4 100,000% change from average 5-year 0.01 (2003-2007) reported cases -43.99 3 % change from average 5-year Age (yrs) 2 (2003-2007) reported cases -43.99 CasesNumber of Mean 57.5 1 Age (yrs) Median 57.5 MeanMin-Max 57.553-62 0 Median 57.5 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 53-62 Year Disease Abstract Two confirmed cases of tetanus were reported in Florida for 2008, which is a decrease from the peak Diseaseof five Abstract cases in 2007 (Figure 1). Both cases were hospitalized and survived, but had very different Two confirmedoutcomes. cases One patient, of tetanus with documentedwere reported history in Florida of vaccine, for 2008, had a whichpuncture is awound decrease from afrom fish thehook peak ofand five developed cases in symptoms 2007 (Fi gurewithin 1). a week. Both Treatmentcases were was hospitalized given and the and patient survived, recovered but had quickly. very In the differentother outcomes. case, the patient One patient, developed with symptoms documented weeks history after a of puncture vaccine, wound had afrom puncture an animal. wound This diabetic from apatient fish hook neglected and developed wound treatment symptoms and developed within a week.paralysis. Treatment Recuperation was givenwas prolonged and the patientand required recoveredintubation quickly. and tubeIn the feeding. other case, the patient developed symptoms weeks after a puncture wound from an animal. This diabetic patient neglected wound treatment and developed paralysis.Prevention Recuperation was prolonged and required intubation and tube feeding. Vaccination against tetanus is recommended to begin at two months of age, and continue through adulthood at appropriate intervals to maintain protection against the disease. Primary tetanus Preventionimmunization with diphtheria and tetanus toxoid and acellular pertussis vaccine (DTaP) is recommended Vaccinationfor all persons, against startingtetanus at is six recommended weeks old, but to<7 begin years atof twoage, monthsand without of age, contraindications. and continue This vaccine through adulthood at appropriate intervals to maintain protection against the disease. Primary tetanus immunization with diphtheria and tetanus toxoid and acellular pertussis vaccine (DTaP) is recommended for all persons, starting at six weeks old, but <7 years of age, and without 149 contraindications. This vaccine is available in combination with other childhood vaccines. Routine tetanus booster immunization, combined with diphtheria toxoid, is recommended for all persons >7 years of age every ten years. The adult formulation of tetanus and diphtheria toxoids and pertussis (Tdap) is the vaccine of choice for at least one dose. As of school year 2009-2010, Tdap vaccine is the required vaccine for entry into seventh grade. When protection from pertussis is needed, this dose can be given two years from the last dose of tetanus- containing vaccine.

The appropriate use of tetanus toxoid and tetanus immune globulin (TIG) in wound management is also important for the prevention of tetanus. Since herd immunity does not play a role in protecting individuals against tetanus, all persons must be vaccinated.

References Centers for Disease Control and Prevention, Manual for the Surveillance of Vaccine- Preventable Diseases, 4th ed., 2008, Chapter 16.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/vaccines/vpd-vac/tetanus/default.htm. 2008 Florida Morbidity Statistics

is available in combination with other childhood vaccines. Routine tetanus booster immunization, combined with diphtheria toxoid, is recommended for all persons >7 years of age every ten years. The adult formulation of tetanus and diphtheria toxoids and pertussis (Tdap) is the vaccine of choice for at least one dose. As of school year 2009-2010, Tdap vaccine is required for entry into seventh grade. When protection from pertussis is needed, this dose can be given two years from the last dose of tetanus-containing vaccine.

References Centers for Disease Control and Prevention, Manual for the Surveillance of Vaccine-Preventable Diseases, 4th ed., 2008, Chapter 16.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/vaccines/vpd-vac/tetanus/default.htm.

Recommended immunization schedule is available at: http://www.cdc.gov/vaccines/recs/ schedules/ default.htm.

Toxoplasmosis Toxoplasmosis Figure 1. Toxoplasmosis Cases by Year Reported, Florida, 1999-2008 Toxoplasmosis:Toxoplasmosis: Crude Crude Data Data Number of Cases 14 50 Number of Cases 14 45 2008 incidence rate per 40 2008100,000 incidence rate per 0.07 35 100,000 0.07 % change from average 30 % change5-year (2003-2007) from average reported 5- 25 yearcases (2003-2007) reported 0.00 20

cases 0.00 Number of Cases 15 Age (yrs) 10 Age (yrs) Mean 42.57 5 Mean 42.57 Median 38.5 0 MedianMin-Max 24 38.5 - 67 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 24 - 67 Year

Disease Abstract DiseaseThe number Abstract of cases of Toxoplasmosis increased between 2000 (14) and 2002 (45), declined to two Thecases number in 2005, of cases and has of Toxoplasmosisbeen steadily increasing increased (Figure between 1). 2000Of the (14) cases and reported 2002 (45), in 2008, declined 11 were to confirmed,two cases inand 2005, three and were has probable. been steadily No outbreaks increasing of toxoplasmosis (Figure 1). Of have the casesbeen reported reported in inthe past 2008,10 years. 11 were Most confirmed, cases of toxoplasmosisand three were occur probable. in immunocompromised No outbreaks of toxoplasmosisindividuals without have a recentbeen or reportedspecific in exposurethe past 10history. years. This Most is also cases true of for toxoplasmosis all the cases ofoccur toxoplasmosis in immunocompromised confirmed in Florida during individuals2008. without a recent or specific exposure history. This is also true for all the cases of toxoplasmosis confirmed in Florida during 2008. During the past five years, the cases reported were distributed throughout all the months of the year; Duringin 2008, the casespast five clustered years, in the July cases through reported October we andre distributed came from throughout only eight counties all the months (Alachua, of theDade, year;Highlands, in 2008, Hillsborough, cases clustered Lee, inPalm July Beach, through Orange October and and Seminole) came from (Figure only 2). eight counties (Alachua, Dade, Highlands, Hillsborough, Lee, Palm Beach, Orange and Seminole) (Figure 2).

Figure 2. Toxoplasmosis Cases by Month of Onset, Florida, 2008 150 4

Numberof Cases 1

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month

5yr average 2008

The average number of cases for the past five years was highest in those aged 25-34 years with a bell-shaped distribution surrounding this group. The 2008 data shows a very similar pattern with cases occurring in those 24 to 67 years old (Figure 3). Between 2002 and 2006, females had a higher incidence rate than males (0.16 and 0.08 per 100,000, respectively), but in Toxoplasmosis Figure 1. Toxoplasmosis Cases by Year Reported, Florida, 1999-2008 Toxoplasmosis: Crude Data 50 Number of Cases 14 45 40 2008 incidence rate per 35 100,000 0.07 30 % change from average 5- 25 year (2003-2007) reported 20

cases 0.00 Number of Cases 15 Age (yrs) 10 5 Mean 42.57 0 Median 38.5 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 24 - 67 Year

Disease Abstract The number of cases of Toxoplasmosis increased between 2000 (14) and 2002 (45), declined to two cases in 2005, and has been steadily increasing (Figure 1). Of the cases reported in 2008, 11 were confirmed, and three were probable. No outbreaks of toxoplasmosis have been reported in the past 10 years. Most cases of toxoplasmosis occur in immunocompromised individuals without a recent or specific exposure history. This is also true for all the cases of toxoplasmosis confirmed in Florida during 2008.

During the past five years, the cases reported were distributed throughout all the months of the year; in 2008, cases clustered in July through October and came from only eight counties (Alachua,Summary ofDade, Selected Highlands, Notifiable Diseases Hillsborough, and Conditions Lee, Palm Beach, Orange and Seminole) (Figure 2).

Figure 2. Toxoplasmosis Cases by Month of Onset, Florida, 2008

Numberof Cases 1

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month

5yr average 2008

The average number of cases for the past five years was highest in those aged 25-34 years with Thea bell-shaped average numberdistribution of surrounding cases for thisthe group. past five The years2008 data was shows highest a very in similarthose patternaged 25-34with years withcases a bell-shapedoccurring in those distribution 24 to 67 years surrounding old (Figure this 3). group. Between The 2002 2008 and 2006, data females shows had a very a higher similar incidence rate than males (0.16 and 0.08 per 100,000, respectively), but in 2008 there were more cases pattern with cases occurring in those 24 to 67 years old (Figure 3). Between 2002 and 2006, 2008in there males were than females. more cases in males than females. females had a higher incidence rate than males (0.16 and 0.08 per 100,000, respectively), but in

Figure 3. Toxoplasmosis Cases by Age Group, Florida, 2008

2 Numberof Cases

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group Previous 5yr average 2008

PreventionPrevention PreventionPrevention measures measures should should includeinclude education education of immunocompromised of immunocompromised persons andpersons pregnant and women pregnant womento include: to include: proper proper handwashing; handwashing; thorough freezing thorough or cooking freezing of meats; or cooking avoidance of meats; of cleaning avoidance cat litter of pans; and wearing gloves when gardening; as well as containment of cats as indoor pets, daily disposal cleaningof cat cat feces litter and pans; litter, and and covering wearing of sandboxesgloves when to prevent gardening; access fromas well stray as cats. containment of cats as indoor pets, daily disposal of cat feces and litter, and covering of sandboxes to prevent access from stray cats.

151 2008 Florida Morbidity Statistics

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health References DavidAssociation L. Heymann Press,(ed.), Control Washington, of Communicable District of DiseasesColumbia, Manual 2004., 18 th ed., American Public Health Association Press, Washington, District of Columbia, 2004. Additional Resources DiseaseAdditional information Resources is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/ncidod/dpd/parasites/toxoplasmosis/default.htmDisease information is available from the Centers for Disease Control and andhttp://www.cdc.gov/ncidod/dpd/ Prevention (CDC) at parasites/toxoplasmosis/moreinfo_toxoplasmosis.htm.http://www.cdc.gov/ncidod/dpd/parasites/toxoplasmosis/default.htm and http://www.cdc.gov/ncidod/dpd/parasites/toxoplasmosis/moreinfo_toxoplasmosis.htm.

152 Tuberculosis Summary of Selected Notifiable Diseases and Conditions Disease Abstract Florida reported 953 cases of tuberculosisTuberculosis (TB) for 2008, a four percent decrease from 2007 (Figure 1). Pulmonary cases representedTuberculosis 81% of all cases while 16% were extra-pulmonary, meaningDisease occurring Abstract outside of the lungs, and three percent were both. Florida’s “Big Six” counties,Florida reported Miami-Dade 953 cases(197), ofDuval tuberculosis (102), Orange (TB) for (87), 2008, Broward a four (85),percent Hillsborough decrease from(69), 2007and Disease(Figure Abstract 1). Pulmonary cases represented 81% of all cases while 16% were extra-pulmonary, FloridaPalm reported Beach (65)953 casesreported of tuberculosis63% of Florida’s (TB) TB for morbidity2008, a four for 2008.percent The decrease case rate from decreased 2007 (Figure 1). frommeaning 5.2 per occurring 100,000 outside population of the in lungs,2007 toand 5.0 three per 100,000percent werepopulation both. inFlorida’s 2008, which “Big Six” Pulmonarycounties, cases Miami-Dade represented (197), 81% Duval of all (102), cases Orange while 16% (87), were Broward extra-pulmonary, (85), Hillsborough meaning (69), occurring and outsiderepresents of the lungs, a decrease and three of 36 percent cases overallwere both. (Figure Florida’s 2). “Big Six” counties, Miami-Dade (197), Duval Palm Beach (65) reported 63% of Florida’s TB morbidity for 2008. The case rate decreased (102), Orange (87), Broward (85), Hillsborough (69), and Palm Beach (65) reported 63% of Florida’s TB from 5.2 per 100,000 population in 2007 to 5.0 per 100,000 population in 2008, which morbidityrepresents for 2008. a decrease The incidence of 36 cases rate decreased overall (Figure from 2).5.2 per 100,000 population in 2007 to 5.0 per 100,000 population in 2008, whichFigure represents 1. TB Morbidity a decrease in Florida, of 36 1990-2008 cases overall (Figure 2).

1,832 2,000 1,707 1,762 Figure 1. TB Morbidity in Florida, 1990-2008 1,417 1,302 1,500 1,832 2,000 1,702 1,7071,655 1,762 1,171 1,556 1,084 1,076 1,038 1,400 953 1,000 1,417 1,3021,277 1,500 1,094 1,702 1,655 1,1711,145 989 1,556 1,0841,046 1,076 1,038 500 1,400 953

Number of Cases 1,000 1,277 1,145 1,094 1,046 989 0 500

Number of Cases 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Figure 2. TB Incidence Rates in Florida, 1999-2008

12 Figure 2. TB Incidence Rates in Florida, 1999-2008 8.1 8 7.2 6.9 12 6.5 6.1 6.1 6.1 5.6 5.2 5.0 6.4 4 8.1 5.8 5.6 5.2 5.1 8 7.2 6.9 4.9 6.5 4.86.1 4.6 4.4 4.2 6.1 6.1 5.6 5.2 5.0 Casesper 100,000 0 6.4 5.8 4 5.6 5.2 5.1 4.9 1999 2000 2001 2002 2003 2004 20054.8 20064.6 20074.4 20084.2 Casesper 100,000 0 Florida United States 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Medically underserved and low-income populationsFlorida as wellUnited as racial States and ethnic minorities disproportionately carry the burden of TB in Florida. In 2008, 41% (386/953) of TB cases were among non-Hispanic blacks, 27% (257/953) were Hispanic, and 10% (94/953) were Asian. Non-Hispanic whites representedMedically 22% underserved (208/953) and of TBlow-income cases. For populations the state asas awell whole, as racial non-Hispanic and ethnic whites minorities comprise 61% disproportionately reflect the burden of TB in Florida. In 2008, 39% (386/953) of TB cases were of the population, Hispanics comprise 21%, and non-Hispanic blacks comprise 16%. Looking at these racial/ethnicMedically comparisons underserved shows and low-income that non-Hispanic populations blacks as make well asup racial a small and minority ethnic ofminorities the population in Floridadisproportionately (16%) but bear reflectthe highest the burden proportion of TB of in the Florida. TB cases In 2008, (41%). 39% Comparing (386/953) the of TBracial cases and wereethnic breakdown of TB cases by place of birth shows that of foreign-born cases, the majority occur among Hispanics (46%), whereas the majority of U.S.-born cases occur among non-Hispanic blacks (52%) (Table 1).

153 among non-Hispanic blacks, 27% (257/953) were Hispanic, and 10% (94/953) were Asian. Non-Hispanic whites represented 22% (208/953) of TB cases. For the state as a whole, non- Hispanic whites comprise 61% of the population, Hispanics comprise 21%, and non-Hispanic blacks comprise 16%. Looking at these racial/ethnic comparisons shows that non-Hispanic blacks make up a small minority of the population in Florida (16%) but2008 bear Florida the highest Morbidity Statistics proportion of the TB cases (39%). Comparing the racial and ethnic breakdown of TB cases by place of birth shows that of foreign-born cases, the majority occur among Hispanics (46%), whereasTable the 1.majority Tuberculosis of U.S.-born Cases by cases Race occurand/or among Ethnicity non-Hispanic and Place of Birth,blacks Florida, (52%) 2008 (Table 1).

U.S. % U.S. Foreign % Foreign Race/Ethnicity Total Total % Table 1. Tuberculosis Cases byBorn Race and/orBorn Ethnicity Bornand Place of BornBirth, Florida, 2008 Black, Non-Hispanic 254U.S. % 52 U.S. Foreign 132 % Foreign 28 386 41 HispanicRace/Ethnicity (all races) Born42 Born 9 215Born Born 46 Total 257 Total 27 % White,Black, Non-HispanicNon-Hispanic 184 254 38 52 13224 285 208 386 22 41 AsianHispanic Only (all races) 423 1 9 21591 20 46 94257 10 27 White, Non-Hispanic 184 38 24 5 208 22 American Indian/ Alaskan Asian Only 13 <1 1 910 N/A 20 194 <1 10 NativeAmerican Indian/ Alaskan NativeNative Hawaiian/ Pacific 1 <1 0 N/A 1 <1 0 N/A 1 <1 1 <1 IslanderNative Hawaiian/ Pacific Islander 0 N/A 1 <1 1 <1 Multiple Race 2 <1 0 N/A 2 <1 Multiple Race 2 N/A 0 N/A 2 <1 UnknownUnknown 22 N/A<1 1 1 <1 <1 3 3 <1 <1 TotalTotal 488488 464 464 952* 952* *One Reported*One Reported case is not case included is not (whiteincluded race (white with raceunknown with unknown ethnicity) ethnicity) Percents have been rounded Percents have been rounded

In 2004, foreign-born people represented almost 50% (526/1,076) of Florida’s TB cases. The In 2004, foreign-born people represented almost 50% (526/1,076) of Florida’s TB cases. The proportion proportion decreased to 45% (496/1,094) in 2005, but began to rise again for the next three decreased to 45% (496/1,094) in 2005, but began to rise again for the next three years. In 2008, foreign- years. In 2008, foreign-born people once again represented almost 50% (464/953) of Florida’s born people once again represented almost 50% (464/953) of Florida’s TB morbidity. This shows that TB morbidity. This shows that while the number of TB cases has been steadily decreasing over while thethe number past five of years, TB cases the proportionhas been steadilyof cases decreasing that are among over theforeign-born past five peopleyears, thehas proportionbeen of cases thatincreasing. are among foreign-born people has been increasing.

Figure 3. Trends in Foreign-Born TB, Florida 1994-2008 TB Cases Percent

2,000 60% 1,800 49% 47% 48% 49% 46% 45% 50% 1,600 43% 44% 40% 1,400 36% 40% 1,200 32% 29% 30% 1,000 27% 28% 30% 800

600 20%

400 10% 200 0 0% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year All TB Cases % Foreign-born

Globally, males represent the largest percentage of TB cases. That same trend is observed in Florida where males were 64% (614/953) of reported TB cases in 2008 and females were 35% (338/953). The TB incidence rate for males was almost twice that of females. Also, males between the ages of 25 and

154 Summary of Selected Notifiable Diseases and Conditions

64 represented 44% (423/953) of cases whereas females of the same age group represented 24% (227/953) of TB cases in 2008. The same level of differences between the genders is not seen when broken down by age group. For children 5-14, the rate among males and females is almost identical, whereas among those 45 to 64 years old, the rate among males is almost two and a half times higher than among females (Table 2). Some available research shows that the gender difference in incidence rates could be due to care-seeking behaviors. Women tend to present to health care providers later in their illness. Additionally, behavioral risk factors for disease including excess alcohol consumption, drug use, homelessness, and incarceration are reported much less frequently in female TB cases.

Table 2. Age and Gender Specific Incidence Rates per 100,000 Population, Florida, 2008 Age Groups Male Female Combined 0-4 years 4.4 2.5 3.5 5-14 years 0.3 0.5 0.39 15-24 years 5.0 2.6 3.8 25-44 years 6.8 4.8 5.8 45-64 years 10.8 4.5 7.6 65 and older 7.2 3.3 5.0

Overall, cases 14 years and younger comprised five percent of TB cases (48/953) and 15 to 24-year-olds were 10% (93/953) of cases. Age group 25 to 44 represented 29% (278/953) and 39% (372/953) were 45 to 64 years of age for 2008. Cases 65 years or older were 17% (162/953) of TB cases (Table 3).

Table 3. Tuberculosis Cases by Age Group, Florida, 2008 Age Groups 2008 Cases % of TB (n=953) 0-4 years 39 4 5-14 years 9 1 15-24 years 93 10 25-44 years 278 29 45-64 years 372 39 65 and older 162 17

At-risk Populations About 31% (308/989) of TB cases in 2007 reported drinking excessive amounts of alcohol, injecting drugs, or using non-injectable drugs within the year of TB diagnosis (Figure 4). In 2008, that number decreased to approximately 29% (280/953) of cases.

155 At-risk Populations About 31% (308/989) of TB cases in 2007 reported drinking excessive2008 amountsFlorida Morbidity of alcohol, Statistics injecting drugs, or using non-injectable drugs within the year of TB diagnosis (Figure 4). In At-risk Populations 2008, that number decreased to approximately 29% (280/953) of cases. About 31% (308/989) of TB cases in 2007 reported drinking excessive amounts of alcohol, injecting drugs, or using non-injectable drugs within the year of TB diagnosis (Figure 4). In Figure 4. Tuberculosis and Substance Abuse During 2008, that number decreased to approximatelyYear of Diagnosis, 29% Florida, (280/953)2007 an dof20 cases.08

Figure 4. Tuberculosis and Substance Abuse During Year of Diagnosis, Florida, 2007 and 2008 20%

20%15%

15%

Percent 10%

Percent 10% 5% 5% 0% 2007 2008 0% Excess alcohol use 200718% 2008 17% withinExcess year alcohol use 18% 17% Injectingwithin yeardrug use 2% 2% withinInjecting yeardrug use 2% 2% within year Non-injecting drug use 11% 11% 11% 11% withinNon-injecting year drug use within year

The homeless are a marginalized population with issues such as poverty, poor nutrition, and, in some The homeless are a marginalized population with issues such as poverty, poor nutrition, and, in cases,The substance homeless abuse. are a marginalizedThese factors population increase the with probability issues such of progression as poverty, frompoor TBnutrition, infection and, in to disease.somesome cases, cases,Infection substance substance may also abuse.abuse. be more TheseThese common factors, factors, because as as well wellof as exposure asfrequenting frequenting to high-risk high high risk settings settings,risk settings, such such as assuch as homelesshomelesshomeless shelters. shelters, shelters, In 2007, increase increase seven the percent probabilityprobability (70/989) of of progression ofprogression Florida’s fromTB from cases TB infectionTB were infection reported to disease. to asdisease. homeless In In (Figure2007,2007, 5). seven Theseven number percent percent of (70/989) (70/989)homeless ofof TB Florida’sFlorida’s cases remainedTB TB cases cases sevenwere were reported percent reported as(65/953) homeless as homeless in 2008. (Figure (Figure 5). The 5). The numbernumber of of homeless homeless TBTB casescases remainedremained seven seven percent percent (65/953) (65/953) in 2008. in 2008.

Figurguree 5. 5. Tuberc Tuberculosulosis isanand Homelessness,d Homelessness, TotalTotal TB TB Florida, 1994-2008 Cases Florida, 1994-2008 Cases % Homeless 2,000 % Home12 less 2,000 12 1,800 10% 10% 10% 10% 1,800 10% 10% 10%9% 9% 10% 9% 10 1,600 9% 10 1,600 8% 9% 9% 9% 8% 9%8% 8% 1,400 8 8% 8% 8% 8%7% 7% 1,4001,200 8 7% 7% 1,2001,000 5% 6 1,000800 5% 6 4 800600 4 600400 2 400200 0 0 2 200 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 0 Year 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total Florida TB Cases Percent Homeless Year Total Florida TB Cases Percent Homeless People who are incarcerated are a potentially at-risk population for TB infection. Failure to diagnose and effectively treat TB in incarcerated populations creates a potential risk of infecting other inmates as well as eventually exposing the general community to possible TB infection. In 2008, three percent (29/953) of Florida’s TB cases were incarcerated at the time of diagnosis. Local jails represented 48% (14/29) of

156

People who are incarcerated are a potentially at-risk population for TB infection. Failure to diagnose and effectively treat TB in incarcerated populations creates a potential risk of infecting other inmates as well as eventually exposing the general community to possible TB infection. In 2008, three percent (29/953) of Florida’s TB cases were incarcerated at the time of diagnosis. SummaryLocal jailsof Selected represented Notifiable 48% Diseases (14/29) and ofConditions TB cases among those incarcerated (Figure 6). Federal and state prisons housed 45% (13/29) of cases and seven percent (2/29) were housed at Krome Detention Center (a federal facility that houses both criminal and non-criminal aliens). Of TB casesthe 29 among cases diagnosedthose incarcerated in correctional (Figure facilities, 6). Federal 21% and (6/29) state were prisons co-infected housed with 45% HIV. (13/29) of cases and seven percent (2/29) were housed at Krome Detention Center (a federal facility that houses both criminal and non-criminal aliens). Of the 29 cases diagnosed in correctional facilities, 21% (6/29) were co-infected with HIV. Figure 6. Tuberculosis in Correctional Facilities, Figure 6. TuberculosisFlorida, in 2008Correctional Facilities, Florida, 2008 Local Jail 48% Other Facility 7%

Federal Prison 7%

State Prison

38%

In 2008, TB/HIV co-infection increased to 17% (161/953) from 15% (150/989) in 2007. From 1993- 2006, 22% of Florida’s TB cases were reported to be co-infected with HIV (Figure 7). Fifty-eight percent (94/161) of TB/HIV cases were in U.S.-born people in 2008. Foreign-born people comprised 42% (67/161)In 2008, of HIV TB/HIV co-infected co-infection TB cases. increased to 17% (161/953) from 15% (150/989) in 2007. From 1993-2006, 22% of Florida’s TB cases were reported to be co-infected with HIV (Figure 7). Fifty-eight percent (94/161) of TB/HIV cases were in U.S.-born people in 2008. Foreign-born Figure 7. Trend of TB and HIV, Florida, 1994-2008 people comprised 42% (67/161) of HIV co-infected TB cases. 2,000 30% 1,800 23% 25% 25% 25% 24% 23% 23% 25% 1,600 21% 1,400 20% 18% 18% 18% 18% 20% 1,200 15% 17% 1,000 15% 800 TB Cases TB 600 10%

400 5% % of TB/HIV Cases 200 0 0% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

TB/HIV All TB Cases %TB/HIV

Drug Resistance Drug Resistance Drug resistant TB cases require additional resources including knowledgeable staff to medically Drug resistantmanage TB cases or provide require expert additional advice to resources treating staff. including Florida’s knowledgeable TB program utilizes staff theto medicallyservices of manage a or provide expertnetwork advice of physicians to treating and A.G.staff. Holley Florida’s State TB Hospital, program a specialty utilizes TB the hospital, services to ofprovide a network expert of physicians medicaland A.G. consultation Holley State in order Hospital, to assist a specialty in the management TB hospital, of drug to provide resistant expert cases medicaland/or ensure consultation in order to assistthe utilization in the managementof appropriate drugof drug regimens. resistant A.G. cases Holley and/or State Hospitalensure theexists utilization to treat the of appropriatemost drug regimens.medically A.G. and Holley behaviorally State Hospital complex exists cases toof TB;treat cases the most that have medically failed treatmentand behaviorally in the complex community. It is one of only a few hospitals in the nation dedicated to the treatment of TB. The hospital treats and cures an average of 100 patients each year, including those with drug resistant strains of TB.

In 2008, five percent (50/953) of Florida’s TB cases were resistant to the first line TB treatment drug Isoniazid (INH) (Figure 8). Less than one percent (4/953) was resistant to Isoniazid (INH) 157 and Rifampin (RIF) – MDR. Florida did not report any extensively drug resistant (XDR) TB cases in 2008.

Figure 8. Primary Antibiotic Resistance of TB Isolates, Florida, 1994-2008 11 12% 11 10 10 10 10% 10 10

7 8% 7 7 7 6 6% 5 55

4% 2.70 1.50 2% 1.20 0.90 0.98 0.92 0.91 1.00 0.86 0.49 0.76 0.74 0.50 0.400.50 0% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Resistant to INH Resistant to INH and RIF (MDR)

Figure 7. Trend of TB and HIV, Florida, 1994-2008

2,000 30% 1,800 23% 25% 25% 25% 24% 23% 23% 25% 1,600 21% 1,400 20% 18% 18% 18% 18% 20% 1,200 15% 17% 1,000 15% 800 TB Cases TB 600 10%

400 5% % of TB/HIV Cases 200 0 0% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

TB/HIV All TB Cases %TB/HIV

Drug Resistance Drug resistant TB cases require additional resources including knowledgeable staff to medically manage or provide expert advice to treating staff. Florida’s TB program utilizes the services of a network of physicians and A.G. Holley State Hospital, a specialty TB hospital, to provide expert medical consultation in order to assist in the management of drug resistant2008 Florida cases Morbidity and/or ensure Statistics the utilization of appropriate drug regimens. A.G. Holley State Hospital exists to treat the most medically and behaviorally complex cases of TB; cases that have failed treatment in the cases community.of TB: cases It that is one have of failedonly a treatment few hospitals in the in community. the nation dedicated It is one ofto onlythe treatmenta few hospitals of TB. in The the nationhospital dedicated treats to the and treatment cures an of average TB. The of hospital100 patients treats each and year,cures including an average those of 100with patients drug each year, includingresistant thosestrains with of TB. drug resistant strains of TB.

In 2008,In 2008,five percent five percent (50/953) (50/953) of Florida’s of Florida’s TB cases TB cases were wereresistant resistant to the to first the line first lineTB treatment TB treatment drug Isoniaziddrug (INH) Isoniazid (Figure (INH) 8). (FigureLess than 8). one Less percent than one (4/953) percent was (4/953) resistant was to resistantboth Isoniazid to Isoniazid (INH) and(INH) Rifampinand (RIF) Rifampin – MDR. (RIF) Florida – MDR. did Florida not report did anynot reportextensively any extensively drug resistant drug (XDR) resistant TB cases(XDR) inTB 2008. cases in 2008.

Figure 8. Primary Antibiotic Resistance of TB Isolates, Florida, 1994-2008 11 12% 11 10 10 10 10% 10 10

7 8% 7 7 7 6 6% 5 55

4% 2.70 1.50 2% 1.20 0.90 0.98 0.92 0.91 1.00 0.86 0.49 0.76 0.74 0.50 0.400.50 0% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Resistant to INH Resistant to INH and RIF (MDR)

Typhoid Fever Typhoid Fever Figure 1. Typhoid Fever Cases by Year Reported, Florida, 1999-2008 TyphoidTyphoid Fever: Fever: Crude Crude Data Data Number of Cases 18 24 Number of Cases 18 21 2008 incidence rate per 2008 incidence rate per 18 100,000 0.10 100,000 0.10 15 % change from average 5 year % change from average 5 year 12 (2003-2007) reported cases 34.33 (2003-2007) reported cases 34.33 9 Number Number of Cases Age Age(yrs) (yrs) 6 MeanMean 22.56 22.56 3 MedianMedian 16 16 0 Min-Max 1 - 68 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 1 - 68 Year

DiseaseDisease Abstract Abstract The Theoverall overall number number of confirmed of confirmed cases cases of typhoid of typhoid fever fever for the for last the 10last years 10 years has rangedhas ranged from from 10-24 10-24annually, annually, and and in 2008in 2008 was was 18 18cases, cases, representing representing an anincidence incidence rate rate of 0.10of 0.10 per per 100,000. 100,000. This was a This34.33% was a 34.33% increase increase from the from average the average number number of cases of in cases the previous in the previous five years five (Figure years 1). All of the (Figure2008 1). cases All of were the 2008classified cases aswere confirmed, classified andas confirmed,the median and age the was median 16. Over age the was past 16. five years, and Overconsistent the past fivewith years, national and data, consistent the majority with national of the cases data, (66-90%)the majority are of acquired the cases outside (66-90%) the U.S. The are acquired outside the U.S. The counties reporting the greatest number of cases were Broward and Palm Beach. Cases tend to be isolated, rather than clustered. They typically occur158 more frequently in the summer months, and in 2008, the majority of cases occurred in July-October. Only a single outbreak of typhoid fever (18 cases, 1997) occurred in Florida in the past 12 years. This outbreak was traced to frozen shakes made with imported frozen mamey fruit. Please see the Summary of Notable Outbreaks and Case Investigations for a description of cases imported from Haiti in 2008.

Prevention Prevention is through proper sanitation, safe food handling practices, and appropriate case management. These include proper handwashing, appropriate disposal of human waste products, access to safe and purified water supplies, control of insects, appropriate refrigeration, and cleanliness in preparation of food products in both home and commercial settings. In endemic areas, this includes drinking bottled or carbonated water, cooking foods thoroughly, peeling raw fruits and vegetables, and in general, avoiding food or drink from street vendors. Immunization is recommended only for those with occupational exposure to enteric infections or for those traveling or living in endemic, high risk areas. Summary of Selected Notifiable Diseases and Conditions

counties reporting the greatest number of cases were Broward and Palm Beach. Cases tend to be isolated, rather than clustered. They typically occur more frequently in the summer months, and in 2008, the majority of cases occurred in July-October. Only a single outbreak of typhoid fever (18 cases, 1997) occurred in Florida in the past 12 years. This outbreak was traced to frozen shakes made with imported frozen mamey fruit. Please see the Summary of Notable Outbreaks and Case Investigations for a description of cases imported from Haiti in 2008.

References David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health References Association Press, Washington, District of Columbia, 2004. David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public AdditionalHealth Association Resources Press, Washington, District of Columbia, 2004. Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// Additionalwww.cdc.gov/ncidod/dbmd/diseaseinfo/typhoidfever_g.htm. Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/ncidod/dbmd/diseaseinfo/typhoidfever_g.htm.

159 Varicella

Varicella: Crude Data 2008 Florida Morbidity Statistics

Number of Cases 1,735 Varicella 2008 incidence rate per 100,000 9.18 Varicella: Crude Data % changeNumber offrom Cases average 5 year 1,735 (2003-2007) reported cases N/A 2008 incidence rate per Age (yrs) 100,000 9.18 Mean 13.9 % change from average 5 year (2003-2007) reportedMedian cases N/A 9 Min-Max 0-93 Age (yrs) Mean 13.9 Disease AbstractMedian 9 Varicella was reportedMin-Max in 51 of the0-93 67 Florida counties. Cases may be under-reported since 2007 was the first full year of case reporting in Florida and 1,321 cases were reported that year. Disease Abstract TheVaricella 1,735 wascases reported reported in 51 inof the2008 67 includeFlorida counties. confirmed Cases and may probable be under-reported cases, as since did all 2007 previously was reportedthe first numbers. full year of caseOf these reporting cases, in Florida 1,060 and had 1,321 a history cases ofwere vaccination. reported that Thereyear. The were 1,735 582 cases outbreak-associatedreported in 2008 include cases. confirmed Childcare and probable centers cases, and schoolsas did all arepreviously the most reported common numbers. sites Of for varicellathese cases, outbreaks. 1,060 had a history of vaccination. There were 582 outbreak-associated cases. Childcare centers and schools are the most common sites for varicella outbreaks.

Figure 2. Varicella Cases by Month of Onset, Florida, 2001-2008

250

200

150

100 Numberof Cases 50

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 2008

Prevention The varicella vaccine is recommended at 12–15 months and at 4–6 years of age. Doses given prior to Prevention13 years of age should be separated by at least three months. Doses given after 13 years of age should Thebe varicella separated vaccine by at least is fourrecommended weeks. Due toat the 12–15 occurrence months of diseaseand at after4–6 oneyears dose of ofage. vaccine, Doses the given priorcurrent to 13 recommendation years of age isshould now for be two separated doses of vaccine. by at least Proof three of varicella months. vaccination Doses or given healthcare after 13 yearsprovider of age documentation should be ofseparated disease is byrequired at least for entryfour andweeks. attendance Due to in thechildcare occurrence facilities, of family disease day aftercare one homes, dose and of schoolsvaccine, for the certain current grades. recommendati on is now for two doses of vaccine. Proof of varicella vaccination or healthcare provider documentation of disease is required for entry and attendance in childcare facilities, family day care homes, and schools for certain grades.

160 Summary of Selected Notifiable Diseases and Conditions

Figure 3. Varicella Incidence Rate by Age Group, Florida, 2008

Cases per 100,000 per Cases 20

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

2008

TheThe ACIP Advisory recommends Committee on the Immunization use of varicella Practices vaccine recommends for susceptible the use of personsvaricella vaccine following for exposure tosusceptible a case of personsvaricella following infection. exposure If administered to a case of varicella within 72infection. hours, If and administered possibly within up to 72 120 hours, hours and possibly up to 120 hours following varicella exposure, varicella vaccine may prevent or significantly followingmodify disease. varicella Post-exposure exposure, varivaccinecella use vaccine should bemay considered prevent followingor significantly exposures modify in health disease. care Post-exposuresettings, where transmissionvaccine use risk should should be be considered minimized at followingall times, and exposures in households. in health If exposure care settings, whereto varicella transmission does not cause risk should infection, be post-exposure minimized at vaccination all times, with and varicella in households. vaccine should If exposure induce to varicellaprotection does against not subsequent cause infection, infection. post-exposure If exposure results vaccination in infection, with the varicellavaccine may vaccine reduce should the induceseverity protection of the disease. against subsequent infection. If exposure results in infection, the vaccine may reduceVaricella the zoster severity immune of theglobulin disease. (VZIG), if available, is recommended for post-exposure prophylaxis of susceptible persons who are at high risk for developing severe disease and when varicella vaccine is Varicellacontraindicated. zoster immuneVZIG is most globulin effective (VZIG), in preventing if available, varicella is infectionrecommended when given for within post-exposure 96 hours of prophylaxisvaricella exposure. of susceptible After the onlypersons U.S. licensedwho are manufacturer at high risk of for VZIG developing announced severe it had discontinued disease and when varicellaproduction, vaccine an investigational is contraindicated. (not licensed) VZIG product, is most VariZIG, effective became in preventingavailable in February varicella 2006 infection under whenan investigational given within new 96 drughours application of varicella (IND) exposure. submitted to After the Food the onlyand Drug U.S. Administration. licensed manufacturer This new of product can be obtained from the distributor (FFF Enterprises, Inc., Temecula, CA) by calling 800-843- VZIG7477. announced it had discontinued production, an investigational (not licensed) product, VariZIG, became available in February 2006 under an investigational new drug application (IND) submitted to the Food and Drug Administration. This new product can be obtained from the distributor (FFF Enterprises, Inc., Temecula, CA) by calling 800-843-7477.

161 2008 Florida Morbidity Statistics

References Centers for Disease Control and Prevention, Manual for the Surveillance of Vaccine-Preventable ReferencesDiseases , 4th ed., 2008, chapter 17. Centers for Disease Control and Prevention, Manual for the Surveillance of Vaccine- AdditionalPreventable Resources Diseases , 4th ed., 2008, chapter 17. Disease information is available from the Centers for Disease Control and Prevention (CDC) at www.cdc. gov/vaccines/vpd-vac/varicella/default.htm.Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at Recommendedwww.cdc. gov/vaccines/vpd-vac/varicella/default.htm immunization schedule is available at:. http://www.cdc.gov/vaccines/recs/ schedules/ default.htm. Recommended immunization schedule is available at: http://www.cdc.gov/vaccines/recs/ schedules/default.htm.

162 Vibriosis Figure 1. Vibrio Infections Incidence Rate by Year Reported, Florida, Vibrio Infections: Crude Data 1999-2008 Summary of Selected Notifiable Diseases and Conditions 0.8 Number of Cases 93 2008 incidence rate per VibriosisVibriosis 0.6 100,000 0.49 Figure 1. Vibrio Infections Incidence Rate by Year Reported, Florida, % changeVibrioVibrio from Infections: Infections: average 5 Crude Crudeyear Data Data 0.4 1999-2008 (2003-2007)Number of incidence Cases rate -15.0193 0.8 Number of Cases 93 Age 2008(yrs) incidence rate per 100,000 per Cases 2008 incidence rate per 0.6 0.2 100,000 0.49 100,000 Mean 0.49 46.86 % change fromMedian average 5 year 48 % change from average 5 year 0.4 (2003-2007)(2003-2007) incidence Min-Maxincidence rate rate -15.01-15.01 1 - 88 0.0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 AgeAge (yrs) (yrs) 100,000 per Cases 0.2 Year MeanMean 46.86 46.86 Disease AbstractMedianMedian 48 48 The genus VibrioMin-Max Min-Maxconsists of gram-negative, 1 1- -88 88 curved,0.0 motile rods, and contains about a dozen 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 speciesDisease known Abstract to cause human illness. Transmission occurs primarilyYear through the foodborne route,TheDisease and genus in Abstract FloridaVibrio consists it is principally of gram-negative, from eatingcurved, rawmotile or rods, undercooked and contains shellfish. about a dozen Transmission species can alsoknown occurThe genus to through cause Vibrio human contactconsists illness. of gram-negative, broken Transmission skin withoccurscurved, seawater primarily motile rods, throughwhere and thecontainsVibrio foodborne species about route, a dozenare and endemic, in Florida whichit speciesis includes principally known the from to coastal causeeating human raw areas or illness.undercooked of the Transmission Gulf shellfish. of Mexico. occurs Transmission The primarily symptoms throughcan also thedependoccur foodborne through on the contact infecting ofroute, broken and skin in Floridawith seawater it is principally where Vibrio from eatingspecies raw are or endemic, undercooked which shellfish. includes Transmissionthe coastal areas can of the VibrioGulfalso species. of occur Mexico. through The The species contactsymptoms of of broken depend greatest skin on thewithpublic infecting seawater health Vibrio where concern species. Vibrio in species The Florida species are are endemic, of V. greatest vulnificus public and V. parahaemolyticushealthwhich concern includes in .the Florida This coastal reportare areas V. vulnificuscombines of the Gulf and data of V. Mexico. parahaemolyticus on Vibrio The symptoms infections. This depend report to provide combines on the ainfecting generaldata on Vibrio measure of diseaseinfectionsVibrio species. burden. to provide The a species general of measure greatest of public disease health burden. concern in Florida are V. vulnificus and V. parahaemolyticus. This report combines data on Vibrio infections to provide a general measure of disease burden. Figure 2. Vibrio Infections Cases by Month of Onset, Florida, 2008 Figure 2. Vibrio Infections Cases by Month of Onset, Florida, 2008 14

1214

1012 10 8 8 6 6

4 4 Number Number of Cases Number Number of Cases 2 2 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month 5yr average 2008Month 5yr average 2008

In comparison to the previous average 5-year incidence, the incidence for Vibrio infections in In comparisonIn2008 comparison declined to to (15.01%)the the previousprevious (Figure average average 1). A 5-yeartotal 5-year of incidence, 93 casesincidence, werethe incidence reported the incidence forin 2008,Vibrio offorinfections which Vibrio 100% in infections 2008 in 2008declinedwere declined confirmed. (15.01%) (15.01%) The(Figure majority (Figure 1). A of total 1).cases of A 93 weretotal cases considered of were 93 cases reported sporadic were in 2008, (93%), reported of not which outbreak- in 100%2008, were of which confirmed. 100% Theassociated, majority ofand cases six were were of considered unknown origin.sporadic Vibrio (93%), infections not outbreak-associated, typically increase duringand six the were of wereunknown warmerconfirmed. months.origin. The Vibrio In 2008,majority infections 85% of of typically casesthe cases increasewere occurred considered during from the April warmer sporadic to October months. (93%), (Figure In 2008, not 2). outbreak- 85% of the associated,cases occurred and six from were April ofto Octoberunknown (Figure origin. 2). Vibrio infections typically increase during the warmer months. In 2008, 85% of the cases occurred from April to October (Figure 2).

163 2008 Florida Morbidity Statistics

Figure 3. Vibrio Infections Incidence Rate by Age Group, Florida, 2008

1.4

1.2

1.0

0.8

0.6

0.4 Cases100,000per

0.2

0.0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group

Previous 5yr average 2008

There are consistently high incidence rates among individuals over 45 years old with a historical peak Thereincidence are consistently occurring in highthe 65-74 incidence age group rates (1.09 among per 100,000) individuals (Figure over 3). This 45 isyears a population old with that a ishistorical peaklikely incidence to have chronicoccurring conditions in the that65-74 predispose age group them (1.09to these per infections. 100,000) However, (Figure in 3).2008, This there is werea relatively high incidence rates among those 10-19 years old. Historically, white males have the highest populationincidence that rate is and likely that tocontinued have chronic in 2008 (0.75condition per 100,000).s that predispose The lowest incidencethem to theserate for infections.2008 was However,among innon-white 2008, therefemales were (0.05 relatively per 100,000). high incidence rates among those 10-19 years old. Historically, white males have the highest incidence rate and that continued in 2008 (0.75 per 100,000).Vibrio cases The werelowest reported incidence in 32 of rate the 67for counties 2008 was in Florida among in 2008. non-white The higher-incidence females (0.05 counties per 100,000).appear to be along the coasts. Vibrio Infections Incidence Rate* by County, Florida, 2008 Vibrio cases were reported in 32 of the 67 counties in Florida in 2008. The higher-incidence counties appear to be along the coasts.

164

Vibrio vulnificus infections V. vulnificus typically manifests as septicemia in persons who have chronic liver disease, chronic alcoholism, or are immunocompromised, and is commonly associated with the consumption of raw oysters. Of the Vibrio species reported in 2008, 16 were Vibrio vulnificus, an important Vibrio infection causing death in 50% of reported cases. Of the 16 reported Vibrio vulnificus cases, six were wound infections (one death) and eight were attributed to oyster consumption (five deaths). Exposure was unknown in two of the cases (two deaths).

Vibrio parahaemolyticus infections V. parahaemolyticus typically manifests as a gastrointestinal disorder with symptoms of diarrhea, abdominal pain, nausea, fever, and headache. It is commonly associated with the consumption of raw oysters and is also associated with the consumption of cross-contaminated crustacean shellfish (crab, shrimp, and lobster). Of the Vibrio species reported in 2008, 21 were Vibrio parahaemolyticus. Of these 21 cases, nine were wound infections, four were attributed to oyster consumption, one was attributed to crab consumption, and one case had multiple seafood exposures. Exposure was unknown in six of the cases. No deaths from Vibrio parahaemolyticus infection were reported.

Summary of Selected Notifiable Diseases and Conditions

Vibrio vulnificus infections V. vulnificus typically manifests as septicemia in persons who have chronic liver disease, or chronic alcoholism, or are immunocompromised, and is commonly associated with the consumption of raw oysters. Of the Vibrio species reported in 2008, 16 were Vibrio vulnificus, an important Vibrio infection causing death in 50% of reported cases. Of the 16 reported Vibrio vulnificus cases, six were wound infections (one death) and eight were attributed to oyster consumption (five deaths). Exposure was unknown in two of the cases (both fatal).

Vibrio alginolyticus infections V. alginolyticus infections typically present as self-limited wound infections and ear infections. Septicemia and death have been reported in immunocompromised individuals and burn patients. Infection is commonly associated with exposure to seawater. Of the Vibrio species reported in 2008, 28 were Vibrio alginolyticus. Of these 28 cases, 22 were wound infections and six were ear infections. No deaths from Vibrio alginolyticus were reported. Table 1. Vibrio Infections- Confirmed Cases by Species and Exposure Type, Florida, 2008 Exposure Total Cases Seafood* Wound† Unknown Vibrio alginolyticus 28 0 22 0 V. parahaemolyticus 21 6 9 6 V. vulnificus 16 8 6 2 V. fluvialis 9 2 4 3 V. cholerae non-O1 2 0 1 0 V. hollisae 1 1 0 0 V. mimicus 4 3 1 0 Other 13 1 8 1 Total 94 21 51 12 *Includes shellfish (raw oysters and clams) †Includes pre-existing and sustained wounds References Chien J, Shih J, Hsueh P, Yang P, Luh K, “Vibrio alginolyticus as the Cause of Pleural Empyema and Bacteremia in an Immunocompromised Patient,” European Journal of Clinical Microbiology & Infectious Diseases, 2002, Vol. 21, pp. 401-403.

David L. Heymann (ed.), Control of Communicable Diseases Manual, 18th ed., American Public Health Association Press, Washington, District of Columbia, 2004.

Additional Resources Disease information is available from the Centers for Disease Control and Prevention (CDC) at http:// www.cdc.gov/nczved/dfbmd/disease_listing/vibriop_gi.html and http://www.cdc.gov/nczved/dfbmd/ disease_listing/vibriov_gi.html.

165 West Nile Virus

Figure 1. West Nile Virus Incidence2008 Rate Florida by Year Morbidity Reported, Statistics Florida, 1999- West Nile Virus: Crude Data 2008 0.6 Number of Cases 3 West Nile Virus West Nile Virus 2008 incidence rate per 0.5 Figure 1. 100,000 0.02 0.4 West Nile Virus: Crude Data West Nile Virus Incidence Rate by Year Reported, Florida, 1999- % changeWest from Nileaverage Virus: 5- Crude Data 2008 Number of Cases 3 0.6 0.3 year (2003-2007)Number of Cases reported 3 cases2008 incidence rate per -91.02 2008 incidence rate per 0.5 0.2 100,000 0.02 per 100,000 Cases Age (yrs)100,000 0.02 0.4 % change% change from fromMean average average 5- 61.33 0.1 0.3 5-yearyear (2003-2007) (2003-2007)Median reported reported 70 casescases -91.02-91.02 0.0 0.2 2001 2002 2003 2004 2005 2006 2007 2008 Min-Max 39 - 75 per 100,000 Cases Age (yrs) Age (yrs) Year Mean 61.33 0.1 Mean 61.33 MedianMedian 70 70 0.0 Disease AbstractMin-Max Min-Max 39 - 3975 - 75 2001 2002 2003 2004 2005 2006 2007 2008 The incidence rate for West Nile virus (WNV) disease, including the neuroinvasiveYear and non- neuroinvasive forms, peaked in Florida in 2003 (Figure 1). In 2008, there were two locally- DiseaseDisease Abstract Abstract acquiredThe human incidence cases, rate for and West one Nile Floridian virus (WNV) became disease, ill including after being the neuroinvasive exposed in and another non- state. All wereThe classified incidence rateas neuroinvasive for West Nile virus disease. (WNV) disease, The level including of virus the neuroinvasive transmission and between non-neuroinvasive bird and forms,neuroinvasive peaked in Florida forms, inpeaked 2003 (Figurein Florida 1). in In 2003 2008, (Figure there 1).were In two 2008, locally-acquired there were two human locally- cases, mosquitoandacquired one populations Floridian human became cases, is dependent ill and after one being Floridian on exposed a number became in another illof after environmental state. being All exposed were classifiedfactors. in another Theas state. neuroinvasive low All levels of activitydisease.were reported classifiedThe level in 2006-2008asof virusneuroinvasive transmission were disease. likely between aThe result bird level and ofof mosquitovirusthe dry transmission conditionspopulations between isexperienced dependent bird and on by a much of thenumber state.mosquito ofThe environmental populations peak transmission factors.is dependent The period lowon alevels number for ofWN activity ofV environmental in Floridareported occursin factors. 2006-2008 July The were throughlow levelslikely September aof result of activity reported in 2006-2008 were likely a result of the dry conditions experienced by much of (Figurethe dry 2). conditions experienced by much of the state. The peak transmission period for WNV in Florida occursthe Julystate. through The peak September transmission (Figure period 2). for WNV in Florida occurs July through September (Figure 2).

Figure 2. WestWest Nile Nile Virus Virus Disease by Month Figureby Month of2. Onset, of Onset, Florida, Florida, 2001-2008 2001-2008 West Nile Virus by Month of Onset, Florida, 2001-2008 70 70 60 60

50 50

40 40

30 30

Numberof Cases 20

Numberof Cases 20 10 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 0 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total # of Cases 2001-2008 Month Total # of Cases 2001-2008 The greatest number of cases occur in individuals over the age of 35 (Figure 3), with more cases among males than females. WNV transmission tends to be localized in Florida. In 2001, TheThe greatestthe greatest epicenter number number of the ofof WNVcases cases outbreak occur occur in wasindividuals in individualsin the north-centralover the over age the partof 35 ageof (Figure the of state. 35 3), (Figure withThe morefollowing 3), cases with year, among more casesmales activityamong than wasfemales. males most thanintenseWNV females.transmission in the northwestern WNV tends transmissi to andbe localized centralon counties. intends Florida. to The be In 2001,focuslocalized inthe 2003 epicenter in wasFlorida. the of the In 2001, WNVpanhandle, outbreak waswhile in south the north-central Florida had thepart most of the activity state. in The 2004. following In 2005, year, 86% activity of the was human most cases intense in thethe epicenter werenorthwestern in Pinellas of the and County.WNV central outbreak Bothcounties. locally was The acquired focusin the incases north-central 2003 in was 2008 the were panhandle, part in ofEscambia the while state. County.south The Florida following had the year, activitymost wasactivity most in 2004. intense In 2005, in the 86% northwestern of the human casesand centralwere in Pinellascounties. County The. Both focus locally in 2003 acquired was the panhandle,cases in 2008 while were south in Escambia Florida County. had the most activity in 2004. In 2005, 86% of the human cases were in Pinellas County. Both locally acquired cases in 2008 were in Escambia County.

166 Summary of Selected Notifiable Diseases and Conditions

Figure 3. West Nile Virus Cases by Age Group, Florida, 2008

Number of Cases of Number 2

0 <1 1-4 5-9 85+ 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84

Age Group Previous 5yr average 2008 In general, approximately 80% of those infected show no clinical symptoms. Twenty percent haveIn general,mild symptoms, approximately and 80% less of thanthose 1%infected experience show no clinicalthe most symptoms. severe Twenty neuroinvasive percent have form mild of illness.symptoms, People and over less thanthe 1%age experience of 50 seem the mostto be severe at increased neuroinvasive risk formfor neuroinvasive of illness. People disease. over the The caseage fatality of 50 seem rate tofor be neuroinvasive at increased risk disease for neuroinvasive is approximately disease. The 7% case in Florida.fatality rate The for neuroinvasive average cost of disease is approximately 7% in Florida. The average cost of a single death from West Nile Virus was a singleestimated death at $225,000 from West in one Nile study Virus (Zohrabian was estimated et al, 2004). at $225,000Interestingly, in activity one study of a related (Zohrabian disease, et al, 2004).St. Louis Interestingly, Encephalitis, activity has decreased of a related dramatically disease, since St. WNV Louis was Encephalitis,first detected in has the statedecreased in 2001. dramaticallyResearch suggests since WNV that antibodies was first for detected WNV may in protect the state against in 2001.SLEV. Research suggests that antibodies for WNV may protect against SLEV. Prevention PreventionThere is no specific treatment for WNV disease, and therapy is supportive for ill persons. Prevention of the disease is a necessity. Measures can be taken to avoid being bitten by mosquitoes. Drain any areas Thereof standing is no specific water from treatment around the for home WNV to eliminatedisease, mosquito and therapy breeding is sites.supportive Use insect for illrepellents persons. that Preventioncontain DEET of the or otherdisease EPA-approved is a necessity. ingredients Measures such as Picaridin,can be takenoil of lemon to avoid eucalyptus, being orbitten IR3535. by mosquitoes.Avoid spending Drain time any outdoors areas during of standing dusk and water dawn, thefrom time around when disease-carryingthe home to eliminate mosquitoes mosquito are breedingmost likely sites. to be Use biting. insect Dress repellents in long sleeves that andcontain long pantsDEET to orprotect other your EPA-approved skin from mosquitoes. ingredients In suchaddition, as Picaridin, inspect screens oil of lemon on doors eucalyptus, and windows or for IR3535. holes to make Avoid sure spending mosquitoes time cannot outdoors enter the during home. A vaccine is available for horses. dusk and dawn, the time when disease-carrying mosquitoes are most likely to be biting. Dress in longReferences sleeves and long pants to protect your skin from mosquitoes. In addition, inspect screensDavid L.on Heymann doors and (ed.), windows Control of for Communicable holes to make Diseases sure Manualmosquitoes, 19th ed., cannot American enter Public the Health home. A vaccine isAssociation available Press, for horses. Washington, District of Columbia, 2009.

ReferencesFang, Y, Reisen WK. “Previous infection with West Nile or St. Louis encephalitis viruses provides cross protection during reinfection in house finches.” Am J Trop Med Hyg. 2006;75 (3): 480-5. David L. Heymann (ed.), Control of Communicable Diseases Manual, 19th ed., American Public ZohrabianHealth A, MeltzerAssociation M, Ratard Press, R, et Washington,al. “West Nile VirusDistrict Economic of Columbia, Impact, Louisiana, 2009. 2002.” Emerging Infectious Diseases. 2004 (10):1736-1744. Fang, Y, Reisen WK. “Previous infection with West Nile or St. Louis encephalitis viruses Additionalprovides Resources cross protection during reinfection in house finches.” Am J Trop Med Hyg. Additional information on WNV and other mosquito-borne diseases can be found in the Surveillance and Control2006;75 of Mosquito-borne (3): 480-5. Diseases in Florida Guidebook, online at http://www.doh.state.fl.us/Environment/medicine/arboviral/2009MosquitoGuide.pdf. Zohrabian A, Meltzer M, Ratard R, et al. “West Nile Virus Economic Impact, Louisiana, 2002.” DiseaseEmerging information Infectious is also available Diseases from. the2004 Centers (10):1736-1744. for Disease Control and Prevention CDC) at http:// www.cdc.gov/ncidod/dvbid/westnile/index.htm. Additional Resources Additional information on WNV and other mosquito-borne diseases can be found in the Surveillance and Control of Mosquito-borne Diseases in Florida Guidebook, online at 167 http://www.doh.state.fl.us/Environment/medicine/arboviral/2009MosquitoGuide.pdf.

Disease information is also available from the Centers for Disease Control and Prevention CDC) 2008 Florida Morbidity Statistics

168 Summary of Foodborne Diseases

Section 3: Summary of Foodborne Diseases

Description Foodborne disease investigation and surveillance are essential public health activities. Globalization of the food supply, changes in individual’s eating habits and behaviors, and newly emerging pathogens have increased the risk for contracting foodborne diseases. The Centers for Disease Control and Prevention (CDC) estimates foodborne diseases account for approximately 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths per year in the U.S. However, only an estimated 14 million illnesses, 60,000 hospitalizations, and 1,800 deaths are accounted for by confirmed pathogens. Florida has had a unique program in place since 1994 to oversee food and waterborne disease surveillance and investigation for the state with the intent to better capture and investigate food and waterborne diseases, complaints, and outbreaks as well as to increase knowledge and prevent illness with regard to this important public health issue.

Foodborne disease outbreaks, as defined by the Florida Department of Health’s Food and Waterborne Disease Program, are incidents in which two or more people have the same disease, have similar symptoms, or excrete the same pathogens; and there is a person, place, and/or time association between these people along with ingestion of a common food. A single case of suspected botulism, mushroom poisoning, ciguatera fish poisoning, paralytic shellfish poisoning, other rare disease, or a case of a disease that can be definitely related to ingestion of a food, is considered as an incident of foodborne illness and warrants further investigation.

The Florida Department of Health has criteria established for suspected and confirmed foodborne disease outbreaks. A suspected foodborne outbreak is one for which the sum of the epidemiological evidence is not strong enough to consider it a confirmed outbreak. A confirmed foodborne outbreak is an outbreak that has been thoroughly investigated and the results include strong epidemiological association of a food item or meal with illness. A thorough investigation is documented by: • diligent case finding, • interviewing of ill cases and well individuals, • collecting clinical and food lab samples where appropriate and available, • confirmation of lab samples where possible, • field investigation of the establishment(s) concerned, and • statistical analysis of the information collected during the investigation.

The summary report of all of the information collected in an investigation in a confirmed outbreak will indicate a strong association with a particular food and/or etiologic agent and a group of two or more people, or single incidents as described above. Similar criteria have been established for confirmed, suspected, and unknown etiology. An outbreak etiology is classified in the “confirmed” category when epidemiologic evidence implicates an agent and confirmatory laboratory data are available. An outbreak etiology is classified in the “suspected” category when epidemiologic evidence and/or a food preparation review implicate(s) an agent, but no confirmatory laboratory data are available. An outbreak etiology is classified in the “unknown” category where epidemiologic evidence clearly associates food with the outbreak, but no laboratory data are available and the epidemiologic evidence does not clearly implicate a specific agent. Data on reported number of outbreaks and reported number of cases associated with outbreaks is considered provisional until it is published in the Food and Waterborne Disease Annual Report. Numbers may change slightly from what is reported here.

Overview In 2008, Florida reported 97 foodborne disease outbreaks with a total of 1,190 associated cases. (Table 1).

169 2008 Florida Morbidity Statistics

Table 1. Summary of Foodborne Disease Outbreaks, Florida, 1999-2008 Year # Outbreaks # Cases Proportion of Proportion of Average Outbreaks per Cases per 100,000 Cases per 100,000 population population Outbreak 1999 273 1,465 1.74 9.34 5.37 2000 269 1,569 1.67 9.76 5.83 2001 288 1,922 1.75 11.71 6.67 2002 240 1,450 1.43 8.65 6.04 2003 185 1,563 1.08 9.11 8.45 2004 174 1,937 0.99 11.00 11.13 2005 128 1,944 0.71 10.79 15.19 2006 143 1,142 0.78 6.19 7.99 2007 117 827 0.62 4.42 7.07 2008 97 1,190 0.51 6.30 12.27

Foodborne disease outbreaks in Florida are classified by outbreak status (confirmed or suspected) as well as by pathogen status (confirmed, suspected, or unknown). Among the 97 reported foodborne disease outbreaks in 2008, 34 (35.05 %) were determined to be confirmed foodborne disease outbreaks accounting for 671 (56.39 %) of the 1,190 reported cases. Of the total reported outbreaks, 68 (70.10 %) had a suspected and/or confirmed etiology accounting for 811 (68.15 %) of the total cases. Of the total reported outbreaks, 29 (29.90%) had unknown etiologies accounting for 379 (31.85 %) of the total cases (Table 2).

Table 2. Total Number and Percentage of Reported Foodborne Outbreaks and Cases by Pathogen Status, Florida, 2008 # Outbreaks # Cases % Outbreaks % Cases Suspected Outbreaks* 63 519 64.95% 43.61% Confirmed Pathogens** 3 20 3.09% 1.68% Suspected Pathogens** 32 129 32.99% 10.84% Unknown Pathogens** 28 370 28.87% 31.09% Confirmed Outbreaks* 34 671 35.05% 56.39% Confirmed Pathogens** 27 419 27.84% 35.21% Suspected Pathogens** 6 243 6.19% 20.42% Unknown Pathogens** 1 9 1.03% 0.76% *Definitions for suspected and confirmed outbreaks are described above in the “Description” section. **Definitions for confirmed, suspected, and unknown etiology are described above in the “Description” section.

170 Summary of Foodborne Diseases

Trends Trends There isThere a general is a general decreasing decreasing trend intrend the intotal the number total number of reported of reported foodborne foodborne disease disease outbreaks and numberTrendsoutbreaks of reported and foodborne number of disease reported outbreaks foodborne per disease 100,000 outbreaks population per 100,000in Florida population over the lastin 10 years There is a general decreasing trend in the total number of reported foodborne disease (FiguresFlorida 1 & 2). over the last 10 years (Figures 1 & 2). outbreaks and number of reported foodborne disease outbreaks per 100,000 population in

Florida over the last 10 years (Figures 1 & 2).

Figure 1. Total Number of Reported Foodborne Figure 2. Number of Reported Foodborne Disease Disease Outbreaks, Florida 1999 - 2008 Outbreaks per 100,000 population, Figure 1. Total Number of Reported Foodborne Figure 2. NumberFlorida of Re po1999rted - F200oodbo8 rne Disease Disease Outbreaks, Florida 1999 - 2008 Outbreaks per 100,000 population, 400 Florida 1999 - 2008 2.00 403000 2.001.50 302000 1.501.00 201000 100,000 0.50 # of Outbreaks 1.00 100,000 1000 Outbreak Rate per0.50 0.00 # of Outbreaks 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 0 Outbreak Rate per 0.00 1999 2000 2001 2002 2003Year 2004 2005 2006 2007 2008 1999 2000 2001 2002 2003Yea200r 4 2005 2006 2007 2008 Year Year

The total number of reported foodborne illness cases (Figure 3) and the number of reported

foodborne illness cases per 100,000 population (Figure 4) in Florida has fluctuated over the last The total number of reported foodborne illness cases (Figure 3) and the number of reported 10 years. foodborne illness cases per 100,000 population (Figure 4) in Florida has fluctuated over the last The total number of reported foodborne illness cases (Figure 3) and the number of reported foodborne 10 years. illness cases per 100,000 population (Figure 4) in Florida has fluctuated over the last 10 years.

Figu re 3. Total Number of Reported Foodborne Disease Outbreak Figure 4. Number of Reported Foodborne Disease Cases, Florida 1999 - 2008 Outbreak Cases per 100,000, Figure 3. Total Number of Reported Foodborne Disease Outbreak Figure 4. NumbeFlr orof idaRe po1999rted - Fo200odborne8 Disease Cases, Florida 1999 - 2008 Outbreak Cases per 100,000, 2,500 Florida 1999 - 2008 15.00 2,2,500000 2,1,005000 1510.00.00 1,1,500000 # of Cas es 105.00.00 Cas e Rate 1,005000 per 100,000

# of Cas es 5.00

0 Cas e Rate 0.00

500 per 100,000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 0.00 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 1999 2000 2001 2002 2003Yea 200r 4 2005 2006 2007 2008 1999 2000 2001 2002 2003Yea 2004r 2005 2006 2007 2008 Year Year

171 Seasonality 2008 Florida Morbidity Statistics Occurrence of reported foodborne disease outbreaks in Florida for 2008 peaked in January Seasonality(Figure 5). SeasonalityOccurrence of reported foodborne disease outbreaks in Florida for 2008 peaked in January Occurrence(Figure 5). of reported foodborne disease outbreaks in Florida for 2008 peaked in January (Figure 5). Figure 5. Total Number of Reported Foodborne Disease Outbreaks by Month, Florida 2008 Figure 5. Total Number of Reported Foodborne Disease Outbreaks by Month, Florida 2008 20

20 15

15 10

10 # # of Outbreaks 5

# # of Outbreaks 5 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 0 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Month Agent Foodborne disease outbreaks caused by bacterial (26.8%) and viral pathogens (26.8%) accounted Agent Agentfor most of the total reported foodborne disease outbreaks with a known etiology (Figure 6). Foodborne disease outbreaks caused by bacterial (26.8%) and viral pathogens (26.8%) accounted for FoodborneFoodborne disease disease outbreaks outbreaks caused caused by bacterialby viral pathogens (26.8%) and accounted viral pathogens for the most(26.8%) reported accounted cases most of the total reported foodborne disease outbreaks with a known etiology (Figure 6). Foodborne for most(45.2%) of the with total a known reported etiology foodborne (Figure disease 7). Pathogen outbreaks type with was a knownunknown etiology for 30.9% (Figure of the6). reported diseaseFoodbornefoodborne outbreaks disease disease caused outbreaks outbreaksby viral causedpathogens and 32.6% by viral accounted of pathogens the reported for the accounted cases.most reported for the cases most reported(45.2%) withcases a known(45.2%) etiology with (Figure a known 7). etiology Pathogen (Figure type 7).was Pathogen unknown typefor 30.9% was unknown of the reported for 30.9% foodborne of the reported disease outbreaksfoodborne and disease32.6% of outbreaks the reported and cases.32.6% of the reported cases.

Figure 6. Percentage of Reported Foodborne Disease Figure 7. Percentage of Reported Foodborne Disease Outbreak Outbreaks by Pathogen Type, Florida 2008 Cases by Pathogen Type, Florida 2008 Figure 6. Percentage of Reported Foodborne Disease Figure 7. Percentage of Reported Foodborne Disease Outbreak Outbreaks by Pathogen Type, Florida 2008 Unknown Cases by0.9% Pathogen Type, Florida 2008 Unknown Bacterial Bacterial 5.1% 3.1% Viral 12.4% UnknowViraln 0.9% Unknown 32.6% BacterMarineial Toxin 30.9% BacterMarineial Toxin 5.1% 3.1% Viral Chemical 12.4% Viral Chemical 32.6% Marine Toxin 30.9% Marine Toxin Chemical Chemical 45.2% 26.8%

45.2% 26.8% 16.1% 26.8%

16.1% 26.8%

The number and percentage of foodborne disease outbreaks and cases by etiology for 2008 is summarized in Table 3. Among foodborne disease outbreaks with a suspected and/or confirmed etiology, Norovirus was the most frequently reported etiology for outbreaks in Florida for 2008 accounting for 26 (26.80%) outbreaks followed by ciguatera which accounted for 12 (12.37%) outbreaks. Norovirus accounted for the highest number of cases associated with reported foodborne disease outbreaks with 538 (45.21%) cases followed by Clostridium perfringens which accounted for 132 (11.09%) cases.

172 Summary of Foodborne Diseases

Table 3. Number and Frequency of Foodborne Outbreaks and Cases by Etiology, Florida 2008 Category Outbreaks Cases Pathogen # % # % Unknown Total Unknown 30 30.93% 388 32.61% Bacterial Staphylococcus 6 6.19% 22 1.85% B. cereus 6 6.19% 14 1.18% V. vulnificus 6 6.19% 6 0.50% Salmonella 3 3.09% 9 0.76% C. perfringens 2 2.06% 132 11.09% E. coli O157:H7 2 2.06% 7 0.59% Campylobacter 1 1.03% 2 0.17% Total Bacterial 26 26.80% 192 16.13% Viral Norovirus 26 26.80% 538 45.21% Marine Toxins Ciguatera 12 12.37% 61 5.13% Other Chemical 3 3.09% 11 0.92% Total 97 100.00% 1,190 100.00%

Implicated Food Vehicles Multiple ingredients, multiple items, and poultry were the most frequently reported general vehicles contributing to foodborne disease outbreaks in Florida for 2008 (Table 4).

Table 4. Foodborne Illness Outbreaks and Cases by General Vehicle, Florida 2008 General Vehicle # Outbreaks % Outbreaks # Cases % Cases Multiple Ingredients* 18 18.56% 101 8.49% Multiple Items** 18 18.56% 151 12.69% Poultry 13 13.40% 187 15.71% Fish 12 12.37% 61 5.13% Unknown 9 9.28% 406 34.12% Shellfish-Molluscan 5 5.15% 5 0.42% Beef 4 4.12% 42 3.53% Pork 4 4.12% 28 2.35% Produce-Vegetable 4 4.12% 149 12.52% Beverage 3 3.09% 41 3.45% Ice 2 2.06% 8 0.67% Rice 2 2.06% 4 0.34% Dairy 1 1.03% 2 0.17% Pizza 1 1.03% 4 0.34% Shellfish-Crustacean 1 1.03% 1 0.08% Total 97 100.00% 1,190 100.00% *Multiple Ingredients are food vehicles in which several foods are combined during preparation or cooking and the entire food product is suspected or confirmed to be contaminated (e.g. casseroles, soups, sandwiches, salads, etc.). **Multiple Items are food vehicles in which several foods are individually prepared or cooked and more than one food is suspected or confirmed to be contaminated (e.g. buffet, salad bar, chicken and shrimp, etc.).

173 2008 Florida Morbidity Statistics

Outbreak Location Most of the reported foodborne disease outbreaks (67.01%) and cases (35.71%) were associated with restaurants (Table 5).

Table 5. Foodborne Illness Outbreaks and Cases by Site Florida 2008 Site # Outbreaks % Outbreaks # Cases % Cases Restaurant 65 67.01% 425 35.71% Caterer 8 8.25% 256 21.51% Home 8 8.25% 51 4.29% Grocery 6 6.19% 26 2.18% Recreational Fishing 2 2.06% 2 0.17% Assisted Living 1 1.03% 4 0.34% Facility Little League Park 1 1.03% 3 0.25% Movie Theater 1 1.03% 7 0.59% Nursing Home 1 1.03% 9 0.76% Prison 1 1.03% 260 21.85% Resort Hotel 1 1.03% 39 3.28% School 1 1.03% 33 2.77% Sorority House 1 1.03% 75 6.30% Total 97 100.00% 1,190 100.00%

Contributing Factors The current systematic data collection regarding contributing factors associated with reported foodborne disease outbreaks began in 2000. The top contributing factors associated with reported foodborne disease outbreaks in Florida for 2008 were associated with time/temperature abuse, poor personal hygiene, and cross contamination (Table 6, 7, 8). Note: There are three categories of contributing factors (contamination factor, proliferation factor, survival factor) and up to three contributing factors per category can be attributed in an outbreak; therefore, the reported numbers may not match the actual number of reported outbreaks and cases.

174 Summary of Foodborne Diseases

Table 6. Most Common Reported Foodborne Contamination Factors, Florida 2008 Contamination Factor # Outbreaks # Cases Bare-Handed Contact 20 126 Infected Person or Carrier 15 360 Toxic Substance 11 55 Cross Contamination from Raw Ingredients Animal 10 25 Origin Inadequate Cleaning 9 158

Table 7. Most Common Reported Foodborne Proliferation Factors, Florida 2008 Proliferation Factor # Outbreaks # Cases Inadequate Cold-Holding Temperature 13 40 Slow Cooling 8 150 Insufficient Time/ Temperature Hot Holding 7 143 Room Temperature 2 13 Pooled Raw Eggs 1 5

Table 8. Most Common Reported Foodborne Survival Factors, Florida 2008 Survival Factor # Outbreaks # Cases Insufficient Time/ Temperature During Cooking/ 3 136 Processing Improper Sanitization 2 5 Insufficient Time/ Temperature During Reheating 2 4 Insufficient Thawing Then Insufficient Cooking 1 2 Temperature Control 1 5

References Bender JB, et al., “Foodborne disease in the 21st century: What challenges await us?” Postgraduate Medicine, Vol. 106, No. 2, 1999, pp. 106-119.

Mead PS, et al., “Food-related illness and death in the United States.” Emerging Infectious Diseases, Vol. 5, No. 5, 1999, pp. 607-625.

Florida Department of Health Memorandum, July 17, 1995. Criteria for Confirmation of a Foodborne Outbreak.

175 2008 Florida Morbidity Statistics

176 Summary of Antimicrobial Resistance Surveillance

Section 4: Summary of Antimicrobial Resistance Surveillance

Background Some scientists consider antibiotics to be the single most impressive medical achievement of the 20th Century. However, the continuing emergence and spread of antimicrobial resistance jeopardizes the utility of antibiotics and threatens public health globally. These pathogens are associated with increased morbidity and mortality, which not only impacts patients but also increases the burden on healthcare services as a result of additional diagnostic testing, prolonged hospital stays, and increased intensity and duration of treatment.

The purpose of the antimicrobial resistance surveillance in Florida is to maintain a statewide surveillance and information system that provides data on the incidence and spread of major invasive bacteria with clinically and epidemiologically relevant antimicrobial resistance. Describing the distribution of infection due to resistant organisms within populations, together with changes in patterns of those infections over time, provides the basic information for action both to control disease caused by resistant microorganisms and to contain the emergence of resistance. Strategies to protect the public’s health can be developed and evaluated on the basis of this surveillance information.

Currently, Streptococcus pneumoniae is the only disease on Florida’s list of notifiable diseases for which drug susceptibilities are required as part of case reporting. Drug-resistant S. pneumoniae (DRSP) invasive disease was added to Florida’s list of notifiable diseases in mid-1996. Drug-susceptible S. pneumonia (DSSP) invasive disease was added to the list of notifiable diseases mid-1999, to permit the assessment of the proportion of pneumococcal isolates that are drug-resistant. These data are currently captured and stored electronically in the Merlin database, though DSSP data wasn’t captured electronically until 2003. The rise of antibiotic resistance among isolates of S. pneumoniae and the severity of disease it causes highlight the importance of monitoring trends to aid in developing effective treatment and intervention strategies.

Data Trends There were a total of 704 DSSP cases and 792 DRSP cases in 2008. Of the 704 DSSP cases, 13 did not have antibiotic susceptibility data because the patient died and further testing was not done. Those 13 cases are excluded from this section. Additionally, it should be noted that not every antibiotic was tested for every case. When calculating percentages for each antibiotic, the denominator is the number of cases that were tested for that antibiotic. Resistant and intermediate susceptibilities were grouped together as “resistant” for this summary.

With the steady rise of antimicrobial resistance among strains of S. pneumoniae in the past decade, it is now more important than ever for physicians to prescribe proper antimicrobial therapy. Where penicillin was previously the drug of choice for all pneumococcal infections, 40.8% of the cases tested in Florida in 2008 were resistant to penicillin (see Figure 1 and Table 1). Resistance was most common for erythromycin, with 47.0% of isolates tested showing resistance or intermediate susceptibility. Seven of the antibiotics tracked (azithromycin, cefuroxime axetil, clarithromycin, erythromycin, penicillin, tetracycline, and trimethoprim/sulfamethoxazole) had greater than 25% resistance. Vancomycin and rifampin had the lowest resistance, at 0.1% and 0.9% respectively.

177 2008 Florida Morbidity Statistics

FigureFigure 1.1. StreptococcusStreptococcus pneumoniaepneumoniae,, InvasiveInvasive Disease,Disease, AntibioticAntibiotic Resistance,Resistance, Florida,Florida, 20082008 1,600

1,400

1,200

1,000

800

600

400 Number of Cases Tested 200

l l n e e e n n n n n i ti o in i in ne le i c m m e c ci em ci lli i o i on i p l y yc y yc c yc ax ci m az ax m epi en oxa x f e am om e riax rom ipen ifa fot ro ft m ph h Peni R racy ho throm C e e nd Im Ofl li et et anc zi C C yt C r T V A roxi larith E am fu C e hloram C C Sulf Antibiotic m/ pri

ho et

Susceptible Intermediate Resistant rim T

TableTable 1. 1.Streptococcus Streptococcus pneumoniae pneumoniae, Invasive, Invasive Disease, Disease, AntibioticAntibiotic Resistance, Resistance, Florida Florida 2008 2008 NumberNumber of of AntibioticAntibiotic name name SusceptibleSusceptible Intermediate Intermediate Resistant Resistant CasesCases Tested Tested AzithromycinnicymorhtizA 562 265 61.9%61.9% 3.0% 3.0% 35.1% 35.1% CefepimeemipefeC 041 140 93.6%93.6% 6.4% 6.4% 0.0% 0.0% CefotaximeemixatofeC 539 935 88.6%88.6% 6.5% 6.5% 4.9% 4.9% CeftriaxoneenoxairtfeC 1,220022,1 89.7% 89.7% 7.0% 7.0% 3.3% 3.3% CefuroximeCefuroxime axetil axetil 272272 70.2%70.2% 4.0% 4.0% 25.7% 25.7% ChloramphenicollocinehpmarolhC 144 441 96.4%96.4% 0.2% 0.2% 3.4% 3.4% ClarithromycinnicymorhtiralC 011 110 60.9%60.9% 4.5% 4.5% 34.5% 34.5% ClindamycinnicymadnilC 434 434 75.1%75.1% 3.9% 3.9% 21.0% 21.0% ErythromycinnicymorhtyrE 199 991 53.0%53.0% 1.4% 1.4% 45.6% 45.6% ImipenemmenepimI 401 104 78.8%78.8% 18.3% 18.3% 2.9% 2.9% OfloxacinnicaxolfO 992 299 96.3%96.3% 2.7% 2.7% 1.0% 1.0% Penicillin 1,384 59.2% 22.1% 18.7% nillicineP 483,1 59.2% 22.1% 18.7% Rifampin 107 99.1% 0.0% 0.9% nipmafiR 701 99.1% 0.0% 0.9% Tetracycline 753 74.4% 0.7% 25.0% enilcycarteT 357 74.4% 0.7% 25.0% Trimethoprim/Sulfamethoxazole 947 62.3% 7.5% 30.1% Trimethoprim/Sulfamethoxazole 947 62.3% 7.5% 30.1% Vancomycin 1,364 99.9% 0.0% 0.1% nicymocnaV 463,1 99.9% 0.0% 0.1%

The prevalence of resistance increased for most antibiotics overall from 2005 to 2008, though decreased for a few antibiotics (see Table 2 and Figure 2). Antibiotics with steady increases in resistance include ceftriaxone, clindamycin, erythromycin, imipenem, and tetracycline. Resistance to the remaining antibiotics fluctuated over the years. Overall increases were seen for azithromycin, cefotaxime, cefuroxime axetil, clarithromycin, rifampin, and trimethoprim/sulfamethoxazole. Overall decreases

178 The prevalence of resistance increased for most antibiotics overall from 2005 to 2008, though decreased for a few antibiotics (see Table 2 and Figure 2). Antibiotics with steady increases include ceftriaxone, clindamycin, erythromycin, imipenem, and tetracycline. Resistance to the remaining antibiotics fluctuated over the years. Overall increases were seen for azithromycin, Summarycefotaxime, of Antimicrobial cefuroxime Resistance axetil, Surveillanceclarithromycin, rifampin, and trimethoprim/sulfamethoxazole. Overall decreases were seen for cefepime, chloramphenicol, ofloxacin, and penicillin. Note that ceftriaxone, erythromycin, imipenem, penicillin, and trimethoprim/sulfamethoxazole are were seen for cefepime, chloramphenicol, ofloxacin, and penicillin. Note that ceftriaxone, erythromycin, highlighted in Table 2 and are presented in Figure 2. These antibiotics were chosen because imipenem,they represent penicillin, most and of trimethoprim/sulfamethoxazole the major antibiotic classes. are highlighted in Table 2 and are presented in Figure 2. These antibiotics were chosen because they represent most of the major antibiotic classes. Table 2. Streptococcus pneumoniae, Invasive Disease, Table Percent2. Streptococcus Resistant pneumoniaeto Antibiotics,, Invasive Florida 2005-2008Disease, AntibioticPercent name Resistant to Antibiotics,2005 Florida2006 2005-2008 2007 2008 AntibioticnicymorhtizA name 2005 %6.03 200645.4% 2007 44.3% 2008 38.1% AzithromycinemipefeC 30.6%%2.9 45.4%14.1% 44.3% 10.2% 38.1% 6.4% Cefepime emixatofeC 9.2%%6.8 14.1%8.0% 10.2% 11.3% 6.4% 11.4% CefotaximeCeftriaxone 8.6%6.2% 8.0% 7.8% 11.3% 8.8% 11.4% 10.3% CeftriaxoneCefuroxime axetil 6.2%22.1% 7.8% 29.3% 8.8% 30.8% 10.3% 29.7% Cefuroxime axetil 22.1% 29.3% 30.8% 29.7% locinehpmarolhC %4.4 2.8% 4.7% 3.6% Chloramphenicol 4.4% 2.8% 4.7% 3.6% nicymorhtiralC %9.03 36.9% 51.1% 39.0% Clarithromycin 30.9% 36.9% 51.1% 39.0% nicymadnilC %2.61 20.2% 23.4% 24.9% Clindamycin 16.2% 20.2% 23.4% 24.9% Erythromycin 31.8% 40.2% 42.0% 47.0% Erythromycin 31.8% 40.2% 42.0% 47.0% Imipenem 8.6% 15.0% 17.5% 21.2% Imipenem 8.6% 15.0% 17.5% 21.2% Ofloxacin nicaxolfO 4.4% %4.4 5.2%5.2% 2.9% 2.9% 3.7% 3.7% PenicillinPenicillin 43.1%43.1% 44.7% 44.7% 44.9% 44.9% 40.8% 40.8% Rifampin nipmafiR 0.0% %0.0 0.6%0.6% 0.0% 0.0% 0.9% 0.9% Tetracycline enilcycarteT 16.1%%1.61 16.6%16.6% 21.2% 21.2% 25.7% 25.7% Trimethoprim/SulfamethoxazoleTrimethoprim/Sulfamethoxazole 29.6%29.6% 35.5% 35.5% 34.4% 34.4% 37.6% 37.6% Vancomycin nicymocnaV 0.1% %1.0 0.8%0.8% 0.3% 0.3% 0.1% 0.1%

FigureFigure 2. 2. Streptococcus Streptococcus pneumoniae pneumoniae, ,Invasive Invasive Disease, Disease, PercentPercent Resistant Resistant to to Select Select Antibiotics, Antibiotics, Florida Florida 2005-2008 2005-2008

50 45 40 35 30

25 20 15

Percent Resistant 10 5

2005 2006 2007 2008 Year Ceftriaxone Erythromycin Imipenem Penicillin Trimeth/Sulf

In general, the prevalence of resistance to antibiotics is highest in the very young, followed by the elderly, and lowest in the middle aged (see Table 3). For example, 66.7% of the cases tested for imipenem in those less than one year old were resistant, compared to 6.4% in those 25 to 64 years old, and 8.7% in those 65 and older. Overall, the highest rate of resistance was seen in erythromycin; 62.3% of cases one to four years old were resistant while only 46.7% of cases 65 and older were resistant.

179 2008 Florida Morbidity Statistics

Table 3. Streptococcus pneumoniae, Invasive Disease, Percent Resistant to Antibiotics by Age Category, Florida 2008

Age Number of Cases Azithromycin Cefepime Cefotaxime Ceftriaxone Cefuroxime axetil Chloramphenicol Clarithromycin Clindamycin Erythromycin Imipenem Ofloxacin Penicillin Rifampin Tetracycline Trimethoprim/ Sulfamethoxazole Vancomycin <1 67 50.0% 14.3% 23.9% 19.6% 64.7% 0.0% 33.3% 34.8% 50.0% 66.7% 0.0% 64.6% 0.0% 34.5% 64.1% 0.0% 1-4 163 63.0% 20.0% 23.2% 22.7% 51.5% 4.0% 53.8% 39.0% 62.3% 53.0% 3.2% 58.8% 4.2% 46.0% 60.6% 0.0% 5-14 53 50.0% 0.0% 10.2% 6.8% 6.2% 0.0% 66.7% 21.4% 44.8% 0.0% 0.0% 44.0% 0.0% 23.8% 52.0% 0.0% 15-24 32 50.0% - 6.7% 3.6% - 10.0% 0.0% 28.6% 36.0% - 0.0% 38.8% 0.0% 22.2% 25.0% 0.0% 25-64 716 28.5% 5.3% 11.1% 8.2% 25.4% 2.9% 25.4% 23.7% 44.4% 6.4% 2.2% 37.2% 0.0% 22.3% 35.3% 0.2% 65+ 452 43.8% 2.8% 5.7% 8.9% 24.4% 5.0% 54.3% 17.7% 46.7% 8.7% 7.4% 36.1% 0.0% 23.8% 30.1% 0.0% Total 1483 38.1% 6.4% 11.4% 10.3% 29.8% 3.6% 39.1% 24.9% 47.0% 21.2% 3.7% 40.8% 0.9% 25.6% 37.6% 0.1%

Resistance patterns were also summarized by region and county. The Regional Domestic Security Task Force regions were used, as depicted in Figure 3.

Figure 3. Regional Domestic Security Task Force Regions

180 Summary of Antimicrobial Resistance Surveillance

The East Central Region of Florida had 254 (17.1%) of the 1,483 cases included in this summary (Figure 4 and Table 4). Only one case was tested for imipenem resistance, and this case was resistant. Two cases were tested for clarithromycin, and one of these cases was resistant. The small denominators for these antibiotics make the resistance percentages misleading. Excluding these antibiotics, the highest rate of resistance was seen in erythromycin (50.8%). Tetracycline, penicillin, trimethoprim/ sulfamethoxazole, cefuroxime axetil, azithromycin, and erythromycin all had resistance rates greater than 25.0%.

The North Central Region of Florida had 37 (2.5%) of the 1,483 cases included in this summary (Figure 5 and Table 4). One case was tested for imipenem resistance; two cases were tested for azithromycin, cefepime, chloramphenicol, and ofloxacin resistance; and six cases were tested for cefuroxime axetil resistance. The small denominators for these antibiotics make the resistance percentages misleading. Excluding these antibiotics, the highest rate of resistance was seen in penicillin (40.0%), followed by erythromycin (35.5%). Tetracycline, trimethoprim/sulfamethoxazole, erythromycin, and penicillin all had resistance rates greater than 25.0%.

The North East Region of Florida had 198 (13.4%) of the 1,483 cases included in this summary (Figure 6 and Table 4). Only three cases were tested for imipenem, making the resistance percentage misleading due to the small denominator. Penicillin had the highest resistance rate (42.2%) followed by erythromycin (41.1%) and azithromycin (40.0%). Clindamycin, trimethoprim/sulfamethoxazole, azithromycin, erythromycin, and penicillin all had resistance rates greater than 25.0%.

The North West Region of Florida had 137 (9.2%) of the 1,483 cases included in this summary (Figure 7 and Table 4). Only one case was tested for rifampin resistance, making the resistance percentage misleading due to the small denominator. Penicillin had the greatest resistance rate (30.0%) followed by trimethoprim/sulfamethoxazole (26.3%). These were the only two antibiotics with resistance rates greater than 25.0%.

The South East Region of Florida had 445 (30.0%) of the 1,483 cases included in this summary (Figure 8 and Table 4). Clarithromycin had the greatest resistance rate (52.6%), though only 19 cases reported clarithromycin susceptibility results. Erythromycin had the next highest resistance rate (48.8%) and also had a large denominator. Clindamycin, trimethoprim/sulfamethoxazole, penicillin, cefuroxime axetil, imipenem, azithromycin, erythromycin, and clarithromycin all had resistance rates greater than 25.0%.

The South West Region of Florida had 127 (8.6%) of the 1,483 cases included in this summary (Figure 9 and Table 4). Susceptibility data for several antibiotics in this region were rarely reported: rifampin (1 case), imipenem (4 cases), cefepime (5 cases), cefuroxime axetil (7 cases), clarithromycin (8 cases), and azithromycin (10 cases). The small denominators for these antibiotics make the resistance percentages misleading. Excluding these antibiotics, the highest rate of resistance was seen in erythromycin (56.1%), followed by penicillin (44.8%). Clindamycin, trimethoprim/sulfamethoxazole, penicillin, and erythromycin all had resistance rates greater than 25.0%.

The West Central Region of Florida had 285 (19.2%) of the 1,483 cases included in this summary (Figure 10 and Table 4). Erythromycin had the greatest resistance rate (51.0%), followed by clarithromycin (50.0%). Clindamycin, tetracycline, cefuroxime axetil, trimethoprim/sulfamethoxazole, penicillin, azithromycin, clarithromycin, and erythromycin all had resistance rates greater than 25.0%.

Resistance rates by county are presented in Table 5.

181 2008 Florida Morbidity Statistics

Figure 4. Streptococcus pneumoniae, Invasive Disease, AntibioticFigureFigure 4.Resistance, 4.Streptococcus Streptococcus East Centralpneumoniae pneumoniae Region, Invasive of, Invasive Florida, Disease, Disease,2008 AntibioticAntibiotic Resistance, Resistance, East East Central Central Region Region of Florida,of Florida, 2008 2008 300300

250250

200200

150150

100100

Number of Cases Tested Number of Cases 50

0 0

l n n n e e l n n n i i n e e n i i l l i n n n i n l n e n e t i o n i n m i l i p i n e e n i me m c o ci c ci m il l i o l ci i o n t i c ci e ac l p l n ci yc me m c y ci y y e c i m i z o y p i xi o xe n i y y x ac i l z y yc a xe y m en x c a m a m e p a xi ax e n m m o n i f yc x a m f a i ax a m m p en l o a yc m o m e r i h e o m o i f l e n f o x r f ot t r da o p f e ac o ot r p h o i O P Ri r h o co h r Ce t me p h r n da hr m P Ri ac t co t h i me t i t hr I m O r h i t Ce i m i h in t I et e t an i Cef Cef a m it et e an Cef Cef ox Cl ry T V a ar Cl ry T V Az ox or ar E am Az ur l or Cl E f am ur l l f Cl u l Ch u Cef Ch /S Cef /S im r im p r Antibiotic p Antibiotic ho ho et et im r im T r SusceptibleSusceptible IntermediateIntermediate ResistantResistant T

Figure 5. Streptococcus pneumoniae, Invasive Disease, AntibioticFigureFigure Resistance,5. 5.Streptococcus Streptococcus North pneumoniaeCentral pneumoniae Region, Invasive ,of Invasive Florida, Disease, Disease, 2008 AntibioticAntibiotic Resistance, Resistance, North North Central Central Region Region of Florida,of Florida, 2008 2008 40 40

35 35

30 30

25 25

20 20

15 15

10 10 Number ofCasesNumber Tested Number ofCasesNumber Tested 5 5

0 0

n e n in n n e n e ol n n n e in ci me etil c ol ci in ci lli ine ol in ci im i one etil ci ci li l ine y im ime c y l c l ol yc y one y az yc ax ici c fep ax ici az riax e ipenem e fep e floxa acy e fotax ft riax pheni dam ipenem floxa r C fotax dam O Pen acy hox e e ft pheni n Im Pen r hox C e e li n Im O zithrom C C li zithrom C C C Tet Vancom A C Erythromyc Tet Vancom A amet furoxim Erythromyc f amet e furoximhloram f hloram C e C C Sul C Sul m/ AntibioticAntibiotic m/ hopri hopri et et Susceptible Intermediate Resistant Susceptible Intermediate ResistanTrimt Trim

182 Summary of Antimicrobial Resistance Surveillance

Figure 6. Streptococcus pneumoniae, Invasive Disease, AntibioticFigureFigure 6.Resistance,6. StreptococcusStreptococcus North pneumoniae pneumoniaeEast Region,, ofInvasiveInvasive Florida, Disease,Disease, 2008 AntibioticAntibiotic Resistance,Resistance, NorthNorth EastEast RegionRegion ofof Florida,Florida, 20082008 202000 181800 161600 141400 121200 101000 8080 6060 40 Number of Cases Tested 40 Number of Cases Tested 2020 00

l l n e e e l l n n n n n e e e o n n n nn le n o li ne le cici m m eti c ci em ci l li i ne o m i m on eti i c ci em ci i l l li o yy i on i yy i xx ax az ax en az fepi en xx fepi ee amam ipen loxaloxa ee romyci ipen fota ftriax m ph romyci racyc comycicomyci C fota ftriax m ph h Of Penic racyc hoho throm C ee e h ImIm Of Penic throm e lindind et et an zi CC C l ytyt et et an zi C oxioxi C TT V A C V A ErEr fur fur hloram ee hloram ulfam C ulfam CC C S / /S AntibioticAntibiotic mm pripri

hoho etet

SusceptibleSusceptible IntermediateIntermediate ResistantResistant rimrim TT

Figure 7. Streptococcus pneumoniae, Invasive Disease, AntibioticFigureFigure Resistance,7.7. StreptococcusStreptococcus North pneumoniaeWestpneumoniae Region,, InvasiveofInvasive Florida, Disease,Disease, 2008 AntibioticAntibiotic Resistance,Resistance, NorthNorth WesWestt RegionRegion ofof Florida,Florida, 20082008 141400

121200

101000

8080

6060

4040 Number of Cases Tested Number of Cases Tested 2020

nn ee ee ee nn nn n n olol mm i in n ci m etil c ci ci ine ole ci i m on etil c ci ci llll pipi l ine ole y i on ycin y ycinycin ne l y x ycin y ne ci m x ax ci m azaz mm aa ax ax eni mycin fepim t ax eni pe oxa fa xx mycin fepim t ee amam i pe oxa i fa cyccyc ee rom i enieni i fofo ftri rom R ra ho C e ftri nd mm Ofl PP R ra t ho nco throthro C e ee nd thromthrom I I Ofl t nco C li zi C CC li zi ramph C TetTet Va A roxim ramph aritharith C Va A roxim l l EryEry fu C fu hlo C lfamelfame ee hlo C CC C SuSu m/ i im/ AntibioticAntibiotic rr opop hh etet

SusceptibleSusceptible IntermediateIntermediate ResistantResistant rimrim TT

183 2008 Florida Morbidity Statistics

Figure 8. Streptococcus pneumoniae, Invasive Disease, AntibioticFigure 8.Resistance, Streptococcus South pneumoniae East Region, Invasiveof Florida, Disease, 2008 Antibiotic Resistance, South East Region of Florida, 2008 Figure 8. Streptococcus pneumoniae, Invasive Disease, 450 Antibiotic Resistance, South East Region of Florida, 2008 40450

35400

30350

25300

20250

15200

10150 Number of Cases Tested 10500 Number of Cases Tested 500

l n e e n n n n n o i in ne le ci ne ci li i 0 m im etil c c l p l o y x y i a ni m az e l n fepi e e n n n n e o omycin i n in cyc le e ne romyci ipenem li ifa ne ox ci m fotax m etil ph c dam ci c l p i o hrom i ftriaxo m h Penic i R ra l t y C e e x y t Im Ofloxa ncomyci ni in m az C a l y et eth a zi C e T fepi e omycinC cyc V A e larithr Er romyci ipenem ifa ox fotax ftriaxo m ph dam ra hrom C furoxi C h Ofloxa Penic R t e e hloram t Im ncomyci e lin et eth a zi C C C y C C T Sulfam V A larithr Er / furoxi C m e hloram Antibiotic C C pri /Sulfam ho m Antibiotic et pri Susceptible Intermediate Resistant rim ho T et Susceptible Intermediate Resistant rim T

Figure 9. Streptococcus pneumoniae, Invasive Disease, FigureAntibiotic 9. Streptococcus Resistance, South pneumoniae West Region, Invasive of Florida, Disease, 2008 AntibioticFigure Resistance,9. Streptococcus South pneumoniae West Region, Invasive of Florida, Disease, 2008 140 Antibiotic Resistance, South West Region of Florida, 2008

12140

10120

10800

6080

4060

Number of Cases Tested 2040 Number of Cases Tested 200

n e e e n n ol m in n 0 ci m etil c ci ci ine ole i on ll pi l y ycin y ycin ne x ax ci m az m a ax eni x mycin n fepim e t e e e am n pe oxa n n fa n cyc e ol i m eni i i ci fo m etil c rom ci ci ll ine ole i ftri on m P R pi ra l ho thro y C e e ycin nd y throm ycin I ne Ofl t nco x ax ci m az m C a C ax li mycin zi t eni oxa Tet x fepim roxim e ramph arith C am pe fa cyc Va A e l Ery i eni i fo rom ftri C R ra ho C e fu nd Im Ofl P lfame t nco thro e e hlo throm C li zi C C C ramph arith C Tet Su Va A roxim l Ery fu C im/ lfame e hlo Antibiotic r C C Su op h im/ Antibiotic et r op Susceptible Intermediate Resistant rim h T et Susceptible Intermediate Resistant rim T

184 Summary of Antimicrobial Resistance Surveillance

Figure 10. Streptococcus pneumoniae, Invasive Disease, AntibioticFigure Resistance,10. Streptococcus West Central pneumoniae Region, Invasiveof Florida, Disease, 2008 Antibiotic Resistance, West Central Region of Florida, 2008 300

250

200

150

100

Number of Cases Tested 50

l n e e n n n n n o i in ne le ci ne ci li i m im etil c c l p l o y x y i a ni m az e fepi e omycin cyc e romyci ipenem ifa ox fotax ph dam hrom ftriaxo m h Penic R ra t C e e t Im Ofloxa ncomyci lin et eth a zi C C y C T V A larithr Er furoxi C e hloram C C /Sulfam Antibiotic m pri

ho et

Susceptible Intermediate Resistant rim T

185

2008 Florida Morbidity Statistics

Vancomycin Vancomycin Vancomycin

Vancomycin Vancomycin

Sulfamethoxazole Sulfamethoxazole

Trimethoprim/ Trimethoprim/ Trimethoprim/

Sulfamethoxazole

Trimethoprim/ Trimethoprim/

Tetracycline Tetracycline

Tetracycline

Rifampin Rifampin Rifampin

Rifampin Rifampin

Penicillin Penicillin Penicillin

Penicillin Penicillin

Ofloxacin Ofloxacin

Ofloxacin

Imipenem Imipenem

Imipenem

Erythromycin Erythromycin Erythromycin Erythromycin Erythromycin

, Invasive Disease, Disease, Invasive , Disease, Invasive , , Invasive Disease, Disease, Invasive ,

Clindamycin Clindamycin Clindamycin Clindamycin Clindamycin

Clarithromycin Clarithromycin Clarithromycin Clarithromycin Clarithromycin

Chloramphenicol Chloramphenicol Chloramphenicol Chloramphenicol Chloramphenicol

Cefuroxime axetil axetil Cefuroxime

Cefuroxime axetil axetil Cefuroxime axetil Cefuroxime

Streptococcus pneumoniae Streptococcus pneumoniae Streptococcus Streptococcus pneumoniae Streptococcus

Ceftriaxone

Ceftriaxone Ceftriaxone

Table 5. Table 5. Table Table 4. Table Percent Resistant to Antibiotics by Region, 2008 Florida by Antibiotics to Resistant Percent Percent Resistant to Antibiotics by County, Florida 2008 County, by Antibiotics to Resistant Percent Percent Resistant to Antibiotics by County, Florida 2008 County, by Antibiotics to Resistant Percent

Cefotaxime

Cefotaxime Cefotaxime

Cefepime Cefepime

Cefepime Cefepime Cefepime

Azithromycin Azithromycin

Azithromycin Azithromycin Azithromycin

Number of Cases Cases of Number

Number of Cases Cases of Number 1483 38.1% 6.4% 11.4% 10.3% 29.8% 3.6% 39.1% 24.9% 47.0% 21.2% 3.7% 40.8% 0.9% 25.6% 37.6% 0.1% Cases of Number 2 2 0.0% 3 0.0% - 0.0% 3 0.0% - - - - 0.0% - 0.0% - 0.0% 50.0% 0.0% 0.0% - 0.0% - - 0.0% - - - - 100.0% 100.0% 0.0% - - - - 33.3% 0.0% 50.0% 0.0% 0.0% - 0.0% 50.0% 7 0.0% 50.0% 0.0% 2 - - 50.0% - 0.0% 6 - 2 0.0% 25.0% 3 - - 50.0% 0.0% 1 100.0% - 50.0% 3 0.0% 0.0% 0.0% 0.0% 3 - - 2 - - - 0.0% - 20.0% 1 - 100.0% 0.0% 16.7% 0.0% - - - 33.3% - - 0.0% - - 0.0% 0.0% - 50.0% 0.0% 1 0.0% - 0.0% - - 0.0% 2 - - 0.0% - - 50.0% - 0.0% - 0.0% 0.0% 3 - - - - 0.0% - 1 - - - 0.0% - - 100.0% 0.0% - 100.0% - 0.0% ------0.0% - - - 0.0% 100.0% - - 28.6% 0.0% - - 50.0% ------0.0% 6 50.0% - 0.0% - 0.0% 33.3% - 0.0% 0.0% 100.0% - 50.0% ------25.0% - - - 100.0% 100.0% - 0.0% 0.0% 0.0% 0.0% - - 0.0% ------100.0% - 100.0% - - 0.0% 0.0% 0.0% 0.0% - - - - 0.0% - 50.0% 0.0% - 60.0% - - 0.0% 0.0% 50.0% 0.0% 0.0% 0.0% 33.3% - 33.3% - 100.0% 0.0% 0.0% 0.0% 33.3% - 0.0% - - - 0.0% 0.0% - - - 0.0% - - - - - 0.0% - - - 100.0% 0.0% 0.0% - - 0.0% 0.0% 100.0% 0.0% 0.0% - - 0.0% 33.3% 0.0% - - 0.0% 0.0% - 33.3% 0.0% - 0.0% - 0.0% 0.0% 0.0% 16.7% 0.0% - - 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 23 14.3% 21 0.0% 12.5% 55 - 14.3% 41.2% 19.0% 0.0% - 14.3% 11 22 0.0% 33.3% - 17 - 5.8% 33.3% 18.2% 37.5% 0.0% 0.0% - - 0.0% 0.0% 33.3% 3.2% 33.3% 100.0% 28.6% 12.5% 0.0% 100.0% 0.0% 27.3% 0.0% 75.0% 20.0% 0.0% - - 0.0% 46.6% 17.6% - 0.0% 0.0% - - - 28.6% - - 0.0% 0.0% - - 14.3% 33.3% 52.4% - 55.6% 25.0% 50.0% - - 12.5% 0.0% - - 0.0% 33.3% 30.0% - 0.0% 41.8% 45.0% 75.0% 81.9% 0.0% 52.4% 0.0% - - - 7.7% 28.6% 33.3% 47.0% 42.9% 25.0% - 0.0% 0.0% 87 63 13.3% 57.1% 23.3% 40.0% 6.2% 25.0% 0.0% 11.6% 5.4% 11.7% 31.8% 3.4% 0.0% 16.7% 4.0% - 23.1% 23 8.8% 42.9% 10 54.6% 45.7% 82 33.3% 37.5% 0.0% 20.0% 0.0% 52.7% 0.0% 30.8% 8.7% 0.0% 16.7% 20.0% 10 - 27.6% 45.7% 33.3% 20.0% 22.2% 100.0% 10.2% - - 11.1% - 0.0% 29 11.5% 11.1% 37.5% 47 22.2% 10.0% 100.0% 25.0% 10.0% 100.0% 15 - 4.3% 28.3% 0.0% 42.5% 20.0% 50.0% 26 - 52.7% 0.0% 0.0% 4.0% 32 0.0% 0.0% - - 29.3% 7.4% - 0.0% 0.0% 40.0% 40.9% 66.1% 100.0% 13.1% 66.6% 10.7% 5.3% - - 0.0% - 0.0% 15.5% 19.1% 10.7% 100.0% - 33.3% 0.0% 4.2% 51.8% 0.0% 12.9% 0.0% 20.0% - 0.0% 29.2% 0.0% 12.5% 11.1% 54.6% - 50.0% 4.3% 50.0% 34.8% 22.2% 42.1% - 0.0% 12.5% - 45.2% 0.0% - - 30.0% - 0.0% - - 0.0% 14.3% 0.0% - 29.4% 46.4% 25.0% 48.0% 50.0% 15.4% - 60.0% 11.1% - 0.0% 0.0% - 22.2% 14.3% - 0.0% 41.4% 0.0% 33.3% 0.0% 45.5% 51.7% 0.0% 40.0% 0.0% - 36.0% - - - 20.0% - 20.7% 20.0% 25.0% 40.7% 40.0% 0.0% 28.5% 0.0% - 0.0% 14.3% 40.0% 0.0% 140 0.0% 20.0% 10.7% 7.7% 50.0% 0.0% 0.0% 18.9% 48.9% 0.0% 0.0% 27.8% - 13.2% 34.3% 0.0% 205 37.5% 25.0% 20.2% 12.2% 61.5% 10.3% 42.9% 39.8% 47.2% 48.1% 20.0% 46.7% 0.0% 40.5% 36.6% 0.5% Region Region East Central North Central 254 North East 37 47.2% North West 6.7% South East 50.0% 198 South West 137 0.0% 7.7% 40.0% West Central 445 20.0% 6.7% 9.8% 4.1% 127 Total 11.1% 9.1% 47.6% 45.8% 12.7% 285 33.3% 40.0% 13.3% 12.6% 2.5% 6.9% 48.1% 14.6% 25.0% 0.0% 0.0% 50.0% 5.9% 0.0% 8.7% 10.0% 3.4% 24.5% 17.3% 12.9% - 14.0% 39.3% 50.7% 12.2% 3.2% 28.6% - 6.8% 100.0% 31.9% 18.2% 24.4% 5.0% 52.6% 0.0% 35.5% 3.4% 14.1% 26.9% 37.5% 26.7% 43.3% 22.4% 41.1% 50.0% 0.0% 33.3% 48.8% 2.7% 28.8% 13.3% 56.1% 0.0% 45.2% 0.0% 34.7% 51.0% 3.0% 0.0% 40.0% 44.1% 0.0% 4.8% 8.8% 30.0% 42.2% 0.0% 37.7% 4.7% - 12.2% 0.0% 0.0% 44.8% 46.3% - 10.8% 23.9% 25.9% 0.0% 0.0% 26.3% 36.9% 30.0% 21.1% 20.5% 30.7% 0.0% 0.2% 0.0% 39.3% 33.4% 40.3% 0.0% 0.0% 0.0% County County County Alachua Alachua Baker Bay Bradford Brevard Broward Charlotte Citrus Clay Collier Columbia Dade Dixie Duval Escambia Flagler Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes River Indian Jackson Jefferson Lafayette Lake Lee Leon Manatee Marion Martin

186

Summary of Antimicrobial Resistance Surveillance

Vancomycin Vancomycin

Sulfamethoxazole

Trimethoprim/ Trimethoprim/

Tetracycline

Rifampin Rifampin

Penicillin Penicillin

Ofloxacin

Imipenem Erythromycin Erythromycin

, Invasive Disease, Disease, Invasive ,

Clindamycin Clindamycin

Clarithromycin Clarithromycin

Chloramphenicol Chloramphenicol Cefuroxime axetil axetil Cefuroxime

Streptococcus pneumoniae Streptococcus Ceftriaxone

Table 5. Table Percent Resistant to Antibiotics by County, Florida 2008 County, by Antibiotics to Resistant Percent

Cefotaxime

Cefepime Cefepime

Azithromycin Azithromycin Number of Cases Cases of Number 7 7 2 - 50.0% 0.0% 6 - 2 0.0% 25.0% 3 - 50.0% 0.0% 1 100.0% - 50.0% 3 0.0% 0.0% 0.0% 3 - - 2 - - - 0.0% - 20.0% 1 - 100.0% 0.0% 16.7% 0.0% - - - 33.3% - - 0.0% - - 0.0% 0.0% - 50.0% 0.0% 1 0.0% - 0.0% - - 0.0% 2 - - 0.0% - - 50.0% - 0.0% - 0.0% 0.0% 3 - - - - 0.0% - 1 - - - 0.0% - - 100.0% 0.0% - 100.0% - 0.0% ------0.0% - - - 0.0% 100.0% - - 28.6% 0.0% - - 50.0% ------0.0% 6 50.0% - 0.0% - 0.0% 33.3% - 0.0% 0.0% 100.0% - 50.0% ------25.0% - - - 100.0% 100.0% - 0.0% 0.0% 0.0% 0.0% - - 0.0% ------100.0% - 100.0% - - 0.0% 0.0% 0.0% 0.0% - - - - 0.0% - 50.0% 0.0% - 60.0% - - 0.0% 0.0% 50.0% 0.0% 0.0% 0.0% 33.3% - 33.3% - 100.0% 0.0% 0.0% 0.0% 33.3% - 0.0% - - - 0.0% 0.0% - - - 0.0% - - - - - 0.0% - - - 100.0% 0.0% 0.0% - - 0.0% 0.0% 100.0% 0.0% 0.0% - - 0.0% 33.3% 0.0% - - 0.0% 0.0% - 33.3% 0.0% - 0.0% - 0.0% 0.0% 0.0% 16.7% 0.0% - - 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 87 63 57.1% 23.3% 6.2% 25.0% 11.6% 5.4% 11.7% 31.8% 3.4% 0.0% 16.7% 4.0% - 23.1% 23 8.8% 42.9% 10 54.6% 45.7% 82 33.3% 37.5% 0.0% 20.0% 0.0% 52.7% 0.0% 30.8% 8.7% 0.0% 16.7% 20.0% 10 - 27.6% 45.7% 33.3% 20.0% 22.2% 100.0% 10.2% - - 11.1% - 0.0% 29 11.5% 11.1% 37.5% 47 22.2% 10.0% 100.0% 25.0% 10.0% 100.0% 15 - 4.3% 28.3% 0.0% 42.5% 20.0% 50.0% 26 - 52.7% 0.0% 0.0% 4.0% 32 0.0% 0.0% - - 29.3% 7.4% - 0.0% 0.0% 40.0% 40.9% 66.1% 100.0% 13.1% 66.6% 10.7% 5.3% - - 0.0% - 0.0% 15.5% 19.1% 10.7% 100.0% - 33.3% 0.0% 4.2% 51.8% 0.0% 12.9% 0.0% 20.0% - 0.0% 29.2% 0.0% 12.5% 11.1% 54.6% - 50.0% 4.3% 50.0% 34.8% 22.2% 42.1% - 0.0% 12.5% - 45.2% 0.0% - - 30.0% - 0.0% - - 0.0% 14.3% 0.0% - 29.4% 46.4% 25.0% 48.0% 50.0% 15.4% - 60.0% 11.1% - 0.0% 0.0% - 22.2% 14.3% - 0.0% 41.4% 0.0% 33.3% 0.0% 45.5% 51.7% 0.0% 40.0% 0.0% - 36.0% - - - 20.0% - 20.7% 20.0% 25.0% 40.7% 40.0% 0.0% 28.5% 0.0% - 0.0% 14.3% 40.0% 0.0% 205 37.5% 25.0% 20.2% 12.2% 61.5% 10.3% 42.9% 39.8% 47.2% 48.1% 20.0% 46.7% 0.0% 40.5% 36.6% 0.5% County County Columbia Columbia Dade Dixie Duval Escambia Flagler Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes River Indian Jackson Jefferson Lafayette Lake Lee Leon Manatee Marion Martin

187

2008 Florida Morbidity Statistics

Vancomycin Vancomycin

Sulfamethoxazole

Trimethoprim/ Trimethoprim/

Tetracycline

Rifampin Rifampin

Penicillin Penicillin

Ofloxacin

Imipenem Erythromycin Erythromycin

, Invasive Disease, Disease, Invasive ,

Clindamycin Clindamycin

Clarithromycin Clarithromycin

Chloramphenicol Chloramphenicol Cefuroxime axetil axetil Cefuroxime

Streptococcus pneumoniae Streptococcus Ceftriaxone

Table 5. Table Percent Resistant to Antibiotics by County, Florida 2008 County, by Antibiotics to Resistant Percent

Cefotaxime

Cefepime Cefepime

Azithromycin Azithromycin Number of Cases Cases of Number 5 5 - 2 7 - - 50.0% - 0.0% - 0.0% - 0.0% 3 0.0% 6 0.0% 0.0% 0.0% - 6.2% - - - 0.0% - 7.7% - 0.0% 7 - 5.6% 2 - - 60.0% 10.0% - - 2 0.0% - 0.0% 0.0% 3 - 9.1% - 0.0% 2 - 71.4% - 0.0% 9.1% - - - 0.0% 0.0% 0.0% - 8.3% - 0.0% - 20.0% 0.0% - - 0.0% 9.1% - 0.0% 0.0% 0.0% 50.0% - 14.3% 0.0% 50.0% 0.0% 0.0% 0.0% - - 5.9% - - 40.0% 0.0% 0.0% - - 20.0% 0.0% - - 33.3% 0.0% - 0.0% - 33.4% - 0.0% - - 5.6% 0.0% - 0.0% 0.0% - 6.2% 50.0% - 0.0% - 0.0% 0.0% 0.0% 0.0% 33.3% 100.0% - 0.0% 0.0% 0.0% 50.0% - - 0.0% 0.0% - - 33.3% - 0.0% - - 50.0% 0.0% - - 0.0% - 0.0% - - 50.0% - 50.0% 57.1% 0.0% 0.0% - 0.0% 50.0% 0.0% 0.0% 0.0% 100.0% 0.0% 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 11 16 0.0% 40.0% 73 0.0% 0.0% 20.0% 40.0% 95 0.0% 0.0% 0.0% 32 7.7% 63.6% 0.0% 55 9.8% 40.0% 0.0% 9.5% 73 0.0% 10.1% 37.5% 0.0% 8.3% 7.1% 0.0% 0.0% 12.5% - - 60.0% 4.9% 13.6% 18 7.7% 0.0% 33.3% 17.8% 0.0% 2.9% 18 6.7% 50.0% 23.1% 8.0% 50.0% 0.0% 20 11.1% 0.0% 9.1% 75.0% 18.4% 0.0% - 63.6% 20 50.0% - 100.0% 14.3% 0.0% 0.0% 0.0% 0.0% - 50.0% 0.0% 50.0% 23.1% 46.2% 17.6% 37.5% 0.0% - 42.9% 51.5% 25.0% 43.9% 42.9% 44 25.0% - 40.0% 50.0% 57.1% 0.0% - - 50.0% 0.0% 25.0% - 0.0% 7.1% - 0.0% - 0.0% 0.0% 0.0% 0.0% 0.0% 10.0% 34.1% 37.9% 22.2% 0.0% 40.6% - 6.7% 22.2% 0.0% 0.0% 0.0% 0.0% - 39.2% - 37.2% 12.4% 0.0% 25.0% 9.8% 0.0% - 35.7% 0.0% 0.0% 0.0% 75.0% 17.4% 61.1% 66.6% 0.0% 37.4% - 0.0% 16.1% 33.3% 0.0% 50.0% - 0.0% 0.0% 38.9% 46.5% - 43.1% - 0.0% 25.0% 0.0% 0.0% - 0.0% - 0.0% - 16.7% - 29.4% 57.9% 100.0% 34.6% 43.3% 0.0% 93.3% 0.0% - 0.0% 100.0% 50.0% - 0.0% 44.4% - - 70.5% 60.0% 0.0% 0.0% 0.0% 25.0% 38.7% - 40.0% 5.9% - 33.3% 0.0% 29.4% 30.8% - - 0.0% 0.0% - 100.0% 0.0% 1483 38.1% 6.4% 11.4% 10.3% 29.8% 3.6% 39.1% 24.9% 47.0% 21.2% 3.7% 40.8% 0.9% 25.6% 37.6% 0.1% County County Monroe Monroe Nassau Okaloosa Okeechobee Orange Osceola Beach Palm Pasco Pinellas Polk Putnam Rosa Santa Sarasota Seminole St. Johns Lucie St. Sumter Taylor Volusia Wakulla Walton Washington Total

188 Summary of Antimicrobial Resistance Surveillance

Other Activities Methicillin-resistant Staphylococcus aureus (MRSA), a major cause of both healthcare-associated and community-associated infections, is not included on Florida’s list of notifiable diseases in 2008. However, the Florida Department of Health began collecting antibiotic susceptibility data in 2005 for all S. aureus isolates processed by Quest Diagnostics, a commercial laboratory that primarily serves outpatient providers operating throughout Florida. Data for all S. aureus isolates from 2003 and 2004 were retrospectively collected and, as of 2008, six years of data are available. These data are not presented here, but please check the Bureau of Epidemiology website (http://www.doh.state.fl.us/Disease_ctrl/epi/ htopics/anti_res/MRSA.html) periodically for updates.

In the November 2008 revision to F.A.C. Rule 64D-3, Florida made community-associated S. aureus mortality a reportable condition. Additionally, antibiotic susceptibilities for all S. aureus isolates from sterile sites became reportable via electronic laboratory reporting. This applies only to laboratories participating in electronic laboratory reporting with the Florida Department of Health, and individual case investigations are not required. The goal of this surveillance is to monitor trends of antimicrobial resistance.

The emergence of quinolone-resistant Neisseria meningitidis in the U.S. has raised important questions regarding current chemoprophylaxis guidelines and highlights the expanding threat of antimicrobial resistance in bacterial pathogens. The Centers for Disease Control and Prevention (CDC) responded to this threat by forming MeningNet, an enhanced meningococcal surveillance system that will be used to monitor antimicrobial susceptibility. As part of MeningNet, Florida began forwarding all N. meningitidis isolates to the CDC for antibiotic susceptibility testing in late 2008. A total of four isolates were tested, all of which were susceptible to penicillin, ceftriaxone, ciprofloxacin, rifampin, and azithromycin.

Nocardia species are weakly acid-fast, gram positive bacteria that can cause severe opportunistic infections including: respiratory infections; brain abscesses; cutaneous and lymphocutaneous disease; and actinomycotic mycetomas. Because Nocardia species are partially acid-fast, hospitals often seek confirmation from the Bureau of Laboratories to be sure they rule out a Mycobacterium species isolate. Sulfonamides have been the traditional treatment of choice for Nocardia species since the 1940’s, but emerging sulfonamide resistance has been reported in Europe, Japan, and there have been a few cases and small case series reported in the U.S. In response to this emerging threat, the CDC started a three year surveillance project in 2007 to assess the burden of disease due to antimicrobial resistant Nocardia. In 2008, the Bureau of Laboratories began forwarding all presumptive Nocardia isolates to the CDC for antibiotic susceptibility testing as part of this surveillance project. Additionally, epidemiologic data will be collected to determine antimicrobial treatments and medical procedures for these cases.

189 2008 Florida Morbidity Statistics

190 Section 5: Enhanced Surveillance for Influenza and Community Associated MRSA Deaths

Enhanced Mortality Surveillance

Bacterial infections can occur as co-infections with influenza or occur after influenza infection. During the 2006-07 influenza season, the Centers for Disease Control and Prevention (CDC) noticed an increase in Staphylococcus aureus co-infections among children who had died from or were hospitalized with influenza infection. The CDC began working with states to monitor the situation and requested enhanced surveillance for influenza co-infections during the subsequent influenza season.

Licensed practitioners and medical examiners who diagnosed, treated, or suspected the occurrence of influenza-associated pediatric mortality are required to report the death per chapter 64D-3, F.A.C. To gather additional data, voluntary reporting of all Community Associated (CA)-S. aureus pneumonia death cases was requested. The Florida Department of Health contacted all Medical Examiners in the state for assistance in a new project to track fatal community associated CA-S. aureus-pneumonia in previously healthy individuals co-infected with influenza. Voluntary reporting of CA-S. aureus deaths by medical examiners began during the 2007-08 influenza season. During the first year of this program, there were nine deaths reported during the influenza season, of which six were due to pneumonia.

In 2008, chapter 64D-3, F.A.C was updated and included the additional requirement that all practitioners (including medical examiners) report all CA-S. aureus deaths. Community-associated S. aureus deaths are defined as deaths due to Staphylococcus aureus that are culture positive for the bacteria from a sterile or respiratory site and within the last year (prior to death) the patient had not: been hospitalized; undergone dialysis; had surgery; or had indwelling catheters or medical devices that pass through the skin into the body. There were five CA-S. aureus deaths reported to the state from the start of the new reporting requirement in November 2008 to the end of the year (December 2008).

Pediatric Influenza-Associated Mortality Surveillance

Background The pediatric influenza-associated mortality surveillance started in 2004 in order to monitor the number of deaths in individuals less than 18 years of age who died as a result of complications from an influenza infection. A pediatric influenza-associated death is defined for surveillance purposes as a death in persons aged <18 years resulting from a clinically compatible influenza illness that was confirmed to be influenza by an appropriate laboratory test and in the absence of an alternative agreed upon cause of death. There should be no complete recovery between illness and death.

In 2008, three cases of pediatric influenza-associated deaths were reported to the Bureau of Epidemiology. Each case is summarized below.

Pediatric Influenza-Associated Mortality, Sarasota County, January 2008 On February 1, 2008 the Sarasota County Health Department (SCHD) received a report from a local hospital of an influenza-related death in a 40-day-old infant. The child was born on December 23, 2007, and discharged three days after birth, then re-admitted December 30, 2007 with a fever of 102.5°F, was generally fussy, and had constipation. The child was initially evaluated for meningitis and received a lumbar puncture in the emergency department. The cerebrospinal fluid (CSF) red cell count was six and white cell count was 836. The CSF serology was negative, glucose was 32, and protein was 103. RSV test was negative and the initial report stated that the child was influenzaA and B negative (testing methodology was not specified). The child was admitted to pediatrics and treated with IV fluids, cefotaxime, and ampicillin but continued to decline.

191 2008 Florida Morbidity Statistics

On January 1, 2008, the mother noted that the child had decreased oral intake and was crying continuously. Acute respiratory failure prompted intubation and transfer to a local children’s hospital. The child was admitted to the pediatric intensive care unit that same day. The child was noted to be in cardiogenic shock and an echocardiogram was performed which revealed poor ventricular function, moderate to severe mitral regurgitation, and mild to moderate pulmonary hypertension.

The next day an influenza screening test (EIA) was positive for influenzaA and a subsequent culture test that was also positive for influenza A. A CT scan on January 6, 2008 revealed a large non-hemorrhagic left hemispheric stroke.

The child died on January 20, 2008 and the cause of death on the death certificate was listed as myocarditis and renal failure. The SCHD contacted the various healthcare providers in order to obtain any specimens or samples still available in order to perform additional testing at the Bureau of Laboratories. However, all samples had been previously discarded. The final discharge summary indicated that the child suffered from acute respiratory failure, severe cardiac compromise, presumed myocarditis secondary to Enterovirus, influenza A positive, large left hemispheric stroke, endotracheal tude positive for Stenotrophomonas and Candida albicans, renal insufficiency, and hyperbilirubinemia.

Pediatric Influenza-Associated Mortality, Indian River County, February 2008 The Indian River County Health Department was notified by the Alachua County Health Department of an influenza-associated pediatric death in an Indian River resident. A 17-year-old female with a history of cystic fibrosis was hospitalized in December 2008 for cystic fibrosis exacerbation and again on February 19, 2008 at a hospital in Alachua County. Her symptoms in February were much worse than they had been in December and included: increased coughing with increased thickening of her mucous; fever (102°F); and nausea that resulted in post-tussis emesis and headaches. Hypoxia was significant (low 70’s) and oxygen support was provided. The patient was positive for influenza A on an antigen screening test. No further testing was done. Although her chart indicated she was given an influenza shot earlier in the year, this could not be confirmed. The patient’s physical status continued to decline. A joint decision between the parents and patient was made to not pursue any continuous means of treatment. She died on March 15, 2008.

Investigation of a Pediatric Influenza A Co-infection Death, Hillsborough County, March 2008 On April 4, 2008, a call was received by the Hillsborough County Health Department (HCHD) from the medical examiner (ME) informing HCHD of a two-year-old child who had succumbed to influenzaA on March 26, 2008. The medical records showed that on March 12, 2008, two weeks prior to the patient’s death, the girl was seen at Hospital X, and diagnosed with an upper respiratory infection. A week later, on March 19th, 2008, she was taken to Hospital Y with symptoms of an upper respiratory infection, prescribed antibiotics, and sent home. On March 26, 2008, she was found in bed not breathing, laying on her stomach. The deceased was transported to Hospital Z and pronounced dead.

The case was referred to the ME, where several additional tests were conducted. These tests revealed that the child’s primary cause of death was due to influenza A, with secondary co-infections of parainfluenza-3 and adenovirus. The ME also discovered that the deceased had sickle cell trait, which was also deemed a contributing factor to her death.

References

The Centers for Disease Control and Prevention, “Influenza-Associated Pediatric Mortality and Staphylococcus aureus co-infection” Official CDC Health Advisory, January 30, 2008. Available at http://www.cdc.gov/flu/professionals/flustaph.htm.

Florida Administrative Code, 64D-3, http://www.doh.state.fl.us/disease_ctrl/epi/topics/64D-3_11-08.pdf.

192 Summary of Notable Outbreaks and Case Investigations

Section 6: Summary of Notable Outbreaks and Case Investigations, 2008

Listed alphabetically by disease

In Florida, any disease outbreak in a community, hospital, or institution, as well as any grouping or clustering of patients having similar disease, symptoms, syndromes, or etiological agents that may indicate the presence of an outbreak is reportable, as per Florida Administrative Code, 64D-3. Selected outbreaks or case investigations of public health interest that occurred in 2008 are briefly summarized below. Following many investigation summaries are citations or links where additional information can be found about the event. Investigation summaries are organized by disease name; within each disease category investigations are listed chronologically (January through December, 2008).

Additional disease summaries and information describing epidemiologic events in Florida can be found in Epi Update. Epi Update, an online publication of the Bureau of Epidemiology, Florida Department of Health, can be accessed through the following site: http://www.doh.state.fl.us/disease_ctrl/epi/Epi_Updates/index.html

Food and waterborne disease outbreaks in Florida are summarized in annual reports produced by the Bureau of Environmental Public Health Medicine accessible via the following site: http://www.doh.state.fl.us/environment/community/foodsurveillance/annualreports.htm

Annual food and waterborne reports include overall statewide data as well as summaries of selected outbreaks. In addition, a bibliography of journal and EpiUpdate articles on food and waterborne disease can be found at the following site: http://www.doh.state.fl.us/environment/medicine/foodsurveillance/ annualreports.htm

Amoebic Encephalitis

Amoebic Encephalitis, Sarasota County, June 2008 On June 24th, the Sarasota County Health Department (SCHD) received a report from a local hospital of a 79-year-old man who was diagnosed with amoebic encephalitis by a pathologist that had examined a brain biopsy of a mass in his right frontal lobe. The pathologist described the brain biopsy as “Edematous brain with necrosis and acute and chronic inflammation with organisms suspicious for amoebic encephalitis.” A second opinion from a Johns Hopkins University pathologist concurred with the diagnosis. The patient had onset of severe lethargy and overall weakness approximately June 12th and he could not move without assistance. On June 14th, the man’s wife noticed increased confusion and had him transported by Emergency Medical Services to a local emergency department (ED). The man was alert in the ED, but somewhat confused, had a temperature of 103.5° F, and a stage two decubitus ulcer at the base of his sacrum. A CT scan showed a mass in the frontal lobe. The patient’s pre-existing conditions included diabetes, autoimmune hepatitis for which the patient was on long term prednisone therapy, a history of skin cancer, and a bone marrow transplant four years ago. He underwent a craniotomy on June 18th to biopsy the brain mass. The patient was comatose post-procedure and expired when he was removed from life support on June 24th. A sample of the brain biopsy was forwarded to the Centers for Disease Control and Prevention, Division of Parasitic Diseases for further identification and confirmation. The specimen tested was positive for Acanthamoeba species via indirect immunofluorescence.

The man’s wife reported no exposure to natural fresh water sources or pools in more than two years. The patient did have limited exposure to a temporary indoor pool used for church services within the

193 2008 Florida Morbidity Statistics

one to two weeks prior to onset. Sarasota County Environmental Health evaluated the pool for basic sanitation and recommended routine chlorination. The man’s wife reports no recent travel, no gardening or exposure to soil, no history of recurrent skin lesions, and no other recent infections (other than the sacral ulcer).

Botulism

Infant Botulism Diagnosed in California, Duval County, August 2008 On August 8, 2008, the Duval County Health Department’s (DCHD) Epidemiology Program was notified by Bureau of Epidemiology staff that a six-week-old infant, a Duval County resident, was diagnosed with botulism in California. The infant, then four weeks old, became ill on a flight to California. The infant slept soundly through first part of flight but on the second part of the flight was noted to suck poorly, drool excessively, and to have a weak cry. An hour before the end of the flight, the infant became limp. After reaching the airport, the infant was driven by parents to a community hospital emergency department where the infant’s condition deteriorated to full respiratory arrest. The infant was intubated and transferred to a larger hospital. California’s Infant Botulism Treatment and Prevention Program consulted with physicians and anti-toxin (BabyBIG) was given July 28th. A stool specimen was collected and was positive for Botulinum Toxin A. Investigation revealed that the infant had experienced constipation a week prior to the flight, was breast-fed entirely except on two occasions, and was never given honey. The family lives in an area of Duval County where new homes are currently being constructed. The infant was transferred to a hospital in Orlando on September 23rd and remained on a ventilator. She was later discharged home from the hospital. Last update revealed that the infant still had a tracheostomy and a gastrostomy button, but was eating some solid foods and breastfeeding. The infant is able to stand with assistance of parents but has not crawled and has one eye that slightly wanders.

Brucellosis

Hunter-Acquired Brucella suis Infection, Lake County, Florida and Pennsylvania, July 2008 On July 24, 2009, the Lake County Health Department (CHD) was advised of a confirmed brucellosis patient (Patient A) in Pennsylvania that had a brother (Patient B) in Lake County, Florida who may have been ill and had the same exposures.

The epidemiologic investigation revealed that Patient A had hunted feral swine with Patient B in December 2007 in Sumter County, FL. Both Patient A and Patient B participated in field dressing and butchering three hogs. The spouses and the children of Patient B assisted in carrying meat and cleaning up. No personal protective equipment was worn during the field dressing and butchering. Soap and water were used to wash hands and instruments/equipment. No other risk factors for brucellosis were identified. Some of the pork was brought back to Pennsylvania, stored in a freezer, and consumed by Patient A’s family members over a seven month period, however adequate cooking was reported. Meat was prepared mainly by the wife of Patient A. In July 2008, Patient A presented with morning fevers (100°-102o F), myalgia, chills, shortness of breath, and night sweats. A 30 pound weight loss over a one month period was also noted. Three specimens were collected for testing and sent to the Centers for Disease Control and Prevention (CDC). Brucella suis was cultured from a blood sample collected from Patient A; two isolates were also recovered from frozen sausage and tenderloin of the wild hog. Genotyping of the three B. suis cultures performed by CDC indicated strong genetic correlation between all three isolates.

When contacted by Lake CHD, Patient B reported having similar signs and symptoms for two months starting in April, 2008 which he attributed to a scorpion bite. No medical attention was sought at that

194 Summary of Notable Outbreaks and Case Investigations time. Other than feral swine hunting, no other brucellosis risk factors were identified for Patient B. Patient B reported that all meat from the Brucella positive pig was either smoked, roasted, or barbequed prior to consumption and all of the meat was consumed at a family cookout except for the meat taken by Patient A back to Pennsylvania.

A serum sample from Patient B was collected by Lake CHD in September 2008 and tested at the CDC for anti-Brucella antibodies, using the Brucella microagglutination test, with a resulting IgG of 640, meeting the brucellosis probable case classification. Treatment was recommended as relapses and chronic illness are often associated with untreated Brucella infections; Patient B’s current status is unknown as he was lost to follow up. Serology was not performed on the families of Patient A or B due to the lack of signs or symptoms.

Case of Brucella melitensis, Palm Beach County, November 2008 In November of 2008, Palm Beach County Health Department (PBCHD) was notified by Focus Diagnostics in California that a patient’s culture was presumptive positive for Brucella and that the sample was being forwarded to the state reference laboratory in California for confirmatory testing and speciation. In late October, the patient had been admitted to a Palm Beach County hospital with the chief complaint of abdominal pain and an admitting diagnosis of cholecystitis. An infectious disease consult was requested on November 5th because the patient was septic with gram-positive coccobacilli; blood samples were submitted for culture. The patient improved with supportive care and antibiotic treatment and was discharged on November 10th. The patient was released from the hospital before the PCR and culture results were available. The primary physician and the patient were unaware of the positive test results and were informed of the results on November 19th by PBCHD when the presumptive positive PCR results were received. The infectious disease doctor initiated treatment for the patient the day he was notified of the results on November 24th. Final laboratory results received from the state laboratory in California on November 25th were positive for Brucella melintensis by PCR.

A review of the patient’s medical history revealed that the patient had reported knee and waist pain since late January 2008 and stopped working as a result. In early February 2008, he started having intermittent night sweats/chills. The patient was seen by several doctors following symptom onset but brucellosis was not suspected. In May 2008, the patient was seen by an infectious disease doctor post-knee surgery because of a possible joint infection. The culture specimens taken at that time were negative for Brucella. A definitive exposure was never identified but is suspected to have been prior to the initial symptoms in January 2008. The only exposure of interest was consuming “leche fresca” while visiting Mexico, which could have been un-pasteurized, but this exposure occurred after the onset of symptoms.

Campylobacteriosis

Pet-Associated Campylobacteriosis, Hillsborough County, March 2008 The Hillsborough County Health Department (HCHD) investigated a case of campylobacteriosis in a seven-year-old girl in April of 2008. Symptoms began on March 31, 2008 and included bloody diarrhea, abdominal pain, cramps, vomiting and a fever. Campylobacter was cultured from the girl’s stool specimen.

The girl’s family had recently purchased a golden retriever puppy (2.5 days before the illness onset in the patient). This puppy was experiencing diarrhea immediately upon arrival in the new household. The dog was brought to a veterinarian and treated for an unspecified bacterial infection. The puppy was later found to have “round worms and spirochetes.” The case investigation revealed that the girl had not eaten any undercooked meat and did not have any other obvious risk factors.

195 2008 Florida Morbidity Statistics

While not a spirochete, Campylobacter is a comma shaped bacteria and could be what was observed on the puppy’s laboratory exam. Transmission of Campylobacter from pets to humans (through fecal-oral contact) is estimated to cause more than 200,000 cases of gastroenteritis per year (see reference below).

On Wednesday, April 30, 2008, Hillsborough County Animal Services and HCHD Environmental Health went to the house where the puppy was purchased and where dogs were being bred. Investigators found a ruptured septic tank and squalid conditions. The dogs had been living in a fly-infested backyard filled with human waste. The dogs were taken to animal services for bathing and treatment for fleas, coccidian, and worms. Fifteen dogs from this breeder had been recently sold, and Animal Services made telephone calls informing pet owners of the situation.

Additional resources Stehr S. “The impact of zoonotic diseases transmitted by pets on human health and the economy“, Vet Clin North Am Small Anim Pract 1987: Vol. 17, pp. 1-15.

Ciguatera

Two Ciguatera Outbreaks, Miami-Dade County, May 2008 In the month of May 2008, two outbreaks of ciguatera poisoning were investigated by the Miami-Dade County Health Department.

The first reported outbreak involved three persons, a 56-year-old woman, her brother, and father who ate a two-foot long grouper at home on May 12, 2008. The woman presented with diarrhea five hours after lunch as well as reversal of cold/hot sensations, joint and muscle pain, body aches, and itching. She was treated with mannitol, but felt strong pain in her arm and discontinued the medication. She continued to experience neurological symptoms. The father and brother ate less fish and presented with mild neurological symptoms and they both recovered. The brother received the grouper as a gift and did not know where it was caught. No leftover or frozen fish was kept, hence no sample could be sent for confirmation to the U.S. Food and Drug Administration (FDA) Gulf Coast Seafood Laboratory in Dauphin Island, AL.

The second outbreak involved a husband and wife who ate eel in a sushi roll at a restaurant in Palm Beach County on May 17, 2008 at 5:30 p.m. The wife had an onset the following day at 10 a.m. with gastrointestinal symptoms, abdominal pain, and diarrhea. A day later, neurological symptoms began including: strong reversal of cold/hot sensations; joint and muscle pain; body aches; itching; weakness in legs; rash; tingling; numbness; pin-prickling; and fatigue. She received mannitol and felt better, though neurological symptoms persisted. Her husband presented with mild neurological symptoms including joint and muscle pain and itching, but later recovered. This was the second time in their lifetime they both had ciguatera; the first event occurred in 1990. The wife contacted 10 of the 14 other diners from the group, but none complained of any similar symptoms.

Three Ciguatera Outbreaks Reported, Palm Beach County, June 2008 Three separate outbreaks of ciguatera poisoning were reported to the Palm Beach County Health Department (PBCHD) Epidemiology Program related to the ingestion of grouper during June 2008. The first report included two men fishing in the Bahamas who caught and ate an 8 lb. grouper on June 22, 2008. Their symptoms began six hours later and included: vomiting; diarrhea; tingling of the lips and tongue; and reversal of hot and cold sensations. Both were evaluated by private medical doctors.

The second outbreak was reported to PBCHD on June 30, 2008 by the Florida Poison Information

196 Summary of Notable Outbreaks and Case Investigations

Network. A family of four purchased and consumed two grouper fillets from a local seafood store on June 26, 2008. Approximately four hours later, they started experiencing symptoms including: vomiting; diarrhea; tingling; reversal of hot and cold sensations; and some difficulty breathing. The family was evaluated at a local emergency department (ED) and offered mannitol therapy. The seafood store was visited by the PBCHD Environmental Health Program. The store had purchased one 20 lb. grouper from a local distributor.

The third outbreak involved a family of four who became ill after consuming black grouper purchased from a market on June 26, 2008. The persons consumed the grouper and developed symptoms 2.5 to 4.5 hours later including: abdominal pain; diarrhea; body aches; dizziness; joint and muscle pain; itching; breathing difficulties; tingling and numbness in lips, nose, and tongue; pains in teeth and gums; reversal of hot and cold sensations; vomiting; and weakness in legs. Patients visited a local ED and were diagnosed with ciguatera intoxication. Trace-back of the fish revealed that grouper had been purchased from the same distributor in Miami as the outbreak listed previously on June 21st and 24th. That fish was reportedly imported from the Bahamas. Black grouper was also purchased on June 24th from a distributor in Sunrise, FL. Grouper from the second and third outbreaks that occurred on June 26th were tested at the FDA Gulf Coast Seafood Laboratory and found to be positive for ciguatera with levels high enough to cause illness.

Outbreak of Ciguatera Associated with Consumption of Grouper, Nassau County, July 2008 On July 3, 2008 the Nassau County Health Department (NCHD) was notified of a physician-diagnosed ciguatera case in a tourist who had consumed grouper at a resort on Amelia Island. From July 3-11, 12 additional cases were reported in persons who consumed grouper at two resort restaurants, for a total of 13 cases. All persons consumed grouper from June 26-29 and developed gastrointestinal illness (GI) from June 27-30. Grouper was served in an 8 oz. entree portion in one restaurant and in a 4 oz. blackened grouper sandwich in the second restaurant. A dose-response relationship was found as cases that ate the 8 oz. portion were more likely to have experienced a longer duration and severity of symptoms. The trace-back investigation of the grouper consumed at both restaurant locations indicated that the fish were bought from the same distributor in Miami, FL as the two ciguatera outbreaks reported above from Palm Beach County. That fish was also reported to be of Bahamian origin. The Palm Beach cluster occurred when a family purchased and consumed grouper on June 26, 2008 from a local grocer and developed GI symptoms and temperature reversal.

Of interest, a breast milk toxin transfer may have occurred when the mother of 2.5-year-old child reported that her son exhibited symptoms of ciguatera intoxication after breast-feeding. The child developed a 72- hour fever and remarked that drinking a cold beverage “burned his mouth” (an indicator of temperature reversal). Immediately, the mother ceased breast-feeding and the child recovered within 24 hours.

Ciguatera Investigation, Pinellas County, September 2008 The Pinellas County Health Department and the Bureau of Environmental Public Health Medicine investigated a case of ciguatera that was reported by the Florida Poison Information center on September 8, 2008. The patient was a 56-year-old woman who had been visiting her daughter in St. Thomas, Virgin Islands at the end of August. On August 27, 2008, her party went on a fishing trip and caught a Blue- eyed Trevally, an amberjack species. The fish was prepared with lime juice and coconut milk and served as sashimi. Illness occurred within five hours, beginning with gastrointestinal symptoms followed by paresthesia, muscle pains, and hot and cold reversal symptoms for approximately a week. The patient was seen at a clinic in St. Thomas and treated for diarrhea and vomiting symptoms. According to the patient, the fish was recreationally caught in the waters north of St.Thomas which was reputed to be a lower risk area for ciguatoxin.

197 2008 Florida Morbidity Statistics

Cryptosporidiosis

Cryptosporidium parvum Outbreak Among a High School Swim Team, Sarasota County, August- September 2008 On September 8, 2008, a single confirmed case of cryptosporidiosis in a swim team member/public pool employee was reported to the Sarasota County Health Department (SCHD). The case’s disease onset was August 15th, with symptoms of bloody diarrhea, abdominal pain, cramps, chills, and nausea. The suspected exposures were the ongoing use of public pool A and swimming in Lake Mead, NV on August 8, 2008. The index case’s symptoms resolved September 5th. During the symptomatic and infectious period, the case swam almost daily at public pool A with a high school swim team and periodically worked at the pool as a life guard.

Interviews of all team members, indicated 13 children reported symptoms of gastrointestinal (GI) illness since August 1st. Symptoms included diarrhea (100%), abdominal pain (69%), nausea (31%), and vomiting (31%). No fevers (>100.4 F) were measured. Average duration of symptoms was 10 days, a median of 8.5 days, with a range of 3-20 days. Six stool ova & parasite specimens were collected from cases, two of which tested positive for Cryptosporidium parvum.

Further case finding efforts at public pool A attempted to identify pool staff and members with GI illness. Signs were posted at the entrance to the building asking persons with symptoms of GI illness to report to the pool staff and call the SCHD. Pool staff were surveyed by pool management. No additional reports of illness were received from members or staff of public pool A. No symptomatic household contacts or other close contacts of cases were reported.

During this outbreak disease control measures included: the exclusion of ill team members from swimming for two weeks after resolution of symptoms; voluntary cancellation of meet participation and practices; the correction of environmental health violations and super-chlorination of the pool; and education regarding good hygiene practices.

Cyclosporiasis

Cyclospora Case Control Study Due to Increase in Reported Cases, May-June 2008 In the summer of 2008, the Food and Waterborne Disease Program observed a moderate increase (two standard deviations of the expected number of cases) in cyclosporiasis cases. In response to this observed increase, the Food and Waterborne Disease Program initiated a case-control study to try to determine the source of the increase. A statewide total of 27 cyclosporiasis cases had symptom onset during May and June of 2008. Initial case investigations by the local county health departments noted cases were sporadic and there were no identified clusters or common food exposures. After excluding cases with history of out-of-state travel during the incubation period, 15 of the 27 cases were able to be interviewed for the case-control study. Twenty-six (26) controls matched by age group and county (approximately two controls per case) were also interviewed. Based on the epidemiological analysis, consuming avocados appeared significantly associated with disease (OR= 3.95, 95% CI: 1.005-15.577). However, only seven out of the 15 interviewed cases reported consuming avocados. Due to the small sample size, low statistical power, potential recall bias, and incomplete or missing data in some interviews, the results of the study were determined to be inconclusive. Without further intervention, case levels for cyclosporiasis eventually dissipated and returned to background levels throughout the state.

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Eastern Equine Encephalitis

Eastern Equine Encephalitis in a Three-Month-Old, Leon County, August 2008 On August 20, 2008 a hospital infection control nurse called the Leon County Health Department (LCHD) to report a suspected case of bacterial meningitis in a three-month-old infant. The child presented to the emergency department on August 19th with a fever (as high as 105° F), lethargy, irritability, and tonic/ clonic seizure activity over a period of 24-48 hours. The infant had been treated with Rocephin and Augmentin for a fever and suspected pneumonia one week prior to admission. The Augmentin was finished one day prior to admission. The medical history was otherwise unremarkable with a normal term delivery.

Cerebrospinal fluid (CSF) was abnormal and the gram stain was initially reported as positive for a “few gram positive coccobacilli in pairs, chains, clusters” but after review, the report was changed to “no organism seen.” The blood and CSF cultures were negative. The chest X-ray was clear. The child was admitted to the intensive care unit (ICU) for suspected bacterial meningitis and was treated with Rocephin, Vancomycin, steroids, and Dilantin.

The pediatric infectious disease physician suspected meningococcal meningitis. Sixteen contacts in the child’s household and the babysitter’s household were provided antibiotic prophylaxis by the LCHD and the sibling’s pediatrician on August 20th. On August 29th the Bureau of Laboratories-Jacksonville reported a positive serum IgM with an Eastern Equine Encephalitis virus titer of 1:40. No antibody was detected to the St. Louis Encephalitis virus.

The mother stated that the child had been exposed to mosquitoes in the two weeks prior to illness. The family lived near a swampy area and often left the front door open in the afternoon. The family would also sit outside in the early evening. The infant was protected from mosquitoes with a “Citronella brand coil bracelet/mosquito repellent” worn on the ankle.

The child required an extended stay in the ICU with ventilator support. It is unknown if there were any long term sequelae.

Ehrlichiosis/Anaplasmosis

Ehrlichiosis in Ocala National Forest, July 2008 On July 10, 2008, the Palm Beach County Health Department received an IgG IFA positive lab result for Ehrlichia chaffeensis (Human Monocytic Ehrlichiosis) through Merlin from an out-of-state hospital where a 70-year-old female patient had been treated. The patient was contacted on Friday, July 11th and she reported that she lives in Vermont part-time and was there when she decided to go to the hospital. Approximately one week prior to becoming ill, the patient and her husband went camping in the Ocala National Forest, in Ocala, Florida. She recalled lots of deer flies and after a day or so her hip area started to itch. A few days later she became ill with fever, chills, and fatigue. By the time she returned to Vermont, she was very disoriented and had to be taken to the hospital on June 14th. Upon examination, a tick was found still embedded in the patient’s hip. The tick was saved to be sent for testing/identification to a university in Vermont for which no results are available. The patient was treated with Doxycycline and was much improved.

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Giardiasis

Gastrointestinal Illness Outbreak in Travelers Returning from Guatemala The Nassau County Health Department’s (NCHD) Epidemiology Program investigated a cluster of gastrointestinal illnesses (GI) in six U.S. missionaries who traveled to the Zacapa region of Guatemala from May 17-24, 2008. The volunteers stayed in a mission house in Guatemala, consumed multiple group meals, and participated in well construction projects in three rural villages near Zacapa. The group was exposed to untreated water sources. On May 23rd, four of the volunteers experienced GI symptoms and received medical care at a local hospital in Antigua, Guatemala. The remaining two volunteers became ill on May 24th and May 25th. One volunteer tested positive for Giardia.

NCHD communicated the investigation findings to the mission group coordinator to share with partners at the mission center in Guatemala. The team leader conducted surveillance for additional cases in Guatemala to determine if there was a continuous risk of exposure, as the mission center hosts new volunteers on a regular basis.

Hemolytic Uremic Syndrome (HUS)

HUS in a Child with Multiple Possible Exposures, Palm Beach County, October 2008 On October 23rd, the Palm Beach County Health Department was notified of a seven-year-old boy with symptoms of abdominal pain, bloody diarrhea, fatigue, and fever who was admitted to the hospital after eight to ten days of illness; illness onset was October 9th. During his illness, he had been seen by a pediatrician on at least one occasion and was also seen at another hospital prior to hospital admission. For various reasons, proper tests were not conducted or were conducted once the child was placed on antibiotics, so a positive culture for Escherichia coli and/or Shiga toxin was unattainable. However, the child was diagnosed as having hemolytic uremic syndrome (HUS) due to an elevated creatinine level and anemia. After his onset of symptoms, his six-year-old sister and 14-month-old brother had the same, yet milder symptoms with onsets of October 11th and 12th. The siblings were also admitted to the hospital and were not properly tested for E. coli and/or Shiga toxin. The siblings’ test results for creatinine and anemia did not meet the criteria to diagnose HUS. All three children were exposed to a petting zoo (duck, rabbit, and goat) on September 27th; two weeks prior to the index child becoming ill. There was also a report of exposure to slightly undercooked burgers at home the night before the index child became ill. The incubation periods relative to each exposure seemed a little too long or too short to pinpoint either as the definitive exposure.

Healthcare-Associated Infections

Invasive Bacterial Infections at a Dialysis Clinic, Osceola County, July 2008 On Monday July 21, 2008, the Osceola County Epidemiologist was notified of three dialysis patients hospitalized over the previous weekend with suspected invasive bloodstream infections. Two of these patients received dialysis at the same clinic. Of these two patients, one was culture-positive for Methicillin-sensitive Staphylococcus aureus (MSSA) and the other for Methicillin-resistant S. aureus (MRSA). The third patient attended a different clinic, and all culture results were negative. That afternoon the Osceola County Health Department (OCHD) conducted an interview at the dialysis clinic shared by the two patients.

The clinic conducts hemodialysis on approximately 40-50 patients at day, and has a current hemodialysis patient census of 100. During the initial phone call, the clinic stated that they were unaware of any of their patients being hospitalized. The clinic also stated that there was a failure in their reverse osmosis

200 Summary of Notable Outbreaks and Case Investigations water treatment system on July 11, 2008. OCHD Environmental Health staff collected water samples from the clinic, which came back negative for coliforms. Based on information collected, the water treatment system failure was ruled out as a causal agent for these infections.

OCHD worked with the clinic and local area hospital to identify additional blood stream infection cases that had dialysis at the same clinic. Three additional cases were identified, making a total of five dialysis patients with bloodstream infections. The first case was admitted to the hospital on July 8, 2008 followed by two cases on July 20th, one case on July 26th and one case on August 1st. Cultures were positive for MSSA in two patients, MRSA in two patients and Proteus mirabilis in one patient. One of the patients died as a result of their bloodstream infection.

A site visit to the clinic was conducted by OCHD on August 6, 2008. During the visit, poor infection control practices were observed, which included improper glove usage and inadequate hand washing techniques. Based on these observations, OCHD contacted the Association for Health Care Administration (AHCA) to report the observance of poor infection control practices at this clinic. Following this complaint, AHCA conducted a site visit to the clinic but observed no infection control problems or violations.

Active surveillance was continued and no additional cases were identified. Findings from this investigation and site visit were communicated to the clinic, along with information on proper infection control practices, hand washing technique, and glove utilization.

Hepatitis A

Three Possible Hepatitis A Cases Associated with an Ill Food Worker, Lee County, February 2008 On February 8, 2008, the Erie County Department of Health reported to the New York State Department of Health a confirmed case of hepatitis A virus (HAV) infection in a produce-handler. The handler worked at a local grocery store in a suburb of Buffalo, NY. The produce-handler may have been contagious and shedding virus from January 7 through February 4, 2008. Some of the produce stocked by the handler may have remained on display through February 8th. Because the handler most likely did not wear gloves while handling produce, persons who ate uncooked fresh produce (raw fruits and vegetables) purchased loose or in a perforated container at the store from January 7th to February 8th may have been at risk for exposure to HAV. According to the grocery store chain, approximately 84,000 produce transactions were completed at the implicated location during that time period.

State and local health officials were notified of this situation through a posting to the Centers for Disease Control and Prevention’s (CDC) information exchange called Epi-X. They were asked to identify cases of HAV infection potentially associated with this exposure and were asked to provide post-exposure prophylaxis (PEP) where indicated. The Lee County Health Department identified three individuals that met the criteria to receive hepatitis A PEP. All three were winter visitors to the state and had eaten fresh produce from the implicated store during the time period of interest.

Hepatitis A, Collier County, August 2008 In August 2008, the Collier County Health Department (CCHD) investigated an isolated cluster of eight cases of hepatitis A within one family residing in a migrant farm community. The family (two adults and six children) traveled to Mexico on July 1, 2008. Onset of vomiting and diarrhea was July 3, 2008 while all family members were still in Mexico. Symptoms resolved before they returned to Florida for all except the 10-year-old girl, who developed jaundice. She was evaluated by a physician in Mexico. Anti- protozoa and anti-amoebic medications were prescribed, but the child’s symptoms did not improve. The family returned to Collier County on August 16th, and on August 29th the 10-year-old girl was hospitalized

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related to vomiting and diarrhea for the past 1½ months, jaundice, weight loss, abdominal pain, and headache. The child’s laboratory reports were positive for acute hepatitis A and the child’s liver function tests were elevated.

A home visit was completed by CCHD, and proper household and personal hygiene were discussed. Serology was completed for all family members, and the results were positive for infections with the hepatitis A virus. The parents were not employed in sensitive positions that would require exclusion during or shortly after illness with hepatitis A, and five of the six children were able to attend the first day of the new school year. None of the family members had previously received the hepatitis A vaccine. Due to the incubation period for hepatitis A and the onset of symptoms two days after arrival in Mexico, the infection was most likely acquired in Florida. Prophylaxis was not provided to any contacts, and no other cases of hepatitis A have been noted in the community.

Klebsiella pneumoniae

Outbreak of Carbapenem-Resistant Klebsiella pneumoniae Infections in a Long-Term Acute Care Hospital, Broward County, March 2008 In March 2008, the Broward County Health Department was notified by a regional medical center about the death of a 59-year-old woman with multi-drug resistant Klebsiella pneumoniae isolated from the urine. This patient had been transferred from a long-term acute care hospital (LTACH) to the medical center one day prior to death, so it was hypothesized the infection was contracted at the LTACH. A review of all LTACH K. pneumoniae culture reports revealed over 20 reports from 13 patients over a four-month period with similar antibiogram results including resistance to carbapenem antibiotics. This class of antibiotic is usually the best for treating highly resistant strains of K. pneumoniae, hence the organism is referred to as carbapenem-resistant Klebsiella pneumoniae (CRKP).

Investigation included performing a case-control study to identify risks for CRKP acquisition. In addition, rectal swab specimens were obtained on all LTACH patients to identify any patients that were infected or colonized with CRKP but who had not previously been cultured (active surveillance). Case-patients were defined as those infected or colonized with CRKP diagnosed ≥72 hours after admission to the LTACH between January 15 and April 30, 2008. Control-patients were those that tested negative for CRKP. Isolates were tested with the Modified Hodge test to identify carbapenemase production and typed with pulsed-field gel electrophoresis (PFGE). Lastly, the investigation team assessed mortality within the LTACH cohort.

CRKP was isolated from 13 case-patients (eight infected; five colonized); active surveillance identified CRKP among six patients, all of whom were known case-patients. All isolates had indistinguishable PFGE patterns and all were carbapenemase-producers (Modified Hodge positive). Case-patients and control-patients were similar in age, sex, race, and Charlson co-morbidity score. Case-patients had longer lengths of stay (LOS) before first positive CRKP culture (versus control-patient LOS before negative screening culture) and had more implanted medical devices (ANOVA and Chi-Square, p-value<0.05). Case-patients were more likely to be exposed to the ICU and to have received penicillin or aminoglycoside antibiotics in the prior 30 days. Nine of 13 case-patients and two of 28 control-patients died (OR 29.3, 95% CI 3.6, 314.6). Deaths per 1,000 patient-days of observation were higher for CRKP patients (incidence density ratio: 4.9; 95% CI, 1.1–22.9).

The intervention consisted of enhanced contact precautions and cohorting of case-patients. After implementation, only one additional case was found with a matching PFGE pattern.

This is the first CRKP outbreak reported in a Florida LTACH and the first in which all in-patients were

202 Summary of Notable Outbreaks and Case Investigations screened. Surveillance cultures demonstrated no on-going transmission to other patients, which allowed the facility to focus control efforts on case-patients. High mortality and limited treatment options underscore the need for prevention efforts of healthcare-associated infections with this highly pathogenic Klebsiella strain.

Legionellosis

Legionellosis in Wedding Attendees, Orange and Pinellas counties, March 2008 On March 11, 2008, the Pinellas County Health Department (PCHD) Epidemiology Program was notified by a local hospital of a laboratory-confirmed case of Legionnaires’ disease with onset on March 7th. On March 12th, an infection control practitioner at the same hospital reported an additional laboratory- confirmed case of Legionnaires’ disease with onset of March 9th. Both people were Canadian residents who had recently attended a wedding in Orlando, Florida and stayed at Hotel A. Further investigation revealed confirmed Legionnaires’ disease cases in another wedding guest from Canada and a United Kingdom resident who had both stayed at Hotel A during the same time period. A letter was distributed to all guests staying in the hotel between February 27th and March 15th, which helped identify one probable Legionnaires’ disease case. Environmental, epidemiological, and laboratory investigations were undertaken in an attempt to determine the source of infection.

Epidemiologic data indicate that the source of the outbreak was the outdoor hot tub at Hotel A. The only common exposure among the five affected people was staying at this hotel between February 23rd and March 8th, 2008. No common exposures outside Hotel A were identified. There was a statistically significant association between spending time in the hotel’s hot tub and acquiring Legionnaires’ disease (odds ratio = 22.11, 95% confidence interval = 1.22-1569.46, p-value = 0.0162). Environmental inspection observations at the hotel support the biological plausibility of a causal association of the hot tub with illness. The chlorine levels observed in the hot tub at the time of inspection were not sufficient for disinfection, which could allow Legionella bacteria to thrive in the warm water. The existing design of the filters and water flow of the hot tub created a condition where a large volume of water was passing through an insufficiently sized filter. The hot tub therapeutic jets produce aerosolized water droplets, less then 5 µm, which can be inhaled. Environmental sampling did not yield any positive laboratory results, though this could be due to laboratory or sampling error. Negative results could also mean that the organism was not present in detectable quantities for the testing methods used, or the organism was not present at time of sampling. This outbreak highlights the risk for transmission of Legionella bacteria from an inadequately maintained hot tub. It is critical that all pools, hot tubs, spas, and whirlpools be properly maintained on a regular basis in a prescribed manner to prevent transmission of disease.

For more information about this investigation please visit Eisenstein L, Bodager D, “Outbreak of Legionellosis Associated with Exposure to a Hotel Outdoor Hot Tub, Orange County, Florida, March 2008”, Florida Journal of Environmental Health, Fall, 2008, Issue 200, p.14-19.

Legionellosis Cluster Associated with Fitness Club, Orange County, June-September 2008 On September 30, 2008, the Orange County Health Department (OCHD) Epidemiology Program was notified by a local hospital of a laboratory-confirmed case of Legionnaires’ disease with illness onset of September 25th. The initial interview of the 33-year-old woman disclosed that during her incubation period she lived in several rooms at a local hotel that she described as humid, moldy, and containing wet carpet. The patient denied hot tub or pool use during the two weeks prior to illness onset. On October 7th, the OCHD Epidemiology Program was notified of another laboratory confirmed case of Legionnaires’ disease with illness onset of September 29th. The 70-year-old woman reported frequenting

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a local health fitness club (Fitness Club A) during the exposure period with no other reported relevant exposures. Exposures at Fitness Club A included a hot tub and showers. The initial environmental inspection at Fitness Club A on October 14th revealed several issues with their pool and hot tub cleaning and maintenance including that the required maintenance logs were not consistently being used. One filter instead of the required two was being used on the hot tub at the time of this inspection. The OCHD Swimming Pool Inspector closed both the pool and hot tub based on these findings per standard Department of Health protocols.

On October 22nd, the OCHD Epidemiology Program learned that the initially reported 33-year-old woman had also visited the same fitness club during the two weeks prior to her illness onset. Her exposures included both the hot tub and shower facilities. As a result of this new information, indicating a potential cluster of two or more similar illnesses linked to a common source, the OCHD Epidemiology Program initiated an investigation. Based on the environmental assessment and epidemiological data, environmental samples were collected from the hot tub and women’s showers at Fitness Club A on October 23rd. Samples included both swabs and water from the hot tub and swabs from the interior of the shower heads in the women’s showers. Only the women’s showers were sampled because all cases occurred in women at the facility. All environmental samples obtained from Fitness Club A collected on October 23rd were culture negative for Legionella pneumophila. It should be noted that the chlorine reading of the samples upon arrival at the laboratory on October 29th was between 0.2-0.3 ppm which could indicate some remaining bactericidal activity during sample transport.

One additional case was linked to Fitness Club A through active surveillance and through re-interviewing willing and accessible legionellosis cases reported January 1st to November 1st in Orange County. All three of the confirmed cases had underlying health conditions, making them more susceptible to Legionnaires’ disease. The only common exposure among the three cases was visiting this facility during the 14 days prior to their reported illness onset. Exposure occurred between June 11 and September 26, 2008 and included both the hot tub and the women’s showers. No common community exposures outside Fitness Club A were identified among the patients.

Environmental inspection observations at the fitness club hot tub indicated conditions that could possibly support biofilm production and the harboring of Legionella bacteria. Maintenance logs indicated chlorine levels below 2 ppm intermittently (five days) during September 2008. The October 14th inspection also showed inadequate disinfection and pH levels. There was no record of routine scrubbing or supershocking of the hot tub. The improper use of the required two filters for the hot tub created a condition where a large volume of water was passing through an insufficiently sized filter. The temperature of the hot water heater supplying water to the showerheads was not available. This information, along with the epidemiologic information gained from interviews with the confirmed cases, implicates Fitness Club A as the source for each case’s infection. The negative laboratory results on the environmental specimens could have been due to many factors including: laboratory error; sampling error; organism not present in detectable quantities for methods used; or the organism not present at time of sampling.

Legionella Positive Environmental Samples from a Hot Tub at a Local Resort Hotel, Orange County, December 2008 The Florida Department of Health was notified on December 4, 2008 by the Centers for Disease Control and Prevention (CDC) of a confirmed case of Legionnaires’ disease in a 60-year-old man who was a resident of England. Initial information provided by the CDC indicated that the patient’s onset date was November 23, 2008 and he stayed at Hotel A in Orlando, Florida from October 20th through November 13th. Hotel A’s hot tub was epidemiologically implicated as a source for five cases of Legionnaires’ disease in March of 2008 (see previous summary). All available case information was forward to the Orange County Health Department (OCHD) on December 4th for surveillance and investigation.

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Environmental samples were collected by OCHD at Hotel A, including samples from the hot tub implicated in the previous outbreak. Laboratory tests on the samples collected from the hot tub were positive for Legionella pneumophila serogroup 1. The finding of Legionnella pneumophila serogroup 1 in a hot tub indicates chronically low disinfection levels and insufficient maintenance practices to ensure prevention of the spread of communicable diseases. The previous documented history of sanitation deficiencies and a previous outbreak of five cases of Legionnaires’ disease linked to exposure to the hot tub at Hotel A indicates a continual pattern of improper maintenance and adherence to appropriate sanitation procedures. The OCHD closed the hot tub at Hotel A on December 5, 2008. It will remain closed until specified revisions are made to the hot tub that will ensure proper operation and sanitation, and therefore reduce the risk of the public acquiring a communicable disease.

Additional resources: Eisenstein L, Bodager D, “Outbreak of Legionellosis Associated with Exposure to a Hotel Outdoor Hot Tub, Orange County, Florida, March 2008”, Florida Journal of Environmental Health, Fall, 2008, Issue 200, p.14-19.

Listeriosis

Listeriosis Case with Fetal Demise, Volusia County, May 2008 In May 2008, the Volusia County Health Department investigated two laboratory confirmed cases of listeriosis. The index case was a 37-year-old woman, who was 27 weeks pregnant when a decrease in fetal movement and severe fetal tachycardia necessitated a C-section. The infant was delivered and expired within a week after birth. Cultures taken of maternal uterine tissue and the infant’s blood were positive for Listeria monocytogenes. These laboratory results were confirmed by the Bureau of Laboratories-Jacksonville.

The patient was interviewed and a four week food history and social history was acquired. There was no history of travel or animal contact, except for two healthy household dogs. The woman did report eating out frequently, three to four times a week during the time period surveyed. Various restaurants and take out foods were consumed by the woman, including cold cuts eaten frequently in salads and sandwiches. A definitive food source was not identified.

Additional resources http://www.cdc.gov/nczved/dfbmd/disease_listing/listeriosis_gi.html http://www.fsis.usda.gov/Fact_Sheets/Listeria_monocytogenes/index.asp

Listeria monocytogenes in an Infant, Palm Beach County, October 2008 On October 27, 2008, Palm Beach County Health Department’s Epidemiology and Disease Control Program was notified by a local hospital’s infection control department of a positive blood culture for Listeria monocytogenes in a three-day-old infant. This baby was born three weeks early as a twin via a C-section. Because the babies were born early, as protocol, a “blood screen” was conducted. Both the mother and the other twin cultured negative for Listeria. Upon further investigation, it was found that on October 3rd the mother developed a stuffy nose and cold-like symptoms. On October 8th, she developed a low grade fever at which time her doctor put her on a Z-pak (azythromicin). The mother stated that her fever never really went away until after she delivered. The baby was born with poor tone, poor respiratory effort, and was intubated. The baby had a scattered exanthema on her torso and extremities, and was placed on ampicillin, gentamicin, and acyclovir. Upon interview with the mother, it was found that during the month prior to onset she consumed one Italian deli sandwich from an establishment, some boiled shrimp from another establishment, and a lot of fresh salads and raw vegetables throughout the pregnancy. During the month prior to onset, the mother did not consume any hotdogs, soft cheeses, unpasteurized products, or refrigerated smoked seafood. On October 31st, the Florida Department

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of Agriculture tested 13 samples from the Italian deli/market where six of the family members ate approximately one month earlier. All samples tested negative for Listeria. No definitive source for the infection was identified. The infant recovered from the illness.

Measles

Confirmed Case of Measles in a Traveler, Sarasota County, December 2008 On December 15th, a probable case of measles was reported to the Sarasota County Health Department (SCHD). The case, a 14-year-old traveler from England, had onset of headache and mild cough on December 13th immediately before beginning a family trip to Florida. The family arrived in Tampa on December 13th and flight information was forwarded to the Bureau of Immunization to notify the Centers for Disease Control and Prevention. On December 14th, a fever of approximately 102° F was measured and a rash appeared on the child’s chest and legs. The father immediately suspected measles, as he was aware of an ongoing outbreak at the child’s boarding school in England. The child was taken to a walk-in clinic that same day, where the father informed the clinic of his suspicion of measles. The child was isolated in the car until the exam and wore a mask when taken through the clinic. The doctor did not order any diagnostic tests and diagnosed the child with acute bronchitis/pharyngitis. The child was prescribed a Z-pack (azythromycin) and pain medication. After consulting the physician at the child’s school in England, the father called the SCHD immunization clinic to inquire about obtaining the MMR vaccination for the family. This call triggered the epidemiologic investigation, as SCHD was not informed by the clinic physician of the family’s suspicion of measles.

On December 15th, the rash was covering most of the child’s body and was characteristic of measles based on pictures examined by SCHD nurses. As of December 15th, symptoms included dry heavy cough, fever, generalized aches/pains, sore eyes, and generalized rash. All three household contacts had incomplete vaccination history with no history of disease. The father (no history of vaccine/disease) was administered immunoglobulin (IG) on December 15th, and the mother and sibling (history of a single vaccination) were administered IG on the 16th, because additional IG had to be ordered. Measles vaccination will be sought by the group in five months.

Blood and urine specimens obtained from the case were tested for measles and rubella IgG/IgM. Results were positive for measles IgM. The activities of the case were limited to the airport, hotel, and doctor’s office. The doctor at the walk-in clinic received MMR vaccination on the 17th due to unknown immunity.

On December 18th and 19th a measles advisory was sent to local emergency departments, walk-in clinics, pediatricians, and primary care physicians to notify them of the case and the possibility of secondary cases presenting from December 20th to January 4th. No secondary cases were detected.

Meningococcal Disease

Fatal Meningococcal Disease Case, Sarasota County, March 2008 On Saturday, March 29th, the Sarasota County Health Department (SCHD) received a report of a confirmed case of meningococcal meningitis in a 68-year-old woman. She presented to the emergency department (ED) on Thursday, March 27th, with a chief complaint of confusion and weakness. The physicians noted a rapidly progressing illness with fever, multiple petechiae, a purpuric rash on face/ legs/chest/arms, hemoptysis, and disseminated intravascular coagulopathy. The patient required intubation in the ED. The gram stain was initially reported as gram positive cocci, but was corrected to gram negative diplococci after admission. Cerebrospinal fluid (CSF) and blood cultures were positive for Neisseria meningitidis on March 29th. This initiated a report from the hospital laboratory to the Bureau of

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Epidemiology on-call epidemiologist, who notified SCHD via the 24/7 contact line. The case’s infectious disease physician was contacted and she agreed to prophylax the case’s husband and notify him of the diagnosis. The husband was also contacted by SCHD to determine the case’s other close contacts. Three close family contacts that visited the prior week, and were now home in Indiana, were contacted and agreed to seek prophylaxis from their family physician. No other at-risk contacts were identified by SCHD. The hospital ED provided prophylaxis to eight contacts (five ED staff, three paramedics/firefighters) that they considered to be at risk. The woman died on March 30th.

Meningococcal Disease in a Daycare Center, Miami-Dade County, May 2008 On May 17, 2008, the Miami-Dade County Health Department (MDCHD) after-hours nurse on-call received a report of a laboratory result positive for meningococcal meningitis (Neisseria meningitidis). The patient was a two-year-old boy seen in the emergency department (ED) on May 12th for abdominal pain and discharged home. On May 15th, the child had the following symptoms: cough, fever, rash, lethargy, nausea, and vomiting. On that date, the child was taken once again to the ED by his parents and preliminary tests (CSF cultures) were done and the child was admitted. On May 16th, the hospital laboratory reported gram positive cocci from the CSF and the child was transferred to the pediatric intensive care unit. On May 17th, the preliminary result was re-evaluated by another laboratory team and found to be gram negative diplococci. On May 20th, the Bureau of Laboratories identified and confirmed the CSF isolates as Neisseria meningitidis, Group B. Household contacts, including well siblings, were prophylaxed and other close contacts were identified. The child’s mother reported being pregnant and in good condition. She was referred to her obstetrician where she received prophylaxis. A parent letter was provided to the daycare on May 19th.

On May 20th, an Epidemiology and Pharmacy team from the MDCHD went to the child’s daycare to educate and distribute prophalyxis to the close contacts. A total of 40 close contacts from the daycare center received prophylaxis (Rifampin). There was no travel history and no known ill close contacts reported. The child was admitted at the hospital for one week and was subsequently discharged home on May 27th.

Probable Meningococcal Meningitis in an Airline Passenger, Palm Beach County, May 2008 On May 21, 2008, the Palm Beach County Health Department (PBCHD) was notified by the infection control practitioner (ICP) at a local hospital of a case of suspected bacterial meningitis. The patient was a 41-year-old woman, with a history of headache, backache, and fever for three days. She traveled by air from London to West Palm Beach with a transfer in Philadelphia the day prior to hospital admission.

Initial laboratory results showed cerebral spinal fluid (CSF) that was cloudy, with elevated protein, white blood cells, and decreased glucose. No organisms were seen on the gram stain and culture results were still pending. According to the ICP the patient had received Rocephin 1 gram IV about two hours prior to the lumbar puncture. The attending physician felt the case fit the profile of bacterial meningitis and started treatment prior to obtaining the specimen for culture and gram stain. PBCHD notified the regional epidemiologist and the Centers for Disease Control and Prevention Miami Quarantine Station. The case was discussed with the Miami Quarantine Station staff and a decision was made to wait for results of the CSF culture before making a decision to prophylax any of the other passengers on her flight.

Culture results on May 22nd showed no growth after 24 hours. It was thought that the Rocephin given before the CSF collection could provide a false negative result. After further discussion with the Miami Quarantine Station, the patient was contacted for specific information regarding her seat location on the flight from London to Philadelphia, which was an 8.5 hour flight.The second portion of the flight was from Philadelphia to West Palm Beach did not meet the threshold of a flight lasting over eight hours and so was not likely to put passengers at risk for contracting disease. The initial report from the airline showed no one was assigned to the seat next to her on the London to Philadelphia leg of her flight. However, when interviewed, she identified that she had changed seats at the beginning of the flight and sat next

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to another couple for the entire flight. The Miami Quarantine Station decided to recommend prophylaxis for the couple sitting next to her and worked with the airline, the Philadelphia Quarantine Station, and the local health department to contact them. PBCHD recommended prophylaxis to the patient’s household and family contacts here and in London.

Mycobacterium abscessus

Mycobacterium abscessus Infections Associated with Epidural Injection at a Pain Clinic, Lee County, February 2008 In February 2008, the Lee County Health Department (LCHD) was notified by a concerned infectious disease physician about a possible cluster of Mycobacterium abscessus infections associated with epidural injections administered by a local pain center. The LCHD and Bureau of Epidemiology investigation that followed identified a total of five laboratory confirmed cases and two probable cases of M. abscessus infection that had received epidural injections at a single pain clinic. A review of records identified two consecutive days in December 2007 when the five culture-confirmed patients were given epidural injections. The five patients developed infections at the site of the injection 20 to 81 days post injection. Molecular laboratory analysis by the Bureau of Laboratories-Jacksonville and the Centers for Disease Control and Prevention (CDC) confirmed the strains were identical by pulse- field gel electrophoresis (PFGE). In order to exclude contaminated drugs at the manufacturer level, the United States Food and Drug Administration (FDA), the CDC, and a pharmaceutical company were contacted to determine if there were similar outbreaks reported in other parts of the United States; none were reported. A review of injection practices revealed that the clinic was using vials of medications that did not contain preservatives and that they were using single use vials on multiple patients. While it is unknown how the M. abscessus was introduced into the clinic practice, breaks in standard infection control appear to have contributed to the transmission of the infection to multiple patients.

Norovirus

Norovirus Outbreak Associated with a Swim Team, Broward County, April 2008 In April 2008, the Broward Regional Environmental Epidemiologist received a report regarding a possible foodborne disease outbreak among members of swim team from Michigan who were in Florida for a competition. A retrospective cohort study was performed by the Broward Regional Environmental Epidemiologist and the Broward County Health Department Epidemiology Team. Fifteen of the 27 swim team members met the case definition for the outbreak and all 27 members were interviewed. Clinical samples were received from one of the ill swim team members as well as an ill food-worker at the hotel restaurant and were submitted for analysis to the Bureau of Laboratories. The Bureau of Laboratories- Tampa detected Norovirus G2 in both samples. Gene-sequencing was performed on both samples to determine the virus strain. Results from these sequencing studies demonstrated that the food-worker and the swim team member had the same virus strain.

Multiple statistically significant food and water items were found in the epidemiological analysis; however the food/water source of the outbreak could not be determined. It was noted in the environmental investigation that the conditions in the restaurant that catered the swim team’s meals were favorable for a food-worker to contaminate a ready-to-eat food item or beverage (such as water) with Norovirus via bare hand contact. The only common source that the swim team and the food-worker had in common was the hotel restaurant; but it is uncertain if this food-worker was the source of the illnesses since the date of onset for this employee did not occur prior to that of the swim team members. No additional reports of illness were received from other guests staying at the hotel.

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Norovirus Illness in Individuals Attending a School Field Trip to Washington, D.C., Duval County, October 2008 The Florida Department of Health was notified on October 30, 2008 of a middle school group from Duval County that became ill during their annual Washington, D.C. field trip. The group (36 children and four adult chaperones) arrived in the Maryland/D.C. area on October 26th. The index patient became ill with nausea and vomiting on October 29th. Subsequently, a total of 25 ill children and three adults were evaluated in the emergency department of Children’s Hospital in D.C. The District of Columbia Epidemiology Program was notified and a team was deployed to the hospital to interview the group. Initial symptomology suggested a viral etiology; however, the District of Columbia Epidemiology Program was unable to obtain stool or vomitus specimens for identification of the pathogen.

The school group returned via bus to Jacksonville on the afternoon of October 31st, where it was met by Duval County Health Department (DCHD) Epidemiology staff and a regional epidemiologist. Information regarding viral gastroenteritis and stool specimen collection kits were distributed to parents. In addition, several questions were answered regarding illness, possibility of transmission, as well as personal and environmental hygiene concerns.

Seven sets of stools specimens (five students and two chaperones) were subsequently collected by DCHD Epidemiology staff for analysis by the Florida Department of Health, Bureau of Laboratories- Jacksonville. All seven specimens were reported as positive for Norovirus G1. The school engaged in enhanced environmental cleaning, and symptomatic students were excluded accordingly. No secondary illnesses were reported.

Since there was still some question regarding the etiology of this outbreak and the Maryland Department of Health and Mental Hygiene and D.C. epidemiologic investigation yielded no probable foodborne or environmental sources, the specimens were forwarded to CDC’s National Calicivirus Laboratory along with recently collected specimens from other local community outbreaks. All specimens were confirmed as Norovirus G1.4. Considering that the Norovirus strain from the school trip matched recent local Duval County clusters, the possibility exists that this outbreak had a local etiology.

Norovirus Outbreaks at Healthcare Facilities, Sarasota County, October-November 2008 Beginning in October, the Sarasota County Health Department (SCHD) saw an increase in Norovirus activity in several healthcare facilties. A local hospital detected an increase in Norovirus illness among employees beginning October 6th through November 18th. A total of 44 employees reported symptoms of gastrointestinal illness. In addition, from October 5th through November 18th, there were 18 nosocomial cases, and five suspected cases in visitors. Fifteen stool specimens from patients were sent to the Bureau of Laboratories-Tampa and were positive for Norovirus G2. Control measures included: exclusion of symptomatic employees for 48 hours after symptom resolution; the use of 1:10 bleach solution for cleaning of high touch/contaminated surfaces and during terminal cleaning of all patient rooms; contact isolation for all suspected patient cases including using masks when around symptomatic persons or cleaning; and placing notices at hospital entrances.

On November 12th, a Sarasota County nursing home reported 15 cases of gastrointestinal (GI) illness with an onset of November 11th. The investigation revealed no ill kitchen staff, and an investigation of the kitchen found the kitchen was satisfactory. Through November 24th there were 68 resident cases, resulting in a 69% attack rate among the 98 residents. There was one resident death associated with this GI outbreak. Additionally, there were 38 staff cases, for an attack rate of 28% among the 135 staff. The pathogen was confirmed to be Norovirus G2 by the Bureau of Laboratories-Tampa. Control measure included: use of 1:20-1:50 bleach cleaning of high touch/contaminated surfaces; exclusion of ill staff for 48 hours after resolution of symptoms; cancellation of activities, visitation, and admissions; emphasis on soap and water hand hygiene; and use of contact precautions with masks when necessary. It was discovered that on November 3rd a case-patient was transferred to this nursing home from the hospital

209 2008 Florida Morbidity Statistics

described above for rehabilitation. The facility resumed allowing visitors and admissions on November 26th, with notices posted about the increase in GI illness and the need to maintain good hand hygiene.

Norovirus Outbreaks in Four Long-Term Care Facilities, Charlotte County, December 2008 On December 5, 2008, the Charlotte County Health Department (CCHD) was notified by infection control staff at a local hospital about a cluster of gastrointestinal (GI) illnesses. Six residents from a long-term care facility (LTCF) were seen in the emergency department with symptoms of nausea, vomiting, and diarrhea. Subsequently, three similar outbreaks at LTCF’s were reported over the next two weeks. CCHD Epidemiology and Environmental Health staff conducted joint investigations at all four facilities. Infection control measures were implemented immediately and active surveillance was initiated. In total, 135 cases of GI illness were associated with these outbreaks. Onset of illness ranged from November 29–December 17. Stool specimens collected from three facilities tested positive for Norovirus G2. The fourth facility was unable to collect specimens for testing, but symptomology was consistent with Norovirus.

No epidemiological link was identified between the four facilities. Data collected from the investigation indicate person-to-person transmission rather than a common source of infection. Given the hardy nature of this virus and its high infectivity, the organism was easily spread throughout these facilities. The source of introduction of virus into these facilities remains unknown.

Pertussis

Pertussis in an Unvaccinated Cohort, Clay County, October 2008 In October 2008, the Clay County Health Department (CCHD) investigated pertussis cases in an unvaccinated family cohort. The family members included five children and two adults (parents). The mother called the health department to report the children had been seen by their family pediatrician with four out of five children being symptomatic. Symptoms included: persistent cough (4); paroxysmal cough (4); whoop (2); posttussive vomiting (3); stridor (2); and facial flushing (4). All five children were tested by PCR for presence of Bordatella pertussis, three tests were positive, one negative, and one indeterminate. The investigation revealed the children were home schooled and not vaccinated. Investigation also revealed a total of eight close contacts. Three of these contacts were family, the parents and an asymptomatic sibling. The other five contacts were neighborhood children who played with the cohort. The benefits of vaccinations and possible side effects were discussed with mother in great detail but she refused vaccinations for her children. The CCHD took this opportunity to send out a press release regarding pertussis and CDC recommendations for Tdap immunizations. The CCHD and local hospital also took this opportunity to offer Tdap vaccines to employees. Currently, the local hospital has implemented a mandatory Tdap immunization policy for its employees.

For more information about this investigation please visit Scoggins, K., “Pertussis in an Unvaccinated Cohort in Clay County,” Epi Update, 2008; December, http:// www.doh.state.fl.us/Disease_ctrl/epi/Epi_Updates/2008/December2008EpiUpdate.pdf

Rabies

Rabid Horse, Glades County, January 2008 In January 2008, the Glades County Health Department (CHD) received a report of a horse that had become ill, aggressive, showed signs of paralysis, and died within 24 hours of exhibiting symptoms. A local veterinarian recognized this as possible rabies and referred the family to the Highlands CHD. Due to the coordinated efforts of the Highlands CHD, the Glades CHD, and under the guidance of the Florida

210 Summary of Notable Outbreaks and Case Investigations

Bureau of Environmental Public Health Medicine, exposed contacts (including the owner who had been attacked and bitten by the horse) were promptly identified and rabies post-exposure prophylaxis (PEP) was initiated the same day.

The Florida Bureau of Laboratories (BOL) was consulted regarding the harvesting and transporting of the brain. Because no standard established protocols or resources were available to address decapitation or brain harvesting of a large animal, a local animal sanctuary was elicited to provide this service, assisted by the local animal control office. Glades CHD transported the specimen directly to the Bureau of Laboratories location in West Palm Beach who reported a positive Fluorescent Rabies Antibody test the next day.

Simultaneously, the Florida Department of Agriculture and Consumer Services was notified and an onsite inspection was conducted in conjunction with the Glades CHD Environmental Health office. None of the farm animals had been vaccinated against rabies. One other horse had been bitten by the rabid horse, but had been euthanized and buried under the direction of the local veterinarian. No other animals on the farm had been exposed.

The owner ultimately admitted ownership of a pet raccoon that he also had previously euthanized. All of the farm animals were vaccinated for rabies after this event. All six exposed human contacts completed the rabies PEP series. In August 2008, the BOL reported the Monoclonal test results as Raccoon A strain.

Rabid Raccoon, Clay County, June 2008 The Clay County Health Department (CCHD) received a positive rabies animal laboratory result on a raccoon via Merlin on June 19, 2008. Investigation revealed the baby raccoon was found in a neighboring county and brought into Clay County by that individual. The person who found and transported the raccoon operates a wolf sanctuary and could not keep the animal. The raccoon was given to a local individual who already had a pet raccoon and claimed to have a license for raccoon rehabilitation. Further investigation revealed that the individual did not possess a license. The baby raccoon became ill approximately three days after being found and was taken to a local veterinarian. The veterinarian immunized the raccoon against rabies and distemper. The raccoon was then sent home. Later in the evening, the raccoon started to have convulsions. It was taken to the local emergency veterinarian who immediately euthanized it. Arrangements were made to have the animal tested for rabies at the Bureau of Laboratories-Jacksonville; results were positive for rabies.

The exposures to this raccoon included kissing the raccoon, allowing the raccoon to bite and ”gnaw” hands and forearms, and sleeping with the raccoon. The animal control personnel questioned the owners regarding the adult raccoon the individual also had as a pet. This adult raccoon was kept in a cage in the garage. The adult raccoon did not have contact with the baby raccoon. The Florida Fish and Wildlife Conservation Commission as well as Florida Department of Health public health veterinarians were notified about the presence of the adult raccoon. After consultation, it was determined that no further follow-up was needed for the adult raccoon. A total of eight people received rabies post-exposure prophylaxis. CCHD worked closely with the Naval Hospital in Jacksonville to get five of the exposed contacts the necessary rabies prophylaxis. One of the contacts had gone to New York. Prophylaxis for this contact was started in a New York emergency department and the local health department in New York was also notified. Post exposure prophylaxis was continued in Clay County upon the contact’s return.

Partners included Clay County Animal Control, County Manager’s office, the local hospitals, including the U.S. Naval Hospital Jacksonville, St. Johns County Health Department, the Florida Department of Health Division of Environmental Health, Florida Fish and Wildlife Conservation Commission and the local media. For more information about this investigation please visit

211 2008 Florida Morbidity Statistics

Wolfe, C., “Rabid Raccoon in Clay County”. Epi Update, 2008;July, http://www.doh.state.fl.us/disease_ ctrl/epi/Epi_updates/2008/July2008EpiUpdate.pdf

Rabies Exposure Due to Contact with a Cat, Alachua County, July 2008 On July 24, 2008 the Alachua County Epidemiology office was notified by the county Environmental Health office of a positive rabies laboratory result on a cat. The investigation was started immediately. The owner of the cat lived in Gilchrist County and the cat was seen at an animal hospital in Alachua County. The owner of the cat was interviewed and indicated that the cat was a stray that came to their yard approximately a year ago and they started feeding it. The cat eventually became their pet. The cat was never vaccinated against rabies.

On July 15, 2008, the cat was seen at a local animal hospital for symptoms of a urinary tract infection. It was treated with antibiotics and was sent home. On July 18, 2008, the cat was seen again for a re- check visit at the same animal hospital. The condition of the cat was worsening. The cat was not eating nor drinking and still had urinary incontinence. According to the veterinarian, the cat was panting and showing intermittent aggressive behavior. Pain medication was prescribed and the cat was sent home. The cat died that same evening. Animal Services picked up the cat and on July 22nd Alachua County Environmental Health sent the specimen to the Bureau of Laboratories-Jacksonville for rabies testing and received the positive report on July 23rd.

There were 15 people exposed to the cat and they all received rabies post-exposure prophylaxis (PEP). The owner, the spouse, and mother-in-law lived in Gilchrist County and the Gilchrist County Health Department (CHD) coordinated their PEP. Twelve employees of the animal hospital received PEP as well. Eleven employees went to Alachua CHD and one employee went to Orange CHD.

PEP was not recommended for the Animal Services staff because the employee handled the cat with proper personal protective equipment (triple gloves, gown, mask, and goggles).

Rabies in a Kitten, Palm Beach County, July 2008 On Monday, July 28th, the Palm Beach County Health Department (PBCHD) received a laboratory report from the Bureau of Laboratories indicating a positive result of rabies on an eight-week-old kitten that died on July 26, 2008. Upon further investigation it was found that the stray kitten was rescued in early July. The kitten was nursed back to some degree of health at a private home for about two weeks before veterinary care was sought as it was not improving. The kitten was kept at this veterinary office for about one week during which time it scratched and/or bit 15 staff members. On July 26th, the kitten expired and was sent to the Bureau of Laboratories for rabies testing. Once the animal was found to be positive, PBCHD contacted all exposed individuals to coordinate post-exposure prophylaxis immediately. Some individuals were exposed as early as July 19th and one individual from the veterinary clinic was bitten on the face on July 20th. The exposed staff members were veterinary technicians and three receptionists and had not received rabies pre-exposure prophylaxis. The veterinarians were the only staff members that had received prior pre-exposure prophylaxis. More stray cats from the area where the kitten was found were trapped and tested by Animal Care and Control to assess if any other animals in the community were positive for rabies. All exposed individuals continued to receive treatment throughout the month.

Rabid Raccoon, Central Florida, August 2008 On August 22, 2008, the Orange County Health Department was notified by the Brevard County Emergency Operations Center in the aftermath of Hurricane Fay of a raccoon that tested positive for rabies at the Bureau of Laboratories-Tampa. The raccoon was submitted for testing by a veterinarian located in Orange County who delivered the specimen to the Animal Diagnostic Laboratory in Kissimmee. The “hairless” raccoon had been transported from a Seminole County dumpster to a wildlife rehabilitation facility in Orange County by the Fish and Wildlife Commission where it gave birth to two babies. The

212 Summary of Notable Outbreaks and Case Investigations raccoon broke through quarantine quarters and was attacked by other raccoons in the facility while in captivity. It was taken to a veterinarian after exhibiting symptoms of illness. The babies and all other raccoons in the facility were destroyed by animal services.

A total of 14 people received rabies post-exposure treatment due to their exposure to the rabid raccoon and/or its babies. Three people receiving treatment were from the veterinary clinic and used no personal protective equipment when handling the raccoon and its babies. Exposures included saliva contact to open wounds or cuts through examination of the oral cavity. Eleven people from the wildlife rehabilitation facility receiving treatment reported no use of personal protective equipment when handling the raccoon or its babies. Exposures included bites, scratches, and contact with saliva through open cuts. One of the wildlife rehabilitation workers took the baby raccoons home to feed and care for them, resulting in the exposure of a child.

Improved communications between Environmental Health and Animal Services and a revised policy is planned. This incident reinforces the importance of interagency collaboration and clear communications in achieving public health objectives. Another important observation is the impact that a natural disaster may have on usual public health practices.

Rash Illness, Un-Confirmed Etiologic Agent

Rash Investigation, Collier County, January 2008 In January 2008, the Collier County Health Department (CCHD) was notified by a medical provider of a pruritic rash illness among employees at a local pet store. The rash was located on the trunk, arms, and neck of symptomatic persons, and one employee also had rash on his legs. Skin scrapings and punch biopsies were negative for mites and scabies and serum cholinesterase results were within normal limits. Employees were diagnosed with irregular dermatitis and symptomatic persons were treated with steroid medication.

The CCHD Epidemiology program conducted interviews with symptomatic and asymptomatic employees, and an onsite inspection of the facility was also conducted. None of the employees that worked in the veterinary clinic or the grooming area were symptomatic. This area is physically separated from the retail area of the store where the symptomatic employees worked. The results of a private air quality inspection completed on February 7th indicated that mold (Stachybotrys) was found on the floor of one room, in air samples from the same room, and on the air conditioning plenums. Samples of new food products, live plants, and animal products used in the store (litter, bedding, food) were tested by a consulting parasitologist. The samples tested negative for mites and other organisms. The animals in the store were examined by a veterinarian and none showed signs of illness.

On February 20th, CCHD Epidemiology staff, a Department of Health Environmental Health Specialist, and private consultants conducted a joint inspection of the facility. Findings revealed several areas for improvement. Recommendations were made to dispose of all dog food infested with mites, sanitize and thoroughly clean the air conditioning system, including the air handler, and perform deep cleaning of the entire facility. The recommended cleaning was done, and employees’ symptoms resolved. To date no etiologic agent for the rashes had been identified.

213 2008 Florida Morbidity Statistics

Salmonellosis

Salmonellosis in Children Associated with Pet Reptiles, Palm Beach County, September 2008 The Palm Beach County Health Department had three reported cases of salmonellosis in children related to exposure to reptiles in the home during the month of September. The first case was in a 16-month-old child. Her onset of illness was September 15th when she developed a fever of 105°F. Salmonella was cultured from a urine specimen. The family had a pet turtle in the home at the time of the child’s illness, but removed it after being counseled by their physician.

The second case was in a five-year-old child. He developed abdominal pain and diarrhea on September 25th. He was seen that day by his physician and a stool specimen was obtained. The stool specimen was cultured and was positive for Salmonella serogroup B. This family also had a pet turtle at the time of the child’s illness but removed it after being counseled by the family physician.

The third case was in an 11-week-old infant. He had developed diarrhea and a fever on September 26th. He was admitted to a hospital where Salmonella was identified from a blood culture. He was treated with several antibiotics. At the time of his illness the family had an iguana in the house as a pet. The iguana was removed after discussion with hospital staff.

None of these children attended daycare or had exposure to any individuals with known gastrointestinal illness. The families denied eating in any restaurants during the incubation periods, or exposure to raw or undercooked food or poultry.

Additional resources King D, Stanley G, “Salmonella and Reptiles”, One Health Newsletter, 2009, Winter. Available online at: http://www.doh.state.fl.us/Environment/medicine/One_Health/OHNLwinter09.pdf

Selenium Poisoning

Investigation of Excess Selenium in a Nutritional Supplement On Friday, March 21, 2008, the Florida Department of Health (FDOH) Food and Waterborne Disease Program was contacted by the Florida Poison Information Center (FPIC). The FPIC had been notified by the United States Food and Drug Administration (FDA) that the Washington County Health Department had received a report from a local health care provider that several people had became ill after consuming a nutritional supplement called Total Body Formula. Symptoms included unusual hair loss, discoloration of finger nails, muscle cramps, and blisters on the tongue and lips. An investigation of the complaint was launched on Monday, March 24, 2008 by the Northwest Florida Regional Environmental Epidemiologist and a Council of State and Territorial Epidemiologists Fellow assigned to FDOH.

Florida had a total of 64 reported confirmed or probable cases of selenosis in 12 counties attributed to the consumption of the tainted nutritional supplement. Over 90% of the cases lived in Washington County or in counties adjacent to Washington County. Ill people who were distant from Washington County were primarily internet or mail order purchasers. The age of the cases ranged from 2 to 93 years of age and 69% were female. Symptoms reported were joint pain (85%), unusual hair loss (70%), diarrhea (70%), nausea (61%), fatigue (59%), discolored nails (56%), headache (42%), tingling in arms or legs (39%), vomiting (25%), and fever (17%). Private laboratory results, as well as FDA laboratory results, confirmed that excessive amounts of selenium had been introduced into the products consumed by the individuals experiencing symptoms of selenium poisoning (selenosis). There was a national recall of the implicated product and the manufacturing company no longer maintained a website. There were legal issues surrounding the product and company which were ongoing as of the end of 2008.

214 Summary of Notable Outbreaks and Case Investigations

Staphylococcus aureus

Staphylococcus aureus Outbreak in a Pain Management Facility, Leon County, March 2008 On March 24, 2008, the Bureau of Epidemiology was contacted by a physician in Leon County, Florida regarding an observed increase in invasive staphylococcal infections, including bacteremia and epidural abscesses, in individuals recently treated at the physician’s free-standing pain management clinic. At the time of report, eight individuals were hospitalized for related illnesses, and the report was referred to the Leon County Health Department (LCHD). On the afternoon of March 24th, LCHD performed a site visit and walk-through at the clinic. Thirty-three environmental specimens were collected at that time including opened vials of injectable medications that were currently in use. Interviews with staff were also conducted and it was determined that the clinic had not seen patients since March 20th, and that the physician had voluntarily closed the clinic to procedures after identifying the increase in illnesses.

All patients receiving injection procedures during March 2008 were interviewed by LCHD staff. Ninety- seven people had injection procedures in the month of March, and twenty-four of those people were identified as cases. The cases either had parameningeal syndrome, epidural abscess, or septicemia. Sixteen patient specimens were available and were forwarded to the Bureau of Laboratories-Jacksonville. All patient specimens were positive for Staphylococcus aureus and were indistinguishable by pulse- field gel electrophoresis. Of the 33 environmental specimens that were tested, two were positive for bacterial contamination. One open vial of Omnipaque was contaminated with S. aureus, but this was not the same strain that was isolated from the patients. The other open vial of Omnipaque grew another bacterium, which was not S. aureus. Upon identification of bacterial growth in open vials of Omnipaque, two unopened vials from the same lot were sent to the Centers for Disease Control and Prevention in Atlanta, Georgia, for sterility testing. Sterility testing was completed on April 24, 2008, and the unopened vials of medication were not found to have any bacterial contamination. There were eight nasal cultures obtained from clinic employees. Two of the eight were positive for two different strains of S. aureus. Neither of these strains matched the strains isolated from the patients or the S. aureus-positive bottle of Omnipaque.

All of the ill individuals were treated in only one of the two procedure rooms, but all of the medications and equipment had been removed from the rooms prior to the LCHD site visit on March 24th. The initial walk-through of the clinic and subsequent interviews with current and former employees revealed several breaches in infection control practices. Among these were: the failure to use masks during medication set-up or pain management procedures, inconsistent usage of gloves when handling open bottles of injectable medications, and the use of single dose vials with no preservative as multidose vials over multiple days without refrigeration. In addition, combining opened vials of the same type of medication together was reported.

This outbreak illustrates the need for continued vigilance in outpatient procedure infection control. Also illustrated is the need for tighter regulatory requirements on physician-licensed outpatient procedure clinics.

Methicillin-Resistant Staphylococcus aureus Death, Osceola County, October 2008 The Osceola County Department’s (OCHD) Epidemiology Program received a call on September 29th, 2008 from a school nurse regarding the possible death of an 18-year-old student football player over the weekend due to bacterial meningitis. OCHD was able to verify that the individual was evaluated by the emergency department (ED) on the evening of September 26th for lower back spasms. At the ED, the patient was treated with prescription pain medicines (Toradol and Norflex) and sent home. The patient had a rigorous practice and a game earlier in the week, consequently, the ED presumed that the pain was due to a football-associated injury. Within hours following the ED visit, the patient developed a rash and was given Benadryl at home by his mother.

215 2008 Florida Morbidity Statistics

On September 27th at 4:00 a.m., the patient returned to the ED with a diffuse rash and complaining of shortness of breath. The initial impression by the ED was that the patient was having an adverse reaction to the prescription pain medicines. Upon examination, the patient had a fever of 102°F and was malaised. Additional Benadryl was administered. While the rash improved, the patient’s status did not. Blood and sputum samples were collected. Due to shortness of breath, a chest tube was inserted. The blood and sputum samples came back positive for methicillin-resistant Staphylococcus aureus (MSRA), and the patient was treated with Gentamicin and Zyvox. The patient’s condition continued to deteriorate. On the evening of September 28th, the patient expired due to septic shock.

On October 9th, a second student at the same high school had a wound that cultured positive for MRSA. Several more students from the high school were either seen at, or admitted to, local hospitals with a diagnosis that included MRSA exposures.

A site visit was conducted at the school by OCHD on October 1, 2008. During the site visit, the school informed OCHD that no other students were reported to have had skin infections. A MRSA fact sheet was drafted by OCHD and was distributed to all students at the high school on September 30th. A letter was also sent out on October 10th, informing the families of the second MRSA case at the school.

In addition to the letters, the school decided to host three question and answer sessions at the school in which the OCHD Medical Director, Environmental Health Director, Epidemiologist, and the school’s sports physician were available to answer questions from concerned parents.

In order to avoid the potential transmission of MRSA in schools, the OCHD recommended that the school clean all shared sports and weight room equipment after each individual’s use. The locker rooms should be cleaned daily, using the appropriate cleaner according to the manufacturer’s instructions. Coaches were also recommended to check for skin infections on all contact and non-contact sports players before, during, and after practices and games in order to avoid potential MRSA transmission during sporting events. OCHD has also recommended that any student participating in contact sports, who has a wound or skin abrasion, should not participate until given clearance by a physician. The school has expanded their cleaning procedures to include all shared sports equipment.

Additional resources The Centers for Disease Control and Preventions/National MRSA Education Initiative. (2008, September 11). MRSA. Retrieved October 8th, 2008, from http://www.cdc.gov/mrsa/.

A Community-Associated Staphylococcus aureus Death, Hillsborough County, October 2008 On October 1, 2008, the Hillsborough County Medical Examiner’s office reported the death of a man in his late twenties from methicillin-sensitive Staphylococcus aureus. Pulse-field gel electrophoresis (PFGE) analysis determined that three isolates from different body tissues of the case (brain and both lungs) all had the same DNA fingerprint. The strain was similar but not identical to the USA 300 strain, a strain that has been implicated in previous community-associated MRSA deaths. The deceased had a history of drug use which included the use of intravenous needles. It was unknown as to whether the deceased had any hospital or healthcare exposures within the year before his death. This case was classified as a community-associated Staphylococcus aureus death.

Note: Deaths due to community-associated Staphylococcus aureus were made reportable in November 2008.

216 Summary of Notable Outbreaks and Case Investigations

Typhoid Fever

Typhoid Fever in South Florida, Fall 2008 On September 3, 2008, the Palm Beach County Health Department Epidemiology Program reported that they were investigating two cases of typhoid fever, which the Bureau of Laboratories confirmed as cases of Salmonella enterica serovar Typhi (serovar Typhi) with indistinguishable patterns on pulse-field gel electrophoresis (PFGE). The infected persons were adolescents who were part of a 50-person church group that traveled to Haiti from June 15th to July 5th, 2008. The group traveled to the Port-au-Prince area, but also traveled outside of the city as well. No specific exposures were identified.

Subsequently, a review of in-depth surveillance data during the weekly Bureau of Epidemiology (BOE) surveillance meeting on October 1, 2008 revealed an unusually high number of typhoid fever cases (N = 5) for the preceding 12 weeks. This included the two cases detailed above, as well as a sporadic imported case in an 18-year-old woman from Palm Beach County who had traveled to Haiti with an onset of September 12, 2008; a sporadic imported case in a 10-year-old boy from Miami-Dade County who traveled to Bangladesh with an onset of symptoms on July 30, 2008; and a sporadic imported case in a 12-year-old boy from Clay County who had recently traveled to the Bahamas and Haiti with an onset of symptoms around August 5, 2008. Both were confirmed by the Bureau of Laboratories-Jacksonville as serovar Typhi. To further examine any possible relationships between the cases, a request was made to the Bureau of Laboratories-Jacksonville for the PFGE profiles of the serovarTyphi cases. Of the 12 cases of serovar Typhi reported as of October 2008, two clusters of identical PFGE patterns were noted. The first cluster of two cases in January 2008 was previously noted by epidemiologists at the BOE and likely represents exposure through travel to endemic regions of Pakistan and Bangladesh. The second cluster of three cases in August 2008 included the two adolescents from Palm Beach County with travel to Haiti that were known to be linked, as well as a 22-month-old girl from Broward County who was originally determined to be a sporadic case from the United States. Further follow-up investigation with the girl’s family revealed she had traveled to Haiti May 3-18, 2008 before becoming ill on June 10, 2008. One month after the initial cluster with travel to Haiti was identified, a fourth serovarTyphi case also was linked by PFGE pattern. A 12-year-old boy from Palm Beach County was sent to live with relatives in Haiti from February 2008 through September 25, 2008. After returning to live with his family in Palm Beach, he presented to a local hospital on October 9, 2008 with fever, vomiting, diarrhea, and abdominal pain. He was admitted and treated for typhoid fever over the next two weeks. Subsequent PFGE typing at the Bureau of Laboratories-Jacksonville on October 31, 2008 revealed an identical pattern to the three cases found in August. Further investigation revealed the boy resided in the St. Marc’s area while in Haiti, consistent with the likely exposures of the other individuals who had the same PFGE pattern.

For more information about this investigation please visit King, D., et al. “A Tale of Typhoid in South Florida,” Epi Update, 2008; November, http://www.doh.state. fl.us/disease_ctrl/epi/Epi_Updates/2008/November2008EpiUpdate.pdf

Unexplained Illnesses

Illness of Unknown Etiology Among Airline Passengers, Broward County, March 2008 In March 2008, the Broward County Health Department was notified about a plane diversion to the Hollywood/Fort Lauderdale International Airport due to a toxin-like illness reported by several passengers. Upon landing in Broward County, they were transported to a local hospital emergency department in Hollywood, FL. The eight passengers taken to the hospital were part of a larger group of 11 (nine family members, two friends) traveling back home to Alberta, Canada from the Dominican Republic. One of the group members reported developing symptoms (emotional lability, confusion, disorientation, dilated pupils, muscle twitching, sweating, dizziness, lightheadedness, dry mouth, and shortness of breath) prior

217 2008 Florida Morbidity Statistics

to leaving the Dominican Republic resort while the rest of the cases did not begin experiencing symptoms until they were on the plane flying home. Symptoms reported were of varying degrees of severity with the initial cases reporting the most intense symptoms and longer durations. All symptomatic people were seated closely together on the plane, either next to each other or within one row. The only common exposure reported was skin contact with a symptomatic person while consoling them.

Clinical samples were obtained and tested at the hospital for five of the cases of which three were positive for Cannabis. These people reported smoking marijuana regularly; however, they reported smoking marijuana only one time while in the Dominican Republic. They denied taking any other illicit substances while on the trip. These were also the first three to report symptoms and were sitting next to each other on the plane. Additional toxicological tests were completed by the Broward Medical Examiners Office including a comprehensive drug panel, GHB, ketamine, methamphetamine analogues, and serum cholinesterase. Results for these additional tests were negative. The source of the illnesses was unable to be determined. It was hypothesized that some of group members may have been exposed to or taken an illicit/toxic substance. However, the other group members with less intense symptoms were possibly sympathetic or psychogenic in nature.

Varicella

Varicella Cluster at a Local University, Miami-Dade County, October 2008 On September 29, 2008, Miami-Dade County Health Department, Office of Epidemiology and Disease Control (OEDC) was notified by the Bureau of Epidemiology of a physician who wanted to know if a student with varicella could eat in the dining hall and go to class. The physician mentioned an additional student with varicella but did not mention any linkage among the two cases. The physician was not aware this was a reportable disease. OEDC recommended isolation of the student until all lesions were crusted.

On October 1st, OEDC received a report from the University Student Health Center of three additional cases of varicella. Initial interviews indicated all five were linked to the biology department. A recommendation letter was faxed to the University Health Center indicating the need for students/staff to receive the second dose of the vaccine and isolate all cases. On October 6th, OEDC investigators visited the biology department and toured through the students’ desks and laboratory. Cases 1 (onset 7/18/08), 2 (onset 7/25/08), 3 (onset 9/4/08), and 4 (9/27/08) had close contact with each other. Case 5 (onset 9/27/08) was a music major undergraduate student who was taking biology class and laboratory, as well as four classes in the music department. No direct linkage was established to the other four cases. Only one of the five cases had documentation of the varicella vaccine.

Varicella information and notification of the cluster was posted on the Student Health Center website with links to the CDC; information flyers were placed under student doors where the undergraduate resided; a physician spoke at a biology lecture informing the students of prevention and control measures; and information was published in the school newspaper.

Vibrio Infections

An Imported Case of Vibrio alginolyticus, Hillsborough County, August 2008 In late August of 2008, The Hillsborough County Health Department investigated and reported a case of Vibrio alginolyticus in a 10-year-old girl. This positive laboratory test was an aerobic bacterial culture from a wound on the back of the girl’s thigh. While on vacation during July 2008, the girl suffered a minor injury while swimming/tubing in the Adriatic Sea near the Island of Pag (Croatia). She was treated with

218 Summary of Notable Outbreaks and Case Investigations antibiotics for this infection. She experienced no sequelae.

Vibrio alginolyticus is a gram negative marine bacterium that causes wound and ear infections. In immunocompromised individuals and severe burn victims, bacteremia can result.

Vibrio vulnificus Death, Marion County, September 2008 In September 2008, the Marion County Health Department investigated a Vibrio vulnificus death in a 55- year-old white man. The patient consumed raw oysters on September 21 or 22, 2008 at a raw oyster bar in Birmingham, Alabama and had symptom onset September 22nd. On September 23rd, the patient was admitted to the hospital and later expired on September 24th. A serum sample that was collected on September 23rd was culture positive for Vibrio vulnificus as was a wound culture. Oyster tags collected by the Alabama Department of Public Health indicated that the raw oysters were purchased from a seafood harvester in Apalachicola, FL. There were no other reported illnesses associated with those oyster beds at that time.

West Nile Virus

Two Cases of West Nile Neuroinvasive Disease, Escambia County, August-September 2008 In mid-August of 2008, the Epidemiology Program of the Escambia County Health Department was notified of an elderly man who was hospitalized with a probable case of estW Nile virus (WNV) infection. Serum samples were sent to the Bureau of Laboratories-Tampa. A week later the case was confirmed as acute WNV neuroinvasive disease. Investigation revealed that the man had no travel history and had not used repellants while sitting outside at his work. He had a celiac condition which resulted in anemia and had previously had a triple bypass. His hospital course was complicated requiring two units of plasma and a PEG tube for feeding. His neurological condition was so severe that he developed respiratory problems and could not sit or stand on his own. He was transferred to an acute long-term care facility after several weeks in the hospital.

Mosquito Control was notified immediately upon receiving the probable diagnosis and sprayed the man’s home zip code area and his work site. Schools and childcare centers were notified and an advisory was issued via the media.

A day after receiving the first case, the Epidemiology Department was notified of a second probable case of WNV. Serum samples were sent to the Bureau of Laboratories-Tampa. This person was a middle aged man with an immune-compromising condition who lived in the same zip code as the first man’s work site. He had not traveled nor had he used mosquito repellant on a regular basis while sitting outside each evening. He had more mild symptoms than the first man, and was able to be discharged home that same week. His laboratory results were confirmatory for acute WNV neuroinvasive disease.

Mosquito Control was notified and modified the second spraying site to include the area around the second case’s residence. Mosquito Control reported all sentinel chickens were free from mosquito- borne virus disease and there was not any disease present in the mosquito pooling efforts at that time. Adulticide fogging for mosquitoes was initiated after notification of the first case and was continued in compliance with usual and customary state regulations. Mosquito Control also set some additional gravid traps in targeted habitats. A second advisory was issued to schools and childcare centers in the area and a county-wide alert was issued by radio, TV, and newspaper.

No additional cases were detected in Escambia County. The communication, cooperation, and quick response from partner agencies all contributed to putting effective control and prevention measures in place.

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220 Recently Published Papers and Reports, 2008

Section 7: Recently Published Papers and Reports, 2008

Included below are selected publications by the Florida Department of Health (FDOH) which appeared in peer reviewed journals during the calendar year of 2008. The complete title, abstract, and reference are included. The publications are ordered by last name of the first author, regardless of whether or not that author is a FDOH employee. All FDOH employees’ names are highlighted in bold. Abstracts and titles are re-printed in the same format that they appeared in their respective journals.

Hepatitis B Vaccine: A Seven Year Study of Adherence to the Immunization Guidelines and Efficacy in HIV-1 Positive Adults

Vaccination against hepatitis B virus (HBV) has been recommended for all high-risk adults since 1982. Since the advent of highly active antiretroviral therapy, few studies have examined adherence to the Infectious Diseases Society of America (IDSA) and Advisory Committee on Immunization Practices (ACIP) guidelines for hepatitis B vaccination in persons infected with HIV. This was a seven-year retrospective, cross-sectional analysis of HBV vaccination practices in HIV-1-positive adults treated in an urban ambulatory care center. Compliance with screening, hepatitis B vaccination recommendations, and response to vaccination were assessed. Of the 1,601 charts reviewed, 717 persons were eligible for vaccination against hepatitis B. Of these patients, 503 received at least one dose of vaccine, but only 356 patients completed the three-dose series. Vaccine response was associated with CD4 count (p = 0.006) and viral load (p = 0.001) at the time of the first dose. However, development of hepatitis B surface antibody was seen at all CD4 counts and viral loads. The multivariate analysis showed only the HIV viral load was predictive of immunologic response. Twenty of the vaccine-eligible patients who did not receive vaccination were infected with HBV during the study period. No vaccinated persons contracted hepatitis B. Failure to implement these guidelines represents a missed opportunity to prevent disease. In our study, HIV viral load was better than CD4 count as a predictor of response to the HBV vaccination. However, neither low CD4 count nor high HIV viral load should be used as justification to delay vaccination of high-risk persons.

Bailey C, Smith V, Sands M. “Hepatitis B Vaccine: A Seven Year Study of Adherence to the Immunization Guidelines and Efficacy in HIV-1 Positive Adults.” IJID, 2008, Vol. 12, No. 6, e77–e83.

Feasibility of Shortening Respiratory Isolation with a Single Sputum Nucleic Acid Amplification Test

Serial smear analysis to guide respiratory isolation (RI) of patients with suspected tuberculosis (TB), the majority of whom will be found not to have TB, leads to expensive and unnecessary isolation, and may potentially result in decreased vigilance of subjects with respiratory compromise. To compare the performance of a single first-sputum, Mycobacterium tuberculosis–specific nucleic acid amplification (NAA) test with three sputum smears for assessing the need for RI. Prospective evaluation of 493 patients with suspected TB (74% HIV positive) admitted to RI in a major county hospital in the United States, who had at least three sputum smears and material available from the first sample for additional NAA testing. Accuracy of the first sputum NAA result and serial smears for identifying patients with potentially infectious TB who truly require RI was determined. Forty-six patients (9.3%) had TB confirmed by culture. First-sputum NAA test detected all patients with TB who had a positive smear (n = 35), even when the first of the three specimens was smear negative. In addition, when compared with serial smears, the first-sputum NAA had a higher sensitivity (0.87; 95% confidence interval [CI], 0.74–0.95) and specificity (1.0) in the detection of subjects with positive M. tuberculosis cultures (smear sensitivity, 0.76; 95% CI, 0.61–0.87; and specificity, 0.96; 95% CI, 0.94–0.98). A single first-sputum NAA testing can

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rapidly and accurately identify the subset of patients with suspected TB who require RI according to serial sputum smears. Its potential use to shorten RI time does not preclude the need to obtain subsequent specimens for culture.

Campos M, Quartin A, Mendes E, Abreu A, Gurevich S, Echarte L, Ferreira T, Cleary T, Hollender E, Ashkin D. “Feasibility of Shortening Respiratory Isolation With a Single Sputum Nucleic Acid Amplification Test.” Am J of Resp and Critical Care Med, 2008 Vol. 178, pp. 300-305.

Outbreaks of Noroviral Gastroenteritis in Florida, 2006–2007

Noroviruses are an important cause of sporadic cases and outbreaks of acute gastroenteritis. During 2006–2007, widespread increases in acute gastroenteritis outbreaks consistent with norovirus were observed in the United States. We conducted a statewide survey to characterize norovirus outbreak activity in Florida during a 1-year period. From July 2006 to June 2007, 257 outbreaks of norovirus gastroenteritis were identified in 39 of Florida’s 67 counties. About 44% of outbreaks were laboratory confirmed as norovirus and 93% of these were due to genogroup GII. About 63% of outbreaks occurred in long-term care facilities and 10% of outbreaks were classified as foodborne. The median number of ill persons per outbreak was 24, with an estimated total of 7,880 ill persons. During the study period, norovirus outbreak activity in Florida was widespread, persistent, and consistent with increased activity observed in other parts of the country.

Doyle TJ, Stark L, Hammond R, Hopkins R. “Outbreaks of Noroviral Gastroenteritis in Florida, 2006–2007.” Epidemiology and Infection, 2008, published online by Cambridge University Press, doi:10.1017/S0950268808000630.

Outbreak of Giardiasis and Cryptosporidiosis Associated with a Neighborhood Interactive Water Fountain — Florida, 2006

An outbreak of giardiasis and cryptosporidiosis was identified in central Florida in September 2006. Environmental and epidemiological investigations indicated the likely source was a neighborhood interactive water fountain in a large upscale urban neighborhood. Forty nine cases meeting the case definition were identified, of which 38 were giardiasis, nine were cryptosporidiosis, and two were co- infections. The median age of cases was five years old with 32 (65.3%) cases being male. This outbreak and other similar occurrences highlight the need to design and implement more stringent disinfection practices and filtration requirements for treated interactive water venues. Giardia cysts and Cryptosporidium oocysts are small, chlorine resistant and may require supplemental disinfection methods such as ultraviolet light irradiation, ozonation, or chlorine dioxide use. Behavior modification by users of these types of venues is also necessary to prevent disease transmission. This is the first documentation of a giardiasis outbreak associated with exposure to an interactive water fountain in the United States.

Eisenstein L, Bodager D, Ginzl D. “Outbreak of Giardiasis and Cryptosporidiosis Associated with a Neighborhood Interactive Water Fountain — Florida, 2006.” Journal of Environmental Health, 2008, Vol. 71, No. 3, pp. 18-22.

Coordinated Care Special Needs Shelter

On a national level, Hurricane Katrina highlighted gaps in services and demonstrated the need for good community practices of care for those medically at risk during disaster events. Locally, the Brevard County Health Department (BCHD) initiated a response to this need in 1992 after returning from

222 Recently Published Papers and Reports, 2008 deployment for Hurricane Andrew. Having a 72-mile-long Atlantic coastline; a county that is one-third water and mostly flood plains; more than 500,000 residents, one-fifth of whom have special needs; and a robust manufactured housing community, Brevard recognized its own vulnerability. BCHD took the lead by creating dialogues with interested community members – those with special needs and those caring for people with special needs. These discussions led to community partnerships and mutual aid agreements culminating in the Coordinated Care Special Needs Shelter (CCSNS) model practice – a virtual network of care wrapping all of the necessary goods and services of the special needs independent citizen safely around them. Victorious events of this network of care were successfully demonstrated in the 2004 hurricane season, when Brevard County expertly sheltered and safely shepherded home or to safe havens 100% of its most vulnerable citizens on three separate occasions, consecutively.

Emgushov O. “Coordinated Care Special Needs Shelter.” Public Health Reports, 2008, Vol. 123, pp. 371-375.

Cancer Risk in People Infected with Human Immunodeficiency Virus in the United States

Data are limited regarding cancer risk in human immunodeficiency virus (HIV)-infected persons with modest immunosuppression, before the onset of acquired immunodeficiency syndrome (AIDS). For some cancers, risk may be affected by highly active antiretroviral therapy (HAART) widely available since 1996. We linked HIV/AIDS and cancer registries in Colorado, Florida and New Jersey. Standardized incidence ratios (SIRs) compared cancer risk in HIV-infected persons (initially AIDS-free) during the 5-year period after registration with the general population. Poisson regression was used to compare incidence across subgroups, adjusting for demographic factors. Among 57,350 HIV-infected persons registered during 1991-2002 (median CD4 count 491 cells/mm(3)), 871 cancers occurred during follow- up. Risk was elevated for Kaposi sarcoma (KS, SIR 1,300 [n = 173 cases]), non-Hodgkin lymphoma (NHL, 7.3 [n = 203]), cervical cancer (2.9 [n = 28]) and several non-AIDS-defining malignancies, including Hodgkin lymphoma (5.6 [n = 36]) and cancers of the lung (2.6 [n = 109]) and liver (2.7 [n = 14]). KS and NHL incidence declined over time but nonetheless remained elevated in 1996-2002. Incidence increased in 1996-2002 compared to 1991-1995 for Hodgkin lymphoma (relative risk 2.7, 95%CI 1.0-7.1) and liver cancer (relative risk infinite, one-sided 95%CI 1.1-infinity). Non-AIDS-defining cancers comprised 31.4% of cancers in 1991-1995, versus 58.0% in 1996-2002. For KS and NHL, risk was inversely related to CD4 count, but these associations attenuated after 1996. We conclude that KS and NHL incidence declined markedly in recent years, likely reflecting HAART-related improvements in immunity, while incidence of some non-AIDS-defining cancers increased. These trends have led to a shift in the spectrum of cancer among HIV-infected persons.

Engels EA, Biggar RJ, Hall HI, Cross H, Crutchfield A, Finch JL, Grigg R, Hylton T, Pawlish KS, McNeel TS, Goedert JJ. “Cancer Risk in People Infected with Human Immunodeficiency Virus in the United States.” Int J Cancer, 2008, Vol. 123, No. 1, pp. 187-94.

Viral Resuppression and Detection of Drug Resistance Following Interruption of a Suppressive Non-nucleoside Reverse Transcriptase Inhibitor-based Regimen

Interruption of a non-nucleoside reverse transcriptase inhibitor (NNRTI)-regimen is often necessary, but must be performed with caution because NNRTIs have a low genetic barrier to resistance. Limited data exist to guide clinical practice on the best interruption strategy to use. Patients in the drug-conservation arm of the Strategies for Management of Antiretroviral Therapy (SMART) trial who interrupted a fully suppressive NNRTI-regimen were evaluated. From 2003, SMART recommended interruption of an

223 2008 Florida Morbidity Statistics

NNRTI by a staggered interruption, in which the NNRTI was stopped before the NRTIs, or by replacing the NNRTI with another drug before interruption. Simultaneous interruption of all antiretrovirals was discouraged. Resuppression rates 4-8 months after reinitiating NNRTI-therapy were assessed, as was the detection of drug-resistance mutations within 2 months of the treatment interruption in a subset (n = 141). Overall, 601/688 (87.4%) patients who restarted an NNRTI achieved viral resuppression. The adjusted odds ratio (95% confidence interval) for achieving resuppression was 1.94 (1.02-3.69) for patients with a staggered interruption and 3.64 (1.37-9.64) for those with a switched interruption compared with patients with a simultaneous interruption. At least one NNRTI-mutation was detected in the virus of 16.4% patients with simultaneous interruption, 12.5% patients with staggered interruption and 4.2% patients with switched interruption. Fewer patients with detectable mutations (i.e. 69.2%) achieved HIV-RNA of 400 copies/ml or less compared with those in whom no mutations were detected (i.e. 86.7%; P = 0.05). In patients who interrupt a suppressive NNRTI-regimen, the choice of interruption strategy may influence resuppression rates when restarting a similar regimen. NNRTI drug-resistance mutations were observed in a relatively high proportion of patients. These data provide additional support for a staggered or switched interruption strategy for NNRTI drugs.

Fox Z, Phillips A, Cohen C et al and the SMART Study Group including Sands M. “Viral Resuppression and Detection of Drug Resistance Following Interruption of a Suppressive Non-nucleoside Reverse Transcriptase Inhibitor-based Regimen.” AIDS, 2008, Vol. 22, pp. 2279-2289.

Ciguatera Fish Poisoning: Treatment, Prevention and Management

Ciguatera Fish Poisoning (CFP) is the most frequently reported seafood-toxin illness in the world, and it causes substantial physical and functional impact. It produces a myriad of gastrointestinal, neurologic and/or cardiovascular symptoms which last days to weeks, or even months. Although there are reports of symptom amelioration with some interventions (e.g. IV mannitol), the appropriate treatment for CFP remains unclear to many physicians. We review the literature on the treatments for CFP, including randomized controlled studies and anecdotal reports. The article is intended to clarify treatment options, and provide information about management and prevention of CFP, for emergency room physicians, poison control information providers, other health care providers, and patients.

Friedman MA, Fleming LE, Fernandez M, Bienfang P, Schrank K, Dickey R, Bottein M-Y, Backer L, Ayyar R, Weisman R, Watkins SM, Granade R, Reich A. “Ciguatera Fish Poisoning: Treatment, Prevention and Management.” Marine Drugs, 2008, Vol. 6, pp. 456-479.

Tracking Childhood Exposure to Lead and Developmental Disabilities: Examining the Relationship in a Population-Based Sample

Elevated levels of lead detected in the blood are associated with harmful effects on children’s learning and behavior. The goal of the current Environmental Public Health Tracking Project was to examine the relationship between selected developmental disabilities and childhood blood lead levels in a population- based sample. Using extant datasets from the Florida Department of Health, Childhood Lead Poisoning Prevention Program, and the Florida Department of Education, we were able to isolate a linked dataset of children who were tested for lead poisoning and attended public schools. Special education categories served as a proxy for developmental disabilities; the prevalence of these disabilities in the sample of children with blood lead levels was compared with that in children who attended the same schools but were not tested for lead poisoning. Results indicated that children screened for lead poisoning were more likely to be receiving services for behavior problems, mental retardation, learning disabilities, or a speech-language impairment than other children attending the same schools. Implications for using administrative datasets to examine this relationship are discussed.

224 Recently Published Papers and Reports, 2008

Kaiser MY, Kearney G, Scott KG, DuClos C, Kurlfink .J “Tracking Childhood Exposure to Lead and Developmental Disabilities: Examining the Relationship in a Population-Based Sample.” J Public Health Management Practice, 2008, Vol. 16, No. 6, pp. 577-580.

Mercury Levels and Fish Consumption Practices in Women of Child-bearing Age in the Florida Panhandle

The southeastern United States, and in particular the coastal areas along the Gulf of Mexico (Gulf Coast) in Florida, experiences some of the highest levels of mercury deposition in the country. Although the State of Florida’s coastal border is among the longest in the United States, and the State has issued fish consumption advisories due to mercury on multiple fish species, few data have been systematically collected to assess mercury levels in the human population of the state or to assess the efficacy of the consumption advisories. Because of the generally high rate of seafood consumption among coastal populations, the human population in the Florida Panhandle, near Pensacola, FL is potentially exposed to elevated levels of mercury. In the present study, we analyzed hair mercury levels in women of childbearing age (16-49 years) who had resided near Pensacola, FL for at least 1 year. We also surveyed the fish consumption practices of the cohort and evaluated awareness of the Florida Fish Consumption Advisory. Hair mercury levels were significantly higher in women who consumed fish within the 30 days prior to sampling (p<0.05) and in those women who were unaware of the consumption advisory (p<0.05). Only 31% of the women reported knowledge of the consumption advisory and pregnant women exhibited lower awareness of the advisory than non-pregnant women. The data suggest that public health interventions such as education and fish advisories have not reached the majority of women in the counties surrounding Pensacola who are most at risk from consumption of fish with high levels of mercury.

Karouna-Renier NK, Rao KR, Lanza JJ, Rivers SD, Wilson PA, Hodges DK, Levine KE, Ross GT. “Mercury Levels and Fish Consumption Practices in Women of Child-bearing Age in the Florida Panhandle.” Environmental Research, Vol. 108, No. 3, 2008, pp. 320-326.

A Procedure for Detecting Childhood Cancer Clusters Near Hazardous Waste Sites in Florida

Despite over 20 years of research on childhood cancer clusters and hazardous waste sites, little evidence has been produced to indicate a causal relationship. Nevertheless, the perception of a childhood cancer cluster being located near a hazardous waste site can raise fear and uncertainty, and it demands attention from health officials. To investigate this public health concern, the author used the spatial-scan statistical software SaTScan to detect childhood cancer clusters and their proximity to National Priority List (NPL), or Superfund, sites in Florida. In the ecological study reported here, “most likely” clusters were defined as those with a p-value of <.05. Distance served as a proxy for exposure; a geographical information system (GIS) was used to determine the number of clusters within a predetermined distance of an NPL site. Spatial clusters were found to occur randomly throughout the state, with most clusters being identified in the more populated counties, and clusters less likely to occur near an NPL site. This article attempts to explain the utility of an emerging public health surveillance tool for detecting cancer clusters near hazardous waste sites. Despite several epidemiological limitations of the study, as well as the fact that there are other environmental exposure hazards such as Toxic Release Inventory facilities and landfills, the SaTScan program proved useful as a surveillance tool for generating more in-depth studies.

Kearney G. “A Procedure for Detecting Childhood Cancer Clusters Near Hazardous Waste Sites in Florida.” Journal of Environmental Health, 2008, Vol. 70, No. 9, pp. 29-34.

225 2008 Florida Morbidity Statistics

Potential Effects of Electronic Laboratory Reporting on Improving Timeliness of Infectious Disease Notification — Florida, 2002-2006

Electronic laboratory reporting (ELR) potentially can improve the timeliness of notifiable disease case reporting and subsequent disease control activities, but the extent of this improvement and the resulting effects on the workload of state or local surveillance teams are unknown. To estimate those effects, investigators from the Florida Department of Health (FDOH) evaluated the timeliness of reporting for four notifiable diseases of varying incubation periods: salmonellosis, shigellosis, meningococcal disease, and hepatitis A. Investigators then calculated the potential improvement expected with ELR using the assumption that ELR can reduce to 1 day the time from completion of a diagnostic laboratory test to notification of the county health department (CHD) of the result. This report summarizes the results of that analysis, which showed that ELR would reduce the total time from symptom onset to CHD notification of a case by nearly half for salmonellosis (from 12 days to 7 days) and shigellosis (from 10 days to 6 days), but would produce no change for meningococcal disease (4 days) and minimal improvement for hepatitis A (from 13 days to 10 days). In Florida, the benefits of ELR for reporting timeliness likely will vary by disease.

Kite-Powell A, Hamilton JJ, Hopkins RS, DePasquale JM. “Potential Effects of Electronic Laboratory Reporting on Improving Timeliness of Infectious Disease Notification — Florida, 2002-2006.” MMWR, 2008, Vol. 57, No. 49, pp. 1325-1328.

Florida Red Tide and Human Health: A Pilot Beach Conditions Reporting System to Minimize Human Exposure

With over 50% of the US population living in coastal counties, the ocean and coastal environments have substantial impacts on coastal communities. While many of the impacts are positive, such as tourism and recreation opportunities, there are also negative impacts, such as exposure to harmful algal blooms (HABs) and water borne pathogens. Recent advances in environmental monitoring and weather prediction may allow us to forecast these potential adverse effects and thus mitigate the negative impact from coastal environmental threats. One example of the need to mitigate adverse environmental impacts occurs on Florida’s west coast, which experiences annual blooms, or periods of exuberant growth, of the toxic dinoflagellate, Karenia brevis. K. brevis produces a suite of potent neurotoxins called brevetoxins. Wind and wave action can break up the cells, releasing toxin that can then become part of the marine aerosol or sea spray. Brevetoxins in the aerosol cause respiratory irritation in people who inhale it. In addition, asthmatics who inhale the toxins report increased upper and lower airway symptoms and experience measurable changes in pulmonary function. Real-time reporting of the presence or absence of these toxic aerosols will allow asthmatics and local coastal residents to make informed decisions about their personal exposures, thus adding to their quality of life. A system to protect public health that combines information collected by an Integrated Ocean Observing System (IOOS) has been designed and implemented in Sarasota and Manatee Counties, Florida. This system is based on real-time reports from lifeguards at the eight public beaches. The lifeguards provide periodic subjective reports of the amount of dead fish on the beach, apparent level of respiratory irritation among beach-goers, water color, wind direction, surf condition, and the beach warning flag they are flying. A key component in the design of the observing system was an easy reporting pathway for the lifeguards to minimize the amount of time away from their primary duties. Specifically, we provided a Personal Digital Assistant for each of the eight beaches. The portable unit allows the lifeguards to report from their guard tower. The data are transferred via wireless Internet to a website hosted on the Mote Marine Laboratory Sarasota Operations of the Coastal Ocean Observation Laboratories (SO COOL) server. The system has proven to be robust

226 Recently Published Papers and Reports, 2008 and well received by the public. The system has reported variability from beach to beach and has provided vital information to users to minimize their exposure to toxic marine aerosols.

Kirkpatrick B, Currier R, Nierenberg K, Reich A, Backer LC, Stumpf R, Fleming L, Kirkpatrick G. “Florida Red Tide and Human Health: A Pilot Beach Conditions Reporting System to Minimize Human Exposure.” Science of the Total Environment, 2008, Vol. 402, No. 1, pp. 1-8.

Cryptosporidiosis Outbreak in a Nassau County, Florida, Return Travel Group from Ireland, May 24, 2006-June 4, 2006

The Nassau County Health Department (NCHD) in Florida investigated an outbreak of gastrointestinal (GI) illness in a returning choral group who toured Ireland from May 24 to June 4, 2006. The travel group, consisting predominantly of retirees, had performed at several churches and at a dinner theater in Ireland. The NCHD administered a telephone questionnaire to 40 of the 41 group members to examine possible water exposures; common meals; and food, travel, and clinical histories. The results of the questionnaire showed that 29 people met the case definition for the outbreak. Five stool samples from travel group members tested positive for Cryptosporidium parvum, a species that is animal in origin and often spread through an environmental contamination with animal feces. All five positive samples were subtyped 11aA16G1R1b, a strain that scientists at the Centers for Disease Control and Prevention (CDC) Division of Parasitic Diseases detected twice in 2006 in other human specimens from Northern Ireland.

Lazensky R, Hammond RM, Van Zile K, Geib K. “Cryptosporidiosis Outbreak in a Nassau County, Florida, Return Travel Group from Ireland, May 24, 2006-June 4, 2006.” J Environ Health, 2008, Vol. 71, No. 2, pp. 20-4.

Gender and Race Specific Comparison of Tobacco-Associated Cancer Incidence Trends in Florida with SEER Regional Cancer Incidence Data

Analysis of state and national tobacco-associated cancer trends is critical for the identification of high- risk regions of the country that require the attention of the public health community. This study compares Florida race- and gender-specific cancer trends with pooled data obtained from nine Surveillance, Epidemiology, and End Results (SEER-9) registries. Age-adjusted, race- and gender-specific cancer incidence trends were evaluated using joinpoint regression analysis. Pooled, age-adjusted incidence rates and standardized incidence rate ratios were computed for each cancer for the years 1999-2003 to compare Florida to SEER-9. Relative to SEER-9 whites and irrespective of gender, lung cancer rates in white Floridians were elevated through the 1990s. However, lung cancer rates have recently declined at a steeper rate among white Floridians than among SEER-9 whites. For years 1999–2003, black Floridians had significantly lower rates of lung, bladder, pancreas, and kidney cancer relative to SEER-9 blacks. The opposite pattern was evident for white Floridians with significantly higher rates of lung and laryngeal cancer relative to SEER-9 whites. Progress in the reduction of tobacco-associated cancers among white Floridians lags behind the progress noted in SEER-9 registries suggesting that additional state-directed smoking prevention and smoking cessation measures are needed. Lee DJ, Voti L, MacKinnon J, Koniaris LG, Fleming LE, Huang Y, Wohler B, Franceschi D, Dietz NA, Sherman R, Soler-Vilá H. “Gender and Race Specific Comparison of Tobacco-Associated Cancer Incidence Trends in Florida with SEER Regional Cancer Incidence Data.” Cancer Causes and Control, 2008, Vol. 19, No. 7, pp. 711-23.

227 2008 Florida Morbidity Statistics

Men Who Have Sex with Men: Racial/Ethnic Disparities in Estimated HIV/AIDS Prevalence at the State and County Level, Florida

Population-based HIV/AIDS prevalence estimates among men who have sex with men (MSM) have been unavailable, but have implications for effective prevention efforts. Prevalent (living) Florida HIV/AIDS cases reported through 2006 (numerators) were stratified by race/ethnicity and HIV exposure category. Based on previous research, MSM populations were posited as 4-10% of all males aged >13 years in each subgroup (denominators). At the estimated lower and upper plausible bounds, respectively, HIV/ AIDS prevalence per 100,000 MSM was significantly higher among black (8,292.6-20,731.4); Hispanic (5,599.5-13,998.7); and Asian/Pacific Islander, American Indian or multi-racial (4,942.6-12,356.8) MSM than among white MSM (3,444.9-8,612.3). HIV/AIDS prevalence among all MSM was 13.8-36.9 times that among all other males. Across 19 high-morbidity counties, MSM HIV/AIDS prevalence was highest among those in the most populous counties and highest among blacks. This methodology, adaptable by other states, facilitates calculation of plausible MSM HIV/AIDS prevalence to guide HIV prevention/care community planners and MSM.

Lieb S, Arons P, Thompson DR, Santana AM, Liberti TM, Maddox L, Bush T, Fallon SJ. “Men Who Have Sex with Men: Racial/Ethnic Disparities in Estimated HIV/AIDS Prevalence at the State and County Level, Florida.” AIDS and Behav., 2008 [Epub ahead of print], DOI 10.1007/s10461-008- 9411-3.

Primary Amebic Meningoencephalitis — Arizona, Florida, and Texas, 2007

Primary amebic meningoencephalitis (PAM) is a rare but nearly always fatal disease caused by infection with Naegleria fowleri, a thermophilic, free-living ameba found in freshwater environments. Infection results from water containing N. fowleri entering the nose, followed by migration of the amebae to the brain via the olfactory nerve. In 2007, six cases of PAM in the United States were reported to CDC; all six patients died. This report summarizes the investigations of the cases, which occurred in three southern tier states (Arizona, Florida, and Texas) during June-September and presents preliminary results from a review of PAM cases during 1937-2007. Because deaths from PAM often prompt heightened concern about the disease among the public, an updated and consistent approach to N. fowleri risk reduction messages, diagnosis and treatment, case reporting, and environmental sampling is needed.

Matthews S, Ginzl D, Walsh D, Sherin K, Middaugh J, Hammond R, Bodager D, et al. “Primary Amebic Meningoencephalitis — Arizona, Florida, and Texas, 2007”. MMWR, 2008, Vol. 57, No. 21, pp. 573-577.

Florida Bladder Cancer Trends 1981-2004: Minimal Progress in the Reduction of Advanced Disease

While bladder cancer (BC) is the 4th most common cancer in males in the U.S. there are no accepted screening recommendations for this disease despite the fact that the greatest risk factors for BC are identifiable and modifiable (i.e., tobacco exposure). Survival from BC is highly correlated with stage of disease. We sought to ascertain if there have been any changes in the stage at presentation of BC in Florida over the last 25 years. The Florida Cancer Data Registry was evaluated for all BC cases between 1981 and 2004. Cases were coded and analyzed as local, in-situ or advanced (regional and distant) disease. Cases were stratified by demographic groups. The overall incidence of BC declined slightly over the last 25 years from 24.3 to 20.5 cases per 100,000. Overall, non-Hispanic White males have a nearly three-fold incidence of BC compared to Black males, while Hispanic males have approximately a two-fold higher incidence compared to Black males. Non-Hispanic White females have nearly a twofold

228 Recently Published Papers and Reports, 2008 increased incidence compared to both Black and Hispanic females. Advanced stage BC decreased minimally over 25 years; White and Black females had the smallest decline in annual percentage changes of advanced BC. Despite knowledge of the main risk factors for BC, there have been only small decreases in the percentage of patients presenting with advanced cases in Florida over the last 25 years. BC may thus be an appropriate cancer for increased public awareness campaigns and potentially targeted screening of high-risk populations.

Nieder AM, MacKinnon JA, Huang Y, Fleming LE, Koniaris LG, Lee DJ. “Florida Bladder Cancer Trends 1981-2004: Minimal Progress in the Reduction of Advanced Disease.” J Urol, 2008, Vol. 179, No. 2, pp. 491-5.

Public Health Consequences of a False-Positive Laboratory Test Result for Brucella — Florida, Georgia, and Michigan, 2005

Human brucellosis, a nationally notifiable disease, is uncommon in the United States. Most human cases have occurred in returned travelers or immigrants from regions where brucellosis is endemic, or were acquired domestically from eating illegally imported, unpasteurized fresh cheeses. In January 2005, a woman aged 35 years who lived in Nassau County, Florida, received a diagnosis of brucellosis, based on results of a Brucella immunoglobulin M (IgM) enzyme immunoassay (EIA) performed in a commercial laboratory using analyte specific reagents (ASRs); this diagnosis prompted an investigation of dairy products in two other states. Subsequent confirmatory antibody testing by Brucella microagglutination test (BMAT) performed at CDC on the patient’s serum was negative. The case did not meet the CDC/ Council of State and Territorial Epidemiologists’ (CSTE) definition for a probable or confirmed brucellosis case, and the initial EIA result was determined to be a false positive. This report summarizes the case history, laboratory findings, and public health investigations. CDC recommends that Brucella serology testing only be performed using tests cleared or approved by the Food and Drug Administration (FDA) or validated under the Clinical Laboratory Improvement Amendments (CLIA) and shown to reliably detect the presence of Brucella infection. Results from these tests should be considered supportive evidence for recent infection only and interpreted in the context of a clinically compatible illness and exposure history. EIA is not considered a confirmatory Brucella antibody test; positive screening test results should be confirmed by Brucella-specific agglutination (i.e., BMAT or standard tube agglutination test) methods.

Pragle A, Blackmore C, Clark TA, Ari MD, Wilkins PP, Gross D, Stern EJ. “Public Health Consequences of a False-Positive Laboratory Test Result for Brucella — Florida, Georgia, and Michigan, 2005.” MMWR, 2008, Vol. 57, No. 22, pp. 603-5.

Mortality Surveillance: 2004 to 2005 Florida Hurricane-Related Deaths

During 2004 and 2005, Florida was struck by eight hurricanes, resulting in 213 deaths. The Department of Health and Florida medical examiners monitor hurricane mortality surveillance. This study analyzed hurricane-related deaths reported by the Florida Medical Examiners Commission (MEC) for 2004 to 2005. The objectives of this study were to 1) describe the Florida hurricane-related mortality for 2004 and 2005 2) accurately characterize the hurricane-related deaths and 3) identify strategies to prevent or reduce future hurricane deaths. For 2004, there were 144 total hurricane-related deaths. The majority (59%) occurred in the post-impact phase, with accidents accounting for 76% of deaths. Among these, over half were caused by trauma, followed by drowning, other injury, electrocution, and carbon monoxide poisoning. For 2005, there were 69 hurricane-related deaths. Sixty-one percent of deaths occurred in the post-impact phase, with accidents accounting for 86% of all deaths. Among these, over half were due to trauma, with drowning and carbon monoxide poisoning being the other major contributors. Most hurricane-related deaths are due to unintentional injury and therefore, preventable. Seventy-nine percent

229 2008 Florida Morbidity Statistics

of deaths are in those aged 40 and older. Prevention messages should target high-risk, post-impact activities, especially in older adults.

Ragan P, Schulte J, Nelson S, Jones K. “Mortality Surveillance: 2004 to 2005 Florida Hurricane-Related Deaths.” American Journal of Forensic Medicine & Pathology, 2008, Vol. 29, No. 2, pp. 148-53.

Florida Epidemic Intelligence Service (FL-EIS) Program: The First Five Years, 2001-2006

The Florida Epidemic Intelligence Service Program was created in 2001 to increase epidemiologic capacity within the state. Patterned after applied epidemiology training programs such as the Centers for Disease Control and Prevention Epidemic Intelligence Service and the California Epidemiologic Investigation Service, the two year post-graduate program is designed to train public leaders of the future. The long term goal is to increase the capacity of the Florida Department of Health to respond to new challenges in disease control and prevention. Placement is with experienced epidemiologists in county health departments/consortia. Fellows participate in didactic and experiential components, and complete core activities for learning as evidence of competency. As evidenced by graduate employment, the program is successfully meeting its goal. As of 2006, three classes (N=18) have graduated. Among graduates, 83% are employed as epidemiologists, 67% in Florida. Training in local health departments and an emphasis on graduate retention may assist states in strengthening their epidemiologic capacity.

Ragan P, Rowan A, Schulte J, Weirsma S. “Florida Epidemic Intelligence Service (FL-EIS) Program: The First Five Years, 2001-2006.” Public Health Reports, 2008, Vol. 123, Supplement 1, pp. 21-27.

Illness Associated with Red Tide — Nassau County, Florida, 2007

A “red tide” is a harmful algal bloom that occurs when toxic, microscopic algae in seawater proliferate to a higher-than-normal concentration (i.e., bloom), often discoloring the water red, brown, green, or yellow. Red tides can kill fish, birds, and marine mammals and cause illness in humans. Florida red tide is caused by the dinoflagellate Karenia brevis, which produces toxins called brevetoxins and is most commonly found in the Gulf of Mexico; however, K. brevis blooms also can occur along the Atlantic coast. On September 25, 2007, a cluster of respiratory illnesses was reported to the Nassau County Health Department (NCHD) in northeastern Florida. All of the ill persons were employed at a beach restoration worksite by a dredging company operating at Fernandina Beach; they reported symptoms of eye or respiratory irritation (e.g., coughing, sneezing, sniffling, and throat irritation). NCHD and the Florida Department of Health promptly conducted epidemiologic and environmental investigations and determined the illnesses likely were associated with exposure to a red tide along the Atlantic coast. These actions highlight the importance of rapid investigation of health concerns with potential environmental causes to enable timely notification of the public and prevent further illness.

Reich A, Blackmore C, Hopkins R, Lazensky R, Geib K, Ngo-Seidel E. “Illness Associated with Red Tide — Nassau County, Florida, 2007.” MMWR, 2008, Vol. 57, No. 26, pp. 717-720.

Fatal Necrotizing Pneumonia Due to a Panton-Valentine Leukocidin Positive Community- associated Methicillin-sensitive Staphylococcus aureus and Influenza Co-infection: A Case Report

Recent studies have described a number of fatalities due to methicillin-resistant Staphylococcus aureus (MRSA) and influenza virus co-infection. MRSA isolates provide a challenge to caregivers due to inherent wide range antibiotic resistance. Many facilities have instituted screening methods, based on the presence of antibiotic resistance genes, to identify MRSA positive patients upon admission. However,

230 Recently Published Papers and Reports, 2008 the resistance profile of the pathogen does not necessarily determine the severity of disease caused by that organism. We describe a fatal case of necrotizing pneumonia in a patient co-infected with Influenza B and a community-associated, PVL-positive methicillin-susceptible Staphylococcus aureus (MSSA). Roberts JC, Gulino SP, Peak KK, Luna VA, Sanderson R. “Fatal Necrotizing Pneumonia Due to a Panton-Valentine Leukocidin Positive Community-associated Methicillin-sensitive Staphylococcus aureus and Influenza Co-infection: A Case Report.” Ann Clin Microbiol Antimicrob, 2008, Vol. 7, No. 5.

Major Clinical Outcomes in Antiretroviral Therapy (ART)-naïve Participants and in Those not Receiving ART at Baseline in the SMART Study

The SMART study randomized 5472 human immunodeficiency virus (HIV)–infected patients with CD4+ cell counts >350 cells/μL to intermittent antiretroviral therapy (ART; the drug conservation [DC] group) versus continuous ART (the viral supression [VS] group). In the DC group, participants started ART when the CD4+ cell count was <250 cells/μL. Clinical outcomes in participants not receiving ART at entry inform the early use of ART. Patients who were either ART naive (n=249) or who had not been receiving ART for 6 months (n=228) were analyzed. The following clinical outcomes were assessed: (i) opportunistic disease (OD) or death from any cause (OD/death); (ii) OD (fatal or nonfatal); (iii) serious non-AIDS events (cardiovascular, renal, and hepatic disease plus non–AIDS-defining cancers) and non-OD deaths; and (iv) the composite of outcomes (ii) and (iii). A total of 477 participants (228 in the DC group and 249 in the VS group) were followed (mean, 18 months). For outcome (iv), 21 and 6 events occurred in the DC (7 in ART-naïve participants and 14 in those who had not received ART for 6 months) and VS (2 in ART-naïve participants and 4 in those who had not received ART for 6 months) groups, respectively. Hazard ratios for DC vs. VS by outcome category were as follows: outcome (i), 3.47 (95% confidence interval [CI], 1.26–9.56; P=0.2); outcome (ii), 3.26 (95% CI, 1.04–10.25; P=0.4); outcome (iii), 7.02 (95% CI, 1.57–31.38; P=0.1); and outcome (iv), 4.19 (95% CI, 1.69–10.39; P=0.002). Initiation of ART at CD4+ cell counts >350 cells/μL compared with <250 cells/μL may reduce both OD and serious non-AIDS events. These findings require validation in a large, randomized clinical trial.

The Strategies for Management of Antiretroviral Therapy (SMART) Study Group, including Sands M. “Major Clinical Outcomes in Antiretroviral Therapy (ART)-naïve Participants and in Those Not Receiving ART at Baseline in the SMART Study.” JID, 2008, Vol. 197, pp. 1133-44.

Inferior Clinical Outcomes of the CD4 Cell Count-guided Antiretroviral Treatment Interruption Strategy in the SMART Study: Role of CD4 Cell Counts and HIV RNA Levels During Follow-up

The SMART study compared 2 strategies for using antiretroviral therapy—drug conservation (DC) and viral suppression (VS)—in 5472 human immunodeficiency virus (HIV)–infected patients with CD4+ cell counts >350 cells/μL. Rates and predictors of opportunistic disease or death (OD/death) and the relative risk (RR) in DC versus VS groups according to the latest CD4+ cell count and HIV RNA level are reported. During a mean of 16 months of follow-up, DC patients spent more time with a latest CD4+ cell count <350 cells/μL (for DC vs. VS, 31% vs. 8%) and with a latest HIV RNA level >400 copies/mL (71% vs. 28%) and had a higher rate of OD/death (3.4 vs. 1.3/100 person-years) than VS patients. For periods of follow-up with a CD4+ cell count <350 cells/μL, rates of OD/death were increased but similar in the 2 groups (5.7 vs. 4.6/100 person-years), whereas the rates were higher in DC versus VS patients (2.3 vs. 1.0/100 person-years; RR, 2.3 [95% confidence interval, 1.5–3.4]) for periods with the latest CD4+ cell count 350 cells/μL—an increase explained by the higher HIV RNA levels in the DC group. The higher risk of OD/death in DC patients was associated with (1) spending more follow-up time with relative immunodeficiency and (2) living longer with uncontrolled HIV replication even at higher CD4+ cell counts. Ongoing HIV replication at a given CD4+ cell count places patients at an excess risk of OD/death.

231 2008 Florida Morbidity Statistics

The Strategies for Management of Antiretroviral Therapy (SMART) Study Group, including Sands M. “Inferior Clinical Outcomes of the CD4 Cell Count-guided Antiretroviral Treatment Interruption Strategy in the SMART Study: Role of CD4 Cell Counts and HIV RNA Levels During Follow-up.” JID, 2008, Vol. 197, pp. 1145-55.

Maternal Obesity and Risk of Infant Death Based on Florida Birth Records for 2004

The purpose of this study was to assess the relationship between pre-pregnancy maternal obesity and risk of infant death. In March 2004, maternal height and pre-pregnancy weight were added to the data collected on the Florida birth certificate. Using birth records linked to infant deaths, these data were used to assess the relationship between pre-pregnancy maternal obesity, as measured by body mass index, and infant death. Pre-pregnancy maternal obesity was associated with increased odds of infant death. The increased risk was found with and without adjustments for maternal race, marital status, age, education, trimester prenatal care began, first birth, and tobacco use. There is a substantial and significant association between pre-pregnancy maternal obesity and infant death.

Thompson DR, Clark CL, Wood B, Zeni MB. “Maternal Obesity and Risk of Infant Death Based on Florida Birth Records for 2004.” Public Health Reports, 2008, Vol. 123, pp. 487-493.

An Intervention to Improve Notifiable Disease Reporting Using Ambulatory Clinics

Strong notifiable disease surveillance systems are essential for disease control. eW sought to determine if a brief informational session between clinic and health department employees followed by reminder faxes and a newsletter would improve reporting rates and timeliness in a notifiable disease surveillance system. Ambulatory clinics were randomized to an intervention group which received the informational session, a faxed reporting reminder and newsletter, or to a control group. Among intervention and control clinics, there were improvements in the number of cases reported and the timeliness of reporting. However, there were no statistically significant changes in either group. Despite improved communication between the health department and clinics, this intervention did not significantly improve the level or the timeliness of reporting. Other types of interventions should be considered to improve reporting such as simplifying the reporting process.

Trepka MJ, Zhang G, Leguen F. “An Intervention to Improve Notifiable Disease Reporting Using Ambulatory Clinics.” Epidemiol. Infect., 2008, Vol. 137, pp. 22-29.

Neurotoxic Shellfish Poisoning

Neurotoxic shellfish poisoning (NSP) is caused by consumption of molluscan shellfish contaminated with brevetoxins primarily produced by the dinoflagellate, Karenia brevis. Blooms of K. brevis, called Florida red tide, occur frequently along the Gulf of Mexico. Many shellfish beds in the US (and other nations) are routinely monitored for presence of K. brevis and other brevetoxin-producing organisms. As a result, few NSP cases are reported annually from the US. However, infrequent larger outbreaks do occur. Cases are usually associated with recreationally-harvested shellfish collected during or post red tide blooms. Brevetoxins are neurotoxins which activate voltage-sensitive sodium channels causing sodium influx and nerve membrane depolarization. No fatalities have been reported, but hospitalizations occur. NSP involves a cluster of gastrointestinal and neurological symptoms: nausea and vomiting, paresthesias of the mouth, lips and tongue as well as distal paresthesias, ataxia, slurred speech and

232 Recently Published Papers and Reports, 2008 dizziness. Neurological symptoms can progress to partial paralysis; respiratory distress has been recorded. Recent research has implicated new species of harmful algal bloom organisms which produce brevetoxins, identified additional marine species which accumulate brevetoxins, and has provided additional information on the toxicity and analysis of brevetoxins. A review of the known epidemiology and recommendations for improved NSP prevention are presented.

Watkins SM, Reich A, Fleming LE, Hammond R. “Neurotoxic Shellfish Poisoning.” Marine Drugs, 2008, Vol. 6, pp. 430-455.

Burden of Cervical Cancer in the United States, 1998-2003

Recent interest in human papillomavirus (HPV)-associated cancers and the availability of several years of data covering 83% of the US population prompted this descriptive assessment of cervical cancer incidence and mortality in the US during the years 1998 through 2003. This article provides a baseline for monitoring the impact of the HPV vaccine on the burden of cervical cancer over time. Data from 2 federal cancer surveillance programs, the Centers for Disease Control and Prevention (CDC)’s National Program of Cancer Registries and the National Cancer Institiute’s Surveillance, Epidemiology, and End Results Program, were used to examine cervical cancer incidence by race, Hispanic ethnicity, histology, stage, and US census region. Data from the CDC’s National Center for Health Statistics were used to examine cervical cancer mortality by race, Hispanic ethnicity, and US census region. The incidence rate of invasive cervical cancer was 8.9 per 100,000 women during 1998 through 2003. Greater than 70% of all cervical carcinomas were squamous cell type, and nearly 20% were adenocarcinomas. Cervical carcinoma incidence rates were increased for black women compared with white women and for Hispanic women compared with non-Hispanic women. Hispanic women had increased rates of adenocarcinomas compared with non-Hispanic women. The South had increased incidence and mortality rates compared with the Northeast. Disparities by race/ethnicity and region persist in the burden of cervical cancer in the US. Comprehensive screening and vaccination programs, as well as improved surveillance, will be essential if this burden is to be reduced in the future.

Watson M, Saraiya M, Benard V, Coughlin S, Flowers L, Cokkinides V, Schwenn M, Huang Y, Giuliano A. “Burden of Cervical Cancer in the United States, 1998-2003.” Cancer (Supplement), 2008, Vol. 113, No. 10, pp. 2588-64.

Assessing the Association Between Environmental Impacts and Health Outcomes: A Case Study From Florida

The Centers for Disease Control and Prevention (CDC) created the Environmental Public Health Tracking (EPHT) program to integrate hazard monitoring, exposure, and health effects surveillance into a cohesive tracking network. Part of Florida’s effort to move toward implementation of EPHT is to develop models of the spatial and temporal association between myocardial infarctions (MIs) and ambient ozone levels in Florida. Existing data were obtained from Florida’s Agency for Health Care Administration, Florida’s Department of Environmental Protection, the U.S. Census Bureau, and CDC’s Behavioral Risk Factor Surveillance System. These data were linked by both ignoring spatial support and using block kriging, a support-adjusted approach. The MI data were indirectly standardized by age, race/ethnicity, and sex. The state of Florida was used as the comparison standard to compute the MI standardized event ratio (SER) for each county and each month. After the data were linked, global models were used initially to relate MIs to ambient ozone levels, adjusting for covariates. The global models provide an estimated relative MI SER for the state. Realizing that the association in MIs and ozone might change across locations, local models were used to estimate the relative MI SER for each county, again adjusting for covariates. Results differed, depending on whether the spatial support was ignored or accounted for in

233 2008 Florida Morbidity Statistics

the models. The opportunities and challenges associated with EPHT analyses are discussed and future directions highlighted.

Young LJ, Gotway CA, Yang J, Kearney G, DuClos C. “Assessing the Association Between Environmental Impacts and Health Outcomes: A Case Study From Florida.” Statist. Med., 2008, Vol. 27, pp. 3998-4015.

Additional reports and articles regarding infectious disease incidence, disease surveillance activities, reportable disease notifications, and heath studies conducted in Florida can be accessed in Epi Update. Epi Update is a publication of the Bureau of Epidemiology and compiles information related to Department of Health activities from around the State. The current issue, as well as archived issues, of Epi Update can be accessed at http://www.doh.state.fl.us/disease_ctrl/epi/Epi_Updates/index.html.

234 Summary of Cancer Data, 2006

Section 8: Summary of Cancer Data, 2006

Cancer incidence data are collected, verified, and maintained by the Florida Cancer Data System (FCDS), Florida’s statewide cancer registry. The FCDS is administered by the Florida Department of Health, Bureau of Epidemiology and operated by the Sylvester Comprehensive Cancer Center at the University of Miami, Leonard M. Miller School of Medicine.

The FCDS began operation with a pilot project for cancer registration in 1980 and commenced statewide collection of cancer incidence data from all Florida hospitals in 1981. The FCDS now collects incidence data from hospitals, freestanding ambulatory surgical centers, radiation therapy facilities, pathology laboratories, and dermatopathologists’ offices. Each facility, laboratory, and practitioner is required to report the FCDS within six months of each diagnosis and within six months of the date of each treatment. Consequently, there is an inherent time lag in the release of cancer registry data for surveillance activities. Currently, data is available through 2006.

During 2006, physicians diagnosed 100,303 primary cancers among Floridians, an average of 275 cases per day. Cancer occurs predominantly among older people as age is the top risk factor. Approximately 60% of the newly diagnosed cancers in 2006 occurred in persons age 65 and older; this age group accounts for 18% of Florida’s population. The four most common cancers in Floridians were lung and bronchus (16,154 cases), prostate (14,043 cases), female breast (12,826 cases), and colorectal (10,173 cases), which accounted for 57% of all new cases in blacks, and 53% in whites. Fifty-three percent of new cancers were diagnosed in males. The number of new cancer cases in Florida’s five most populous counties (Broward, Miami-Dade, Hillsborough, Orange, and Palm Beach) which had 42% of Florida’s population accounted for 39% of the new cancer cases in Florida in 2006.

Over the 26-year period from 1981 to 2006, males had a higher incidence (age-adjusted incidence rate) than females. Among blacks, the incidence among males was between 55% and 102% higher than that among females. Among whites, the incidence among males was between 28% and 53% higher than that among females. White females had higher age-adjusted incidence rates than black females in all 26 years. The racial disparity varied between 10% and 27%. Black males had higher age-adjusted incidence rates than white males in all years, except in 1987, 1988, and 2006. The racial disparity between black and white males increased from 1989 until 1995; however, it has steadily declined since 1996.

More information about the burden of cancer in Florida is provided in the Florida Annual Cancer Report, an epidemiological series, available on the department’s web site at www.doh.state.fl.us/disease_ctrl/epi/ cancer/CancerIndex.htm, or the FCDS web site at www.fcds.med.miami.edu.

235 2008 Florida Morbidity Statistics

Table 1. Number of New Cancer Cases by Sex and Race, Florida, 2006

All Lung & Head & Non- Cancers Bronchus Prostate Breast Colorectal Bladder Neck Hodgkin(1) Melanoma Ovary Cervix Florida (2) 100,303 16,154 14,043 12,826 10,173 4,740 3,881 3,905 3,388 1,478 907

Female 46,787 7,306 - 12,826 4,939 1,138 1,089 1,833 1,342 1,478 907

Male 53,442 8,835 14,043 - 5,222 3,601 2,787 2,071 2,046 --

Black 8,888 1,153 1,704 1,226 986 152 323 318 - 117 159

White 88,506 14,755 11,837 11,203 8,914 4,440 3,468 3,486 3,388 1,315 719

Black Female 4,162 405 - 1,226 530 57 92 147 - 117 159

White Female 41,236 6,769 - 11,203 4,270 1,041 968 1,635 1,342 1,315 719

Black Male 4,718 746 1,704 - 456 95 230 171 ---

White Male 47,216 7,976 11,837 - 4,633 3,398 2,498 1,850 2,046 -- Source of data: Florida Cancer Data System (1) Non-Hodgkin refers to Non-Hodgkin lymphoma throughout this report. (2) Florida incidence total counts and rates throughout this report include 1,140 new cancer cases in persons of “Other” races, 882 cases with unknown race, 44 cases with unknown or unspecified sex, and 2 cases with unknown age.Totals by sex include cases with unknown age and race, as well as cases with Other race. Totals by race include unknown sex and age.

236 Summary of Cancer Data, 2006

Table 2. Number of New Cancer Cases by County, Florida, 2006 All Lung & Head & Non- Prostate Breast Colorectal Bladder Melanoma Ovary Cervix Cancers Bronchus Neck Hodgkin Florida 100,303 16,154 14,043 12,826 10,173 4,740 3,881 3,905 3,388 1,478 907 Alachua 912 135 133 132 100 27 33 34 31 15 10 Baker 98 18 14 ^ ^ ^ ^ ^ ^ ^ ^ Bay 859 137 134 113 72 39 38 34 40 13 ^ Bradford 111 23 22 ^ 12 ^ ^ ^ ^ ^ ^ Brevard 3,739 612 548 474 349 191 154 145 153 44 28 Broward 8,424 1,198 997 1,143 898 379 317 368 261 142 87 Calhoun 51 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Charlotte 1,242 224 229 126 102 90 46 43 38 14 ^ Citrus 1,152 232 194 111 124 83 41 29 36 17 ^ Clay 806 131 108 124 73 34 27 22 36 ^ ^ Collier 2,095 294 427 190 180 112 79 81 107 34 11 Columbia 322 78 32 29 35 14 14 10 ^ ^ ^ Miami-Dade 10,872 1,329 1,574 1,454 1,299 384 436 468 183 175 148 DeSoto 145 25 26 17 13 ^ ^ ^ ^ ^ ^ Dixie 95 23 ^ 10 ^ ^ ^ ^ ^ ^ ^ Duval 4,028 645 577 585 358 159 148 154 124 57 51 Escambia 1,531 259 227 214 137 60 67 52 39 14 11 Flagler 568 107 69 82 53 26 17 36 14 ^ ^ Franklin 49 13 ^ ^ ^ ^ ^ ^ ^ ^ ^ Gadsden 218 44 23 20 22 ^ 15 ^ ^ ^ ^ Gilchrist 76 14 10 ^ ^ ^ ^ ^ ^ ^ ^ Glades 44 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Gulf 75 12 10 ^ ^ ^ ^ ^ ^ ^ ^ Hamilton 75 18 11 ^ ^ ^ ^ ^ ^ ^ ^ Hardee 115 16 16 ^ 13 ^ ^ ^ ^ ^ ^ Hendry 144 29 16 21 13 ^ 10 ^ ^ ^ ^ Hernando 1,324 249 171 151 147 79 48 58 48 16 ^ Highlands 856 163 103 64 100 35 20 40 31 14 ^ Hillsborough 5,312 832 717 710 517 199 233 216 160 86 47 Holmes 145 28 14 14 15 ^ ^ ^ ^ ^ ^ Indian River 1,037 189 120 134 115 47 40 37 44 17 ^ Jackson 275 48 48 36 29 10 17 ^ ^ ^ ^ Jefferson 75 10 10 16 ^ ^ ^ ^ ^ ^ ^ Lafayette 17 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Lake 2,501 440 392 259 242 153 70 98 89 52 15 Lee 3,693 635 597 452 332 158 153 125 141 53 26 Leon 821 127 115 121 90 18 37 27 43 10 ^ Levy 238 48 32 34 21 11 12 ^ ^ ^ ^ Liberty 24 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Madison 73 ^ 11 11 10 ^ ^ ^ ^ ^ ^ Manatee 1,888 303 293 209 199 122 81 68 70 44 16 Marion 2,398 429 424 291 256 103 93 85 80 26 22 Martin 1,009 151 144 130 98 69 47 30 41 15 ^ Monroe 396 85 39 35 40 19 24 13 19 ^ ^ Nassau 367 65 73 38 38 20 13 ^ 11 ^ ^ Okaloosa 1,009 177 134 149 93 42 49 31 34 14 ^ Okeechobee 229 48 29 23 24 11 ^ ^ 11 ^ ^ Orange 4,201 599 560 581 456 150 147 181 138 56 51 Osceola 941 140 112 115 112 35 39 32 33 15 20 Palm Beach 8,064 1,235 956 1,062 744 550 274 333 353 116 69 Pasco 2,971 540 400 326 310 167 105 106 115 39 28 Pinellas 6,064 1,041 719 869 619 339 242 234 209 82 44 Polk 3,502 627 501 383 345 148 110 150 145 41 35 Putnam 464 112 64 60 41 17 19 15 12 ^ ^ Saint Johns 902 142 133 127 82 30 42 38 36 12 10 Saint Lucie 1,498 268 225 191 161 99 58 46 46 18 17 Santa Rosa 709 115 106 85 80 26 37 23 32 10 ^ Sarasota 3,010 509 521 412 277 173 108 102 99 55 16 Seminole 1,710 250 218 270 172 72 61 68 62 22 14 Sumter 655 113 138 81 57 41 19 24 27 ^ ^ Suwannee 249 42 29 23 36 10 11 ^ ^ ^ ^ Taylor 109 23 16 12 19 ^ ^ ^ ^ ^ ^ Union 181 45 24 13 20 ^ ^ ^ ^ ^ ^ Volusia 3,058 591 368 369 319 115 120 134 80 49 20 Wakulla 119 21 16 14 11 ^ ^ ^ ^ ^ ^ Walton 249 41 35 26 25 12 ^ 11 12 ^ ^ Washington 114 23 12 14 ^ ^ 10 ^ ^ ^ ^ ^ Statistics for cells with fewer than 10 cases are not displayed. Source of data: Florida Cancer Data System 237 2008 Florida Morbidity Statistics

Table 3. Age-Adjusted Incidence Rates (1) by Sex and Race, Florida, 2006 Lung & All Cancers Bronchus Prostate Breast Colorectal Bladder Rate CI Rate CI Rate CI Rate CI Rate CI Rate CI Florida (2) 433.1 430.4 435.9 67.0 66.0 68.1 128.8 126.7 131.0 108.7 106.8 110.6 42.8 41.9 43.6 19.2 18.7 19.8

Female 380.9 377.3 384.4 55.3 54.0 56.6 --- 108.7 106.8 110.6 37.6 36.5 38.6 8.3 7.8 8.8

Male 500.4 496.2 504.7 81.3 79.7 83.1 128.8 126.7 131.0 --- 48.9 47.6 50.2 33.0 31.9 34.1

Black 389.7 381.4 398.2 52.8 49.7 56.1 179.1 170.3 188.4 90.6 85.5 95.9 44.4 41.6 47.4 7.6 6.4 8.9

White 432.5 429.6 435.4 68.3 67.2 69.4 120.8 118.6 123.0 109.6 107.5 111.8 41.9 41.0 42.8 19.9 19.3 20.5

Black Female 319.2 309.4 329.3 32.6 29.5 36.1 --- 90.6 85.5 95.9 41.6 38.1 45.4 5.0 3.8 6.5

White Female 384.7 380.8 388.6 57.6 56.2 59.1 --- 109.6 107.5 111.8 36.3 35.2 37.5 8.5 7.9 9.0

Black Male 487.8 473.1 503.0 80.7 74.6 87.2 179.1 170.3 188.4 --- 48.3 43.7 53.4 10.9 8.7 13.6

White Male 494.3 489.9 498.9 81.2 79.5 83.1 120.8 118.6 123.0 --- 48.2 46.8 49.7 34.2 33.1 35.4

Head & Neck Non-Hodgkin Melanoma Ovary Cervix

Rate CI Rate CI Rate CI Rate CI Rate CI Florida (2) 17.1 16.6 17.7 17.0 16.5 17.6 17.6 17.0 18.3 12.2 11.5 12.8 9.2 8.6 9.9

Female 8.9 8.4 9.4 14.6 13.9 15.3 14.2 13.4 15.0 12.2 11.5 12.8 9.2 8.6 9.9

Male 26.5 25.5 27.5 19.9 19.1 20.8 22.1 21.2 23.1 ------

Black 13.7 12.2 15.3 12.7 11.3 14.2 --- 9.1 7.5 10.9 11.3 9.6 13.3

White 17.5 16.9 18.1 17.1 16.5 17.7 17.6 17.0 18.3 12.5 11.8 13.2 9.0 8.3 9.7

Black Female 7.0 5.6 8.7 10.8 9.1 12.8 --- 9.1 7.5 10.9 11.3 9.6 13.3

White Female 9.1 8.5 9.7 14.7 13.9 15.5 14.2 13.4 15.0 12.5 11.8 13.2 9.0 8.3 9.7

Black Male 22.4 19.4 25.8 14.8 12.5 17.5 ------

White Male 27.0 26.0 28.1 20.0 19.0 20.9 22.1 21.2 23.1 ------

Source of data: Florida Cancer Data System (1) Rates are expressed as number of cases per 100,000 population per year, adjusted to the 2000 U.S. standard population. (2) Florida incidence rates throughout this report include 1,140 new cancers in persons of “Other” races, 882 cases with unknown race, 44 cases with unknown or unspecified sex, and 2 cases with unknown age. Rates calculated by sex include cases with unknown age and race, as well as cases with Other race. Rates by race include unknown sex and age.

238 Summary of Cancer Data, 2006

Table 4. Age-Adjusted Incidence Rates (1) by County, Florida, 2006 All Cancers Lung & Bronchus Prostate Breast Colorectal Rate CI Rate CI Rate CI Rate CI Rate CI

Florida 433.1 430.4 435.9 67.0 66.0 68.1 128.8 126.7 131.0 108.7 106.8 110.6 42.8 41.9 43.6

Alachua 443.3 414.6 473.5 68.7 57.5 81.6 141.2 117.8 168.3 118.4 98.8 141.0 49.2 39.9 60.0 Baker 403.7 325.9 496.8 77.1 44.9 126.3 116.5 62.1 223.3 ^ ^ ^ ^ ^ ^ Bay 441.2 411.9 472.3 69.7 58.5 82.8 141.0 117.7 168.3 110.5 90.8 133.8 37.0 28.9 47.0 Bradford 352.3 289.5 426.5 71.7 45.3 110.1 144.0 89.6 223.4 ^ ^ ^ 38.0 19.6 69.1 Brevard 474.4 458.9 490.4 74.1 68.3 80.5 142.0 130.3 154.8 122.1 111.0 134.4 43.2 38.7 48.3 Broward 422.0 412.9 431.3 59.5 56.2 63.1 114.2 107.1 121.6 107.8 101.5 114.4 43.9 41.1 47.0 Calhoun 322.5 239.6 428.1 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Charlotte 386.5 361.8 413.4 59.7 51.7 69.9 132.3 114.9 153.9 84.5 67.7 106.4 27.6 22.1 35.4 Citrus 410.5 384.3 439.1 77.1 66.9 89.9 135.1 116.1 159.4 86.5 68.9 109.9 41.5 33.9 51.8 Clay 451.6 420.4 484.7 74.5 62.0 88.9 121.0 98.6 147.8 129.0 107.0 154.5 41.4 32.3 52.4 Collier 403.1 385.2 422.0 52.3 46.3 59.1 159.8 144.8 176.4 75.3 64.2 88.3 33.9 28.9 39.8 Columbia 428.7 382.7 479.6 100.3 79.2 126.3 88.2 60.0 126.5 75.4 50.0 112.1 48.4 33.5 68.6 Miami-Dade 415.9 408.1 423.9 50.2 47.6 53.0 135.8 129.2 142.8 102.7 97.4 108.1 49.4 46.8 52.2 DeSoto 347.2 290.2 414.3 57.2 36.1 89.0 112.3 73.1 170.0 89.1 47.8 159.0 31.2 16.1 57.7 Dixie 444.2 356.8 551.1 101.8 63.8 160.6 ^ ^ ^ 79.3 37.9 178.3 ^ ^ ^ Duval 479.7 464.9 495.0 78.7 72.7 85.1 158.0 145.1 172.0 124.4 114.5 135.1 42.6 38.2 47.3 Escambia 448.4 426.1 471.8 74.8 65.9 84.6 146.0 127.5 166.6 120.6 104.7 138.5 39.9 33.5 47.4 Flagler 351.8 321.3 385.9 60.2 48.9 75.3 80.3 62.3 106.3 108.4 84.2 141.1 34.6 25.3 48.2 Franklin 291.5 212.9 397.6 76.5 39.6 144.0 ^ ^ ^ ^ ^ ^ ^ ^ ^ Gadsden 425.5 370.5 486.9 85.5 62.0 115.7 104.8 65.9 160.3 72.0 43.8 113.4 42.7 26.7 65.7 Gilchrist 388.5 305.0 491.6 66.2 36.0 117.2 97.9 46.7 193.9 ^ ^ ^ ^ ^ ^ Glades 309.5 222.5 428.0 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Gulf 377.2 296.1 480.6 60.1 31.0 115.0 99.6 47.1 204.1 ^ ^ ^ ^ ^ ^ Hamilton 510.4 400.5 643.1 125.5 74.0 201.2 139.6 68.7 266.7 ^ ^ ^ ^ ^ ^ Hardee 424.6 349.9 511.6 59.5 33.9 98.2 120.0 68.4 197.4 ^ ^ ^ 46.5 24.8 81.4 Hendry 435.1 366.6 513.3 86.9 58.1 125.7 94.1 53.7 158.3 129.9 80.2 200.6 40.3 21.4 69.7 Hernando 486.0 457.1 516.9 81.7 71.2 94.2 116.6 99.4 137.9 113.2 93.9 136.8 56.7 46.8 68.9 Highlands 491.3 454.0 532.0 79.1 66.6 95.0 118.9 95.6 149.3 79.6 57.9 109.7 48.0 38.1 61.4 Hillsborough 455.6 443.4 468.1 72.3 67.4 77.4 135.6 125.8 146.1 113.1 104.9 121.8 44.4 40.6 48.4 Holmes 612.8 515.7 725.3 113.7 75.4 167.9 121.8 66.0 211.5 114.9 61.8 207.0 60.7 33.8 104.2 Indian River 440.3 411.5 471.4 74.4 63.6 87.4 106.5 87.8 129.8 126.8 104.3 154.4 45.6 37.0 56.5 Jackson 463.0 409.5 522.7 80.8 59.5 108.6 169.8 124.9 228.1 126.1 87.3 179.8 50.2 33.5 73.7 Jefferson 433.5 340.2 550.2 58.0 27.6 115.5 130.1 62.1 251.9 176.2 99.9 305.5 ^ ^ ^ Lafayette 203.8 118.2 335.4 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Lake 542.4 519.8 566.0 88.1 79.7 97.5 165.0 148.8 183.3 118.1 102.8 135.6 49.9 43.5 57.3 Lee 402.0 388.4 416.2 63.3 58.3 68.7 126.6 116.5 137.6 104.3 94.1 115.5 34.4 30.7 38.7 Leon 377.8 351.8 405.5 64.3 53.4 76.9 117.7 96.4 142.8 98.9 81.8 119.0 42.0 33.6 52.1 Levy 429.6 375.4 491.5 81.6 59.9 111.3 115.7 78.5 170.0 116.1 79.6 168.5 39.4 24.0 63.5 Liberty 327.0 208.7 495.8 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Madison 329.7 257.8 417.9 ^ ^ ^ 102.0 50.6 188.7 93.2 45.9 180.0 46.9 22.2 89.8 Manatee 404.0 385.1 423.9 59.4 52.7 67.0 130.9 116.1 147.5 90.4 77.9 104.9 41.6 35.7 48.3 Marion 479.0 458.9 500.0 81.0 73.2 89.6 169.9 153.8 187.7 115.9 102.0 131.6 50.5 44.1 57.7 Martin 401.7 375.1 430.5 51.9 43.6 62.4 113.8 95.7 136.4 107.2 87.7 131.9 35.8 28.7 45.3 Monroe 366.3 330.2 406.4 75.1 59.8 94.8 65.6 46.2 93.7 67.7 46.7 98.3 38.7 27.5 54.6 Nassau 446.1 400.5 496.2 81.2 62.3 104.8 174.5 135.9 224.6 88.5 62.1 124.7 47.8 33.5 67.0 Okaloosa 492.3 462.2 524.1 87.0 74.5 101.0 134.9 112.7 161.1 136.3 115.1 160.6 46.4 37.4 57.0 Okeechobee 489.9 427.6 560.1 96.6 71.0 130.2 121.2 81.0 176.8 106.8 66.6 167.9 50.4 32.1 77.3 Orange 455.3 441.5 469.6 68.4 63.0 74.2 134.7 123.5 146.8 114.6 105.4 124.4 50.8 46.2 55.7 Osceola 392.6 367.6 418.9 60.6 50.9 71.7 101.1 83.0 122.6 86.3 71.1 103.9 47.8 39.3 57.8 Palm Beach 426.6 416.9 436.5 60.9 57.5 64.6 112.2 105.1 119.8 114.1 106.9 121.7 36.6 33.9 39.5 Pasco 449.1 432.2 466.7 76.0 69.5 83.2 124.8 112.7 138.2 100.3 88.9 113.2 44.2 39.2 49.9 Pinellas 437.1 425.8 448.8 71.1 66.8 75.8 112.2 104.1 120.9 124.0 115.5 133.2 41.5 38.2 45.1 Polk 480.0 463.9 496.5 81.7 75.4 88.6 141.6 129.4 154.8 102.7 92.4 114.1 45.6 40.8 50.8 Putnam 457.2 415.4 503.1 105.4 86.5 128.6 123.9 95.2 161.4 117.8 88.8 156.1 39.5 28.1 55.5 Saint Johns 434.9 406.6 465.1 67.6 56.9 80.3 133.1 111.3 158.8 118.2 98.2 142.0 38.6 30.6 48.5 Saint Lucie 392.1 371.6 413.6 66.0 58.1 75.0 119.1 103.9 136.6 104.3 89.1 121.9 39.5 33.5 46.6 Santa Rosa 480.0 444.7 517.5 76.0 62.5 91.9 149.3 121.6 182.8 108.5 86.4 134.9 54.8 43.3 68.8 Sarasota 407.1 391.1 424.0 61.0 55.5 67.2 146.0 133.4 160.3 120.2 107.2 135.1 34.1 29.9 39.1 Seminole 409.4 389.9 429.6 63.3 55.6 71.8 111.7 97.0 128.4 116.6 103.0 131.6 41.2 35.2 48.0 Sumter 385.9 354.5 420.9 68.1 55.2 85.1 155.0 129.3 188.3 106.2 81.6 140.7 33.8 24.9 47.1 Suwannee 471.7 413.9 537.2 73.1 52.6 101.7 114.6 76.5 169.7 91.3 56.6 144.5 67.0 46.7 95.7 Taylor 437.1 358.2 530.1 95.6 60.4 146.0 127.7 72.4 217.6 104.2 52.8 192.0 73.7 44.2 118.2 Union 1249.0 1066.7 1460.8 317.6 229.0 437.6 318.2 194.1 530.9 260.3 138.1 457.6 152.6 90.8 248.8 Volusia 412.1 397.1 427.6 75.8 69.7 82.4 103.6 93.2 115.1 99.4 89.0 111.0 40.2 35.8 45.2 Wakulla 385.6 317.6 465.5 67.6 41.4 106.5 94.6 52.8 168.1 86.6 46.8 151.7 41.9 20.6 77.0 Walton 331.6 291.1 377.4 52.3 37.5 72.8 89.0 61.9 126.9 70.3 45.4 107.6 32.5 21.0 49.8 Washington 413.5 340.3 500.6 81.3 51.3 126.1 92.0 47.3 168.1 99.2 52.8 177.8 ^ ^ ^ (1) Rates are expressed as number of cases per 100,000 population per year, adjusted to the 2000 U.S. standard population. ^ Statistics for cells with fewer than 10 cases are not displayed Source of data: Florida Cancer Data System 239 2008 Florida Morbidity Statistics

Table 4. Age-Adjusted Incidence Rates (1) by County, Florida, 2006 Bladder Head & Neck Non-Hodgkin Melanoma Ovary Cervix Rate CI Rate CI Rate CI Rate CI Rate CI Rate CI

Florida 19.2 18.7 19.8 17.1 16.6 17.7 17.0 16.5 17.6 17.6 17.0 18.3 12.2 11.5 12.8 9.2 8.6 9.9

Alachua 13.4 8.8 19.7 16.2 11.1 23.0 17.3 11.9 24.4 18.6 12.5 27.1 12.3 6.8 21.1 9.7 4.6 18.3 Baker ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Bay 21.0 14.9 29.1 18.9 13.3 26.3 17.8 12.3 25.3 23.9 16.9 33.1 13.1 6.9 23.4 ^ ^ ^ Bradford ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Brevard 22.7 19.6 26.4 19.5 16.4 23.0 18.5 15.5 22.0 23.0 19.3 27.4 9.9 7.2 13.9 9.3 6.0 14.0 Broward 18.3 16.4 20.3 16.1 14.3 18.0 18.4 16.6 20.5 16.4 14.4 18.7 13.5 11.3 16.0 8.9 7.1 11.0 Calhoun ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Charlotte 23.4 18.5 30.6 14.5 10.1 21.5 14.1 9.6 21.2 19.2 12.3 29.5 7.9 3.8 18.4 ^ ^ ^ Citrus 25.8 20.3 34.1 18.0 12.4 26.7 11.9 7.1 20.1 12.7 8.5 20.4 9.4 5.4 20.6 ^ ^ ^ Clay 20.0 13.8 28.3 14.9 9.7 22.2 12.9 8.0 20.0 22.4 15.6 31.4 ^ ^ ^ ^ ^ ^ Collier 19.5 16.0 23.9 15.6 12.2 20.0 15.8 12.3 20.2 24.0 19.3 29.7 14.3 9.5 21.3 7.4 3.6 13.8 Columbia 17.6 9.6 31.0 18.2 9.8 32.1 14.8 7.0 28.4 ^ ^ ^ ^ ^ ^ ^ ^ ^ Miami-Dade 14.5 13.1 16.1 16.6 15.1 18.2 18.1 16.5 19.8 8.6 7.4 10.0 12.1 10.3 14.0 11.2 9.5 13.2 DeSoto ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Dixie ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Duval 19.7 16.7 23.1 17.2 14.5 20.3 18.3 15.5 21.5 20.2 16.8 24.2 12.2 9.2 15.9 10.9 8.1 14.4 Escambia 17.2 13.1 22.3 19.5 15.1 25.0 14.9 11.1 19.7 14.1 10.0 19.7 7.4 4.0 13.1 7.2 3.6 13.4 Flagler 13.8 9.0 23.1 9.8 5.6 18.7 21.4 14.8 32.3 10.3 5.4 21.2 ^ ^ ^ ^ ^ ^ Franklin ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Gadsden ^ ^ ^ 28.4 15.8 48.0 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Gilchrist ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Glades ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Gulf ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Hamilton ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Hardee ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Hendry ^ ^ ^ 31.0 14.8 57.9 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Hernando 24.7 19.1 32.3 21.1 14.9 29.7 20.1 14.5 27.9 24.0 16.7 34.0 9.4 5.1 18.8 ^ ^ ^ Highlands 15.6 10.7 24.6 16.6 9.5 28.4 20.1 13.7 30.4 21.8 13.4 35.5 13.4 6.4 29.9 ^ ^ ^ Hillsborough 17.5 15.1 20.1 19.7 17.2 22.4 18.6 16.2 21.3 16.3 13.8 19.0 13.5 10.8 16.7 8.2 6.0 10.9 Holmes ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Indian River 16.3 11.6 23.4 20.4 14.0 29.5 14.8 10.1 22.0 19.7 13.7 28.8 11.9 6.6 23.0 ^ ^ ^ Jackson 16.9 8.1 32.9 28.7 16.6 47.7 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Jefferson ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Lafayette ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Lake 29.4 24.7 35.1 15.2 11.7 19.8 21.9 17.5 27.5 23.8 18.6 30.3 25.5 18.4 35.3 8.7 4.6 15.8 Lee 15.2 12.8 18.0 17.7 14.9 21.1 13.8 11.3 16.8 17.5 14.5 21.1 12.2 8.8 16.7 7.7 4.9 11.8 Leon 8.9 5.2 14.3 16.9 11.8 23.7 12.5 8.2 18.6 26.0 18.6 35.6 8.7 4.1 16.7 ^ ^ ^ Levy 19.5 9.7 38.4 19.8 10.2 38.3 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Liberty ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Madison ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Manatee 22.5 18.6 27.3 19.4 15.2 24.6 13.6 10.4 17.7 16.5 12.6 21.5 18.2 12.9 25.5 10.1 5.7 17.1 Marion 18.1 14.6 22.4 20.0 16.0 25.1 17.5 13.7 22.4 17.8 13.8 23.1 10.3 6.4 16.3 14.1 8.6 22.2 Martin 25.4 19.2 34.1 21.9 15.6 30.8 10.6 7.1 16.8 17.8 12.1 26.6 10.2 5.3 21.6 ^ ^ ^ Monroe 18.5 11.1 30.8 20.6 13.1 32.8 12.5 6.4 23.8 19.7 11.7 33.2 ^ ^ ^ ^ ^ ^ Nassau 23.4 14.2 37.6 16.0 8.4 28.9 ^ ^ ^ 14.4 6.9 27.8 ^ ^ ^ ^ ^ ^ Okaloosa 20.4 14.7 27.9 23.0 17.0 30.7 15.5 10.5 22.3 18.2 12.6 25.9 12.9 7.0 22.2 ^ ^ ^ Okeechobee 22.1 10.9 42.3 ^ ^ ^ ^ ^ ^ 27.5 13.3 52.6 ^ ^ ^ ^ ^ ^ Orange 17.5 14.8 20.6 15.5 13.0 18.2 19.1 16.3 22.1 18.1 15.2 21.5 11.2 8.5 14.7 9.7 7.2 12.9 Osceola 15.4 10.7 21.6 15.5 11.0 21.5 13.7 9.4 19.6 15.7 10.8 22.2 11.6 6.4 19.5 15.3 9.3 23.9 Palm Beach 25.2 23.0 27.5 15.6 13.7 17.6 17.2 15.3 19.4 22.4 19.9 25.1 12.0 9.8 14.7 9.6 7.4 12.4 Pasco 22.8 19.4 26.9 16.9 13.7 20.9 16.2 13.1 20.1 19.3 15.6 23.8 11.8 8.1 17.1 11.4 7.3 17.3 Pinellas 22.4 20.1 25.1 18.0 15.7 20.5 17.3 15.0 19.8 18.0 15.5 21.0 10.8 8.5 13.8 8.3 5.9 11.4 Polk 18.8 15.9 22.2 16.1 13.2 19.6 21.3 17.9 25.2 23.8 19.9 28.3 10.9 7.7 15.3 12.9 8.9 18.2 Putnam 15.2 8.9 26.5 19.8 11.7 32.9 16.3 9.0 28.8 17.2 8.4 33.0 ^ ^ ^ ^ ^ ^ Saint Johns 14.0 9.4 20.7 19.6 14.1 27.2 18.3 12.9 25.8 18.5 12.9 26.4 10.1 5.2 19.4 12.1 5.6 23.6 Saint Lucie 24.0 19.4 29.8 15.0 11.3 19.9 11.9 8.6 16.5 12.8 9.2 17.9 10.5 6.0 17.7 13.6 7.7 22.6 Santa Rosa 18.7 12.1 27.8 24.3 17.0 34.0 15.3 9.7 23.5 23.9 16.3 34.3 13.3 6.4 25.1 ^ ^ ^ Sarasota 19.9 16.8 23.8 17.8 14.3 22.3 12.2 9.8 15.6 15.5 12.2 19.9 14.1 10.3 19.9 6.5 3.4 12.1 Seminole 18.5 14.4 23.4 14.2 10.8 18.3 16.5 12.8 21.0 16.6 12.7 21.4 9.8 6.1 15.0 5.7 3.1 9.9 Sumter 22.2 15.8 33.1 11.8 6.7 21.9 14.9 9.0 25.7 15.7 9.9 27.1 ^ ^ ^ ^ ^ ^ Suwannee 17.6 8.4 36.1 21.5 10.6 41.7 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Taylor ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Union ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Volusia 14.3 11.7 17.4 17.9 14.7 21.7 17.8 14.8 21.4 13.1 10.2 16.8 11.8 8.6 16.3 6.5 3.8 10.6 Wakulla ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ Walton 14.6 7.5 27.8 ^ ^ ^ 16.4 8.1 31.3 17.2 8.8 32.8 ^ ^ ^ ^ ^ ^ Washington ^ ^ ^ 35.8 17.1 70.5 ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ (1) Rates are expressed as number of cases per 100,000 population per year, adjusted to the 2000 U.S. standard population. ^ Statistics for cells with fewer than 10 cases are not displayed 240 Source of data: Florida Cancer Data System Summary of Cancer Data, 2006 600 500 400 300 200 100 0 600 500 400 300 200 100 0

2006 2006 (per 100,000) 2005 (per 100,000) 2005 ge-Adjusted Rate 2004 ge-Adjusted Rate 2004 A A 2003 2003 2002 2002 2001 2001 2000 2000

1999 1999 Age-Adjusted Rate 1998 1998 1997 1997 1996 1996 1995 1995 1994 1994 Black 1993 White 1993 1992 1992 1991 1991 1990 1990 1989 1989 1988 1988 1987 1987 New Cases 1986 1986 1985 1985 1984 1984 1983 1983 1982 1982 1981 1981 9 8 7 6 5 4 3 2 1 0 0 10 New Cases (x 1,000) 80 60 40 20 New Cases (x 1,000) 100 700 600 500 400 300 200 100 0 500 450 400 350 300 250 200 150 100 50 0

2006 2006 2005

2005 (per 100,000) (per 100,000) Florida, 1981-2006 2004 2004 ge-Adjusted Rate ge-Adjusted Rate

A 2003 A 2003 2002 2002 2001 2001 2000 2000

1999 1999 Age-Adjusted Rate 1998 1998 1997 1997 1996 1996 1995 1995 1994 1994 1993 1993 1992 Male 1992 Female 1991 1991 1990 1990 1989 1989 1988 1988 1987 1987

1986 1986 New Cases 1985 1985 1984 1984 1983 1983 1982 1982

1981 1981 Source of data: Florida Cancer Data System 5 0 0 50 45 40 35 30 25 20 15 10 60 50 40 30 20 10 New Cases (x 1,000) New Cases (x1000) Figure 1. New Cases and Age-Adjusted Incidence Rates for All Cancers by Sex Race,

241 2008 Florida Morbidity Statistics

Figure 2. Age-Adjusted Incidence Rates by Sex and Race, Florida, 1981-2006

Age-Adjusted Rate (per 100,000) Lung and Bronchus Colorectal 160 90

120 60 Black Female 80 White Female Black Male White Male 30 40 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 0 0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Bladder Head and Neck 50 50

40 40

30 Black Female 30 White Female Black Male 20 20 White Male

10 10 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 0

Non-Hodgkin Melanoma

30 30

20 Black Female 20 White Female Black Male White Male 10 10

0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Breast Prostate 150 320

100 Black Female 240 White Female Black Male 160 White Male 50

0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Cervix Ovary 40 25

20 30

Black Female 15 20 White Female 10

10 5

Source of data: Florida Cancer Data System

242 Summary of Cancer Data, 2006

Figure 2. Age-Adjusted Incidence Rates by Sex and Race, Florida, 1981-2006 Figure 3. Age-Specific Incidence Rates for All Cancers by Sex, Race, and Age Group, Florida, 1981-2006 Age-Adjusted Rate (per 100,000) Lung and Bronchus Colorectal 160 90 Log of Age-Specific Rate (per 100,000) Black Female White Female 10000 10000 120 60 Black Female 80 White Female Black Male 1000 1000 White Male 30 40 65+

40-64

15-39 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 0 0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 100 100 0-14

Bladder Head and Neck 50 50 10 10 40 40

30 Black Female 30 White Female 1 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 1 Black Male 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 20 20 White Male

10000 10000 Non-Hodgkin Melanoma

30 30

1000 1000 20 Black Female 20 65+ White Female 40-64 Black Male 15-39 White Male 10 10 100 0-14 100

10 10 Breast Prostate 150 320 1 1 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

100 Black Female 240 White Female Source of data: Florida Cancer Data System Black Male 160 White Male 50

0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Cervix Ovary 40 25

20 30

Black Female 15 20 White Female 10

10 5

Source of data: Florida Cancer Data System

243 2008 Florida Morbidity Statistics

Section 9: Notifiable Disease Reporting: Changes to Chapter 64D-3, Florida Administrative Code (F.A.C.)

Notifiable disease or condition reporting is a core public health function codified in state law, Florida Statute 381.0031. Periodically, the Florida Department of Health (FDOH) updates Rule 64D-3, F.A.C. in order to ensure effective disease reporting. This enables FDOH the ability to collect accurate data about diseases occurring in Florida and to investigate and respond to cases of disease present in communities across the state in order to protect the health of all Floridians. Chapter 64D-3 specifies what diseases or conditions are required to be reported, the information to be included in the report, who is required to report, and the methods and time period for reporting.

During 2007 and 2008, FDOH conducted a rewrite of Chapter 64D-3 F.A.C. The updated version of Chapter 64D-3, F.A.C., became effective November 24, 2008. Making updates to Chapter 64D-3 and the list of notifiable diseases or conditions is a collaborative process between the FDOH central office, the county health departments, and reporting partners such as hospitals, physicians, and laboratories. In addition, when making revisions, the process includes official public comment periods and often topic- specific workshops. (Chapter 64D-3 previously underwent a significant rewrite that was completed in 2006). For changes that became effective November 24, 2008, the year 2009 will be the first complete reporting year where these changes will be effective and reflected in the data.

There are over 90 different diseases or conditions that FDOH requires for each individual case to be reported in addition to reporting of outbreaks or clusters of any type of disease.

Five new diseases or conditions were added during the 2008 revision: 1) Amebic encephalitis, 2) Arsenic poisoning, 3) Carbon monoxide, 4) Staphylococcus aureus community-associated mortality, 5) Staphylococcus aureus isolated from a normally sterile site (to be reported only by those laboratories participating in FDOH’s electronic laboratory reporting process).

One disease was removed from the list of reportable diseases: disease due to Clostridium perfringens, epsilon toxin.

Several important items are taken into consideration when determining if a disease or condition should be added to the list of diseases or conditions in Chapter 64D-3. In particular, surveillance takes place if a characteristic of a disease or condition requires rapid public health response due to the potential to cause significant illness or death and potential for spread between people or spread to people (from the environment or animals).

To obtain more information, such as the updated version of Chapter 64D-3, F.A.C., or other important reporting documents and guidelines, please visit http://www.doh.state.fl.us/disease_ctrl/epi/topics/surv. htm or contact the Florida Department of Health state offices, or your local county health department.

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Florida Department of Health Bureau of Epidemiology