Florida Department of Health - Hillsborough County Disease Surveillance Newsletter EpiNotes April 2018 Director Douglas Holt, MD 813.307.8008
Medical Director (HIV/STD/EPI) Articles and Attachments Included This Month Charurut Somboonwit, MD 813.307.8008 Health Advisories and Alerts 1 Medical Director (TB/Refugee) Beata Casanas, MD Florida Food Recalls 2 813.307.8008 Vaccine Preventable Disease Update 2
Medical Director (Vaccine Outreach) Arboviral Testing Fact Sheet 3 Jamie P. Morano, MD, MPH Seasonal Influenza Update 4 813.307.8008 Reportable Disease Surveillance Data 5
Community Health Director Seasonal Arboviral Update 8 Leslene Gordon, PhD, RD, LD/N Reportable Diseases/Conditions in Florida, Practitioner List 15 813.307.8015 x7107 FDOH, Practitioner Disease Report Form 16
Disease Control Director Carlos Mercado, MBA 813.307.8015 x6321
Environmental Administrator Health Advisories and Alerts Brian Miller, RS 813.307.8015 x5901 FDA Update on Ongoing Investigation into Lead Epidemiology Michael Wiese, MPH, CPH Testing Issues 813.307.8010 Fax 813.276.2981
TO REPORT A DISEASE: Multistate Outbreak of E. coli O157:H7 Infections Epidemiology Linked to Chopped Romaine Lettuce: Information 813.307.8010 collected to date indicates that romaine lettuce from the
After Hours Emergency Yuma, Arizona growing region could be contaminated with 813.307.8000 E. coli O157:H7 and could make people sick. At this time, no common grower, supplier, distributor, or brand has Food and Waterborne Illness Patrick Rodriguez been identified. Unless you can confirm the romaine 813.307.8015 x5944 Fax 813.272.7242 lettuce you have is not from the Yuma, AZ region, do not consume it. HIV/AIDS Surveillance Erica Botting 813.307.8011 Outbreak Alert: Potential Life-Threatening Vitamin K-
Lead Poisoning Dependent Antagonist Coagulopathy Associated With Cynthia O. Keeton Synthetic Cannabinoids Use 813.307.8015 x7108 Fax 813.272.6915
Sexually Transmitted Disease CDC Travel Notices: Sophia Hector Malaria and Yellow Fever in Brazil 813.307.8045 Fax 813.307.8027 Listeriosis in South Africa Tuberculosis Lassa Fever in Nigeria Irma B. Polster 813.307.8015 x4758 Fax 813.975.2014
Rick Scott Mission: To protect, promote & improve the health of all people Governor in Florida through1 integrated state & community efforts. 1 Celeste Philip, MD, MPH Vision: To be the Healthiest State in the Nation 1 State Surgeon General & Secretary EpiNotes April 2018
Florida Food Recalls (March 24 – April 24)
Date of Link to Brand Names Food Health Risk Recall Recall NutriZone, LLC of Expanded recall of various Kratom dietary 4/18/2018 Salmonella Details Houston supplements Triangle Pharmanaturals Recalling all kratom (mitragyna speciosa) 4/17/2018 Salmonella Details LLC powder products since April 4, 2017 Boost Me Mighty Meaty Beef Topper Meal TruPet, LLC 4/17/2018 Salmonella Details Enhancer Viable Solutions, LLC Kratom-containing powder products 4/17/2018 Salmonella Details Carnivore Meat Company Limited batches of "Vital Essentials" pet food 4/16/2018 Salmonella Details Cal-Maine Foods, Inc. Shell Eggs 4/16/2018 Salmonella Details Vitakraft Sun Seed Sunseed Vita Prima Sugar Glider Food 4/14/2018 Salmonella Details Rose Acre Farms Shell Eggs 4/13/2018 Salmonella Details Bob's Red Mill Natural 2,099 cases of Organic Amaranth Flour (22 4/6/2018 Salmonella Details Foods oz.) Club 13 of St. Augustine, Kratom Maeng Da Red Powder and Capsules 4/5/2018 Salmonella Details FL Triangle Pharmanaturals All food products containing powdered kratom 4/3/2018 Salmonella Details LLC NutriZone, LLC of Multiple Dietary Supplements 3/30/2018 Salmonella Details Houston Arrow Reliance Inc. & Darwin’s Natural Pet Darwin’s Brand Dog Foods 3/26/2018 Salmonella/STEC Details Products Blue Ridge Beef BRB Complete Raw Pet Food Lot#GA0131 3/26/2018 Salmonella/Listeria Details
Vaccine Preventable Disease Update
In Hillsborough County, cases of varicella (chickenpox) and pertussis (whooping cough) increased slightly from February to March, but remain well within levels seen during previous years. No confirmed or probable cases of mumps have been reported in 2018 in Hillsborough County.
Statewide data for vaccine preventable diseases is compiled into a monthly surveillance report, available online here.
2 EpiNotes April 2018
Arboviral Testing Fact Sheet
For most arboviruses, PCR testing on serum (or CSF if applicable) is confirmatory and most useful during the first 5-8 days of illness. A negative PCR result more than 5 days from For Questions or Reporting: symptom onset does not rule out the possibility of infection. DOH-Hillsborough There may be serologic cross-reactivity between viruses of the Epidemiology Program same genus. For instance, antibody testing for West Nile virus Office: 813.307.8010 (WNV) may cross react with St. Louis encephalitis (SLE), Fax: 813.276.2981 dengue, or Zika. Depending on clinical presentation, antibody testing should be ordered for all arboviruses circulating where the patient was exposed to compare results.
Suspected Cases of Endemic Arboviruses: Suspected Cases of Imported Arboviruses: (West Nile Virus, St. Louis Encephalitis, (Zika, Dengue, Chikungunya) Eastern Equine Encephalitis) Reportable upon suspicion (laboratory test Reportable by next business day order) during business hours. Cases suspected to be acquired locally, or PCR testing is available commercially cases of yellow fever, are reportable for West Nile Virus (WNV). PCR testing is immediately upon suspicion 24/7. not commercially available for SLE or EEE as these infections are less common and Testing for Zika, dengue, and chikungunya detectable viremia is generally shorter. should be ordered concurrently since all viruses have similar symptoms and are For most arboviral infections, IgM endemic in the same locations. antibodies are generally first detectable 3- 8 days after the onset of illness and PCR testing is available commercially for persist 30-90 days (or longer). Serum dengue, chikungunya, and Zika. collected within 8 days of illness onset may not have detectable IgM and testing For most arboviral infections, IgM antibodies should be repeated on a convalescent- are generally first detectable 3-8 days after phase sample. the onset of illness and persist 30-90 days (or longer). Serum collected within 8 days of IgM antibody testing for WNV, SLE, and illness onset may not have detectable IgM EEE is available commercially for serum and testing should be repeated on a and CSF. convalescent-phase sample.
A single positive IgG titer with no other IgM antibody testing for dengue, laboratory results may be indicative of chikungunya, and Zika is available past infection, and a convalescent sample commercially. There may be serologic should be collected 2-4 weeks later for cross-reactivity between Zika and dengue. titer comparison. An individual with a dengue re-infection may show elevated IgG titers but no IgM titers. IgG testing for dengue is available commercially.
3 EpiNotes April 2018
2017-2018 Seasonal Influenza Update, Hillsborough County
Influenza activity in Hillsborough County has been decreasing for the last eight weeks. Influenza activity peaked in week 5, 2018. Although activity has decreased, it remains elevated above off season levels.
The most important prevention measure you can take to prevent influenza infection is to receive your yearly influenza vaccine. It is not too late to receive the vaccine this year as different strains of influenza tend to circulate later in the season. You can receive the vaccine for free at the DOH-Hillsborough Immunizations Clinic while supplies last. Call (813) 307-8077 for more information.
Other important ways to prevent the spread of illness include covering your cough or sneeze, frequent handwashing with soap and water, and staying home from work or school until 24 hours fever free without the use of medication.
See the most recent state Florida Flu Review on our website.
Figure 1. Data are from participating Urgent Care Center (UCC) and Hospital Emergency Departments (ED) in Hillsborough County. Visits are searched for key terms related to influenza-like illness (ILI), which includes report of fever and cough or sore throat. This graph is not inclusive of all influenza diagnoses and may include visits not related to influenza.
4 EpiNotes April 2018
Reportable Disease Surveillance Data
Annual Totals** Year-To-Date** Disease Category 3 Year Jan-Mar Jan-Mar 2015 2016 2017 Average 2017 2018 Vaccine Preventable Diseases Diphtheria 0 0 0 0.00 0 0 Measles 0 0 0 0.00 0 0 Mumps 1 2 8 3.67 0 0 Pertussis 41 73 45 53.00 8 13 Poliomyelitis 0 0 0 0.00 0 0 Rubella 0 1 0 0.33 0 0 Smallpox 0 0 0 0.00 0 0 Tetanus 0 0 0 0.00 0 0 Varicella 74 70 35 59.67 5 9 CNS Diseases & Bacteremias Creutzfeldt-Jakob Disease 3 3 2 2.67 0 0 H. influenzae (Invasive Disease in children <5) 2 4 4 3.33 1 0 Listeriosis 2 0 4 2.00 0 2 Meningitis (Bacterial, Cryptococcal, Mycotic) 16 9 6 10.33 1 0 Meningococcal Disease 2 2 0 1.33 0 1 Staphylococcus aureus (VISA, VRSA) 0 0 1 0.33 0 0 S. pneumoniae (Invasive Disease in children <6) 2 3 2 2.33 0 0 Enteric Infections Campylobacteriosis 152 197 315 221.33 78 59 Cholera 0 0 0 0.00 0 0 Cryptosporidiosis 101 62 54 72.33 5 14 Cyclospora 1 1 12 4.67 0 0 Escherichia coli, Shiga toxin-producing (STEC) 16 24 15 18.33 3 18 Giardiasis 55 105 73 77.67 15 13 Hemolytic Uremic Syndrome 2 1 3 2.00 2 0 Salmonellosis 287 308 315 303.33 43 52 Shigellosis 216 76 163 151.67 35 13 Typhoid Fever 0 1 3 1.33 1 3 Viral Hepatitis Hepatitis A 5 5 10 6.67 1 6 Hepatitis B (Acute) 62 53 63 59.33 12 14 Hepatitis C (Acute) 48 31 33 37.33 4 9 Hepatitis +HBsAg in Pregnant Women 27 23 14 21.33 1 5 Hepatitis D, E, G 1 0 1 0.67 1 0
5 EpiNotes April 2018
Reportable Disease Surveillance Data
Annual Totals** Year-To-Date Disease Category 3 Year Jan-Mar Jan-Mar 2015 2016 2017 Average 2017 2018 Vectorborne, Zoonoses Chikungunya 10 1 1 4.00 0 1 Dengue 7 2 0 3.00 0 0 Eastern Equine Encephalitis 0 0 0 0.00 0 0 Ehrlichiosis/Anaplasmosis 0 0 1 0.33 0 0 Leptospirosis 1 0 1 0.67 0 1 Lyme Disease 12 6 12 10.00 2 0 Malaria 2 6 7 5.00 0 1 Plague 0 0 0 0.00 0 0 Psittacosis 0 0 0 0.00 0 0 Q Fever (Acute and Chronic) 0 0 1 0.33 0 0 Rabies (Animal) 3 3 4 3.33 0 4 Rabies (Human) 0 0 0 0.00 0 0 Rocky Mountain Spotted Fever 0 0 1 0.33 1 0 St. Louis Encephalitis 0 0 0 0.00 0 0 Trichinellosis 0 0 0 0.00 0 0 Tularemia 0 0 0 0.00 0 0 Typhus Fever (Epidemic) 0 0 0 0.00 0 0 Venezuelan Equine Encephalitis 0 0 0 0.00 0 0 West Nile Virus 2 1 0 1.00 0 0 Western Equine Encephalitis 0 0 0 0.00 0 0 Yellow Fever 0 0 0 0.00 0 0 Zika Fever NA 39 15 NA 8 1 Others Anthrax 0 0 0 0.00 0 0 Botulism, Foodborne 0 0 0 0.00 0 0 Botulism, Infant 0 0 0 0.00 0 0 Brucellosis 0 1 0 0.33 0 0 Glanders 0 0 0 0.00 0 0 Hansen's Disease (Leprosy) 0 0 0 0.00 0 0 Hantavirus Infection 0 0 0 0.00 0 0 Legionellosis 20 25 19 21.33 4 3 Melioidosis 0 0 0 0.00 0 0 Vibriosis 11 11 21 14.33 0 3
6 EpiNotes April 2018
Reportable Disease Surveillance Data
Annual Totals** Year-To-Date Disease Category 3 Year Jan-Mar Jan-Mar 2015 2016 2017 Average 2017 2018 Chemicals/Poisoning Arsenic 0 0 0 0.00 0 0 Carbon Monoxide 20 20 32 24.00 4 4 Lead 246 154 140 180.00 17 10 Mercury 13 0 3 5.33 0 0 Pesticide 1 2 6 3.00 0 1 Influenza Influenza, Pediatric Associated Mortality 0 0 5 1.67 3 0 Influenza, Novel or Pandemic Strain 0 0 0 0.00 0 0 Tuberculosis TB 41 43 28 37.33 3 3 Food and Waterborne Illness Outbreaks Food and Waterborne Cases 27 1 NA 14.00 NA NA Food and Waterborne Outbreaks 2 1 NA 1.50 NA NA
**Includes confirmed and probable cases reported in Florida residents (regardless of where infection was acquired) by date reported to the Bureau of Epidemiology in Merlin. Data for 2017/2018 are provisional and subject to change until the 2017/2018 database closes. Counts are current as of the date and time above, but may change. Please note that counts presented in this table may differ from counts presented in other tables or reports, depending on the criteria used.
Changes in case definitions can result in dramatic changes in case counts. Please see Florida Surveillance Case Definitions on the Bureau of Epidemiology for information on case definition changes (http://www.floridahealth.gov/diseases-and-conditions/disease-reporting-and-management/disease-reporting-and- surveillance/case-def-archive.html).
7 Rick Scott Mission: Governor To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts. Celeste Philip, MD, MPH Surgeon General and Secretary
Vision: To be the Healthiest State in the Nation
April 23, 2018
Dear Health Care Provider,
The Florida Department of Health (the Department) would like to remind health care providers of the importance of reporting suspect non-endemic mosquito-borne disease cases to your county health department immediately upon suspicion (yellow fever) or immediately upon suspicion during business hours (Zika, dengue, chikungunya). Other mosquito-borne diseases endemic to Florida, such as West Nile virus illness, Eastern equine encephalitis, and St. Louis encephalitis, are reportable by the next business day. For more information on these endemic diseases, please visit: www.floridahealth.gov/diseases-and- conditions/mosquito-borne-diseases/index.html
Local introduction of one or more non-endemic viruses has occurred annually since 2009, when infected travelers were bitten by mosquitoes while in Florida. Prompt reporting of suspect cases helps ensure county health department and local mosquito control officials are able to rapidly implement appropriate control measures.
Zika, dengue, chikungunya and yellow fever viruses circulate in many of the same areas of the world. The diseases they cause are often difficult to differentiate clinically and co-infections are possible. Providers should consider all relevant mosquito-borne diseases when evaluating, testing, and managing ill travelers. The Centers for Disease Control and Prevention (CDC) Yellow Book is an on-line, open access travel health reference that includes the geographic distribution of many diseases associated with international travel: wwwnc.cdc.gov/travel/page/yellowbook-home. Testing for Zika, dengue and chikungunya is available commercially. In addition, testing for Zika, dengue and chikungunya can be requested through your county health department for suspect local cases or for uninsured patients meeting clinical criteria. Yellow fever testing is available through your county health department for patients meeting clinical criteria.
Precautions that should be taken to avoid mosquito bites while traveling and at home include: Use EPA registered insect repellant with any of the following active ingredients o DEET o Oil of lemon eucalyptus o Picaridin o IR3535 o It is safe for pregnant or nursing women to use EPA-approved repellants if applied according to package label instructions. Cover skin with long-sleeved shirts and long pants. o Apply a permethrin repellent directly to clothing or purchase pre-treated clothing. Follow the manufacturer’s directions and do not apply directly to skin. Keep mosquitoes out of homes and other buildings. o Use air conditioning and maintain intact screens on windows and doors. Travelers can protect family members and prevent infection of local mosquitoes by avoiding mosquito bites for at least 3 weeks following return home.
Florida Department of Health Division of Disease Control and Health Protection Bureau of Epidemiology 4052 Bald Cypress Way, Bin A-12 • Tallahassee, FL 32399 PHONE: 850/245-4401 • FAX: 850/922-9299 FloridaHealth.gov
General Arbo Awareness Page Two April 23, 2018
Protect family members by draining standing water near residences and businesses at least weekly to keep local mosquito populations low and prevent local introductions.
Additional virus specific precautions include: Zika virus o Zika virus infection during pregnancy can cause certain birth defects, including microcephaly. Pregnant women in any trimester should consider postponing travel to areas where Zika virus transmission is ongoing. Pregnant women who must travel to these areas should talk to their doctor or other health care provider first and strictly follow steps to avoid mosquito bites during the trip. o There is also a risk of sexual transmission of Zika virus. Pregnant women and their sexual partners should consistently and correctly use condoms or other barrier precautions, or abstain from sex for the duration of the pregnancy if the partner travels to an area with Zika virus activity. o Women and men trying to become pregnant should consult with their health care provider before traveling to areas with Zika virus activity and strictly follow steps to prevent mosquito bites during the trip. Couples should consider delaying attempts to become pregnant for 2 months following female partner’s travel to Zika active areas. Couples should consider delaying attempts to become pregnant for 6 months if male partners traveled to Zika active areas. Yellow fever virus o An FDA approved yellow fever vaccine is recommended for travelers visiting endemic countries. Additional information on clinics offering the vaccine as well as vaccine recommendations for specific countries are available on the Center for Disease Control and Prevention’s website: www.cdc.gov/yellowfever/vaccine/index.html.
Mosquito-borne disease related resources: CDC Yellow Book health information for providers consulting with international travelers: wwwnc.cdc.gov/travel/page/yellowbook-home CDC Health Alert Network (HAN) includes travel-related disease alerts: emergency.cdc.gov/han/index.asp DOH mosquito-borne disease information including current Florida surveillance data: www.floridahealth.gov/diseases-and-conditions/mosquito-borne-diseases/index.html CDC mosquito-borne disease prevention information: www.cdc.gov/westnile/prevention/index.html DOH county health department contact information: www.floridahealth.gov/diseases-and-conditions/disease-reporting-and-management/index.html.
Thank you for supporting public health!
Sincerely,
Carina Blackmore, DVM, PhD, Dipl ACVPM State Epidemiologist Director, Division of Disease Control & Health Protection
Zika Fever - Information for Clinicians Version 4.1 3/28/2018
Please contact your County Health Department immediately during business hours if you suspect a patient has Zika fever to ensure prompt mosquito control efforts.
Zika virus continues to circulate in numerous countries and territories in Central and South America, Mexico and the Caribbean: https://www.cdc.gov/zika/geo/index.html. Active transmission occurred in Miami-Dade County in 2016, and sporadic activity is possible in other parts of the state. Zika virus infection during pregnancy can cause certain birth defects, including microcephaly. Fetuses and infants of women infected with Zika virus during pregnancy should be evaluated for possible congenital infection and neurologic abnormalities. Zika virus infection has also been linked to Guillain-Barre syndrome (GBS).
Transmission occurs through the bite of an infected mosquito. Perinatal, in utero, sexual, transfusion and bodily fluid transmissions have also been reported. Potentially infected men or women with pregnant partners should either abstain from sex or use condoms consistently and correctly during intercourse for the duration of the pregnancy. Suspected Zika fever cases should be advised to avoid mosquito bites while ill to prevent infection of local mosquitoes.
Incubation period is approximately 3 to 14 days.
Clinical Presentation: Only about 1 in 5 people infected with Zika virus are symptomatic. Zika fever is a mild illness with symptoms similar to those of mild dengue fever or influenza. Symptoms can be treated; however, there is no medication to treat the disease and illness typically resolves within a week. Co-infections with dengue or chikungunya are possible and should be considered. Aspirin and other non-steroidal anti- inflammatory drugs are not advised, in case of co-infection with dengue. Pregnant women with fever should be treated with acetaminophen.
Zika fever signs and symptoms may include: Acute fever (often low grade) Conjunctivitis Vomiting Rash (may be pruritic) Myalgia Cough or sore throat in some Arthralgia Headache cases
Laboratory testing: Polymerase chain reaction (PCR) can detect viral RNA in serum during the first week of illness and in urine for samples collected within two weeks of illness onset. Serum antibody tests are recommended for samples collected ≥4 days after illness onset. Dengue IgM antibody testing should be run on samples from patients with positive Zika IgM antibody tests due to cross-reactivity. Both Zika virus PCR and antibody testing are commercially available. Zika virus testing is available at the Florida Department of Health for symptomatic patients who are uninsured, potentially exposed uninsured asymptomatic pregnant women through the end of the first post-natal week, infants of potentially exposed pregnant women, suspected GBS cases with recent potential exposure to Zika, and suspected local cases meeting criteria below.
Please contact your county health department to report on the same business day suspect Zika infections including:
All persons with two or more of the following signs/symptoms: fever, maculopapular rash, arthralgia or conjunctivitis (GBS could follow) AND a history of travel to an area reporting Zika virus activity in the two weeks prior to illness onset. Suspect local cases in a county/area with no reported local Zika virus infections AND three or more of the following signs/symptoms: fever, maculopapular rash, arthralgia and conjunctivitis. Infant or fetus with microcephaly, intracranial calcifications, or abnormalities, or poor fetal outcome diagnosed after the first trimester AND with history of travel to an area with Zika virus activity during pregnancy. Testing of both mother and infant is recommended; testing of the infant is still recommended even if the mother previously tested negative.
Resources: Florida Department of Health in Hillsborough County: 813-307-8010 DOH: www.zikafreefl.org CDC: http://www.cdc.gov/Zika se Control & Health Protection
Yellow Fever - Information for Clinicians Version 1.1 3/28/2018
Please contact your county health department immediately if you suspect a patient has yellow fever. Yellow fever (YF) is a mosquito-borne flavivirus that is endemic to tropical and subtropical areas of Trinidad and Tobago, Panama, South America and Sub-Saharan Africa. Since the end of 2017, the Ministry of Health of Brazil has reported an outbreak in several states, including areas near large cities and popular tourist destinations. The outbreak is still ongoing and there have been reports of several unvaccinated travelers becoming infected. Expansion of the outbreak into urban settings may increase the risk of infection in travelers to/from those areas.
Transmission occurs through the bite of an infected Aedes aegypti mosquito which is present in Florida.
Incubation period is approximately 3 to 6 days.
Clinical Presentation: Yellow fever virus infections are generally asymptomatic or cause a mild, self-limited illness. If symptomatic, the patient is usually viremic during the initial symptomatic period, which lasts for approximately 3 days. Three clinical stages have been identified: infection; remission; and in approximately 15% of infected persons, progression to the toxic stage. The toxic stage is characterized by jaundice, hemorrhage and multiorgan dysfunction or failure, including renal insufficiency, cardiovascular instability, organ ischemia, and death (20–50% fatality rate). YF signs and symptoms may include: Acute fever Backache Jaundice Chills Myalgia Hemorrhagic diathesis Severe headache Bradycardia with fever Mucosal bleeding Nausea (Faget’s sign) Elevated serum transaminase Vomiting Scleral icterus
Laboratory testing: For patients that meet testing criteria, polymerase chain reaction (PCR) at the Florida Department of Health is recommended for serum samples collected within three days after illness onset. Serum antibody tests are available for serum samples collected ≥4 days after illness onset. Commercial testing for YF is currently not available.
Prevention: An FDA approved yellow fever vaccine from Sanofi Pasteur (YF-Vax) is recommended for travelers to endemic countries. However, due to recent manufacturing problems, the YF-Vax will be unavailable through the end of 2018. The FDA has granted an expanded access investigational new drug (eIND) protocol for use of the yellow fever vaccine “Stamaril,” which has been used in more than 70 countries, with comparable safety and efficacy to the currently available YF-Vax in the U.S. A listing of clinics approved to provide the Stamaril vaccine is posted at wwwnc.cdc.gov/travel/page/search-for-stamaril-clinics. Because other mosquito- borne diseases such as dengue and Zika circulate in the same areas, travelers should also use general precautions to avoid mosquito bites, including use of EPA-approved insect repellent such as DEET.
Please contact your county health department to report suspected YF cases and to request laboratory testing for patients meeting the following criteria: All persons, including pregnant women, with two or more of the following signs/symptoms: acute fever, headache, backache, myalgia, Faget’s sign, jaundice/scleral icterus, mucosal bleeding, AND history of travel to an area reporting YF activity in the week prior to illness onset. Immediately report suspect local case (no recent travel) with three or more of the following signs/symptoms: acute fever, headache, backache, myalgia, nausea and vomiting, Faget’s sign, jaundice/scleral icterus, mucosal bleeding AND no other identified cause.
Resources: Florida Department of Health in Hillsborough County: 813-307-8010 DOH: www.floridahealth.gov/diseases-and-conditions/yellow-fever/index.html CDC: www.cdc.gov/yellowfever/healthcareproviders/index.html West Nile Fever and Neuroinvasive Disease - Information for Clinicians
Please contact Hillsborough County Health Department (CHD) by the next business day if you suspect West Nile virus infection to ensure prompt mosquito control efforts.
Transmission: West Nile virus is transmitted to humans primarily through the bites of infected mosquitoes. Other modes of transmission include blood transfusion and organ transplantation.
Incubation period: Two to 14 days.
Clinical presentation: The clinical spectrum for WNV infection includes asymptomatic infection or mild illness (fever and headache), aseptic meningitis, and encephalitis that can progress to coma and death. West Nile virus infection cases are often categorized into two primary groups: neuroinvasive disease and non-neuroinvasive disease. Approximately 80% of those infected show no clinical symptoms. Twenty percent have mild symptoms, and less than 1% experience the neuroinvasive form of illness.
Neuroinvasive disease such as aseptic meningitis, encephalitis, or acute flaccid paralysis (AFP). Symptoms include . Fever . Stiff neck . Altered mental status . Seizures . Limb weakness . Cerebrospinal fluid (CSF) pleocytosis . Abnormal neuroimaging. Non-neuroinvasive disease (e.g., West Nile fever). Symptoms include . Fever . Headache . Myalgias . Arthralgias . Rash . Gastrointestinal symptoms
Patients at risk for severe disease: Individuals over 60 years of age Immunosuppressed patients
Laboratory testing
Testing for WNV specific IgM antibodies should be requested for serum specimens or CSF. Hillsborough CHD can provide guidance on how and when to submit samples to the Department of Health (DOH) Bureau of Public Health Laboratories.
Resources: Hillsborough County Health Department phone number: 813-307-8010 DOH Bureau of Epidemiology: http://www.floridahealth.gov/diseases-and-conditions/mosquito- borne-diseases/index.html Centers for Disease Control and Prevention: http://www.cdc.gov/westnile/index.html
Dengue Fever - Information for Clinicians Version 1.1 3/28/2018
Please contact your County Health Department (CHD) immediately during business hours if you suspect a patient has dengue to ensure prompt mosquito control efforts.
Dengue infection is caused by any of four distinct but closely related dengue virus (DENV) serotypes (called DENV-1, -2, -3, and -4). Dengue is currently the most frequent cause of acute febrile illness among returning U.S. travelers from the Caribbean, Central and South America, and Asia.
Transmission occurs through the bite of an infected mosquito. Dengue may also be transmitted from mother to fetus in utero or to neonate at parturition. An infected person should avoid mosquito bites while ill to prevent infection of local mosquitoes.
Incubation period is 3 to 14 days.
Clinical Presentation: Dengue Fever can range from a mild non-specific febrile syndrome, to classic dengue fever or “break-bone fever,” or in the most severe forms of the disease (2-4% of cases), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). More than 20% of cases may be asymptomatic. Dengue should be considered when locally acquired infection is suspected, or in persons that live in or have traveled to a dengue endemic area in the two weeks prior to symptom onset and have fever.
Dengue fever signs and symptoms may include: Headache or retro-orbital pain Anorexia and Thrombocytopenia Myalgia, bone pain, and/or nausea Leukopenia arthralgia Rash
Hemorrhagic fever or shock symptoms may appear after the febrile phase and include abdominal pain or tenderness, persistent vomiting, mucosal bleeding, liver enlargement, clinical fluid accumulation, or laboratory results indicating an increase in hematocrit concurrent with a rapid decrease in platelets.
Patients at risk for severe disease: Previously infected with another Infants Chronic renal failure dengue virus Sickle cell anemia Elderly Diabetes mellitus
Patients with suspected dengue fever also should be evaluated, tested and managed for possible chikungunya virus infection if travel was to areas where both are present, as co-infection is possible.
Laboratory testing: Polymerase chain reaction (PCR) can be used to detect viral RNA in serum samples collected during the first 5 days post symptom onset. Testing for DENV specific IgM antibodies should be requested for serum specimens taken ≥ 6 days after onset. Approximately 20% of dengue patients that have been previously exposed to another dengue serotype may show elevated IgG titers and have transient or no elevated dengue IgM titers, making identification of such cases difficult without PCR testing on the acute sample. Your CHD can provide guidance on how and when to submit samples to the Department of Health (DOH) Bureau of Public Health Laboratories.
Resources: Florida Department of Health in Hillsborough County: 813-307-8010 DOH: http://www.floridahealth.gov/diseases-and-conditions/dengue/index.html CDC: http://www.cdc.gov/dengue/clinicallab/clinical.html
Chikungunya - Information for Clinicians Version 1.1 3/28/2018
Please contact your County Health Department immediately during business hours if you suspect a patient has a chikungunya infection to ensure prompt mosquito control efforts.
Chikungunya, a dengue-like illness, has been identified in the Caribbean, Central America, and South America. Outbreaks have been documented in Africa, Southern Europe, Southeast Asia, the Indian subcontinent, and islands in the Indian and Pacific Oceans, prior to the introduction into the Caribbean in December 2013. An infected person should avoid mosquito bites while ill to prevent infection of local mosquitoes.
Transmission occurs through the bite of an infected mosquito. Chikungunya infection can also occur in neonates (aged <1 month) via transmission from infected mothers during the intrapartum period.
Incubation period is 1 to 12 days.
Clinical Presentation: A majority of people infected with chikungunya virus become symptomatic. Relapse of joint pain and fatigue may occur within three months after acute illness. Chronic joint pain and fatigue of several weeks to years duration is seen in some patients, especially those > 45 years of age or with preexisting joint disease. Persons at risk for more severe acute disease include: neonates exposed intrapartum, adults > 65 years of age, and persons with underlying medical conditions (e.g., hypertension, diabetes, or cardiovascular disease). Chikungunya fever signs and symptoms may include: Acute fever Myalgia Polyarthralgia Arthritis Headaches Rash
Patients with suspected chikungunya fever also should be evaluated, tested and managed for possible dengue virus infection if travel was to areas where both are present, as co-infection is possible. Aspirin is not advised in case of co-infection with dengue.
Laboratory testing: Polymerase Chain Reaction (PCR) can be used to detect viral RNA in serum samples collected during the first week post-symptom onset. Virus-specific IgM and neutralizing antibody testing should be requested for serum specimens taken > 1 week post-onset. Both acute (< 1 week post onset) and convalescent (> 1 week post onset) sera should be collected. Your County Health Department can provide guidance on how and when to submit samples to the Department of Health Bureau of Public Health Laboratories.
Please contact your County Health Department if you have a patient that has: Acute onset of high fever and polyarthralgia with or without recent (2 weeks prior to onset) travel to an endemic area including the Caribbean, Central and South America.
Resources: Florida Department of Health in Hillsborough County: 813-307-8010 DOH: http://www.floridahealth.gov/diseases-and-conditions/chikungunya/index.html CDC: http://www.cdc.gov/chikungunya/hc/clinicalevaluation.html
Reportable Diseases/Conditions in Florida Practitioner List (Laboratory Requirements Differ) Per Rule 64D-3.029, Florida Administrative Code, promulgated October 20, 2016 Florida Department of Health
! Report immediately 24/7 by phone upon initial suspicion or laboratory test order www.FloridaHealth.gov/DiseaseReporting Report immediately 24/7 by phone Report next business day www.FloridaHealth.gov/CHDEpiContact + Other reporting timeframe
! Outbreaks of any disease, any case, ! Haemophilus influenzae invasive Pesticide -related illness and injury, cluster of cases, or exposure to an disease in children <5 years old acute infectious or non-infectious disease, Hansen ’s disease (leprosy) ! Plague condition, or agent found in the general Hantavirus infection Poliomyelitis community or any defined setting (e.g., ! hospital, school, other institution) not Hemolytic uremic syndrome (HUS) Psittacosis (ornithosis) listed that is of urgent public health Hepatitis A Q Fever significance Hepatitis B, C, D, E, and G Rabies, animal or human Acquired immune + Hepatitis B surface antigen in pregnant deficiency syndrome (AIDS) ! Rabies, possible exposure women and children <2 years old Amebic encephalitis ! Ricin toxin poisoning Herpes B virus, possible exposure ! Anthrax Rocky Mountain spotted fever and other Herpes simplex virus (HSV) in infants spotted fever rickettsioses Arsenic poisoning <60 days old with disseminated ! Rubella ! Arboviral diseases not otherwise listed infection and liver involvement; encephalitis; and infections limited to St. Louis encephalitis Babesiosis skin, eyes, and mouth; anogenital HSV Salmonellosis Botulism, foodborne, wound, and ! in children <12 years old Saxitoxin poisoning (paralytic shellfish unspecified + Human immunodeficiency virus (HIV) poisoning) Botulism, infant infection ! Severe acute respiratory disease ! Brucellosis HIV-exposed infants <18 months old syndrome associated with coronavirus California serogroup virus disease born to an HIV-infected woman infection Human papillomavirus (HPV)- Shigellosis Campylobacteriosis associated laryngeal papillomas or + Cancer, excluding non-melanoma recurrent respiratory papillomatosis in ! Smallpox skin cancer and including benign and children <6 years old; anogenital Staphylococcal enterotoxin B poisoning borderline intracranial and CNS papillomas in children ≤12 years old Staphylococcus aureus infection, tumors ! Influenza A, novel or pandemic strains intermediate or full resistance to Carbon monoxide poisoning vancomycin (VISA, VRSA) Influenza-associated pediatric mortality Chancroid in children <18 years old Streptococcus pneumoniae invasive disease in children <6 years old Chikungunya fever Lead poisoning (blood lead level ≥5 µg/dL) Syphilis Chikungunya fever, locally acquired Legionellosis Syphilis in pregnant women and Chlamydia Leptospirosis neonates ! Cholera (Vibrio cholerae type O1) Tetanus Listeriosis Ciguatera fish poisoning Trichinellosis (trichinosis) Lyme disease + Congenital anomalies Tuberculosis (TB) Lymphogranuloma venereum (LGV) Conjunctivitis in neonates <14 days old Tularemia Malaria ! Creutzfeldt -Jakob disease (CJD) Typhoid fever (Salmonella serotype ! Measles (rubeola) Cryptosporidiosis Typhi) ! Melioidosis Cyclosporiasis ! Typhus fever, epidemic Meningitis, bacterial or mycotic Vaccinia disease ! Dengue fever ! ! Meningococcal disease Varicella (chickenpox) ! Diphtheria Mercury poisoning Eastern equine encephalitis ! Venezuelan equine encephalitis Mumps Vibriosis (infections of Vibrio species Ehrlichiosis/anaplasmosis + Neonatal abstinence syndrome (NAS) and closely related organisms, Escherichia coli infection, Shiga toxin- excluding Vibrio cholerae type O1) producing Neurotoxic shellfish poisoning ! Viral hemorrhagic fevers Giardiasis, acute Paratyphoid fever (Salmonella serotypes Paratyphi A, Paratyphi B, and West Nile virus disease ! Glanders Paratyphi C) ! Yellow fever Gonorrhea Pertussis ! Zika fever Granuloma inguinale
*Subsection 381.0031(2), Florida Statutes, provides that “Any practitioner licensed in this state to practice medicine, osteopathic medicine, chiropractic medicine, naturopathy, or veterinary medicine; any hospital licensed under part I of chapter 395; or any laboratory licensed under chapter 483 that diagnoses or suspects the existence of a disease of public health significance shall immediately report the fact to the Department of Health.” Florida’s county health departments serve as the Department’s representative in this reporting requirement. Furthermore, subsection 381.0031(4), Florida Statutes, provides that “The Department shall periodically issue a list of infectious or noninfectious diseases determined by it to be a threat to public health and therefore of significance to public health and shall furnish a copy of the list to the practitioners…”
Practitioner Disease Report Form
Complete the following information to notify the Florida Department of Health of a reportable disease or condition. This9 can be filled in electronically.
Per Rule 64D-3.029, Florida Administrative Code, promulgated October 20, 2016 (laboratory reporting requirements differ).
Patient Information Medical Information SSN: MRN: Last name: Date onset: Date diagnosis: First name: Died: Yes No Unknown Middle: Hospitalized: Yes No Unknown Parent name: Hospital name:
Gender: Male If female, Yes Date admitted: Date discharged: Female pregnant: No Unknown Unknown Insurance:
Birth date: Death date: Treated: Yes No Unknown
Race: American Indian/Alaska native White Specify Asian/Pacific islander Other treatment: Black Unknown Laboratory Ethnicity: Hispanic Yes No Unknown Attach laboratory Non-Hispanic testing: result(s) if available Unknown Address: Provider Information ZIP: County: Physician: City: State: Address: Home phone: City: State: ZIP: Other phone: Phone: Emergency phone: Fax: Email: Email: To obtain local county health department contact information, see www.FloridaHealth.gov/CHDEpiContact. See www.FloridaHealth.gov/DiseaseReporting for other reporting questions. HIV/AIDS and HIV-exposed newborn notification should be made using the Adult HIV/AIDS Confidential Case Report Form, CDC 50.42A (revised March 2013) for cases in people ≥13 years old or the Pediatric HIV/AIDS Confidential Case Report, CDC 50.42B (revised March 2003) for cases in people <13 years old. Please contact your county health department for these forms (visit www.FloridaHealth.gov/CHDEpiContact to obtain contact information). Congenital anomalies and neonatal abstinence syndrome notification occurs when these conditions are reported to the Agency for Health Care Administration in its inpatient discharge data report pursuant to Chapter 59E-7 FAC. Cancer notification should be directly to the Florida Cancer Data System (http://fcds.med.miami.edu). All other notifications should be to the CHD where the patient resides. Reportable Diseases and Conditions in Florida Notify upon suspicion 24/7 by phone Notify upon diagnosis 24/7 by phone
Amebic encephalitis Gonorrhea Melioidosis Staphylococcus aureus infection, intermediate or full resistance to Anthrax Granuloma inguinale Meningitis, bacterial or mycotic vancomycin (VISA, VRSA) Arsenic poisoning Haemophilus influenzae invasive Meningococcal disease Streptococcus pneumoniae invasive disease in children <5 years old disease in children <6 years old Arboviral diseases not otherwise listed Mercury poisoning Hansen’s disease (leprosy) Syphilis Babesiosis Mumps Hantavirus infection Syphilis in pregnant women and Botulism, foodborne, wound, and neonates Neurotoxic shellfish poisoning unspecified Hemolytic uremic syndrome (HUS) Paratyphoid fever (Salmonella Tetanus
Botulism, infant Hepatitis A serotypes Paratyphi A, Paratyphi B, Trichinellosis (trichinosis) and Paratyphi C) Brucellosis Hepatitis B, C, D, E, and G Tuberculosis (TB) Pertussis California serogroup virus disease Hepatitis B surface antigen in pregnant women and children <2 years old Pesticide-related illness and injury, Tularemia Campylobacteriosis Herpes B virus, possible exposure acute Typhoid fever (Salmonella serotype Typhi) Carbon monoxide poisoning Herpes simplex virus (HSV) in infants Plague Typhus fever, epidemic Chancroid <60 days old with disseminated Poliomyelitis infection and liver involvement; Vaccinia disease Chikungunya fever encephalitis; and infections limited to Psittacosis (ornithosis) Varicella (chickenpox) Chikungunya fever, locally acquired skin, eyes, and mouth; anogenital HSV Q Fever in children <12 years old Venezuelan equine encephalitis Chlamydia Human papillomavirus (HPV)- Rabies, animal or human Vibriosis (infections of Vibrio species associated laryngeal papillomas or Cholera (Vibrio cholerae type O1) Rabies, possible exposure and closely related organisms, recurrent respiratory papillomatosis in excluding Vibrio cholerae type O1) Ciguatera fish poisoning children <6 years old; anogenital Ricin toxin poisoning papillomas in children ≤12 years old Viral hemorrhagic fevers Conjunctivitis in neonates <14 days old Rocky Mountain spotted fever and Influenza A, novel or pandemic strains other spotted fever rickettsioses West Nile virus disease Creutzfeldt-Jakob disease (CJD) Influenza-associated pediatric mortality Rubella Yellow fever in children <18 years old Cryptosporidiosis St. Louis encephalitis Lead poisoning (blood lead level Zika fever Cyclosporiasis ≥5 ug/dL) Salmonellosis Outbreaks of any disease, any case, Dengue fever Legionellosis Saxitoxin poisoning (paralytic shellfish cluster of cases, or exposure to an poisoning) infectious or non-infectious disease, Diphtheria Leptospirosis Severe acute respiratory disease condition, or agent found in the Eastern equine encephalitis Listeriosis syndrome associated with coronavirus general community or any defined infection setting (e.g., hospital, school, other Ehrlichiosis/anaplasmosis Lyme disease Shigellosis institution) not listed above that is of Escherichia coli infection, Shiga toxin- Lymphogranuloma venereum (LGV) urgent public health significance. producing Smallpox Specify in comments below. Malaria Giardiasis, acute Staphylococcal enterotoxin B poisoning
Glanders Measles (rubeola) Comments: