on Epidemiology

ye on Epidemiology News from the Division of Epidemiology & Health Information Spring 2001 TCPHD Vol. 3, No. 1 Eye on Epidemiology is a periodic publication from the Division of Epidemiology and Health Information, Tarrant County Public Health Department. The newsletter offers health care providers and other interested individuals information on the incidence of disease in Tarrant County. This issue contains • Changes in Reporting Rules (hepatitis, chickenpox) • Growing Food-borne Illness Problem in Tarrant County • Gastrointestinal Illness Outbreak at Tarver Rendon Elementry School • Notifiable Conditions in Texas • Rabies 101 • Confidentiality of Disease Reporting • Tarrant County Disease Morbidity Summary, 19902000 • Rumors and Hoaxes (Response of CDC to internet false reports) • Mold in My House? Please forward comments to: Div. of Epidemiology & Health Info. Tarrant County Public Health Dept. 1800 University Drive, Suite 209 Fort Worth, Texas 76107 (817) 871-7279. TARRANT COUNTY PUBLIC HEALTH DEPARTMENT Lou K. Brewer, RN, MPH, Director Changes in Reporting Rules Hepatitis Effective December 20, 2000, hepatitis C reporting rules were changed to include all cases newly diagnosed since January 1, 2001. With hepatitis C, most acute infections are asymptomatic and most acute infections become chronic. Based on these key features of the natural history of hepatitis C infection, the inclusion of all newly diagnosed cases in reporting will better capture the scope of hepatitis C infection in Texas, and facilitate public health planning. The previous reporting rules were limited to acute cases. Such reporting failed, however, to effectively portray the dynamics of hepatitis C infection. Hepatitis C reporting is still required on a weekly basis, but now includes all newly diagnosed cases (Texas Administrative Code, Chapter 97.3.(b)1). For hepatitis A, all acute cases remain reportable. Since this infection can spread quickly from a common source, the timeline for hepatitis A reporting has been shortened from one week to one working day. This accelerated, one working day, reporting should translate into quicker intervention and reduce community morbidity. - Charles E. Bell, M.D. TDH Executive Deputy Commissioner Chickenpox (Varicella) The Texas Board of Health approved named- reporting of varicella (chickenpox) on November 10, 2000. Starting on January 2001, all cases of varicella with onset date on or after January 1, 2001 should be reported by name, address, date of birth, sex, race, ethnicity, and vaccination status. Chicken-pox morbidity has significantly declined since the vaccine was licensed in March 1995, and became a requirement for children entering school and day-care. * To report these conditions, call the Epidemiology division at (817) 871-7279 Notifiable Conditions in Texas Several Texas laws (Health & Safty Code, chapter 81, 84, and 87) require specific information regarding notifiable conditions to be provided to the local Health Department. Health care providers, hospitals, laboratories schools, and others are required to report patients who are suspected of having a notifiable condition. (chapter 97, Title 25, Texas Administrative Code.) General Instructions What: all notifiable conditions in Texas are on the right column. In addition to these, any outbreaks, exotic diseases, and unusual group expressions of disease must be reported. All diseases must be reported by name, age, sex, race/ethnicity, DOB, address, telephone number, disease, date of onset, method of diagnosis, and name, address, and telephone number of physician. When: The table on the right side lists when to report each condition. How: Any notifiable condition can be reported by calling Tarrant County Public Health Department (TCPHD) at (817)871-7279 and (817)871-7380, or by calling TDH hotline at (800)705-8868. Paper forms can be obtained by calling TCPHD. • Special Instructions Acquired immune deficiency syndrome (AIDS) should only be reported once following initial physician diagnosis. The report date, type and results of tests including a CD4+ T lymphocyte cell count below 200 cells per µl/ percentage<14% must also be included with the report. Chancroid, chlamydia, gonorrhea, HIV and syphilis reports must include the report date, type and results of tests, including a CD4+ T lymphocyte cell count below 200 cells perµl/ percentage<14% for HIV infection. Meningitis types include aspectic/viral, bacterial (specify etiology), fungal, parasite and other. Invasive streptococcal disease or invasive Meningococcal infection refers to isolates from normally sterile sites and includes meningitis, septicemia, cellutis, epiglottis, osteomyelitis, pericarditis, and septic arthritis. • • • * See ‘Special Instructions’ in the left column. NOTIFIABLE CONDITION Acquired immune deficiency syndrome (AIDS)* Amebiasis Anthrax Asbestosis Botulism, foodborne Botulism (infant) Brucellosis Campylobacteriosis Chancroid* Chickenpox (varicella) Chlamydia trachomatis infection* Creutzfeldt-Jakob disease (CJD) Cryptosporidiosis Cyclosporiasis Dengue Diphtheria Drowning/near drowning Ehrlichiosis Encephalitis (specify etiology) Escherichia coli, enterhemorrhagic Gonorrhea* Hansen’s disease (leprosy) Hantavirus infection Hemolytic uremic syndrome (HUS) Haemophilus influenzae type b infection, invasive* Hepatitis A (acute) Hepatitis B, D, E and unspecified (acute) Hepatitis C (newly diagnosed infection) Human immunodeficiency virus (HIV) infection* Lead, adult elevated blood Lead, childhood elevated blood Legionellosis Listeriosis Lyme disease Malaria Meningococcal infections, invasive* Meningitis (specify type)* Measles (rubella) Mumps Pertussis Pesticide poisoning- acute occupational Plague Poliomyelitis- acute paralytic Q fever Rabies- human Relapsing fever Rubella (including congenital) Salmonellosis- including typhoid fever Shigellosis Silicosis Smallpox Spotted fever group rickettsioses Streptococcal disease (group A or B), invasive* Syphilis* Tetanus Trichinosis Tuberculosis Tularemia Typhus Vibrio infection, including cholera Viral hemorrhagic fever Yellow fever Yersiniosis WHEN TO REPORT Within one week Within one week Immediately Within one week Immediately Within one week One working day Within one week Within one week Within one week Within one week Within one week Within one week Within one week Within one week Immediately Within one week Within one week Within one week Within one week Within one week Within one week Within one week Within one week Immediately One working day Within one week Within one week Within one week Within one week Within one week Within one week Within one week Within one week Within one week Immediately Within one week Immediately Within one week Immediately Within one week Immediately Immediately One working day Immediately Within one week One working day Within one week Within one week Within one week Immediately Within one week Within one week Within one week Within one week Within one week One working day One working day Within one week One working day Immediately Immediately Within one week Gastrointestinal Illness Outbreak at Tarver Rendon Elementary School There was a sudden outbreak of gastrointestinal illness involving approximately 50% of the students enrolled at Tarver Rendon Elementary School in the city of Mansfield from February 21 to 28, 2001. On February 23, 2001, one hundred and five students were absent due to gastrointestinal sickness, as well as thirty additional students who experienced nausea, vomiting, abdominal cramps and malaise. The duration of each illness was short in most cases, and no one reported chronic complications from their illness. A comprehensive investigation was conducted by the Tarrant County Public Health Department and TDH, Region III; however, none of the results of food, water source and stool specimen testing showed positive for any kind of bacteria or virus that could have been responsible for the illness. From the analysis of questionnaires, the patients’ food history did not reveal any food served in the school as the source of illness. The pattern of illness suggests an unknown point source of infection that was then transmitted from person to person. A report of the investigation, which includes recommendations to the school for prevention and control of future outbreaks, is available at the office of Epidemiology and Health Information. High Numbers of Food-borne Illness Complaints in Tarrant County During the First Three Months of 2001 In the first three months of 2001, the total reported number of complaints from food-borne illnesses reached 204. This was an increase of 50% more than the number of reported complaints for the entire year 2000. This high figure is due partially to the outbreak at Tarver Rendon Elementary School which involved about 150 students and a few staff members. Most other complaints were reported by groups or individuals after eating at local restaurants. These cases have been followed by epidemiological investigation and facility inspection. In January 2001, 13 out of 20 members of a local middle school band became sick after eating at a fast-food restaurant on the way to a band competition. On another occasion, 11 people complained of symptoms of food poisoning after dining at a buffet restaurant. During February 2001, eight people complained of abdominal cramps and other symptoms of illness after eating at a Mexican food restaurant. In each of these three cases, a full inspection and follow-up inspection were conducted. No definite causes of food-borne illness were observed. For acute diarrhea or some other unwelcome gastrointestinal upset, people often give an ordinary explanation, "I ate something wrong." Although America's food supply is the safest in the world, seventy-six million cases of food-borne diarrheal diseases occur in the United States every year.1 Due to the characteristics of food-borne illness, it is always difficult to find the exact cause of illness. Basic food handling safety precautions and practicing good hygiene and sanitation are the most important ways of preventing food-borne diseases. 1. http://catsmeow-club.org/visitor/mewsletter/orbitfoodborne.html Number of Complaints Related to Food-borne Illness in Tarrant County, 1991-2001* 250 203 200 176 167 # of Complaints 150 126 96 183 172 229 230 204 135 100 50 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 * 1991-2000: complaints during each entire year 2001: complaints during the 1st quarter (Jan.-Mar.) only Tarrant County Disease Morbidity Summary, 1990-2000 Disease Acquired Immunodeficiency Syndrome HIV Seropositive (anonymously reported until 1999) Amebiasis Botulism (Infant) Campylobacteriosis Chickenpox Dengue fever E. coli 0157:H7 Infection Encephalitis (etiology) Ehrlichiosis Foodborne Illness: Complaints Investigations Haemophilus Influenza (invasive) Hantavirus Infection Hemolytic Uremic Syndrome (HUS) Hepatitis: Type A Type B Type C Type Unspecified Influenza/Flu-Like Illnesses Lead Legionellosis Listeriosis Lyme Disease Malaria Measles (Rubeola) Meningitis: Aseptic Haemophilus Influenzae Meningococcal Other Bacterial Mumps Mycobacteria tuberculosis Pertussis Rocky Mountain Spotted Fever (RMSF) Rubella (German Measles) Rubella (Congenital) Salmonellosis: Shigellosis Streptococcal disease: drug resistant invasive Group A non-Group A Tetanus Typhus, murine STD: Chlamydia Gonorrhea Syphilis: Congenital (<1 yr.) Primary Secondary Other Vancomyocin Resistant Enterococcus Vibro Infections: Non-Cholera OI 0 4 2 0 0 2 2 0 0 2543 2 135 152 195 1 0 0 0 847 1964 19 147 204 111 0 0 1391 3212 12 142 184 314 0 0 1375 2596 14 156 195 470 1 0 2518 2822 11 88 105 393 0 1 2526 2365 7 64 79 351 0 0 1945 1334 0 36 64 297 0 0 2039 1469 10 13 26 188 0 0 4076 3324 2 8 13 148 0 0 9 5 68 Typhoid Fever Non-typhoid 3 2 7 8 300 61 23 8 28 36 101 24 1 13 0 0 139 211 3 3 0 11 14 84 9 8 30 21 113 35 2 5 0 4 111 112 2 2 5 7 2 105 3 12 28 9 115 38 0 1 0 0 76 250 0 0 0 3 1 150 2 8 15 17 159 6 0 4 0 0 94 222 6 2 3 8 8 129 3 13 22 16 174 5 1 0 0 0 67 58 4 2 2 6 0 202 1 23 17 1 129 13 1 2 0 2 92 159 1 2 4 10 0 132 3 33 23 22 106 15 0 0 0 0 95 100 0 1 9 0 0 49 0 13 10 2 108 55 0 0 0 0 34 41 171 248 16 5 4153 167 164 19 2 3213 241 166 23 13 1064 446 135 49 13 1855 139 139 13 126 119 10 176 176 0 203 203 0 229 229 3 0 2 135 156 39 2 386 230 230 4 0 0 165 167 30 2 48 167 167 1 0 0 146 72 35 4 164 96 96 1 0 0 127 65 15 0 43 183 183 5 0 0 111 92 25 0 10 57 2 1 2 8 3 362 0 17 29 6 113 13 0 1 0 1 131 123 3 7 3 5 3 1 3 0 1 0 0 0 6 2 58 2249 44 1782 44 2722 37 2778 1990 201 269 0 1991 202 300 2 1992 228 296 0 1993 439 292 1 1994 603 427 0 0 45 1645 1995 253 280 0 0 41 2190 1996 231 258 0 0 19 1149 1997 198 565 0 0 15 351 1998 224 225 4 1 34 177 1999 132 114 1 0 73 419 2 4 2 3 172 172 5 0 2 129 32 20 1 22 58 3 3 8 7 0 176 0 14 29 0 109 24 2 1 0 3 151 198 78 60 58 0 3 3711 2779 3 10 11 184 65 1 2000 167 309 3 1 51 48 1 11 0 0 135 135 3 0 0 137 17 16 0 7 70 5 2 4 2 0 256 2 5 12 1 66 14 0 0 0 2 163 253 32 53 107 0 0 4097 2730 3 8 14 161 42 3 In Tarrant County, the number of reports of rabies has been increasing recently. As a whistle of caution on this emerging disease, this column informs the basic facts on rabies from CDC. It is very important to educate people on the epidemiology and prevention of rabies in order to keep people and pets from being infected. Rabies is a preventable viral disease of mammals which is most often transmitted through the bite of a rabid animal. The vast majority of rabies cases reported to CDC each year occur in wild animals like raccoons, skunks, bats, and foxes. Domestic animals account for less than 10% of the reported rabies cases, with cats, cattle, and dogs most often reported rabid. Rabies virus infects the central nervous system, causing encephalopathy and ultimately death, if left untreated. Death usually occurs within days of the onset of symptoms. In 1999, total 7067 cases of rabies in animals and no cases in humans were reported to CDC. In recent years in the United States, most human fatalities have occurred in people who did not seek appropriate medical assistance, because they were unaware of their exposure. Rabies in Domestic Animals by Month, US, 1999 50 Cats Cattle Dogs 40 30 • • • • • • Rabies 101 Rabies is an acute fatal viral inflammation of the brain Rabid dogs infect thousands of people in developing countries every year. Rabid wildlife includes raccoons, skunks, foxes, coyotes, and bats. People get rabies from the bite of an infected animal. Be a responsible pet owner and keep your pet's rabies vaccination current. Avoid possible rabies exposure - love your own animals and leave other animals alone. Rabies in people can be prevented after exposure by a series of vaccinations. If a mammal bites you, wash the wound and contact a doctor about possible rabies exposure immediately. 20 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec • • Sources: http://www.fas.org/ahead/docs/rabies.html http://www.cdc.gov/ncidod/dvrd/rabies/default.html Surveillance information is not public information. By law, all surveillance information is confidential and privileged. No one can obtain an individual’s disease status by filing an open records request or a Freedom of Information Act request. Surveillance workers cannot be subpoenaed or deposed to release surveillance information about an individual. Surveillance workers cannot be questioned in a civil, criminal, special or other proceeding about the existence or contents of surveillance records for a person who is examined or treated for a reportable disease without that person's consent (Health and Safety Code Section 81.046). Surveillance workers do not give law enforcement agencies, immigration agencies, the media, insurance companies, employers or families access to the databases which contain surveillance information. Health departments do not provide lists of names of people with reportable diseases. There are very limited circumstances under which surveillance information containing a name might be released. Surveillance workers can be ordered to release information on the disease status of an individual to protect the health of a spouse (Health and Safety Code Section 81.107), health care workers (Section 81.107), first responders, emergency personnel, peace officers, fire fighters (Sections 81.048, 81.050), and victims of sexual assault (Code of Criminal Procedure). Surveillance workers who negligently release or disclose surveillance information are liable for actual damages, a penalty of not more than $1,000, and the cost of bringing the case to court and attorney's fees. Surveillance workers who intentionally breach confidentiality are liable for actual damage, which includes a penalty of not less than $1,000 and not more than $5,000, and the cost of bringing the case to court and attorney's fees. Intentional or criminally negligent breaches of confidentiality are Class A misdemeanors. TDH employees who breach confidentiality are subject to disciplinary action up to and including termination. Clients who believe their confidentiality has been breached should tell the director of the organization responsible for the breach. If the issue is not resolved or the client feels that it is inappropriate to discuss the breach with the organization's -TDH director, the client can file a complaint with the TDH. Complaints can be filed anonymously. Many warnings and concerns over several health issues are going around through e-mail, but are all of them true? CDC responds to some of these reports - “It’s a hoax.” False Report 1: Texas Child Dies of Heroin Overdose After Being Stuck by Used Needle Found in Playground Response from CDC to Report 1: This story was investigated and found to be a hoax. To become overdosed on a drug from a used needle and syringe, a person would have to have a large amount of the drug injected directly into their body. A needle stick injury such as that mentioned in the story would not lead to a large enough injection to cause a drug overdose. In addition, drug users would leave very little drug material in a discarded syringe after they have injected. If such an incident were to happen, there would likely be concerns about possible blood-borne infections, such as human immunodeficiency virus and hepatitis B or C. The risk of these infections from an improperly disposed of needle, such as that described in the story, would be extremely low. Response from CDC to Report 2: The e-mail report is untrue. CDC could not substantiate this report of a hantavirus infection, nor has CDC been asked to participate in an investigation of the incident described in the e-mail. Hantaviruses can cause a serious, often life-threatening disease called hantavirus pulmonary syndrome, or HPS. The viruses are carried by certain species of mice and can be spread to humans by exposure to virus-contaminated rodent droppings, urine, or saliva. For more information about hantavirus disease and ways to reduce the risk for exposure to hantaviruses, please refer to the following CDC web page: http://www.cdc.gov/ncidod/diseases/hanta/hps/index.htm. Response from CDC to Report 3: The e-mail is a hoax. There is no "Klingerman virus," and the information in the e-mail notice is untrue. If you receive an e-mail message about "Klingerman virus," please do not forward it to others. Although the e-mail message is a hoax, if you are concerned about the contents of a package you receive in the mail, contact your local post office. It is a criminal offense to send potentially hazardous agents through the mail for the purpose of deliberately causing harm to human health. When such an incident occurs, the local emergency response system should be activated by dialing 911 in most communities; in communities without 911 systems, local law enforcement authorities should be notified. The local FBI field office and local and state public health authorities also should be notified. Response from CDC to Report 4: The current email rumor circulating about Costa Rican bananas causing the disease 'necrotizing fasciitis' is false. We have not heard any reports of cases of necrotizing fasciitis associated with bananas. There is no evidence that necrotizing fasciitis is transmitted by food. The bacteria which most commonly cause necrotizing fasciitis live in the human body. The usual route of transmisson for these bacteria is from person to person. http://www.snopes.com/toxins/bananas.htm. False Report 2: Hantavirus Spread by Contact With Soda Cans or Grocery Packages A stock clerk who became infected with hantavirus while working in a storeroom. The e-mail message warns the reader to take precautions when handling items such as soda cans and grocery packages (for example, cereal boxes) because they may be contaminated with hantavirus. False Report 3.: "Klingerman Virus" People who have been infected with "Klingerman virus" after opening gift packages delivered to them in the mail. According to the e-mail message, a number of people became ill with a viral infection after handling a sponge contained in a package marked, "A gift for you from the Klingerman Foundation." False Report 4. Costa Rican bananas causing the disease 'necrotizing fasciitis'. Though more than welcomed rain quenched our thirsty land, the rain became literally so much more than welcome, that residences had widespread concerns of flooding in the North Central Texas area. Serious flooding has not occurred in Tarrant County; however, excessive rain and high humidity brought another health concern to our attention: MOLD. There have been numerous complaints on this primitive form of plant throughout the County, and in one particular case, it was hazardous enough to evacuate all employees in the Forest Hill Fire Department. Molds must live off other organic matter, either dead or alive, because they do not contain chlorophyll in them. Prime targets for mold are plants, compost heaps, paper products, and some animals, including humans. Molds grow around cabinets and on walls, around bath tubs, shower stalls, sinks, furnaces, in lined HVAC ducts, all inaccessible areas, as well as in and on carpets. Mold spores are the particles which cause allergies. In one study conducted by CDC, an apparent association between mold contamination of the indoor environment and a number of cases of infant pulmonary hemorrhage (or bleeding from the lung) was found.1 The mold suspected to be associated with pulmonary hemorrhage is Stachybotrys atra - one of the most commonly found molds in Tarrant County. Here are some basic information on common mold problems and how to exterminate them.2 How am I exposed to indoor molds? Molds are found everywhere. Therefore, everyone is exposed to some molds on a daily basis without evident harm. Mold spores primarily cause health problems when they enter the air and are inhaled in large numbers. How much mold can make me sick? It depends on the sensitivity of each person. The basic rule is, if you can see or smell it, take steps to remove the mold. Who is at greater risk when exposed to mold? Although exposure to molds is not healthy for anyone inside buildings, the following individuals appear to be at higher risk for adverse health effects of molds: Infants and children, elderly, immune compromised patients (people with HIV infection, cancer chemotherapy, liver disease, etc.), pregnant women, individuals with existing respiratory conditions, such as allergies, multiple chemical sensitivity, and asthma. What symptoms are common? Allergic reactions may be the most common health problem of mold exposure. Typical symptoms reported (alone or in combination) include: • respiratory problems, such as wheezing, and difficulty in breathing / shortness of breath • nasal and sinus congestion / dry, hacking cough • eyes-burning, watery, reddened, blurry vision, light sensitivity • sore throat / nose and throat irritation • skin irritation / aches and pains / possible fever • central nervous system problems (constant headaches, memory problems, and mood changes) Are there any circumstances where people should vacate a home or other building because of mold?3 These decisions have to be made individually. If you believe you are ill because of exposure to mold in a building, you should consult your physician to determine the appropriate action to take. Are some molds more hazardous than others? Certain types of molds can produce toxins, called mycotoxins, that the molds use to inhibit or prevent the growth of other organisms. Exposure to mycotoxins may present a greater hazard than that of allergenic or irritative molds. Mycotoxins have been found in homes, agricultural settings, food, and office buildings. How can I tell if I have mold in my house? If you can see mold, or if there is an earthy or musty odor, you can assume you have a mold problem. Allergic individuals may experience the symptoms listed above. Look for previous water damage. Visible mold growth is found underneath materials where water has damaged surfaces, or behind walls. Look for discoloration and leaching from plaster. - More on MOLD on page 8 1. CDC, “Important Facts about Pulmonary Hemorrhage” and also see CDC, Morbidity and Mortality Weekly Report, Jan. 17, 1997 2. http://www.cal-iaq.org/mold9803.htm 3. http://www.cdc.gov/nceh/asthma/factsheets/molds/default.htm -From page 7, "MOLD in My House? No Kidding?!" How can I clean-up the mold?4 • Identify and correct the moisture source • Clean, disinfect, and dry the moldy area: All moldy surfaces should be cleaned with a household bleach (like Clorox) and water mix = 1 cup of bleach mixed in 1 gallon of water. You can add a little dish soap to the bleach water to cut dirt and oil on the wall that can hold molds. With good ventilation, apply the bleach and water mix to the surface with a sponge, let it sit for 15 minutes, then thoroughly dry the surface. Be sure to wear a dust mask, rubber gloves and open lots of windows when cleaning with bleach and water. DO NOT mix bleach and ammonia! Bag and dispose any material that has moldy residues, such as rags, paper, leaves, or debris. • * Call your city or county health department if you have questions or need assistance. Can cleaning up molds be hazardous to my health? Yes. Exposure to molds can occur during the cleaning stage. Mold counts are typically 10 to 1000 times higher than background levels during the cleaning of mold damaged materials. Take steps to protect your health during cleanup: • When handling or cleaning moldy materials, consider using a mask or respirator to protect you from breathing airborne spores (Respirators can be purchased from hardware stores; sometimes referred to as a N95 or TC-21C particulate respirator). Wear protective clothing that is easily cleaned or discarded Use rubber gloves Try cleaning a small test patch of mold first. If you feel that this adversely affected your health, you should consider paying a licensed contractor or professional to carry out the work Ask family members or bystanders to leave areas when being cleaned. Work over short time spans and rest in a fresh air location. Air your house out well during and after the work. 4. http://gcrc.cwru.edu/stachy/cleanup.htm • • • • • • Eye News from the Division of Epidemiology & Health Information on Epidemiology DIVISION OF EPIDEMIOLOGY & HEALTH INFORMATION TARRANT COUNTY PUBLIC HEALTH DEPARTMENT 1800 UNIVERSITY DRIVE RM 209 FORT WORTH TX 76107 RETURN SERVICE REQUESTED