ye on Epidemiology
News from the Division of Epidemiology & Health Information TCPHD
Spring 2001 Vol. 3, No. 1
Eye on Epidemiology is a periodic
Changes in Reporting Rules publication from the Division of
Epidemiology and Health
Information, Tarrant County Public
Hepatitis Health Department. The newsletter
offers health care providers and
Effective December 20, 2000, hepatitis C reporting rules were changed other interested individuals
to include all cases newly diagnosed since January 1, 2001. With hepatitis C, information on the incidence of
most acute infections are asymptomatic and most acute infections become disease in Tarrant County.
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 This issue contains
• Changes in Reporting Rules
capture the scope of hepatitis C infection in Texas, and facilitate public health
planning. The previous reporting rules were limited to acute cases. Such
• Growing Food-borne Illness
reporting failed, however, to effectively portray the dynamics of hepatitis C Problem in Tarrant County
infection. Hepatitis C reporting is still required on a weekly basis, but now • Gastrointestinal Illness
includes all newly diagnosed cases (Texas Administrative Code, Chapter Outbreak at Tarver Rendon
97.3.(b)1). Elementry School
• Notifiable Conditions in Texas
For hepatitis A, all acute cases remain reportable. Since this infection • Rabies 101
can spread quickly from a common source, the timeline for hepatitis A reporting • Confidentiality of Disease
has been shortened from one week to one working day. This accelerated, one Reporting
working day, reporting should translate into quicker intervention and reduce • Tarrant County Disease
community morbidity. Morbidity Summary, 1990-
- Charles E. Bell, M.D. 2000
TDH Executive Deputy Commissioner • Rumors and Hoaxes
(Response of CDC to internet
• Mold in My House?
Please forward comments to:
The Texas Board of Health approved named- reporting of varicella Div. of Epidemiology & Health Info.
(chickenpox) on November 10, 2000. Starting on January 2001, all cases of Tarrant County Public Health Dept.
varicella with onset date on or after January 1, 2001 should be reported by name, 1800 University Drive, Suite 209
address, date of birth, sex, race, ethnicity, and vaccination status. Chicken-pox Fort Worth, Texas 76107
morbidity has significantly declined since the vaccine was licensed in March (817) 871-7279.
1995, and became a requirement for children entering school and day-care.
PUBLIC HEALTH DEPARTMENT
Lou K. Brewer, RN, MPH, Director
* To report these conditions, call the Epidemiology division at (817) 871-7279
Notifiable NOTIFIABLE CONDITION
Acquired immune deficiency syndrome
WHEN TO REPORT
Within one week
Conditions in Texas
Several Texas Amebiasis Within one week
laws (Health & Anthrax Immediately
Safty Code, chapter Asbestosis Within one week
81, 84, and 87) Botulism, foodborne Immediately
require specific information regarding notifiable Botulism (infant) Within one week
Brucellosis One working day
conditions to be provided to the local Health
Campylobacteriosis Within one week
Department. Health care providers, hospitals, Chancroid* Within one week
laboratories schools, and others are required to report Chickenpox (varicella) Within one week
patients who are suspected of having a notifiable Chlamydia trachomatis infection* Within one week
condition. (chapter 97, Title 25, Texas Administrative Creutzfeldt-Jakob disease (CJD) Within one week
Code.) Cryptosporidiosis Within one week
Cyclosporiasis Within one week
Dengue Within one week
General Instructions Diphtheria Immediately
What: all notifiable conditions in Texas are on the right Drowning/near drowning Within one week
Ehrlichiosis Within one week
column. In addition to these, any outbreaks, exotic
Encephalitis (specify etiology) Within one week
diseases, and unusual group expressions of disease must Escherichia coli, enterhemorrhagic Within one week
be reported. All diseases must be reported by name, age, Gonorrhea* Within one week
sex, race/ethnicity, DOB, address, telephone number, Hansen’s disease (leprosy) Within one week
disease, date of onset, method of diagnosis, and name, Hantavirus infection Within one week
address, and telephone number of physician. Hemolytic uremic syndrome (HUS) Within one week
Haemophilus influenzae type b infection, Immediately
When: The table on the right side lists when to report Hepatitis A (acute) One working day
each condition. Hepatitis B, D, E and unspecified (acute) Within one week
Hepatitis C (newly diagnosed infection) Within one week
How: Any notifiable condition can be reported by Human immunodeficiency virus (HIV) Within one week
calling Tarrant County Public Health Department Lead, adult elevated blood Within one week
(TCPHD) at (817)871-7279 and (817)871-7380, or by Lead, childhood elevated blood Within one week
calling TDH hotline at (800)705-8868. Paper forms can Legionellosis Within one week
be obtained by calling TCPHD. Listeriosis Within one week
Lyme disease Within one week
Malaria Within one week
Special Instructions Meningococcal infections, invasive* Immediately
• Acquired immune deficiency syndrome (AIDS) Meningitis (specify type)* Within one week
should only be reported once following initial Measles (rubella) Immediately
physician diagnosis. The report date, type and Mumps Within one week
results of tests including a CD4+ T lymphocyte cell Pertussis Immediately
Pesticide poisoning- acute occupational Within one week
count below 200 cells per µl/ percentage<14% must
also be included with the report. Poliomyelitis- acute paralytic Immediately
• Chancroid, chlamydia, gonorrhea, HIV and Q fever One working day
syphilis reports must include the report date, type Rabies- human Immediately
and results of tests, including a CD4+ T lymphocyte Relapsing fever Within one week
cell count below 200 cells perµl/ percentage<14% Rubella (including congenital) One working day
Salmonellosis- including typhoid fever Within one week
for HIV infection. Shigellosis Within one week
• Meningitis types include aspectic/viral, bacterial Silicosis Within one week
(specify etiology), fungal, parasite and other. Smallpox Immediately
• Invasive streptococcal disease or invasive Spotted fever group rickettsioses Within one week
Meningococcal infection refers to isolates from Streptococcal disease (group A or B), Within one week
normally sterile sites and includes meningitis, Syphilis* Within one week
septicemia, cellutis, epiglottis, osteomyelitis, Tetanus Within one week
pericarditis, and septic arthritis. Trichinosis Within one week
Tuberculosis One working day
Tularemia One working day
Typhus Within one week
Vibrio infection, including cholera One working day
Viral hemorrhagic fever Immediately
Yellow fever Immediately
* See ‘Special Instructions’ in the left column. Yersiniosis Within one week
Outbreak at Tarver
School of Food-borne Illness
Complaints in Tarrant County
There was a sudden outbreak
of gastrointestinal illness
During the First Three Months of 2001
involving approximately 50% of
the students enrolled at Tarver In the first three months of 2001, the total reported number of
Rendon Elementary School in the complaints from food-borne illnesses reached 204. This was an
city of Mansfield from February increase of 50% more than the number of reported complaints for the
21 to 28, 2001. On February 23, entire year 2000. This high figure is due partially to the outbreak at
2001, one hundred and five Tarver Rendon Elementary School which involved about 150 students
students were absent due to and a few staff members. Most other complaints were reported by
gastrointestinal sickness, as well groups or individuals after eating at local restaurants. These cases have
as thirty additional students who been followed by epidemiological investigation and facility inspection.
experienced nausea, vomiting, In January 2001, 13 out of 20 members of a local middle school
abdominal cramps and malaise. band became sick after eating at a fast-food restaurant on the way to a
The duration of each illness was band competition. On another occasion, 11 people complained of
short in most cases, and no one symptoms of food poisoning after dining at a buffet restaurant. During
reported chronic complications February 2001, eight people complained of abdominal cramps and
from their illness. other symptoms of illness after eating at a Mexican food restaurant. In
A comprehensive investi- each of these three cases, a full inspection and follow-up inspection
gation was conducted by the were conducted. No definite causes of food-borne illness were
Tarrant County Public Health observed.
Department and TDH, Region For acute diarrhea or some other unwelcome gastrointestinal upset,
III; however, none of the results
people often give an ordinary explanation, "I ate something wrong."
of food, water source and stool
Although America's food supply is the safest in the world, seventy-six
specimen testing showed
positive for any kind of bacteria million cases of food-borne diarrheal diseases occur in the United
or virus that could have been States every year.1 Due to the characteristics of food-borne illness, it is
responsible for the illness. From always difficult to find the exact cause of illness. Basic food handling
the analysis of questionnaires, safety precautions and practicing good hygiene and sanitation are the
the patients’ food history did not most important ways of preventing food-borne diseases.
reveal any food served in the 1. http://catsmeow-club.org/visitor/mewsletter/orbitfoodborne.html
school as the source of illness.
The pattern of illness suggests
Number of Complaints Related to Food-borne Illness
an unknown point source of in Tarrant County, 1991-2001*
infection that was then
transmitted from person to 250
person. A report of the 203 204
investigation, which includes 200
recommendations to the school
# of Complaints
for prevention and control of 126
future outbreaks, is available at 100
the office of Epidemiology and
Health Information. 50
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 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Acquired Immunodeficiency Syndrome 201 202 228 439 603 253 231 198 224 132 167
HIV Seropositive (anonymously reported until
269 300 296 292 427 280 258 565 225 114 309
Amebiasis 0 2 0 1 0 0 0 0 4 1 3
Botulism (Infant) 0 0 0 0 1 0 1
Campylobacteriosis 58 44 44 37 45 41 19 15 34 73 51
Chickenpox 2249 1782 2722 2778 1645 2190 1149 351 177 419 48
Dengue fever 2 1
E. coli 0157:H7 Infection 3 3 1 0 6 4 11
Encephalitis (etiology) 3 7 3 5 1 0 0 0 2 2 0
Ehrlichiosis 3 0
Foodborne Illness: Complaints 139 126 176 203 229 230 167 96 183 172 135
Investigations 139 119 176 203 229 230 167 96 183 172 135
Haemophilus Influenza (invasive) 13 10 0 0 3 4 1 1 5 5 3
Hantavirus Infection 0 0 0 0 0 0 0
Hemolytic Uremic Syndrome (HUS) 2 0 0 0 0 2 0
Hepatitis: Type A 171 167 241 446 135 165 146 127 111 129 137
Type B 248 164 166 135 156 167 72 65 92 32 17
Type C 16 19 23 49 39 30 35 15 25 20 16
Type Unspecified 5 2 13 13 2 2 4 0 0 1 0
Influenza/Flu-Like Illnesses 4153 3213 1064 1855 386 48 164 43 10 22 7
Lead 57 58 70
Legionellosis 3 3 2 0 6 4 1 0 2 3 5
Listeriosis 2 3 2 0 2 2 2 1 1 3 2
Lyme Disease 7 0 5 0 3 2 4 9 2 8 4
Malaria 8 11 7 3 8 6 10 0 8 7 2
Measles (Rubeola) 300 14 2 1 8 0 0 0 3 0 0
Meningitis: Aseptic 61 84 105 150 129 202 132 49 362 176 256
Haemophilus Influenzae 23 9 3 2 3 1 3 0 0 0 2
Meningococcal 8 8 12 8 13 23 33 13 17 14 5
Other Bacterial 28 30 28 15 22 17 23 10 29 29 12
Mumps 36 21 9 17 16 1 22 2 6 0 1
Mycobacteria tuberculosis 101 113 115 159 174 129 106 108 113 109 66
Pertussis 24 35 38 6 5 13 15 55 13 24 14
Rocky Mountain Spotted Fever (RMSF) 1 2 0 0 1 1 0 0 0 2 0
Rubella (German Measles) 13 5 1 4 0 2 0 0 1 1 0
Rubella (Congenital) 0 0 0 0 0 0 0 0 0 0 0
Salmonellosis: Typhoid Fever 0 4 0 0 0 2 0 0 1 3 2
Non-typhoid 139 111 76 94 67 92 95 34 131 151 163
Shigellosis 211 112 250 222 58 159 100 41 123 198 253
Streptococcal disease: drug resistant 78 32
invasive Group A 0 0 9 5 68 60 53
non-Group A 58 107
Tetanus 1 0 0 0 1 0 0 0 0 0 0
Typhus, murine 0 0 0 0 0 1 0 0 0 3 0
STD: Chlamydia 847 1391 1375 2518 2526 1945 2039 4076 3711 4097
Gonorrhea 2543 1964 3212 2596 2822 2365 1334 1469 3324 2779 2730
Syphilis: Congenital (<1 yr.) 2 19 12 14 11 7 0 10 2 3 3
Primary 135 147 142 156 88 64 36 13 8 10 8
Secondary 152 204 184 195 105 79 64 26 13 11 14
Other 195 111 314 470 393 351 297 188 148 184 161
Vancomyocin Resistant Enterococcus 65 42
Vibro Infections: Non-Cholera OI 0 4 2 0 0 2 2 0 0 1 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
• Rabies is an acute fatal viral inflammation of the brain
• Rabid dogs infect thousands of people in developing countries every year.
Cats Cattle Dogs
• Rabid wildlife includes raccoons, skunks, foxes, coyotes, and bats.
30 • People get rabies from the bite of an infected animal.
• Be a responsible pet owner and keep your pet's rabies vaccination
• 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
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
• If a mammal bites you, wash the wound and contact a doctor about
possible rabies exposure immediately.
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
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
director, the client can file a complaint with the TDH. Complaints can be filed anonymously. -TDH
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: Response from CDC to Report 1:
Texas Child Dies of Heroin This story was investigated and found to be a hoax. To become overdosed on a
Overdose After Being Stuck by drug from a used needle and syringe, a person would have to have a large amount
Used Needle Found in Playground 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
False Report 2: Response from CDC to Report 2:
Hantavirus Spread by Contact
With Soda Cans or Grocery
The e-mail report is untrue. CDC could not substantiate this report of a
Packages hantavirus infection, nor has CDC been asked to participate in an investigation of
A stock clerk who became infected the incident described in the e-mail.
with hantavirus while working in a Hantaviruses can cause a serious, often life-threatening disease called
storeroom. The e-mail message hantavirus pulmonary syndrome, or HPS. The viruses are carried by certain species
warns the reader to take precautions of mice and can be spread to humans by exposure to virus-contaminated rodent
when handling items such as soda droppings, urine, or saliva.
cans and grocery packages (for For more information about hantavirus disease and ways to reduce the risk for
example, cereal boxes) because they exposure to hantaviruses, please refer to the following CDC web page:
may be contaminated with
False Report 3.: "Klingerman Response from CDC to Report 3:
Virus" The e-mail is a hoax. There is no "Klingerman virus," and the information in
People who have been infected with
the e-mail notice is untrue. If you receive an e-mail message about "Klingerman
"Klingerman virus" after opening gift
packages delivered to them in the virus," please do not forward it to others.
mail. According to the e-mail Although the e-mail message is a hoax, if you are concerned about the contents
message, a number of people became of a package you receive in the mail, contact your local post office. It is a criminal
ill with a viral infection after offense to send potentially hazardous agents through the mail for the purpose of
handling a sponge contained in a deliberately causing harm to human health. When such an incident occurs, the
package marked, "A gift for you local emergency response system should be activated by dialing 911 in most
from the Klingerman Foundation." 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.
False Report 4. Costa Rican Response from CDC to Report 4:
bananas causing the disease
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.
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
-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
• 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.
Eye on Epidemiology
News from the Division of Epidemiology & Health Information
DIVISION OF EPIDEMIOLOGY & HEALTH INFORMATION
TARRANT COUNTY PUBLIC HEALTH DEPARTMENT
1800 UNIVERSITY DRIVE RM 209
FORT WORTH TX 76107
RETURN SERVICE REQUESTED