Carina Blackmore

Alabama Department of Health, Montgomery, Alabama, United States

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Publications (30)74.15 Total impact

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    ABSTRACT: Neonatal abstinence syndrome (NAS) is a constellation of physiologic and neurobehavioral signs exhibited by newborns exposed to addictive prescription or illicit drugs taken by a mother during pregnancy. The number of hospital discharges of newborns diagnosed with NAS has increased more than 10-fold (from 0.4 to 4.4 discharges per 1,000 live births) in Florida since 1995, far exceeding the three-fold increase observed nationally. In February 2014, the Florida Department of Health requested the assistance of CDC to 1) assess the accuracy and validity of using Florida's hospital inpatient discharge data, linked to birth and infant death certificates, as a means of NAS surveillance and 2) describe the characteristics of infants with NAS and their mothers. This report focuses only on objective two, describing maternal and infant characteristics in the 242 confirmed NAS cases identified in three Florida hospitals during a 2-year period (2010-2011). Infants with NAS experienced serious medical complications, with 97.1% being admitted to an intensive care unit, and had prolonged hospital stays, with a mean duration of 26.1 days. The findings of this investigation underscore the important public health problem of NAS and add to current knowledge on the characteristics of these mothers and infants. Effective June 2014, NAS is now a mandatory reportable condition in Florida. Interventions are also needed to 1) increase the number and use of community resources available to drug-abusing and drug-dependent women of reproductive age, 2) improve drug addiction counseling and rehabilitation referral and documentation policies, and 3) link women to these resources before or earlier in pregnancy.
  • Katherine Kendrick, Danielle Stanek, Carina Blackmore
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    ABSTRACT: On June 27, 2014, the Florida Department of Health in Miami-Dade County was notified by the Florida Poison Information Center Network of a patient with travel to Southeast Asia who was suspected of having chikungunya virus infection. After further investigation and additional testing, it was determined that the patient had not recently traveled to an endemic area, and this case was confirmed as the first locally acquired chikungunya case in the continental United States. Since the first case of locally acquired chikungunya virus infection in the Americas was reported on the Caribbean island of St. Martin in December 2013, the United States has seen an increase in chikungunya cases among travelers returning from areas where chikungunya has become endemic, particularly the Caribbean and South America. Compared with other states, Florida has seen an especially large number of chikungunya fever cases. During January 1-October 14, 2014, a total of 272 imported cases were reported in Florida, compared with 1,110 reported in the other 47 contiguous states. In addition, 11 locally acquired chikungunya cases have been identified. The recent spread of the virus and the presence of competent mosquito vectors provide the conditions for transmission of chikungunya virus in Florida.
    MMWR. Morbidity and mortality weekly report 12/2014; 63(48):1137.
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    ABSTRACT: BACKGROUND: Local introductions of dengue have been identified annually in Florida since a sustained outbreak occurred from 2009-2010 in Key West. A cluster of three locally-acquired cases of dengue fever with exposure in Martin County, Florida was reported to the Florida Department of Health in August 2013. Mosquito control efforts were enhanced immediately. The outbreak investigation identified 21 cases in two geographically separate areas, with the earliest onset date in mid-June. A seroprevalence survey was launched in September 2013 to determine the extent of the outbreak, determine whether transmission was ongoing, and identify potential risk factors. METHODS: The survey employed two different sampling strategies. A random sample of households within a one kilometer radius of each index case exposure address was selected. In addition, a cluster sampling of all businesses within a 100 meter radius of the two index exposure sites was conducted. All residents or employees of selected households and businesses were asked to complete a questionnaire concerning dengue risk factors, as well as participant medical and travel histories. Participants were also asked to provide blood samples for dengue IgM and IgG enzyme-linked immunosorbent assay (ELISA), reverse transcriptase polymerase chain reaction (RT-PCR), and plaque-reduction neutralizing antibody testing (PRNT). Data will be analyzed using Chi-squared or Fisher exact tests, weighted logistic regression modeling to assess risk factors. Variables associated with infection in a univariate analysis (P≤0.05) will be included in the multivariate model. RESULTS: The serosurvey included 364 individual household participants from 256 households and 41 employees from 11 businesses. Six (1.6%) had evidence of current (positive RT-PCR) or recent dengue infection (positive dengue IgM ELISA). One of the six had recent symptoms compatible with dengue fever, bringing the total clinical case count to 22. PRNT testing of sera from 53 individuals is currently being completed and will likely yield additional cases. Individual, business, and household level environmental and behavioral risk factors will be assessed in the final analysis. CONCLUSIONS: After completion of the PRNT testing, the estimated incidence of dengue in the two areas of activity will be calculated. No cases have been identified in Martin County since mid-September 2013; however, passive surveillance is still ongoing. This incident illustrates that the potential for sustained outbreaks of dengue exists in Florida outside the Florida Keys.
    2014 Council of State and Territorial Epidemiologists Annual Conference; 06/2014
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    ABSTRACT: BACKGROUND: As required by the Food Safety Modernization Act, in August 2012, CDC used a competitive grant process to designate five Integrated Food Safety Centers of Excellence (CoEs) headquartered in state health departments (Colorado, Florida, Minnesota, Oregon and Tennessee) and partnered with one or more academic centers to serve as resources for other local, state, and federal public health professionals to respond to outbreaks of foodborne illness. METHODS: CoE activities include: * · Collaborate with frontline public health professionals to strengthen routine foodborne illness surveillance and outbreak investigations. * · Evaluate and analyze the timeliness and effectiveness of foodborne illness surveillance and outbreak response activities. * · Train local and state public health personnel in epidemiological and environmental investigation of foodborne illness, including timeliness, coordination, and standardization of the investigation process. * · Establish fellowships, stipends and scholarships to train future epidemiology and food safety leaders in foodborne disease surveillance and outbreak investigation and to address critical workforce shortages. * · Strengthen capacity to participate in existing or new foodborne illness surveillance and environmental assessment information systems. * · Conduct program evaluation and outreach activities focused on increasing prevention, communication and education regarding food safety. RESULTS: During this session CDC will moderate a CSTE panel of state health department CoE directors who will summarize activities of the CoEs to date and solicit feedback from CSTE members on how the Centers can provide assistance to other state and local health departments in enhancing foodborne outbreak surveillance and response activities. CONCLUSIONS: CDC responded to Congress’s mandate to designate five Integrated Food Safety Centers of Excellence. The CoEs have received limited funding to begin to address some, but not all, of the required activities. CSTE member input is needed to determine how the CoEs can best meet the needs of state and local health departments, especially in the areas of: continuing education of existing staff, training of future employees, assessing and improving performance, and evaluating the effectiveness of interventions.
    2014 Council of State and Territorial Epidemiologists Annual Conference; 06/2014
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    ABSTRACT: BACKGROUND: A cluster of three locally-acquired dengue fever cases was reported by a local hospital in Martin County, Florida to the Florida Department of Health (FDOH) in August, 2013. Enhanced mosquito control efforts were implemented immediately. Active surveillance and outreach was initiated to identify additional cases, determine the extent of the outbreak, and to determine if transmission was continuing. METHODS: All suspect cases were interviewed to obtain symptoms, date of onset, and recent travel history. Mosquito control officials were provided relevant information for surveillance and control efforts. Local physicians and medical facilities were reminded to report suspect cases of dengue fever to the appropriate county health department (CHD), and a CDC developed dengue training for physicians was provided in two hospitals. The public was encouraged to drain standing water from their property, take mosquito bite precautions, and report to their health care provider if they experienced a febrile illness. Outreach was also conducted with homeless persons in the impacted area. Suspect cases reported by the public directly to the CHD were directed to their health care provider if currently ill, or offered free dengue testing if the illness was resolved. In addition, a query was created to search the FDOH syndromic surveillance system (ESSENCE-FL) for discharge diagnoses and chief complaints consistent with dengue. A seroprevalence survey was also conducted in September. Serum samples from suspect cases were tested using dengue IgM and IgG enzyme-linked immunoassays (ELISA) and reverse transcriptase polymerase chain reaction (RT-PCR) assays as appropriate. All testing was performed at the FDOH Bureau of Public Health Laboratories. RESULTS: In total 152 acute and convalescent serum samples from 139 suspect cases were tested with collection dates from 8/2/13 – 10/31/13. As a result, 22 cases with onset dates from 6/16/13 to 9/12/13 were identified. Ages ranged from 4 – 63 years; 41% of cases were female, 59% male. Fifteen cases were Martin County residents, five resided in other Florida Counties, and two were out-of-state visitors. All had outdoor exposure in at least one of two epicenters in the northern part of Martin County. One (4.5%) case was identified using the ESSENCE-FL query, one (4.5%) from the serosurvey, nine (41%) were hospital or physician reported, and 11 (50%) self/family-reported to the CHD. CONCLUSIONS: Self/family-reporting identified the highest number of cases followed by hospital or physician reporting. Effective communication and outreach to local partners and the public were critical to successful outbreak surveillance and response.
    2014 Council of State and Territorial Epidemiologists Annual Conference; 06/2014
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    ABSTRACT: Since mid-March 2014, the frequency with which cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection have been reported has increased, with the majority of recent cases reported from Saudi Arabia and United Arab Emirates (UAE). In addition, the frequency with which travel-associated MERS cases have been reported and the number of countries that have reported them to the World Health Organization (WHO) have also increased. The first case of MERS in the United States, identified in a traveler recently returned from Saudi Arabia, was reported to CDC by the Indiana State Department of Health on May 1, 2014, and confirmed by CDC on May 2. A second imported case of MERS in the United States, identified in a traveler from Saudi Arabia having no connection with the first case, was reported to CDC by the Florida Department of Health on May 11, 2014. The purpose of this report is to alert clinicians, health officials, and others to increase awareness of the need to consider MERS-CoV infection in persons who have recently traveled from countries in or near the Arabian Peninsula. This report summarizes recent epidemiologic information, provides preliminary descriptions of the cases reported from Indiana and Florida, and updates CDC guidance about patient evaluation, home care and isolation, specimen collection, and travel as of May 13, 2014.
    MMWR. Morbidity and mortality weekly report 05/2014; 63(19):431-6.
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    ABSTRACT: The health effects of mercury in humans are mostly on the developing nervous system. Pregnant women and women who are breastfeeding must be targeted in order to decrease mercury exposure to the populations at highest risk-infants, unborn fetuses, and young children. This purpose of this study is to understand the demographics of fish-consumption patterns among women of childbearing age (including pregnant women) in Martin County, Florida, and to analyze the associations of mercury levels in participants' hair with socio-demographic variables in order to better design prevention messages and campaigns. Mercury concentrations in hair samples of 408 women ages 18-49 were assessed. Data on demographic factors, pregnancy status, fish consumption, and awareness of fish advisories were collected during personal interviews. Data were analyzed using descriptive statistics and multivariate logistic regression. The geometric and arithmetic means of hair mercury concentration were 0.371 and 0.676 µg/g of hair. One-fourth of the respondents had a concentration ≥1 µg/g of hair. Consuming a higher number of fish meals per month, consumption of commercially purchased or locally caught fish higher in mercury, White race and income ≥$75,000 were positively associated with the likelihood of having higher hair mercury levels. This study confirms the existence of a higher overall mean hair mercury level and a higher percentage of women with ≥1 µg/g hair mercury level than those reported at the national level and in other regional studies. This suggests the need for region-specific fish consumption advisories to minimize mercury exposure in humans.
    Maternal and Child Health Journal 05/2014; 18(10). DOI:10.1007/s10995-014-1475-2 · 2.24 Impact Factor
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    ABSTRACT: Inhalation anthrax occurred in a man who vacationed in 4 US states where anthrax is enzootic. Despite an extensive multi-agency investigation, the specific source was not detected, and no additional related human or animal cases were found. Although rare, inhalation anthrax can occur naturally in the United States.
    Emerging Infectious Diseases 02/2014; 20(2-2):280-3. DOI:10.3201/eid2002.130021 · 7.33 Impact Factor
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    ABSTRACT: During routine screening in 2011, US Customs and Border Protection (CBP) identified 2 persons with elevated radioactivity. CBP, in collaboration with Los Alamos National Laboratory, informed the Food and Drug Administration (FDA) that these people could have increased radiation exposure as a result of undergoing cardiac Positron Emission Tomography (PET) scans several months earlier with rubidium Rb 82 chloride injection from CardioGen-82. We conducted a multistate investigation to assess the potential extent and magnitude of radioactive strontium overexposure among patients who had undergone Rb 82 PET scans. We selected a convenience sample of clinical sites in 4 states and reviewed records to identify eligible study participants, defined as people who had had an Rb 82 PET scan between February and July 2011. All participants received direct radiation screening using a radioisotope identifier able to detect the gamma energy specific for strontium-85 (514keV) and urine bioassay for excreted radioactive strontium. We referred a subset of participants with direct radiation screening counts above background readings for whole body counting (WBC) using a rank ordering of direct radiation screening. The rank order list, from highest to lowest, was used to contact and offer voluntary enrollment for WBC. Of 308 participants, 292 (95%) had direct radiation screening results indistinguishable from background radiation measurements; 261 of 265 (98%) participants with sufficient urine for analysis had radioactive strontium results below minimum detectable activity. None of the 23 participants who underwent WBC demonstrated elevated strontium activity above levels associated with routine use of the rubidium Rb 82 generator. Among investigation participants, we did not identify evidence of strontium internal contamination above permissible levels. This investigation might serve as a model for future investigations of radioactive internal contamination incidents.
    Biosecurity and bioterrorism: biodefense strategy, practice, and science 02/2014; 12(1):42-48. DOI:10.1089/bsp.2013.0072 · 1.64 Impact Factor
  • MMWR. Morbidity and mortality weekly report 08/2013; 62(33):667-668.
  • Xiaohong Li, Sharon Watkins, Carina Blackmore
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    ABSTRACT: BACKGROUND: Lead poisoning has been reported among refugee populations that resettled in the United States in recent years. Because refugee populations are considered at high risk for lead exposure, the Centers for Disease Control and Prevention recommends Blood Lead Level (BLL) testing of all refugee children age 6 months to 16 years old at entry to the US and a repeated BLL testing of all refugee children after they are placed in permanent residences. We aim to provide a description of childhood lead poisoning risk among Florida refugee children less than six years old; compare the prevalence between Florida refugee children and Florida non-refugee children; and to assess whether refugee children are still at high risk for lead poisoning. METHODS: Demographic data from newly arrived refugee children less than 6 years of age were merged with Florida BLL screening data. The children had arrived in the United States between January 2010 and June 2011 and were tested between January 2010 and December 2011. Confirmed cases of lead poisoning were identified based on the CDC case definition: a child with one venous specimen greater than or equal to 10 micrograms of lead per deciliter, or two capillary specimens greater than or equal to 10 micrograms lead per deciliter drawn within 12 weeks (84 days) of each other. Prevalence was calculated and comparisons made between refugee children and Florida children. RESULTS: The prevalence of lead poisoning was 19.9 per 1000 children tested (25 positive of 1258, 1.99 %) among refugee children; the corresponding prevalence among Florida non-refugee children during this time was 1.4 per 1000 children tested (451 positive of 311,814, 0.14%). Refugee children were 14 times more likely to be considered lead poisoned compared with Florida non-refugee children (95% CI: 9.32, 21.02). The majority (94.1%) of refugee children in this sample (n=1996) were from the following seven countries, Cuba (80.7%), Haiti (3.6%), Iraq (3.0%), Thailand (2.8%), Malaysia (2.4%) and Burma (1.6%). Among the 25 lead poisoned refugee children identified in Florida during this period, 21 were from Cuba. CONCLUSIONS: Refugee children resettled in Florida are at higher risk for lead poisoning compared with non-refugee Florida children. The majority of lead poisoned refugee children in Florida are from Cuba.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: BACKGROUND: Early morning on May 26, 2012, several individuals presented at local hospital emergency departments with severe eye irritation and pain. Patients indicated that they attended a foam party, an event where foam is sprayed onto a dance floor while participants dance to music, at a local nightclub. An investigation was conducted by the Florida Department of Health to ascertain the number of injured individuals, and determine the epidemiology and risk factors associated with the injuries. METHODS: Medical records for exposed persons were obtained from local and surrounding county hospital systems, ophthalmology clinics, and urgent care centers. Contact information, clinical results, and related event information captured in the medical records were abstracted. Interviews were attempted for all individuals with a medical record abstraction, as well as interviewee contacts that attended the foam party. RESULTS: Ultimately, 56 individuals out of an estimated 350 party-goers were identified as sustaining injuries to the eye following attendance at the foam party. Thirty-two cases had medical record abstractions and an interview conducted, 14 had an interview only, and 10 had medical record abstractions only. All cases reported getting foam in their face and 96% reported direct exposure to their eyes. Symptoms included eye irritation (95%), eye pain (91%), photophobia (71%), decreased visual acuity (81%), chemical conjunctivitis (77%), corneal abrasions (50%), and skin irritation (25%). Onset of symptoms was rapid, with most cases reporting onset between midnight and 3 a.m. on the night of the event. The average duration of symptoms was seven days, ranging from one hour to 34 days, with seven individuals failing to have resolution of symptoms at time of their interview. Injuries were severe enough to cause 77% of cases to seek medical care. In addition, 89% of cases stated rubbing their eyes following exposure, 80% mentioned a strong soap smell, and 74% stood directly under one of the foam blowers. CONCLUSIONS: In this investigation, 56 cases were identified, most with symptoms requiring medical attention. Due to the limited ability to detect cases that did not seek medical care, the attack rate of 16% most likely underestimates the true number of affected individuals. Based on duration of symptoms and number of individuals requiring medical attention, injuries sustained at this event were not minor, but in many cases resulted in long term injury. Taking safety precautions in events where chemicals are used for entertainment, such as foam parties, is important to help prevent these injuries from occurring.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
  • James Matthias, Jamie DeMent, Carina Blackmore
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    ABSTRACT: BACKGROUND: Florida has the highest number of Salmonella infections reported annually. In addition, incidence rates are 1.9 times higher than the national average of 15.2 cases per 100,000 population. Previously reported data identified eleven counties with consistently high (CHC) (>48.4 cases/100,000 population) and eleven counties with consistently low (CLC) (<17.1 cases/100,000 population) incidence rates of salmonellosis from 2005-2010. Overall incidence rate ratio (IRR) between CHCs and CLCs was 2.8, and across demographic characteristics the IRR were similar. The purpose of this analysis was to compare Salmonella serogroups and serotypes reported from CHCs and CLCs. METHODS: Reported cases of Salmonella infections acquired in CHCs and CLCs of Florida from 2005-2010 were aggregated by county and reported serogroups and serotypes were compared. RESULTS: From 2005-2010, CHC reported 6,399 cases of which 1,654 (n=26%) had serogroup and 306 (5%) had serotype testing performed. Serogroups D1 (26%), C2 (23%), and B (17%) represented nearly two-thirds of CHC isolates. Serotypes Javiana (39%) and Newport (17%) were most frequently isolated in CHC. CLC reported 7,929 cases of which 4,974 (63%) had serogroup and 259 (3%) had serotype testing performed. Serogroups B (37%), D (20%), and C (11%) also represented two-thirds of isolated for CLC cases. However, serogroup B isolates were far more common in CLC than CHC and D1 and C2 serogroups were less than 10% of all Salmonella isolates in CLC. Only serotype IV 50:z4,z23:-, formerly designated as serotype Flint, (24%) represented more than 10% of the serotyped isolates for CLC. CONCLUSIONS: CHC and CLC in Florida varied considerably in reported Salmonella isolate serogroup and serotype results. CLC had significantly more samples serogrouped than CHC and may have resulted in some bias towards rare strains being serotyped more frequently. Serotype IV 50:z4,z23:- (serogroup Z) is an exceedingly rare Salmonella strain nationally, as a result of this rarity this may have increased likelihood of being serotyped. The larger percentage of serogroups D1 and C2 and serotypes Javiana and Newport could indicate favorable environmental conditions in CHC resulting in increased rates compared to CLCs. Serotypes Javiana and Newport have been associated with reptile exposures, compared to typical foodborne serotypes like Enteritidis, Typhimurium, and Heidelberg, and finding these environmental associations between strains and high incidence rates could help reduce incidence and morbidity. A more robust protocol for serotyping a larger proportion of reported Salmonella isolates could aid in determining the effects certain Salmonella strains drive increasing rates of salmonellosis in CHC.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: BACKGROUND: Chemical incidents are a serious public health concern in Florida. The State Emergency Response Commission for Hazardous Materials reported a total of 1,576 incidents in Florida for 2010. Most chemical incidents that occur do not result in exposures to the general public, workers, or first responders, but some do, and may result in minor to severe symptoms or injuries. Early identification of exposures to hazardous chemicals through syndromic surveillance, and the use of this surveillance following an incident can help minimize adverse health effects. The Chemical Disease Surveillance Program (CDSP), located within the Florida Department of Health, performs surveillance and investigation activities related to chemical exposures. METHODS: The CDSP uses the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) system, which allows for near-real time access to emergency department (ED) data and call data from the Florida Poison Information Center Network (FPICN). Substance-specific queries are used to search ED chief complaints and discharge diagnoses for terms related to chemical exposures (e.g., “ammonia”, “chlorine”, “chemical”, etc.). Potential exposures may also be identified by searching chief complaints for common chemical exposure symptoms (e.g., “shortness of breath”, “cough”, “burns”, etc.). FPICN queries in ESSENCE use pre-existing substance categories for more common chemicals and product specific codes for chemicals less commonly reported. FPICN also records health effects for all exposure calls, and potential chemical exposures may be identified by searching health effects for common chemical exposure symptoms. Methods for identification of chemical incidents also involve review of State Watch Office alerts and media reports in near-real time. RESULTS: Surveillance efforts to identify exposures to chemical substances have resulted in timely follow-up by county health department (CHD) staff. Initial follow-up has involved the review of reports from FPICN, medical record review for exposures identified in ED data, or patient contact to determine specifics of the incident. In some instances, an epidemiologic investigation, including active case finding and incident-specific questionnaires and interviews were warranted. Efforts during surveillance and follow-up have provided valuable information for monthly reports that are distributed to partners, which include federal, state, and local agencies. In addition, this process has led to the development and use of protocols for the identification and follow-up of chemical incidents. CONCLUSIONS: Use of syndromic surveillance methods helps to identify chemical incidents that affect the public. Early identification and notification of potential incidents to CHDs benefits the residents and visitors of Florida by providing timely follow-up.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: BACKGROUND: Florida has one of the highest number imported cases of dengue fever reported in the US and has reported local introductions of dengue every year since 2009. In addition, since 2001 Florida has had seasonal transmission of the West Nile virus (WNV) resulting in an average of 25 cases per year (range 0-92). Dengue fever and non-neuroinvasive WNV illness can demonstrate a similar clinical presentation, and significant antibody cross-reaction can occur on immunologic tests. This poses a challenge to health care providers as well as local and state public health agencies. In addition, persons with repeat dengue infections may mount a transient IgM response that can be missed. The misclassification of dengue fever as non-neuroinvasive WNV illness or other febrile illness can result in suboptimal patient treatment, cause delays in identification of local dengue introductions, and result in ineffective vector surveillance and control measures. A nationwide WNV outbreak in 2012, resulted in media and public attention focusing on WNV activity while a Caribbean dengue epidemic received little attention, highlighting the need for public health surveillance and rapid confirmatory testing for endemic arboviruses as well as dengue. METHODS: Dengue and WNV illness are both reportable conditions in Florida. Confirmatory testing at the state public health laboratory is required for all WNV illness cases and is recommended for all acute dengue fever samples. A dengue polymerase chain reaction (PCR) test developed by Centers of Disease Control and Prevention was routinely used to test all suspect acute dengue and WNV fever samples. Dengue IgM enzyme-linked immunoassay (EIA) was routinely performed on all suspect dengue and WNV fever samples. RESULTS: Implementation of dengue testing for suspected WNV fever cases resulted in identification of the first local dengue case in Florida in 2012 as well as misidentified imported dengue cases. Routine use of dengue PCR resulted in definitive identification and serotype of a second local dengue case with IgM negative test results. Approximately half of all probable and confirmed dengue cases identified in Florida in 2012 had positive dengue PCR results. CONCLUSIONS: In areas where cases of both WNV illness and dengue fever may be found, it is essential that public health officials have access to tests that can rapidly and accurately identify both, and should craft standard surveillance procedures to target cases most likely to be misidentified.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: BACKGROUND: The Hillsborough County Health Department (HCHD) in Tampa, FL, became aware of rash illnesses associated with caterpillar exposure after multiple child care facilities reported children with pruritic rashes on their arms, legs, and abdomen during the months of March and April in the successive years of 2004 and 2005. Additionally, these caterpillar-associated child care outbreaks recurred at the same time of year in 2011 and 2012. While, in general, the rashes did not cause severe morbidity, misdiagnosis and inappropriate treatment of these children was common. Most of the affected children had direct contact with the caterpillars or their cocoons. METHODS: In March/April 2004, the HCHD Program investigated multiple outbreaks of rash illness of unknown etiology among child care attendees. Physicians diagnosed the affected children with a wide range of conditions including: varicella, scabies, flea bites, mosquito bites, scarlet fever, fifth disease, contact dermatitis or nonspecific viral rash. One year later, additional rash illness outbreaks at child care facilities were reported – including some of the same facilities that reported a problem the year before. This prompted a thorough epidemiologic investigation with associated site visits. Outbreak line lists were collected from all affected facilities. The identical caterpillar was seen on the playgrounds of all of the affected child care facilities. Digital photos were taken and emailed to an entomologist with the Florida Department of Agriculture and Consumer Services (DOACS). A significant effort was made to inform our medical community and other county health departments (CHDs) around the state of these caterpillar associated rashes. RESULTS: Attack rates for the children at the affected child care facilities ranged from 12.6% to 21.7%. The Florida DOACS entomologist identified the caterpillar as the white-marked tussock moth caterpillar. Child care facilities were instructed to minimize contact between the children and the caterpillars. In 2005, the HCHD was unable to identify other Florida CHDs experiencing caterpillar-associated rash outbreaks. By 2012, numerous other CHDs in Florida were reporting the same phenomenon. CONCLUSIONS: When investigating rash outbreaks of unknown etiology among children, caterpillar-associated etiology should be considered. Characteristics of these rash outbreaks include: 1) a mild pruritic rash on the abdomen, back, arms, or legs; 2) varied physician diagnoses; and 3) the presence of caterpillars and cocoons that have been associated with rashes. Better awareness of caterpillar-associated outbreaks by medical and public health professionals will spare children unnecessary treatment or exclusion from child care or school.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: Brief Summary The Florida Department of Health uses the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) to track illness related to wildfire smoke and excessive heat. The Florida ESSENCE system provides near-real time access to emergency department (ED) chief complaint data from hospitals throughout the state. Syndromic surveillance, using the ESSENCE system, has been found to be useful in the early detection of infectious diseases and exposures to hazardous chemicals. During wildfire events or times of excessive heat in Florida, climate data are closely monitored. For wildfire events, air quality data, specifically, fine particle pollution (PM2.5), from the Florida Department of Environmental Protection and smoke plume imaging maps from the National Oceanic and Atmospheric Administration (NOAA) are monitored. Syndromic surveillance of respiratory-related illness (i.e., asthma, acute bronchitis, cough, shortness of breath, wheezing, and difficulty breathing sub-syndrome categories) are conducted when the Air Quality Index exceeds 100 (unhealthy air for sensitive populations). Similarly, NOAAs graphical depiction of high temperatures and apparent temperatures are monitored for excessive heat. Syndromic surveillance for heat-related illness (e.g., chief complaints of “heat exhaustion”, “heat cramps”, “sunburn”, and “overheated”) is conducted when the heat index exceeds 110 for a particular day. Other evidences of poor air quality, such as media reports or concerns from the public, are also taken into consideration. All environmental monitoring and subsequent syndromic surveillance are assessed at the county level. If county specific data are unavailable, the closest county air monitoring data is used. Syndromic surveillance in surrounding counties (in wildfire events) is also conducted. ESSENCE has been able to detect increases in ED visits for respiratory-related chief complaints during days when PM2.5 was elevated or when there was a presence of smoke from wildfires. Similarly, ED visits with heat-related illness chief complaints were increased when the heat index was high. ESSENCE has been very useful in monitoring ED visits during wildfire events and periods of excessive heat. Surveillance reports have been distributed and used to inform Incident Command for situational awareness during times of emergency response and to assist with media inquiries. The background and methods of wildfire- and heat-related syndromic surveillance will be shared and discussed in detail during the roundtable discussion.
    2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: In 2010, malaria caused approximately 216 million infections in people and 655,000 deaths. In the United States, imported malaria cases occur every year, primarily in returning travelers and immigrants from endemic countries. In 2010, five Plasmodium falciparum malaria cases occurred among crew members of one US commercial airline company (Airline A). This investigation aimed to assess the malaria prevention knowledge, attitudes, and practices (KAP) of Airline A crew members to provide information for potential interventions. The web link to a self-administered on-line survey was distributed by internal company communications to Airline A pilots and flight attendants (FA) eligible for international travel. The survey collected demographic information as well as occupation, work history, and malaria prevention education. Of approximately 7,000 nonrandomly selected crew members, 220 FA and 217 pilots completed the survey (6%). Respondents correctly identified antimalarial medication (91% FA, 95% pilots) and insect repellents (96% FA, 96% pilots) as effective preventive measures. While in malaria-intense destinations, few FA and less than half of pilots always took antimalarial medication (4% FA, 40% pilots) yet many often spent greater than 30 minutes outdoors after sundown (71% FA, 66% pilots). Less than half in both groups always used insect repellents (46% FA, 47% pilots). Many respondents were unaware of how to get antimalarial medications (52% FA, 30% pilots) and were concerned about their side effects (61% FA, 31% pilots). Overall, FA and pilots demonstrated good knowledge of malaria prevention, but many performed risky activities while practicing only some recommended malaria preventive measures. Malaria prevention education should focus on advance notification if traveling to a malaria-endemic area, how to easily obtain antimalarial medications, and the importance of practicing all recommended preventive measures.
    Journal of Travel Medicine 10/2012; 19(6):366-72. DOI:10.1111/j.1708-8305.2012.00655.x · 1.68 Impact Factor
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    ABSTRACT: After 3 dengue cases were acquired in Key West, Florida, we conducted a serosurvey to determine the scope of the outbreak. Thirteen residents showed recent infection (infection rate 5%; 90% CI 2%-8%), demonstrating the reemergence of dengue in Florida. Increased awareness of dengue among health care providers is needed.
    Emerging Infectious Diseases 01/2012; 18(1):135-7. DOI:10.3201/eid1801.110130 · 7.33 Impact Factor
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    ABSTRACT: Previous population-based analyses of emergency department (ED) visits for anaphylaxis have been limited to small populations in limited geographic areas and focused on children or have included patients who had allergic conditions other than anaphylaxis. We sought to describe the epidemiology and risk factors among patients with anaphylaxis presenting to Florida EDs. Two thousand seven hundred fifty-one patients with anaphylaxis were identified for 2005-2006 within ED records by using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and a validated ICD-9-CM-based algorithm. Age- and sex-specific rates were calculated. Regression analyses were used to determine relative risks for anaphylaxis caused by various triggers (food, venom, and medication) and risk factors (age, sex, race, and ethnicity). The highest observed rates were among the youngest male subjects (8.2/100,000 Floridians aged 0-4 years) and among adult female subjects (15-54 years) grouped in 10-year age categories (9.9-10.9/100,000 Floridians). Male and black subjects were 20% and 25%, respectively, more likely to have a food trigger than female and white subjects. White, male, and older subjects were more likely to have an anaphylaxis-related ED visit caused by insect stings. Venom-induced anaphylaxis was more likely in August through October. Children were less likely than those older than 70 years (referent) to have medication-induced anaphylaxis (P < .03). This is the only ED-based population study in a US lower-latitude state. The overall rate is considerably lower than other US ED-based population studies. The rates of anaphylaxis by age group differed by sex. Male and black subjects were more likely to have a food trigger.
    The Journal of allergy and clinical immunology 06/2011; 128(3):594-600.e1. DOI:10.1016/j.jaci.2011.04.049 · 12.05 Impact Factor