Travel Medicine and Infectious Disease (2015) 13, 102e103
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
CORRESPONDENCE
Fatal influenza outbreak aboard a sport fishing vessel in San Diego, California
KEYWORDS Influenza; Sport fishing; Outbreak
Dear editor, In January 2014, the Centers for Disease Control and Prevention (CDC) was notified about a death aboard a sport fishing vessel on a 16-day cruise off the Baja California peninsula. The male passenger, aged 70 years, had chronic obstructive pulmonary disease, coronary artery disease, was obese, and had not received the seasonal influenza vaccine. He had chills, productive cough, and dyspnea before his death on January 22, 2014. A second passenger, unrelated to the decedent, was medically evacuated on January 24, 2014, while at an international port due to respiratory illness. Upon return of the vessel to a U.S. port on January 27, 2014, federal and local public health officials assessed symptoms, offered influenza testing (rapid test and nasal swab for reverse transcription polymerase chain reaction [RT-PCR]) for all persons onboard, and planned for interviews to assess seasonal influenza vaccination beliefs. Among 25 passengers (including the evacuee) and nine crew, all male adults, seven passengers (28%) and two crew (22%) met criteria for influenza-like illness (ILI), defined as subjective fever plus either cough or sore throat. Subjective fever could not be confirmed for the decedent via proxy interview; hence, he was not deemed to meet ILI criteria. Among persons with ILI, the median age was 52 years (range: 43e65 years). Illness onset dates among persons with ILI ranged from 13 to 23 January, 2014. The majority (78%) with ILI had not received the 2013e2014 influenza vaccine. The ILI attack rate was 26% among all passengers and crew, 28% among the unvaccinated, and 22% among the vaccinated. Twenty-seven passengers and crew (79%) onboard agreed to influenza testing, including seven of the nine persons with ILI. Among persons with ILI, http://dx.doi.org/10.1016/j.tmaid.2014.12.002 1477-8939/ª 2014 Elsevier Ltd. All rights reserved.
specimens were collected a median of 12 days after illness onset (range: 5e15 days). All rapid tests were negative. Two (7.4%) passengers were positive for H1N1pdm09 virus by RT-PCR; neither met criteria for ILI. The evacuated passenger was hospitalized; convalescent serum was positive for influenza A H1N1pdm09 virus by hemagglutination inhibition assay. Additionally, the decedent had a postmortem nasopharyngeal swab positive for H1N1pdm09 virus by RT-PCR; cause of death by autopsy report was acute viral influenza and bacterial bronchopneumonia. Within two weeks of vessel arrival, we conducted a telephone survey regarding seasonal influenza vaccination attitudes and practices among the passengers and crew. Twenty-six passengers and crew (76%) participated, all of whom resided in California, Nevada or Colorado, and 65% were unvaccinated. Common reasons for not having received the seasonal influenza vaccine included a lack of perceived need (59%) and a belief that the vaccine can cause influenza (41%). However, when asked about general vaccine attitudes, 59% of unvaccinated participants agreed or strongly agreed that vaccines can prevent disease. Among those vaccinated, reasons cited for having received the seasonal influenza vaccine included protection from illness (100%), prevention of illness spread (89%), and receiving vaccination recommendations from their children (89%). Only 15% of participants sought travel health advice from a doctor, nurse or other health professional before departure. Influenza is a contagious viral respiratory illness with potentially severe complications, including death. Influenza rapid tests vary in their accuracy; a negative test does not rule out influenza [1]. Influenza outbreaks have been documented as a public health concern on cruise and military ships [2,3]. Sports fishing vessels might be unrecognized sites for influenza outbreaks, especially during influenza season. In this outbreak, similar ILI attack rates were observed for vaccinated and unvaccinated persons onboard. Vessel passengers and crew might benefit from travel health care and advice, including influenza vaccination and hygiene measures to prevent influenza transmission on board.
Financial support This report was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists (CSTE)
Correspondence and funded by the Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number 1U380T00014301. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Conflict of interest None.
References [1] Centers for Disease Control and Prevention. Guidance for clinicians on the use of rapid influenza diagnostic tests [Internet]. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2013. Available from:, http://www.cdc.gov/flu/professionals/diagnosis/ clinician_guidance_ridt.htm [cited 2014 Oct 14]. [2] Bell T, Kornylo Duong K, Finelli L, Slaten DD. Influenza surveillance on cruise ships. Am J Prev Med 2014;46:327e9. [3] Khaokham CB, Selent M, Loustalot FV, Zarecki SM, Harrington D, Hoke E, et al. Seroepidemiologic investigation of an outbreak of pandemic influenza A H1N1 2009 aboard a US Navy VesseldSan Diego, 2009. Influenza Other Respir Viruses 2013;7:791e8.
Jessica K. Adam Epidemic Intelligence Service, Centers for Disease Control and Prevention, USA
103 County of San Diego Health and Human Services Agency, San Diego, CA, USA Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, USA Aiden K. Varan* CDC/CSTE Applied Epidemiology Fellowship, USA County of San Diego Health and Human Services Agency, San Diego, CA, USA Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, USA Annie S. Kao Eric C. McDonald County of San Diego Health and Human Services Agency, San Diego, CA, USA Stephen H. Waterman Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, USA *Corresponding author. 3851 Rosecrans St, Suite 715 (MS: P577), San Diego, CA 92110-3115, USA. Tel.: þ1 619 692 8052; fax: þ1 858 715 6458. E-mail address: [email protected] (A.K. Varan) 17 November 2014 Available online 10 December 2014
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
CORRESPONDENCE
Fatal influenza outbreak aboard a sport fishing vessel in San Diego, California
KEYWORDS Influenza; Sport fishing; Outbreak
Dear editor, In January 2014, the Centers for Disease Control and Prevention (CDC) was notified about a death aboard a sport fishing vessel on a 16-day cruise off the Baja California peninsula. The male passenger, aged 70 years, had chronic obstructive pulmonary disease, coronary artery disease, was obese, and had not received the seasonal influenza vaccine. He had chills, productive cough, and dyspnea before his death on January 22, 2014. A second passenger, unrelated to the decedent, was medically evacuated on January 24, 2014, while at an international port due to respiratory illness. Upon return of the vessel to a U.S. port on January 27, 2014, federal and local public health officials assessed symptoms, offered influenza testing (rapid test and nasal swab for reverse transcription polymerase chain reaction [RT-PCR]) for all persons onboard, and planned for interviews to assess seasonal influenza vaccination beliefs. Among 25 passengers (including the evacuee) and nine crew, all male adults, seven passengers (28%) and two crew (22%) met criteria for influenza-like illness (ILI), defined as subjective fever plus either cough or sore throat. Subjective fever could not be confirmed for the decedent via proxy interview; hence, he was not deemed to meet ILI criteria. Among persons with ILI, the median age was 52 years (range: 43e65 years). Illness onset dates among persons with ILI ranged from 13 to 23 January, 2014. The majority (78%) with ILI had not received the 2013e2014 influenza vaccine. The ILI attack rate was 26% among all passengers and crew, 28% among the unvaccinated, and 22% among the vaccinated. Twenty-seven passengers and crew (79%) onboard agreed to influenza testing, including seven of the nine persons with ILI. Among persons with ILI, http://dx.doi.org/10.1016/j.tmaid.2014.12.002 1477-8939/ª 2014 Elsevier Ltd. All rights reserved.
specimens were collected a median of 12 days after illness onset (range: 5e15 days). All rapid tests were negative. Two (7.4%) passengers were positive for H1N1pdm09 virus by RT-PCR; neither met criteria for ILI. The evacuated passenger was hospitalized; convalescent serum was positive for influenza A H1N1pdm09 virus by hemagglutination inhibition assay. Additionally, the decedent had a postmortem nasopharyngeal swab positive for H1N1pdm09 virus by RT-PCR; cause of death by autopsy report was acute viral influenza and bacterial bronchopneumonia. Within two weeks of vessel arrival, we conducted a telephone survey regarding seasonal influenza vaccination attitudes and practices among the passengers and crew. Twenty-six passengers and crew (76%) participated, all of whom resided in California, Nevada or Colorado, and 65% were unvaccinated. Common reasons for not having received the seasonal influenza vaccine included a lack of perceived need (59%) and a belief that the vaccine can cause influenza (41%). However, when asked about general vaccine attitudes, 59% of unvaccinated participants agreed or strongly agreed that vaccines can prevent disease. Among those vaccinated, reasons cited for having received the seasonal influenza vaccine included protection from illness (100%), prevention of illness spread (89%), and receiving vaccination recommendations from their children (89%). Only 15% of participants sought travel health advice from a doctor, nurse or other health professional before departure. Influenza is a contagious viral respiratory illness with potentially severe complications, including death. Influenza rapid tests vary in their accuracy; a negative test does not rule out influenza [1]. Influenza outbreaks have been documented as a public health concern on cruise and military ships [2,3]. Sports fishing vessels might be unrecognized sites for influenza outbreaks, especially during influenza season. In this outbreak, similar ILI attack rates were observed for vaccinated and unvaccinated persons onboard. Vessel passengers and crew might benefit from travel health care and advice, including influenza vaccination and hygiene measures to prevent influenza transmission on board.
Financial support This report was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists (CSTE)
Correspondence and funded by the Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number 1U380T00014301. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Conflict of interest None.
References [1] Centers for Disease Control and Prevention. Guidance for clinicians on the use of rapid influenza diagnostic tests [Internet]. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2013. Available from:, http://www.cdc.gov/flu/professionals/diagnosis/ clinician_guidance_ridt.htm [cited 2014 Oct 14]. [2] Bell T, Kornylo Duong K, Finelli L, Slaten DD. Influenza surveillance on cruise ships. Am J Prev Med 2014;46:327e9. [3] Khaokham CB, Selent M, Loustalot FV, Zarecki SM, Harrington D, Hoke E, et al. Seroepidemiologic investigation of an outbreak of pandemic influenza A H1N1 2009 aboard a US Navy VesseldSan Diego, 2009. Influenza Other Respir Viruses 2013;7:791e8.
Jessica K. Adam Epidemic Intelligence Service, Centers for Disease Control and Prevention, USA
103 County of San Diego Health and Human Services Agency, San Diego, CA, USA Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, USA Aiden K. Varan* CDC/CSTE Applied Epidemiology Fellowship, USA County of San Diego Health and Human Services Agency, San Diego, CA, USA Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, USA Annie S. Kao Eric C. McDonald County of San Diego Health and Human Services Agency, San Diego, CA, USA Stephen H. Waterman Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, USA *Corresponding author. 3851 Rosecrans St, Suite 715 (MS: P577), San Diego, CA 92110-3115, USA. Tel.: þ1 619 692 8052; fax: þ1 858 715 6458. E-mail address: [email protected] (A.K. Varan) 17 November 2014 Available online 10 December 2014
