Georgia epidemiology report, Vol. 12, no. 1 (Jan. 1996)

Georgia Epidemiology Report
The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Department of Human Resources

January 1996

Volume 12 Number 1

Division Of Public Health
Patrick J. Meehan, M.D. - Director
Epidemiology and Prevention Branch State Epidemiologist Kathleen E. Toomey, M.D., M.P.H.- Director
Epidemiology Section Paul A. Blake, M.D., M.P.H.-Director Surveillance Jeffrey D. Berschling, M.P.H.; Karen R. Horvat, M.P.H.; Jane E. Koehler, D.V.M, M.P.H.; Patrick L. Osewe, M.D., M.P.H.; Preeti Pathela, M.P.H.; Russell C. Sexton Jr., M.H.S.; Sabrina Walton, M.S.P.H. Chronic Disease Nancy E. Stroup, Ph.D.-Director Patricia M. Fox, M.P.H.; David M. Homa, Ph.D., M.P.H.; Thomas W. McKinley, M.P.H.; Edward E. Pledger, M.P.A.; D. Lee Warner, M.P.H. Tuberculosis Bharat K. Pattni, M.B.B.S., M.P.H. HIV\AIDS Awal D. Khan, Ph.D., M.A. Sexually Transmitted Diseases Quimby E. McCaskill, M.P.H.; Dhelia Williamson, M.S. Office of Perinatal Epidemiology Roger W. Rochat, M.D. - Director Mary D. Brantley, M.P.H.; Raymond E. Gangarosa, M.D., M.P.H.; Rebekah Hudgins, M.P.H.; Mary P. Mathis, Ph.D., M.P.H.; Florina Serbanescu, M.D.; Edward F. Tierney, M.P.H.
Preventive Medicine Residents Lorenzo D. Botto, M.D.; Isabella A. Danel, M.D., M.S.; Hector S. Izurieta, M.D., M.P.H.;Michael M. McNeal, M.D., M.P.H.; Peter Strebel, M.D.;Sherrilyn Wainwright, M.D.;
EIS Officers Luis G. Castellanos, M.D., Ph.D; Patricia M. Dietz, Dr.P.H.

Outbreak of Escherichia coli O157:H7 Infection
in Georgia and Tennessee, 1995
Background On June 25, 1995 the Epidemiology and Prevention Branch of the Georgia
Division of Public Health (DPH) was notified of three cases of E. coli O157 infection diagnosed in a north Georgia hospital. All of the cases occurred during a 48 hour period (June 19-20) in a community where only two cases had been reported in the previous two years. Within 24 hours of the initial report, a fourth case was identified by the same hospital. Given the proximity of this hospital to the Tennessee border, the State Epidemiologist for Tennessee was contacted. He identified two similar cases of E. coli infection with onset of illness on June 23 and 24. Active surveillance and an epidemiologic investigation was initiated June 28 in north Georgia and east Tennessee to identify possible additional cases.
On July 2, the Georgia State Laboratory determined that all 4 Georgia stool isolates had the H7 flagellar antigen, and on July 3, the Tennessee isolates were also confirmed as E. coli O157. Subsequently, additional cases of E. coli O157 infection were detected in eastern Tennessee.
Methods A case was defined as any person with laboratory-confirmed E. coli O157:H7
infection, or a household contact of a laboratory-confirmed case who reported stomach cramps and bloody diarrhea for at least 72 hours, between June 11 and 25, 1995. In households with more than one case, only the index case (earliest date of onset) was included in the case-control study. For each case, two controls matched by age and area of residence were selected.
At the onset of the investigation, the local media had suggested that hamburgers at a local chain of restaurants located in north Georgia and east Tennessee were the source of the infection. Information about the production, shipment, storage, and cooking of the hamburger meat was collected from the restaurants by a team consisting of local environmental specialists, DPH, the United States Department of Agriculture (USDA), and the restaurant chain. Several samples of ground beef from 2 of the 3 suspected restaurants were collected for culture in Georgia and Tennessee State Laboratories. Because of rapid turnover of ground beef at the restaurants, the samples were not from the suspect lot or lots.

Georgia Epidemiology Report Editorial Board
Editorial Executive Committee Patrick L. Osewe, M.D. - Editor Kathleen E. Toomey, M.D., M.P.H. Mary D. Brantley, M.P.H. Jeffrey D. Berschling, M.P.H.
Mailing List Edward E. Pledger, M.P.A.

Results Nine of ten possible cases identified met the case definition. Six (67%) of the
nine cases were white males age 7 to 89 years. Seven (88%) of the 8 cases who agreed to participate had eaten a hamburger in one of the three restaurants, while only 1 of 16 controls had eaten in any of the chain's restaurants. The hamburgers were eaten over a period of 8 days, June 14-21, 1995. Three of the cases from Georgia visited restaurant #1 on June 14, 17 or 19, while the cases from Tennessee visited at the restaurant #2 on June 19 or 21. Two cases, one from Georgia and one from Tennessee, reported eating at restaurant #3 on June 16. The laboratory analy-

Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186

Phone: (404) 657-2588

FAX: (404) 657-2586

sis indicated that all but one of the 8 E. coli O157:H7 isolates shared the same DNA pattern, which is consistent with a common source outbreak. The case with the different strain did not eat at the restaurant chain.
An environmental inspection was performed without prior notice in several of the chain's restaurants in Georgia and Tennessee. Temperature readings were taken from several locations along the cooking chain, including the freezers store areas, grills, meat holding areas, and meat patties during and after cooking. Neither incorrect temperatures nor errors in cooking procedures were found. None of the meat samples cultured yielded E. coli O157:H7.
In Georgia, 13 (68.4%) of 19 stores used frozen meat, and 6 (31.6%) used unfrozen meat. In Tennessee, 9 (37.5%) of 24 stores use frozen meat, and 15 (62.5%) used unfrozen meat. The unfrozen meat was transported from the grinding plant, and was supposed to be consumed within 8 days of grinding. Upon reaching the restaurant, the turnaround time for unfrozen meat was only 3 days. All 3 restaurants implicated in this outbreak were using unfrozen meat.
Editorial Note E coli O157:H7 is a gram-negative bacillus first recog-
nized as a pathogen in humans in 19821. In the U.S. the disease is now among the three most frequently isolated bacterial pathogens responsible for bloody diarrhea, with about 21,000 infections annually2. The infection can cause Hemolytic Uremic Syndrome (HUS), and is the most common cause of renal failure in children1,2. Outbreaks associated with this pathogen are most commonly described in northern states of the U.S.1,2. However, this outbreak the first reported to occur in Georgia and Tennessee, should alert public health authorities in southern states to look for E. coli O157:H7 infections.
Thirty-eight states currently include E. coli O157:H7 infection as a reportable disease3. Before the occurrence of this outbreak, neither Georgia nor Tennessee mandated the reporting of either E. coli O157:H7 infection or HUS. Beginning in 1996, both states will include the two diseases in their lists of reportable diseases.
This outbreak was identified because routine screening for E. coli O157:H7 infection was being done at the local

hospital where the cases from Georgia were treated. As a consequence, the Georgia State Laboratory started testing all stool specimens for E. coli O157:H7 infection routinely.
Special laboratory methods are necessary to isolate and identify E. coli O157:H74. Sorbitol-MacConkey medium and O157 antiserum, which are both available and inexpensive, are used to identify the pathogen.
The following recommendations were developed as a result of this investigation:
1. Have a food scientist assess restaurant chain food handling procedures.
2. Provide basic training in food handling practices for all restaurant employees who handle food in the workplace.
3. Routinely examine bloody stools for E. coli O157:H7, as well as Salmonella, Shigella, and Campylobacter.
4. Develop guidelines for testing for E. coli O157:H7 infection in persons with nonbloody diarrhea and stomach cramps.
References 1. Boyce, T., Swerdlow, D., Griffin, P. Escherichia coli 0157:H7 and the Hemolytic-Uremic Syndrome. The New England Journal of Medicine: 333:364-8, 1995. 2. Boyce, T., Pemberton, A., Wells, J., Griffin, P., Screening for Escherichia coli 0157:H7: A nationwide survey of clinical laboratories. IN PRESS Journal of Clinical Microbiology 3. Centers for Disease Control and Prevention. 1995. Escherichia coli 0157:H7 outbreak linked to commercially distributed dry-cured salami--Washington and California, 1994. MMWR. 44:157-160 4. Bradford, A., Griffin, P., Strockbine, N., Wells, J., The epidemiology of infections causedby Escherichia coli 0157:H7, other enterohemorrhagic E. coli, and the associated hemolityc uremic syndrome. Epidemiologic Reviews: 13:60-98, 1991.
This report was contributed by Mike Cannon and Howard Thomas, Ringold Health Dept; Marsha Ray, GA Public Health Laboratory; Luis Castellanos, Paul Blake and Harrison Stetler, Epidemiology and Prevention Branch, GA DPH.

Recommended Childhood Immunization Schedule United States, JanuaryJune 1996

In January 1995, the recommended childhood immunization schedule was published in MMWR following issuance by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics, and the American Academy of Family Physicians1. This schedule was the first unified schedule developed through a collaborative process among the recommending groups, the pharmaceutical manufacturing industry, and the Food and Drug Administration. This collaborative process should assist in maintaining a common childhood vaccination schedule and enabling further simplification of the schedule. This notice presents the recommended childhood immunization schedule for JanuaryJune 1996 (Figure 1) to incorporate licensure of varicella zoster virus vaccine (Var) and recommendations for adolescent hepatitis B vaccination. OPV remains the recommended vaccine for routine polio vaccination in the United States. IPV is recommended for persons with compromised immune sys-

tems and their household contacts and is an acceptable alternative for other persons. ACIP is developing recommendations for expanded use of IPV in the United States.
For detailed information and specific recommendations for administration of vaccines, practitioners should consult the Report of the Committee on Infectious Diseases (Red Book)2, the vaccine-specific recommendations of the ACIP, and the official manufacturers' package inserts or the Physicians' Desk Reference (PDR)3. For more information from the Georgia Immunizations Program call Michael Chaney at (404) 657-3158.
Date The schedule is dated JanuaryJune 1996, and will be
republished in July 1996 to revise or add recommendations and/or to include any changes resulting from licensure of new vaccines. Publishing an updated schedule will permit provid-

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ers to be certain they are using the most current schedule.
Format Changes A column has been added to the figure for age 1 month
to indicate the second dose of hepatitis B vaccine may be given to infants as early as age 1 month. Shaded bars indicate ages at which adolescents should receive "catch-up" vaccinations if they have not received vaccinations before and, for chickenpox, lack a reliable history of the disease
Vaccine Recommendations Changes Hepatitis B, infant.
Because of the availability of different formulations of hepatitis B vaccine, doses are presented in micrograms rather than volumes. In addition, the footnote includes recommendations for vaccination of infants born to mothers whose hepatitis B surface antigen status is unknown.
Hepatitis B, adolescent. A bar has been added to indicate that the three-dose
series of hepatitis B vaccine should be initiated or completed for adolescents aged 1112 years who have not previously received three doses of hepatitis B vaccine.
Poliovirus. A footnote has been added to indicate that, although
oral poliovirus vaccine (OPV) is recommended for routine vaccination, inactivated poliovirus vaccine (IPV) is indicated for certain persons (i.e., those with a compromised immune system and their household contacts) and continues to be an acceptable alternative for other persons. The schedule for IPV

is included in the footnote.
Measles-mumps-rubella vaccine. The footnote has been changed to indicate that although
the second dose of measles-mumps-rubella vaccine is routinely administered at age 46 years or at age 1112 years, it may be administered at any visit if at least 1 month has elapsed since receipt of the first dose.
Varicella vaccine (Var) Varicella vaccine was licensed in March 1995 and has
been added to the schedule. This vaccine is recommended for all children at age 1218 months. The footnote indicates that it may be administered to susceptible persons any time after age 12 months, and that it should be given at age 1112 years to previously unvaccinated persons lacking a reliable history of chickenpox.
References 1. CDC. Recommended childhood immunization schedule--United States, January 1995. MMWR 1995;43:95960. 2. American Academy of Pediatrics. Active and passive immunization. In: Peter G, ed. 1994 Red book: report of the Committee on Infectious Diseases. 23rd ed. Elk Grove Village, Illinois: American Academy of Pediatrics, 1994:167. 3. Medical Economics Data. Physicians' desk reference. 49th ed. Montvale, New Jersey: Medical Economics Company, Inc., 1995.

Figure 1. Recommended Childhood Vaccination Schedule* -- United States, JanuaryJune 1996

Vaccine Hepatitis B
Diphtheria, tetanus toxoids and pertussis vaccine
Haemophilus influenzae type b** Poliovirus Measles-mumps-rubella Varicella zoster virus

1

Birth

Mo.

Hep B-1 Hep B-2

2 Mos.

DTP Hib

4 Mos.

6 Mos.

Age 12 Mos.

15 Mos.

18 Mos.

Hep B-3

DTP Hib

DTP Hib

DTP(DTaP at >15 mo.) Hib

4-6 11-12 14-16

Yrs.

Yrs.

Yrs.

DTP or
DTaP

Hep B Td

OPV OPV OPV

MMR Var

OPV MMR or MMR
Var***

Range of Acceptable Ages for Vaccination

"Catch-Up" Vaccination

* Vaccines are listed under the routinely recommended ages. Infants born to hepatitis B surface antigen (HBsAg)-negative mothers should receive 2.5g of Recombivax HB (Merck & Co.) or 10g of Engerix-B (SmithKline Beecham). The second dose should
be administered >1 month after the first dose. Infants born to HBsAg-positive mothers should receive 0.5mL hepatitis B immune globulin (HBIG) within 12 hours of birth, and either 5g of Recombivax HB or 10g of Engerix-B at a separate site. The second dose is recommended at age 12 months and the third dose at age 6 months. Infants born to mothers whose HBsAg status is unknown should receive either 5g of Recombivax HB or 10g of Engerix-B within 12 hours of birth. The second dose of vaccine is recommended at age 1 month and the third dose at age 6 months. Adolescents who have not received three doses of hepatitis B vaccine should initiate or complete the series at age 1112 years. The second dose should be administered at least 1 month after the first dose, and the third dose should be administered at least 4 months after the first dose and at least 2 months after the second dose. The fourth dose of diphtheria and tetanus toxoids and pertussis vaccine (DTP) may be administered at age 12 months, if at least 6 months have elapsed since the third dose of DTP. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) is licensed for the fourth and/or fifth vaccine dose(s) for children aged >15 months and may be preferred for these doses in this age group. Tetanus and diphtheria toxoids, adsorbed, for adult use (Td) is recommended at age 1112 years if at least 5 years have elapsed since the last dose of DTP, DTaP, or diphtheria and tetanus toxoids, absorbed, for pediatric use (DT). ** Three Haemophilus influenzae type b (Hib) conjugate vaccines are licensed for infant use. If PedvaxHIB (Merck & Co.) Haemophilus b conjugate vaccine (Meningococcal Protein Conjugate) (PRP-OMP) is administered at ages 2 and 4 months, a dose at 6 months is not required. After completing the primary series, any Hib conjugate vaccine may be used as a booster. Oral poliovirus vaccine (OPV) is recommended for routine infant vaccination. Inactivated poliovirus vaccine (IPV) is recommended for persons--or household contacts of persons--with a congenital or acquired immune deficiency disease or an altered immune status resulting from disease or immunosuppressive therapy, and is an acceptable alternative for other persons. The primary three-dose series for IPV should be given with a minimum interval of 4 weeks between the first and second doses and 6 months between the second and third doses. The second dose of measles-mumps-rubella vaccine (MMR) is routinely recommended at age 46 years or at age 1112 years but may be administered at any visit provided at least 1 month has elapsed since receipt of the first dose. Varicella zoster virus vaccine (Var) can be administered to susceptible children any time after age 12 months.
*** Unvaccinated children who lack a reliable history of chickenpox should be vaccinated at age 1112 years.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services. Source: Advisory Committee on Immunization Practices, American Academy of Pediatrics, and American Academy of Family Physicians.

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The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186

January 1996

Volume 12 Number 1

Reported Cases of Selected Notifiable Diseases in Georgia Profile for October 1995

Selected Notifiable Diseases

Total Reported for October 1995

Previous 3 Months Total Ending in October
1995 1994 1993

Previous 12 Months Total Ending in October
1995 1994 1993

Campylobacteriosis

78

Giardiasis

71

H. influenzae B

1

Meningococcal Disease

17

Rubella

0

Salmonellosis

214

Shigellosis

81

Viral Meningitis

12

Tuberculosis

46

Congenital Syphilis

4

Early Syphyilis

181

Other Syphilis

80

Cryptosporidiosis

13

E. coli O157:H7

5

Legionnaires' Disease

0

Lyme Disease

0

Mumps

0

Pertussis

1

300

333

174

204

136

109

13

7

13

32

6

16

0

0

0

724

577

422

308

564

115

40

25

48

205

170

203

13

12

23

598

685

882

228

192

257

76

9

1

11

12

6

0

21

10

1

33

14

2

7

2

12

9

20

1071 546 67 111 0
1643 1647
83 782
51 2442
961 104
33 21 20
8 31

968 486
73 83
7 1506 1538
85 770
56 2705
791 16 24
111 122
20 37

786 316
67 89
0 1350
497 188 781 129 4045 976
13 10 38 48 24 56

The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office; and therefore are subject to change overtime due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.
* Data not available for this time period
AIDS Profile Update

Report Period

Total Cases Reported *

Percent Female

MSM

Risk Group Distribution (%)

Race Distribution (%)

IDU MSM&IDU HS Blood Unknown White Black Other

Last 12 Mos 1/95 to 12/95 5 Yrs Ago 1/90 to 12/90 Cumulative 1/80 to 12/95

2,240 1,232 14,481

18.7 9.9 13.5

44.4 19.1

4.6

62.6 16.2

7.0

53.4 19.1

6.1

13.2

1.5

17.2

34.0 62.8 3.2

7.1

2.9

4.2

49.6 49.1 1.3

9.6

2.2

9.6

42.1 56.0 1.9

MSM - Men having sex with men

IDU - Injection drug users

* Case totals are accumulated by date of report to the Epidemiology Section

HS - Heterosexual

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