Georgia epidemiology report, Vol. 12, no. 9 (Sept. 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

September 1996

Volume 12 Number 9

Outbreak of Psittacosis Linked to a

Shipment of Birds to Pet Stores

in Atlanta, August 1995

http://www.ph.dhr.state.ga.us
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.-Chief
Notifiable Diseases
Jeffrey D. Berschling, M.P.H.; Karen R. Horvat, M.P.H.; Jane E. Koehler, D.V.M, M.P.H.; Preeti Pathela, M.P.H.; Sabrina Walton, M.S.P.H.; Amri B. Johnson, M.P.H.
Chronic Disease
Nancy E. Stroup, Ph.D.-Program Manager 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
Naomi Bock, M.D., M.S.
HIV/AIDS/Sexually Transmitted Diseases
Kim Cook, M.D., M.S.P.H.-Program Manager Awal D. Khan, Ph.D., M.A.; Stephanie Bock, M.P.H.; Andrew Margolis, M.P.H.
Office of Perinatal Epidemiology
Roger W. Rochat, M.D. - Program Manager 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.
Preventive Medicine Residents
Hussain R. Yusuf, M.B.B.S., M.P.H..; E. Anne Peterson, M.D.
EIS Officer
Michael S. Friedman, M.D.
Georgia Epidemiology Report Editorial Board
Editorial Executive Committee Paul A. Blake, M.D., M.P.H.- 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.

Psittacosis is a zoonotic illness caused by Chlamydia psittaci. It is most commonly transmitted through inhalation of the aerosolized excreta from psittacine birds which include birds like parakeets, parrots, and cockatiels. Illness in humans is termed "psittacosis". Symptoms in humans generally consist of fever, chills, headache, myalgia, and malaise with or without respiratory symptoms. Avian infection is termed "chlamydiosis" and may be intermittent and asymptomatic. Signs in birds may include anorexia, ruffled feathers, lethargy, and green watery droppings.
On August 28, 1995, the Georgia Department of Agriculture was notified by a veterinarian that a bird from a pet store chain had died of chlamydiosis. A review of store records revealed that this bird was part of an August 8 shipment of 700 birds from a Florida distributor. The birds were shipped to nine Atlanta area pet stores belonging to a single chain. On August 29, birds from all nine stores were quarantined. Approximately 500 birds were moved from the nine Atlanta area pet store outlets to a tenth, yet unopened store which was being used as a quarantine facility. Of the over 700 birds from the August 8 shipment, along with the unsold birds already in the stores with which they were allowed to co-mingle, 280 birds eventually died. Sales records indicated that 210 households purchased 282 birds from the implicated flock. On August 31, the Georgia Department of Agriculture issued a press release asking that bird purchasers with symptoms contact the Georgia Department of Human Resources (DHR). On September 5, DHR began receiving reports of illness in humans.
The Centers for Disease Control and Prevention (CDC) was then invited to join an investigation to determine if Chlamydia psittaci had been transmitted to humans from birds in the implicated shipment. After psittacosis was confirmed in a number of persons who initially reported illness to DHR, a broader investigation was launched to identify risk factors for human infection and to assess the public health significance of a pet bird flock infected with Chlamydia psittaci.
Households that purchased birds from one of the implicated stores during August 1995 were surveyed and unexposed (control) households were contacted for comparison of the rates of illness. An adult from each household was asked about underlying medical conditions and development of

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

Phone: (404) 657-2588

FAX: (404) 657-2586

illness in each household member and, in the exposed with respect to age, gender, existence of underlying

households, about the health status of the bird that was medical conditions, or frequency with which medical at-

purchased and exposures to the bird.

tention was sought.

The clinical case definition of psittacosis consisted of fever or chills plus one or more of the following: cough, shortness of breath, chest pain, headache, or myalgia. The laboratory case definition was a Chlamydia psittaci IgG titer >1:32 measured by microimmunofluorescence (MIF).

Of 58 persons from the exposed households who agreed to serologic testing by MIF, 10 had serologic evidence of psittacosis meeting the laboratory case definition. However a positive serologic result did not correlate with symptoms compatible with psittacosis, suggesting that some infections were asymptomatic.

All members of exposed households were offered serologic testing. Serum specimens were sent to the State Public Health Laboratory, tested by complement fixation, and forwarded to CDC to measure Chlamydia psittaci IgG titers by MIF. Dead birds collected by the Georgia Department of Agriculture were tested by tissue staining methods, polymerase chain reaction (PCR), and culture.
Of 428 persons in the 114 exposed households that were reached, 46 (10.7% of those exposed) had an illness meeting the clinical case definition for psittacosis. The epidemic curve is shown in Figure 1 below.
Figure 1. Date of onset of psittacosis in Atlanta, August-September 1995.

Fifty-six dead birds from the pet store chain that either died in the stores or were returned by customers were sent to the University of Georgia for testing; two of the specimens were positive by tissue staining methods. Twenty-six of the birds were also tested at CDC using culture and PCR. Five of these specimens were positive by PCR; two were also culture positive.
This outbreak of human psittacosis was identified by recognition of avian chlamydiosis and not by surveillance of human illness. The illness in birds was detected by compliance with the Georgia Bird Dealer Licensing Act--a unique legislation which gives the state Department of Agriculture considerable authority in regulating the pet bird trade in the state and requires retailers to keep records identifying both the supplier and the purchaser of pet birds and to report bird deaths to the Georgia Department of Agriculture. Although in this investigation, infection in humans was mild or asymptomatic, psittacosis can have a very severe, even fatal course. PCR analysis of avian specimens improved the ability to detect Chlamydia psittaci over traditional tissue staining methods.

Illness compatible with psittacosis was more common in households if the bird became sick or died or if the bird was let out of the cage to move about the house. Kissing/nuzzling the bird, handling the bird, and feeding the bird were significantly associated with illness, but cleaning the cage was not (Table 1).

Table 1. Exposures and their association with development of psittacosis.

Exposure

% exposed ill Not ill

RR* 95% CI

Kissing

35 12

Handling

61 39

Feeding

63 46

Cage cleaning 43 40

3.12 1.82-5.36 2.17 1.24-3.79 1.83 1.04-3.23 1.11 0.64-1.92

* relative risk

95% confidence interval

Only 1.8% of persons from 48 unexposed households representing 167 persons developed illness meeting the clinical case definition (odds ratio 6.52, 95% confidence interval 1.99-21.3). Individuals from exposed and unexposed households did not differ significantly

To improve the detection and prevention of psittacosis in humans, resources should be directed to the following areas:
q Education of pet store personnel in the proper handling of dead birds so that detection of Chlamydia psittaci is more likely and appropriate quarantine measures can be implemented.
q Informing customers about psittacosis and chlamydiosis so that should they develop illness and seek medical attention, their physicians would be more likely to consider the diagnosis of psittacosis and prescribe appropriate antibiotics.
q Implementation of a notification system so that if a case of well-documented psittacosis is linked to a flock, others who have had contact with the flock are warned of the potential for developing psittacosis.
q Wider use of polymerase chain reaction and microimmunofluorescence leading to improved diagnostic capabilities and greater recognition of human psittacosis.
This report was contributed by John F. Moroney, M.D., Epidemic Intelligence Service Officer, Childhood and Respiratory Diseases Branch, CDC; in collaboration with R Guevara, C Iverson, F Chen, S Skelton, T Messmer, B Plikaytis, J Wenger & J Butler, CDC; P Williams & L Brooks, Ga Dept. of Ag.; T Munro & P Blake, Ga DHR; and numerous nurses and other health professionals from 11 health districts.

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Sudden Infant Death Syndrome Awareness Month, October 1996

Sudden Infant Death Syndrome (SIDS) is the most common cause of infant death after the first week of life. SIDS is the sudden death of an infant which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history1.
In June 1994, the U.S. Public Health Service and other organizations started a national Back-to-Sleep Campaign to prevent SIDS by positioning young infants to sleep on their back or side, by preventing exposure to cigarette smoke--before and after delivery--and by increasing breast-feeding during the first few months of life. Between 1994 and 1995, SIDS mortality in Georgia--as reported on death certificates--dropped 20%-- from 1.5 to 1.2 deaths per 1,000 live births--and declined more in the colder winter months (Figure 1).
Figure 1. Infant Mortality Rate from SIDS, Georgia, 1985-89, 1990-95, and 1995

stomach, and 27% put the infant in different positions2. During 1993-1994, the Pregnancy Risk Assessment Monitoring System (PRAMS) reported that 11.2% of mothers said they smoked during the last 3 months of pregnancy and 48% breastfed their infant for at least one week3.
Overall the United States experienced a larger reduction in SIDS mortality--a drop of 30% between October 1993-September 1994 and October 1994-September 1995. Moreover, an April 1995 national survey of 1000 U.S. households with infants under 8 months of age reported that during the previous 2 weeks, the nighttime caretaker had placed 70% of infants on their side or back4.
Georgia physicians and communities may lower SIDS mortality more rapidly by vigorously joining the national and state campaign supported by the Governor's announcement of SIDS Awareness Month. Free Back-to-Sleep literature may be obtained by calling 1-800-505-CRIB. Contact Ms. Lee Hackel (404) 679-0531 for further information on SIDS prevention efforts in Georgia.

In the 1995 Georgia Womens Health Survey of 3,130 women, 871 reported they had delivered an infant during the past 5 years. During the first 2 months of life, 40% of mothers reported they put the infant to sleep on their back or side; 32% put the infant on their

References 1. Centers for Disease Control and Prevention. Guidelines for death scene investigation of sudden, unexplained infant deaths: recommendations of the Interagency Panel on Sudden Infant Death Syndrome. MMWR 1996;45(No.RR-10):1-22. 2. Serbanescu F, Rochat R: Preliminary Report of the 1995 Georgia Womens Health Survey, Division of Public Health, Georgia Department of Human Resources, 1996 (in press). 3. PRAMS, 1996, Office of Perinatal Epidemiology, Ga DPH 4. NICHD News Notes, National Institutes of Health, June 24, 1996.
This report was contributed by Roger Rochat, MD, Office of Perinatal Epidemiology, Ga DPH.

By the Governor of the State of Georgia A Proclamation
Sudden Infant Death Syndrome Awareness Month, October 1996

Whereas: Sudden Infant Death Syndrome (SIDS), the sudden and unexpected death of apparently healthy babies, is the leading cause of death in Georgia for infants one week to one year of age; and
Whereas: SIDS claimed the lives of 163 babies in Georgia in 1994, as well as more than 4,000 infants in the United States; and
Whereas: A coalition of federal, state and private agencies launched a "Back to Sleep" awareness campaign in 1994 to educate parents about ways to reduce the risk of SIDS by placing infants on their backs or sides to sleep, by breastfeeding and by smoking cessation; and
Whereas: As a result of public awareness of methods to reduce the risk of SIDS, twenty to forty Georgia infants each year live to celebrate their first birthday; and

Whereas: The risk of SIDS in Georgia, as elsewhere, is higher in colder months (November through April) than warmer months; and
Whereas: Public awareness of SIDS and risk reduction measures can save the lives of babies and spare many Georgia families needless tragedy; now
Therefore: I, Zell Miller, Governor of the State of Georgia, do hereby proclaim the month of October, 1996, as "Sudden Infant Death Syndrome Awareness Month" in Georgia, and urge all citizens to be mindful of the safety measures that decrease the risk of SIDS.
In Witness Whereof, I have hereunto set my hand and caused the Seal of the Executive Department to be affixed, this 27th day of September 1996.

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

September 1996

Volume 12 Number 9

Reported Cases of Selected Notifiable Diseases in Georgia

Profile for June 1996

Selected Notifiable Diseases Campylobacteriosis Giardiasis

Total Reported for June 1996 92 47

Previous 3 Months Total

Ending inJune

1996 1995 1994

188

304

282

122

114

124

Previous 12 Months Total

Ending inJune

1996 1995 1994

888

1143

745

620

473

408

Meningococcal Disease Rubella Salmonellosis Shigellosis Viral Meningitis Tuberculosis Congenital Syphilis Early Syphilis Other Syphilis Cryptosporidiosis E. coli O157:H7 Legionnaires' Disease Lyme Disease Mumps Pertussis

18

46

19

29

170

87

92

0

0

0

7

0

0

7

130

272

317

338

1653

1538 1357

58

151

440

517

776

1993

949

4

9

11

24

100

65

142

38

165

209

208

771

744

794

2

15

16

19

64

49

72

130

452

608

693

2293

2557 3201

51

214

261

225

1055

919

900

11

18

7

2

129

28

9

5

11

9

4

33

31

19

0

2

7

37

5

55

91

0

1

5

45

5

59

93

0

1

3

3

7

13

15

0

7

4

6

33

31

51

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 over time 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.

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 09/95 to 08/96 5 Yrs Ago 09/90 to 08/91 Cumulative 01/80 to 08/96

2359 1409 16192

17.6 11.7 13.9

45.7 17.1

4.5

60 19.6

5.3

52.8 19

6

15.7

1.5

15.5

35.4 61.5 3.1

8.4

2.1

4.6

47.4 51.5 1

10.5

2.1

9.5

41.5 56.5 2

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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