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 June 1997 Volume 13 Number 6 Yersinia enterocolitica Screening in Georgia Laboratories 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. ; Amri B. Johnson, M.P.H.; Jane E. Koehler, D.V.M, M.P.H.; Katherine GibbsMcCombs, M.P.H.; Preeti Pathela, M.P.H.; Sabrina Walton, M.S.P.H. Chronic Disease Nancy E. Stroup, Ph.D.-Program Manager Patricia M. Fox, M.P.H.; A. Rana Bayakly, M.P.H.; Edward E. Pledger, M.P.A. Tuberculosis Naomi Bock, M.D., M.S. HIV/AIDS/Sexually Transmitted Diseases Kim Cook, M.D., M.S.P.H.-Program Manager Stephanie Bock, M.P.H.; Mary Lynn Gaffield, M.P.H.; Andrew Margolis, M.P.H. Perinatal Epidemiology Mary D. Brantley, M.P.H.; Paul C. Gangarosa, M.P.H.; Raymond E. Gangarosa, M.D., M.P.H.; Leslie E. Lipscomb, M.P.H.; Mary P. Mathis, Ph.D., M.P.H. Preventive Medicine Resident Hussain R. Yusuf, M.B.B.S., M.P.H. 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. The epidemiology of Yersinia enterocolitica infections in the United States is poorly understood. Yersiniosis, characterized by a febrile diarrheal illness, primarily affects young children. Surveillance data show that cases typically peak during the winter months, and that many of these cases occur among African American children. An investigation conducted in the Atlanta area has shown a strong association between household preparation of chitterlings or "chitlins" (pork intestines) and Y. enterocolitica (YE) infection among infants. Chitterlings are a traditional food prepared in some Southern homes during the winter holiday season. Methods A telephone survey of laboratories throughout the state was conducted to determine the extent to which stools submitted for culture are screened for YE. All 217 licensed laboratories with bacteriology sections were contacted and asked if they accept stools for primary culture. Those that did were questioned about their policy regarding screening for Y. enterocolitica. Labs which sent their primary stool cultures to reference labs were asked for the name of the reference lab, and the reference lab was called to determine their procedures for YE testing. Results Of the 204 (94%) laboratories accepting stools for primary culture, 112 (55%) perform the stool cultures in-house and 92 (45%) send them to a reference lab. Of the 112 labs that perform stool cultures in-house, 72 (64%) screen for YE only under certain circumstances (e.g. a doctor's specific request); only 40 labs (36%) routinely screen all stools for YE. The 92 labs that sent specimens out for culture used a total of 30 reference labs; 19 (66%) of these reference labs did not screen for YE, and 11 (33%) routinely screened for YE. Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186 Phone: (404) 657-2588 FAX: (404) 657-2586 We also examined variations in screening by geographic location, contrasting laboratories located in Macon or above with those located in the southern part of the state. Of the 82 laboratories located in north Georgia that perform stool cultures, only 33% included routine screening for YE compared with 43% for laboratories in south Georgia. More north Georgia laboratories screen only under special circumstances (67% versus 57%), while more laboratories in south Georgia (55% vs. 40%) refer specimens to reference laboratories. South Georgia laboratories were more likely to use a reference laboratory that screens routinely for YE (42% vs. 30%). Conclusion This brief survey indicates that most laboratories in Georgia are not screening for Y. enterocolitica infection. A total of 132 (65%) of labs statewide either do not culture stools routinely for YE or send them to a reference lab that does not routinely screen for YE. Only 32 (35%) labs sending stools to a reference lab use one that routinely screens for YE. Failure to culture for YE probably allows many cases of YE to remain undetected, causing the burden of illness from this infection to be greatly underestimated. Recommendation The Division of Public Health encourages laboratories to add screening for Yersinia to their routine stool culturing protocol. Recent active surveillance activities nationwide have shown that YE infections are up to four times more common in Georgia than in other regions of the country. Use of cefsulodinirgasan-novobiocin (CIN) agar, which will selectively isolate YE, is likely to be cost effective in this area, especially during the winter holiday season when most cases occur. As more cases are discovered, the epidemiology of this emerging infection can be more clearly understood, aiding the development of effective preventive measures. This report was contributed by Amri Johnson, Michael McNeil and Jane Koehler, Epidemiology and Prevention Branch; and Marsha Ray, Georgia State Public Health Laboratory. Active Laboratory-based Surveillance for Invasive Neisseria meningitidis Active laboratory-based surveillance for meningococcal disease began in the metropolitan Atlanta area in 1988 and was expanded to include the rest of Georgia in January 1997. Public health officials hope to identify all cases of invasive meningococcal disease that occur in Georgia. This effort is part of Georgia's Emerging Infections Program, a collaboration between the Division of Public Health and Emory University, supported by a grant from the Centers for Disease Control and Prevention. coccal isolates from sterile sites to the State Public Health Laboratory for serogrouping. Because few laboratories perform serogrouping and many isolates were not sent to the State laboratory in previous years, the pre-1997 data on serogroups are sparse. Figure 1. Reported Neisseria meningitidis Cases, GA, Jan 1, 1995 to May 31, 1997 Number of Cases During the first 5 months of 1997, 57 cases of invasive Neisseria meningitidis infection were identified in Georgia. These cases reflect reports of cultures from sterile sites only--commonly blood and cerebrospinal fluid. In the first five months of 1995, there were 54 cases of meningococcal disease. During the same time period in 1996, there were 86 cases. (Figure 1.) Through this active surveillance effort, laboratories statewide are encouraged to submit all meningo- Months - 2 - For the first 5 months of 1997, there have been 3 serogroup B isolates, 11 serogroup C isolates, 32 serogroup Y isolates, 1 C/W135 and 1 A/Y isolate, as well as 9 isolates of unknown serogroup. Although a small proportion of these isolates of unknown serogroup were not "typable", most of them were never submitted for serogrouping. This year the proportion of isolates with serogroup information has increased. Invasive Neisseria meningitidis cases have been seen sporadically throughout the state; no outbreaks have been identified this year. Serogroup Y has been isolated from specimens throughout the state, and is increasing in prevalence. A higher incidence of cases throughout the winter and spring months is the typical seasonal pattern of this infection. Serogroup C, most often associated with outbreaks, occurs sporadically in the northwest area of the state (Figure 2). Cases per 100,000 persons Figure 2. Rate of Meningococcal Disease by Health District, Georgia 1995 and 1996 Health District Unit This report was contributed by Katherine McCombs and Jane Koehler, Epidemiology and Prevention Branch. Mark your Calendars! Third Annual Georgia Nurses' Tuberculosis Conference Tuesday - Wednesday November 18-19, 1997 Holiday Inn Select, Decatur, GA Keynote Speaker: Patricia Simone, MD Chief, Field Services Branch, Division of Tuberculosis Elimination National Center for HIV, STD, and TB Prevention Centers for Disease Control and Prevention Atlanta, GA Sponsors American Lung Association of Georgia, Division of Infectious Diseases Emory University School of Medicine, Georgia Department of Human Resources Epidemiology and Prevention Branch, Georgia Nurses' Association, Georgia Infection Control Network, and Emory AIDS Training Network Contact hours will be offered Call for information TB Conference Hotline (404) 727-2931 - 3 - The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186 June 1997 Volume 13 Number 6 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for March 1997 Selected Notifiable Diseases Campylobacteriosis Total Reported for March 1997 34 Previous 3 Months Total Ending in March 1995 1996 1997 190 161 110 Previous 12 Months Total Ending in March 1995 1996 1997 799 1019 742 Chlamydia genital infection Cryptosporidiosis 1121 2 2595 0 3257 13 3189 8 2595 0 12113 13 13527 88 E. coli O157:H7 1 2 4 14 4 31 49 Giardiasis Gonorrhea Haemophilis influenzae (invasive) 62 1486 3 119 4875 18 161 5376 21 210 4408 17 336 4875 27 614 21949 40 869 18969 48 Hepatitis A (acute) 34 38 55 102 46 101 461 Hepatitis B (acute) 4 Blood Lead Level > 10 g/dL (cap) 183 Blood Lead Level > 10 g/dL (ven) 73 Legionellosis 0 Lyme Disease 0 Meningococcal Disease (invasive) 15 51 8 22 555 573 489 116 135 208 10 1 0 5 0 1 40 58 36 82 60 75 555 2973 2901 116 623 690 18 10 2 7 9 2 53 129 125 Mumps 0 3 1 2 3 9 10 Pertussis Rubella 2 6 6 7 14 30 36 0 0 0 0 0 0 0 Salmonellosis 74 214 261 233 1113 1708 1440 Shigellosis Syphilis - Primary Syphilis - Secondary 73 407 132 242 1622 1083 1235 16 53 55 49 189 294 185 30 151 156 101 493 642 447 Syphilis - Early Latent 129 503 348 313 1625 1525 1285 Syphilis - Other** Syphilis - Congenital 122 257 233 347 736 1139 1049 2 10 16 8 33 65 28 Tuberculosis 65 143 219 173 742 813 743 * 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. ** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis. Report Period Total Cases Reported * AIDS Profile Update Percent Risk Group Distribution (%) Race Distribution (%) Female MSM IDU MSM&IDU HS Blood Unknown White Black Other Last 12 Mos 06/96 to 05/97 5 Yrs Ago 06/91 to 05/92 Cumulative 01/80 to 05/97 2159 1951 17837 21.0 39.2 17.9 4.7 14.7 52.6 23.0 7.8 14.7 51.7 19.1 6.0 16.5 1.4 20.3 10.3 1.6 4.7 11.2 2.0 10.0 28.0 69.5 2.5 39.3 59.0 1.7 40.2 57.8 2.0 MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section - 4-