Georgia epidemiology report, Vol. 14, no. 10 (Oct. 1998)

October 1998

volume14 number10

Division of Public Health

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

http://www.ph.dhr.state.ga.us

Director

Head Lice ((PPeeddiiccuulluuss hhuum maannuuss ccaappiittiiss))

Kathleen E. Toomey, M.D., M.P.H.

In September of this year, the Georgia Division of Public Health and selected schools in the

Epidemiology and Prevention Branch metro Atlanta area began a study of head lice (pediculosis).

State Epidemiologist
Acting Director Kathleen E. Toomey, M.D., M.P.H.

The head louse, Pediculus humanus capitis, is a parasitic insect which infests the human scalp. Humans are the only known carriers of head lice; and as the louse requires frequent blood meals, it can be separated from its host for only two to three days. There are three stages in the

Epidemiology Section
Chief Paul A. Blake, M.D., M.P.H.

louse life cycle: larva(egg), nymph, and adult. Eggs, also known as ova or nits, are attached to the base of a hair shaft by a female louse. A nymph emerges from the egg after seven to ten days of incubation, and subsequently matures into a reproductive adult approximately nine days later. An adult lives an estimated 16 to 27 days, during which time adult females produce

Public Health Advisor

approximately ninety eggs.

Mel Ralston
Notifiable Diseases
Jeffrey D. Berschling, M.P.H., Carol Hoban, M.S., M.P.H. Katherine Gibbs McCombs, M.P.H. Jane E. Koehler, D.V.M., M.P.H.
Laura Gilbert, M.P.H., Kathryn E. Arnold, M.D. Amanda Reichert, R.N., M.S.
Susan E. Lance-Parker, D.V.M., Ph.D.

It is estimated that there are up to 12 million new cases of head lice per year in the United States. Since head lice mostly affect school-age children, it is believed that the only communicable disease more common in this group is the "common" cold. Fortunately, in the United States, head lice rarely transmit other diseases. Although historically lice have been implicated in the spread of typhus, relapsing fever, and trench fever, currently the stigma of lice infestation is disproportionate to their actual health threat. Over ten years ago, the annual U.S. expenditure for lice eradication was estimated to be $367 million. Therefore, despite minimal

Chronic Disease and Injury

public health risk, lice represent an important societal problem.

Ken Powell, M.D., M.P.H.- Program Manager, Patricia M. Fox, M.P.H., Rana Bayakly, M.P.H., Mary P. Mathis, Ph.D., M.P.H., Alexander K. Rowe, M.D., M.P.H.
Linda M. Martin, M.S.

Currently, three medications are available in the United States for the treatment of lice: lindane, pyrethrin with piperolyl butoxide, and permethrin. The use of lindane is limited by both its modest efficacy and its potential for central nervous system toxicity. The remaining

Tuberculosis
Rose Marie Sales, M.D., M.P.H.- Program Manager Naomi Bock, M.D., M.S., Beverly DeVoe, M.S.
HIV/AIDS/Sexually Transmitted Diseases
John F. Beltrami, M.D., M.P.H.&T.M.- Program Manager Andrew Margolis, M.P.H., Lyle McCormick, M.P.H. Ann Buckley, M.P.H., Amy Hephner, M.P.H.
Perinatal Epidemiology
James W. Buehler, M.D. - Program Manager Leslie E. Lipscomb, M.P.H., Cheryl Silberman, Ph.D.,M.P.H.
M.P.H. Hui Zhang, M.D., M.P.H.

agents are derived from Chrysanthemum flowers. It has long been recognized that flowers from this genus have insecticidal properties. Dried flowers from Chrysanthemum cinerariaefolium (called pyrethrum) were used in World War II for malaria and vector-control. Today, the active agent, pyrethrin, is often combined with piperonyl butoxide to provide a synergistic pesticidal effect. The combination of a high pediculicidal activity and low mammalian toxicity made pyrethrin a popular louse treatment. However, pyrethrin is limited by its inability to kill lice eggs (low ovicidal activity) and its inactivation by light. In 1973, a pyrethrin analog, permethrin, was synthesized which demonstrated both photostability and good ovicidal activity. These properties permitted effective lice eradication from a single application. Since 1986, a 1% permethrin solution has been available in the U.S. for the treatment of head lice. Unfortunately, permethrin-resistant lice are now being reported in Czech republic and Israel. As yet, permethrin resistance has not been reported in the United States.

Mohamed Qayad, M.D., M.P.H. Corliss Heath, M.P.H.
Preventive Medicine Residents
Mark E. Anderson, M.D., M.P.H. Anthony Fiore, M.D., M.P.H.
EIS Officers

Even when lice are not resistant to pesticides, no treatment is completely effective. As a result, some groups advocate the manual removal of nits as an adjunct to pesticides. Nit removal is often attempted using a fine tooth comb, called a nit comb. Unfortunately, no study to date has clearly demonstrated the added benefit of nit combing in lice eradication. Some scientists believe that manual nit removal is just cosmetic, since a portion of nits will evade both combing and detection. Additionally, there have been anecdotal reports of home remedies,

Julia Samuelson, R.N., M.P.H. & Keoki Williams, M.D.

such as mayonnaise, petroleum jelly, and olive oil, being effective. There have been occasional

Graphics Dept.
Jimmy Clanton Jr. & Christopher Devoe
Georgia Epidemiology Report

reports of parents trying dangerous therapies such as gasoline and household insecticides in an attempt to rid their children of head lice. Therefore, despite our long cohabitation with lice, many questions remain unanswered. Are there emerging drug-resistant lice? How effective are our current therapies? Do alternative therapies work? Does manual nit removal help?

Editorial Board

Editorial Executive Committee
Andrew Margolis, M.P.H. - Editor Paul A. Blake, M.D., M.P.H.

In an attempt to answer some of these questions, the Georgia Division of Public Health is conducting a randomized controlled trial comparing 1% permethrin to an "alternative agent",

Jane E. Koehler, D.V.M., M.P.H. Jeffrey D. Berschling, M.P.H.
Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Christopher Devoe - Graphics

Georgia Department of Human Resources Division of Public Health Epidemiology & Prevention Branch, Epidemiology Section Two Peachtree St., N.W., Atlanta, GA 30303 - 3186 Phone: (404) 657-2588 Fax: (404) 657-2586

such as mineral oil. Additionally, participants are being randomized to nit combing or no nit combing to determine if this practice improves eradication. Lice collected from participants will be analyzed at the Centers for Disease Control and Prevention for drug resistance. The information obtained from this study may allow us to identify effective treatment strategies and evaluate the need for new pediculocides.
Written by: Keoki Williams, M.D.

Active Surveillance Results for Invasive Neisseria meningitidis, January-June, 1998

Bacterial meningitis and septicemia caused by Neisseria meningitidis infects over one hundred Georgians a year and causes considerable concern in the population. Since January 1, 1997, the Georgia Emerging Infections Program (GA EIP) has conducted statewide active surveillance for invasive N. meningitidis by contacting all microbiology labs in the state at least once monthly. This active surveillance system has identified 57 cases of invasive N. meningitidis for the first six months of 1998 compared to 65 cases during the same time period in 1997. More isolates were identified in January and February than any other month this year (Figure 1). In 1998, cases occurred in every health district except for 5-1 (Dublin), 6-0 (Augusta) and 9-1 (Savannah).
Serogroup Y was the most commonly isolated serogroup; it accounted for 51% (25/49) of all serogrouped isolates (Figure 2). During the first six months of the year, isolations of serogroup C have increased from 25% (14/55) in 1997 to 35% (17/49) in 1998. In approximately 18% (10/57) of the cases, the patient did not survive the illness. Of those

Written by : Katherine Gibbs McCombs, M.P.H.
who died, 10% (1/10) had serogroup B, 50% (5/10) had serogroup C, 30% (3/10) had serogroup Y, and 10% (1/10) had serogroup W-135 meningococcus.
The distribution of race and sex among those with invasive N. meningitidis has been similar to the distribution for the total population. Approximately half (51%, 29/57) of those with N. meningitidis were male, almost 65% (37/57) were white, and 30% (17/57) were black.
Although commonly thought to be a disease of children, almost 60% (34/57) of all cases for the first six months of 1998 were in adults (Figure 2). All of the African-American cases were in adults (>17 years old) except for one. Of the isolates collected from AfricanAmericans, 77% (13/17) were serogroup Y, compared to only 32% (12/37) of isolates from whites. Serogroup Y disease was also more prevalent in African-Americans in 1997.

Number of Cases Number of Serogrouped Invasive Isolates

Figure 1
Number of Invasive Neisseria meningitidis Cases by Month
Georgia, January - June, 1997 & 1998
20
(

15

(

+

+

+ 10
+ (

( 1998

+ (

+ 1997

+N=65

5

(N=57

(

0

Jan

Feb

Mar

Apr

May

Jun

Figure 1

Figure 2

Number of Invasive Neisseria meningitidis Isolates That Are Serogroup B, C, and Y by Age Group
Georgia, January - June, 1998
10

8

Serogroup B

Serogroup C

Serogroup Y 6

4

2

0 <02

2-4

5-11 12-17 18-29 30-59 >=60

Age Groups in Years

Prostate Cancer in Georgia
Written by A. Rana Bayakly, M.P.H., and Carol Steiner, R.N., M.N.
Cancer in all of its forms is the second leading cause of death in Georgia and the United States. Prostate cancer is the second leading cause of cancer deaths among men in Georgia and the United States, exceeded only by lung cancer. African-American males have higher cancer mortality rates (315 per 100,000 population), than Caucasian males (224 deaths per 100,000 population). At the national level, African-American males are over two times more likely to die from prostate cancer (56 per 100,000) than Caucasian males (24 deaths per 100,000 population).

Age-adjusted mortality rates for prostate cancer are higher in Georgia (32 deaths per 100,000 population) than in the United States as a whole (27

deaths per 100,000 population). While age-specific prostate cancer mortality rates are low for men less than 40 years of age (1 per 100,000), the rate

climbs as age increases. In Georgia, men 65 to 69 years of age have a prostate cancer mortality rate of 97 per 100,000 population, men 70 to 74

have a rate of 194 per 100,000, men 75 to 79 years have a rate of 328 deaths per 100,000 population, and among men 80 years plus of age the

mortality rate is 591 per 100,000 population. In Georgia, the prostate cancer mortality rate among African-American males (61 per 100,000) is

higher than rates for Georgia Caucasian males (26 per 100,000), African-American males (56 per 100,000) nationally, and Caucasian males (24 per

100,000) nationally. Prostate cancer mortality rates in Georgia also vary geographically (Table 1). In the Clayton County Health District, the

prostate cancer mortality rate among Caucasian Georgians is 24 per 100,000, while the rate quadruples to 99 per 100,000 among African-American

males living in the same health district. Comparatively, the racial gap narrows in the Dalton Georgia Health District, where the prostate cancer

mortality rate of 25 per 100,000 among Caucasian males, is very close to the rate of 27 per 100,000 among African-American males in the same

health district.

- 2 -

The most important risk factor for developing prostate cancer is an increase in age (Figure 1). Also, a diet that is high in fat and low in fiber approximately doubles the risk of developing prostate cancer. Studies also suggest an overall two-to-three fold increase in the risk of prostate cancer in men with a positive family history. Hormonal factors and influences also add to the increased risk of developing prostate cancer.

Although primary prevention programs stress lifestyle changes to reduce the risk of developing prostate cancer, early detection screening programs which diagnose disease at an early stage increase the opportunity for successful treatment of prostate cancer. Prostate-Specific Antigen (PSA) and Digital Rectal Exam (DRE) are the most common methods for early detection.

Table 1

Age-Adjusted Prostate Cancer Mortality Rates By Health District and Race: Georgia 1992-1996

Health Districts
Albany Athens Augusta Bruns w ic k Clayton Columbus Dalton DeKalb Dublin Fulton Gainesville LaGrange La w re nc e ville Macon Marietta Rome Savannah Valdosta W a yc ros s

Caucasian
25 22 24 24 24 26 25 26 26 27 26 25 24 24 25 26 20 22 27

African-American
56 63 55 78 99 71 27 67 51 66 68 67 51 59 61 67 47 66 57

Difference Between Rates 2.2 2.9 2.3 3.3 4.1 2.7 1.1 2.6 2.0 2.4 2.6 2.7 2.1 2.5 2.4 2.6 2.3 3.0 2.1

Rates were adjus ted to the 1970 U.S. Population

Rate (per 100,000 population)

Figure 1
Age-Specific Prostate Cancer Mortality Rates By Race: Georgia, 1992-1996

1600 1400 1200 1000
800 600 400 200
0 &!
<40

! Caucasian & African-American &

&

!

&

&

!

&

!

&!

&!

&!

&!

&!

!

!

40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Age Group

Note: Georgia mortality data from 1992 to 1996 were obtained from the Georgia Department of Human Resources, Health Assessment Services Section. Population estimates for the State of Georgia were obtained from the United States Census Bureau. Mortality rates were calculated per 100,000 population, and age-adjusted by direct method to the 1970 United States population.
(MMWR) Morbidity & Mortality Weekly Reports
YYoouu M Maayy HHaavvee M Miisssseedd October 23, 1998 / Vol. 47 / No. 41 Assessment of Infant Sleeping Position - Selected States, 1996 Progress Toward Poliomyelitis Eradication - West Africa, 1997
October 16, 1998 / Vol. 47 / No.40 Lifetime and Annual Incidence of Intimate Partner Violence and Resulting Injuries Use of Cervical and Breast Cancer Screening Among Women With and Without Functional Limitations - U.S.
October 9, 1998 / Vol. 47 / No.39 National Breast cancer Awareness Month - October 1998 Update: Influenza Activity - Worldwide, April-September 1998
The Morbidity and Mortality Weekly Report (MMWR) series is produced by the Centers for Disease Control and Prevention (CDC). Publications are available on the World-Wide Web at http://www.cdc.gov or by calling 202.512.1800 for paper copy.

Measures of Morbidity

Measure

Numerator (x)

Denominator (y)

Incidence Rate
Attack Rate
Secondary Attack Rate Point Prevalence
Period Prevalence

# new cases of a disease reported during a given time interval
# new cases of a disease reported during an outbreak period
# new cases of a disease among contacts of known cases
# current cases, new & old, of a disease at a given point in time
# current cases, new & old, of disease identified over a given time interval

average population during time interval
population at start of the outbreak period
size of contact population at risk
estimated population at the same point in time
estimated population at mid-interval
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Expressed per number at risk (e.g. 25 cases per 100,000 population)
100 or 1,000 or 10,000 or 100,000 or 1,000,000
100 or 1,000 or 10,000 or 100,000 or 1,000,000
100 or 1,000 or 10,000 or 100,000 or 1,000,000
100 or 1,000 or 10,000 or 100,000 or 1,000,000
100 or 1,000 or 10,000 or 100,000 or 1,000,000

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

October 1998

Volume 14 Number 10

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for July 1998

Selected Notifiable Diseases Campylobacteriosis Chlamydia genital infection Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for July 1998
1998 98 1554 16 14 122 1731 5 41 1 3 1 4 0 5 0 239 157 5 14 51 68 2 62

Previous 3 Months Total

Ending in July

1996

1997

1998

265

202

246

3098

5405

5280

25

9

30

15

15

43

177

111

289

5213

5619

4838

10

8

12

127

231

131

13

53

30

1

0

6

1

0

1

36

28

17

1

2

0

10

5

16

0

0

0

394

369

467

213

198

447

44

39

20

110

98

43

321

279

171

233

332

199

9

9

6

181

168

175

Previous 12 Months Total

Ending in July

1996

1997

1998

1021

773

945

13067

17186

20994

140

79

123

40

58

64

709

899

1198

23086

21384

20173

39

46

52

254

624

814

40

156

272

5

2

10

5

1

13

163

123

109

8

16

2

39

30

29

0

0

0

1843

1602

1628

918

1341

1563

265

198

140

632

491

297

1533

1388

971

1169

1381

1017

58

27

17

852

803

682

* 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
Latest 12 Months: 10/97 to 9/98 Five Years Ago: 10/92 to 9/93 Cumulative: 7/81 to 9/98

Total Cases Reported *
1343 2008 19645

AIDS Profile Update

Percent Female

Risk Group Distribution (%)

MSM IDU MSM&IDU

HS Blood

Unknown

18.6 14.8 15.1

38.7

18.5

4.6

14.3

1.0

22.9

46.9

21.8

6.6

12.3

1.7

10.8

51.0

19.3

5.8

12.1

1.9

9.8

Race Distribution (%) White Black Other

23.7 73.8

2.5

34.5 63.6

1.9

38.6 59.3

2.1

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-