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 - 3 - 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-