Georgia epidemiology report, Vol. 14, no. 11 (Nov. 1998)

November 1998

volume 14 number 11

Division of Public Health
http://www.ph.dhr.state.ga.us

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

Director Kathleen E. Toomey, M.D., M.P.H.
Epidemiology and Prevention Branch State Epidemiologist
Acting Director Kathleen E. Toomey, M.D., M.P.H.
Epidemiology Section
Chief Paul A. Blake, M.D., M.P.H.
Public Health Advisor 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.
Chronic Disease and Injury
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.

COULD IT BE PERTUSSIS?
Pertussis, or whooping cough, is an infectious disease of the respiratory tract caused by the bacterium Bordetella pertussis. The bacteria attach to the respiratory cilia and produce toxins that paralyze the cilia and interfere with the clearing of pulmonary secretions, which in some cases may lead to pneumonia.
Pertussis infection can be described by three clinical stages: The first stage, or catarrhal stage, is characterized by coryza, sneezing, low-grade fever, and a mild cough. The cough becomes more severe over the next 1-2 weeks, as the second stage (known as the paroxysmal stage) begins. During this stage paroxysms of frequent, rapid coughs will occur, generally followed by a high-pitched whoop on inspiration. Vomiting and exhaustion may occur following the episode. Paroxysmal attacks generally occur more frequently at night. This stage usually lasts 1 to 6 weeks, but may last up to 10 weeks. The last stage, known as the convalescent stage, lasts 2 to 3 weeks. During this time, coughing occurs less frequently and will generally disappear but paroxysms may recur for many months. Infection with the B. pertussis bacterium may not produce life long immunity (2).
Adolescents and adults previously vaccinated for pertussis may become infected, but will generally develop a milder form of disease. These mild cases of pertussis may be indistinguishable from other respiratory infections, especially in the absence of the classical whoop. B. pertussis accounts for many cases of protracted cough in adults. In fact, some studies have shown 25% or more of adults with cough persisting for more than 7 days were infected with B. pertussis (2).
EPIDEMIOLOGY

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.
Hui Zhang, M.D., M.P.H. 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
Julia Samuelson, R.N., M.P.H. & Keoki Williams, M.D.
Graphics Dept.
Jimmy Clanton Jr. & Christopher Devoe
Georgia Epidemiology Report Editorial Board
Editorial Executive Committee
Andrew Margolis, M.P.H. - Editor Paul A. Blake, M.D., M.P.H.
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

Pertussis was once a serious bacterial disease in the United States with approximately 200,000 cases and 5,000-10,000 deaths each year before the introduction of the whooping cough vaccine in the 1940s. Over the next forty years, the incidence of pertussis cases decreased to an average of 3,700 cases per year. Since the 1980's, the reported number of pertussis cases has increased steadily, with almost 8,000 reported in 1996. The Centers for Disease Control and Prevention (CDC) estimates that only 10% of actual cases are reported annually (2). In addition to an increase in cases, the proportion of pertussis cases occurring in persons over the age of 10 is also increasing.

As pertussis is often unrecognized in adults, physicians need to be aware of the resurgence of

this disease. Although pertussis in adults often produces mild symptoms, adults are often the

first case in a household contribut-

ing to the transmission of disease

TABLE 1: FEATURES OF PERTUSSIS*

among unvaccinated children. An CATARRHAL PHASE (1 TO 7 DAYS):

important part of the increase in pertussis cases among adults is the decline in immunity over time (1).

Nasal congestion Mucoid rhinorrhea Sneezing Dry, non-productive cough

Beginning January 1, 1998, Georgias Division of Public Health, Epidemiology and Prevention Branch will be one of five states participating in enhanced surveillance for cases of pertussis. The core aspects of this project are to increase reporting with active

PAROXYSMAL PHASE (TYPICALLY 2 WEEKS): Paroxysmal cough (series of short expiratory bursts, followed by inspiratory gasp)
when severe, may result in cyanosis, inspiratory whooping, vomiting, sub-conjuctival hemorrhage, epistaxis, laceration of lingual frenulum, hernia, seizures, encephalopathy
Between paroxysms, clinically well
CONVALESCENT PHASE (TYPICALLY 3 TO 4 WEEKS): Less intensive chronic cough

laboratory surveillance, obtain de-

*ATYPICAL PRESENTATION IS COMMON AMONG INFANTS AND ADULTS

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

tailed vaccination histories on all cases of pertussis (including dates of vaccination, type and lot number of vaccine), determine if erythromycin resistant strains are present, and perform pulsed-field gel electrophoresis (PFGE) on all isolates to determine which strains are circulating. These core activities will enable us to better determine the incidence of pertussis among adolescents and adults, evaluate the impact of new vaccine policies by examining vaccination coverage (type and manufacturer) among preschool children, and determine if adolescents or adults are a source of infection for cases < 1 year of age. Finally, the Division of Public Health encourages all physicians to consider and culture for pertussis when diagnosing an adolescent or adult patient with a chronic cough lasting more than 7 days.

IMPROVING THE DIAGNOSTIC ACCURACY OF

Figure 2

CULTURES FOR PERTUSSIS

Figure 1

Use samples of nasopharyngeal mucus for culture.

Use a Dacron or calcium alginate swab for collecting samples; do NOT use a cotton swab.

Notify the microbiology laboratory that pertussis is suspected.

Written by: Carol Hoban, M.S., M.P.H. And Jane Koehler, D.V.M., M.P.H.
REFERENCES

Source: Waggoner-Fountain, LA and GF Hayden. Pertussis: A growing problem in children and adults. J of Resp Dis 1994: 15:335-334

1. Boden, MD and KM Edwards. Chronic cough in an adult: Could it be pertussis? Journal of Respiratory Disease 1995; 16:876-882.

2. Centers for Disease Control and Prevention. Epidemiology & Prevention of Vaccine Preventable Diseases. The Pink Book 1997; 4: 65-80.

3. Waggoner-Fountain, LA and GF Hayden. Pertussis: A growing problem in children and adults. Journal of Respiratory Disease 1994; 15:335-344.

4. Herwaldt, LA. Pertussis in Adults. Arch Intern Med 1991; 151:1510-1512.

Child Safety Seats Save Lives in Georgia

In 1996, 30,558 children 0-4 years of age were occupants in motor vehicles involved in a collision in Georgia and included in the Georgia Accident

Reporting System. 32 of these children were killed and 151 were seriously injured. Unrestrained children were 20 times more likely to die and 8

times more likely to be severely injured than properly restrained children (Figure 1). While the benefit of car seats is known, the proper use of

car seats is either not known or not followed by many drivers. This article contains information about proper car seat use for small children and

information about how car seats commonly are used.

Figure 1. Fatality and Severe Injury Rates for Restrained and

A National Survey of Car Seat Use

Unrestrained Children, 0-4 Years of Age, Georgia, 1996

Between November 1996 and January 1997, the National Highway Safety Administration (NHTSA) conducted a national telephone survey of drivers age 16 and older to ask about child safety seats and other issues. Nearly half of drivers age 16 and older in the United States have, in the past year, driven a vehicle with a child under age 6 as a passenger. For about a third of these, or 17 percent of all drivers, the young child lives in their household. A substantially larger percentage, 29 percent, have driven young children who do not live with them. Nearly four in ten of these were grandparents, more than one-third were other relatives, and one in five were not related to the child.
The most important findings from the survey included 1) children are being moved from car seats to seat belts prematurely, 2) almost everyone knew that the safest place for a car seat is in the back seat but not
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Events per 1,000 Child-occupants

35

30

25

20

15

10

8.3

5
0.4 0
Restrained Unrestrained
Fatalities

28.3
3.4 Restrained Unrestrained
Severe Injuries

The Proper Use of Car Seats/Prevention tips:
1. Use child safety seats and/or safety belts correctly every time you ride. Seventy-five percent of motor vehicle crashes occur within 25 miles of home.
2. Georgia law requires all children under the age of three to be secured in an approved child safety seat and anyone under age 18 to be appropriately restrained. Regardless of age, young children are safest in a car seat appropriate for their size. (See Table 1.)
3. A rear seat is the safer place for all children to be secured.
4. The child safety seat must be secured tightly with the seat belt into the vehicle.
5. Harness straps must fit snugly on the body. Keep the harness straps placed over the child's shoulders. The harness should be adjusted so you can slip only one finger underneath the straps at your child's chest. Place the chest clip at armpit level.
6. Read your child safety seat instruction manual and your motor vehicle owner's manual for directions on proper safety seat installation. Call the manufacturer for clarification, or use local resources such as SAFE KIDS or the University of Georgia Cooperative Extension Service's toll-free occupant safety information line (1-800 342-9819) to ask about difficulties with a safety seat.
7. Understand air bags. Air bags do not replace the need for all motor vehicle occupants to be properly restrained. Air bags are designed for adults. Never put a rear-facing infant or convertible safety seat in the front passenger seat of a vehicle with a passenger air bag.
everyone placed it there, 3) the most common reasons given for not placing a child in the car seat were that the child would only be in the car for a short period of time or because the child didnt like being placed in the car seat, and 4) most support strict enforcement of car seat laws.

Table 1

Child Restraint Recommendations

All infants and children should be secured

appropriately for their age and size

From Birth To (20 lbs. and 12 months) Use infant or convertible child restraint system facing the rear of the car (rear-facing)
If a child under 1 yr. weighs more than 20 lbs., use a convertible seat facing the rear of the car. Look for seats accommodating higher weight limits.
From (20 lbs. and 12 months) To (40 lbs. and/or 4 years) Keep children in convertible or toddler seats as long as they will fit based on weight limits of the child restraint system.
When a child outgrows convertible or toddler seat:
Best Practice: If the vehicle has a lap/shoulder belt in the rear seat, use a booster seat that positions the lap/shoulder belt correctly--the lap belt can be secured across the child's hips, and the shoulder belt does not cross the face or the front of the neck.
IF A BELT-POSITIONING BOOSTER SEAT IS NOT AVAILABLE FOR USE: use the rear lap/shoulder belt alone if it fits properly--the lap/ shoulder belt does not cross the face or neck and fits across the child's hips and does not ride up across the stomach.
MINIMUM: if no other type of restraint is available, use the lap belt, positioned low on the hips and adjusted snugly.
From 70 lbs. and More Use the protection system in the vehicle.
1. Ages and weights are approximate. Manufacturer's instructions should be consulted for exact figures. Use only safety seats with a label stating that the seat is approved for use in motor vehicles. Not all safety seats fit in all cars. Try a seat in your car before buying it.

Premature use of seat belts by children
The NHTSA survey suggests that children under six are being moved from car seats to set belts prematurely. While almost all infants (96 percent) under 20 pounds were said to be in their car seats all of the time, this drops to 86 percent for those 20-29 pounds, 68 percent for those 30-39 pounds, and only 29 percent for children weighing 40 pounds or more. In general, children were either placed in car seats all the time or never. Children never placed in car seats reportedly wore seat belts all the time (92 percent). Seat belts, however, generally will not fit a child appropriately until the child is larger.
Most know the safest place for a car seat is in the back seat

2. Georgia law requires child safety seat use until age 3. Children age 3 and older are safer in a child safety seat as long as they are within the maximum height and weight limits of the restraint. All youths under age 18 must be appropriately restrained.
Sources for Table: National SAFE KIDS Campaign, General Motors, American Medical Association, National Highway Traffic Safety Administration, American Academy of Pediatrics.
If a child under six never used a car seat, the adult said the child was considered too big (86 percent), and already was using a seat belt (96 percent).
Most support enforcement of car seat laws

Among those who used car seats, almost all (97 percent) knew that the Most adults (69 percent) support strict enforcement of car seat laws.

safest place for a car seat is in the back seat. Only 85 percent, however, This is higher (77 vs 68 percent) for drivers with children under age 6

said they put the car seat in the back. These are improvements over in the household than for those without children in this age range.

NHTSA survey findings in 1994, when only 91 percent considered the More than nine out of ten adults (94 percent) believe that children who

back seat to be the safest location, and only 78 percent placed the car outgrow car seats should be required by law to wear seat belts when

seat in the back. Drivers in 1996 were more likely than drivers in 1994 riding in a motor vehicle. Few believe there should be an upper age

(65 vs 46 percent) to place their children in the back seat when they limit where the requirement no longer applies. The vast majority of

were not in car seats. More good news is that fewer drivers in 1996 (14 adults believe that the requirement should apply to all children.

percent) than in 1994 (22 percent) said that children rode in a

passengers lap when they were not in a car seat.

This report was submitted by Steve Davidson, Director of the Office

of Injury Control, Environmental Health Branch, Georgia Division of

Reasons for not putting a child in a car seat

Public Health, and adapted from Traffic Tech, NHTSA Technology

Transfer Series, Number 178, May 1998. To receive a copy contact:

If a child rode in a car seat but not all the time, the most frequent Linda Cosgrove, Ph.D., Editor, Evaluation Staff, (202)366-2759, fax

reasons were that the child would be in the vehicle only a short time (39 (202)366-7096, email lcosgrove@nhtsa.gov. For additional information

percent) and that the child does not like the car seat (39 percent).

about the Georgia Injury Control Program, please call (404)679-0500. - 3 -

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

November 1998

Volume 14 Number 11

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for August 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 August 1998
1998 79 1697 17 11 129 1955 3 69 0 2 0 8 0 2 0 319 87 2 18 54 51 0 41

Previous 3 Months Total

Ending in August

1996

1997

1998

281

250

249

3555

4665

5143

27

33

42

21

12

51

225

209

348

5499

5101

5228

4

6

11

125

244

156

24

74

10

0

0

5

0

4

1

32

25

17

2

0

0

8

5

11

0

0

0

474

469

703

263

245

411

54

40

17

126

105

47

330

274

171

242

315

176

2

9

6

180

164

159

Previous 12 Months Total

Ending in August

1996

1997

1998

881

679

834

12600

15891

20020

91

87

108

40

45

66

688

837

1142

21979

18894

18981

38

46

51

279

623

733

47

167

214

5

2

12

1

5

9

161

113

100

8

15

2

33

26

27

0

0

0

1664

1444

1599

798

1238

1456

239

169

119

565

432

241

1357

1245

848

1040

1314

861

48

29

11

776

733

611

* 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: 11/97 to 10/98 Five Years Ago: 11/92 to 10/93 Cumulative: 7/81 to 10/98

Total Cases Reported *
1267 1955 19695

AIDS Profile Update

Percent Female

Risk Group Distribution (%)

MSM IDU MSM&IDU

HS Blood

Unknown

18.7

39.3

18.4

4.8

13.7

0.8

22.9

15.0

46.1

22.4

6.1

12.8

1.5

11.1

15.2

51.0

19.3

5.9

12.1

1.9

9.8

Race Distribution (%) White Black Other

23.8 73.6

2.6

33.6 64.4

2.0

38.5 59.4

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

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