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 March 1998 Volume 14 Number 3 World TB Day http://www.ph.dhr.state.ga.us Division Of Public Health Kathleen E.Toomey, MD, MPH- Director Epidemiology and Prevention Branch State Epidemiologist Kathleen E. Toomey, MD, MPH- Acting Director Epidemiology Section Paul A Blake, MD, MPH- Chief Notifiable Diseases Jeffrey D. Berschling, MPH; Cherie L. Drenzek, DVM, MS; Katherine Gibbs McCombs, MPH; Jane E. Koehler, DVM, MPH; Preeti Pathela, MPH, Laura Gilbert Chronic Disease Ken Powell, MD,MPH- Program Manager , Nancy E. Stroup, PhD, Patricia M. Fox, MPH; A. Rana Bayakly, MPH; Mary P. Mathis, PhD, MPH Tuberculosis Rose Marie Sales, MD, MPH- Program Manager Naomi Bock, MD, MS; Beverly DeVoe HIV/AIDS/Sexually Transmitted Diseases John F Beltrami, MD, MPH- Program Manager Andrew Margolis, MPH, Lyle McCornick,MPH Perinatal Epidemiology James W. Buehler, MD- Program Manager Leslie E. Lipscomb, MPH, Cheryl Silberman,PHD,MPH Preventive Medicine Residents Scott E. Kellerman, MD,MPH; Alexander K. Rowe, MD,MPH; EIS Officer Michael S. Friedman, MD Georgia Epidemiology Report Editorial Board Editorial Executive Committee Cherie Drenzek, DVM, MS - Editor Jeffrey D. Berschling, MPH Paul A. Blake, MD, MPH Kathleen E. Toomey, MD, MPH Mailing List Marsha Wilson Graphics Jimmy Clanton & Christopher DeVoe March 24 is World Tuberculosis (TB) Day, a day created by international health experts to bring greater attention to the global TB epidemic. The date commemorates the discovery of the TB bacterium by German physician Robert Koch in 1882. Although tuberculosis is an ancient disease (in fact, the bacillus has been found in the remains of Egyptian mummies), today it remains the leading infectious cause of death among adults worldwide. The threat of a growing TB epidemic is so great that, in 1993, the World Health Organization (WHO) declared TB to be a "global emergency"- the first declaration of its kind in WHO history. In the United States, during the past ten years, the number of TB cases dramatically increased after previous decades of decline. During the period from 1985-1992, the resurgence of TB in the United States was attributed to the following: 1) the HIV epidemic; 2) immigration of people from countries where TB is prevalent; 3) cut-backs in public health expenditures; and, 4) increased prevalence of TB cases among the homeless, substance abusers, prisoners, and elderly persons in nursing homes. In 1996, Georgia ranked first among southeastern states and sixth in the United States in TB case rates. More than half of all TB cases in Georgia are diagnosed in metropolitan Atlanta, mostly in Fulton and DeKalb Counties. The city of Atlanta ranked eighth nationally in TB case numbers among 65 cities monitored by the Centers for Disease Control and Prevention. Due to major public health efforts initiated over the last several years, TB is again considered on the decline. Between 1995 and 1996, reported TB cases decreased nationwide by 7%. In Georgia, TB case numbers decreased by 12% from 790 cases in 1996 to 696 cases in 1997. However, TB disease containment continues to face new challenges. Multi-drug resistant strains (MDR-TB) of the tuberculosis bacillus, which do not respond to standard antibiotics, have recently emerged. Since 1993, when Georgia began tracking MDR-TB cases in the state, there has been an average of four (4) MDR-TB cases reported per year. The burden placed on the public health care system by MDR-TB is tremendous. The cost of outpatient treatment of a TB patient, which is usually around $2,000, can be as high as $250,000 when a patient has MDR-TB. Other trends which concern TB controllers and public health officials are high case rates in young children, and increases in TB cases Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186 Phone: (404) 657-2588 FAX: (404) 657-2586 (World TB Day Continued) among the foreign-born, the homeless, substance abusers and persons in correctional facilities. There is good news about this epidemic, however. It can be controlled with a simple strategy that public health workers call "directly-observed therapy" or DOT. Because the TB treatment regime includes antibiotic administration for six months or longer, patients often fail to complete therapy. This causes treatment failures and gives rise to resistant TB strains. With DOT, a health worker watches patients swallow their medications to ensure compliance throughout the entire regimen. DOT, which has consistently produced 85% cure rates, can protect against the relentless onslaught of MDR-TB. As such, the TB outreach worker is one of the heroes in the war against TB. In addition, a public health infrastructure which provides diagnostic services, maintains a dependable drug supply, and keeps an efficient reporting system is an essential part of the successful DOT strategy. With these measures in place, World TB Day may someday become a celebration of something more positive--a world finally rid of this age-old killer, tuberculosis. This article was contributed by Rose Marie Sales, MD, MPH, Chief, TB Epidemiology Unit, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources Expanded Hemolytic Uremic Syndrome (HUS) Surveillance to be Conducted by the Georgia Division of Public Health Escherichia coli O157:H7, the most commonly identified member of a group of organisms now referred to as the Shiga toxin-producing E. coli (STEC), causes bloody and nonbloody diarrhea that progresses to hemolytic uremic syndrome (HUS) in 5-10% of reported cases, primarily among patients less than 5 years of age (1). Despite the substantial gains in knowledge about E. coli O157:H7 since its recognition 15 years ago, much remains to be learned. For example, how frequent is the infection? Are clinical laboratories screening all stools or all bloody stools for the presence of E. coli O157:H7? What risk factors are involved in the progression of E. coli O157:H7 infection to HUS? Once E. coli O157:H7 infection is diagnosed in an individual, are there any effective secondary measures to prevent progression to HUS? To evaluate some of these issues, the Georgia Division of Public Health has conducted active surveillance for pediatric cases of HUS occurring in the metro-Atlanta area during 1997. In 1998, the surveillance area will be expanded to include the entire state of Georgia. This project is part of the Emerging Infections Program, a collaborative initiative between the Georgia Division of Public Health, Emory School of Medicine, and the Centers for Disease Control and Prevention. As part of the expanded surveillance for HUS, cases will be identified by nephrologists, nurses, and pediatric ICU nurses across the state of Georgia. Information will be collected on each case regarding underlying medical conditions, complications during the course of HUS, and procedures performed. Hospital records of the HUS patients will be reviewed to determine the clinical outcome and potential sequelae of the acute illness. The data collected from this project will be analyzed by the Division of Public Health and forwarded to the CDC to be analyzed with similar data from other states. Laboratory specimens will be collected from each HUS case. Acute and convalescent sera will be collected and sent to the Georgia Public Health Laboratory to be tested for antibodies to E. coli O157:H7. Stool samples may be also collected to test for the presence of E. coli O157:H7. If a stool specimen is identified as being E. coli O157:H7- negative, it will then be tested for the presence of Shiga toxin. In total, this expanded surveillance effort may lead to improved diagnostic methods for E. coli O157:H7 infections, a better understanding of the spectrum of illness caused by E. coli O157:H7 infections, and identification of risk factors associated with progression to HUS in children. If you identify a case of HUS, please report it immediately to the Georgia Division of Public Health at (404) 657-2588. If you have any questions about this project, please feel free to contact Laura Gilbert, Georgia's HUS Surveillance Officer, at (404) 657-2636. References 1. Griffin PM, Tauxe RV. The epidemiology of infections caused by Escherichia coli O157:H7, other enterohemorrhagic E. coli, and the associated hemolytic uremic syndrome. Epidemiol Rev 1991; 13:60-98. This article was contributed by Laura Gilbert, HUS Surveillance Officer, Notifiable Disease Unit, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources - 2 - Two Months Instead of Twelve Months: Effective Short-Course TB Prophylaxis in HIV- Infected Persons Results of a five-year randomized clinical trial sponsored by the National Institute of Allergy and Infectious Diseases, the Centers for Disease Control and Prevention (CDC), and the Pan American Health Organization indicate that a two-month course of daily rifampin and pyrazinamide is as effective in preventing active tuberculosis (TB) in persons co-infected with TB and HIV as the currently-recommended regimen of 12 months of daily isoniazid (INH). The study results were presented at a meeting of TB researchers at the World Health Organization (WHO) headquarters in Geneva last February by Fred Gordin of the Veterans Affairs Medical Center in Washington, D.C. Nearly 1,600 HIV-infected people participated in the study. 70% of participants were from the United States; other participants were from Haiti, Brazil, and Mexico. After 36 months of follow-up, the number of TB cases detected in each treatment regimen group (i.e. rifampin/pyrazinamide vs. INH) was the same. Treatment compliance was 80% in the two-drug regimen group but less than half, in the INH group. This study is generating much excitement among TB controllers and public health officials. The two-month course of prophylactic antibiotic administration, if officially recommended and implemented, could greatly improve treatment compliance and reduce the cost of TB prevention programs. Study findings hold promise for reducing HIV-related TB disease and could also be useful for preventing active TB in persons without HIV who have latent TB infection. This article was contributed by Rose Marie Sales, MD, MPH, Chief, TB Epidemiology Unit, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources Alternative Housing Project (AHP) Facilitates TB Treatment Compliance among the Homeless Homeless persons with tuberculosis (TB) often fail to complete TB treatment regimens and thus present a public health risk. In 1996, the Alternative Housing Project (AHP) for homeless TB patients was established to place these patients in transient low-cost housing in order to facilitate TB treatment compliance. The AHP is managed by Pamela Collins of the American Lung Association of Georgia and funded by the Georgia Department of Human Resources, TB Control Section. During the first year, the program served 73 patients, of which 54 (74%) were referred by Fulton and DeKalb Counties. Patients stayed in the program for a mean duration of 2.5 months. The average daily cost of $19.00 covered rent, utilities, food, personal supplies, laundry, transportation tokens, and social worker services. The AHP was recently evaluated by the TB Epidemiology Unit of the Georgia Division of Public Health to determine its impact on completion of TB treatment regimens and to assess client satisfaction with project services. Results showed that TB patients in the project had a significantly higher treatment completion rate (85%) and shorter mean treatment duration (7 months) than homeless TB patients not involved in the AHP, for whom the completion rate was 53% with a mean treatment duration of 9 months. Nine out of 10 program participants interviewed found their housing satisfactory. In addition, the 12 Health District TB coordinators who referred patients to the project concluded that the AHP greatly facilitated directly-observed therapy, sputum collection, and treatment compliance among homeless TB patients. Project evaluation findings will be presented by Rose Marie Sales, MD, in a poster session at the American Lung Association/American Thoracic Society International Conference in Chicago, Illinois on April 26-29, 1998. This article was contributed by Rose Marie Sales, MD, MPH, TB Epidemiology Unit, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources - 3 - The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186 March 1998 Volume 14 Number 3 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for December 1997 Selected Notifiable Diseases Total Reported for Dec. 1997 1997 Previous 3 Months Total Ending in Dec. 1995 1996 1997 Previous 12 Months Total Ending in Dec. 1995 1996 1997 Campylobacteriosis 62 211 160 224 1048 793 665 Chlamydia genital infection 1812 2665 3394 4139 11450 13601 16145 Cryptosporidiosis 5 26 18 24 110 93 74 E. coli O157:H7 2 8 4 7 29 39 45 Giardiasis 79 146 231 310 573 820 914 Gonorrhea 1839 6437 4540 4598 21452 19940 18529 Haemophilis influenzae (invasive) 5 5 14 14 37 52 45 Hepatitis A (acute) 50 14 106 217 85 414 751 Hepatitis B (acute) 15 7 14 44 103 61 215 Lead Poisoning (capillary BLL >= 10 ug/dL) 26 759 578 126 2955 2985 1852 Lead Poisoning (venous BLL >= 10 ug/dL) 24 135 118 84 604 617 801 Legionellosis 2 2 0 4 19 3 6 Lyme Disease 0 0 0 3 14 1 9 Meningococcal Disease (invasive) 6 38 23 17 111 147 108 Mumps 1 3 2 1 11 9 11 Pertussis 1 5 8 1 30 35 15 Rubella 0 0 0 0 0 0 0 Salmonellosis 112 470 396 362 1661 1469 1355 Shigellosis 138 180 482 490 1359 1125 1129 Syphilis - Primary 4 73 44 32 287 194 152 Syphilis - Secondary 10 161 121 62 640 498 345 Syphilis - Early Latent 51 347 313 199 1652 1321 1034 Syphilis - Other 42 271 305 151 1139 1041 1135 Syphilis - Congenital 0 17 7 3 62 34 22 Tuberculosis 50 172 207 171 737 791 696 * 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. AIDS Profile Update Report Period Total Cases Reported * Percent Female Risk Group Distribution (%) Race Distribution (%) MSM IDU MSM&IDU HS Blood Unknown White Black Other Latest 12 Months: 03/97 to 02/98 Five Years Ago: 03/92 to 02/93 Cumulative: 7/81 to 02/98 1640 1951 19017 20.9 14.8 15.0 36.7 17.7 3.9 16.7 1.3 23.7 50.1 22.2 7.2 11.4 2.1 6.9 51.0 19.1 5.8 11.9 2.0 10.2 23.5 73.7 2.8 36.0 62.4 1.6 39.2 58.8 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-