Georgia epidemiology report, Vol. 14, no. 5 (May 1998)

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

May 1998

Volume 14 Number 5

Summary of the 1997-98 Influenza Season
in Georgia
Background & Methods

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 Mel Ralston- Public Health Advisor
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, MPH Amanda Reichert, RN
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, MS
HIV/AIDS/Sexually Transmitted Diseases
John F Beltrami, MD, MPH- Program Manager Andrew Margolis, MPH, Lyle McCornick, MPH Ann Buckley, MPH, Amy Hephner, MPH, Laura Axelson, 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

Each year, from October 1 to May 31, the Centers for Disease Control and Prevention (CDC) monitors influenza in the United States via the following four systems: 1) the sentinel physician network; 2) the State and Territorial Epidemiologist reporting system; 3) the World Health Organization (WHO) collaborating laboratories system; and 4) the vital registrars surveillance system located in 122 cities across the country.

As part of the sentinel physician reporting system, volunteer physicians in each state submit

weekly reports by telephone to a central data repository at CDC indicating the number of patients

seen with influenza-like illness (ILI) as well as the total number of patient visits for any reason.

During the 1997-98 influenza season, Georgia established 32 sentinel physician sites distributed

throughout the state in a manner generally representative of the population density in that area.

Besides weekly reporting, sentinel physicians were asked to perform nasopharyngeal cultures on

a representative number of patients

seen with ILI and submit them to the Georgia Public Health Laboratory for

Figure 1. Laboratory Confirmed Influenza Cases by County of Residence, Georgia, 1997-98 Influenza Season.

virologic confirmation and subtyping.

In addition, during this season, a semi-automated data management

Health Districts Counties

system for sentinel physician influ-

enza reports was developed. It con-

sisted of a protected Internet site ac- Number of Cases

cessible to state public health officials

1 - 2

that displayed Georgias sentinel phy-

sician surveillance data in real time

3 -6

(as they were reported), as well as

7 - 12

state-specific graphs summarizing

data visually. Advantages of the sys-

13 - 17

tem included immediate availability

of statewide influenza data (via the Internet site) for timely epidemiologic analysis and public

health response. This website also allowed monitoring of the regularity of reporting by indi-

vidual Georgia sentinel physicians such that any reporting problems were addressed in a timely

fashion.

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

Results
During the 1997-98 season, 72 laboratory-confirmed cases of influenza were reported from 17 counties in Georgia. The first confirmed influenza case of the season occurred in mid-November, 1997, while the last influenza case was diagnosed in late March, 1998. The number of confirmed influenza cases reported per county ranged from 1 to 17; 12 (71%) of 17 counties reported a total of 1-2 confirmed influenza cases during the 1997-98 season, while 2 (12%) of the 17 reported a total of 13-17 cases. (Figure 1). The two Georgia counties reporting the highest number of confirmed influenza cases (DeKalb and Richmond) each experienced nursing home-related influenza outbreaks during the course of the season; there were two such outbreaks in DeKalb County (one in mid-December and one in mid-January) while the Richmond County outbreak occurred in

Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186

Phone: (404) 657-2588

FAX: (404) 657-2586

late January. No other laboratory-confirmed influenza outbreaks were documented in Georgia during the 1997-98 season.
Among the 72 laboratory-confirmed cases of influenza in Georgia, the median age was 25 years (range: 1 month - 83 years), and 46 (64%) cases occurred among males. All 72 influenza virus isolates were identified as Influenza A. Subtyping results were available for 15 isolates; all were type H3N2. Further antigenic characterization of select virus isolates was performed by CDC; most isolates were A/ Nanchang/933/95, similar to the strain included by United States manufacturers in the 1997-98 influenza vaccine, although subtype A/Sydney/ 05/97 was also found.
The proportion of patients reported with ILI by Georgia sentinel physicians exceeded baseline levels (0-3%) during the weeks of November 3, December 22, January 5, and January 12 (Figure 2). Although reported activity peaked during the week of November 3 when 7% of reported patient visits were due to ILI, this may in fact be an artifact of reporting as the levels dramatically decreased back to baseline levels during the next 6 weeks. A more accurate gauge of peak flu activity in Georgia during the 1997-98 season perhaps was represented by reported flu activity during the weeks from December 22 to January 12, when 5-6% of reported patient visits were due to ILI (Figure 2). This corresponds more closely to national flu peaks reported during the season (1,2).

Discussion
During the 1997-98 influenza season in Georgia, the predominance of influenza type A(H3N2) among those with laboratory-confirmed influenza was consistent with both worldwide and national trends. In fact, this is the second consecutive year in which the primary influenza subtype isolated in the United States was type A(H3N2) (2). Identification of circulating strains not included in the United States 1997-98 influenza vaccine such as A/Sydney/05/97 as well as international identification of 18 human cases of avian influenza A(H5N1) in Hong Kong underscore the continued need for worldwide influenza surveillance and rapid subtyping of influenza A isolates for timely public health response.
The Food and Drug Administrations Vaccine and Related Biologic Products Advisory Committee announced in February 1998 that the United States trivalent influenza vaccine for use during the 1998-99 influenza season will contain A/Sydney/05/97-like (H3N2), A/Beijing/ 262/95-like (H1N1), and B/Beijing/184/93-like influenza virus strain (2). This recommendation was based on antigenic analyses of influenza viruses isolated during the 1997-98 season. Recommendations for the use of vaccine and antiviral agents for prevention and control of influenza in the upcoming season are currently published by the Advisory Committee on Immunization Practices (ACIP) in an Morbity and Mortality Weekly Report (MMWR) Recommendations and Reports issue dated May 1, 1998 (3).

% Influenza-Like Illness
9/29 10/6 10/13 10/20 10/27 11/3 11/10 11/17 11/24 12/1 12/8 12/15 12/22 12/29
1/5 1/12 1/19 1/26
2/2 2/9 2/16 2/23 3/2 3/9 3/16 3/23 3/30 4/6 4/13 4/20 4/27 5/4 5/11 5/18 5/25

Figure 2. Influenza-like Illness as Reported by Sentinel Physicians, Georgia, 1997-98 Influenza Season
8 7 6 5 4 3 2 1 0
Week beginning

References
1. CDC. Update: Influenza ActivityUnited States, 1997-98 Season. MMWR 1998; 47:196-200.
2. CDC. Update: Influenza ActivityUnited States and Worldwide, 1997-98 Season, and Composition of the 1998-99 Influenza Vaccine. MMWR 1998;47:280-284.
3. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998;47(no. RR-6).
This report was contributed by Cherie L. Drenzek, DVM,MS, Infectious Disease Epidemiologist, Notifiable Disease Unit, Epidemiology and Prevention Branch, Division of Public Health, Georgia Department of Human Resources.

Successful Perinatal Hepatitis B Prevention Efforts

Physicians, diagnostic laboratories, and other health care providers are required by law to report Hepatitis B surface antigen (HBsAg)-positive pregnant women to either the County, District, or State Health Department within 7 days after diagnosis so that public health intervention efforts can begin. In cooperation with local health departments, the Perinatal Hepatitis B Prevention Program (PHBPP) of the Georgia Immunization Program offers free hepatitis B testing and vaccine to infants and sexual/household contacts of HBsAg-positive pregnant women identified via these reporting mechanisms. Additionally, this program ensures follow-up for infants born to hepatitis B virus (HBV)-infected mothers to complete the recommended hepatitis B immunoprophylaxis regimen (Hepatitis B Immune Globulin (HBIG) and 3 doses of Hepatitis B vaccine).
During the last several years in Georgia, increased cooperation among the reporting parties and direction of additional resources to the PHBPP have improved identification of (HBV) infected pregnant women and their infants. For example, in 1994, the program identified and provided follow-up services to 7 of the estimated 500 infants born annually to HBsAg-positive mothers in Georgia; in 1995, 46 infants were identifed, while in 1996 the total increased to 74 infants.
This partnership for prevention can be improved in the following areas: 1) more timely identification and reporting of HBV-infected pregnant women; 2) educating HBV-infected pregnant women and their contacts about hepatitis B; 3) ensuring that hepatitis B prevention services are provided to infants and contacts of these women; and, 4) documenting and communicating pertinent information to the appropriate health care providers, such as labor and delivery staff and pediatricians.
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The following are frequently-asked questions about HBV infection during pregnancy and reporting requirements thereof:
If I identify a HBsAg-positive pregnant woman, what is the reporting procedure?
The Notifiable Disease Unit the of Epidemiology and Prevention Branch of the Georgia Division of Public Health provides Notifiable Disease Reporting Forms to all health care professionals. If you need forms, please call 404-657-2588. After completing the form, forward it to the appropriate County or District Health Department or to the Epidemiology and Prevention Branch within seven days after diagnosis of HBsAg-positivity in a patient.
If laboratories report all HBsAg-positive results, why should prenatal care providers also report this information?
Physician reporting of HBsAg-positive pregnant women facilitates these intervention efforts because reporting laboratories often do not have patient demographic information or information regarding pregnancy status of individuals. Health department epidemiologists must then try to determine patient pregnancy status and county of residence; these efforts are time-consuming and can delay public health follow-up actions such as administration of immunopropylaxis to infants and/or contacts. Reporting also provides valuable information for evaluating the success of the PHBPP as well as identifying overall hepatitis B disease trends in Georgia.

acute infection and ultimately will become HBsAg-negative and antiHBs-positive. Another possibility is that the individual is infected with two different HBV subtypes. In this case the individual resolved one infection but not the second. (Figure 1.)
When I have identified a HBsAg-positive pregnant woman and have submitted a Notifiable Disease Reporting Form to the appropriatepublic health officials, are my responsibilities completed?
No. It is important to inform and educate the mother about the positive HBsAg test result and evaluate potential liver disease and treatment options. The HBsAg results must be documented on the prenatal record, transferred to the hospital medical record, communicated to the labor and delivery staff, and recorded in the infants hospital record. In this way the infant is assured of receiving Hepatitis B Immune Globulin (HBIG) and the correct dose of hepatitis B vaccine within 12 hours after birth. In turn, it is vital that this information be communicated to the infants pediatrician so that proper hepatitis B testing procedures and hepatitis B vaccine administration intervals/doses can be followed. Every prenatal care providers efforts are crucial to the success of the partnership for prevention.
Should women who have received three doses of Hepatitis B vaccine be screened during each pregnancy?
Yes. Since HBsAg testing is not a standard procedure before vaccination, a woman may receive the hepatitis B vaccination series when, in fact, she is already infected with the virus.

Can I release to County, District, or State health officials the information requested on the Notifiable Disease Reporting Form without obtaining the patients consent?
Yes, and you are legally required to do so.
Who is responsible for providing care to the contacts of a HBsAg-positive pregnant woman?
Testing and/or vaccinating household and sexual contacts of the HBsAg-positive pregnant woman may be performed by a primary care provider or by the County Health Department. Health departments may charge a nominal fee for hepatitis B services, but testing and/or vaccine will not be denied if the patient is unable to pay.
What is the definition of a chronic carrier?
A chronic carrier is an individual who has been HBsAg-positive for six months or longer. The presence of IgM antibody to hepatitis B core antigen (anti-HBc) differentiates an acute from a chronic infection. An individual who is HBsAg-positive and anti-HBc-positive and IgM antiHBc-negative is a chronic carrier. (Figure 1).
Is a pregnant woman who is diagnosed as a chronic hepatitis B carrier considered infectious?
Yes. Anyone who tests HBsAg-positive is a potential source of infection to others.
How does one interpret simultaneous positive HBsAg and antiHBsAg lab test results?
Fortunately this rarely occurs. After the possibility of a laboratory error has been ruled out, there are several interpretations. The first explanation is that the individual may be in the recovery phase of an

This report was contributed by Patricia Thiede, RN-C, Georgia Immunization Program, Division of Public Health, Georgia Department of Human Resources, and Susan Margolis, RN, Womens Health, Georgia Department of Human Resources
Interpretation of Hepatitis B Profile (Fig.1)

Tests

Results

Interpretation

Recommendations

HBsAg anti-HBc anti-HBs

negative negative negative

susceptible

vaccinate

HBsAg anti-HBc anti-HBs

negative neg. or pos. positive

immune

do not vaccinate

HBsAg anti-HBc anti-HBs

positive pos. or neg. negative

acutely infected or chronically infected

do not vaccinate

HBsAg anti-HBc anti-HBs HBeAg

positive pos. or neg. negative positive

acutely infected or chronically infected, highly infectious

do not vaccinate

HBsAg anti-HBc anti-HBs HBeAg

positive pos. or neg. negative negative

chronically infected or acutely infected, not as highly infectious as HBeAg+

do not vaccinate

HBsAg anti-HBc anti-HBs

negative positive negative

multiple interpretations*

vaccinate (if not acutely infected)

*1. May be recovering from acute HBV infection.
2. May be distantly immune and test not senstive enough to detect very low level of anti-HBs in serum.
3. May be susceptible with a false positive anti-HBc. 4. May be undetectable level of HBsAg present in the serum and the person
is actually chronically infected.

Laboratory evaluation beyond the basic hepatitis B panel IgM anti-HBc will differentiate acute hepatitis B infection (IgM anti-HBc positive) from chronic hepatitis B infection (IgM anti-HBc negative) Persons who are chronically infected should be evaluted to determine if chronic liver disease is present and if treatment is indicated.

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

May 1998

Volume 14 Number 5

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

Selected Notifiable Diseases

Total Reported for Feb. 1998 1998

Previous 3 Months Total Ending in Feb.
1996 1997 1998

Previous 12 Months Total

Ending in Feb.

1996

1997

1998

Campylobacteriosis

35

138

117

150

1013

778

678

Chlamydia genital infection

2244

3377

2891

5425

12114

13415

17697

Cryptosporidiosis

5

11

11

15

113

92

78

E. coli O157:H7

0

3

14

4

30

50

34

Giardiasis

62

122

208

205

598

878

892

Gonorrhea

1700

6114

4229

4989

21734

18959

18785

Haemophilis influenzae (invasive)

7

15

20

22

40

53

48

Hepatitis A (acute)

35

34

99

141

96

453

773

Hepatitis B (acute)

20

6

24

64

75

78

248

Lead Poisoning (capillary BLL >= 10 ug/dL)

n/a

550

489

26

3008

2984

1482

Lead Poisoning (venous BLL >= 10 ug/dL)

n/a

126

183

24

639

672

643

Legionellosis

0

1

0

2

11

3

6

Lyme Disease

1

0

1

2

14

2

10

Meningococcal Disease (invasive)

13

50

27

39

116

133

120

Mumps

0

2

4

1

10

11

8

Pertussis

0

7

9

2

30

38

11

Rubella

0

0

0

0

0

0

0

Salmonellosis

54

308

301

257

1710

1437

1340

Shigellosis

67

105

303

285

1196

1205

1104

Syphilis - Primary

11

51

50

24

283

193

142

Syphilis - Secondary

19

148

90

47

644

455

324

Syphilis - Early Latent

70

344

301

203

1579

1301

981

Syphilis - Other

51

255

347

180

1138

1107

1071

Syphilis - Congenital

2

20

8

3

68

27

19

Tuberculosis

40

204

192

116

769

772

644

* 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:
05/97 to 04/98 Five Years Ago: 05/92 to 04/93 Cumulative: 7/81 to 04/98

1510 1817 19146

19.4 14.5 15.0

38.3

18.8

3.2

16.1

1.5

22.2

48.9

21.5

6.1

12.0

2.3

9.2

51.1

19.2

5.8

11.9

2.0

10.0

24.2 73.1

2.7

36.8 61.5

1.7

39.0 58.9

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

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