Georgia epidemiology report, Vol. 14, no. 9 (Sept. 1998)

September 1998

volume 14 number 9

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

Healthcare Providers: Be Alert for Yersiniosis

Epidemiology and Prevention Branch State Epidemiologist

Every holiday season many babies and small children in Georgia are hospitalized with infections caused by the gram-negative bacterium Yersinia enterocolitica. In fact, of 7 sites around the country funded by the Centers for Disease Control and Prevention to study bacterial

Acting Director

illnesses, Georgia has the highest incidence of yersiniosis. In 1996, the incidence of

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

yersiniosis in Georgia was four times that of some other areas of the country.1 The Georgia

Epidemiology Section

Division of Public Health has identified prevention of yersiniosis as a high priority in their disease prevention efforts. The following article identifies ways that health care professionals

Chief

can diagnose this illness and counsel patients on simple measures that can be taken to avoid

Paul A. Blake, M.D., M.P.H.

acquiring yersiniosis.

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.
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. 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

In children, yersiniosis usually presents as a diarrheal illness (sometimes bloody), with fever and abdominal pain. In some patients, especially older children and adults, the clinical presentation is that of a mesenteric lymphadenitis that can be mistaken for appendicitis or colitis. Complications can include bacteremia, needless surgery and even death.2 Nearly half of the cases reported nationwide are in children less than 1 year old.1
Standard stool culture workups in most Georgia laboratories DO NOT include the cefsulodin-irgasan-novobiocin (CIN) culture medium required to grow Yersinia; thus, the diagnosis is often overlooked. The actual number of cases of yersiniosis in Georgia likely far exceeds the number of reported cases.3 When adjusted for the number of laboratories that routinely culture for the organism, the incidence in Georgia exceeds some other areas of the country by as much as thirteen-fold.1
Surveillance data show that the number of cases of yersiniosis in Georgia peaks during the winter months. Most reported cases are among African-American children. Past research has shown that preparation and cleaning of raw pork chitterlings (chitlins) in the home is strongly associated with acquiring yersiniosis. Children who acquire the disease need not have directly handled the chitlins; infection is usually spread by the hands of food preparers.4 Chitlins are a common food in many Georgia households, especially around the winter holidays. Most raw chitlins available in retail outlets in Georgia are contaminated with Yersinia, a bacterium that can multiply even under refrigeration.5
Health care workers can advise families on how to avoid acquiring yersiniosis from chitlins. Recent studies done at the Georgia Division of Public Health demonstrated that briefly boiling the chitlins for 5 minutes before cleaning kills all Yersinia. This change in preparation practices is simple, safe and effective, and cuts down on the cleaning time. While the chitlins are boiling, families should use scouring powder or detergent to scrub counters and other items that have touched the raw chitlins or their juice, and then wash their hands with soap. Unlike most bacteria, Yersinia grows well in the cold, so refrigerators used to store raw chitlins should also be cleaned. Most importantly, children should be kept out of areas where raw chitlins are prepared. Alternatively, chitlins can also be purchased pre-cooked, eliminating the hazard of raw chitlins in the kitchen. Pre-cleaned, but uncooked, chitlins that are commercially available are usually contaminated with Yersinia, so families should also pre-boil these chitlins before handling.5
Many cultural and ethnic groups eat chitlins, including African-Americans, Asians, and Hispanics, as well as families from rural and farming regions. Across the country in 1996, 41% of persons with yersiniosis were African-Americans, 34% were white, 10% were Asian-Americans, and 5% were Hispanic. Physicians caring for children with diarrheal illness should ask about chitlins exposure and specifically request cultures for Yersinia enterocolitica.
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

The Georgia Division of Public Health has patient information kits available free of charge to physicians and other health care providers. For more information or materials, please call Dr. Anthony Fiore at 404-657-2635, or e-mail aef0600@dhr.state.ga.us. You may also visit the Georgia Division of Public Health Epidemiology Web Page at http:// www.ph.dhr.state.ga.us/epi/epistart.htm.
References 1. Ray S, Voetsch D, Segler S, et al. FoodNet active surveillance for Yersinia enterocolitica: 1996. In: Abstracts of the International Conference on Emerging Infectious Diseases. Atlanta, GA: Centers for Disease Control and Prevention, 1998.

2. Tacket CO, Ballard J, Harris N, et al. An outbreak of Yersinia enterocolitica infections caused by contaminated tofu (bean curd). Am. J. Epidemiology 1985;121:705-11.
3. Johnson A, McNeil MM, Koehler JE, Ray M. Yersinia enterocolitica screening in Georgia laboratories. Georgia Epidemiol Rep 1997;13:1-2.
4. Lee LA, Gerber AR, Lonsway DR, et al. Yersinia enterocolitica O:3 infections in infants and children associated with the household preparation of chitterlings. N Engl J Med 1990;322:984-7.
5. Cobb LL, Ray ML, Peterson EA, et al. Isolation and enumeration of potentially pathogenic strains of Yersinia enterocolitica from chitterlings. In: Proceedings of the Annual Meeting of the American Society for Microbiol ogy, 1997. Washington, DC: American Society for Microbiology.

OVERVIEW OF THE BEHAVIORS AND EXPERIENCES OF MOTHERS IN GEORGIA, GA PRAMS, 1993-1996
Georgia PRAMS Perinatal Epidemiology Unit, 2 Peachtree Street, NW Atlanta, Georgia 30303 (404) 657-6462 Leslie Lipscomb, M.P.H. PRAMS Project Coordinator, Tonya Johnson, B.S. PRAMS Program Coordinator

The Pregnancy Risk Assessment Monitoring System (PRAMS) is a state-wide, ongoing, population-based surveillance system that collects and analyzes data on women who give birth in Georgia. PRAMS began in January of 1993 and supplements birth certificate data by collecting information on womens attitudes, experiences, and behaviors before, during, and after the delivery of a live born infant. Each month, a random sample of approximately 200 women is drawn from Georgia birth records and stratified by birthweight (low birthweight, normal birthweight) and race (black, other). Women are contacted by mail or telephone (for nonresponders) within 2-6 months after delivery. Each mother's questionnaire is linked to her infant's birth certificate. The data are weighted to adjust for survey design and nonresponse, and are representative of all Georgia women who deliver live infants.
This report summarizes PRAMS data for 1993 to 1996. In this report, the percentages given represent estimates for all of Georgia unless otherwise stated. All percentages were rounded to the nearest whole number and represent only those responding to the question.

Year of birth 1993 1994 1995 1996
1993-1996

Mothers sampled Mothers responding Response rate PRAMS births in GA

2,702

1828

68%

107,114

2,582

1842

71%

107,742

2,626

2,001

76%

109,101

2,329

1,761

76%

110,673

10,239

7,432

73%

434,630

Age/Race
Of the women responding to the survey from 1993 to 1996, 17% were less than 20 years old, 54% were between the ages of 20 and 29, and 30% were 30 years old or older. Nearly two-thirds (63%) of the mothers were white and 35% were black.
Figure 1

percent

Smoking status

30

25 24

21 22

20

16

15

18 14

10

5

0

1993

1994

24 20
14

21 19 13

1995

1996

year of birth

before pregnancy during pregnancy after pregnancy

Marital Status
Overall, thirty-six percent of all the mothers were unmarried at the time of delivery. The number of unmarried mothers decreased from 38% in 1993 to 35% in 1996 (Figure 1).
Education/Income
Almost a quarter (23%) of the women had less than 12 years of education, 36% had a high school education, 20% had 13-15 years of education, and 21% had 16 or more years of education. Among mothers at least 19 years old (the age by which most are expected to graduate from high school), 16% had not completed high school, 38% had a high school education, and 46% had more than a high school education. During the 12 months before delivery, the total family income was less than $8,000 for 26% of mothers, $8,000 to $19,999 for 25%, $20,000 to $39,999 for 22%, and $40,000 or more for 28% of the women.
Intention of Pregnancy
Nearly half (48%) of the women reported that their pregnancy was unintended; either they wanted to be pregnant later (35%) or did not want to be pregnant at all (13%). The number of unintended pregnancies declined from 52% in 1993 to 45% in 1996. Among teenage mothers, nearly three-fourths (74%) reported that their pregnancy was unintended; either wrong timing (57%) or unwanted (17%).
Pregnancy History
Eight percent of mothers had a preterm delivery (less than 37 weeks of gestation). Eleven percent had a previous premature baby. Among the mothers who had previous livebirths and whose most recent birth was preterm, 33% had a previous premature birth, and 10% of the women had a previous low birthweight (<2500 grams) baby.
WIC/Medicaid
Almost half (49%) of the women were enrolled in WIC (Special Supplemental Food Program for Women, Infants, and Children) during their pregnancy. The WIC program goal is to enroll women during the first trimester of pregnancy. Of the women participating in WIC, 57% enrolled during the 1st trimester, 30% enrolled during the 2nd trimester, and 13% enrolled during the 3rd trimester. Twenty-two percent of mothers were on Medicaid before they became pregnant. During pregnancy, 50% of the women had some or all of their prenatal care paid by Medicaid, and 51% of the women had their delivery paid by Medicaid.
Smoking
Twenty-three percent of mothers reported smoking cigarettes in the 3 months before pregnancy. Cigarette smoking declined to 14% during the last trimester of pregnancy and then increased to 20% 2-6 months

- 2 -

Figure 2
Unmarried Mothers at the time of Delivery

Breast-feeding
Forty-four percent of all women breastfed their baby one week or more. From 1993 to 1996, there was an increase in the number of women who breastfed at least one week. Overall, teenagers breastfed 52 percent less often than adults.

percent

40 30

38

37

36

35

20

10

0

1993 1994 1995 1996

year of birth

Prenatal Care
One fourth of the mothers did not start prenatal care by the 12th week of pregnancy (1st trimester). Twenty percent of the women did not receive prenatal care as early as they wanted. Of these women, 31% attributed their delay in seeking prenatal care to late recognition of their pregnancy, 30% attributed their delay to difficulties in getting an appointment, 21% to lack of money or insurance, 9% to transportation problems, and 5% to lack of child care.

after delivery. This trend is apparent for each year (Figure 2). Smoking during pregnancy declined from 16% in 1993 to 13% in 1996. Of the women who continued smoking cigarettes during the last trimester of pregnancy, 62% reduced the number of cigarettes smoked and 35% smoked the same amount or more as compared to pre-pregnancy levels; 43% smoked 1-9 cigarettes a day, 29% smoked 10-19 cigarettes a day, and 28% smoked 20 or more cigarettes a day.
Drinking
Drinking (1 or more alcoholic drinks per week) among mothers 3 months before pregnancy and during the last 3 months of pregnancy declined from 1994 to 1996 (Figure 3). Drinking before pregnancy declined from 46% in 1994 to 39% in 1996. There was a decrease in last trimester drinking from 13% in 1994 to 6% in 1996. Of the women who drank during pregnancy, 32% reduced the amount of their drinking, and 58% consumed the same amount or more as compared to prepregnancy levels. Over two-thirds of all women who drank stopped drinking during their pregnancy.
Figure 3

percent

50 40

45

30

20

10 9

0

1993

Drinking status

46

42

39

13

9

1994

1995 year of birth

6 1996

before pregnancy during pregnancy

Routine/Well-baby Care
At 3 to 4 months after delivery, an infant is expected to have received at least 2 to 3 well baby check-ups, and at 5 to 6 months after delivery, an infant is expected to have received at least 3 to 4 well baby checkups. The majority of Georgia babies received the expected number of visits for routine care. At 3 to 4 months after delivery, 29% of mothers had taken their baby for 2 visits and 35% had gone for 3 visits. At 5-6 months after delivery 30% had taken their baby for 3 visits, 22% had gone for 4 visits, and 26% had gone for 5 or more routine visits. Nine percent of mothers had not taken their baby for routine care as often as they wanted. The reasons for not having enough routine care visits included: lack of transportation (24%), lack of money or insurance (17%), not being able to get an appointment (17%), and lack of child care (9%).
Violence/Physical Abuse
Nearly one in ten (8%) women were involved in a physical fight in the 12 months before they delivered their baby. Of these women, over 50% were physically hurt by their husband or partner in the 12 months before they delivered their baby.
PRAMS data are collected retrospectively and concern events that may have occurred up to one and half years before completing the questionnaire or interview, which may lead to errors in recall. PRAMS represents women who deliver liveborn infants and not women who had spontaneous abortions or fetal deaths. Even with these limitations, PRAMS is a valuable source of information about pregnancy health in Georgia and will be used to provide more specific analyses in the future. This report was contributed by Leslie Lipscomb, M.P.H., GA PRAMS and James Buehler, M.D., Perinatal Epidemiology Unit.
(MMWR) Morbidity and Mortality Weekly Reports
YYoouu M Maayy HHaavvee M Miisssseedd

Terms used to describe infectious disease outcomes that may occur after exposure

Infectivity

The proportion of exposed persons who become infected.

September 11, 1998 / Vol. 47 / No. RR-15 Preventing Emerging Infectious Diseases: A Strategy for the 21st Century
September 11, 1998 / Vol. 47 / No.35 Youth Agricultural Work-Related Injuries Treated in Emergency Departments, 10/95-09/97.

Pathogenicity

The proportion of infected persons who develop clinical disease.

Haemophilus influenzae Invasive Disease Among Children Aged <5 Years California, 1990-1996.

Virulence

The proportion of persons with clinical disease who become severely ill or die

CDC. Principles of Epidemiology: An Introduction to Applied Epidemiology and Biostatistics. 2nd ed. Atlanta:, U.S. Department of Health and Human Services Public Health Services, 1992.

September 4, 1998 / Vol. 47 / No.34 Maternal Mortality - United States, 1982-1996 Hepatitis A Vaccination of Men Who Have Sex With Men Atlanta, Georgia
Use of Reminder and Recall to Increase Vaccination Rates
The Morbidity and Mortality Weekly Report (MMWR) series is produced by the Center 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
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The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186

September 1998

Volume 14 Number 9

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for June 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 June 1998
1998 65 1894 9 26 96 1542 3 44 9 0 0 5 0 3 0 145 161 9 13 57 49 4 52

Previous 3 Months Total

Ending in June

1996

1997

1998

212

138

194

3304

5218

5668

18

1

23

10

13

29

122

78

245

4761

5365

4667

11

5

10

127

207

169

6

50

47

2

2

3

1

0

2

44

31

19

2

5

1

13

2

13

0

0

0

288

271

315

166

161

383

42

41

26

100

95

55

304

290

178

224

332

205

11

5

4

195

179

151

Previous 12 Months Total

Ending in June

1996

1997

1998

927

671

835

12350

15545

19444

129

71

106

32

52

50

622

829

1076

21318

19511

18443

38

43

47

209

551

771

33

127

271

5

2

7

5

1

12

157

111

105

8

16

2

39

26

23

0

0

0

1679

1432

1389

809

1241

1402

245

186

134

586

448

281

1408

1291

915

1087

1267

939

58

23

15

801

745

614

* 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

Total Cases Reported *

AIDS Profile Update

Percent Female

Risk Group Distribution (%)

MSM IDU MSM&IDU

HS Blood

Unknown

Race Distribution (%) White Black Other

Latest 12 Months:
10/97 to 09/98 Five Years Ago: 10/92 to 09/93 Cumulative:
7/81 to 09/98

1343 2008 19645

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

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-