Georgia epidemiology report, Vol. 15, no. 1 (Jan. 1999)

January 1999

volume 15 number 01

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

Women with Sexually

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.
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., 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

Transmitted Diseases in Georgia:
Results from the Chlamydia Project, 1997
Introduction
Chlamydia, the most common bacterial sexually transmitted disease (STD) in the United States, causes chronic pelvic pain, ectopic pregnancy, pelvic inflammatory disease (PID), epididymitis, infertility, and an increased risk of human immunodeficiency virus (HIV) transmission. In 1997, there were 526,653 cases of chlamydia reported in the United States,1 (rate of 207 cases per 100,000 population) and 16,164 cases reported in Georgia (rate of 220 cases per 100,000 population). Because most women infected with chlamydia are asymptomatic, screening is essential to prevent and control the spread of this disease and to decrease costs associated with its treatment and complications. For uncomplicated chlamydial infections, an effective, single-dose oral medication (Azithromycin, 1 gram) is now widely available.
Since 1994, the Georgia Department of Human Resources, Division of Public Health has participated in the Region IV Chlamydia Project, which is sponsored by the Centers for Disease Control and Prevention (CDC) and coordinated by the Emory University Regional Training Center. Region IV includes Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee and is the first region in the United States whose Chlamydia Project database has information on gonorrhea. The main goals of the project are to determine the prevalence of chlamydia and to prevent and control chlamydia and its complications through the collaborative efforts of STD and family planning (FP) providers and laboratories. A previous analysis of data from the Georgia Chlamydia Project showed a 7% chlamydia positivity in women 10 to 44 years old who were screened at nine FP clinics between July 1994 and October 1995.2 In that analysis, 76% of chlamydia positive women were asymptomatic, and the chlamydia positivity was highest in women 10 to 19 years old (13%). Since the beginning of the Chlamydia Project, the number and type of screening sites in Georgia has increased. This report presents and interprets results from 1997 and considers the implications of the project in Georgia.
Methods
In 1997, 51 sites (43 FP and 8 STD) throughout Georgia participated in the Chlamydia Project. Women who had a pelvic exam during their FP or STD clinic visit were screened for chlamydia and gonorrhea. At the FP sites, screening was done for women who were less than 27 years old and for women at least 27 years old who also reported symptoms or new or multiple sex partners in the last 60 days. At the STD sites, screening was done for all women 10 to 44 years old. For this project, symptoms primarily include vaginal discharge or bleeding, abdominal pain, and pain with urination or intercourse. Women were screened for chlamydia with the Gen-Probe Pace II assay and for gonorrhea with cell culture. Women needing treatment for chlamydia were given a single, oral dose of Azithromycin (1 gram). Treatment for gonorrhea was site-specific and consistent with CDC guidelines.3 Partner notification and treatment services were available at each site for women infected with chlamydia.

Editorial Board
Editorial Executive Committee
Andrew Margolis, M.P.H. - Editor Kathryn E. Arnold, M.D.
Jeffrey D. Berschling, M.P.H. Paul A. Blake, M.D., M.P.H. Jane E. Koehler, D.V.M., M.P.H. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Christopher Devoe - Graphics

Results
In 1997, 29,385 women were screened in this project. Of women with positive or negative results, 6.5% (1,863/28,628) were infected with chlamydia and 2.3% (655/27,945) were
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

infected with gonorrhea. The chlamydia positivity was 6.0% (1,514/ 25,132) at the FP sites and 8.2% (349/4,253) at the STD sites. By age group, the chlamydia positivity was 10% (984/9,886) in women 10 to 19 years old, 4.9% (760/15,412) in women 20 to 29 years old, 2.0% (57/2,828) in women 30 to 39 years old, and 0.8% (4/505) in women 40 to 49 years old. By race/ethnicity, the chlamydia positivity was 8.5% (1,385/16,305) in African Americans, 3.5% (376/10,841) in Whites, and 3.3% (34/1,018) in Hispanics. Of chlamydia positive women with documented information on symptoms, 63% (1,064/ 1,698) were asymptomatic, and of the women who were pregnant, 12% (30/248) were infected with chlamydia.
Discussion
Similar to a previous report,2 the results of this analysis show that women screened in the Georgia Chlamydia Project have a high chlamydia positivity, especially among young persons and minorities. The results also underscore the importance of screening asymptomatic women for STDs. Because women infected with STDs are at risk of acquiring and transmitting HIV, successful treatment of their STDs should decrease the spread of HIV.4 Women who are infected with chlamydia or at high risk for STDs should have access to STD screening and treatment services and effective HIV/STD prevention interventions. One recent study showed that brief, interactive HIV/ STD counseling interventions which are tailored to each individual's risks can increase condom use and prevent new STDs.5 These interventions were acceptable and feasible in busy, publicly funded clinics and were particularly effective in young persons.

References
Figure 2
1. FDigiuvreis1ion of STD Prevention. Sexually Transmitted Disease Surveillance, 1997. U.S. Department of Health and Human Services, Public Health Service. Atlanta: Centers for Disease Control and Prevention (CDC), September 1998.
2. Williamson DM, Mertz KJ, Toomey KE. Chlamydial infections among family planning clinic patients in Georgia: who should be screened? JMAG 1998;87:152-154.
3. Centers for Disease Control and Prevention. 1998 Guidelines for treatment of sexually transmitted diseases. MMWR 1998; 47 (No. RR-1).
4. Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania: randomised controlled trial. Lancet 1995;346:530-536.
5. Kamb ML, Fishbein M, Douglas JM, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. JAMA 1998;280:1161-1167.
6. Institute of Medicine. The neglected health and economic impact of STDs. In: Eng TR, Butler WT, eds. The hidden epidemic: confronting sexually transmitted diseases. Washington, DC: National Academy Press, 1997:28-68.

Chlamydial infections and their complications result in an estimated $2 billion in annual health care costs in the United States.6 In Georgia, the annual costs are estimated to be over $50 million, and for every one dollar spent on screening and treatment, about $11 in complications is saved. Since 1998, state legislation has required that health insurance plans pay for the cost of an annual chlamydia screening for women less than 30 years old. Partner notification is a cost-effective public health strategy for the prevention of PID7 and available to women infected with chlamydia in Georgia. As screening and treatment for chlamydia continues to expand in Georgia, it is anticipated that the chlamydia epidemic will be better understood and controlled and that the complications and costs of this disease will decrease.

7. Howell MR, Kassler WJ, Haddix A. Partner notification to prevent pelvic inflammatory disease in women: cost effectiveness of two strategies. Sex Transm Dis 1997;24:287-292.
Acknowledgment
The work of Teresa Edwards is appreciated and invaluable to the conduct of the Georgia Chlamydia Project.
Written by: John F. Beltrami, M.D., M.P.H. & T.M.

Usefulness of PFGE in evaluating a cluster of Salmonella Rubislaw infections in south Georgia

In November 1998, Salmonella surveillance alerted Georgia public health authorities to an unusual cluster of Salmonella Rubislaw infections. From September 17 to October 6, 1998, five infants, ages 27 days to 14 months, had stool cultures positive for S. Rubislaw. One infant was from north Georgia, but the other four were all located in south Georgia - two in the Valdosta Health District and two in the Waycross Health District. In addition, twelve cases of S. Rubislaw were recently reported in Florida, also primarily in infants.

Rubislaw is an unusual Salmonella serotype in the United States, with an average of 65 isolates per year (0.16% of all isolates) reported nationwide between 1986 and 1996. In 1968-1986, the cases were concentrated in Louisiana, Arkansas, and Texas (Figure 1).1 In Georgia, an average of 5 isolates (0.44% of all isolates) were reported statewide each year between 1993 and 1996. The serotype is somewhat more common in Florida than in Georgia, with an average of 14 isolates (2.02%) reported per year in Florida between 1993 and 1996.

Figure 1. Age-standardized rates of reported isolates of Salmonella Rubislaw, by state, United States, 1968-1986

State and local Epidemiologists began an investigation to identify a potential common source for the September - October cluster. Parents of three affected infants were interviewed; the affected infants had presented with fever and/or non-bloody diarrhea. No common source exposure was identified by the interviews. Although the infants were all enrolled in nutritional assistance programs, they were fed different formulas, cereals, and jarred baby food. No
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infants ate other types of food prepared by their families. No common brands in pacifiers, bottles, or rubber nipples were identified. Additionally, only one of the three households kept domestic pets and none of the infants had exposure to reptiles. All three families used well water, but their distance from one another argues against this being a common source.
During the investigation, the Georgia Public Health Laboratory performed pulsed-field gel electrophoresis (PFGE) on all 5 of the S. Rubislaw isolates. PFGE generates a DNA fingerprint pattern for each isolate that helps to determine if the isolate is related to other tested isolates.2 This PFGE analysis revealed that all five of the S. Rubislaw isolates differed on PFGE. Four of these are shown in Figure 2; lanes 1, 4, and 7 are control strains. Additionally, no genotypic similarities were found between the Georgia and Florida isolates. Together, these data argue strongly against a common source expo-
Figure 2. Pulsed-Field Gel Electrophoresis Patterns of Salmonella Rubislaw isolates
1 2 3 4 5 67

sure. The apparent cluster may have occurred by chance, or the environmental niche occupied by this poorly understood serotype may have provided unusually favorable conditions for the serotype in the fall of 1998. Local authorities were made aware of these findings.
Within the last 6 months, PFGE has been used in several ways in Georgia, including:
1. Showing that E. coli O157:H7 isolates of a unique PFGE pattern had all come from persons who visited a single water park.
2. Showing that Salmonella Typhimurium strains from ill customers, meat specimens, and food handlers from a BBQ restaurant all had the same PFGE pattern.
3. Showing that S. Typhimurium strains from ill Georgians in October, 1998 were different from the strain associated with a recalled chicken product.
4. Showing that E. coli O157:H7 strains from a patient and from ground beef at a fast food restaurant where he ate were different.

The State Public Health Laboratorys ability to do PFGE has become an invaluable tool in the investigation of notifiable diseases in Georgia.

Reference
1. Martin MS, Hargrett-Bean N, Tauxe RV. An atlas of Salmonella in the United States: Serotype-specific surveillance, 1968-1986. Centers for Disease Control, Public Health Service, U.S. Department of Health and Human Services.
2. Park M. A Laboratorians Look into E. coli O157:H7. Georgia Epidemiology Report 1998;7:2-3.

"EMERGING INFECTIOUS DISEASES"
Modern demographic and environmental conditions increasing the spread of infectious diseases include:
Global Travel.
Globalization of the food supply and centralized processing of food.
Population growth and increased urbanization.
Population movements caused by civil wars, famines, and other man-made natural disasters.
Irrigation, deforestation, and projects altering the habitats of disease-carrying insects and animals.
Human behaviors, such as intravenous drug use and risky sexual behavior.
Increased use of antimicrobial agents and pesticides, hastening the development of resistance.
Increased human contact with rain forests and other habitats that are reservoirs for insects and animals harboring unknown infectious agents.
CDC. Preventing Emerging Infectious Diseases, A Strategy for the 21st Century. Atlanta, Ga. U.S. Department of Health And Human Services, 1998.

Contributed by: Keoki Williams, M.D., Susan Lance-Parker, D.V.M., Ph.D., Robert Manning, B.S., Jane Koehler, D.V.M., M.P.H., Paul Blake, M.D., M.P.H.
(MMWR) Morbidity & Mortality Weekly Reports
You May Have Missed
January 8, 1999 / Vol. 47 / No. RR-01
Human Rabies Prevention - United States, 1999 Recommendations of the Advisory Committee on Immunization Practices (ACIP).
January 8, 1999 / Vol. 47 / No. 51 & 52
Transmission of Measles Among a Highly Vaccinated School Population - Anchorage, Alaska, 1998.
Decrease in AIDS Related Mortality in a State Correctional System New York, 1995-1998.
Update: Multi State Outbreak of Listeriosis - United States, 1998-1999.
December 25, 1998 /Vol. 47 / No. 50
HIV Testing Among Populations at Risk for HIV Infection - Nine States, November 1995-December 1996.
Self-Reported Physical Inactivity by Degree of Urbanization - United States, 1996.
December 18, 1998 /Vol. 47 / No. 49
Rapidly Growing Mycobacterial Infection Following Liposuction and Liposculpture: Caracas, Venezuela, 1996-1998.
Impact of Closure of a Sexually Transmitted Disease Clinic on Public Health Surveillance of Sexually Transmitted Diseases -Washington, D.C., 1995.
Outbreak of Primary and Secondary Syphilis -- Guilford County, North Carolina, 1996-1997.
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.
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The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186

Bulk Rate U.S. Postage
Paid Atlanta, Ga Permit No. 4528

January 1999

Volume 15 Number 01

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for October 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 October 1998
1998 73 2436 21 8 136 1580 7 80 6 0 0 7 0 3 0 218 84 15 25 50 37 0 49

Previous 3 Months Total

Ending in October

1996

1997

1998

228

263

217

4872

2718

6467

40

45

59

14

10

27

309

365

439

5537

3497

5408

10

9

13

117

246

225

32

74

31

0

1

2

0

7

0

24

15

19

5

0

0

11

2

8

0

0

0

493

485

805

396

365

248

55

44

30

141

86

54

361

264

169

281

274

144

8

5

1

194

163

142

Previous 12 Months Total

Ending in October

1996

1997

1998

823

714

799

13793

14315

23102

95

73

129

39

46

76

754

868

1203

21364

17576

20210

47

44

54

347

708

724

58

191

219

4

3

11

1

8

6

155

108

101

11

11

2

34

21

31

0

0

0

1455

1430

1779

895

1201

1348

214

167

116

521

390

222

1379

1168

786

1028

1296

793

41

24

9

778

721

608

* 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: 1/98 to 12/98 Five Years Ago: 12/92 to 12/93 Cumulative: 7/81 to 12/98

Total Cases Reported *
1325 2013 19977

AIDS Profile Update

Percent Female

Risk Group Distribution (%)

MSM IDU MSM&IDU

HS Blood

Unknown

19.1

38.7

16.7

4.6

13.9

0.8

25.3

15.2

45.4

23.1

5.7

12.6

1.5

11.6

15.3

50.8

19.2

5.8

12.1

1.9

10.2

Race Distribution (%) White Black Other

23.8 73.7

2.5

32.9 65.3

1.8

38.3 59.6

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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