Georgia epidemiology report, Vol. 15, no. 3 (Mar. 1999)

March 1999

volume 15 number 3

Division of Public Health
http://health.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 Acting Director
Kathleen E. Toomey, M.D.,M.P.H.
Acting State Epidemiologist Paul A. Blake, 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 A. 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 Lyle McCormick, M.P.H., Ann Buckley, 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 Editorial Board
Editorial Executive Committee Carol A. Hoban, M.S., 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

Listeriosis: A foodborne disease
with serious complications
Listeriosis is caused by Listeria monocytogenes, a gram-positive bacillus that is commonly found in soil, decaying vegetation, and the fecal flora of many mammals, including man. The organism can be found in stool specimens from 5% of healthy adults. Listeria grows readily in the laboratory on blood agar; a selective medium is also available. In clinical specimens, Listeria can be gram-variable and look like diphtheroids, cocci or bacilli. Clinicians should note that isolation from blood or cerebrospinal fluid of diphtheroids, which are commonly considered contaminants, may in fact indicate listeriosis.1
A recent multi-state outbreak of listeriosis has prompted inquries from the public regarding the diagnosis and prevention of listeriosis. In the current outbreak, a single virulent strain of Listeria (serotype 4b) is responsible for over 100 cases of listeriosis in 22 states. Fifteen adults died of listeriosis, and 6 pregnant women suffered miscarriages or stillbirths. The vehicle for transmission has been traced to hot dogs and deli meats manufactured by Bil Mar Foods, and the outbreak strain was isolated from unopened packages of Bil Mar hot dogs.2, 3
In the United States, an estimated 1,100 persons become seriously ill with listeriosis each year, and approximately 250 die.4 Listeriosis is a reportable disease in Georgia, and the number of reported cases has ranged from 10 in 1996 to 31 in 1998. Any isolation of Listeria from a normally sterile site (such as blood or cerebrospinal fluid) fulfills laboratory criteria for the diagnosis of listeriosis, and a confirmed case is defined as a clinically compatible case that is laboratory confirmed.
Previously reported outbreaks of listeriosis have been associated with eating contaminated cold cuts and deli meats, hot dogs, soft cheeses, and undercooked meat.1 The organism is commonly found in these products, and several food recalls each year are based on the isolation of Listeria from food products. However, most of these contaminated products are not linked to human disease, and it is likely that many persons ingest Listeria each year without becoming ill. Weakened host immunity, number of organisms ingested and differences in virulence among strains are also important factors in determining whether a person becomes ill following exposure. Pasteurization kills Listeria in dairy products, and thorough heating eliminates Listeria in other products. However, contamination of cooked products such as deli meats and hot dogs can occur after cooking. Unlike most bacteria, it multiplies well at refrigeration temperatures. In one study, 64% of refrigerators in homes of listeriosis patients contained at least one food item contaminated with Listeria.5
Certain persons are at higher risk of developing serious illness from eating Listeriacontaminated food (Table 1). Most reported cases of severe listeriosis are in pregnant women, newborns, and persons with impaired immunity caused by cancer, HIV infection, or other serious underlying illnesses. The elderly, and persons who take glucocorticosteroid medications are also at higher risk. The incubation period (time from ingestion to clinical illness) is highly variable, ranging from 11 to 70 days in some reports.1 In pregnant women, listeriosis may present as an acute febrile illness, often accompanied by backache, headache, myalgias, and arthralgias. The risk of listeriosis among pregnant women is 20 times that of the general population. Bacteremia is a common finding among pregnant women with listeriosis, and infection is frequently complicated by premature labor and stillbirth; 22% of perinatal infections result in stillbirth or neonatal death. Antibiotic treatment of pregnant women with listeriosis can sometimes avert miscarriage.1 Neonatal listeriosis may present as an early-onset sepsis syndrome or as a later-onset meningitis. Listeria is the second most common cause of meningitis in infants less than 1 month old.6
Listeria infection is also a common cause of meningitis among adults in the U.S., especially the elderly. For adults older than 60 years, Listeria is the second most common cause of bacterial meningitis,6 and the most common cause of meningitis among persons of
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

all ages with lymphomas, organ transplant recipients, and those receiving glucocorticosteroids.1 Thirty six percent of invasive listeriosis cases present with meningitis.6 Listeria bacteremia may present also as an acute febrile illness, or as a febrile gastroenteritis. Since it is not routinely cultured for, listeriosis should be considered for persons with gastroenteritis when stool studies fail to yield a pathogen.1
No controlled study has compared antibiotic regimens for the treatment of listeriosis. Based upon in vitro susceptibility testing and clinical experience, most experts recommend ampicillin as the drug of choice for treatment of listeriosis. For those allergic to penicillin, trimethoprim-sulfamethoxazole has also been used successfully.1 Antibiotic treatment of persons exposed to Listeria (such as by eating a product that is the subject of a recall), but with no symptoms of listeriosis, is not recommended.
Table 1. Persons at higher risk of listeriosis (Adapted from Listeriosis Fact Sheet, CDC, 1999)
Pregnant women (20 times population risk) Newborns Persons with weakend immune systems Persons with cancer, diabetes, or kidney disease Persons with AIDS (300 times population risk) Persons who take glucocorticosteroid medications The elderly

The CDC has issued dietary recommendations for avoiding listeriosis (Table 2). Since 1989, the U.S. Department of Agriculture has enforced a zero-tolerance policy for Listeria contamination of ready-to-eat processed meats. The incidence of invasive listeriosis has been reduced in recent years, possibly as the result of this policy change.7
Further information about listeriosis, including details of the recent outbreak, is available at the Georgia Division of Public Health, Epidemiology and Prevention Section webpage (http:// health.state.ga.us/epi/epistart.htm). Health care providers are required to report all cases of confirmed listeriosis to their local health departments.
Table 2. How can one reduce the risk of listeriosis? (Adapted from Listeriosis Fact Sheet, CDC, 1999)
General recommendations: Cook thoroughly raw food from animal sources, such as
beef, pork or poultry Wash raw vegetables thoroughly before eating Keep uncooked meats separate from vegetables and from
cooked or ready-to-eat foods Avoid raw (unpasteurized) milk or foods made from raw milk Wash hands, knives, and cutting boards after handling
uncooked foods

References
1. Lorber B. Listeriosis. Clin Infect Dis 1997;24:1-11.
2. Centers for Disease Control and Prevention. Update: Multistate outbreak of listeriosis United States, 1998-1999. MMWR 1999;47:1117-8.
3. Centers for Disease Control and Prevention. Update: Multistate outbreak of listeriosis. Press release, March 2, 1999. http:// www.cdc.gov.od/media/pressrel/r990114.htm
4. Centers for Disease Control and Prevention. Listeriosis Fact Sheet. http://www.cdc.gov/ncidod/diseases/foodborn/lister.htm
5. Centers for Disease Control and Prevention. Listeriosis outbreak associated with Mexican-style cheese California. MMWR 1985;34:357-9.

Recommendations for persons at high risk, such as pregnant women and persons with weakened immune systems, in addition to the recommendations listed above:
Avoid soft cheeses such as feta, Brie, Camembert, blueveined, and Mexican-style cheese. Hard or processed cheese, cream cheese, cottage cheese and yogurt need not be avoided
Cook until steaming hot left-over foods or ready-to-eat foods, such as hot dogs, before eating
Although the risk of listeriosis associated with foods from deli counters is relatively low, pregant women and immunosuppressed persons may choose to avoid these foods or throughly reheat cold cuts before eating.

6. Schuchat A, Robinson K, Wenger JD, Harrison LH, Farley M, et al. Bacterial meningitis in the United States in 1995. N Engl J Med 1997;337:970-6.

7. Tappero JW, Schuchat A, Deaver KA, Mascola L, Wenger JD. Reduction in the incidence of human listeriosis in the United States: effectiveness of prevention efforts? JAMA 1995;273:1118-22.

This article was contributed by Anthony Fiore, M.D., M.P.H.

Invasive Meningococcal Disease in Georgia, 1998

We have completed the second year of active surveillance for invasive Neisseria meningitidis as part of the Georgia Emerging Infections Program (GA EIP)! The GA EIP is part of a multi-site CDC-funded project that conducts active laboratory-based surveillance for certain organisms (which involves Public Health Staff directly contacting labs), as opposed to passive surveillance. This project would not be possible without the excellent assistance from microbiology laboratory and infection control personnel throughout the state.

Figure 1. Invasive Neisseria meningitidis Cases Georgia, 1997 & 1998
20
1998 (N=92) 1997 (N=100) 15

Number of Cases

This surveillance is helping us to obtain more accurate reports of all

the culture-confirmed invasive Neisseria meningitidis cases in Georgia

10

and to obtain more isolates for serogrouping. This information has

allowed us to map and identify trends in the strains of N. meningitidis

circulating in Georgia and the characteristics of persons affected by this

5

organism.

Figure 1: There were 92 cases reported in 1998, down from 100 in 1997. There were more cases reported for 1998 compared to 1997 in the months of January, February, August, October and November.
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0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Figure 2. Rate of Invasive Neisseria meningitidis
Disease by Age Group
Georgia, 1998
6

Rate per 100,000 Persons

5

4

3

2

1

0 <=1

2-4

5-11 12-17 18-29 30-59 60+

Age Groups in Years

Figure 2: The rate of disease in children <=1 is greater than 5 per 100,000 persons compared to all other age groups where the rate is 2 or less. All persons<=1 and 18-29 years old with invasive disease survived the illness. In children who contracted the disease, 14% between ages 2-4, 17% between 5-11 and 25% between 12-17 died. In adults, 28% in the 30-59 age group and 21% in those 60+ died.

Serogroup B was only isolated from persons 12 years and older. If isolates were not forwarded to the State Public Health Laboratory for serogrouping, they were not included in this figure.
Figure 4: These pie charts depict only those isolates that were sent to the State Public Health Laboratory for serogrouping and for which race information is known. The few persons who were not either African-American or white were excluded from this figure. There were proportionately more Serogroup Y isolates recovered from African-Americans and more Serogroup C isolates recovered from whites. Serogroup W-135 and Serogroup B were isolated in small numbers from both populations. One Serogroup Z isolate was recovered.

Figure 5. Percentage of Serogrouped and Non-Serogrouped Isolates Causing Invasive
Meningococal Disease

Georgia, 1998 (N=92)

C (32) 34.8%

B (8) 8.7%
Z (1) 1.1%

Unk (14) 15.2%

Figure 3. Invasive Neisseria meningitidis Isolates

That Are Serogroup B, C, and Y

by Age Group

Georgia, 1998

Serogroup B

Serogroup C

10

Serogroup Y

8

Number of Isolates

6

4

2

0

<=1

2-4

5-11 12-17 18-29 30-59 >=60

Age Groups in Years

Figure 3: Serogroup Y was the most common serogroup in children under 2 and in persons 30 and older and was isolated from persons in every age category. Serogroup Y was particularly dominant in persons 60+ years old, accounting for 60% of the serogrouped isolates. Serogroup C was prominent in all age groups except the elderly.

Figure 4: Invasive Neisseria meningitidis Isolates* by Race and Serogroup
Georgia, 1998

C (4) 16.7%

C (28) 56.0%

Y (33) 35.9%

W-135 (4) 4.3%

Figure 5: This pie chart shows the number and percentage of isolates that were not forwarded to State Public Health Laboratory for serogrouping compared to those that were forwarded. Obtaining the isolates for serogrouping is critical to our understanding of N. meningitidis and how it is transmitted in the population. Furthermore, once the laboratory has the isolates, more sophisticated tests can be done to examine the molecular relationships between the strains isolated in Georgia.
This type of specific information about Neisseria meningitidis was not available before this study began. If you suspect infection with Neisseria meningitidis, please remember to request that isolates be sent to the State Public Health Laboratory for serogrouping.

This article was contributed by Katherine Gibbs McCombs, M.P.H.
(MMWR) Morbidity & Mortality Weekly Reports
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Y (16) 66.7%

B (2) 8.3%
W-135 (2) 8.3%
Z (1) 2.0%

African-American N=24

B (3) 6.0%
W-135 (2) 4.0%
Y (16) 32.0%
White N=49

* Serogrouped isolates only, does not include isolates for w hich serogroup is unknow n

February 2, 1999 /Vol. 4 / No. 7 Decline in Cigarette Consumption Following Implementation of a Comprehensive Tobacco Prevention and Education Program - Oregon, 1996-1998.
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

March 1999

Volume 15 Number 3

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for December 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 December 1998
1998 55 3349 9 4 82 2472 9 53 15 0 0 5 0 3 0 158 54 11 21 63 37 3 76

Previous 3 Months Total

Ending in December

1996

1997

1998

160

232

191

3397

4181

7922

18

24

47

4

7

17

231

313

337

4540

4601

5514

14

12

24

106

224

232

14

52

35

0

4

0

0

3

0

23

17

22

2

1

1

8

2

8

0

0

0

396

363

508

482

491

203

45

38

37

122

72

67

320

237

170

307

216

131

10

5

5

207

171

172

Previous 12 Months Total

Ending in December

1996

1997

1998

793

766

773

13604

16196

25254

93

74

152

39

46

83

820

916

1218

19942

18541

20677

52

42

71

414

763

884

61

224

208

3

6

8

1

9

5

147

107

102

9

11

2

35

18

38

0

0

0

1468

1380

1858

1125

1204

1148

199

161

119

503

362

225

1344

1121

779

1068

1230

778

33

21

12

791

695

631

* 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: 4/98 - 3/99 Five Years Ago: 4/93 - 3/94 Cumulative: 7/81 - 3/99

Total Cases Reported *

AIDS Profile Update

Percent

Risk Group Distribution (%)

Female

MSM IDU MSM&IDU

HS Blood

Unknown

Race Distribution (%) White Black Other

1291

20.4

36.8

15.2

4.9

13.1

0.8

29.1

23

74.5

2.5

1944

15.7

44.8

22.4

5.6

13

1.1

13.1

31.6 66.5

1.9

20322

15.4

50.6

19.2

5.8

12.2

1.9

10.3

38

59.9

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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