Georgia epidemiology report, Vol. 15, no. 7 (July 1999)

July 1999

volume 15 number 7

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
Additions to the Notifiable Disease List

New On The Web This Month:
E. coli Outbreak

(effective July 1, 1999)
Seven diseasesplague, tularemia, Q fever, cyclosporiasis, yersiniosis, ehrlichiosis and infection with Staphylococcus aureus with reduced susceptibility to vancomycinhave been added to the Notifiable Diseases List for Georgia, effective immediately. The first three were considered in the June 1999 Gerogia Epidemiology Report (GER). Yersiniosis was reviewed in the October 1998 GER (available at web address). Cyclosporiasis, ehrlichiosis and infection with Staphylococcus aureus with reduced susceptibility to vancomycin are discussed below.
Ehrlichiosis

Waterpark Report

Pedestrian

Fatalities

Atlantas

Most dangerous Roads

health.state.ga.us/epi/ manuals/ger.htm
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
Georgia Epidemiology Report Editorial Board
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 Jimmy Clanton, Jr. - Graphics

Ehrlichiosis is a newly recognized disease caused by rickettsial bacteria of the genus Ehrlichia. Ehrlichiosis is transmitted by tick bites, and increases in late spring to early summer during peak tick-biting season. Human monocytic ehrlichiosis (HME) is caused by Ehrlichia chaffeensis, and was first described in 1986. Amblyomma americanum (the lone star tick) and Dermacentor variabilis (the dog tick) are responsible for transmission of HME. Human granulocytic ehrlichiosis (HGE) was first reported in 1992, and is caused by an Ehrlichia species that has yet to be named. HGE is transmitted by Ixodes scapularis (the deer tick) and Ixodes pacificus. Ixodid ticks are the principle vectors of other diseases also, and ticks multiply infected with Ehrlichia species and Borrelia burgdorferi (the agent of Lyme disease), or Ehrlichia species and Babesia microti have been reported. Presumably dual transmission of ehrlichiae and other rickettsial bacteria (such as Rickettsia ricketsii, the cause of Rocky Mountain spotted fever) is also possible.
Most patients are adult males, perhaps reflecting greater participation in outdoor activities. HME is more common in the southern United States (U.S.), while HGE infections are more common in the North. Active surveillance data from hospitalized patients over an 18 month period in southeast Georgia during the late 1980s demonstrated an incidence rate of 3.5 cases of HME per 100,000 person-years.
Both HME and HGE are characterized by fever, headache, myalgia and malaise, but nausea, diarrhea, and confusion are also reported by many patients, underscoring the systemic manifestations of the disease.. The incubation period may range from 0 to 34 days, but is generally 7 to 10 days. Pulmonary infiltrates, renal insufficiency or neurologic complications may occur. While ehrlichiosis can cause severe illness or even death, a self limited, less severe illness is more common. Rash is seen in only one third of patients, and can assume a variety of forms. Leukopenia, thrombocytopenia, and elevated aminotransferases are commonly observed. In several case-series, more than half of the patients required hospitalization, but less than 5% died.
Diagnosis of ehrlichiosis is made by demonstrating a fourfold rise in serum antibody titer to Ehrlichia antigens, using an immunofluorescent antibody test. Separate testing for HME and HGE is required. Paired sera (acute and convalescent specimens) for testing should be sent to the Georgia Public Health Laboratory. Occasionally the organisms can be visualized within leukocytes or monocytes on a peripheral blood smear. Examination of the blood smear is an insensitive test, but it is the only rapid diagnostic tool available in most settings. If ehrlichiosis or other tick-bite-transmitted disease is suspected, treatment should not be delayed until a definitive diagnosis can be made. Doxycycline treatment often provides rapid clinical improvement, and is the antibiotic of choice in all age groups. Chloramphenicol has been used by some in pediatric patients, but treatment failures have occurred.
Human exposure to ticks capable of transmitting ehrlichiosis is common in Georgia. Avoiding tick bites by wearing long sleeved, light colored clothing, using insect repellants, and promptly removing attached ticks will lessen the risk of ehrlichiosis. Given the low incidence of ehrlichiosis, use of prophylactic antibiotics after tick bites is not recommended.
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

Ehrlichiosis should be suspected as the cause of any systemic febrile illness in a person with outdoor exposures. Reporting cases of ehrlichiosis will help health officials understand the extent of the disease, and guide tick control efforts.
Cyclosporiasis
Cyclosporiasis is a newly recognized gastrointestinal infection caused by the protozoan, Cyclospora cayatenensis. Large, multistate outbreaks traced to imported raspberries occurred in 1996, 1997, and 1998. Cyclosporiasis outbreaks following ingestion of mesclun lettuce, fresh basil, and other fresh produce have also been reported. Contaminated water was the source of several outbreaks in Nepal, and a small outbreak among staff in a Chicago hospital. An animal reservoir for cyclosporiasis has not been found.
Symptoms of cyclosporiasis include watery diarrhea, nausea, anorexia, cramping, myalgia, fatigue, and weight loss. Diarrhea, often with intermittent symptoms, may persist as long as 9 weeks. Fatigue, anorexia, and weight loss may predominate after the initial diarrheal symptoms. Disease may be even more protracted in immunosuppressed persons. The incubation period is usually about 1 week, but may be as short as 1 day. Infected persons excrete unsporulated oocysts, which then require 1-2 weeks outside the host to sporulate. Only sporulated oocysts are capable of causing infection; therefore, direct person-to-person transmission is unlikely. Cyclosporiasis is diagnosed by identifying the organism in stool specimens, either by the characteristic refractile pattern on concentrated wet mount preparations or by using a modified acid-fast staining technique. Oocysts are larger (8-10 microns) than those of Cryptosporidium parvum, another enteropathogenic protozoan that causes similar symptoms. Cyclospora may exhibit autofluorescence when examined under an ultraviolet fluorescence microscope with a 365 nanometer excitation filter. Clinicians suspecting cyclosporiasis must specifically request acid-fast staining, because standard ova and parasites testing may not include these special techniques. Confirmation of suspected positive tests in a reference laboratory is advised; the Georgia Public Health Laboratory can provide this service. Trimethoprim-sulfamethoxazole is the only antibiotic proven to be an effective treatment.
Washing produce and avoidance of untreated drinking water may reduce the risk of cyclosporiasis. However, the number of organisms required to cause infection is probably fewer than 100, and even washing produce may not remove all Cyclospora. Cyclospora may also be relatively resistant to chlorine. Cyclosporiasis should be suspected in any person with a protracted gastrointestinal illness, especially if following recent travel to the developing world.
Staphylococcus aureus infections with reduced
susceptibility to vancomycin
Staphylococcus aureus is the most common cause of skin, soft tissue, and wound infections, and a leading cause of osteomyelitis, endocarditis, pneumonia, and prosthetic device infections. Since the introduction of antibiotics in the 1940s, staphylococci have proven adept at developing resistance. In many hospitals, nosocomial infections caused by S. aureus resistant to all antibiotics except for vancomycin are common. Following the emergence of methicillin-resistant S. aureus (MRSA) in the 1970s, vancomycin has been the only uniformly effective antimicrobial agent for treatment of serious infections with MRSA. Recently, several persons in the U.S. and Japan have been found to have infection with S. aureus that has intermediate resistance to vancomycin (VISA). These VISA-infected patients have all been chronically ill and undergoing prolonged vancomycin treatment for MRSA infections. Prolonged treatment with various combinations of rifampin, trimethoprim-sulfamethoxazole, gentamicin, and vancomycin have successfully eradicated VISA in most cases. No carriage of VISA by household or health care worker contacts has been noted. VISA is neither more nor less virulent than antibiotic susceptible

strains of S. aureus, and likely causes a similar spectrum of illness. However, infection with VISA or even vancomycin-resistant S. aureus (VRSA) is likely to become more common, and will be difficult and costly to treat.
In order to examine risk factors for acquiring infection with S. aureus with reduced susceptibility to vancomycin, the Centers for Disease Control and Prevention has requested that states add S. aureus isolates with a minimum inhibitory concentration (MIC) sensitivity to vancomycin of 4 micrograms per milliliter (mcg/ml) or greater to states reportable diseases list. Strains having a susceptibility of 4 mcg/ml to vancomycin are nearly resistant, and may yield clues as to how resistance develops. Clinical laboratories should be certain that isolates are in pure culture and reconfirm species identification as part of the workup. Pure cultures of the suspected VISA or VRSA should be sent to the Georgia Public Health Laboratory, and reported by phone to the Georgia Division of Public Health, Epidemiology and Health Information Branch.
Recommended infection control procedures for patients infected with VISA or VRSA are based upon routine contact isolation procedures, and include strict enforcement of contact precautions among health care workers, minimization of the number of personnel caring for the infected patient, and consultation with public health authorities before discharge or transfer of the patient home or to another facility.
Ehrlichiosis, cyclosporiasis, or infection with Staphylococcus aureus with reduced susceptibility to vancomycin should be reported to the Georgia Division of Public Health, Epidemiology and Health Information Branch at 404-657-2588. Details on submitting specimens to the Georgia Public Health Laboratory can be found in the on line manual at http:// www.ph.dhr.state.ga.us/manuals/lab/contents.htm
Bibliography (Note that full text of MMWR and Emerging Infectious Diseases is available on line http://www.cdc.gov/).
Walker DH, Dumler JS. Emergence of the ehrlichioses as human health problems. Emerg Infect Dis 1996;2:18-29.
Fritz CL, Glaser CA. Ehrlichiosis. Infect Dis Clin North Am 1998;12:123-36.
Standaert SM, Dawson JE, Schaffner W, et al. Ehrlichiosis in a golf-oriented retirement community. N Engl J Med 1995 Aug 17;333(7):420-5
Sterling CR, Ortega YR. Cyclospora: an enigma worth unraveling. Emerg Infect Dis 1999;5:48-53.
Herwaldt BL, Ackers M-L, Cyclospora Working Group. An outbreak in 1996 of cyclosporiasis associated with imported raspberries. N Engl J Med 1997;336:1548-56.
Hoge CW, Shlim DR, Ghimire M, et al. Placebo-controlled trial of co-trimoxazole for Cyclospora infections among travelers and foreign residents in Nepal. Lancet 1995;345:691-3.
Soave R, Herwaldt BL, Relman DA. Cyclospora. Infect Dis Clin North Am 1998;12:1-12.
Centers for Disease Control and Prevention. Interim guidelines for prevention and control of staphylococcal infection associated with reduced susceptibility to vancomycin. MMWR 1997;46:626-8.
Smith TL, Pearson ML, Wilcox KR, et al. Emergence of vancomycin resistance in Staphylococcus aureus. New Engl J Med 1999;340:493-501.
This article was contributed by Anthony Fiore, M.D., M.P.H.

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D I S E A S E

R E P O R T I N G
Division of Public Health - Epidemiology and Health Information Branch
GEORGIA NOTIFIABLE DISEASE

UNIT

All Georgia physicians, laboratories and other health care providers are required by law to report patients with the following conditions to their County Health Department or District Health Office. Cases may also be reported to the Notifiable Disease Unit of the Epidemiology and Prevention Branch. Both lab-confirmed and clinical diagnoses are reportable within the time interval specified below. Reporting enables appropriate public health follow-up for your patients, helps identify outbreaks, and provides a better understanding of disease trends in Georgia. For the latest information from the Division of Public Health, visit our web site at: http://health.state.ga.us

IMMEDIATELY any cluster of illnesses animal bites anthrax arboviral encephalitis botulism brucellosis cholera diphtheria E. coli O157:H7
*Haemophilus influenzae (invasive)
hantavirus pulmonary syndrome
emolytic uremic syndrome hepatitis A (acute)

OCTOBER

WITHIN 7 DAYS
AIDS aseptic meningitis campylobacteriosis cancer treated as an outpatient chancroid Chlamydia trachomatis (genital infection) cryptosporidiosis cyclosporiasis ehrlichiosis giardiasis gonorrhea # HIV hepatitis B (acute) hepatitis C (acute)
** newly identified HBsAg+ carriers ** HBsAg+ pregnant women
lead blood level > 10ug/dl legionellosis

measles (rubeola)

meningitis (specify agent)

*

meningococcal pertussis

disease

(invasive)

plague

poliomyelitis

Q fever

rabies (human & animal)

S. aureus with vancomycin MIC>4 mcg/ml

syphilis (congenital & adult)

tuberculosis

tularemia

leptospirosis
* listeriosis (invasive)
Lyme disease lymphogranuloma venereum malaria mumps psittacosis Rocky Mountain spotted fever rubella (including congenital) salmonellosis shigellosis
* streptococcal disease, Group A or B (invasive) * Streptococcus pneumoniae, drug-resistant (invasive)
tetanus toxic shock syndrome typhoid Vibrio infections yersiniosis

*Invasive = isolated from blood, bone, CSF, joint,
pericardial fluid, peritoneal fluid, or pleural fluid # HIV is reportable without personal identifiers
**HBsAg+ = hepatitis B surface antigen positive
Infant mortality is reportable to Vital Records Potential agent of bioterrorism

Complete a Notifiable Disease Report Form and mail in an envelope marked CONFIDENTIAL
or Call your County Health Department or District Health Office - the District Health Offices are listed below.
If your District Health Office cannot be reached, call the Georgia Division of Public Health directly at 404-657-2588

-The disease or condition -Patient's name (except for HIV) -Patient's address, phone, and date of birth -Physician's name and phone -Name, institution, and phone of person reporting -Pregnancy status

District 1, Unit 1 Epidemiology Bldg. 614 1305 Redmond Circle Rome, GA 30165 Phone (706) 295-6656 FAX (706) 802-5342
District 1, Unit 2 100 West Walnut Ave. Suite 92 Dalton, GA 30720 Phone (706) 272-2342 FAX (706) 272-2221
District 2 1280 Athens Street Gainesville, GA 30507 Phone (770) 535-5743 FAX (770) 535-5958
District 3, Unit 1 1650 County Service Pkwy. Room 41 Marietta, GA 30008 Phone (770) 514-2468 FAX (770) 514-2313

District 3, Unit 2 99 Butler Street SE Atlanta, GA 30303 Phone (404) 730-1391 FAX (404) 730-1397
District 3, Unit 3 Administrative Office 1380 Southlake Plaza Dr. Morrow, GA 30260 Phone (770) 961-1330 FAX (770) 961-8370
District 3, Unit 4 Office of Infectious Diseases P. O. Box 897 Lawrenceville, GA 30046 Phone (770) 339-4260 FAX (770) 339-4265
District 3, Unit 5 445 Winn Way Decatur, GA 30030 Phone (404) 508-7851 FAX (404) 294-3883

District 4 122 Gordon Commercial Dr. Suite A LaGrange, GA 30240 Phone (706) 845-4035 FAX (706) 845-4038
District 5, Unit 1 2121-B Bellevue Road Dublin, GA 31021 Phone (912) 275-6568 FAX (912) 275-6575
District 5, Unit 2 811 Hemlock Street Infectious Disease Unit Macon, GA 31201-2198 Phone (912) 751-6214 FAX (912) 752-1710
District 6 1916 North Leg Rd. Augusta, GA 30909 Phone (706) 667-4342 FAX (706) 667-4728
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District 7 District Clinical Services Box 2299 2100 Comer Ave. Columbus, GA 31902-2299 Phone (706) 321-6411 FAX (706) 321-6409
District 8, Unit 1 312 North Patterson Street Valdosta, GA 31601 Phone (912) 333-5290 FAX (912) 333-7822
District 8, Unit 2 1306 South Slappey Dr. South Colony Square, Suite L Albany, GA 31701 Phone (912) 430-5138 FAX (912) 430-2920
District 9, Unit 1 2011 Eisenhower Dr. P.O. Box 14257 Savannah, GA 31416-1257 Phone (912) 353-3125 FAX (912) 353-5195

District 9, Unit 2 1115 Church Street Waycross, GA 31501 Phone (912) 285-6022 FAX (912) 284-2522
District 9, Unit 3 1716 Ellis St. Brunswick, GA 31520 Phone (912) 264-3236 FAX (912) 262-1721
District 10 468 N. Milledge Ave. Suite 202 Athens, GA 30601-3808 Phone (706) 542-9667 FAX (706) 542-9663
Notifiable Disease Unit Division of Public Health 2 Peachtree Street, N.W. Suite 14.283 Atlanta, GA 30303-3168 Phone (404) 657-2588 FAX (404) 657-2608

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

July 1999

Volume 15 Number 7

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for April 1999

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 April 1999
1999 4
269 5 1 8
252 0 23 3 0 0 5 0 0 0 15 1 1 0 0 0 0 43

Previous 3 Months Total

Ending in April

1997

1998

1999

116

132

110

3928

6660

3591

6

27

44

8

0

1

180

220

165

4567

5078

2736

11

15

14

134

224

111

48

70

27

2

0

0

0

3

0

38

31

20

6

1

0

6

6

7

0

0

0

220

203

163

236

246

41

40

35

17

107

68

21

318

221

90

365

232

46

5

0

3

193

142

121

Previous 12 Months Total

Ending in April

1997

1998

1999

742

800

747

14162

19477

21523

84

102

174

50

30

82

878

951

1198

19210

19080

17591

47

49

65

475

893

760

109

268

151

3

4

8

2

12

1

125

108

75

15

4

1

35

15

39

0

0

0

1463

1359

1836

1247

1215

894

183

148

100

457

310

192

1308

982

643

1207

1042

573

27

16

16

765

619

604

* 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: 5/98 - 4/99 Five Years Ago: 5/93 - 4/94 Cumulative: 7/81 - 4/99

Total Cases Reported *

AIDS Profile Update

Percent

Risk Group Distribution (%)

Female

MSM IDU MSM&IDU

HS Blood

Unknown

Race Distribution (%) White Black Other

1400

21.6

35.8

14.6

4.6

13.3

1.2

30.5

22.4 75.4

2.2

2019

16.6

43.8

23.2

5.1

12.9

1.4

13.6

30.5 67.7

1.8

20572

15.5

50.4

19.1

5.8

12.2

1.9

10.6

37.8 60.1

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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