Georgia epidemiology report, Vol. 16, no. 7 (July 2000)

July 2000

volume 16 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 Health Information Branch, Division of Public Health, Georgia Department of Human Resources

Epidemiology of Tuberculosis (TB) in Georgia through 1998

In 1998, 631 TB cases were reported in Georgia a 9% decrease from 696 cases reported in 1997. The state case rate (8.3 per 100,000 persons) was higher than the national average of 6.8 per 100,000 and was the third highest in the southeast region of the United States. Georgia ranked ninth in the nation in TB case rates and eighth in TB case numbers.

More than half of all TB cases in 1998 were reported from the health districts of Fulton, DeKalb, Waycross, Augusta, and Albany. The five counties that reported the highest number of TB cases in 1998 were all within the metropolitan Atlanta area: Fulton (132), DeKalb (85), Cobb (32), Clayton (28), and Gwinnett (24). Eight of 19 (42%) health districts and 47 of 159 (30%) counties had case rates above the state average. Eleven health districts reported decreases in TB case numbers while seven districts reported increases of more than 30%.

In 1998, TB cases in Georgia were predominantly male (64%), African-American (67%), and U.S.- born (81%), with 36.7% occurring in those 25-44 years old. The highest incidence rate of TB (16.4 per 100,000) occurred among persons 65 years old and older. The incidence rate among children less than five years of age (an indication of recent transmission) was 5.8 per 100,000 compared with the national rate of 3.4 per 100,000. Forty-one persons died of TB disease in Georgia in 1997, the year for which the most recent data are available. Of persons who died of TB that year (59%)were age 65 and older. The age-adjusted mortality rate for TB has been decreasing from 1.63 per 100,000 persons in 1985 to 0.62 in 1997.

From 1985 to 1992, Georgia witnessed a resurgence in TB that has been partly attributed to the dramatic increase in the number of

persons diagnosed with AIDS. However, from 1993 to 1998, the number of TB cases

with HIV infection decreased from 140 (17%) to 69 (11%) cases, while reporting of HIV

status among TB cases increased from 41% in 1993 to 59% in 1998. Of TB cases with

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

available information on HIV status in 1998, co-infection with HIV is common among males (64%), adults aged 25-44 (75%), and among African-Americans (87%). Seventy-one percent of TB cases with HIV infection were from the metropolitan Atlanta area.

Epidemiology and Health Information 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.

While the majority of TB cases in Georgia are U.S.-born, the proportion of TB cases in the foreign-born population has been increasing from 5% (40 cases) in 1993 to 19% (120 cases) in 1998. Of foreign-born TB cases reported in 1998, more than half were from the health districts of DeKalb, Cobb, Gwinnett, Fulton, and Waycross. From 1993 to 1998, the largest number of foreign-born cases (159) was reported from DeKalb County.
TB is an important health problem among homeless persons, substance abusers, and residents of jails and nursing homes where infection may be easily transmitted. From 1993 to 1998, there was a slight increase in the percentage of TB cases who were homeless or in correctional facilities (from 4% to 8% and from 3% to 5%, respectively). The proportion of TB cases with a substance abuse problem (25%) and TB cases in long-term care facilities for the elderly (3%) have remained relatively stable over time.

Public Health Advisor Mel Ralston
Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D. Paul A. Blake, M.D., M.P.H.
Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H.
Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphics

Development of resistance to two of the most potent first-line anti-TB drugs, isoniazid and rifampin, present a critical challenge to TB control. From 1993 to 1998, 164 isoniazid resistant (INH-R) cases were reported in Georgia. The health districts of Fulton (50 cases), DeKalb (25 cases), and Cobb (14 cases) reported the largest number of INH-R cases over this six-year period. INH-R levels increased from 4.0% in 1993 to 6.1% (30 cases) in 1997, then decreased to 5.7% (24 cases) in 1998. Rifampin resistance (RIF-R) decreased from 1.6% (9 cases) in 1997 to 0.2% (1 case) in 1998. We attribute the
Georgia Department of Human Resources Division of Public Health, Epidemiology Section Epidemiology & Health Information Branch Two Peachtree St., N.W., Atlanta, GA 30303 - 3186 Phone: (404) 657-2588 Fax: (404) 657-2608

descreasing incidence of TB and drug-resistant cases in Georgia to the successful implementation of strategies such as directly observed therapy for TB patients, aggressive outreach efforts to achieve higher rates of treatment completion, and thorough evaluation of contacts to TB cases. Relative to other states with large metropolitan areas, the incidence of multidrug-resistant TB (MDR-TB, i.e., resistance to at least INH and RIF) in Georgia is low. Between 1993 and 1998, 22 MDR-TB cases were

reported, an average of four MDR-TB cases per year. In 1998, only 1 (0.2%) MDR-TB case was reported, compared to 8 (1.0%) cases in 1997. The Centers for Disease Control and Prevention (CDC) recommends that in areas where INH resistance is >4%, as it is in Georgia, the initial 2-month phase of TB treatment should include four anti-tuberculous drugs.

Figure 1.
TB Case Rates Georgia and the United States, 1982-1998

case rate (per 100,000) 16

Georgia U.S.

14

12

Georgia 8.3

10

8

6

U.S. 6.8

4

2

0 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98

Year

Figure 2.

Number of reported TB cases Georgia, 1982-1998

Number of cases

1000 800

830808784828846889822860800909893809740737791696

631

600

400

200

0 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98
Year

Human Ehrlichiosis
Human ehrlichiosis became a reportable disease in Georgia on July 1, 1999. During 1999, 6 presumptive cases of Human Monocytic Ehrlichiosis (HME) were reported to the Georgia Division of Public Health. So far this year, 3 confirmed cases of HME have been reported in Georgia. In this issue of the GER, Dr. Carlos Lopez from Atlanta ID Group, PC presents his recent experience in diagnosing and treating a patient with HME.
On June 13, 2000, a 60-year-old white male was hospitalized with a four-day history of fever (oral temperature on admission was 103F), chills, generalized aches, and slowly progressive shortness of breath. The patient was previously healthy except for a history of rheumatoid arthritis, ulcerative colitis, and a 6-month history of sulfasalazine use. Levofloxacin treatment had been administered two days prior to this hospital admission for presumed prostatitis.
Physical exam revealed bilateral basilar rhonchi upon auscultation. Laboratory exam revealed a white cell count of 1500 with 81% granulocytes and a platelet count of 52,000/mm3. Serum glutamic-oxaloacetic transminase (SGOT) was 113 iu/L. A chest x-ray on admission showed bilateral infiltrates. In the hospital, levofloxacin was continued and vancomycin and gentamicin were added. A bone marrow exam was performed because of progressive thrombocytopenia (as low as 16,000/ mm3 on his eighth day of illness). Four days after admission, an infectious disease consult was obtained. After evaluation of history (which included tick exposure at Lake Oconee), physical examination, and laboratory work, a presumptive diagnosis of ehrlichiosis was made and the patient was empirically given doxycycline 100 mg. i.v. b.i.d..
The course of illness was marked by defervescence within 24 hours after initiation of doxycycline therapy. However, respiratory distress continued.

Eight days after admission the patient had new onset of fever and hypotension and was intubated. Atrial fibrillation was noted and a cardiology consult was obtained. The patient was given i.v. furosemide with significant improvement of the chest x-ray appearance, suggestive of fluid overload. Vancomycin and ceftazidime were added to his treatment due to concern about possible sepsis and rifampin was added. Digoxin and a calcium channel blocker were given on the recommendation of the cardiology consultant. A lung biopsy on the ninth hospital day showed organizing interstitial pneumonitis.
The patient was extubated after five days of ventilator therapy. He had persistent thrombocytopenia through one week of doxycycline therapy. His white blood cell count improved spontaneously after only four days in the hospital and before doxycycline therapy was begun. Serum transaminases improved after one week of empiric doxycycline therapy. The patient was discharged on doxycycline and rifampin after 2.5 weeks of hospitalization.
Whole blood and serum were submitted to the Centers for Disease Control and Prevention (CDC) Rickettsial Laboratory for diagnostic tests. Whole blood was PCR-positive for E. chaffeensis. Acute and convalescent serum samples revealed a greater than four-fold change in antibody titer to E. chaffeensis. Lab confirmation became available shortly before hospital discharge.
Ehrlichiosis can be a severe or fatal illness, especially if untreated. All three cases of human ehrlichiosis reported in Georgia during 2000 have been hospitalized. It is believed that many cases of HME are unrecognized because the non-specific clinical presentation of the illness resembles many other infectious and non-infectious diseases and because many infected patients have a mild clinical course and never seek medical attention.

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Ehrlichiosis symptoms usually begin approximately one week (range: 0 to 28 days) after the bite of a tick. Many patients will not recall being bitten by a tick. Clinical signs and symptoms of an infection with E. chaffeensis typically include fever, headache, malaise, chills, myalgias, and rigors, which may be accompanied by nausea, vomiting, diarrhea, abdominal pain, cough, and confusion. Laboratory tests often reveal thrombocytopenia, leukocytopenia, and /or elevated liver enzymes. It is estimated that approximately 30% of adult and 60% of pediatric HME patients will have a rash, usually a maculopapular rash, or, rarely, a petechial rash. Severe complications (meningoencephalitis, adult respiratory distress syndrome, renal failure) and deaths due to human ehrlichiosis have been documented. Elderly and immunocompromised patients are at particular risk for the more severe manifestations of the disease.
Ehrlichiosis should be in the differential diagnosis for patients who present with a non-specific febrile illness and have had potential exposure to ticks, especially during the late spring and summer months when humans are most likely to come into contact with ticks.

Non-pregnant adult or child >45 kg: Doxycycline, 100mg bid p.o. or i.v.
Child <45 kg: Doxycycline, 3 to 4 mg/kg/day in 2 divided doses, p.o. or i.v.*
Pregnant adult or tetracycline allergic person: Rifampin or Chloramphenicol**
*Although the use of tetracyclines is contraindicated in children under the age of 9, the prompt treatment of a potentially severe ehrlichiosis infection may outweigh the associated risk of discoloration of bones and permanent teeth that usually occurs only after multiple courses of treatment (American Academy of Pediatrics).
**Chloramphenicol is an alternative therapy for some patients with Rocky Mountain spotted fever (RMSF) but its efficacy is undefined for ehrlichiosis. Rifampin has been used successfully in some pregnant women with HGE, but its clinical efficacy has not been fully evaluated (Buitrago et al.). Other broad-spectrum antibiotics are characteristically ineffective.

Epidemiology of the Human Ehrlichioses:

Human Monocytic Ehrlichiosis (HME)

Agent:

Ehrlichia chaffeensis

Tick Vector:

Amblyomma americanum (Lone Star Tick)

Distribution: Southeastern and south-central United

States

Human Granulocytic Ehrlichiosis (HGE)

Agent:

Ehrlichia phagocytophila or a closely

related species

Tick Vector:

Ixodes scapularis (Blacklegged Tick)

Distribution: Northeastern United States, Minnesota,

and Wisconsin

Newly Discovered HGE

Agent:

Ehrlichia ewingii

Tick Vector:

Amblyomma americanum

Distribution: Unknown at this time, but probably

similar to the geographic distribution

of the Lone Star Tick.

Treatment of Human Ehrlichiosis Symptoms abate quickly after initiation of treatment with
doxycycline or other tetracycline derivative. Empiric therapy for suspect cases of ehrlichiosis is appropriate
because of the potential for severe or fatal illness. Appropriate treatment should be initiated immediately and without laboratory confirmation if ehrlichiosis is suspected based on clinical and epidemiologic findings. Routine administration of prophylactic treatment after a tick bite is not currently recommended.

Testing for human ehrlichiosis is available from many commercial laboratories and can also be obtained through the Georgia Public Health Laboratory. Indirect immunofluorescent antibody (IFA) assay is commonly used to detect antibodies to E. chaffeensis in serum. The collection of paired acute- and convalescent-phase blood samples (collected 4-6 weeks apart) is required in order to detect a seroconversion or a significant change in antibody titer. Whole blood PCR can also be used to detect Ehrlichia during the acute stage of illness.
Written by Carlos E. Lopez, M.D. and Catherine A. Rebmann, M.P.H.
References: The Centers for Disease Control and Prevention website; http://www.cdc.gov/ncidod/dvrd/ehrlichia/
Walker DH, Dumler JS. Ehrlichia chaffeensis (Human Monocytotropic Ehrlichiosis), Ehrlichia phagocytophila (Human Granulocytotropic Ehrlichiosis), and other Ehrlichiae. In: Mandell GL, Bennett JE, and Dolin R, eds. Mandell, Douglas, and Bennetts Principles and Practice of Infectious Diseases. 5th ed. Churchill Livingstone, PA; 2000: 2057-2064.
American Academy of Pediatrics. Ehrlichiosis (human). In: Pickering, LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2000: 234236.
Buitrago MI, Ijdo JW, Rinaudo P, Simon H, Copel J, Gadbaw J, Heimer R, Fikrig E, Bia FJ. Human granulocytic ehrlichiosis during pregnancy treated successfully with rifampin. Clinical Infectious Diseases 1998;27:213-5.

Therapy should be continued for at least 72 hours after defervescence and until evidence of clinical improvement, for a minimum total course of 5 to 7 days.

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

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

July 2000

Volume 16 Number 7

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for April 2000

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 2000
2000 43
2131 10 1 73
1209 11 18 13 2 0 4 0 3 0 73 20 7 25 49 38 0 55

Previous 3 Months Total

Ending in April

1998 1999 2000

132

184

119

6793

6330

7090

27

61

36

0

2

3

218

247

270

5137

4285

4128

15

22

25

221

136

54

70

46

52

0

0

3

3

0

0

32

24

16

1

0

1

6

12

11

0

0

0

194

256

220

242

67

81

34

28

28

63

63

81

217

242

147

170

155

98

2

4

3

141

118

153

Previous 12 Months Total

Ending in April

1998 1999 2000

799

820

632

15287

24535

33198

102

193

145

30

85

45

949

1280

1364

15171

19404

22300

49

73

89

889

785

361

268

173

242

4

8

9

12

1

0

109

79

69

4

1

6

15

44

60

0

0

0

1349

1921

1918

1208

917

284

150

120

141

309

246

300

995

837

632

996

820

735

18

21

17

618

601

673

* 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: 5/99 - 4/00 Five Years Ago: 5/94 - 4/95 Cumulative: 7/81 - 4/00

Total Cases Reported*

Percent Female

AIDS Profile Update
Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood

Unknown

1431

26.8

30

13.1

3

16.6

1.3

36

2397

18

45.6

22.2

6.3

14

1.8

10.1

21768

16.2

49.5

18.8

5.8

13

1.9

11.1

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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Race Distribution (%) White Black Other

18.7 78.6

2.7

34.6 63.7

1.7

36.6 61.3

2.1