October 2001 volume 17 number 10 Division of Public Health http://health.state.ga.us Kathleen E. Toomey, M.D., M.P.H. Director State Health Officer Epidemiology Branch http://health.state.ga.us/epi Paul A. Blake, M.D., M.P.H. Director State Epidemiologist Mel Ralston Public Health Advisor 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. - Graphic Designer Georgia Department of Human Resources Division of Public Health Epidemiology Branch Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588 Fax: (404) 657-7517 Please send comments to: Gaepinfo@dhr.state.ga.us The Georgia Epidemiology Report is a publication of the Epidemiology Branch, Division of Public Health, Georgia Department of Human Resources INFLUENZA VACCINATION IN GEORGIA: ROOM FOR IMPROVEMENT Epidemics of influenza A occur nearly every winter and are responsible for an average of 20,000 deaths per year in the United States. Influenza viruses can also cause global epidemics of disease known as pandemics, during which rates of illness and death from influenza-related complications increase dramatically. Influenza viruses cause disease in all age groups. Rates of infection are highest among children, but rates of serious illness and death are highest among persons > 65 years and among persons of any age who have medical conditions that place them at increased risk for complications from influenza (Table 1). OVERVIEW OF INFLUENZA SURVEILLANCE IN GEORGIA Each year from October through May, Georgia monitors influenza activity throughout the state via a sentinel physician network, part of a nationwide surveillance network coordinated by the Centers for Disease Control and Prevention (CDC). Data from these volunteer physicians is used to characterize influenza disease activity and geographic distribution, and to provide specimens for strain typing. Because not all cases of influenza are diagnosed, confirmed, or reported, the sentinel network cannot be used to determine the precise number of influenza infections or rates of disease during a given season. During influenza season, information about current influenza activity in Georgia is posted weekly on the Georgia Division of Public Health web site, at health.state.ga.us/epi/flu/, with links provided to nationwide data from CDC. For the 2000-2001 influenza season, 33 Georgia volunteer physicians reported each week on the total number of patients seen and the number of those patients with influenza-like illness by age group. Influenza-like illness was defined as fever > 100 F AND cough and/or sore throat. Participating physicians were also asked to submit throat swabs from representative patients several times during the season. Influenza isolates were characterized to facilitate planning for future vaccines. SUMMARY OF THE 2000-2001INFLUENZA SEASON IN GEORGIA Last season, the first throat swab positive for influenza was collected by a sentinel physician in mid-December. Influenza activity in Georgia began to increase in mid-January, peaked in late January and early February, and returned to baseline by mid-February, 2001. Figure 1 illustrates influenza activity in Georgia based on reports of patient visits for influenza-like illness submitted by volunteer sentinel physicians throughout the state. Despite concerns resulting from delays in the availability of vaccine, this was a relatively mild influenza season (confirmed by pneumonia and influenza mortality data gathered by CDC). Sixty-four (44%) of 146 throat swabs submitted by sentinel physicians in Georgia were positive for influenza. Thirty-two (50%) of the viruses isolated were influenza type A and 32 (50%) were type B. Of the 23 influenza A viruses, all were type A(H1N1). CDC characterized 11 influenza A viruses from Georgia; seven were antigenically similar to A/New Caledonia/20/99, which was a strain included in the 2000-2001 vaccine, and four were antigenically similar to A/Johannesburg/82/96. The absence of influenza A(H3N2) in Georgia may explain the relatively mild influenza season in 2000-2001, as influenza A(H3N2) has been associated with greater morbidity than other strains in recent years. PREVENTION AND CONTROL OF INFLUENZA Influenza vaccine is the primary method for preventing influenza and its more severe complications. The primary target groups for vaccination are (Table 1): (a) persons at high risk for serious complications from influenza, including persons aged 65 and older, (b) persons aged 50-64 years, because this group has an elevated prevalence of certain chronic medical conditions, and Oct 7 Oct 14 Oct 21 Oct 28 Nov 4 Nov 11 Nov 18 Nov 25 Dec 2 Dec 9 Dec 16 Dec 23 Dec 30 Jan 6 Jan 13 Jan 20 Jan 27 Feb 3 Feb 10 Feb 17 Feb 24 Mar 3 Mar 10 Mar 17 Mar 24 Mar 31 Apr 7 Apr 14 Apr 21 Apr 28 May 5 May 12 May 19 (c) persons who live with or care for persons at high risk, including health care providers, hospital workers, and staff of long-term care facilities. Figure 1. Reported Influenza-like Illness* based on sentinel physician reports in Georgia, 2000-2001 GEORGIA NEEDS IMPROVEMENT IN FLU VACCINE COVERAGE, ESPECIALLY FOR MINORITY GROUPS According to data from the Behavioral Risk Factor Surveillance System (BRFSS), since 1993 Georgia has consistently fallen below the national average for rates of influenza vaccination among persons aged 65 and older. Recently Georgia has narrowly succeeded in meeting the Healthy People 2000 goal of 60% annual vaccination against influenza in this age group. BRFSS data show that Georgia still falls well below the Healthy People 2010 goal of 90% influenza vaccination among persons aged 65 and older. BRFSS data also show a striking disparity in influenza vaccination rates of whites and non-whites in Georgia. In more than onethird of Georgia's counties, the percentage of minority individuals aged 65 and older that received vaccine was less than one half that of whites in the same age group, according to 1999 Georgia Medicare billing data (data courtesy Georgia Medical Care Foundation). Widespread Regional Sporadic None Week Ending * Influenza-like illness: Fever > 100 oF and cough and/or sore throat. Table 1: Target Groups for Vaccination Persons at High Risk for Influenza-Related Complications: Persons aged > 65 years Residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions Adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma Adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), kidney dysfunction, blood disorders (hemoglobinopathies), or immune system problems (immunosuppressed or immunocompromised) Children and teenagers (aged 6 months - 18 years) who are receiving long-term aspirin therapy and, therefore, might be at risk for developing Reye's syndrome after influenza infection Women who will be in the second or third trimester of pregnancy during the influenza season Persons Aged 50-64 Years Vaccination is recommended for persons aged 50-64 years because this group has an increased prevalence of persons with high-risk conditions. Persons Who Can Transmit Influenza to Those at High Risk: Physicians, nurses, and other personnel in hospital and outpatient-care settings, including emergency response workers Employees of nursing homes and chronic-care facilities who have contact with patients or residents Employees of assisted living and other residences for persons in high-risk groups Persons who provide home care to persons in high-risk groups Household members (including children) of persons in high-risk groups Persons Who Should Not be Vaccinated: Persons known to have anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine without first consulting a physician* Persons with acute febrile illness usually should not be vaccinated until their symptoms have abated* *See MMWR April 20, 2001/vol. 50/No. RR-4. The complete report and other information on influenza can be accessed at http://www.cdc.gov/ncidod/diseases/flu/fluvirus.htm. -2 - STRATEGIES FOR IMPROVING INFLUENZA THANKS TO THE INFLUENZA SENTINEL PHYSICIAN VACCINATION RATES What the Division of Public Health is doing: 1. The Georgia Division of Public Health in conjunction with the Office of Regulatory Services, Department of Human Resources, is working with long-term care facilities to promote use of the influenza and pneumococcal vaccines for residents and staff. 2. Influenza and pneumococcal vaccines are made available through most county health departments; contact your local health department for specific details. 3. The Georgia Medical Care Foundation maintains a web site regarding locations where influenza and pneumococcal vaccinations are available at www.immunizeadultga.org. The Georgia Division of Public Health refers patients to this web site, and to local health departments. If you would like to be included as a vaccine provider, you may sign up on the web site. What health care providers can do: 1. Identify high-risk patients in your practice and order influenza vaccine early (ideally in the spring for the following influenza season). Ordering early allows manufacturers to plan for production needs. 2. Ask your staff to flag the charts of high-risk patients so that you will be reminded to offer vaccine when they return to the office, or consider contacting them to make a vaccination visit appointment. 3. Consider using standing orders for nurses, rather than requiring a patient-specific physician's order, to identify and vaccinate eligible high-risk patients. 4. Remember to immunize eligible patients before hospital discharge to reduce the likelihood of future hospitalizations. 5. Use a practice-based tracking system to monitor the proportion of eligible patients who are vaccinated. 6. During flu season, include a routine provider reminder system in the medical chart to remind the provider to review vaccination status and administer vaccine to those at risk. 7. Promote use of influenza vaccine by talking about its benefits. Know the indications for vaccine. 8. Overcome misinformation about influenza vaccine; one cannot catch flu from taking the killed-virus influenza vaccine. 9. Encourage your office staff and other health care providers to be immunized. 10. Display information about influenza vaccine in your office to encourage patient awareness and education. An influenza vaccine information sheet can be downloaded at http://www.cdc.gov/ nip/vaccine/flu/default.htm. Immunization materials also be ordered online at https://www2.cdc.gov/nchstp_od/PIWeb/ NIPorderform.asp. 11. If you are unable to offer influenza vaccine, be aware of locations in your community where vaccine is available and refer high-risk patients for vaccination. The web site www.immunizeadultga.org lists many vaccine providers in Georgia. 12. BE IMMUNIZED against influenza. REMEMBER: Influenza and pneumococcal vaccinations can be administered at the same time. Consider administering both vaccines when an eligible candidate for one vaccine is identified. Both vaccines are covered by Medicare, and recommended for persons aged 65 and older. INFLUENZA VACCINE UPDATE FOR THE 2001- 2002 SEASON SURVEILLANCE NETWORK The Georgia Division of Public Health would like to thank the 33 medical providers statewide who participated in the influenza surveillance network for 2000-2001 (Table 2). Thanks to you, we were able to identify the onset of the influenza season, detect widespread influenza activity, and determine the influenza strains occurring locally in Georgia. The Food and Drug Administration's Vaccines and Related Biologic Products Advisory Committee makes decisions about which strains of influenza are to be included in the yearly vaccine. Such decisions are based on surveillance data and must be made months in advance to allow for production time. As part of the larger sentinel system, Georgia's volunteer physicians play an important part in this work. For more information about participation in the surveillance network, or to report outbreaks of influenza-like illness, please contact Katherine Bryant, Influenza Surveillance Coordinator, at 404-657-2588. Table 2. Georgia Sentinel Physicians Who Reported in 2000-2001 Influenza Season Andy Rimmer, M.D., Dublin Medical Services Department, Coca-Cola Company, Atlanta Louise A. Goodman, M.D., Eastman Park Avenue Women's Health Center, Lindale Terrence L. Wogan, M.D., Rochelle Douglasville Community Health Center Eastman Pediatric Clinic Jo Middlebrooks, Henry Medical Center, Stockbridge James H. Tison, M.D., Eastman Powers Ferry Neighborhood Healthcare Center, Marietta Hamilton Medical Center, Dalton Pediatric and Adolescent Medicine, Marietta Robin Dretler, M.D., Decatur Patricia Andrews, Emory Peachtree Regional, Newnan Murray Medical Center, Chatsworth Mary Wysochansky, Americus Primary Medicine Center Spalding Regional Hospital, Griffin Mary Wysochansky, GA Southern Health Center, Americus Glenda VanHouten, RN, Thomaston Diane Christopher, The Medical Center, Columbus Tanner Medical Center, Villa Rica GA Southern University Health Service, Statesboro Coleman Community Health Center, La Grange Ellen Richardson, M.D., Jesup Holli Cook, Community Care Center, Riverdale Phoebe Family Care, Albany Northwest Georgia Family Practice, Summerville Phoebe Family Medical Center of Ashburn Gail Hurley, M.D., Athens Phoebe Family Medical Center of Dawson Jean Chin, M.D., Athens Dr. Sidhwa and Staff, Phoebe East Convenient Care, Albany Sorahi Toloyan-Rahimi, M.D., Savannah Sources of Information on Influenza Georgia Epidemiology Branch: 404-657-2588 and http://health.state.ga.us/epi/flu Georgia Immunization Program: 404-657-3158 CDC Voice Information System (influenza update): 888-232-3228 CDC Influenza Branch: http://www.cdc.gov/ncidod/diseases/flu/ fluvirus.htm The CDC and FDA project moderate delays in influenza vaccine distribution for the 2001-2002 season. However, delays will not be as severe as those experienced last year, and the distribution is expected to be complete by December 2001. Based on recommendations made by the Advisory Committee on Immunization Practices (ACIP) and CDC, This article contains excerpts and information from MMWR April 20, 2001/vol. 50/No. RR-4. The complete report and other information on influenza can be accessed at http://www.cdc.gov/ncidod/diseases/ flu/fluvirus.htm. the Georgia Division of Public Health suggests offering vaccine to the This article was written by Katherine Bryant, M.P.H. and Kathryn Arnold, M.D. groups listed in Table 1 to ensure optimal use of influenza vaccine. -3 - The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186 PRESORTED STANDARD U.S. POSTAGE PAID ATLANTA, GA PERMIT NO. 4528 October 2001 Volume 17 Number 10 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for July 2001 Selected Notifiable Diseases Total Reported for July 2001 2001 Previous 3 Months Total Ending in July 1999 2000 2001 Previous 12 Months Total Ending in July 1999 2000 2001 Campylobacteriosis 62 229 234 188 899 718 664 Chlamydia trachomatis 354 8816 7731 4720 31902 30727 29786 Cryptosporidiosis 9 25 52 25 202 184 181 E. coli O157:H7 1 15 26 11 71 65 45 Giardiasis 87 294 317 243 1407 1510 1198 Gonorrhea 345 6092 5089 2603 23054 20973 18272 Haemophilus influenzae (invasive) 5 27 15 17 92 80 102 Hepatitis A (acute) 66 122 81 257 790 372 749 Hepatitis B (acute) 26 56 83 77 197 309 420 Legionellosis 1 0 2 5 5 11 13 Lyme Disease 0 0 0 0 1 0 0 Meningococcal Disease (invasive) 1 19 12 6 85 68 52 Mumps 0 1 0 0 2 5 7 Pertussis 0 17 17 2 49 73 29 Rubella 0 0 0 0 0 0 1 Salmonellosis 196 586 550 468 2279 2141 1841 Shigellosis 20 74 83 60 705 328 331 Syphilis - Primary 6 45 32 12 148 155 95 Syphilis - Secondary 17 76 69 56 290 311 281 Syphilis - Early Latent 30 157 136 108 848 628 533 Syphilis - Other** 10 182 171 77 857 767 682 Syphilis - Congenital 0 2 4 1 18 20 18 Tuberculosis 40 208 180 98 689 705 644 * 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: 08/00 - 07/01 Five Years Ago: 08/95 - 07/96 Cumulative: 7/81 - 07/01 Total Cases Reported* 1331 Percent Female 24.7 AIDS Profile Update Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood 28.8 9.5 2.1 10.6 1.5 Unknown 47.5 2282 17.4 48.3 18.5 4.9 17.4 1.3 9.6 23473 16.9 48.1 18.1 5.6 13.1 1.9 13.2 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 - Race Distribution (%) White Black Other 19.1 76.3 4.6 35.7 61.4 2.9 35.3 62.4 2.2