Georgia epidemiology report, Vol. 17, no. 11 (Nov. 2001)

November 2001

volume 17 number 11

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

Increased Hepatitis A Among Men Who
Have Sex with Men in Metropolitan
Atlanta, 2001
Summary Georgia presently has the highest rate of Hepatitis A in the United States, and many of the cases in Georgia have occurred in the five-county metropolitan Atlanta area (Clayton, Cobb, DeKalb, Fulton and Gwinnett counties). This outbreak primarily involves adult men who are African-American or Caucasian and is predominantly among men who have sex with men (MSM). The Georgia Division of Public Health in partnership with local health departments and community-based organizations is undertaking an intensive campaign to provide education and immunization to the Atlanta MSM community. Health care providers can assist in this endeavor by educating their clients, providing immunization services and rapidly reporting all cases of Hepatitis A to their local health department.
Background Hepatitis A is characteristically a self-limited illness caused by infection of the liver with an enterically transmitted picornavirus, Hepatitis A virus (HAV). Symptoms include malaise, anorexia, nausea, fever and jaundice. The severity and duration of symptoms are variable. Infections in young children are often asymptomatic, but infections in older children and adults are typically symptomatic and can last for several weeks. HAV infection rarely produces fulminant hepatitis except in some patients with underlying liver disease. Hepatitis A is not known to cause chronic liver disease.
In the United States, Hepatitis A demonstrates a cyclic pattern of disease with peaks every 5 to 10 years in areas with high and intermediate rates of disease (1). This pattern generally involves community-wide epidemics in children and adults with transmission occurring among households and in extended family settings (1). During community-wide epidemics, disease is not limited to specific risk groups (2). Common source foodborne and waterborne outbreaks are infrequent. Outbreaks among urban MSM populations have occurred throughout the United States in the past decade (3,4,5). In 1996, a large outbreak of Hepatitis A in metropolitan Atlanta was identified among men who have sex with men. At that time, an educational and vaccine campaign targeting this population was undertaken; however, disease rates were not greatly impacted (6).
2001 Georgia Hepatitis A Incidence During January to August, 2001 the reported incidence of Hepatitis A in Georgia was 7.6 cases per 100,000 persons. During all of 2000, the incidence was 2.31 cases per 100,000 persons. Georgia, previously identified as a low-incidence state, now has the highest rate of Hepatitis A in the United States. The rate of Hepatitis A in Georgia has surpassed the 2001 rates in traditional high-incidence states such as California (4.02 cases per 100,000 persons) and Arizona (5.83 cases per 100,000 persons) (7). The five-county metropolitan Atlanta area accounts for 75.3% (475/631) of the cases in the state and has a much higher incidence rate (15.7 cases per 100,000 persons) than the remainder of the state (3.0 cases per 100,000 persons).
2001 Atlanta Hepatitis A Outbreak The number of newly diagnosed cases of Hepatitis A in Atlanta men of ages 15-49 years began to increase at the end of 2000, rose rapidly through the first half of 2001 and reached 78 cases for the month of August (Figure 1). Males make up 86.1% (415/482) of Hepatitis A cases in 2001 with an approximately equal number of African-American and Caucasian males affected (69 versus 67 cases). From January through August 2001, less than 5% (22/482) of all cases were among children less than 15 years of age, and 87.8% (423/482) of cases were among adults 15 through 49 years of age. Fifty-four percent of men (74/138) with Hepatitis A infection who were interviewed identified themselves as either bisexual or homosexual.

Figure 1

Reported Hepatitis A Cases Aged 15 through 49 years by Sex and Month, January 98 - August 01, Metropolitan Atlanta

Cases

100 80 60 40 20 0

Me n W omen

Jan-98 May
JanS-e9p9 May
JanS-e0p0 May
JanS-e0p1 May

M onth

Intervention Plan In response to this outbreak, the Division of Public Health in collaboration with local health authorities has developed and is beginning to implement an intervention plan in the five-county metropolitan Atlanta area. The plan will target the MSM community and includes education and an immunization campaign. The education component involves partnering with a community-based organization skilled in working with the MSM community in Atlanta to provide Hepatitis A risk education. Outreach and education about Hepatitis A prevention and control will be offered for health care providers.
Hepatitis A vaccine will be made available through public health for MSM at 14 clinics as well as a mobile clinic. The Georgia Division of Public Health has purchased 12,000 doses of Hepatitis A vaccine to be administered at these venues beginning in October 2001. A nominal administration fee will be charged for this service.

Health Care Provider Role As health care providers, you can assist by: 1. Educating your high risk patients about Hepatitis A infection 2. Recommending Hepatitis A vaccine to those patients (especially sexually
active MSN adult males) who may be at risk. 3. Immediately reporting all new cases of Hepatitis A infection to your local
health department
For further information about Hepatitis A infection, you may refer to the Georgia Epidemiology web page at http://health.state.ga.us/epi. This site includes information in a question and answer format that you can share with your patients.
If you have any questions regarding this outbreak or Hepatitis A in general, please call us at (404) 657-2588 and ask to speak to Dr. Travis Sanchez or Dr. Julie Fletcher.

Public Health Clinics Offering Hepatitis A Immunization

Clayton County Jonesboro Health Center 134 Spring Street Jonesboro, GA (770) 471-8656
Cobb County Marietta Community Health Center 1650 County Services Pkwy. Marietta, GA 30008 (770) 514-2300
DeKalb County T.O. Vinson Center 440 Winn Way Decatur, GA 30030 (404) 294-3762

East DeKalb Health Center 2277 S. Stone MountainLithonia Rd. Lithonia, GA 30058 (770) 484-2600
North DeKalb Health Center 3807 Clairmont Rd., NE Chamblee, GA 30341 (770) 454-1144
South DeKalb Health Center 3110 Clifton Springs Rd. Decatur, GA 30034 (404) 244-2200

Kirkwood Health Center 30 Warren Street, SE Atlanta, GA 30317 (404) 370-7360

College Park Regional Health Center 1920 John Wesley Ave. College Park, GA 30337 (404) 765-4146

Fulton County Adamsville Health Center 3699 Bakers Ferry Rd, SW Atlanta, GA 30331 (404) 699-4215
Aldredge Health Center 99 Butler Street, SE Atlanta, GA 30303 (404) 730-1211 ext 1485

North Fulton Regional Health Center 2260 Old Milton Pkwy. Alpharetta, GA 30004 (770) 740-2400
Gwinnett County Lawrenceville Health Center 15 S. Clayton Street Lawrenceville, GA 30045 (770) 339-4283

Norcross Health Center 5030 Georgia Belle Court Norcross, GA 30093 (770) 638-5700
Buford Health Center 2755 Sawnee Ave. Buford, GA 30518 (770) 614-2401

References 1 Mandell, Bennett, and Dolin, 2000. Hepatitis A Virus. In Principles and Practice of Infectious Diseases, Fifth Edition, Churchill Livingston, Philadel-
phia, PA. 2 Bell, BP, et al. The Diverse Patterns of Hepatitis A Epidemiology in the United States-Implications for Vaccination Strategies. JID 1998;178:1579-84 3 Friedman, MS, et al. Factors Influencing a Communitywide Campaign to Administer Hepatitis A Vaccine to Men Who Have Sex With Men. AJPH
2000;90 (No. 12):1942-46. 4 CDC. Hepatitis A Among Homosexual Men United States, Canada, and Australia. MMWR 1992; 41 (No. 9):155,161-164. 5 Katz, MH, et al. Seroprevalence of and Risk Factors for Hepatitis A Infection among Young Homosexual and Bisexual Men. JID 1997; 175:1225-9. 6 CDC. Hepatitis A Vaccination of Men Who Have Sex With Men Atlanta, Georgia, 1996-1997. MMWR 1998; 47 (No. 34):708-711. 7 CDC. National Electronic Telecommunications Surveillance System data, September 15, 2001.
By Travis H. Sanchez, D.V.M., M.P.H. and Julie A. Fletcher, D.V.M., M.P.H.
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E. coli O157:H7 Outbreak Associated with Contaminated Ground Beef

Introduction

Georgia has had four outbreaks of E. coli O157:H7 infections during the past 6 years, and this pathogen continues to be an important public health concern. E. coli O157:H7 infection is characterized by bloody diarrhea and can lead to kidney failure in a small percentage of cases (2-7%) through the development of Hemolytic Uremic Syndrome. Cattle are the most common and significant natural carrier of E. coli O157:H7. Most people become infected with this bacterium by eating contaminated food items, especially ground beef. Person-to-person contact can also lead to the spread of this organism.
In early June 2001, an infection control practitioner notified the Georgia Division of Public Health (GDPH) of three cases of E. coli O157:H7 infection identified at a Metro-Atlanta Hospital during a two-day period. Two of the cases were in relatives living in the same household, but the other case was in an unrelated person who resided in a different county. All three cases were in children under 15 years of age and their symptoms resolved without complications.

to the Georgia Public Health Lab (GPHL) for confirmation and DNA fingerprinting using Pulsed Field Gel Electrophoresis (PFGE). United States Department of Agriculture (USDA) Compliance Officers obtained the intact package of ground beef and delivered it to the USDA laboratory and GPHL, where it was tested for E. coli O157:H7 and PFGE was completed on isolated strains.
The USDA laboratory and GPHL isolated E. coli O157:H7 from the intact ground beef sample. The PFGE patterns for the three human cases and ground beef sample were indistinguishable by two different enzymes. On June 24, 2001, USDA announced a voluntary recall of ground beef produced by the Grocery Chain As supplier. This recall included over 190,000 pounds of ground beef and pork product that had been distributed throughout the southeastern United States. The product involved in the recall was removed from store shelves, and the public was asked to bring any remaining packages back to the store of purchase.
Discussion

Epidemiologic Investigation
Following standard GDPH protocol, District Public Health personnel contacted the parents of the three children for an interview. The questionnaire asked about symptoms, hospitalization, and exposures including: food, water, contact with animals, attendance at a daycare, travel, and contact with people having similar symptoms.
The dates of illness onset were clustered in a four-day period. Two of the infected children had eaten ground beef purchased at two different stores of Grocery Chain A. The third childs only identified exposure was being a sibling of one of the previously mentioned infected children and was therefore considered a secondary case. One of the parents informed GDPH that an intact package of ground beef, identical to that consumed by the case, had been purchased on the same day from the same Chain A store. This intact package was in the parents freezer.
Laboratory Investigation
E. coli O157:H7 isolates from these three cases were transported

Consuming contaminated food products, especially ground beef, is a primary mode of transmission for E. coli O157:H7. Only a few organisms are required for infection. Because of this risk, all ground beef products should be cooked thoroughly to a temperature of 155oF. Also, since E. coli O157:H7 can be passed easily from person to person, hand washing is an important means of limiting transmission, especially within households and child care centers.
This outbreak and subsequent recall exemplifies the importance of immediately reporting E. coli O157:H7 cases to public health officials, quickly investigating every case, acquiring isolates of the bacteria for PFGE testing, obtaining related food samples for testing, and cooperation between public health and other governmental agencies.
The immediate reporting of these E. coli O157:H7 cases by the hospital allowed immediate follow-up with the family about potential exposures and identification of the intact package of ground beef. Rapid DNA fingerprinting through PFGE provided direct evidence that the cases were linked to the contaminated ground beef. Communication between district, state, and federal agencies was essential in this investigation. The resulting ground beef recall may have prevented other cases throughout the Southeast.

This article was written by Stepy Thomas, M.S.P.H.

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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

November 2001

Volume 17 Number 11

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for August 2001

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis 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 August 2001
2001 53 811 12
3 73 659
3 118
33 0 0 1 0 0 0
170 34 5 13 26 16 0 18

Previous 3 Months Total

Ending in August

1999

2000 2001

206

234

218

8622

7847

5733

35

76

34

19

27

14

380

369

231

6198

5381

3310

18

12

11

124

108

293

72

94

82

1

2

4

0

0

0

11

7

4

2

0

0

20

18

1

0

1

0

693

710

552

85

86

78

51

33

18

82

80

69

153

128

105

202

194

75

3

7

0

179

172

109

Previous 12 Months Total

Ending in August

1999 2000 2001

771

665

593

30507 27563 28018

185

190

132

50

54

28

1326

1355

1008

21448 18730 16581

84

77

100

682

336

792

198

288

394

1

10

13

0

0

0

75

61

51

4

3

7

47

61

15

0

1

0

1965

1903

1524

486

297

310

150

129

83

281

285

260

765

569

502

778

709

627

17

23

11

620

663

575

* 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: 09/00 - 08/01 Five Years Ago: 09/95 - 08/96 Cumulative: 7/81 - 08/01

Total Cases Reported*

Percent Female

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

1267

24.8

28.8

8.9

2.1

10.5

1.4

48.3

2368

18.1

47.1

18.0

5.3

18.2

1.4

10.0

23545

17.0

48.1

18.1

5.6

13.1

1.9

13.3

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

19.6 75.6

4.8

35.0 62.2

2.8

35.3 62.5

2.2