Georgia epidemiology report, Vol. 17, no. 2 (Feb. 2001)

February 2001

volume 17 number 02

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) 657-2608
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

Seasonal increase of Salmonella infections among Fulton County Children Associated with Chitterling
Preparation, November-December 2000
Introduction:
Enterocolitis caused by Salmonella bacteria is characterized by sudden onset of diarrhea (which may be bloody), nausea, vomiting, abdominal pain, and headache. Salmonellosis is caused by ingestion of bacteria, frequently from undercooked meat, poultry, egg and dairy products, or foods cross-contaminated by these raw products, exposure to sick pets, or person-to-person spread by the fecal-oral route. In 1999, the incidence of salmonellosis in the United States was 17.7 per 100,000. Georgia had the highest rate of any reporting state, with 25.5 laboratory-confirmed cases per 100,000 population (1). The rate of salmonellosis is highest among infants and young children due to increased susceptibility to gastrointestinal pathogens.
After an infection control practioner noticed what appeared to be an unusual number of cases of salmonellosis in infants and toddlers in Atlanta, an investigation showed that the infections were associated with the preparation of chitterlings (pork intestines) in the homes of affected children.
Methods:
A case was defined as a child < 2 years old, living in metropolitan Atlanta, with a positive stool or blood culture for Salmonella between November 26th and December 14th, 2000. Cases were identified through routine notifiable disease reporting. Fulton County Epidemiology Staff contacted the affected children's guardians and administered a comprehensive questionnaire, which included questions about exposures over the Thanksgiving holiday. Two to three controls per case were enrolled, matched by race and 6-month age category, using random telephone dialing, church groups, and immunization clinic attendees. Abridged questionnaires were administered to controls.
Team members purchased chitterlings from various local grocery vendors for analysis at the Georgia Public Health Laboratory (GPHL). Salmonella isolates from clinical and food specimens were typed by GPHL.
The Epidemiology Branch, Division of Public Health
Is looking for . . .
Primary care physicians and rheumatologists to participate in a study of dispensing pedometers to patients with arthritis and related conditions who could benefit from a regular walking program.
For more information, please call (404-463-3748) or email (opharris@dhr.state.ga.us) Stic Harris.

Results:

Eight Fulton County children met the case definition; four (50%) were male and all (100%) were African-American. Mean age was 12 months (range 2 to 24). Three were hospitalized. Symptoms included diarrhea (100%), melena (25%), fever (87.5%), and vomiting (37.5%). Blood and stool cultures were positive for Salmonella with 4 different serotypes (Salmonella Heidelberg, Salmonella Montevideo, Salmonella Oranienberg, and Salmonella Typhimurium). Two children were co-infected with Yersinia enterocolitica in addition to Salmonella.

identified chitterlings and tripe as the source of a protracted outbreak of Salmonella Typhimurium infections (4). However, that study was descriptive in nature, identified only a single supplier, and contained no statistical data.
An investigation by the USDA:APHIS revealed that 65.5% of adult hogs in Georgia shed Salmonella in their feces (5), suggesting that chitterlings are frequently contaminated by Salmonella, a finding confirmed by the GPHL testing in this study.

Five of eight cases (63%) had a known history of exposure to chitterlings; four children were in the home when the chitterlings were prepared, and two were fed by the person preparing the chitterlings. No child consumed chitterlings directly. In contrast, 3 of 21 controls were exposed to chitterlings. Cases were 10 times more likely than controls to have been in a home where chitterlings were prepared over Thanksgiving (OR=10.0, p=0.0187).

Review of cases of salmonellosis in children 2 years of age and under reported in Georgia during 1996-2000 shows that this cluster of cases, which appeared to be an outbreak, may be part of an annual December increase in cases of salmonellosis in African-American children in Georgia. For white children, the disease is most common during the summer and fall months,

Twenty chitterling samples, which varied by brand name and cleaning process, were cultured. Salmonella species of five different serotypes were recovered from nine specimens (Salmonella Derby, Salmonella Heidelberg, Salmonella Mbandaka, Salmonella Typhimurium, and Salmonella Typhimurium var Copenhagen). Two chitterling samples labeled "Super Clean-Ready to Cook and Eat" produced multiple Salmonella serotypes.
Conclusions/Discussion:
Chitterling consumption is customary during the winter holiday season, especially among many African-American households. One study in Atlanta suggested that chitterlings are prepared in approximately 20% of African-American households over the holidays (2). Strong cultural traditions surround preparation techniques and recipes, which are passed down from generation to generation. Cleaning raw chitterlings is a time-consuming process (median 5 hours in the above study), providing ample opportunity for cross-contamination of surfaces and hands (2). Chitterlings are usually cooked very thoroughly, and none of the children in our study consumed chitterlings directly. However, preparation of chitterlings in the home was a significant risk factor for salmonellosis among infants and young children. The infectious dose of Salmonella required to cause illness in adults is approximately 103 organisms, but because of lower gastric acidity and the buffering capacity of milk and formula in young children, a much lower inoculum is required to cause disease in this age group (3). It is likely that older family members also were exposed to Salmonella, but were either asymptomatic or undiagnosed because of better resistance to infection.
Many studies have linked Y. enterocolitica with chitterling preparation and consumption, but this is the first case-control study demonstrating an association between exposure to chitterlings in the home and salmonellosis. A European report in 1998

No. cases/month

Figure 1. Seasonal distribution of reported cases of salmonellosis in children 2 years of age and under, by month and race, Georgia, July 1996 - June 2000
140 120 100 80 60 40 20
0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Black White
and least common during December through March (Figure 1). However, the seasonal distribution is markedly different for African-American children; for them, the incidence of salmonellosis is highest in December. Salmonellosis from chitterlings may be a widespread and recurring problem.
Maintaining sanitary conditions during the preparation of chitterlings is difficult at best, and changing traditional practices can be challenging. However, a safe technique for chitterling preparation entails boiling the chitterlings for 5 minutes before the traditional cleaning process of stripping the membranes and removing debris from the insides. After cleaning, the chitterlings are cooked thoroughly in the traditional manner. In health department demonstration projects, incorporating this safety measure (brief boiling before handling) was not associated with a discernible change in the taste or texture of chitterlings (6). Building this new step into a cherished tradition will ensure a safe and healthy holiday season for Georgia families, but will require the participation of community leaders and holiday planners to carry the message to the affected community.

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References:

1. Centers for Disease Control and Prevention. Preliminary FoodNet Data on the Incidence of Foodborne Illnesses--Selected Sites, United States 1999. MMWR 2000: 49 (10); 201-5.

4. Cornell J, Neal KR. Protracted outbreak of Salmonella typhimurium definitive phage type 170 food poisoning related to tripe, `pig bag', and chitterlings. Commun Dis Public Health 1998;1:28-30.

2. Lee LA, Gerber R, Lonsway DS, et al. Yersinia enterocolitica 0:3

5. Centers for Epidemiology and Animal Health. Shedding of

infections in infants and young children, associated with the

Salmonella by finisher hogs in the US. USDA:APHIS , N223.196.

household preparation of chitterlings. NEJM 1990: 322 (14); 984-7.

6. Peterson EA, Koehler JE. "Changing traditions: preventing illness

3. Miller SI, Pegues DA. Salmonella Species, Including Salmonella typhi.

associated with chitterlings". Abstract in: 1997 Innovations in Social

In: Mandell, Douglas, and Bennett's Principles and Practice of

Marketing Conference Proceedings; Boston, MA.

Infectious Diseases Fifth Edition, 2000, pp. 2344-2363.

This article was written by: J. Renee' Warner-Watson, R.N.C., Travis Sanchez, D.V.M., M.P.H, Dennis E. Daniels, M.P.H., Dr.P.H., and Jim Benson

Hemolytic Uremic Syndrome

As the 1998 water park outbreak demonstrated, the immediate identification and investigation of Hemolytic Uremic Syndrome (HUS) and the associated infections with E. coli 0157and other Shiga-like toxin (SLT) producing E. coli is necessary to determine the type and source of infection and to prevent further spread of disease (1). Therefore, post-diarrheal HUS is a reportable disease in Georgia; it is essential to immediately report all cases of HUS to the Georgia Division of Public Health's Notifiable Disease Section (404-657-2588) or your local health department.
HUS is characterized by hemolytic anemia, thromocytopenia, and acute renal failure and is usually a result of infection by E. coli O157 or other toxin-producing bacteria. Physicians treating a patient with HUS should obtain a stool specimen and specifically request testing for E. coli O157 and SLT, since some clinical laboratories do not routinely perform these tests. Isolates or negative stool specimens should also be for-

warded to the Georgia Public Health Laboratory (GPHL) for further characterization. GPHL has new techniques for identifying small amounts of E. coli O157 not normally detectable by standard measures.
Georgia Division of Public Health's Notifiable Disease Section has developed an active surveillance network to identify post-diarrheal HUS cases more rapidly. This network includes physicians and areas that are likely to identify or treat HUS patients. If you are likely to care for HUS cases and would like to be a member of the HUS active surveillance network, please call Stepy Thomas at 404-657-2588.
Reference: 1. Gilbert, L. and Blake, P. Outbreak of Escherichia coli 0157:H7 infections associated wtih a water park. Georgia Epdiemiology Report, 1998, Vol. 14:7.
This article was written by: Bill MacKenzie, M.D., and Stepy Thomas, M.P.H.

Nevirapine: To Treat or Not to Treat

CDC recently issued a warning on the use of nevirapine (NVP) for postexposure prophylaxis (PEP) after occupational exposure to HIV (MMWR January 5, 2001). Twenty-two cases of serious adverse events including a case of fulminant hepatitis and hepatic failure necessitating a liver transplant and a case of life threatening fulminant hepatitis were reported in persons receiving NVP for PEP. NVP has never been recommended for basic or expanded PEP regimens. The risks of the exposure need to be weighed against the risks of the drugs prescribed for PEP.

This warning does not apply to NVP use in other settings. Single dose NVP is a recommended regimen for the prevention of perinatal HIV transmission.
Perinatal HIV prevention guidelines are at: http:// hivatis.org/guidelines/perinatal/Nov_00/text/ PerinatalNov00.pdf PEP regimens are continually evolving. Two excellent resources are: PEPLine: 1-888-HIV-4911 (24 hours) and PEPNET http://epi-center.ucsf.edu/PEP/PEPNet.html

PEP guidelines can be found at: http://www.cdc.gov/ epo/mmwr/preview/mmwrhtml/00052722.htm.

Reference: Minnesota Department of Health (MDH) Bug Bytes, February 1, 2001 Vol. 2: No. 3 -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

February 2001

Volume 17 Number 02

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

Selected Notifiable Diseases

Total Reported for November 2000
2000

Previous 3 Months Total

Ending in November

1998

1999 2000

Previous 12 Months Total

Ending in November

1998

1999

2000

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

33 2510
8 1 82 1704 6 27 31 0 0 5 0 0 0 99 25 17 15 33 60 1 39

199 6969
59 21 428 4961 18 264 36
0 0 21 1 9 0 615 230 31 59 197 194 4 148

175 8257
39 12 431 6081 17 101 68
4 0 13 1 12 0 651 66 34 77 149 192 10 150

113 7639
38 4
294 5256
14 102
87 3 0
11 0 3 0
449 87 33 71
122 205
2 152

779 22304
148 82
1213 18508
64 879 215
10 5
104 3
37 0
1797 1223
120 234 842 845
14 603

743 32654
165 41
1328 22764
83 519 230
5 0 67 4 50 0 2001 321 144 286 722 752 24 629

600 29907
189 47
1216 19398
76 338 281
9 0 58 2 46 0 1700 303 128 299 580 736 12 683

* 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: 12/99 - 11/00 Five Years Ago: 12/94 - 11/95 Cumulative: 7/81 - 11/00

Total Cases Reported*

Percent Female

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

Unknown

1172

26.5

28.7

10.0

2.5

12.5

2.4

43.9

2284

19.0

47.2

20.9

5.6

15.9

1.6

8.8

22516

16.6

48.9

18.5

5.7

13.0

1.9

12.1

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

19.2 77.4

3.4

35.2 62.1

2.8

36.0 61.9

2.1