Georgia epidemiology report, Vol. 17, no. 4 (Apr. 2001)

April 2001

volume 17 number 04

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

West Nile Virus Update
West Nile virus (WNV) is transmitted from wild birds to humans, horses, and other animals by bites of infected mosquitoes. The virus was first detected in the US in 1999 when it caused an outbreak of encephalitis among humans, horses, and birds in the New York City area. Surveillance data collected during 2000 indicate that the virus is now endemic in the northeastern US and it has been detected in 12 states along the Atlantic Coast (VT, NH, MA, RI, CT, NY, NJ, PA, MD, Washington DC, VA, and NC). As of April 1, 2001 WNV has not been detected in Georgia. However, a WNV-infected crow was collected approximately 40 miles southwest of Raleigh, NC in late September 2000 and it is likely that we will have WNV activity in Georgia during 2001.
In response to the 1999 outbreak, the Centers for Disease Control and Prevention (CDC) distributed funds to public health agencies in states that were considered most likely to see WNV activity during 2000. The Georgia Division of Public Health (GDPH) received approximately $197,000 to perform surveillance for arbovirus infections in birds, horses, and humans during the 2000/2001 season. We expect to receive similar funding for 2001/2002 and all surveillance programs will be continued. The purpose of these surveillance programs is to detect the virus so control measures may be instituted before human infections occur.
Avian/Equine/Human Surveillance
When WNV emerges in Georgia it will probably be detected first in birds. Dead bird surveillance has been a very sensitive indicator of local epizootic transmission of WNV in the Northeast and could play a significant role in predicting human risk of infection. In Georgia, reports of dead bird sightings are recorded by local health departments. Some dead birds are collected and tested for the presence of WNV and other arboviruses. Initially just dead crows and bluejays were accepted for testing, but now any bird that is fresh (dead <24 hours) and in good condition (no signs of decomposition) may be tested. To date nearly 200 dead birds have been submitted, all with negative virus isolation results.
To supplement dead bird surveillance, active surveillance for arbovirus infections in live birds is performed by the Southeastern Cooperative Wildlife Diseases Study (SCWDS) at the University of Georgia College of Veterinary Medicine. Collection of several species of resident and migratory birds is conducted in Coastal, Coastal Plain and Piedmont regions of the state. Blood is collected and tested for the presence of arboviruses as well as for antibodies to WNV and other arboviruses. Nearly 2000 birds have been sampled to date and more than 1900 of them have been negative (results of the remainder are pending).
While dead bird surveillance is useful in densely populated urban areas, it may not be a sensitive indicator of WNV transmission in rural areas. In these areas, other indicators such as equine surveillance might be required to detect and monitor WNV activity. Large animal veterinarians throughout Georgia are encouraged to seek diagnostic support from Tifton or Athens Veterinary Diagnostic Laboratories for all horses with clinical CNS disease manifestations. Testing is provided free of charge for horses exhibiting clinical signs of encephalitis and includes screening for WNV and other arboviruses after rabies has been ruled out.
Most human WNV infections are mild or asymptomatic. CNS involvement is rare and predominantly affects elderly or immunocompromised individuals. To detect clinical cases of West Nile encephalitis, active surveillance for human viral encephalitis is being performed in 5 health districts in Coastal and South Georgia (48 counties) and passive surveillance for arboviral encephalitis is conducted in the rest of Georgia. Passive surveillance has been facilitated by the Georgia Public Health Laboratory's (GPHL) ability to test CSF or paired sera from patients with symptoms of encephalitis, meningitis, or Guillain-Barr Syndrome for antibodies to a panel of arboviruses. The panel includes capture ELISA to detect IgM antibodies to WNV and IFA detection of IgG or IgM antibody to St. Louis encephalitis, eastern equine encephalitis, western equine encephalitis, and California group viruses.

Control Measures
Public education is the best way to prevent infections with WNV or other mosquito-transmitted diseases. A vector-based webpage (http:// health.state.ga.us/epi/vbd.shtml) has been established to provide up-to-date information about vector-borne diseases to the public and to healthcare providers. Information about WNV and other arboviruses is also disseminated at in-service trainings and professional meetings.
A statewide arbovirus response plan is currently being developed by a group of representatives from GDPH, the Georgia Department of Agriculture, Georgia Emergency Management Agency, Department of Natural Resources, and other state and federal agencies. Some health districts in the state have also developed and instituted their own plans to prevent arboviral disease and to respond if an arbovirus does appear in their jurisdictions. These plans emphasize the importance of educating the public about how to avoid mosquito bites and how to eliminate mosquito breeding habitats (i.e. standing water).
What to Expect in 2001
WNV successfully established itself throughout the northeastern US within just one year after its first appearance in New York City. The virus's emergence has taken some surprising twists; numerous non-Culex

mosquito species are competent vectors and the virus is already known to cause illness in various species of birds and other animals.
Information collected about WNV in the northeastern states during 1999 and 2000 provides a foundation on which other states can base their detection and response protocols. However, we cannot completely rely on a single year of data collected in only one region of the country. The virus might have a greater public health impact in the South because the warmer climate allows for a longer season of mosquito activity, the different species and densities of birds may be more efficient virus reservoirs, and we have some very aggressive mosquito species that could be competent vectors. There is still much to be learned about WNV, including how to perform surveillance for it, and how to minimize its affects on human and animal populations.
For WNV updates and more specific information about these surveillance programs (including forms and instructions for submission of samples), please visit the vector-borne disease webpage.
This article was written by: Catherine Rebmann, M.P.H. Stacy Kramer, M.P.H. David Stallknecht, Ph.D. (SCWDS, UGA College of Veterinary Medicine)

New tests for identifying E. coli O157 and other Shiga Toxin producing E. coli New Notifiable Condition in Georgia

Outbreaks of hemolytic uremic syndrome (HUS) and bloody diarrhea such as the one associated with a water park in Cobb County in 1998 have maintained E. coli O157 as a focus of the nation's attention. The bloody diarrhea and HUS caused by E. coli O157 result from the Shiga toxins that the organism produces. Although E. coli 0157 is the serotype most often incriminated, some other E. coli serotypes can also produce Shiga toxins. For example, E. coli 0111:H8 is a Shiga toxin producing E. coli (STEC) that caused an outbreak of bloody diarrhea and HUS in a group of teenage campers in Texas in 1999.1 Non-O157 STEC are thought to have symptoms, exposures, and transmission vehicles similar to those of E. coli O157.
Special culture media that include sorbitol are required for isolating E. coli O157; however, this technique can miss certain STEC since some of these E. coli ferment sorbitol.2 Stool containing either E. coli O157 or non-O157 STEC can be identified by testing for the presence of the Shiga toxin using a commercially available EIA kit. Some laboratories are beginning to use this test instead of a culture to identify STEC. Due to the increasing importance of STEC as a public health issue, the state of Georgia has made positive Shiga toxin tests reportable as of February 21, 2001. All laboratories should now report any Shiga-toxin positive results to the Notifiable Disease Epidemiology Section of the Georgia Division of Public Health immediately by calling the county, district, or state health office (404-657-2588).

The Georgia Division of Public Health will follow up on all cases with positive Shiga toxin testing to identify possible exposures and to implement measures that will decrease further spread of the organism. Since it is still important to identify which serotype of E. coli is causing the infection to help recognize outbreaks, all Shiga toxin positive stool specimens and E. coli isolates should be submitted to the Georgia Public Health Lab for further testing, e.g. culture, serotyping, and pulsed-field gel electrophoresis (PFGE).
References:
1Escherichia coli O111:H8 Outbreak Among Teenage Campers Texas, 1999. Morbidity and Mortality Weekly Report. 2000; 49:321-4.
2Fey P, Wickert R, Rupp M, Safranek T, and Hinrichs S. Prevalence of nonO157:H7 Shiga toxin-producing Escherichia coli in diarrheal stool samples from Nebraska. Emerging Infectious Disease. 2000; 6:530-3.
Authors: Bill MacKenzie, M.D. and Stepy Thomas, M.S.P.H.

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Highlights from the Georgia Arthritis Report, 2000

Arthritis is a Major Public Health Issue in Georgia:
Arthritis affects 1 out of every 3 adult Georgians (34%) or approximately 1.8 million people.
The 34% of people who report arthritis include the following: 13% who have been told by a physician they have arthritis and report chronic joint symptoms (pain, aching, stiffness or swelling in or around a joint on most days for at least one month over a 12-month period). 12% who have been told by a physician they have arthritis, but do not report chronic joint symptoms. 9% who have not been told by a physician they have arthritis, but do report chronic joint symptoms.
Percent of Adult Georgians with Arthritis, 1998

13%

66%

ARTHRITIS

12%

34%

9%

13% =Physician Diagnosed Arthritis, Chronic Joint Symptoms 12% =Physician Diagnosed Arthritis, No Chronic Joint Symptoms
9% =No Physician Diagnosed Arthritis, Chronic Joint Symptoms

People with arthritis are also 3 times more likely to report fair/poor health status.
While there are many forms of arthritis, some types are curable and all can be helped. Early diagnosis and appropriate, ongoing arthritis management are known to reduce or improve long-term discomfort and disability as well as improve emotional health and overall quality of life. These data indicate many are not receiving arthritis-related health care nor adequately selfmanaging their disease.
Behavioral characteristics among people with arthritis People with arthritis are more likely to be inactive (34%) when
compared to people without arthritis (26%). Also, among people with arthritis, 41% are classified as overweight,
while 28% of those without arthritis are overweight.
The level of discomfort and disability people with arthritis regularly experience is directly impacted by lifestyle. Regular physical activity (as appropriate for condition) and maintaining an appropriate body weight can be helpful in keeping arthritis-related discomfort to a minimum, while maximizing physical ability with most types of arthritis. These data suggest people with arthritis are less likely to engage in healthy behaviors, thereby affecting their arthritis and their overall health status.
About the Georgia Arthritis Report, 2000 The Georgia Arthritis Report, 2000 was written as a collaborative effort between the Division of Public Health, Georgia Department of Human Resources and the Arthritis Foundation, Georgia Chapter. The source for all statistics used in the report is the 1998 Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey which samples adults 18 and older each year about their health behaviors and conditions.

Prevalence of adult Georgians with arthritis by age, race, sex, education, income, geography: The prevalence of arthritis increases with age, rising from 13%
among those 18-24 years old, to 62% among those 65 years and older. However, while older people as a group are more likely to be affected than younger people, over half of the 1.8 million Georgians with arthritis are less than 55 years old. The prevalence of arthritis is higher among whites (37%) than among blacks (27%). Arthritis is more common among females (38%) than males (29%). Half (51%) of people with less than a 12th grade education report arthritis. Among people with a 12th grade education or greater, 2832% report arthritis. People with less than $20,000 a year in household income report a higher prevalence of arthritis (42%) when compared to households with lower income levels (28-33%). The prevalence of arthritis is evenly distributed across regions of Georgia.
Arthritis awareness and impact in Georgia among people who report arthritis: 68% do not know the type of their condition 77% are not under a physician's care for arthritis
When comparing people with arthritis to people without arthritis: People with arthritis are almost 2 times more likely to report days of
poor physical health and about 1.5 times more likely to report days of poor mental health.

The Georgia Arthritis Report, 2000 was written to assist health professionals, volunteers and staff of arthritis organizations, community groups, and others who are working to reduce the burden of arthritis throughout Georgia. Currently, the Georgia Arthritis Action Plan (GAAP), a collaborative intervention and public health planning effort to reduce the burden of arthritis, incorporated 2 main objectives into their health plan based on findings from the Georgia Arthritis Report, 2000. These activities are currently being piloted in Columbus, GA.
To obtain a copy of the Georgia Arthritis Report 2000, please contact: The Arthritis Foundation (Georgia Chapter) 550 Pharr Road, Suite 550 Atlanta, GA 30305 (404) 237-8771
Submitted by: Jennifer McGinnis, M.S.P.H. Director, Arthritis Surveillance & Epidemiology The Arthritis Foundation (Georgia Chapter) Kenneth E. Powell, M.D., M.P.H. Chief: Chronic Disease, Injury, and Environmental Epidemiology Unit Division of Public Health, Georgia Department of Human Resources
Primary Contact: Jennifer McGinnis Phone: 404-657-2577/404-237-8771 Fax: 404-657-7517

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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

April 2001

Volume 17 Number 04

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

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 January 2001
2000 25
2886 10 0 87
1496 12 57 41 1 0 8 0 0 0
117 17 7 13 44 40 2 20

Previous 3 Months Total

Ending in January

1999

2000 2001

162

107

91

5511

6438

7689

40

33

29

10

12

4

302

335

259

4173

4615

4544

24

29

35

193

62

137

44

60

115

0

2

2

0

0

0

19

22

17

1

1

0

5

18

3

0

0

0

393

357

327

150

50

79

33

25

22

73

72

46

216

134

110

184

174

140

7

1

3

154

166

200

Previous 12 Months Total Ending in January
1999 2000 2001

768

701

609

25119 32138 31450

159

166

184

84

43

41

1251

1344

1200

20415 22308 19872

66

86

84

870

443

417

197

237

337

8

6

10

4

0

0

87

78

51

2

5

1

38

61

36

0

0

0

1858

1955

1732

1092

270

339

129

139

120

254

280

265

860

647

531

885

760

681

18

14

18

624

646

712

* 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.

AIDS Profile Update

Reporting Period
Latest 12 Months: 02/00 - 01/01 Five Years Ago: 02/95 - 01/96 Cumulative: 7/81 - 01/01

Total Cases Reported*
1217 2270 22725

Percent Female
26.7 19.2 16.7

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

28.7

10.2

2.0

12.3

2.1

44.8

46.7

20.5

5.3

16.7

1.3

9.5

48.7

18.4

5.6

13.0

1.9

12.3

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

19.1 77.2

3.8

34.8 62.1

3.2

35.9 62.0

2.1