Georgia epidemiology report, Vol. 17, no. 6 (June 2001)

June 2001

volume 17 number 06

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

Outbreaks of Foodborne Disease in
Georgia, 2000
Progress in surveillance of foodborne disease outbreaks
Georgia has experienced a dramatic increase in the number of outbreaks of foodborne disease recognized and recorded at the state level during 1995-2000. The three foodborne outbreaks recorded in 1995 have increased more than 10-fold to 43 outbreaks in 2000 (Figure 1). This increase is primarily due to improved communication between state, district, and county health departments, and to better ascertainment and reporting of outbreaks at all levels. Support for these enhancements has come from federal and state sources. New federal grants targeting emerging infectious diseases have provided increased resources to support activities at the state level, where the number of infectious disease epidemiologists rose from 3.5 to 16.5 during 1995-2000 (Figure 2). State resources have boosted epidemiologic capacity in the 19 health districts, providing funding for epidemiologists for 13 of the districts.
Foodborne outbreaks are reported to the state Division of Public Health by the county and district health departments, health care professionals, and the public. County, district and state public health personnel are striving to improve foodborne outbreak reporting, and to develop strong collaboration and communication between epidemiologists, environmental health specialists, and laboratorians to conduct better outbreak investigations.
Summary of foodborne outbreaks
Forty-three foodborne illness outbreaks were reported to the Georgia Division of Public Health in 2000, with at least one outbreak identified every month. These outbreaks resulted in over 2,387 individual cases of foodborne illness. One death occurred in a person who had listeriosis. Outbreaks ranged in size from 3 cases of Salmonella Newport infection (part of a multistate outbreak caused by contaminated mangos) to over 1,000 cases of Norwalk-like virus infection caused by cake frosting prepared by an infected foodhandler. Of the 43 foodborne outbreaks, 22 (51%) had a lab-confirmed etiology, while 21 (49%) were of unknown etiology (Figure 3). Of 22 outbreaks with a confirmed etiology, 11 (50%) were caused by viral agents, 10 (45%) were caused by bacterial agents, and one (5%) was caused by a parasite. Norwalk-like calicivirus was the most commonly identified foodborne agent (11 outbreaks, 1443 cases). Of outbreaks with a confirmed bacterial etiology, Staphylococcus food intoxication was the most commonly identified bacterial agent (five outbreaks, 242 cases) followed by Salmonella (four outbreaks, 59 cases), and Listeria (one multi-state outbreak, three Georgia cases). One outbreak of Cyclospora infections was reported (21 cases). The serotypes responsible for the outbreaks of salmonellosis were S. Enteritidis (one outbreak, 18 cases), S. Newport (1 outbreak, 3 cases), and S. Javiana (1 outbreak, 30 cases). One outbreak of eight cases of salmonellosis was caused by mixed serotypes.
A specific food item was epidemiologically implicated as the vehicle of transmission in 16 of 43 (37%) foodborne outbreaks in 2000. The most commonly implicated vehicle was barbecue pork (2 outbreaks). Other implicated foods were catered meals (specific food item uncertain), ice, chitterlings, frosting, mangos, scrambled eggs, fruit smoothies, delicatessen turkey, chicken salad, roast beef, berries, sandwiches, and mashed potatoes. For 39
Editor's Note: Due to production problems some of our subscribers to the GER may have received a May 2001 newsletter with the front and back pages missing. If your issue was one of these, please contact us using the address, phone, fax, or email information in the left-hand margin and we will send you another issue promptly. We apologize for any inconvenience.

of the foodborne outbreaks, the site of preparation is known. The most common sites were commercial settings such as restaurants, delicatessens, caterers, grocery store bakeries, and hotels (44%), followed by institutions such as schools, day care centers, prisons, camps, and long-term care facilities (36%). Other settings included events such as weddings, family reunions, and amusement parks (20%). Investigations often clearly identify factors that contribute to outbreaks, and provide opportunities to tailor prevention messages to food establishments at the "teachable moment". For example, in an outbreak of Staphylococcus aureus intoxications caused by barbecue pork, processing methods were not adequate to kill bacteria or to keep them from growing. Problems identified that could contribute to bacterial growth included slow cooling because the containers were large and deep, failure to use thermometers to monitor the temperature of barbecue pork stored in coolers, and prolonged duration of warming. Another outbreak of Staphylococcus aureus intoxications stemmed from contamination by an infected foodhandler. "Bacterial fingerprinting" by pulsed-field gel electrophoresis (PFGE) in the Georgia Public Health Laboratory showed that Staphylococcus aureus bacteria from the food, the ill patrons, and a plastic bandage from a foodhandler finger were indistinguishable. Because of recurring problems with barbecue pork, the state is drafting recommendations on the safe preparation of barbecue pork, focusing on the problems identified in these outbreaks.
Report on the largest outbreak
The largest outbreak reported in Georgia during 2000 occurred in Gwinnett County in February. Concerned customers called the Georgia Division of Public Health and the Georgia Department of Agriculture to report that people had become ill with gastroenteritis following birthday parties, baby showers and other celebrations beginning on February 8.
Investigation showed that all of the gatherings had served frosted cake or frosted puffed rice bars purchased from a single supermarket bakery. Interviews of ill and well attendees found that eating the frosting was statistically associated with illness. Almost all of the implicated frosted desserts were frosted on February 5. The cake decorator had become ill with gastroenteritis on February 4, but went to work on February 5 anyway and frosted approximately 80 cakes. She had long artificial fingernails, which are notoriously difficult to clean, and did not wear gloves during frosting preparation or application. Laboratory tests detected Norwalk-like virus in stools from 15 party attendees, but no stool was received from the ill cake decorator for testing.

The Georgia Department of Agriculture issued a press release on February 9 to advise persons to discard any cake purchased from the supermarket bakery on February 5 and 6. Based on cohort studies of 30 events at which the cake was served, we estimate that more than 1000 persons were ill in this outbreak.
Prevention of foodborne disease outbreaks
Foodborne illnesses can result from a variety of foodhandling mistakes.
Cross-contamination of ready-to-eat foods with raw prod-
ucts can occur during storage or during processing by utensils, containers, or hands.
Food that remains at an unsafe temperature for extended
periods, either because of inadequate heating or cooling, is a common source of foodborne outbreaks.
Foodhandlers shedding bacteria, viruses, or parasites can
contaminate foods if they handle ready to eat foods without good handwashing practices and without clean gloves.
Education of foodhandlers who work in restaurants and those who prepare food in homes is fundamental for prevention of foodborne disease.
Other measures that can contribute to control of foodborne disease include health regulations requiring education and training of foodhandlers in commercial settings, and education of consumers about foodhandling techniques, avoiding dangerous foods, and protecting especially vulnerable populations such as young children, the elderly and pregnant women. New technologies such as irradiation of red meats can decrease the number of pathogens entering our kitchens. Finally, rapid identification and thorough investigation of outbreaks can identify critical problems in the chain of events between the farm and the table and lead to control of disease transmission and prevention of future outbreaks.
Reporting outbreaks
Everyone--health care professionals, laboratory and hospital personnel, managers of facilities that provide food, and the public-- has a role to play in identifying and reporting outbreaks of disease. In fact, the Department of Human Resources Board has declared that any cluster of illnesses should be reported immediately to the County Health Department or District Health Office.

Figure 1: Reported Foodborne Disease Outbreaks 1995-2000,Georgia

Figure 2: Number of Infectious Disease Epidemiologists by year at the state level,
Georgia, 1995-2000

Figure 3: Etiology of Reported Outbreaks of foodborne diseases in
Georgia, 2000

Number of Outbreaks No. of Epidemiologists Number of Outbreaks

Year

Year
-2 -

Biology

The Georgia laws regarding the reporting of disease can be found on the world wide web at http://gnsun1.ganet.state.ga.us/cgi-bin/ pub/ocode/ocgsearch?docname=OCode/G/31/12/2. Information about notifiable disease reporting and statistics can also be found on the web at http://health.state.ga.us/epi/. Early identification and investigation of outbreaks increases the probability that the causes

will be identified and that disease can be prevented. The Epidemiology Branch is available to offer guidance and assist with outbreak investigations and can be reached at 404-657-2588, or after 5:00pm at 770-578-4104.

Authors: Kimberly M. Lane, MPH, Notifiable Diseases Section, Epidemiology Branch; Melinda Scarborough, Environmental Health Branch, and Mahin Park, Ph.D., Public Health Laboratory.

Shortage of Tetanus and Diphtheria Toxoids

Currently, a shortage of DT, DTaP and Td vaccine is impacting Georgia and the rest of the United States. The Centers for Disease Control and Prevention (CDC) reports the shortage is because:
1) Wyeth Lederle stopped production of all tetanuscontaining products; and
2) a temporary decrease in vaccine inventory at Aventis Pasteur following routine maintenance activities lasted longer than expected.
Aventis Pasteur will be limiting orders for tetanus and diphtheria toxoid containing products to assure the widest possible distribution of available doses until vaccine supplies are restored.

On June 7, 2001, the Georgia Vaccines for Children (VFC) Program implemented the following changes to maximize vaccine in its present inventory. These changes reflect the CDC recommendations published May 25, 2001 in the Morbidity and Mortality Weekly Report (MMWR).

Pediatric DT:
DT will be distributed to providers who have a child with a previous serious adverse reaction to DTaP. A specific request to the VFC Program for one vial of this product is required. Supplies will no longer be provided for inventory purposes.
Once the VFC Program's supply of DT is exhausted, the product will no longer be provided.

DTaP


The VFC Program is working to ensure equitable distribution of available DTaP vaccine. Therefore, DTaP orders will be reduced and based upon each practice's recorded two-month usage rather than the present 3-month replacement schedule.

DTaP vaccine is recommended as a five dose series. The primary series is given at 2, 4, and 6 months of age followed by a booster at 15-18 months of age and at 4-6 years of age. Some vaccine providers may face difficulties obtaining sufficient privately purchased supplies of DTaP to vaccinate fully insured children in their practices.

If quantities are insufficient, priorities should be given to vaccinating infants with the primary series since pertussis is most severe among children aged <1 year. If needed, the fourth dose can be deferred. Children should be immunized with all other recommended vaccines according to the Childhood Immunization Schedule.

Providers should recall all children who did not receive the fourth dose of DTaP once adequate supplies become available.
If DTaP supplies are sufficient, children aged 4-6 should be vaccinated according to current ACIP recommendations to assure immunity to pertussis, diphtheria and tetanus during elementary school years.
The CDC will provide more guidance to the Georgia Immunization Program if current DTaP supply problems are prolonged.
Td:
Td vaccine will be replaced based on each practice's onemonth usage.
Adolescents should not be routinely immunized with Td.
Clinics and hospitals that routinely treat acute wounds will be given priority to receive Td vaccine.
Four populations should be given priority for Td administration. They are:
1) Persons requiring tetanus vaccination for prophylaxis in wound management. For persons with >3 doses of tetanus toxoid-containing vaccine and severe or contaminated wounds, Td should be given only if >5 years have passed since the last dose of tetanus toxoid-containing vaccine. Td vaccine for wound care can be purchased privately by calling Aventis Pasteur at 1-800-822-2463.
2) Persons who are traveling to a country where the risk for diphtheria is high. High risk countries include Africa-- Algeria, Egypt, and sub-Saharan Africa; Americas--Brazil, Dominican Republic, Ecuador, Haiti; Asia/Oceania--Afghanistan, Bangladesh, Cambodia, China, India, Indonesia, Iran, Iraq, Laos Mongolia, Myanmar, Nepal, Pakistan, Philippines, Syria, Thailand, Turkey, Vietnam, Yemen; and Europe--Albania and all countries of the former Soviet Union.
3) Persons who have received <3 doses of any vaccine containing tetanus and diphtheria toxoids; and
4) Pregnant women who have not been vaccinated with Td during the preceding 10 years.
Additional questions or concerns regarding the shortage of tetanus and diphtheria toxoids can be addressed by calling Jean Popiak, Vaccine Manager for the Georgia immunization Program at 404-657-5013 or 1800-848-3868. -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

June 2001

Volume 17 Number 06

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

Selected Notifiable Diseases

Total Reported for March 2001
2001

Previous 3 Months Total

Ending in March

1999

2000 2001

Previous 12 Months Total

Ending in March

1999

2000

2001

Campylobacteriosis

53

175

101

130

815

655

635

Chlamydia trachomatis

2790

8592

7615

8218

26357

31203

31998

Cryptosporidiosis

5

60

43

31

185

149

179

E. coli O157:H7

0

1

4

2

84

45

42

Giardiasis

74

280

285

230

1289

1362

1146

Gonorrhea

1414

5360

4589

4395

20381

21637

20132

Haemophilus influenzae (invasive)

12

24

26

31

73

82

91

Hepatitis A (acute)

62

147

57

163

831

392

482

Hepatitis B (acute)

28

41

66

104

172

257

390

Legionellosis

1

0

2

2

8

7

10

Lyme Disease

0

0

0

0

3

0

0

Meningococcal Disease (invasive)

6

19

22

22

76

75

53

Mumps

3

0

2

5

2

6

5

Pertussis

2

7

18

3

42

63

37

Rubella

0

0

0

0

0

0

0

Salmonellosis

56

271

229

220

1911

1935

1680

Shigellosis

28

83

80

68

997

281

327

Syphilis - Primary

6

24

37

22

123

152

108

Syphilis - Secondary

14

59

86

50

249

303

251

Syphilis - Early Latent

33

239

141

124

850

603

511

Syphilis - Other**

33

226

171

134

881

736

677

Syphilis - Congenital

0

7

5

4

18

16

17

Tuberculosis

28

106

103

85

593

659

672

* 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: 04/00 - 03/01 Five Years Ago: 04/95 - 03/96 Cumulative: 7/81 - 03/01

Total Cases Reported*

Percent Female

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

1189

26.7

29.1

10.3

1.7

11.1

1.9

46.0

2319

18.5

48.5

18.9

5.0

17.0

1.4

9.2

22890

16.8

48.5

18.4

5.6

13.0

1.9

12.6

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

18.8 77.5

3.8

36.7 60.2

3.0

35.7 62.1

2.2