Georgia epidemiology report, Vol. 17, no. 9 (Sept. 2001)

September 2001

volume 17 number 09

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

Update on Pneumococcal Disease and
Prevention in Georgia
Streptococcus pneumoniae (pneumococcus) is a major bacterial pathogen that affects children and adults worldwide. In the United States (U.S.), it is the most commonly identified bacterial cause of meningitis (3000 cases), otitis media (7 million cases), and community-acquired pneumonia (500,000 cases), as well as a frequent cause of bacteremia (50,000 cases). The rapid evolution and spread of antimicrobial resistance among U.S. pneumococcal isolates during the 1990's has caused much concern, and has been associated with treatment failures among patients with meningitis and otitis media. This report summarizes surveillance and control efforts in Georgia, and newer developments for the prevention of pneumococccal disease.
SURVEILLANCE FOR PNEUMOCOCCAL DISEASE AND
PNEUMOCOCCAL DRUG-RESISTANCE
Georgia is one of 9 states participating in the Centers for Disease Control and Prevention (CDC) Emerging Infections Program (EIP). Active surveillance for invasive pneumococcal disease and antimicrobial resistance is one component of the Active Bacterial Core Surveillance (ABCs) system of the EIP. This program seeks to identify all cases of invasive pneumococcal disease occurring in the Atlanta Metropolitan Statistical Area (Pickens, Bartow, Cherokee, Forsyth, Paulding, Cobb, Gwinnett, Barrow, Douglas, Fulton, DeKalb, Walton, Carroll, Coweta, Fayette, Henry, Spalding, Rockdale, and Newton) and to collect pneumococcal isolates for antimicrobial resistance testing. These population-based data can be used to project disease rates to the wider population. In 1998, overall rates of pneumococcal disease were 23 per 100,000 population, with the highest rates occurring among the very young and the elderly.
DRUG-RESISTANT PNEUMOCOCCAL INFECTIONS ARE COMMON IN
GEORGIA
Strains of drug-resistant Streptococcal pneumoniae (DRSP) have become increasingly common in Georgia, in the U.S. and in other parts of the world. In 1998, 33% of 726 invasive pneumococcal isolates in Georgia showed intermediate or high level resistance to penicillin (MIC> 0.12 ug/ml), a higher percentage than all other participating states except Tennessee (Table 1).1 While pneumococci that are susceptible to penicillin are likely to be susceptible to other drug classes, pneumococcal isolates that are resistant to penicillin are more likely to be resistant to other beta-lactam antimicrobials, and to be resistant to other classes of drugs. Evolving pneumococcal resistance to newer macrolides and fluoroquinolones is important because they are a popular choice for empiric treatment of respiratory infections. Ominous trends in pneumococcal resistance data between 1995 and 1998 include an increase in pneumococcal resistance to macrolides (erythromycin) and fluoroquinolones, although resistance levels to fluoroquinolones are currently low. In the EIP study above, Georgia had the highest percentage of pneumococcal isolates that were resistant to at least 3 classes of antimicrobial drug (24%).*1
Choosing an effective therapy for patients with drug-resistant pneumococcal infections is increasingly difficult under these circumstances. Treatment guidelines have been developed by groups of experts to address these problems.2-4 Reasons for geographic variation in rates of pneumococcal antimicrobial resistance are unknown, but may reflect spread of resistant pneumococcal clones or local patterns of antimicrobial use. Regardless of cause, the high prevalence of drug-resistant pneumococcal disease in Georgia is a compelling reason to prevent pneumococcal disease whenever possible.
*Pneumococcal isolates were tested for resistance to the following drug classes: beta-lactams, fluoroquinolones, erythromycin, clindamycin, chloramphenicol, vancomycin, rifampin, tetracycline, and quinupristin-dalfopristin.
PREVENTION OF PNEUMOCOCCAL DISEASE THROUGH VACCINATION
Two forms of pneumococcal vaccine are available. The 23-valent pneumococcal polysaccharide vaccine (PPV23) has been available since 1983, and is recommended for high-risk adults and older children (Table 3).5 In February 2000, a new 7-valent pneumococcal conjugate vaccine (PCV7) was licensed by the FDA and is recommended for young children (Table 2).6 Pneumococcal infection causes an estimated 40,000 deaths annually in the U.S., accounting for more deaths than any other vaccine-preventable bacterial disease. Most of these deaths are among adults, and approximately half these deaths could be prevented through the use of PPV23.5

Table 1. Factors Independently Associated with Invasive Disease Due to S. pneumoniae with Resistance to Penicillin among all Patients with Invasive Pneumococcal Disease, 1998 1

Characteristic
State Tennessee Georgia Maryland Oregon Minnesota Connecticut California New York
Age group < 5 yr 5-17 yr 18-64 yr >=65 yr
Race White Black

No. of Isolates
419 726 579 228 472 679 181 191
915 105 1461 993
1858 1130

% with Resistance to Penicillin
35.1 33.2 22.5 20.6 20.1 18.3 14.9 14.7
32.2 21.0 19.3 24.2
26.1 22.4

Table 2. 7-Valent Pneumococcal Conjugate Vaccine (PCV7) for Infants and Children6
Children for whom PCV7 is recommended: All children aged < 23 months Children aged 24-59 months with the following conditions:
Sickle cell disease and other sickle cell hemoglobinopathies, congenital or acquired asplenia, or splenic dysfunction
Infection with human immunodeficiency virus Immunocompromising conditions, including
Congenital immunodeficiencies: B-(humoral) or T-lymphocyte deficiency; complement deficiencies, particularly c1, c2, c3, and c4 deficiency; and phagocytic disorders, excluding chronic granulomatous disease Renal failure and nephrotic syndrome Diseases associated with immunosuppressive therapy or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin's disease; or solid organ transplantation Chronic illness, including Chronic cardiac disease, particularly cyanotic congenital heart disease and cardiac failure Chronic pulmonary disease, excluding asthma unless on high dose corticosteroid therapy Cerebrospinal fluid leaks Diabetes mellitus
Children for whom PCV7 should be considered: All children aged 24-59 mos, with priority given to
Children aged 24-35 mos Children of Alaska Native or American Indian descent Children of African-American descent Children who attend group day care centers (defined as a setting
outside the home where a child regularly spends > 4 hours per week with >2 unrelated children under adult supervision).

INVESTIGATION OF DRUG-RESISTANT
PNEUMOCOCCAL DISEASE AND PCV7 USE IN A
RURAL GEORGIA COMMUNITY, DECEMBER, 20007
In December 2000, the Georgia Division of Public Health investigated a report from rural southwest Georgia of a child with refractory otitis media caused by multidrug-resistant pneumococcus. The child attended daycare, had not received PCV7, and was hospitalized to receive intravenous vancomycin. Other children (10 of 21 who underwent nasopharyngeal swab collection) in the daycare carried pneumococci with the same multidrug-resistant pattern, and most (17 of 21) carried pneumococci of serotypes included in PCV7. No daycare children had been vaccinated with PCV7, and 10 of 16 parents were unaware of PCV7's existence. While some Georgia children have alternative ways to pay for vaccination, approximately two thirds of PCV7 in Georgia is paid for by the Vaccines for Children (VFC) program. In this community, PCV7 was not available through VFC until 2 months after the investigation.
POTENTIAL IMPACT OF PCV7 ON INVASIVE
PNEUMOCOCCAL DISEASE AMONG GEORGIA'S
CHILDREN
Pre-licensure efficacy trials for PCV7 have shown good efficacy (~97%) against invasive pneumococcal disease for vaccine serotypes among fully vaccinated children. Because only 7 serotypes are in the vaccine, overall efficacy is somewhat less against all pneumococcal disease. Reductions in clinical pneumonia and acute otitis media were also found.8 PCV7 was licensed in February 2000, but not widely implemented in Georgia until it became available through VFC in February 2001. Preliminary analysis of active surveillance data in Georgia reveals that cases of invasive pneumococcal disease among all ages for the first 6 months of 2000 were down 6% from 1999, and for the first 6 months of 2001 were down a further 13% from 2000. This reduction was most striking for children aged 1 month to 4 years, where cases were down 37% for the first 6 months of 2001 relative to 2000 (Wendy Baughman, Georgia Emerging Infections Program, June 2001). Although not a required vaccine, the Georgia Immunization Program indicates that PCV7 implementation is now proceeding quickly statewide.
23-VALENT PNEUMOCOCCAL POLYSACCHARIDE
VACCINE FOR ADULTS
Despite appropriate antimicrobial therapy and intensive medical care, the overall case-fatality rate for pneumococcal bacteremia is 15-20% among adults; among elderly patients, the rate approaches 30 to 40%. The 23valent pneumococcal polysaccharide vaccine (PPV23) is effective against invasive disease, such as bacteremia and bacteremic pneumonia, in many patient populations.9 Indications for PPV23 are shown in Table 3.5,6
GEORGIA NEEDS TO IMPROVE ADULT
PNEUMOCOCCAL VACCINATION
Data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1999 reported that only 50% (95% CI 44-57%) of Georgia residents > 65 years of age reported having ever had a pneumonia vaccination.10 Although steady improvement has been seen in this indicator since 1991, Georgia's point estimate was among the lowest for the 50 states, and below the Healthy People 2000 goal of 60% (Figure 1). Medicare reimbursement records show that only 32% of Georgia Medicare beneficiaries who were aged 65 or older in 1999 had received Medicare reimbursement for a pneumococcal vaccine between 1991 and 1999 (Data courtesy of the Georgia Medical Care Foundation).
Influenza and pneumococcal vaccinations can be administered at the same time. Both vaccines are reimbursed for Medicare patients. Many persons at high risk for influenza complications are also at high risk for pneumococcal disease. Simultaneous administration of influenza and pneumococcal vaccine should be considered when an eligible candidate for one vaccine is identified.

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Table 3. The Advisory Committee on Immunization Practices (ACIP) recommends vaccination with the 23-valent polysaccharide pneumococcal vaccine (PPV23) for the following groups*5

Figure 1.Percent of Georgia Residents aged > 65 years answering "yes" to the question "Have you ever had a pneumonia vaccination?" (from BRFSS Data 19931999).

Immunocompetent persons Persons aged >65 years. Second dose of vaccine if patient

100%

Percent of seniors vaccinated

received vaccine >5 years previously and was aged <65 years at the time of vaccination. Persons aged 2-64 years with chronic cardiovascular disease (including congestive heart failure and cardiomyopathy), chronic pulmonary disease (including chronic obstructive pulmonary disease and emphysema), diabetes mellitus, alcoholism, chronic liver disease (including cirrhosis), or cerebrospinal fluid

80%

60%

40%

27%

20%

38%

48% 49.50%

leaks. For children with chronic illness (chronic cardiac disease, particularly cyanotic congenital heart disease and cardiac failure, chronic pulmonary disease, excluding asthma unless on

0% 1993

1995

1997

1999

high dose corticosteroid therapy, cerebrospinal fluid leaks or

Year

diabetes mellitus), PPV23 should be administered at age 2

yrs, and 2 mos after last dose of PCV7 (see Table 2). Revacci-

nation not recommended.

Persons aged 2-64 years with functional or anatomic asplenia

REFERENCES

(including sickle cell disease and splenectomy). For children

1. Whitney C, Farley M, Hadler J, et al. Increasing prevalence of

with these conditions, PPV23 shFouigldurbee 3a:dmPinroispteorretdioant aogfeW>o2men with SingmleutlotindrVuge-rrseussistant Streptococcus pneumoniae in the United States.

yrs, and >2 mos after last dosMe uoltfipPlCe VG7es(tsaeteioTnabPlereg2n).aInfcies by Site oNf EDJeMliv2e0r0y0;aVndol. 343: No. 26: pp 1917-24.

patient is aged >10 years: singlRe erseivdaecncicnea,tiGoneo>rg5iay,ea1r9s94aft-er1996

previous dose. If patient is aged <10 years: consider revaccina-

2. Dowell SR et al. Acute otitis media: management and surveillance in

tion 3 years after previous dose.

an era of pneumococcal resistance: a report from the Drug-Resistant

Persons aged 2-64 years living in environments (such as nursing

Streptococcus pneumoniae Therapeutic Working Group. Pediatr Infect

homes, long-term care facilities, hospitals, and day care centers)

Dis J 1999;18:1-9.

or social settings (including Alaskan Natives and certain American Indian populations) in which the risk for disease is high. Revaccination not recommended.

3. Bartlett JG, et al. Community-acquired pneumonia in adults: guidelines for management. Clin Infect Dis 1998;26:811-38.

Immunocompromised persons Immunocompromised persons aged >2 years (including those
with HIV infection, leukemia, lymphoma, Hodgkins disease, multiple myeloma, generalized malignancy, chronic renal failure, or nephrotic syndrome; those receiving immunosuppressive

4. Heffelfinger JD, et al. Management of community-acquired pneumonia in the era of pneumococcal resistance: a report from the Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group. Arch Intern Med 2000;160:1399-408.

chemotherapy (including corticosteroids); and those who have received an organ or bone marrow transplant). For children with these conditions, PPV23 should be administered at age
2 yrs and 2 mos after last dose of PCV7 (see Table 2).

5. CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46 (No. RR-8):1-24.

Single revaccination if >5 years have elapsed since receipt of first dose. If patient is aged <10 years: consider revaccination 3 years after previous dose.

6. CDC. Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2000; 49 (No. RR-9):1-35.

*For all listed groups, if earlier vaccination status is unknown, patients should be administered PPV23.

7. CDC. Multi-resistant Streptococcus pneumoniae--Southwest Georgia, December 2000 (MMWR In press).

APPROPRIATE ANTIBIOTIC USE AND
DRUG-RESISTANCE
Many authorities believe that inappropriate use of antibiotics for upper respiratory tract infection (URI) is the single most important reason for increasing pneumcococcal antibiotic resistance. Many physicians report feeling pressure from patients to provide antibiotics, and that time constraints make it difficult to resist prescribing. Diagnostic uncertainty and worries about follow-up can also lead to over-prescribing. Patients who have been given antibiotic prescriptions in the past may believe they need antibiotics for URI. The Georgia Division of Public Health plans to work with medical providers, insurers, corporations, and other community partners to build a coalition for better antibiotic use. This program will include outreach to educate the public and tools for medical providers to facilitate the discussions that prevent inappropriate antibiotic prescribing.

8. Black S, Shinefield H, Fireman B, et al. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Pediatr Infect Dis J 2000;19:187-95.
9. Butler JD, et al. Pneumococcal polysaccharide vaccine efficacy: an evaluation of current recommendations. JAMA 1993;270:1826-31.
10. CDC. Influenza and pneumococcal vaccination levels among persons aged >65 years--United States, 1999. MMWR 2001;50 (No. 25):532-7.
This article was written by Kathryn Arnold, M.D.

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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

September 2001

Volume 17 Number 09

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for June 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 June 2001 2001 77 1299 7 8 68 739 3 104 18 1 0 2 0 1 0 155 18 1 17 28 17 0 28

Previous 3 Months Total

Ending in June

1999

2000 2001

222

202

165

8552

7961

5750

32

31

25

7

10

12

245

263

227

5946

5003

2973

27

23

27

131

80

278

48

73

76

0

4

3

0

0

0

23

14

12

1

0

2

10

12

3

0

0

0

423

389

343

59

74

56

37

31

9

78

62

53

161

155

113

180

179

108

3

4

3

186

186

121

Previous 12 Months Total

Ending in June

1999 2000 2001

832

635

600

28951

30608

29871

193

148

173

61

48

44

1289

1380

1111

21083

20689

18149

87

78

97

753

341

682

170

282

393

5

11

10

1

0

0

80

66

51

2

5

7

37

65

29

0

0

1

2022

1901

1634

673

296

309

129

146

90

263

288

257

802

600

490

812

738

695

18

17

19

624

659

606

* 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: 07/00 - 06/01 Five Years Ago: 07/95 - 06/96 Cumulative: 7/81 - 06/01

Total Cases Reported*

Percent Female

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

1333

25.0

28.4

9.1

1.7

10.8

1.6

48.4

2376

17.2

49.0

18.9

4.9

17.3

1.1

8.8

23370

16.9

48.2

18.2

5.5

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

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Race Distribution (%) White Black Other

19.0 76.3

4.7

36.7 60.4

2.9

35.4 62.4

2.2