January 2002 
 
volume 18 number 01 
 
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 
 
Outbreak of Cyclosporiasis in Fulton County, Georgia 
 
Outbreak and Investigation 
Following a bridesmaids brunch at a Fulton County country club on May 20, 2000, an outbreak of diarrhea involving 19 attendees occurred. Affected individuals resided in seven states (GA, FL, MD, NJ, IL, NC, and NY). The median incubation period was 7 days (range: 2-9 days). All ill persons had diarrhea, and in most cases it was prolonged. The median duration of diarrheal illness was 18 days (range: 1-21+ days). No one required hospitalization. Of the eleven persons who sought treatment initially, eight were prescribed ciprofloxacin. No one was treated appropriately with trimethoprim/ sulfamethoxazole (TMP/SMX) until after the Georgia Public Health Laboratory (GPHL) identified Cyclospora as the etiologic agent, and the Georgia Division of Public Health (GDPH) notified those affected. 
The bridesmaids brunch menu included eggs benedict with broiled tomato, asparagus and sauted mushrooms, bread and butter, mixed fresh raspberries, strawberries and blackberries over ice cream, mimosas, iced tea, coffee and orange juice. GDPH focused on the berries because the literature supports them as likely vehicles for Cyclospora. Case-finding uncovered two additional cases among others who had access to the same shipment of berries at Country Club A between May 19-21. There were nine laboratory-confirmed cases, including three identified by the New York City Bureau of Laboratories and the Florida Public Health Laboratory. 
The epidemiologic analysis of this outbreak was difficult because most of the attendees ate most of the available foods at the bridesmaids brunch, the attack rate was high (leaving few well persons to compare with ill persons), and three types of berries were served mixed together. No specific food item was implicated until the cohort under study was expanded to include persons who ate at Country Club A during a three-day period, May 19-21, 2000. Eating raspberries, blackberries or both was significantly associated with illness (n=45, RR=6.3 [1.68<RR<23.93], Fisher exact 2-tailed p-value=.000094). Anecdotally, one person with a laboratory-confirmed case arrived late at the brunch and only consumed coffee, water, two bites of ice cream, and all of the berries on her ice cream. 
 
Attack rates among those who ate, did not recall eating or dont know whether they ate raspberries, blackberries or 
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In conjunction with the Centers for Disease Control and Prevention (CDC), the Food and 
 
Drug Administration (FDA) coordinated a traceback of berries, the most likely food ve- 
 
hicle. One Guatemalan farm and an unknown number of Chilean farms were possible 
 
sources of the raspberries served at Country Club A. The same Guatemalan farm was also 
 
the only possible source of the blackberries served at the bridesmaids event. A subsequent 
 
investigation showed that this Guatemalan farm was a possible source of raspberries used 
 
Editors Note: 
In the November 2001 issue of the GER, the phone number for the Jonesboro Health Center in Clayton County was listed incorrectly. The correct phone number is 770 471-8635. 
 
 Number of Cases 
 
Date of Onset for 21 Persons Who Became Ill After Eating at Country Club A between May 19-21, Fulton County, GA 
9 8 7 
Eating period under study: 
6 
EatingMperaioydun1d9er-st2ud1y:,M2ay0190-201,2000 
5 4 3 
BriBdersmuanidcs' Bhrunch 
2 1 0 
 
05/19/2000 05/20/2000 05/21/2000 05/22/2000 05/23/2000 05/24/2000 05/25/2000 05/26/2000 05/27/2000 05/28/2000 05/29/2000 
 
DaDteateooffOOnnsestet *Note: The individual with 5/22/00 onset had intermittent gastrointestinal symptoms from other causes. 
 
for a June 10, 2000 event in Philadelphia, that was associated with another cyclosporiasis outbreak. 
Discussion 
A protozoan parasite, Cyclospora cayetanensis, causes cyclosporiasis. Following a median incubation period of about one week, affected persons usually experience diarrhea, nausea, anorexia, abdominal cramping, fatigue, and weight loss. If the person has no underlying illness, the diarrhea is self-limited, but it can be prolonged, lasting 943 days. Oocysts can be identified in wet mount under phase contrast microscopy, or a modified Kinyoun acid-fast stain can be used. The CDC can also identify oocysts using a technique called epifluorescence. 
Transmission is primarily waterborne, but fruits and vegetables can serve as vehicles for transmission when the sporulated oocysts are ingested. The mechanisms of contamination of food and water remain unclear. Recent outbreaks have been traced to raspberries, basil and lettuce. While washing produce thoroughly before consumption should be standard practice, it does not eliminate the risk of Cyclospora infection. 
Conclusion 
It was initially difficult to establish Cyclospora as the etiologic agent even under the circumstances of this large outbreak. Many ill persons consulted private physicians before the outbreak was detected and investigated. Even when some astute physicians suspected Cyclospora 
 
and requested laboratory testing for the agent, results were negative. No laboratory-confirmed diagnosis was made until the GPHL tested stool specimens on June 14, 2000, approximately three weeks after the earliest date of symptom onset. This suggests that contaminated food vehicles could be consumed throughout the U.S. and cause cyclosporiasis without the illnesses being correctly diagnosed. Providers should include cyclosporiasis in the differential diagnosis when a patient presents with prolonged watery diarrhea. Providers also need to know which laboratories have experience testing for Cyclospora. In Georgia, the State Public Health Laboratory has demonstrated that it can make the diagnosis, even when commercial laboratories have not. 
This experience emphasizes the value of rapid outbreak investigation. The Epidemiology Branch and the Environmental Health and Injury Prevention Branch, GDPH, can help in any investigation, but it is especially important that the Branches be notified when residents of multiple Georgia counties are involved. For this outbreak involving multiple states, GDPH worked closely with local health authorities, other state health authorities, CDC and FDA to conduct an effective investigation. In part because of this investigation, FDA is tightening restrictions on Guatemalan raspberries. 
Evidence of contaminated imported produce required rapid notification of appropriate agencies. Prompt collection of stool specimens during outbreaks of gastroenteritis increases the likelihood that laboratory analyses will yield useful results. When epidemiologic investigation and traceback activities pinpoint where improvement is needed, suitable control measures can then be implemented to prevent additional cases. 
 
Written by: Laurel B. Murrow, M.S., Paul Blake, M.D., M.P.H. and Lexie 
Kreckman, A.B. -2 - 
 
 Current Epidemiology of TB in Georgia 
 
A total of 700 TB cases were reported in Georgia in 2000, an increase of 4% from 670 cases in 1999. In 2000, Georgia ranked 5th in the nation in tuberculosis case rates (8.6 per 100,000 persons) and continues to have higher case rates than the national average (5.8 per 100,000). 
TB cases in Georgia are predominantly male (67%), AfricanAmerican (61%), and U.S.-born (78%). The TB case rate is significantly higher in minority populations. In 2000, the rate of tuberculosis was 2.5 per 100,000 among non-Hispanic whites compared to 17.7 per 100,000 among Hispanics of all races (RR=7.2, 95% CI 5.4-9.6), 18.3 per 100,000 among non-Hispanic blacks (RR=7.46, 95% CI 6.1-9.1), and 38.5 per 100,000 among Asians (RR = 15.7, 95% CI 11.6-21.1). The largest proportion of cases among age groups (33%, 229 cases) occurred in those 45-64 years old. TB case rates for persons 18 years old and over was 10.4 per 100,000 persons compared to 3.6 per 100,000 in persons younger than 18 years. Six percent (45 cases) of TB cases occurred in children under five years old  the age group at risk for disseminated TB. 
Geographic Distribution of cases 
The metropolitan Atlanta area reported 52% of TB cases in 2000. The counties reporting the highest number of cases were: Fulton (180 cases), DeKalb (86), Gwinnett (40), Cobb (38), and Clayton (23). Zip code areas in inner-city Atlanta that consistently report the highest number of cases in Fulton County had case rates that ranged from 37 to 85 per 100,000 persons in 2000. Nine of 11 health districts reported increases in TB case numbers. Of nonmetropolitan Atlanta counties, Richmond County in District 6 (Augusta area) and Chatham County in District 9.2 (Savannah area) reported the highest number of TB cases (22 and 20, respectively). Of 159 counties in the state, 78 (49%) attained the 2000 TB Elimination case rate goal of <= 3.5 per 100,000 persons (Map1) and 55 (35%) counties did not report a single case of TB. 
 
the proportion of foreign-born TB cases is more than 50%. However, the number and proportion of foreign-born TB cases in Georgia has been increasing over the past decade though unevenly distributed through the state. In 2000, foreign-born TB cases were mostly reported from metropolitan Atlanta Health Districts, e.g., DeKalb (43 cases, 50% of DeKalb cases), Lawrenceville (35, 81%), and Cobb (14, 37%). The most common countries of origin of foreign-born persons with TB were Mexico (39 cases), Vietnam (24), India (16), Somalia (12), and Guatemala (11). More than half (52%) of foreign-born TB cases reported between 1993 and 2000 were diagnosed with TB within 5 years after their arrival in the U.S. 
HIV testing was performed in a large proportion (74%) of TB cases in 2000. Among TB cases in the 25-44 year old age group, the high-risk age group for HIV/AIDS, HIV testing was performed in 84%. Of TB cases whose HIV status is known, 87(12%) were HIV seropositive. The majority of HIV/TB co-infected cases are male (76%), African-American (92%), and in the 25-44 year age group (59%). Most HIV/TB co-infected cases (67%) live in the metropolitan Atlanta area. 
In 2000, TB cases living in settings where infection is easily transmitted included 41 (6% of TB cases) persons who were homeless, 37 (5%) cases in correctional facilities, and 21 (3%) cases residing in long-term care facilities. There has been no substantial change in the proportion of TB cases in these settings over time. 
Primary drug resistance 
Drug susceptibility testing done on isolates from 484 cases with no previous history of TB indicated that 32 (7%) were resistant to isoniazid, 5 (1%) to rifampin, 5 (1%) to ethambutol, and 10 (2%) to streptomycin. Six cases (1%) were multidrug-resistant (resistant to at least isoniazid and rifampin). All six multidrug-resistant cases were born in Mexico, four had no previous history of TB, and three were diagnosed with TB within three years after their arrival in the U.S. 
 
Distribution in High-risk Populations 
Foreign-born TB cases accounted for 22% (155) of cases reported in Georgia in 2000, lower than the proportion of foreign-born TB cases in the U.S. in 2000 (46%) and much lower than the Pacific Northwest, Great Lakes and the Northeast regions where 
 
TB mortality 
Thirty-five persons died of TB in Georgia in 1999, the year for which the most recent mortality data are available. The age-adjusted TB mortality rate was 1.11 per 100,000 persons in 1999 compared to 1.17 per 100,000 in 1998. 
Written by: Rose-Marie Sales, M.D., M.P.H. 
 
-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 
 
January 2002 
 
Volume 18 Number 01 
 
Reported Cases of Selected Notifiable Diseases in Georgia Profile* for October 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 Oct 2001 
2001 16 
2676 9 7 13 
1435 7 61 21 0 0 1 0 0 0 
139 59 3 20 33 15 0 69 
 
Previous 3 Months Total 
 
Ending in Oct 
 
1999 
 
2000 2001 
 
181 
 
153 
 
136 
 
6978 
 
7693 
 
8170 
 
47 
 
61 
 
46 
 
14 
 
9 
 
12 
 
468 
 
351 
 
198 
 
5443 
 
5557 
 
4725 
 
8 
 
12 
 
15 
 
123 
 
129 
 
271 
 
75 
 
104 
 
110 
 
4 
 
3 
 
0 
 
0 
 
0 
 
0 
 
13 
 
6 
 
5 
 
3 
 
0 
 
0 
 
14 
 
11 
 
1 
 
0 
 
1 
 
0 
 
756 
 
622 
 
610 
 
79 
 
92 
 
164 
 
40 
 
30 
 
22 
 
66 
 
79 
 
58 
 
144 
 
125 
 
103 
 
187 
 
205 
 
109 
 
7 
 
6 
 
1 
 
151 
 
175 
 
136 
 
Previous 12 Months Total 
 
Ending in Oct 
 
1999 2000 2001 
 
756 
 
623 
 
591 
 
30110 
 
28332 
 
30962 
 
172 
 
188 
 
138 
 
41 
 
50 
 
34 
 
1311 
 
1275 
 
921 
 
21170 
 
19021 
 
17376 
 
81 
 
79 
 
99 
 
574 
 
341 
 
870 
 
221 
 
311 
 
403 
 
4 
 
10 
 
10 
 
0 
 
0 
 
0 
 
75 
 
56 
 
48 
 
5 
 
2 
 
7 
 
48 
 
58 
 
18 
 
0 
 
1 
 
0 
 
1992 
 
1750 
 
1630 
 
371 
 
309 
 
382 
 
145 
 
126 
 
89 
 
279 
 
296 
 
269 
 
721 
 
556 
 
522 
 
761 
 
728 
 
666 
 
20 
 
20 
 
15 
 
626 
 
663 
 
582 
 
* 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: 11/00 - 10/01 Five Years Ago: 11/95 - 10/96 Cumulative: 7/81 - 10/01 
 
Total Cases Reported* 
 
Percent Female 
 
AIDS Profile Update 
Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 
 
1385 
 
24.8 
 
31.9 
 
9.4 
 
1.9 
 
10.7 
 
1.2 
 
44.8 
 
2408 
 
18.8 
 
47.0 
 
17.9 
 
5.2 
 
18.4 
 
1.3 
 
10.2 
 
23832 
 
17.1 
 
48.1 
 
18.1 
 
5.5 
 
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 
 
- 4 - 
 
Race Distribution (%) White Black Other 
 
19.9 75.1 
 
5.0 
 
34.1 63.2 
 
2.7 
 
35.1 62.6 
 
2.3