September 2002 volume 18 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 Influenza Surveillance in Georgia Yearly epidemics of influenza occur during the winter months, causing an average of 114,000 hospitalizations and 20,000 deaths per year in the United States (U.S.). While influenza infects persons of all ages, rates of illness are highest among children, the elderly, and persons with certain chronic medical conditions. Young children have increased rates of influenza-related hospitalization. Rates of death from influenza are especially high among the elderly and persons whose medical conditions place them at an increased risk for complications from influenza. Prevention strategies are designed to prevent and ameliorate disease in these higher risk populations. Annual influenza vaccination is routinely recommended for persons at high risk of developing complications from influenza, such as persons aged > 65 years and persons with chronic medical conditions, listed in Table 1 (page 2). In 2001, the Advisory Committee on Immunization Practices (ACIP) expanded the age for routine annual influenza vaccination to include those aged 50 to 65 because of the high prevalence of high-risk medical conditions in this population. In 2002, the ACIP made new recommendations regarding vaccination of household contacts and out-ofhome caretakers of children 0-23 months of age. Although current (inactivated trivalent) influenza vaccines have not been approved for use in children less than 6 months of age, the ACIP now encourages vaccination of children aged 6-23 months where feasible. Overview of Flu Surveillance in Georgia Each year from October through May, the Georgia Division of Public Health (GDPH) monitors influenza activity throughout the state via a sentinel provider network, part of a nationwide surveillance network coordinated by the Centers for Disease Control and Prevention (CDC). On a weekly basis during flu season, approximately 40 volunteer sentinel health-care providers throughout Georgia report the total number of patients seen and the number of those patients with influenza-like illness. Influenza-like illness is defined as fever >100 F AND cough and/or sore throat. Sentinel providers also submit throat swabs from representative patients several times during the season for testing at the Georgia Public Health Laboratory (GPHL). Data from these volunteer providers are used to characterize the intensity of influenza disease activity and geographic distribution. The swabs provide isloates for strain typing and to assist in planning for future vaccines. Because not all cases of influenza are diagnosed, confirmed, or reported, the sentinel network cannot be used to determine the precise number of influenza infections or rates of disease during a given season. During influenza season, information about current influenza activity in Georgia is posted weekly on the Georgia Division of Public Health web site, at http:// health.state.ga.us/epi/flu, with links provided to nationwide data from CDC. Summary of 2001-2002 Flu Season in Georgia Influenza activity peaked in early January and remained at elevated levels through mid-March. The first influenza isolate in Georgia was reported in early January. One hundred seventy-two clinical samples were submitted to GPHL for respiratory virus testing and 72 (42%) were positive for influenza. Of the positive specimens, 54 (75%) were influenza A (H3N2), 2 (3%) were influenza A (H1N1), 14 (19%) were influenza B, and 2 (3%) were not typed. Antigenic profiling was conducted on selected specimens, revealing that circulating type A strains were antigenically similar to the A(H3N2) and A(H1N1) strains contained in the 2001-2002 influenza vaccine. However, 9 of 9 tested type B strains were type B/Hong Kong/330/2001-like. This strain is antigenically dissimilar to the type B strain included in the 2001-2002 vaccine and until this past flu season had not been found outside of Asia for more than a decade. Because Georgians had little or no immunity to this type B strain, an unusual increase in influenza B infections was detected in parts of Georgia in May and June, as well as in other locations in the U.S. The new type B strain will be included in the 2002-2003 trivalent influenza vaccine. Table 1. Target Groups for Annual Influenza Vaccination (Vaccination should begin no later than October, if vaccine is available) Persons at High Risk for Influenza-Related Complications: Persons aged > 65 years Residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions Adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma Adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), kidney dysfunction, blood disorders (hemoglobinopathies), or immune system problems (immunosuppressed or immunocompromised) Children and teenagers (aged 6 months 18 years) who are receiving long-term aspirin therapy and, therefore, might be at risk for developing Reye syndrome after influenza infection Women who will be in the second or third trimester of pregnancy during the influenza season Persons Aged 50-64 Years Vaccination is recommended for persons aged 50-64 years because this group has an increased prevalence of persons with high-risk medical conditions. Persons Who Can Transmit Influenza to Those at High Risk: Physicians, nurses, and other personnel in hospital and outpatient-care settings, including emergency response workers Employees of nursing homes and chronic-care facilities who have contact with patients or residents Employees of assisted living and other residences for persons in high-risk groups Persons who provide home care to persons in high-risk groups Household members (including children) of persons in high-risk groups Household contacts and out-of-home caretakers of children 0-23 months of age Persons Who Should Not Be Vaccinated: Persons known to have anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine should not be vaccinated without first consulting a physician* Persons with acute febrile illness usually should not be vaccinated until their symptoms have abated* * See MMWR April 12, 2002/vol. 51/No. RR-3. The complete report and other information on influenza can be accessed at http://www.cdc.gov/nip/Flu/default.htm. Preventing Influenza Annual influenza vaccination is the most effective way to prevent influenza and its complications. Studies have shown that influenza vaccination is associated with reductions in influenza infection among all age groups, hospitalizations and death among persons at high risk for influenza complications, otitis media in children, and work absenteeism in healthy adults (1-4). Persons at greatest risk for developing complications from influenza should be vaccinated beginning in October. In Georgia, influenza activity typically peaks after January, so influenza vaccination should continue throughout flu season as long as vaccine is available. Figure 1 suggests the ideal times to conduct influenza vaccination campaigns and to order vaccine. Target groups for vaccination (see Table 1) Figure 1. Influenza Timeline Influenza Season Begins in October Each Year Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep BEST TIME TO IMMUNIZE NOT TOO LATE TO IMMUNIZE IMMUNIZATION NOT ROUTINELY RECOMMENDED Other persons not at high risk who want to prevent the flu BEST TIME TO IMMUNIZE NOT TOO LATE TO IMMUNIZE IMMUNIZATION NOT ROUTINELY RECOMMENDED Order influenza vaccine for upcoming season VACCINE MAY BE IN SHORT SUPPLY BEST TIME TO ORDER VACCINE FROM MANUFACTURER ("PRE-BOOK") VACCINE MAY ONLY BE AVAILABLE FROM DISTRIBUTOR Georgia Shows Improvement Data from the 2001 Behavioral Risk Factor Surveillance System (BRFSS) indicate that influenza and pneumococcal vaccination rates have improved in recent years among Georgians over the age of 55, and especially among persons aged > 65 years. Although vaccination rates are increasing, they are still far below the Healthy People 2010 goal of 90% vaccination for both vaccines among people aged > 65 years. Figure 2 (page 3) shows influenza and pneumococcal vaccination rates in this age group. -2 - Flu News Figure 2. Influenza and Pneumococcal Vaccination Rates among Persons Anged > 65 Years, Georgia, 1995-2001 100 80 60 40 20 0 1995 1997 1999 2001 Healthy Healthy People People 2000 Goal 2010 Goal Influenza Pneumococcal During June through September 2002, Georgia was one of several states participating in a pilot influenza summer surveillance program. Several sentinel health-care providers from across the state volunteered to continue reporting the percentage of patients seen for influenza-like illness each week during the summer. The sentinels also continued to send occasional throat specimens from flulike illness cases to GPHL for isolation and characterization of circulating influenza viruses. Although influenza activity typically peaks during the winter months, influenza viruses circulate yearround and remain a threat to persons who are very young or old or who have chronic medical conditions. The emergence of a novel influenza strain capable of causing a pandemic is also a possibility. Year-round influenza surveillance improves public health's ability to rapidly identify new strains of the virus. Many illnesses have signs and symptoms similar to influenza, making a clinical diagnosis difficult. Knowing when influenza is active in the community can enhance the accuracy of clinically diagnosing influenza. During flu season, GDPH emails periodic updates on flu activity in the state to those who are interested. If you would like to receive these updates, send an email to flu@dhr.state.ga.us with the word "subscribe" in the subject line. GDPH has developed materials to assist long-term care facilities and other care providers in preventing influenza. The materials Table 2. include outbreak control guidelines, resources for ordering vaccine, using rapid tests, administering antiviral medications, or billing Medicare for immunizations, and important contact and reference information. These materials are available at http://health.state.ga.us/epi/flu. The 2002-2003 influenza trivalent vaccine will contain the following strains: A/Moscow/10/99 (H3N2)-like, A/New Caledonia/20/99 (H1N1)-like, and B/Hong Kong/330/2001-like strains. Manufacturers are not expecting any delays in delivery of vaccine, as has been experienced in previous years. For more information about flu vaccine visit http://health.state.ga.us/programs/immunization. If you are providing influenza vaccine and would like to get the word out, go to http://www.immunizeadultga.org. Healthcare professionals who will have vaccine available are able to sign up on the website so that Georgians seeking vaccine can find providers in their community. GDPH would like to thank the 2001-2002 Influenza Sentinel Providers, including those who agreed to continue reporting through summer 2002 (Table 2). These generous volunteers provide essential information that permits influenza surveillance to follow statewide disease trends and circulating influenza strains. If you are a healthcare provider interested in volunteering to conduct influenza surveillance, contact Alison Han, Influenza Surveillance Coordinator, at 404-657-2588. Written by Katherine Bryant, M.P.H. 2001-2002 Georgia Influenza Sentinel Providers Andy Rimmer, MD James Stillerman, MD Jo Middlebrooks, RN Mary Key, RN Glenda van Houten, RN Herman Spivey, MD Gail Hurley, MD Jean Chin, MD William Yang, MD, MPH Robin Dretler, MD Curtis Hames, MD William Manns, MD Morris Jenkins, MD David McCann, MD Kim Baird, FNP Jill Goggans, MD Philip Keating, MD Immediate Med G. Saurina, MD Susan Reines, MD and Lalitha Chikkala, MD Andrew Mecca, MD Linda Roberts, FNP Charles Coster, DO Philip Plotz, MD Dublin, GA Covington, GA Stockbridge, GA Griffin, GA Thomaston, GA Summerville, GA Athens, GA Athens, GA Atlanta, GA Decatur, GA Statesboro, GA Atlanta, GA Calhoun, GA Colquitt, GA Woodbine, GA Waycross, GA Savannah, GA Savannah, GA Valdosta, GA Decatur, GA Columbus, GA Riverdale, GA Ball Ground, GA Atlanta, GA -3 - References: 1. Nichol KL, Lind A, Margolis KL, et al. Effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med 1995;333:889- 93. 2. Wilde JA, McMillan JA, Serwint J, Butta J, O'Riordan MA, Steinhoff MC. Effectiveness of influenza vac- cine in health care professionals: a ran- domized trial. JAMA 1999;281:908- 13. 3. Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowski RA. Efficacy of influenza vaccine in elderly persons: a meta-analysis and review of the lit- erature. Ann Intern Med 1995;123:518-27. 4. Heikkinen T, Ruuskanen O, Waris M, Ziegler T, Arola M, Halonen P. Influ- enza vaccination in the prevention of acute otitis media in children. Am J Dis Child 1991;145:445-8. 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 2002 Volume 18 Number 09 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for June 2002 Selected Notifiable Diseases Total Reported for June 2002 2002 Previous 3 Months Total Ending in June 2000 2001 2002 Previous 12 Months Total Ending in June 2000 2001 2002 Campylobacteriosis 42 202 181 150 636 616 590 Chlamydia trachomatis 948 7394 7637 6083 28123 30988 31384 Cryptosporidiosis 1 31 30 11 147 178 137 E. coli O157:H7 8 10 12 15 48 45 53 Giardiasis 60 263 226 206 1380 1109 886 Gonorrhea 610 4726 4117 3469 19262 18883 17614 Haemophilus influenzae (invasive) 3 23 25 16 78 92 99 Hepatitis A (acute) 32 80 284 126 341 688 756 Hepatitis B (acute) 28 73 80 82 282 399 433 Legionellosis 1 4 5 4 11 12 11 Lyme Disease 0 0 0 0 0 0 1 Meningococcal Disease (invasive) 2 14 11 10 66 50 42 Mumps 0 0 2 2 5 7 4 Pertussis 1 12 9 4 65 36 17 Rubella 0 0 0 0 0 1 0 Salmonellosis 132 389 360 357 1901 1641 1732 Shigellosis 100 74 60 316 296 316 1195 Syphilis - Primary 9 31 15 21 146 100 98 Syphilis - Secondary 19 62 78 59 285 291 255 Syphilis - Early Latent 25 157 168 89 588 562 576 Syphilis - Other** 11 176 217 60 722 817 642 Syphilis - Congenital 0 4 8 0 18 25 9 Tuberculosis 34 184 133 109 656 615 541 * 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: 08/01-07/02 Five Years Ago: 08/97-07/98 Cumulative: 07/81-07/02 Total Cases Reported* <13yrs >=13yrs Total 1 1,788 1,789 7 1,355 1,362 211 25,087 25,298 Percent Female AIDS Profile Update Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 25.5 39.7 7.6 2.3 13.9 2.0 34.5 19.1 43.2 17.9 5.8 17.4 1.1 14.7 17.6 47.7 17.4 5.4 13.4 1.9 14.1 Race Distribution (%) White Black Other 18.9 76.7 4.4 23.1 74.4 2.5 34.2 63.4 2.4 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 -