Georgia epidemiology report, Vol. 19, no. 1 (Jan. 2003)

January 2003

volume 19 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

Update on the Pertussis Resurgence
Pertussis, also known as whooping cough, is an infectious disease of the respiratory tract caused by the bacterium, Bordetella pertussis. Before the introduction of the pertussis vaccine in the 1940's, the disease caused significant morbidity and mortality among children. The bacterium is transmitted via the respiratory route through contact with respiratory secretions from an infected patient. Pertussis is a highly communicable disease, demonstrating secondary attack rates of 80% among susceptible household contacts. Infants are most susceptible to B. pertussis infection and pertussis-related morbidity and mortality.
Pertussis Trends in the United States
Although the pertussis incidence declined significantly between the 1940's and the 1960's, the disease remains a public health problem in the Unites States today. Between 1980-1990 the average annual incidence was 2900 cases per year (approximately 1 per 100,000 population) (1). However, over the last 20-year period, pertussis incidence has been gradually increasing despite a stable or increasing vaccination rate. The reasons for the increase are not definitively known, but may be attributed to the cyclic nature of the disease, changes in reporting and laboratory testing, or a true increase in the incidence. Since protection from pertussis vaccine wanes over time, infections in adolescents and adults may be contributing to the increased incidence. In 2000, a total of 7,867 cases were reported, the largest number since 1967 (1). Last year, 5,396 cases were reported nationally (1). The most frequently reported age group with pertussis infection is children < 5 years of age. In 1997-2000, the highest annual incidence (55 cases per 100,000 population) was reported in children less than 1 year of age (1).
Ongoing Outbreaks in the United States
Pertussis incidence began increasing dramatically in Texas in 2000, when 327 cases of whooping cough were reported, more than doubling the number of cases reported the previous year (2). The following year, Texas reported 615 cases and 5 pertussis-related deaths (2). As of October 15, 2002, 847 cases were identified in Texas and the number of cases is expected to exceed 1000 for the year 2002 (3). Nine pertussisrelated deaths have occurred in Texas since the outbreak began in 2000 (3). The Texas Department of Health has been working to distribute information to providers and public health staff on the diagnosis, treatment, and prevention of pertussis. Other states reporting high numbers of pertussis cases for 2002 include Arkansas, Washington, and Ohio.
Clinical Features
Clinically, pertussis is divided into three stages: the catarrhal stage, paroxysmal stage, and the convalescent stage. Sneezing and coryza, low-grade fever and a mild, occasional cough characterize the catarrhal stage. This stage lasts 1-2 weeks, during which the cough progressively worsens. In the paroxysmal stage, the patient has bursts (paroxysms) of rapid coughs usually followed by a long inspiratory gasp (whoop). The classic symptomatology in this stage leads to diagnosis of pertussis. The patient, especially children and young infants or severe cases, may become cyanotic during these cough "attacks". The paroxysmal stage typically lasts 2 weeks, but can persist up to 6-10 weeks. In third stage, convalescence, recovery is gradual. The cough paroxysms begin to decrease and the cough generally dissipates over 2-3 weeks. Young infants are at highest risk for acquiring clinical pertussis and complications from pertussis infection. Secondary bacterial pneumonia is the most common complication for this age group and is the cause of most pertussis-related deaths. Other serious complications are seizures and encephalopathy, which may occur as a result of hypoxia from coughing or toxin production.

Diagnostic Testing

The diagnosis of pertussis is often made clinically after a history

and physical exam have been performed. However, for public health purposes, confirmatory laboratory testing should be

Pertussis: Quick Facts
! Pertussis incidence is on the rise despite stable

performed for all suspect or probable cases, especially in young infants, in atypical cases, and in cases modified by vaccine. The standard and preferred laboratory test for confirmation of pertussis infection is isolation of B. pertussis by culture (1). Nasopharyngeal swabs (collected with Dacron or calcium alginate swabs, not cotton) are the specimens of choice and should be collected as soon as possible after illness onset. A second method of identifying B. pertussis in nasopharyngeal specimens is the direct fluorescent antibody (DFA) technique. This method has been shown to have low sensitivity and variable specificity (1). Serologic testing has not been shown to be useful in practice because

immunization rates
! Some states are experiencing community-wide
outbreaks
! Notify public health when a case of pertussis is
identified
! Laboratory confirmation should be obtained on all
suspect cases
! Nasopharyngeal culture with Dacron swab is the
preferred test
! All household contacts should be placed on chemo-

results are difficult to interpret due to the lack of association between antibody levels and immunity to pertussis. DFA and

prophylaxis regardless of age and immunization status

serologic testing should not be relied upon as a criterion for

laboratory confirmation (1). Polymerase chain reaction (PCR) testing of nasopharyngeal swabs, available in some laboratories,

This article was written by Julie Gabel, D.V.M., M.P.H.

has been found to be a rapid, sensitive and specific method for diagnosing pertussis; however, it should be used as an adjunct and not as a replacement for culture (1). Culture should always be performed, as isolates may be required for evaluation of antimicrobial resistance, or for molecular typing (1). Routine susceptibil-

References
1. Atkinson W, Wolfe C. Pertussis. In: Epidemiology and Prevention of Vaccine Preventable Diseases. 7th Ed. Centers for Disease Control and Prevention: Atlanta, GA 30333, 2002:Chapter 6.

ity testing for B. pertussis isolates is not routinely recommended. Surveillance for erythromycin resistance is conducted through the Center's for Disease Control and Prevention's Pertussis Labora-

2. Texas Department of Health. Disease Prevention News. Texas Department of Health, Vol. 61, No. 16, July 31, 2001: 1-2.

tory (4).

3. Verbal Communication, Carmen Vega, Immunization Division,

Texas Department of Health.

Treatment and Prevention
Treatment of pertussis is generally supportive, although antibiotic use has some value in prevention of transmission to contacts. The antimicrobial of choice for the treatment of pertussis is erythromycin (5); the estolate preparation is preferred because it achieves

4. Centers for Disease Control and Prevention. Guidelines for the Control of Pertussis Outbreaks. Centers for Disease Control and Prevention: Atlanta, GA, 2000.

higher serum levels compared to ethylsuccinate or stearate when equal doses are given (4). All household contacts of cases should be placed on chemoprophylaxis regardless of age and immunization status. Careful attention should be paid to ensure adults in

5. American Academy of Pediatrics. Pertussis. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th Ed. Elk Grove Village, IL: American Academy of Pediatrics; 2000: p 437.

the household are treated as they often serve as the source of infection for others. Data suggest that treatment of patients and prophylaxis of contacts are most effective when erythromycin is administered in the early stages of the disease (4). All close contacts less than 7 years of age who are unimmunized or who

6. Guris D, Strebel PM, Wharton, M. Pertussis. In: CDC's Manual for the surveillance of vaccine preventable diseases. Centers for Diseases Control and Prevention: Atlanta, GA 30333, 1997:Chapter 8.

have received fewer than 4 doses of pertussis-containing vaccine (DTaP) should have pertussis immunization initiated or should complete the series with the minimal intervals (6).

Web Resources
Centers for Disease Control and Prevention: MMWR "Pertussis, United States 1997-2000" http://www.cdc.gov/

mmwr/PDF/wk/mm5104.pdf

Conclusion
Pertussis continues to be a public health problem in the United States despite a stable or increasing vaccination rate. Practitioners should be aware that community-wide pertussis outbreaks have been identified in other states. Cases should be identified

MMWR "Pertussis Deaths--United States 2000" http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm5128a2.htm Guidelines for the Control of Pertussis Outbreaks http://www.cdc.gov/nip/publications/pertussis/guide.htm

promptly and confirmed appropriately. Please notify your County, Texas Department of Health, Pertussis Information District, or State Health Department immediately of any suspect, http://www.tdh.texas.gov/immunize/pertussis.htm probable or confirmed cases. Contacts of cases should be placed

on chemoprophylaxis to prevent transmission to susceptible persons. Please call Dr. Julie Gabel at (404) 657-2629, Notifiable Diseases Section, Epidemiology Branch, Georgia Division of

NAPNAP Pertussis Page http://www.pertussis.com

Public Health, for any questions.

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GUARD (Georgia United against Antibiotic-Resistant Disease): A Broad-Based Coalition Combating Antibiotic Resistance in Georgia's Communities

When penicillin was first developed in the 1940s, it was hailed as a miracle drug. Over time, however, increasing drug resistance has compromised the strength of penicillin and other antibiotics. No longer just a problem in hospitals, the issue of escalating antibiotic resistance is considered to be one of the major public health threats of the 21st century. Increasingly, an individual's use of antibiotics carries potential for risk as well as benefit by enhancing the risk of subsequent resistant infection at an individual and surrounding community level. For this reason, careful consideration is needed in deciding when and which antibiotics to prescribe.
The problem is clearly demonstrated in rising rates of resistance among Streptococcus pneumoniae, the major cause of bacterial meningitis, bacteremia, community-acquired bacterial pneumonia and otitis media (1). In Georgia, for instance, penicillin-resistant Streptococcus pneumoniae infections increased from 34% to 40% from 1997-2000 (2). Resistance to third-generation cephalosporins, trimethoprimsulfamethoxazole, and macrolides are also common in this pathogen. Because of pneumococcal antibiotic resistance, clinicians now must routinely include vancomycin in regimens used to treat suspected bacterial meningitis, and treatments for otitis media and communityacquired bacterial pneumonia have also evolved. Spread of antibioticresistant bacteria occurs commonly in settings such as daycare because of crowding and high rates of antibiotic use. In these settings, antibiotic use in one child may select for antibiotic-resistant bacteria that can be transmitted to other children. Other examples of community organisms with escalating antibiotic resistance include Shigella, Salmonella, Escherichia coli, Staphylococcus aureus, gonorrhea, and even group A Streptococcus.
Inappropriate use of antibiotics for viral infections does not benefit patients, increases the risk of antibiotic-resistant disease, and increases health care costs. Despite this, antibiotic overuse and over-prescribing occurs commonly in the United States for multiple complex reasons. Reasons for over-prescribing include requests for antibiotics by patients with viral illness. Such patients often have inadequate understanding of viral vs. bacterial disease, and of expected symptoms and duration of viral illness. Patients may believe that antibiotics will shorten the course of a viral illness, allowing them to return to work sooner, and may have expectations for antibiotic prescription that result from previous experiences. Physicians rarely have time to explain these concepts fully to patients and find that writing a prescription is more expedient. Physicians have also cited concerns about patient satisfaction and about losing patients. A 1996 study found that Georgia physicians also overprescribe. In this audit of pediatric charts, researchers found that 43% of encounters resulted in an antibiotic prescription, including 11% of routine checkups, 18% of telephone calls, and 72% of visits for upper respiratory illness (3). To assist physicians' prescribing practices for upper respiratory infections, pediatric and adult treatment guidelines for appropriate antibiotic use have been published and widely distributed (4, 5).
To combat the problem of resistance, the Georgia Department of Human Resources, Division of Public Health has begun a broad-based, statewide campaign. The GUARD (Georgia United against Antibiotic Resistant Disease) Coalition was formed to tackle this issue on all fronts. Participating organizations so far include: the Division of Public Health, Medical Association of Georgia, Georgia Chapter-American Academy of Pediatrics, Georgia Hospital Association, Georgia Association of Health

Plans, Georgia Infection Control Nurses, Georgia Academy of Family Physicians, Parent Teacher Association, Childcare Licensing SectionOffice of Regulatory Services, American College of PhysiciansAmerican Society of Internal Medicine, Food and Drug Administration, Georgia Pharmacy Association, Council for Affordable Quality Healthcare, Daiichi Pharmaceuticals, Pfizer, GlaxoSmithKline, Pharmaceutical Research and Manufacturers of America and the Infectious Disease Society of Georgia. Other interested organizations are welcome. GUARD's goals are to improve consumer awareness, understanding and behavior regarding the responsible use of antibiotics, to optimize physician behavior regarding the appropriate prescribing of antibiotics to treat infectious disease, and to reduce the incidence of antibiotic-resistant disease and thereby save antibiotic strength.
To carry out its goals, the GUARD Coalition seeks to educate the public about appropriate antibiotic use through a variety of credible sources including physicians, employers, health plans, schools, daycares, pharmacies, and the media. This includes developing tools for physicians to provide consistent messages to their patients, explaining treatment guidelines, emphasizing the differences between viruses and bacteria, and working with institutional policies that may require parents to have their children on an antibiotic before their return to daycare or school. GUARD seeks to promote appropriate antibiotic use by encouraging physicians to prescribe antibiotic therapy only when it is beneficial and according to published guidelines, by prescribing the appropriate (narrowest spectrum) agent, and to choose the appropriate dose and duration. The Coalition plans to implement a DHR-approved training program for childcare providers in Georgia on appropriate use of antibiotics, to distribute information-laden prescription pads to pediatricians' offices for patient education on viruses and bacteria, and to develop a peer-to-peer CME education program for physicians and a media campaign to reinforce educational messages.
We encourage participation from throughout the state and welcome your involvement. If you are interested in joining GUARD, please contact Heather Kotler, M.P.H. at 404-463-4623 or at hkotler@dhr.state.ga.us.
This article was written by Heather Kotler, M.P.H.
1. Emmer, C, Besser, R. Combating Antimicrobial Resistance: Intervention Programs to Promote Appropriate Antibiotic Use. Infect. Med. 2002 19(4):160-173.
2. Farley, M, Baughman, W, Arnold, K. The Georgia Emerging Infections Program: Monitoring Trends in Invasive Pneumococcal Disease. Journal of the Medical Association of Georgia. Summer 2002: 20-23.
3. Watson, R, Dowell, S, Jayaraman, M, Keyserling, H, Kolczak,M, Schwartz, B. Antimicrobial Use for Pediatric Upper Respiratory Infections: Reported Practice, Actual Practice, and Parent Beliefs. Pediatrics. 1999;104:1251-1257
4. Dowell, S, Marcy S, Phillips W, Gerber M, Schwartz, B. Principles of judicious use of antimicrobial agents for pediatric upper respiratory tract infections. Pediatrics. 1998;101(suppl):163-165
5. Guidelines for Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults. Annals of Internal Medicine. 2001;134:478-529

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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

January 2003

Volume 19 Number 01

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for October 2002

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 October 2002
2002 23
2655 9 3 34
1444 2 21 2 2 0 3 0 1 0
167 206
7 20 34 22 0 19

Previous 3 Months Total

Ending in October

2000

2001

2002

153

171

162

7699

8720

8134

61

69

33

9

21

9

351

300

245

5561

5091

4581

12

19

8

129

304

58

104

152

3

3

2

7

0

1

0

6

10

6

0

1

0

11

3

5

1

0

0

622

669

718

92

232

485

32

25

22

80

69

74

127

156

138

208

204

92

6

5

2

176

137

91

Previous 12 Months Total

Ending in October

2000

2001

2002

623

639

587

28364

32264

32963

188

165

114

50

44

45

1275

1021

841

19031

18341

18226

79

102

94

341

903

477

311

452

305

10

12

15

0

1

1

56

53

40

2

8

3

58

23

17

1

0

0

1750

1682

1872

309

455

1577

130

95

99

298

290

269

559

605

641

741

832

621

20

24

12

662

582

527

* 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

Report Period
Latest 12 Months: 12/01-11/02 Five Years Ago: 12/97-11/98 Cumulative: 07/81-11/02

Total Cases Reported* <13yrs >=13yrs Total

2

1,456 1,458

6

1,285 1,291

212

25,425 25,637

Percent Female
25.3
18.7
17.7

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

38.5

6.5

2.1

13.5

2.2

37.3

41.8

18.4

6.1

16.0

0.9

16.8

47.6

17.3

5.4

13.4

1.9

14.4

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

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Race Distribution (%) White Black Other

18.2 76.3

5.4

24.6 72.8

2.6

34.0 63.6

2.4