Georgia epidemiology report, Vol. 19, no. 2 (Feb. 2003)

February 2003

volume 19 number 02

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

Statewide Terrorism Workshops:
Improving Georgia's Emergency
Preparedness
The attacks of September 11, 2001 and the intentional release of anthrax spores via the mail during the fall 2001 highlighted the reality of the threat of terrorism (including bioterrorism) in the United States. This reality compels us to look at emergency preparedness in a new way. From a local perspective, a core preparedness activity is to enhance connectivity between all community partners with a role in terrorism response, including public health personnel, health care providers, emergency management agencies, hospitals, law enforcement officers, public safety personnel, pharmacists, veterinarians, mental health professionals, and others.
To develop enhanced connectivity among community partners, it is important to provide standardized education about terrorism (including conventional terrorism, bioterrorism, chemical terrorism, and nuclear terrorism) to facilitate a regional emergency preparedness framework in which partners will interact under both pre-emergency and emergency conditions.
To help build a strong foundation of emergency preparedness across Georgia, the Georgia Department of Human Resources Division of Public Health (DPH) collaborated with the Georgia Hospital Association (GHA), the Medical Association of Georgia (MAG), the Georgia Academy of Family Practitioners (GAFP), the University of Georgia, the Medical College of Georgia, the Georgia Office of Rural Health Services, the Infectious Disease Society of Georgia, and Georgia Emergency Management Agency (GEMA) to develop a one-day training workshop entitled "Terrorism and the Medical Community". The faculty consisted of renowned experts from academic institutions, medical institutions, public health agencies, and private entities across Georgia. For consistency in regional emergency planning approaches, the workshop was delivered in each of the eight GEMA areas across the state during September, October, and November 2002.
Workshop objectives included:
1. To provide an overview of emergency management and response, including the incident command system.
2. To address specific coordination issues between the medical community and public health, emergency management, law enforcement, and other partners.
3. To provide clinical, diagnostic, and treatment information concerning agents potentially used in a terrorist attack, including biological agents, chemical agents, and radiological/ nuclear agents.
4. To provide a suggested template for actions to be taken by individual medical providers, hospitals, and communities following the detection of a potential terrorist attack (which will be further developed at local and regional levels).
5. To facilitate future community-wide emergency planning efforts by providing resources, information, and networking opportunities.
The workshops were a resounding success and, statewide, were attended by hundreds of physicians, nurses, hospital administrators, infection control practitioners, physician assistants, emergency management personnel, medical examiners, coroners, EMS personnel, pharmacists, social workers, respiratory therapists, other public safety personnel, and local and district public health staff including epidemiologists, environmentalists, clinical coordinators, and immunization program managers.
The day-long workshop included eleven didactic sessions (divided into two delivery tracks) followed by a concluding interactive panel discussion to explore lessons learned, next steps, and strategies to engage additional community partners. The topics for the didactic sessions included "Overview of Incident Command," "Overview of Weapons of Mass Destruction," "Detection of a Bioterrorism Event," The National Pharmaceutical Stockpile," "Medical Management for Nuclear/Radiological/Conventional Terrorism Agents," "Mental Health Considerations during a Disaster," "Medical Management for Chemical Terrorism Agents," "Medical Management for Bioterrorism Agents," "Decontamination and Personal Protective Equipment," "The How-To of Community-Wide Response," and "Hospital Disaster Preparedness Planning." A brief synopsis of some highlighted session material follows:

Incident Command System: Organizing
Emergency Response:
For all emergencies, incident management involves assessment of the incident's magnitude and scope, establishing an incident command system, managing the scene, victim triage, coordination of medical treatment, documentation of response activities, and recovery. The incident command system breaks response activities into four main areas: operations, planning, logistics, and finance, all of which are coordinated by one incident commander (Figure 1). This structure can be scaled up or down to meet the requirements of the response, provides a standard organization for mutual aid augmentation, and also provides an organizational means for tracking costs associated with emergency response activities.
FFigiguurere11. I.nIcnidceidnet nCtoCmommamndaSntdruScttruurceture

diate notification to local or state public health officials, the medical community serves as the integral bridge to rapid epidemiologic investigation. This investigation (in coordination with criminal investigation if bioterrorism is being considered) will establish the potential source and/or risk factors of the outbreak, followed by determination of the at-risk population so that appropriate preventive measures (for example, immunization or administration of antibiotic prophylaxis) can be implemented. Therefore, preparedness activities for the medical community include having a heightened sense of vigilance, being aware of unusual epidemiologic trends, immediately notifying public health of reportable diseases or unusual events, and participating in community planning exercises.
Overview of Medical Management for Chemical
Terrorism Agents

Incident Commander
Public Information Safety Officer Liaison Officers

Operations Planning Logistics

Finance

Overview of Weapons of Mass Destruction:

The term "Weapons of Mass Destruction" refers to the use of conventional weapons, biological weapons, chemical weapons, or nuclear/radiological weapons as part of a terrorist act resulting in mass casualties or widespread fear. Currently, many countries worldwide are thought to possess the technology and/or the capability to produce and disseminate such weapons, although the precise threat remains difficult to quantify. The biological agents of greatest concern are listed in Table 1. Concern is elevated around these agents due to high potential impact of use: the agents are easily disseminated or transmitted from person to person, cause high mortality rates, result in widespread public panic and social disruption, and require special actions for public health preparedness.

TTaabblele11.. CCrriittiiccaallAAgegnetnstsofoBf iBotieortreorrroisrmism

Category A Variola major (smallpox) Bacillus anthracis (anthrax) Yersinia pestis (plague) Clostridium botulinum toxin (botulism) Francisella tularensis (tularemia) Filoviruses (Ebola, Marburg) Arenaviruses (Lassa, Junin)
MMWR.2000;49:RR-4

Can be easily disseminated or transmitted person-toperson
High mortality with public health impact
Public panic and social disruption
Requires special action for public health preparedness

Detection of a Bioterrorism Event:

Detection of a bioterrorism event requires several complementary mechanisms including traditional public health disease surveillance, innovative surveillance mechanisms capturing other health indicators in a community, information-sharing between public health, law enforcement, and medical provider communities, and, as always, astute and alert clinicians. By increased vigilance for unusual diseases and improved clinical recognition of syndromes potentially caused by bioterrorism agents, the medical community actually serves as "first responders" to bioterrorism events. In addition, by providing imme-

The threat of chemical terrorism can be illustrated by the Tokyo sarin attacks of 1995 as well as recent events in which cyanide and cyanide derivatives were found in a police raid of an apartment complex in Rome, Italy. The chemical agents of greatest concern include nerve agents, vesicants, pulmonary agents, cyanides, and riot control-type agents (Table 2). The nerve agents GA, GB, and VX are organophosphorus esters that act as cholinesterase inhibitors; signs and symptoms are primarily related to accumulation of excess acetylcholine and are characterized by the mnemonic "DUMBELS" (diarrhea, urination, miosis, bradycardia/bronchospasm, emesis, lacrimation, and salivation/sweating). Treatment modalities (antidotes) for nerve agent poisoning include pralidoxime (2-PAM), atropine, and benzodiazepines. Effects of and antidotes for the other classes of chemical terrorism agents are also found in Table 2.

TTaabbllee 22..CChheemmiciaclaTleTrreorrrisomrisAmgenAtsgents

Class
Nerve agents Vesicants Pulmonary Agents Riot Control Agents Cyanides

Names
Tabun, Sarin, Soman, VX

Effects
Cholinergic crisis, paralysis, vent failure, coma

Antidotes
2-PAM, atropine

Lewisite, sulfur, mustard, phosgene oxime

Vesiculation, chemical British-Anti-Lewisite

burns of skin and

(BAL) for Lewisite

mucous membranes only

Phosgene

Noncardiac pulmonary None edema, hypoxemia, Respiratory failure

CN, CS (Mace)

Mucous membrane & None skin irritation lacrimation

Hydrogen cyanide, cyanogen chloride

Cellular asphyxia, cardiovascular collapse, coma

Amyl nitrite, Sodium nitrite, Sodium thiosulfate

Hospital Preparedness for Mass Casualty Di-
sasters
A recent study (1) examining 30 hospitals in the mid-Atlantic region of the United States showed that: 1) 100% of the hospitals were not fully prepared to respond to a bioterrorism incident; 2) 73% were not prepared for a chemical incident; 3) 73% were not prepared for a nuclear incident. In addition, lessons learned from mass casualty events involving a chemical release (such as the Tokyo sarin attack of 1995) indicate that only 10-15% of victims arrive at the hospital via EMS; by far, the majority of victims are ambulatory and self-transport to the hospital ED. These individuals can easily overwhelm a hospital's limited resources. To conserve valuable hospital resources and to direct them to those individuals most in need of immediate care, one proposed strategy is the use of disaster triage mechanisms followed by transport of the ambulatory, minimally injured, or worried well to Secondary Treatment Facilities. Individual hospital disaster plans should include the following elements (referred to as the "DISASTER" paradigm): D = detect; I= incident command; S = scene safety and security; A = assess hazards; S = support needed; T= triage/treatment; E = evacuation; R =

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recovery. In addition, other strategies to improve hospital disaster preparedness involve: coordination of assets, reassessing the approach to the mass casualty incident, developing individual facility plans for decontamination, coordination of federal, state, and local planning initiatives, and delivery of advanced training programs to hospital personnel.
Overall, through the joint efforts involved in the development and delivery of the Statewide Terrorism Workshops, we have raised community awareness about terrorism and medical response, and have strengthened critical relationships important to effective emergency response in Georgia. This is just the first step in our journey. During 2003, we, along with our

collaborating partners, plan to implement a series of regional medical tabletop exercises to build on the foundation we established with these regional trainings.
References: 1. Treat K.N. Hospital preparedness for weapons of mass destruction incidents: An initial assessment. Ann Emerg Med; Nov. 2001.
This article was contributed by Cherie L. Drenzek, D.V.M., M.S., and Michael A. Coletta, M.P.H.

Georgia Immunization Study Results, 2002

Introduction
The Georgia Department of Human Resources, Division of Public Health performed the 2002 Georgia Immunization Study to assess immunization coverage rates of two-year-old children in Georgia.
Research Design
The study conducted a survey to determine immunization rates for children born in Georgia in January 2000. These children were 24 months of age in January 2002. Information from both public and private providers was included. Children and their parents were identified through birth certificate data.
Statewide Immunization Results
The final sample used to calculate the 2002 immunization rates consisted of the 2,721 children who were located.
The Georgia Immunization Study evaluated "adequate immunization status" in two different ways for analysis:
"4:3:1" status (the traditional standard for immunization status): A
child has received four DTP/DTaP (Diphtheria,Tetanus, Pertussis), three OPV/IPV (Polio oral or injected), one MMR (Measles, Mumps, Rubella)
4:3:1+3" status: A child has received four DTP/DTaP, three OPV/
IPV, one MMR, three Hib (Haemophilus Influenzae type b), and three Hep B (Hepatitis B) by age two, and one Varicella (Chickenpox)
The proportion of the children in the survey who were adequately immunized at the 4:3:1 level has increased from 71.3% to 83.9% during 19972002 (Table 1, Figure 1). The proportion of children adequately immunized with the 4:3:1+3 series increased dramatically from 16.0% percent in 199798 to 78.9% in 2002 (Table 1, Figure 1).
The dramatic increase in children who were adequately immunized with the 4:3:1+3 series largely reflects an increase in the use of varicella vaccine.
In 1997-98, 1998-99, 1999-00, and 2001 none of the immunization rates for single vaccines met the State goal of 90 percent coverage (Table 1). However, in the 2002 study four (OPV/IPV, MMR, Hib, Hep B) of the six vaccines met the State goal of 90 percent coverage (Table 1).
Immunization rates varied among health districts, ranging from 74 percent to 94 percent. In 2002, two of the 19 health districts had immunization coverage rates exceeding the goal of 90 percent, fifteen districts had coverage rates of 80-89%, and two districts had coverage rates of 70-79%.
The results of the recent immunization assessment demonstrate that the newly introduced varicella vaccine is now given to more than eighty-eight

percent of the children in Georgia. Maintaining high immunization rates among two-year old children for varicella and other vaccines requires persistent effort by parents, providers and health departments because there is a new cohort of children each year. The task is increasingly difficult because of the expanding complexity of childhood immunization schedule as new and beneficial vaccines are added to it.

Acknowledgements

We would like to thank the providers in Georgia for their support and cooperation throughout this study. Over seventy percent of all immunizations in this year's study were received at a physician's office. Without their cooperation with the public health representatives attempting to retrieve this information, this study would not have been possible.

This article was written by : Carol A. Hoban, M.S., M.P.H., Mike Chaney, and Susan Lance-Parker, D.V.M., Ph.D.

Table 1. Immunization coverage by vaccine and study year, Georgia

Immunization Status
4:3:1 Adequately Immunized

1997-98 Percent
71.3

1998-99 Percent
73.3

1999-00 Percent
78.8

2001* Percent
75.1

2002 Percent
83.9

4:3:1+3 Adequately

16.0

41.9

56.3

66.7

78.9

Immunized

4 DTP/DTaP

72.9

74.2

79.9

76.0

84.6

3 OPV/IPV

85.4

83.6

84.4

80.8

90.6

1 MMR

80.8

80.2

84.6

82.0

90.9

3 Hib

83.6

83.6

87.4

84.3

90.9

3 Hep B

83.2

82.9

86.7

83.8

90.8

1 Varicella

19.0

47.1

64.3

77.9

88.5

* Immunization rates for the 2001 Study may be inaccurate due to

incomplete data ascertainment.

Figure 1. Changes in vaccine coverage by two definitions, 4:3:1 and 4:3:1+3. Georgia, 1997-2002

100 90 80 70 60 50 40 30 20 10 0 97-98

98-99 99-00 2001

4:3:1 4:3:1+3
2002

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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

February 2003

Volume 19 Number 02

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for November 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 November 2002
2002
49 2163
9 1 57 1148 8 32 19 2 0 2 0 1 0 106 144 4 17 30 10 0 16

Previous 3 Months Total

Ending in November

2000

2001 2002

125

119

150

7342

8264

8065

41

51

31

6

21

5

301

255

241

5271

4709

4426

18

25

20

116

234

87

112

131

63

4

2

8

0

0

0

11

16

10

0

1

0

5

6

5

0

0

0

470

560

647

92

354

644

30

16

19

69

67

60

121

173

123

184

205

78

3

6

0

152

148

83

Previous 12 Months Total

Ending in November

2000

2001 2002

615

631

629

28812

32559

33153

192

161

123

48

47

42

1224

1005

889

19200

18171

18170

78

105

95

351

929

481

331

441

402

10

11

19

0

1

1

59

56

36

2

9

2

54

26

27

1

0

0

1721

1698

1955

323

597

1689

129

93

97

294

296

267

556

626

627

737

842

588

20

25

10

665

578

532

* 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: 01/02-12/02 Five Years Ago: 01/98-12/98 Cumulative: 07/81-12/02

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

2

1,384 1,386

10

1,286 1,296

212

25,589 25,801

Percent Female
24.5
19.6
17.7

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

37.8

7.2

2.0

11.8

2.2

41.1

18.0

5.7

17.1

0.9

47.5

17.3

5.4

13.4

1.9

Unknown
39.1 17.3 14.5

Race Distribution (%) White Black Other

19.1 75.3

5.6

23.5 74.2

2.3

33.9 63.7

2.5

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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