Georgia epidemiology report, Vol. 19, no. 3 (Mar. 2003)

March 2003

volume 19 number 03

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

Georgia Responds to Smallpox
Concerns
The last case of smallpox in the US was in 1949, and smallpox was eradicated worldwide in the late 1970's through a global vaccination campaign. Routine vaccination against smallpox in the US was phased out by 1972. However, there is concern that stores of smallpox virus may exist outside of the two World Health Organization designated repositories, and that the US may be at risk of a bioterrorist attack with smallpox. It has been estimated that fewer than 20% of persons vaccinated before the early 1970s may have some immunologic protection, and it is unclear to what degree a remote history of receiving smallpox vaccine would be protective against disease today.
In response to the potential use of smallpox against civilians, the State of Georgia has committed to upgrading smallpox response preparedness in three major areas: 1) Phased-in voluntary pre-event vaccination 2) Improved surveillance for early detection and case reporting 3) Detailed planning and preparations for outbreak response
Background
Smallpox is a serious and frequently fatal infectious disease characterized by fever and rash. It is normally spread through direct contact with someone infected with variola, the smallpox virus. Generally, direct and prolonged face-to-face contact is required to spread smallpox from one person to another. It is far less transmissible than measles or influenza viruses. In a bioterrorist attack, smallpox could possibly be spread by aerosol spray. People cannot catch smallpox from animals or insects.
A person who has been infected with smallpox can spread the infection to others only after a rash appears usually 13-18 days after infection. After the appearance of a rash, the infected person is contagious until the last smallpox scab falls off around 21 days after onset of the rash.
The diagnosis of smallpox may be suspected on the basis of distinctive clinical signs and symptoms, but confirmation requires testing of infected tissue by polymerase chain reaction (PCR), electron microscopy (both soon to be available at the Georgia Public Health Laboratory), and viral culture [available only at the Centers for Disease Control and Prevention (CDC)].
Vaccination is highly effective in preventing disease, even if given within 3-4 days after exposure. The smallpox vaccine contains live vaccinia virus, which is similar to the variola virus but does not cause smallpox. The vaccinia virus may spread from person to person through direct contact with the vaccination site, and may have serious and rarely fatal adverse reactions. Persons at increased risk for adverse reactions to the smallpox vaccine (whether acquired through vaccination or direct contact with a vaccination site) include women who are pregnant; people who have now, or have ever had, certain skin conditions (especially eczema and atopic dermatitis); and people with weakened immune systems, such as those on immunosuppressive therapy (e.g. following organ transplant), and those who are HIV positive or are receiving treatment for cancer. Persons who received the vaccine previously are believed to be less likely to have serious adverse reactions with subsequent doses. The smallpox vaccine is given as a single dose by multiple shallow piercings of the skin with a double-pronged (bifurcated) needle, not by injection.
There is no specific treatment for smallpox, but since smallpox was eradicated, many new antiviral drugs have become available. Their effect on smallpox has never been tested, but these new drugs may have a future role in treatment of severe adverse vaccine events or smallpox diease.

Smallpox Disease

Incubation Period Initial Symptoms (Prodrome Days 1-4

Exposure to the virus is followed by an incubation period during which people do not have any symptoms and may feel fine. This incubation period averages about 12 to 14 days, but can range from seven to 17 days. During this time, people are not contagious.
The first symptoms of smallpox include fever, malaise, head and body aches and sometimes vomiting. The fever is usually high, in the range of 101 to 104 degrees. At this time, people are usually too sick to carry on their normal activities. This is called the prodrome phase and may last for two to four days.
A rash emerges first as small red spots on the tongue and in the mouth. These spots develop into sores that break open and spread large amounts of the virus into the mouth and throat. At this time, the person is the most contagious.

Rash Distribution

Within 24 hours, a rash appears on the skin, starting on the face and then spreading to the arms and legs and then to the hands and feet. Usually the rash spreads to all parts of the body within 24 hours. As the rash appears, the fever usually falls and the person may start to feel better.

By Day 3, the rash becomes raised bumps.

By Day 4, the bumps fill with a thick, opaque fluid and often have a depression in the center that looks like a bellybutton. (This is a major distinguishing characteristic of smallpox.)

Fever often will rise again at this time and remain high until scabs form over the bumps.

Days 5-10

Over the next five to 10 days, the bumps become "pustules" -- sharply raised, usually round and firm to the touch. They feel like there's a small round object under the skin. People often say it feels like there is a BB pellet embedded under the skin.

Days 11-14

The pustules begin to form a crust and then scab. By Day 14, most of the sores have scabbed over.

After Day 2

The scabs begin to fall off, leaving marks on the skin that eventually become pitted scars. The person is contagious to others until all of the scabs have fallen off. Most scabs will fall off after three weeks.

Days 15 - 21

Scabs have fallen off. Person is no longer contagious.

If an outbreak of smallpox were to occur, several factors could contribute to a more rapid spread of smallpox than was routinely seen before this disease was eradicated. These factors include: 1) Virtually non-existent immunity to smallpox in the absence of
naturally occurring disease and the discontinuation of routine vaccination in the United States in the early 1970's, 2) Potentially delayed recognition of smallpox by health personnel who are unfamiliar with the disease, and 3) Increased mobility and crowding of the population.
Because of these factors, a single case of smallpox will require an immediate and coordinated public health and medical response to contain the outbreak and prevent further infection of susceptible individuals.
Georgia smallpox vaccination plan summary
The State of Georgia has received no information identifying the existence of a bioterrorist threat or the capacity of any enemy to launch an attack on Georgia with smallpox. But the Georgia Department of Human Resources Division of Public Health (GDPH) is implementing a smallpox pre-event vaccination plan that has been approved by the CDC, in response to concerns about the possible use of smallpox as a bioterrorist weapon. The four-phased approach outlined in the plan follows the recommendations of the Advisory Committee on Immunization Practices (ACIP) and the President of the United States to start with voluntary vaccination of selected healthcare providers and public health teams. It also limits the potential for complications from the smallpox vaccine.
Phase I
Offering the smallpox vaccine to healthcare providers and public health teams Step 1 - "Smallpox Public Health Response Teams" from across
the state, with emphasis on those in metro Atlanta and "Smallpox

Healthcare Teams" from trauma hospitals in metro Atlanta Step 2 - "Smallpox Public Health Response Teams" from across
Georgia and "Smallpox Healthcare Teams" from trauma hospitals across Georgia Step 3 - Full complement of staff (up to 45 people/hospital) from trauma hospitals in metro Atlanta as well as volunteers from other metro Atlanta hospitals Step 4 - Full complement of staff (up to 45 people/hospital) from trauma hospitals outside metro Atlanta as well as volunteers from any other hospital outside metro Atlanta with an emphasis on hospitals with isolation units
Phase II
Offering the smallpox vaccine to first responders including emergency medical service, fire, police and other public safety officers
Phase III
Offering the smallpox vaccine to general public volunteers, in the absence of a known smallpox case
Phase IV
In the event of a known case, administering the smallpox vaccine to people who come in contact with smallpox cases and others in conjunction with a disease investigation.
Implementation of each part of the plan is contingent upon federal guidance and successful completion and assessment of the preceding phase or step.
Even without prior vaccination, health care workers and first responders actually exposed to a patient with smallpox have at least three days after exposure to receive the vaccine and still be protected from developing -2 -

disease. Systems are in place to deliver smallpox vaccine anywhere in Georgia within 24 hours, and to administer preventive mass vaccination
within 72 hours after an exposure.

Primary Vaccination Site Reaction

Update
As of February 14, there have been 69 people successfully vaccinated during Phase I, Step1 activities, and no reports of severe adverse reactions.

Recognition, treatment and reporting of adverse
events
Smallpox vaccine has significant side effects among those vaccinated, and the vaccinia virus used in the smallpox vaccine can be spread inadvertently to family members or others in close contact with those vaccinated. A brochure from the CDC, entitled "Smallpox Vaccination: Vaccination Method & Reactions" can help guide initial assessment of potential vaccine complications and is available electronically at the CDC website: http://www.bt.cdc.gov/training/smallpoxvaccine/reactions/ download_pocket_guide.htm.
More extensive information about smallpox, smallpox vaccine, and clinical recognition of vaccine complications is available online at the CDC website: www.bt.cdc.gov/agent/smallpox/index.asp and from the Infectious Diseases Society of America (IDSA) at: http://www.idsociety.org/BT/ ToC.htm.
Other sources of information include: Adverse Reactions Following Smallpox Vaccination (fact sheet for clinicians) - http://www.bt.cdc.gov/agent/smallpox/vaccination/ reactions-vacc-clinic.asp Smallpox Vaccination and Adverse Events Training Module - http:// www.bt.cdc.gov/training/smallpoxvaccine/reactions/default.htm Smallpox: What Every Clinician Should Know - http://www.cdc.gov/nip/ ed/smallpox-trg/clinician-should-know/default.htm Medical Management of Smallpox (Vaccinia) Vaccine Adverse Reactions http://www.bt.cdc.gov/agent/smallpox/vaccination/mgmt-advreactions.asp Smallpox Preparedness: Considerations for Response Team Volunteers http://www.bt.cdc.gov/agent/smallpox/training/webcast/dec2002/ webcast-1220.asp
Any suspected smallpox vaccine reactions should be reported to your District Health Office, or by calling 1-866-782-4584 (866-PUB-HLTH) toll-free 24/7. Reporting will make available local, state and federal smallpox resources to assist with diagnosis and case management.
General questions from the public regarding smallpox vaccination may be addressed by calling the Georgia Public Health Information Line at 1-866752-3442.

Day 4

Day 7

Day 14

Day 21

Any suspected case of smallpox should be reported immediately to your District Health Office, or by calling 1-866-782-4584 (866PUB-HLTH) toll-free 24/7. Reporting will make available local, state and federal smallpox resources to assist with diagnosis, case management, and outbreak control.
call for "...surveillance and containment, which includes isolation of smallpox cases and vaccination of persons at risk of contracting smallpox. This strategy involves identification of infected persons through intensive surveillance, isolation of smallpox patients to prevent further transmission, vaccination of household contacts and other close contacts of infected persons (i.e., primary contacts), and vaccination of close contacts of the primary contacts (i.e., secondary contacts who would be exposed should disease develop in the primary contacts). This strategy was instrumental in the ultimate eradication of smallpox as a naturally occurring disease even in areas that had low vaccination coverage."

Each of Georgia's 19 Health Districts is identifying and assembling district-level Smallpox Public Health Assessment and Survey Teams (SPHAST) capable of conducting field investigations in response to a suspected smallpox case, including active surveillance to identify other potential smallpox cases, identifying contacts of cases, conducting exposure assessments, performing contact tracing, investigating sources of exposure, and recommending smallpox vaccination for individuals at risk.

The phased approach to pre-event smallpox vaccination is providing practical training to assure the presence of experienced smallpox vaccinators across the state, who will be ready to respond in the event of an attack, as well as trained clinicians to provide patient care. In addition, personnel are being recruited and trained by the Georgia Nurses Foundation and the Georgia Pharmaceutical Association to assist with outbreak response, under the direction of the State Nursing and Pharmacy Program Offices.

Smallpox surveillance
Early recognition is critical to assuring an effective response to a smallpox attack. Immediate reporting of suspected cases will minimize disease transmission, case morbidity and mortality. As smallpox has not been seen in the US in over 40 years, all healthcare providers are encouraged to become familiar with the clinical presentation of the disease. Excellent educational materials are available at the websites given above, many presentations on smallpox are being organized around the state, and direct mailings on smallpox are being sent to licensed medical doctors, registered nurses, and physician's assistants throughout Georgia.
The CDC has approved Georgia's plan for response to a smallpox attack. The strategy is consistent with recommendations of the ACIP (http:// www.bt.cdc.gov/agent/smallpox/vaccination/acip-guidelines.asp), which

Additional information about the Georgia plans for bioterrorism preparedness and response is available on the Division of Public Health website: http://health.state.ga.us.
This article was written by, W. Gary Hlady, M.D., M.S., and Richard Quartarone.
References
1. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon: medical and public health management. JAMA 1999;281 (22):2127-39
2. CDC website http://www.bt.cdc.gov/agent/smallpox/index.asp 3. Dixon CW. Smallpox in Tripolitania, 1946: an epidemiological and
clinical study of 500 cases, including trials of penicillin treatment. J Hygiene 1948;46(4):351-77

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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

March 2003

Volume 19 Number 03

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for December 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 December 2002
2002 38 2027 3 2 59 1103 2 29 14 0 0 3 0 2 0 67 177 7 17 26 15 0 29

Previous 3 Months Total

Ending in December

2000

2001 2002

122

107

142

7100

8071

7664

37

39

28

8

18

7

271

200

207

4731

4648

4093

30

38

17

112

192

122

114

121

106

3

2

6

0

0

0

11

16

9

0

1

0

5

3

5

0

0

0

390

434

443

91

476

714

28

19

20

53

71

61

114

205

115

172

198

81

2

4

0

219

225

101

Previous 12 Months Total

Ending in December

2000

2001 2002

607

640

645

29227

32690

33924

190

162

119

45

45

44

1201

961

908

19254

18343

18387

86

110

79

376

930

489

353

434

441

10

12

19

0

1

2

53

57

33

2

9

2

52

23

29

1

0

0

1688

1721

1934

339

752

1764

127

95

100

292

301

279

537

676

617

716

854

588

21

24

11

683

564

486

* 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: 02/02-01/03 Five Years Ago: 02/98-01/99 Cumulative: 07/81-01/03

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

2

1,438 1,440

9

1,290 1,299

212

25,730 25,942

Percent Female
25.3
19.2
17.8

MSM
37.0 41.6 47.4

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

7.2

1.9

12.4

1.8

39.7

17.4

5.4

17.0

0.9

17.8

17.2

5.4

13.4

1.9

14.7

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

19.4 74.9

5.7

23.4 74.2

2.4

33.8 63.7

2.5