Georgia epidemiology report, Vol. 19, no. 4 (Apr. 2003)

April 2003

volume 19 number 04

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

West Nile Virus in Georgia, 2002
Introduction
West Nile virus (WNV) is an arbovirus (arthropod-borne virus) recently introduced into the United States. WNV belongs to the genus Flavivirus, which includes closely related viruses such as Japanese encephalitis and St. Louis encephalitis viruses. WNV was first detected in the U.S. during an outbreak of encephalitis in New York City in 1999. The virus first appeared in Georgia in the summer of 2001 when it caused six cases of encephalitis, including one death. Since 1999 WNV has rapidly spread across the U.S. and is already considered endemic in many states, including Georgia.
Infection with WNV is usually asymptomatic. Approximately 1 in 20 people infected experience a mild, flu-like illness. An estimated 1 in 150 people infected with WNV develop meningitis or encephalitis. The risk of developing severe disease increases markedly with age. The incubation period is believed to be 2-14 days. The case fatality rate for severe illness is approximately 3-15%.
The WNV epidemic in the U.S. is caused by a viral strain originating in Israel in 1998. This WNV strain has been associated with several disturbing epidemiologic trends not previously seen in other outbreaks: 1) Increased frequency of outbreaks among humans and horses; 2) Apparent increase in severe human disease; and 3) High avian death rates accompanying the human outbreaks. The clinical presentation of WNV in the U.S. remains to be completely discerned.
WNV Activity in Georgia
Human Cases Nationwide, WNV was responsible for 4008 human cases and 263 deaths in 2002 (CDC data as of 2-6-03). WNV activity was reported in 44 states and the District of Columbia in 2002; human cases were reported in 39 states and the District of Columbia.
In 2002, WNV accounted for 44 cases and seven deaths in Georgia. The first human case occurred in Georgia on 7/29/02 in Muscogee county and the last cases occurred on 11/09/ 02 in Fulton and Houston counties. Twenty-eight (64%) cases were diagnosed with West Nile meningoencephalitis, 15 (34 %) cases were diagnosed with WNV fever or infection, and one case (2 %) was asymptomatic. Three cases were infected due to blood transfusion or organ transplantation. The average age of all cases (excluding transfusion/transplant cases) was 56 years (range 12-82) and the average age of death (excluding transfusion/transplant cases) was 70.5 years (range 50-82 years). Twenty-eight (64%) cases were male and 80% of cases were hospitalized. West Nile surveillance in Georgia also detected one case of LaCrosse (LAC) meningitis in a 3-year-old child. No cases of St. Louis encephalitis (SLE) or Eastern Equine encephalitis (EEE), other arboviruses endemic in Georgia, were reported in 2002.
Clinical Guidance As mentioned previously, the WNV strain circulating in the U.S. has been associated with severe neurological symptoms and death. Many questions remain regarding the clinical presentation of persons infected with this WNV variant. The Georgia Division of Public Health (GDPH) collected information on 37 WNV cases in Georgia in 2002. Among all patients, the most common signs and symptoms included fever (92%), muscle weakness (65%), headache (62%), altered mental status (62%), and muscle pain (38%). Among the 24 patients diagnosed with meningitis or encephalitis, the most frequent complaints were fever (92%), altered mental status (83%), muscle weakness (71%), headache (46%), stiff neck (38%), and other neurologic signs (38%, including gait dysfunction, incontinence, tremors, photophobia, balance problems). Among the 13 patients diagnosed with WNV fever or infection, common signs and symptoms included fever (92%), headache (92%), muscle pain (69%), muscle weakness (54%), rash (46%), and joint pain (38%). Additional clinical guidance for suspected WNV infection is available at http://www.cdc.gov/ncidod/dvbid/ westnile/clinical_guidance.htm.

WNV Surveillance
In addition to surveillance for human disease caused by WNV in GA, GDPH and its partners conduct dead bird, mosquito, and horse surveillance. Below is a summary of WNV surveillance results in 2002.
Bird Surveillance Bird mortality surveillance remains a sensitive tool to determine the geographic range and extent of WNV activity in various parts of the state and to predict risk of human disease. One hundred twelve counties (of 159) submitted at least one bird for WNV testing in 2002. Positive birds were reported from 92 of the 112 counties. Of 2421 birds submitted to the Southeastern Cooperative Wildlife Disease Study (SCWDS) for testing, 931 (38%) were positive. Eight birds were submitted to other facilities for testing; all eight were positive. The mean number of positive birds per county was 10.1 (range: 1-248). The first positive bird in 2002 was submitted for testing on 5/15/02. The last positive bird was submitted on 12/12/ 02. While more than 120 species of birds were submitted for testing, crows and blue jays made up 55% of the birds submitted. More than 60% of crows and jays submitted were positive.
Horse Surveillance Like humans, horses are incidental hosts for WNV infection. Detection of WNV infection in equine hosts provides a valuable method to recognize foci of viral activity. Seventy counties reported a total of 175 horses positive for WNV in 2002. The number of positive horses per county ranged from one to 11. The first case of WNV in a horse occurred on 7/07/02 and the last case occurred on 12/10/02. The peak onset of illness in positive horses was on 11/ 11/02. Information about immunization status of the infected horses is currently unavailable.
Mosquito Surveillance Mosquito surveillance is conducted to detect the presence of WNV in potential vectors and guide mosquito control programs. Twelve counties conducted mosquito surveillance in 2002. Surveillance was also conducted at Georgia military installations by the U.S. Army Center for Health Promotion and Preventive Medicine (USACHPPM) and in several metro Atlanta counties by CDC-Atlanta, and the results were submitted to GDPH. Seven counties had positive mosquito pools detected during 2002, with peaks in the number of positive mosquito pools occurring on 8/05/02 and 9/02/02. While more than 30 different species of mosquitoes were collected for testing, over 90% of the positive mosquitoes were Culex quinquefasciatus, the southern house mosquito. This mosquito is primarily active at dusk and dawn.
New in 2002
In 2002, newly recognized methods of WNV transmission were reported. In August, four individuals were shown to have contracted WNV through transplanted organs received from a single organ donor. The organ donor became infected with WNV through blood transfusions received shortly before organ procurement. This was the first documented instance of transmission of WNV through blood transfusions and organ transplantation. Subsequent investigations by CDC revealed up to 47 cases of possible transfusion- or transplantation-associated cases of WNV infection nationwide in 2002.

Although testing of all pregnant women for WNV is not necessary, healthcare providers should educate pregnant and nursing women about reducing the risk of WNV infection.
In addition to newly recognized modes of transmission, a novel clinical presentation of WNV infection was described in 2002. Acute WNV infection was associated with acute flaccid paralysis (AFP) in several cases investigated by the Centers for Disease Control and Prevention (CDC). While acute WNV infection has been shown in the past to be associated with Guillian-Barr Syndrome (GBS), these cases were the first where acute WNV infection presented as an acute poliomyelitis. In a case series prepared by CDC, the six patients with AFP had acute onset of asymmetrical weakness without pain or sensory loss. All but one patient with cerebrospinal fluid (CSF) drawn had pleocytosis. In comparison with these patients, GBS is more often symmetric, generally involves sensory changes or paresthesias, and is associated with an elevation of CSF protein in the absence of pleocytosis. Additional features of GBS include an onset of several days following signs of an acute infection and a generally favorable outcome with rapid improvement in strength. As of November 2002, the CDC reported that very few of these six AFP patients were showing signs of improvement, which again is very similar to an acute poliomyelitis (1; CDC, unpublished data). In summary, in areas where WNV transmission is occurring, clinicians should suspect acute WNV infection and conduct appropriate diagnostic tests in patients presenting with acute, painless, asymmetric weakness, particularly in the setting of an acute febrile illness with CSF pleocytosis.
New in 2003
Minor changes have been made to the Viral Encephalitis Case Report Form, which must be submitted for arboviral testing at the Georgia Public Health Laboratory (GPHL) to be performed. In particular, the form now contains questions pertaining to recent blood donations, blood transfusions, or organ transplants. This information will assist GDPH in expediting a response to potentially infected blood products, tissues, or organs. The criteria for testing at GPHL has not changed from 2002 and are listed in Table 1. Persons suspected of having milder cases of WNV infection can be tested through commercial laboratories. GPHL will continue to perform verification testing on specimens that test positive at commercial laboratories.
Table 1
Georgia Public Health Laboratory will continue to offer free testing for persons who meet the following criteria:
Persons over 6 months of age hospitalized with any of the following syndromes: 1) Viral encephalitis (at least 2 of the following clinical signs):
Fever (greater than 38.0C or 100.4F)
Altered mental status (altered level of consciousness,
agitation, lethargy)
Abnormal CSF (pleocytosis with predominant lymphocytes
and/or elevated protein, and negative laboratory tests for bacterial pathogens)
Muscle weakness (especially flaccid paralysis) confirmed by
neurologic exam or by EMG 2) Aseptic meningitis in patients over age 17 years 3) Guillain-Barr syndrome, especially with atypical features, such as
fever, altered mental status, and/or pleocytosis

Also reported in 2002 were instances of WNV transmission from mother to infant in utero or via breast milk. These modes of transmission have been well documented with other flaviviruses.

In November 2002, the Georgia Department of Human Resources Board approved a change in the reporting requirements regarding West Nile virus and other arboviruses. Currently, all acute arboviral infections are now notifiable. Arboviral infections must be reported to public health immediately.

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The Georgia Division of Public Health would like to thank its partners in West Nile virus surveillance throughout the state. GDPH is especially grateful to the individuals at the Southeastern Cooperative Wildlife Disease Study at the University of Georgia, the Veterinary Diagnostic and Investigational Laboratory at University of Georgia in Tifton, the Georgia Public Health Laboratory, district and county environmentalists, the Centers for Disease Control and Prevention, the U.S. Army Center for Health Promotion and Preventive Medicine, the Georgia Mosquito Control Association, researchers at universities throughout the state, and other public health personnel for their efforts in tracking WNV in Georgia.
References 1. Centers for Disease Control and Prevention. Acute flaccid paralysis syndrome
associated with West Nile virus infection Mississippi and Louisiana, JulyAugust 2002. MMWR 2002;51(37):825-828.
Written by Katherine Bryant, M.P.H. and Rosmarie Kelly, Ph.D., M.P.H.
Notifiable Disease Reporting
In November 2002 and January 2003 the Georgia Department of Human Resources Board approved several new additions and changes to the list of notifiable conditions in Georgia:
Suspected Creutzfeldt-Jacob Disease (CJD) Among Persons Aged <55 Years. In 1996, a new form of "variant" CJD (vCJD) first appeared in Britain among humans. This disease, which is caused by an abnormal form of a cellular glycoprotein called a prion, predominantly affects younger persons and is causally linked to ingestion of beef products from cattle with Bovine Spongiform Encephalopathy (BSE), or "Mad Cow Disease." vCJD is clinically indistinguishable from typical CJD without laboratory testing of brain tissue. Therefore, it is important that all probable cases of CJD in persons <55 years be examined to evaluate the type of disease present. CDC established the National Prion Disease Pathology Surveillance Center in 1996 to launch surveillance among U.S. residents for vCJD. Suspected CJD among persons aged <55 years should be reported to public health within 7 days.
Streptococcus pneumoniae Invasive Infections: Previously in Georgia, notifiable S. pneumoniae (SP) infections included only meningitis and drug-resistant SP. The Georgia Division of Public Health now wishes to assess complete pneumococcal invasive disease incidence and antibiotic resistance rates. Many pneumococcal infections among young children may now be preventable with 7valent pneumococcal conjugate vaccine (PCV7). SP is also the most common cause of bacterial community-acquired pneumonia and bacterial meningitis, causing significant disease among older persons. Many cases occurring among adults are potentially preventable with the 23-valent pneumococcal polysaccharide vaccine. Removing the qualifier of drug-resistance from the types of SP infection that are notifiable will simplify the decision about reporting a case, but antibiotic-resistance information must still be provided once it is available. The simplest way to do this may be to fax a copy of the antibiotic-susceptibility report associated with an invasive SP case to notifiable diseases epidemiology at 404-657-7517. S. pneumoniae invasive infections should be reported to public health within 7 days.
Arboviral Infections. Arboviral infections are mosquito-transmitted viral infections. Previously, only cases of arboviral encephalitis were reportable in Georgia. As only a very small percentage of arboviral infections progress to encephalitis, the true number of arboviral infections has not been apparent. We need to accurately assess the burden of arboviral disease in Georgia. To plan public education and mosquito control programs, Arboviral infections should be reported to public health immediately.
Maternal Deaths. The maternal mortality rate in Georgia is sixth highest in the U.S., and rates have not declined since 1982. It is

estimated that at least half of all maternal deaths (deaths among women who are pregnant or have been pregnant within the previous 90 days) are preventable. Data from maternal deaths will be analyzed to develop public health and/or clinical strategies that can prevent future deaths. Maternal deaths must be reported to public health within 7 days. Latent Tuberculosis Infections (LTBI) in Children Aged <5 Years. Latent tuberculosis (TB) infection in this age group indicates recent community transmission of the TB bacillus, the bacterium that causes TB disease. Infants and young children with LTBI are known to be recently infected and are at a high risk for progressing to TB disease. Children aged <5 years are more likely to develop life-threatening forms of TB such as meningeal and disseminated disease. Early identification and treatment of LTBI in young children can prevent progression to active TB disease and help public health officials identify a previously undiagnosed and untreated case of active TB disease in the community. When LTBI in a child <5 years is reported, public health workers will conduct interviews to determine the source of infection, the child will be evaluated to rule out active TB disease, and preventive treatment for LTBI will be recommended. LTBI in children aged <5 years should be reported to public health immediately. Birth Defects. Birth defects are the leading cause of infant mortality and morbidity in the United States. In Georgia, few statewide data exist, making improvements in public health programs difficult. In response to this, birth defects have been made reportable statewide. The following conditions (ICD-9 codes) will be reportable: congenital anomalies (740-759.9), genetic and metabolic conditions (240279), sickle cell anemia and other hemoglobinopathies (282-282.9), fetal alcohol syndrome (760.7), and cerebral palsy (343). Birth defects should be reported to public health within 7 days after diagnosis in a child less than 6 years old. Hearing Impairment in Newborns and Young Children. Newborns - Both suspect and confirmed hearing loss in newborns should be reported to Public Health through the Children 1st program within 7 days after screening or confirmatory diagnosis. A suspect case is one referred for further evaluation after initial or follow-up newborn screening. A confirmed case is hearing impairment (ICD-9 codes 389.0 through 389.9) confirmed by a licensed audiologist or physician following the state protocol. Young Children - Initial diagnosis (determined or suspected) of permanent and/or progressive hearing loss in children < 5 years of age is reportable within 7 days after screening.
These data will be used to assess the incidence and prevalence of hearing loss in Georgia, and to determine the impact of the Universal Newborn Hearing Screening and Intervention (UNHSI) Program on infants identified through screening. For detailed information about case identification and reporting, please call the Georgia UNHSI Program at 404-657-4143. Reporting Forms will be available on the DHR website at: http://health.state.ga.us/programs/child/ index.shtml.
These conditions are reportable under O.C.G.A. 31-12-2. For more information about these or other reportable conditions, visit the Georgia Division of Public Health website at http:// health.state.ga.us or call 404-657-2588. A Georgia Notifiable Disease Reporting poster, which lists all notifiable conditions in Georgia and includes reporting instructions and health department contact information, is available in electronic format at http:// health.state.ga.us/pdfs/epi/notifiableposter.032102.pdf. If you would like a poster mailed to you please call 404-657-2588 or send an email to gaepinfo@dhr.state.ga.us.

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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

April 2003

Volume 19 Number 04

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for January 2003

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 January 2003
2003 17 2942 3 1 13 1481 4 16 8 4 0 4 0 0 0 33 125 5 23 38 35 0 21

Previous 3 Months Total

Ending in January

2001

2002

2003

103

106

117

7915

8087

8202

33

27

19

5

9

7

262

179

145

4757

4690

4263

36

41

19

138

153

109

127

94

96

3

2

6

0

0

0

17

16

10

2

1

0

3

4

3

0

0

0

317

336

275

83

461

535

27

28

21

55

60

72

125

202

124

188

190

123

6

4

0

193

163

99

Previous 12 Months Total

Ending in January

2001

2002

2003

619

642

637

31955

33377

34872

188

159

118

43

48

46

1202

938

870

20284

18717

18704

86

108

77

417

918

475

376

418

446

11

11

22

0

1

2

51

52

35

3

7

2

43

24

28

1

0

0

1711

1701

1928

342

833

1837

134

97

101

285

303

321

563

696

652

784

862

680

25

23

10

691

551

531

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

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

1

1,448 1,449

10

1,273 1,283

211

25,832 26,043

Percent Female
26.1
19.8
17.8

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

36.5

7.6

1.9

12.9

1.8

39.4

41.0

17.4

5.3

17.4

0.9

18.0

47.3

17.2

5.4

13.5

1.9

14.7

Race Distribution (%) White Black Other

19.3 75.5

5.2

23.3 74.2

2.5

33.7 63.8

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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