September 2003 volume 19 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 Epidemics of influenza usually occur during the winter, causing an average of 114,000 hospitalizations for influenza-related complications and 36,000 deaths per year in the United States (1). While influenza infects persons of all ages, rates of influenza complications requiring hospitalization are highest among young children under two years of age, the elderly, and persons with certain chronic medical conditions. Rates of death from influenza are especially high among the elderly. Prevention strategies are designed to prevent and ameliorate disease in these high-risk populations. Preventing Influenza Annual influenza vaccination is the most effective way to prevent influenza and its complications. Influenza vaccination is associated with reductions in influenza-related illnesses and physician visits 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 (2-5). Annual influenza vaccination is strongly recommended for persons at high risk of developing complications from influenza (Table 1). The Advisory Committee on Immunization Practices (ACIP) now recommends annual influenza vaccination for persons aged 50 to 64, because of the high prevalence of high-risk medical conditions in this population, and for household contacts and out-of-home caretakers of children 0-23 months of age. While influenza vaccine is not approved for use in children less than 6 months of age, the ACIP encourages vaccination of children aged 6-23 months when feasible. The optimal time to receive influenza vaccine is October-November. In Georgia, influenza activity typically peaks after December, so influenza vaccination should continue throughout influenza season as long as vaccine is available. Figure 1 suggests the ideal times to vaccinate against influenza and to order influenza vaccine. Children less than 9 years receiving the vaccine for the first time require a booster one month later. Therefore, they should receive vaccination early in the season. Table 1. Target Groups for Annual Influenza Vaccination 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 with chronic medical conditions Adults and children with chronic pulmonary or cardiovascular disorders, including asthma Adults and children who have required 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's syndrome after influenza infection Women who will be in the second or third trimester of pregnancy during the influenza season 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 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 conditions. Healthy Young Children Vaccination is encouraged when feasible for healthy young children 6-23 months of age because they are at increased risk for hospitalization. Persons Who Should Not Be Vaccinated: Persons known to have anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine without first consulting a physician* Persons with acute febrile illness usually should not be vaccinated until their symptoms have abated* * See MMWR April 25, 2003/vol. 52/No. RR-8. The complete report and other information on influenza can be accessed at http://www.cdc.gov/nip/Flu/default.htm. The Georgia Epidemiology Report Via E-Mail To better serve our readers, we would like to know if you would prefer to receive the GER by e-mail as a readable PDF file starting in 2004. If yes, please send your name and e-mail address to Gaepinfo@dhr.state.ga.us. Overview of Influenza 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). Weekly during influenza season, volunteer sentinel healthcare providers throughout Georgia report the total number of patient visits and the number of those patient visits with influenza-like illness. Influenza-like illness is defined as fever >100 F AND cough and/or sore throat. Sentinel providers also submit throat or nasopharyngeal swabs from representative patients with influenza-like illness several times during the season for testing at the Georgia Public Health Laboratory (GPHL). These volunteer providers furnish data that are used to estimate influenza disease activity and geographic distribution, and provide specimens for virologic surveillance and strain selection for next year's influenza vaccine. Because not all influenza-like illnesses are influenza and not all influenza illnesses are diagnosed, confirmed by laboratory testing, or reported, the sentinel network cannot be used to determine the precise number of influenza illnesses during a given season. However, the illness data coupled with the results of virologic testing help estimate influenza disease activity and distribution. During influenza season, Georgia influenza activity is posted weekly on the GDPH web site, at http://health.state.ga.us/epi/flu, with links provided to nationwide data from CDC. Figure 1. Influenza Timeline Influenza activity may begin to increase as early as November. Target groups for vaccination (see Table 1) Sep OFFER VACCINE* Oct Nov BEST TIME TO VACCINATE Dec Jan Feb Mar NOT TOO LATE TO VACCINATE Apr May Jun Jul Aug VACCINATION NOT ROUTINELY RECOMMENDED Other persons not at high risk who wish to decrease their risk of influenza BEST TIME TO VACCINATE NOT TOO LATE TO VACCINATE VACCINATION NOT ROUTINELY RECOMMENDED Order influenza vaccine for upcoming season 2003-2004 INFLUENZA SEASON: NO DELAYS EXPECTED FOR VACCINE PRODUCTION AND DISTRIBUTION BEST TIME TO ORDER VACCINE FROM MANUFACTURER ("PRE-BOOK") VACCINE MAY ONLY BE AVAILABLE FROM DISTRIBUTOR * If available, vaccine may be offered to those at high risk during routine healthcare visits or during hospitalizations to avoid missed opportunities. Summary of 2002-2003 Influenza Season in Georgia The influenza sentinel provider network showed peak activity in early February and remained at elevated levels through March (Figure 2). During the peak of the 2002-2003 influenza season, GDPH received reports of outbreaks of acute respiratory disease consistent with influenza among students and school staff across Georgia. All ages, from pre-kindergarten to high school, were affected. Peak absenteeism ranged from 10 to 39%. Influenza B viruses antigenically characterized as B/Hong Kong/330/2001-like (the B/Victoria lineage of viruses) were the predominant strain in Georgia schools. Type B viruses of this lineage reappeared in North America during the 20012002 flu season (and in Georgia in May-June 2002) after more than a decade during which they circulated only in Asia. Therefore, children in Georgia had little immunity to type B viruses of this lineage. These influenza B viruses continued to circulate during the 2002-2003 season. Influenza viruses isolated at the GPHL during the 2002-2003 influenza season were 54% B, 25% A(H1N1), 10% A(H3N2), 1% A(H1N2) and 10% A(not typed). Georgia Shows Improvement, But Vaccination among those at High Risk Remains Low Data from the Behavioral Risk Factor Surveillance System (BRFSS) indicate that, among Georgians aged > 65 years, influenza vaccination rates have been stable at about 60% since 1997, while pneu- mococcal vaccination rates have risen from 49% to 57% between 1997 and 2002. Vaccination rates are still far below the Healthy People 2010 goal of 90% vaccination for both vaccines among people aged > 65 years. In 2001, whites were significantly more likely than blacks to receive the influenza vaccine. Greater efforts should be made to vaccinate older blacks in Georgia. BRFSS details can be found at http:// health.state.ga.us/epi/brfss/index.shtml. % of Visits Figure 2. Percent of Visits for Influenza-like Illness Georgia Influenza Sentinel Provider Surveillance Network 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 1 23 4 51 23 41 234 12 34 51 23 4 12 34 12 34 123 45 1234 1 23 4512 34 1 23 4 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Month and week 2002-2003 2001-2002 2000-2001 1999-2000 -2 - Georgia Enhances Influenza Surveillance following Worldwide Reports of New Influenza Strains and SARS After a new severe acute respiratory syndrome (SARS) was discovered, Georgia sentinel providers were asked to continue reporting during the summer of 2003 and to send occasional throat or nasopharyngeal specimens from persons with influenza-like illness to GPHL. Although influenza activity typically peaks during the winter months, influenza viruses circulate year-round. A novel influenza subtype capable of causing a pandemic could emerge at any time. Year-round influenza surveillance improves the public health system's ability to rapidly identify new influenza virus subtypes, as well as other emerging respiratory viruses. In February 2003, 2 cases of Influenza A (H5N1) detected in one Hong Kong family were the first confirmed cases of Influenza A (H5N1) since 1997, when 18 people in Hong Kong were hospitalized and six died. The 1997 and 2003 strains were of the same subtype, but the strains are genetically different. To improve capacity to rapidly identify the importation of a case of influenza A (H5N1) into the United States from Asia, the Georgia Division of Public Health asked all hospitals to REPORT IMMEDIATELY and to obtain throat or nasopharyngeal swabs on all patients meeting both of the following criteria: 1 Patient hospitalized with unexplained pneumonia, acute respiratory distress syndrome (ARDS), or severe respiratory illness AND 2 Travel to Asia within 10 days before onset of symptoms Thank You Georgia Influenza Sentinel Providers GDPH would like to thank the 2002-2003 Influenza Sentinel Providers, especially those who continued to report through the summer (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. References: 1. Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003;298:179-186. 2. Bridges CB, Thompson WW, Meltzer MI, et al. Effectiveness and cost-benefit of influenza vaccination of healthy working adults: a randomized controlled trial. JAMA 2000;284:1655--63. 3. Nordin J, Mullooly J, Poblete S, et al. Influenza vaccine effectiveness in preventing hospitalizations and deaths in persons 65 years or older in Minnesota, New York, and Oregon: data from 3 health plans. J Infect Dis 2001;184:665--70. 4. Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowski RA. Efficacy of influenza vaccine in elderly persons: a meta-analysis and review of the literature. Ann Intern Med 1995;123:518-27. 5. Heikkinen T, Ruuskanen O, Waris M, Ziegler T, Arola M, Halonen P. Influenza vaccination in the prevention of acute otitis media in children. Am J Dis Child 1991;145:445-8. At the end of February 2003, influenza A (H7N7) was reported among poultry workers and their family members in the Netherlands. Most of the infections caused conjunctivitis, although some caused influenza-like illnesses. This article was written by Alison Han, M.S., Kathryn Arnold, M.D. and Pauline Terebuh, M.D., M.P.H. Resources Many illnesses have signs and symptoms similar to those of influenza, making a clinical diagnosis difficult. Knowing when influenza is circulating in the community can enhance the accuracy of clinically diagnosed influenza. During influenza season, GDPH emails periodic updates on influenza activity in Georgia 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 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/ outbreakcontrol.shtml. 2003-2004 Influenza Vaccine The 2003-2004 trivalent inactivated injectable influenza vaccine will contain: A/Moscow/10/99 (H3N2)-like, A/New Caledonia/20/99 (H1N1)-like, and B/Hong Kong/330/2001-like antigens. This vaccine will be available from two manufacturers. Manufacturers are not expecting delays in manufacturing or distribution of vaccines. A limited supply of a live, attenuated intranasal influenza vaccine recently approved by the Food and Drug Administration (FDA) will also be available for the 2003-2004 season. This intranasal vaccine is licensed for use only in healthy children and adults ages 5-49 years, and will contain the same influenza strains as the inactivated vaccine. 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 may sign up on the website so that Georgians seeking vaccine can find providers in their community. Table 2. Regularly Reporting Georgia Sentinel Providers Surveillance Network 2002-2003* Name Julie Hooks, NP Julia Weeks, MD Gail Hurley, MD L. Kitty Price, RN Linda Roberts, FNP Cathy Mincey Lalitha Chikkala, MD Susan Reines, MD Brian Palmer, MD San Jay Serrao, MD Michael Huey, MD J. Ray Grant Jr., MD William Manns, MD Robin Dretler, MD David McCann, MD Suzanne Scheussler, MD Andrew Mecca, MD William Yang, MD, MPH Monisa Moore Herman Spivey, MD Morris Jenkins, MD Lt. Colonel Joaquin Oronoz, MD Diana Allen Karen Eschedor, MD Philip Saleeby, MD Mary Key, RN Naomi Fehrle, FNP Sandra Cook, RN Lea Hicks, RN Jean Chin, MD Jimmy Peoples, MD Tura Anthony, RN Glenda van Houten, RN Donald Hatig, MD *Reported >50% of the flu season. Practice Name Adult Health Promotion Clinic, Tift County Health Department Archibald Urgent Care Athens Neighborhood Health Center Coleman Community Health Center Community Care Center Dalton Family Practice, P.C. DeKalb County Board of Health DeKalb County Board of Health DeKalb County Board of Health, Ryan White Clinic East Georgia Health Care Center Emory University Student Health Services Forsyth Family Physicians Georgia Tech University Infectious Disease Specialists of Atlanta Infomedix Professional Corporation LaGrange Pediatrics Dr. Andrew Mecca Medical Services Dept, Coca-Cola Company Newton Medical Associates Northwest Georgia Family Practice Owasa Family Medicine Preventive Medicine Primary Care Center of Dade County Primary Health Care Clinic Philip R. Saleeby MDPC Spalding Regional Hospital Sutter Family Practice Sylvan Grove Hospital Tanner Medical Center/Villa Rica University Health Center University Hospital Emergency Room University of West Georgia Health Services Upson Regional Medical Center Valdosta State University Student Health Center City Tifton Thomasville Athens La Grange Riverdale Dalton Decatur Decatur Decatur Swainsboro Atlanta Forsyth Atlanta Decatur Colquitt La Grange Columbus Atlanta Covington Summerville Calhoun Ft. Benning Trenton Gainesville Brunswick Griffin Chatsworth Jackson Villa Rica Athens Augusta Carrollton Thomaston Valdosta -3 - 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 2003 Volume 19 Number 09 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for June 2003 Selected Notifiable Diseases Total Reported for June 2003 2003 Previous 3 Months Total Ending in June 2001 2002 2003 Previous 12 Months Total Ending in June 2001 2002 2003 Campylobacteriosis 48 181 176 140 616 618 614 Chlamydia trachomatis 2765 7851 8544 8541 32024 33928 35109 Cryptosporidiosis 7 30 24 17 178 152 111 E. coli O157:H7 3 12 17 5 45 55 32 Giardiasis 41 226 218 154 1109 904 871 Gonorrhea 1417 4225 4652 4124 19399 18848 18250 Haemophilus influenzae (invasive) 4 25 18 17 92 102 73 Hepatitis A (acute) 11 284 128 95 688 759 466 Hepatitis B (acute) 2 80 110 63 399 464 458 Legionellosis 3 5 4 11 12 11 28 Lyme Disease 0 0 2 5 0 4 10 Meningococcal Disease (invasive) 0 11 10 5 50 42 32 Mumps 0 2 2 1 7 4 1 Pertussis 0 9 8 6 36 22 25 Rubella 0 0 0 0 1 0 0 Salmonellosis 164 360 383 337 1641 1761 1882 Shigellosis 121 60 354 352 316 1235 1916 Syphilis - Primary 5 16 25 21 102 110 102 Syphilis - Secondary 22 78 82 79 292 295 372 Syphilis - Early Latent 32 170 159 144 570 691 694 Syphilis - Other** 25 225 167 123 839 789 700 Syphilis - Congenital 0 8 5 0 25 21 6 Tuberculosis 31 134 141 106 615 578 510 * 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: 08/02-07/03 Five Years Ago: 08/98-07/99 Cumulative: 07/81-07/03 Total Cases Reported* <13yrs >=13yrs Total 0 1,532 1,532 11 1,616 1,627 211 26,609 26,820 Percent Female AIDS Profile Update Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 24.7 33.7 7.4 1.6 11.6 2.0 43.7 24.4 36.1 16.5 4.1 18.9 1.6 22.8 18.0 47.1 16.9 5.4 13.6 1.9 15.0 Race Distribution (%) White Black Other 20.2 75.1 4.8 20.8 76.9 2.3 33.4 64.1 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 - 4 -