March 2004 volume 20 number 3 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 prepares for global respiratory disease threats: Severe Acute Respiratory Syndrome (SARS) and avian influenza In February 2003, the world was introduced to Severe Acute Respiratory Syndrome (SARS), caused by a newly identified strain of coronavirus (SARS-CoV). It quickly spread to many countries worldwide, causing thousands of illnesses and 774 deaths. The epidemic was controlled within 8 months through international surveillance, education, and infection control measures including isolation of patients and quarantine of some exposed contacts. Since July 2003, only sporadic cases have occurred. During January 2004, China reported four (1 probable, 3 confirmed) cases of SARS-CoV infections. Georgia needs to prepare for a possible recurrence of person-to-person SARS-CoV transmission that could spread to the United States. Currently, a second global respiratory disease threat is evolving. Between January 13 and March 24, 2004, the World Health Organization (WHO) received reports of 34 confirmed human cases (23 deaths) and widespread poultry outbreaks of highly pathogenic avian influenza A (H5N1) in Asia. Human cases were attributed to direct exposure to infected live poultry or their contaminated environment, but limited human-to-human transmission may be possible. Human exposure to poultry outbreaks may enhance the potential for genetic change of avian influenza A (H5N1) viruses or their recombination with human influenza viruses, producing a new influenza A virus that is easily transmitted human-to-human and can cause an influenza pandemic. During the last century, three influenza pandemics caused millions of deaths worldwide. Since February 2004, several U.S. states have reported avian influenza in poultry. However, the subtype of the U.S. strains is different from the subtype circulating among Asian poultry, and the risk to humans exposed to ill poultry in the U.S. strains is unknown. The following paragraphs describe important measures to enhance preparedness in Georgia for these global respiratory disease threats. Recognizing SARS and avian influenza SARS and avian influenza cannot be clearly distinguished clinically from other causes of pneumonia, respiratory distress, or febrile respiratory illness. The key to recognizing these infections is to screen patients by asking about possible exposure through travel to infected areas, or exposure to poultry or patients with disease. All patients with febrile respiratory illness should be asked about recent travel history and exposures to infected poultry or ill persons (Figure 1). Note that some patients with pneumonia (based on travel history) could be at risk for both SARS and avian influenza. Posters with screening criteria to use in healthcare settings can be downloaded from http://health.state.ga.us/healthtopics/sars.shtml and http://health.state.ga.us/healthtopics/flu.shtml. Reporting potential SARS and avian influenza cases Report potential SARS or avian influenza cases when suspected, even before confirmatory testing (Figure 1). Once a suspect case is reported, public health officials share responsibility for protecting the wider community, and will strive to ensure patient follow-up, identify and monitor contacts, assist with laboratory testing, and enhance community infection control measures. Reports can be made to Georgia's district health offices (http://health.state.ga.us/ regional/). Healthcare facilities should know their district health office SARS and influenza liaisons, who can assist with investigations. Testing for SARS During the 2003 SARS epidemic, only eight of hundreds of U.S. patients evaluated for SARS had laboratory-confirmed SARS-CoV infection, and an alternative diagnosis was found for many. Testing for alternative pathogens may reduce anxiety about SARS and reduce the need 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. for SARS testing. The Georgia Public Health Laboratory (GPHL) and CDC offer SARS-CoV laboratory testing, including reverse transcription polymerase chain reaction (RT-PCR) and serology, for patients meeting testing criteria (Figure 1). However, SARS testing should be limited to patients with epidemiologic risk factors for SARS to minimize false-positive results. A positive test should be considered provisional until confirmed by independent testing. Regardless of early test results, patients should be managed presumptively until the definitive test for SARS-CoV infection is available, a convalescent serum antibody titer collected more than 28 days after onset of illness. When there is no SARS activity worldwide, SARS testing should generally be considered only after a search for alternative pathogens is negative at 72 hours (Figure 1). Routine testing in potential SARS patients should include blood cultures, sputum Gram's stain and culture, and rapid testing, such as direct or indirect fluorescent antibody, PCR, or other rapid diagnostic tests, for likely viral respiratory pathogens including influenza A and B and respiratory syncytial virus, and legionella and pneumococcal urinary antigen testing. For laboratory safety reasons, do not culture potential SARS patients for respiratory viruses. If no alternative diagnosis is found after 72 hours, consult with the Division of Public Health (DPH) for consideration of SARS testing by GPHL. Because recent sporadic SARS cases have occurred in Guangdong Province, China, potential SARS patients who recently traveled to Guangdong Province should be tested immediately. Criteria for GPHL SARS testing may broaden if person-to-person SARS transmission resumes. Any SARS-CoV testing by non-public health laboratories should be reported immediately and the GPHL should confirm any positive test. Hospital and healthcare worker (HCW) preparedness In healthcare settings, all patients with a febrile respiratory illness should be managed using "Respiratory Hygiene/Cough Etiquette in HealthCare Settings Guidelines" (see guidelines below). Posters are available at http:/ /health.state.ga.us/healthtopics/sars.shtml. Hospitals need to be prepared to care for one or more SARS patients. Given the speed and complexity of the required response, facilities should consider developing a formal SARS preparedness and response plan using CDC's Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS), Supplement C (http://www.cdc.gov/ncidod/sars/updateguidance.htm). The facility's SARS plan may build upon pre-existing emergency response plans. The goals of SARS preparedness include the ability to rapidly identify and isolate all potential SARS patients, implement strict infection control practices to prevent transmission of SARS-CoV to HCWs or other patients, and enhance communication between the facility and public health. These measures also are recommended for suspected avian influenza patients. Hospitals are responsible for ensuring adequate screening of patients for SARS and avian influenza risk factors. Planners should identify a system to routinely screen for risk factors. Facilities should train staff and visitors on infection control measures and correct use of personal protective equipment (PPE). In 2003, SARS-CoV transmission sources in hospitals included infected patients, infected visitors, and infected HCWs. Most transmission in hospitals was attributable to unprotected exposure to unrecognized cases. SARS-CoV transmission was interrupted by enhanced surveillance for potential SARS patients, follow-up, quarantine of some contacts, and strict measures to ensure patient isolation and correct use and removal of PPE. Testing for avian influenza Initial testing of potential avian influenza cases should include testing for influenza by polymerase chain reaction (PCR) assay (available through GPHL for patients meeting testing criteria) or commercially available rapid influenza tests (Figure 1). Negative results on rapid tests do not rule out avian influenza because of limited test sensitivity. Specimens from patients meeting clinical and epidemiologic criteria and testing positive for influenza A by PCR or antigen detection will be sent to CDC by arrangement with GPHL for further testing. CDC recommends that viral culture for avian influenza be performed only in a Biosafety Level-3+ laboratory. Therefore, respiratory virus cultures should not be performed in most clinical laboratories and such cultures should not be ordered for patients suspected of having avian influenza infection. Healthcare workers, particularly those involved in aerosol-generating procedures such as intubation, mechanical ventilation, nebulizer use, or induction of sputum specimens, should familiarize themselves with infection control guidelines and recommended PPE for SARS patient care. During the 2003 SARS epidemic, many HCWs were infected during patient care primarily because of improper or inconsistent use of PPE or other infection control measures, especially when a source patient was not recognized as having SARS. Transmission of SARS to unprotected HCWs occurs because SARS-CoV shedding increases during the second week of infection, as patients become severely ill and are likely to be hospitalized. Employment in a healthcare setting is a recognized risk factor for SARS infection; therefore, patients who are hospitalized with pneumonia should be asked about recent work in or visits to healthcare Respiratory Hygiene/Cough Etiquette Strategy for Healthcare Facilities To contain respiratory secretions, all persons with signs and symptoms of a respiratory infection, regardless of presumed cause, should be instructed to: Cover the nose/mouth when coughing or sneezing. Use tissues to contain respiratory secretions. Dispose of tissues in the nearest waste receptacle after use. Perform hand hygiene after contact with respiratory secretions and contaminated objects/materials. Healthcare facilities should ensure the availability of materials for adhering to respiratory hygiene/cough etiquette in waiting areas for patients and visitors: Provide tissues and no-touch receptacles for used tissue disposal. Provide conveniently located dispensers of alcohol-based hand rub. Provide soap and disposable towels for hand washing where sinks are available. Masking and separation of persons with symptoms of respiratory infection During periods of increased respiratory infection in the community, offer masks to persons who are coughing. Either procedure masks (i.e., with ear loops) or surgical masks (i.e., with ties) may be used to contain respiratory secretions; respirators are not necessary. Encourage coughing persons to sit at least 3 feet away from others in common waiting areas. Some facilities may wish to institute this recommendation year-round. Droplet precautions Healthcare workers should practice Droplet Precautions (i.e., wear a surgical or procedure mask for close contact), in addition to Standard Precautions, when examining a patient with symptoms of a respiratory infection. Droplet Precautions should be maintained until it is determined that they are no longer needed (see www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm). -2 - settings. HCWs with pneumonia should be reported to DPH and investigated as potential SARS patients. Infection control measures for SARS and avian influenza Isolation precautions for all hospitalized patients who have or are under evaluation for SARS or avian influenza include: Careful attention to hand hygiene before and after all patient contact. Gloves and gown for all patient contact. Eye protection when within 3 feet of the patient. Airborne isolation room (i.e., monitored negative air pressure in relation to surrounding areas with six to 12 air changes per hour). When entering the patient's room, use a NIOSH-approved fit-tested respirator at least as protective as an N95 filtering-facepiece respirator How and Where to Find Information about Current Locally Circulating Respiratory Viruses Georgia's year-round statewide surveillance for influenza and respiratory syncytial virus (RSV) provides weekly updates (http://health.state.ga.us/ epi/flu/index.shtml and http://health.state.ga.us/epi/rsv/tracking.shtml). CDC's National Respiratory and Enteric Virus Surveillance System (NREVSS) monitors national and regional influenza, RSV, parainfluenza virus, adenovirus, and rotavirus activity (http://www.cdc.gov/ncidod/ dvrd/revb/nrevss/trends.htm and http://www.cdc.gov/flu/weekly/ fluactivity.htm). Laboratories can join NREVSS at http://www.cdc.gov/ ncidod/dvrd/revb/nrevss/appl.htm. Isolation and quarantine preparations Separating and restricting the movement of ill persons with potential SARS, termed "isolation," reduces exposure of others to SARS infection. Restricting the movement of persons who may have been exposed to an infectious SARS patient but who are not yet ill is termed "quarantine." In 2003, both isolation and quarantine were necessary to control SARS in severely affected communities. Additional Resources: CDC. Revised U.S. Surveillance Case Definition for Severe Acute Respiratory Syndrome (SARS) and Update on SARS Cases -- United States and Worldwide, December 2003. MMWR 2003;52:1202-06. CDC. Outbreaks of avian influenza A (H5N1) in Asia and interim recommendations for evaluation and reporting of suspected cases United States. MMWR 2004; 53:97-100. This article was written by Katie Arnold, M.D., Pauline Terebuh, M.D., M.P.H., Alison Han, M.S., and Melissa Tobin-D'Angelo, M.D. Figure 1. Evaluation and management of patients requiring hospitalization for radiographically confirmed pneumonia for SARS-CoV (in the absence of SARS-CoV disease activity worldwide) or avian influenza infection. http://www.cdc.gov/ ncidod/sars/clinicalguidance.htm) Radiographic evidence of pneumonia or acute respiratory distress syndrome(ARDS) requiring hospitalization? Yes 1. Use droplet precautions 2. Treat as clinically indicated 3. Screen for SARS risk factors: A. Recent travel (within 10 days) to mainland China*, Hong Kong, or Taiwan, or close contact with ill persons with a history of travel to such areas B. Healthcare worker with direct patient contact, work in a laboratory containing live SARS-CoV, or other occupational exposure risk C. Close contact with others who have unexplained pneumonia 4. Screen for avian influenza risk factors: A. Recent travel (within 10 days) to an H5N1-affected country** B. Contact with poultry or human case of avian influenza in an H5N1-affected country** or US state*** with confirmed avian influenza outbreaks among poultry (Poultry exposure: e.g., visited a poultry farm, household raising poultry, or live bird market. It does NOT include exposure to cooked or processed poultry.) Yes to at least one risk factor 1. Notify public health 2. Perform diagnostic testing (consider blood cultures, sputum Gram stain and culture, rapid testing**** for influenza A and B, respiratory syncytial virus, specimens for legionella and pneumococcal urinary antigen) 3. Look for evidence of clustering of patients with radiographically-confirmed pneumonia without alterna- tive diagnosis In consultation with public health, testing may be performed if patient is highly suspicious for SARS-CoV or avian influenza. Yes Testing will be performed 1. Use SARS isolation precautions (http://www.cdc.gov/ncidod/sars/ic.htm) 2. Immediate SARS-CoV and/or avian influenza testing will be arranged through public health No Treat as clinically indicated No to all risk factors No Testing not necessary Treat as clinically indicated * Travelers to Guangdong Province, China should be tested immediately for SARS-CoV. ** As of March 24, 2004, these countries/territories include: Cambodia, China, Hong Kong, Indonesia, Japan, Laos, South Korea, Thailand, and Vietnam. For an updated listing of H5N1- affected countries, see the OIE website at http://www.oie.int/eng/en_index.htm and the WHO website at http://www.who.int/en/. *** As of March 24, 2004, these states include: Delaware, New Jersey, Maryland, Pennsylvania, and Texas. See http://www.cdc.gov/flu/avian/ for an updated list. **** For the safety of agriculture and laboratory workers, influenza culture is not recommended. -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 March 2004 Volume 20 Number 3 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for November 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 November 2003 2003 25 195 12 1 57 190 1 42 41 0 0 2 0 0 0 162 44 2 10 19 13 0 37 Previous 3 Months Total Ending in November 2001 2002 2003 119 177 107 8278 9014 3457 51 34 34 21 6 4 255 244 237 4715 4894 1914 25 22 9 234 117 363 131 112 176 2 9 5 0 1 1 16 7 5 1 0 1 6 5 2 0 0 0 561 681 722 354 772 213 16 25 18 73 100 53 178 205 83 212 196 81 6 1 0 148 131 114 Previous 12 Months Total Ending in November 2001 2002 2003 634 657 629 32877 34552 30224 161 127 119 47 45 29 1005 898 862 18324 18946 15256 108 97 61 929 509 796 441 464 670 11 20 30 1 5 13 56 34 29 9 2 3 26 27 20 0 0 0 1699 1968 2013 597 1818 1314 94 110 106 304 329 368 637 745 635 866 776 661 25 14 10 579 603 492 * 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. Note: Due to activities to ensure completeness and timeliness of reporting, STD data in this edition of the GER are not current. STD data will be updated and complete in the next GER. 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 Unknown 37.8 7.2 2.0 11.8 2.2 39.1 41.1 18.0 5.7 17.1 0.9 17.3 47.5 17.3 5.4 13.4 1.9 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 - 4 -