Georgia epidemiology report, Vol. 20, no. 9 (Sept. 2004)

September 2004

volume 20 number 09

Please Note: An update has been published to this article in the December 2004 GER issue. To view the update, please click http://health.state.ga.us/pdfs/epi/gers/ger1204.pdf

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 recommended for persons at high risk of developing complications from influenza (Table 1). New for the 2004-2005 season, the Advisory Committee on Immunization Practices (ACIP) now recommends annual influenza vaccination for children 6-23 months of age because they are at increased risk for influenza-related hospitalizations (6). Influenza vaccine is not indicated for children < 6 months of age, but they are also at increased risk for influenza-related hospitalizations. Therefore, influenza vaccine is recommended for household contacts and out-of-home caretakers of children 0-23 months of age.
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 aged less than 9 years who are receiving the vaccine for the first time require a booster one month later. Therefore, they should begin vaccination early in the season.

Influenza
providers throughout Georgia report the total number of patient visits and the number of those patient visits with influenza-like illness (ILI). ILI is defined as fever >1000 F AND cough and/or sore throat. Sentinel providers also submit throat or nasopharyngeal swabs from

representative patients with ILI several times during the season for testing at the Georgia Public Health Laboratory (GPHL). Because not all influenza-like illnesses are influenza and not all influenza illnesses are diagnosed, confirmed by laboratory testing, or reported,

Table 1. Target Groups for Annual Influenza Vaccination
Persons at High Risk for Influenza-Related Complications: Children aged 6-23 months Persons aged > 65 years Residents of long-term 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, 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 syndrome after influenza infection Women who will be pregnant during the influenza season
Persons Aged 50-64 Years Vaccination is recommended for persons aged 50-64 years because this group has a large proportion of
persons with high-risk conditions.
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 long-term 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 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 May 28, 2004/vol. 53/No. RR-6. The complete report and other information on influenza can be accessed at http://www.cdc.gov/flu/.

Figure 1. Influenza Timeline 2004 -2005

Target groups for vaccination (see Table 1)

Sep

Oct

Nov

OFFER BEST TIME TO VACCINE* 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

VACCINE BEST MAY BE TIME TO AVAIL- VACCIABLE** NATE

NOT TOO LATE TO VACCINATE

VACCINATION NOT ROUTINELY RECOMMENDED

Overview of Influenza Surveillance in Georgia
Each year from October through May, the Georgia Division of Public Health (GDPH) monitors influenza activity 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

Order influenza vaccine for upcoming season

2004 - 2005 INFLUENZA SEASON: EXPECT VACCINE DELIVERY

BEST TIME TO ORDER VACCINE FROM
MANUFACTURER ("PREBOOK")

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. ** Efforts to vaccinate anyone who wants to prevent the flu (those not in the high-risk group) should begin in November; however, if such persons request vaccination in October, vaccination should not be deferred.

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.

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, and provide specimens for virologic surveillance and strain selection for next year's influenza vaccine. During influenza season, Georgia influenza activity is posted weekly on the GDPH website, at http://health.state.ga.us/epi/flu, with links provided to nationwide data from CDC.

% of Visits

Figure 2. Percent of visits for influenza-like illness, Georgia Influenza Sentinel Providers Surveillance Network
10.0
8.0
6.0
4.0

Summary of 2003-2004 Influenza Season in Georgia
On November 14, 2003, the GPHL identified the 2003-2004 influenza season's first influenza virus isolate from a Georgia resident whose illness onset was in late October. During the 2003-2004 season, Influenza A (H3N2) predominated. CDC antigenically characterized 11 of the 88 influenza A isolates; 3 were antigenically similar to the vaccine strain A/Panama/2007/99 (H3N2), which was contained in the 2003-2004 season's vaccine, whereas 8 were antigenically similar to A/Fujian/411/2002 (H3N2), a drift variant of A/Panama/2007/99. Retrospective studies done in Colorado found that the 20032004 influenza vaccine had some effectiveness in preventing illness among children and adults even though the vaccine was not an optimal match to the predominant Fujian strain (7).

Table 2. Influenza Isolates from Georgia Reported by GPHL, 2003-2004* (N=97)

Influenza Virus

Isolates

No.

A (H1)

1

A (H3N2)

87

A (not-typed)

8

B

1

(%) (1) (90) (8) (1)

Influenza activity peaked in Georgia during late December, the earliest peak of activity documented by the current surveillance system in use since 1997 (Figure 2). During the month of December 2003 (before public schools' winter break beginning December 22), GDPH received reports of ILI and high absenteeism among school children. One school in metro-Atlanta reported absenteeism as high as 23% in December. Reports of ILI outbreaks in 6 long-term care facilities were also reported in December. Influenza A was confirmed at GPHL as the cause of the outbreak in one of those facilities.
Early in the 2003-2004 influenza season, media reports of influenza-associated deaths among children caused concern that children were being disproportionately affected by influenza. To better understand the burden of severe disease among children, CDC asked that states voluntarily report pediatric influenza illnesses with encephalopathy and pediatric deaths possibly associated with influenza. During the 2003-2004 in-

2.0

0.0 123412 3451234123412 3412345123412 3451234123412 3451234

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Month and week

2003-2004

2002-2003

1999-2000

Note: 1999-2000 is the last season in which Influenza A (H3H2) predominated.

fluenza season, approximately 152 laboratoryconfirmed influenza-associated pediatric deaths were reported to CDC, of which 10 were reported from Georgia. Approximately 50 influenza-associated pediatric encephalopathy cases were identified in the US, of which 7 were reported from Georgia. Because these data had not been collected in previous years, whether or not these are higher than baseline is uncertain. Additional data are necessary to monitor and describe characteristics of influenza-associated pediatric deaths, and to better understand which children are at high risk for serious complications from influenza. Therefore, GDPH has made laboratory confirmed influenza-associated deaths among children < 18 years of age a reportable condition. The Georgia Emerging Infections Program is also collaborating on a multi-state investigation of the burden of influenza on pediatric hospitalizations, based on data from 7 metro-Atlanta hospitals.
Early influenza activity and media reports of influenza affecting children created an unprecedented demand for influenza vaccine early in the season and resulted in a nationwide shortage of the inactivated, injectable vaccine in mid-November. During the 2004-2005 season, CDC plans to reserve a limited quantity of pediatric vaccine through the Vaccines for Children (VFC) Program. To find out more about VFC in Georgia, please go to http:// health.state.ga.us/programs/immunization/vfc.
Avian Influenza Since December 2003, WHO has received reports of confirmed human cases and widespread poultry outbreaks of avian influenza A (H5N1) in Asia. Although the human cases are thought to have resulted from direct exposure to infected live poultry or their contaminated environment, limited human-to-human transmission may be possible. The exposure of humans to ongoing poultry outbreaks is a grave concern because it enhances the potential for avian influ-

enza A (H5N1) viruses to undergo genetic changes or recombine with human influenza viruses and result in a new influenza A virus that is easily transmitted human-to-human, thus triggering an influenza pandemic. During the last century, 3 influenza pandemics resulted in millions of deaths worldwide.
In the US, several states have reported avian influenza among poultry. However, the strains identified in the US are not the same subtype that is circulating in Asia. State and national authorities are monitoring the situation closely to prevent transmission to humans and to ensure widespread outbreaks do not occur.
Healthcare providers are asked to report to public health patients who have respiratory symptoms and who have recently traveled to a country with poultry outbreaks or had recent close contact with potentially infected poultry or a human case of avian influenza. Close contact includes visiting a poultry farm, household where poultry are raised, or live bird market in an affected country. It does NOT include exposure to cooked or processed poultry. Please go to http://health.state.ga.us/healthtopics/ avianflu.asp for more information.
Georgia shows improvement, but vaccination among those at high risk remains low Data from the Behavioral Risk Factor Surveillance System (BRFSS) indicate that influenza and pneumococcal vaccination rates have improved in recent years among Georgians aged > 65 years (Figure 3). Although vaccination rates are increasing, they are still far below the Healthy People 2010 goal of 90% vaccination for both vaccines among people aged > 65 years. In 2002, white persons (63.2%) were significantly more likely than black persons (44.8%) to receive the influenza vaccine. Greater efforts should be made to vaccinate older black persons in Georgia.

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Figure 3. Influenza and pneumococcal vaccination rates among persons aged > 65 years, Georgia, 1995 - 2003

enza surveillance, contact Alison Han, Influenza Surveillance Coordinator, at 404-657-2588.

Vaccination rate (%)

100

This article was written by Alison Han, M.S.,

80

Kathryn Arnold, M.D., and Pauline Terebuh,

60

Influenza

M.D., M.P.H.

40

Pneumococcal

20

0 1995

1997

1999

2001

2002

2003

Healthy Healthy People People
2000 2010 Goal Goal

References:
1. Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003;298:179186.

BRFSS details can be found at http:// health.state.ga.us/epi/brfss/.

If you are providing influenza vaccine and would like to get the word out, go to http:// www.immunizeadultga.org. Healthcare providers

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.

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

who will have vaccine available may sign up on the website so that Georgians seeking vaccine can find providers in their community. Public health will monitor the website during influenza season to know where influenza vaccine may be available.

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

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 longterm care facilities and other care providers in preventing influenza. The materials include out-

Thank you Georgia Influenza Sentinel Providers: GDPH would like to thank the 2003-2004 Influenza Sentinel Providers, especially those who continued to report through the summer (Table 3). 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 influ-

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. 6. CDC. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2004; 53:RR-6. 7. CDC. Assessment of the Effectiveness of the 200304 Influenza Vaccine Among Children and Adults Colorado, 2003. MMWR 2004; 53(31):707-710.

break control guidelines, resources for ordering

vaccine, using rapid tests, administering antiviral Table 3. Georgia Influenza Sentinel Provider Network participants who submitted reports for

medications, billing Medicare for immunizations, at least half of the 34 weeks in the 2003-2004 influenza season

and important contact and reference informa-

tion. These materials are available at http:// health.state.ga.us/epi/flu/outbreakcontrol.asp.

Name Gail Hurley, MD Sally Williams, RN, CIC

Practice Name Athens Neighborhood Health Center Children's Healthcare of Atlanta at Egleston

City Athens Atlanta

Sally Williams, RN, CIC

Children's Healthcare of Atlanta at Scottish Rite

Atlanta

GDPH is also developing materials to promote influenza vaccination among healthcare workers

L. Kitty Price, RN Linda Roberts, FNP Melody Hawthorne, Nurse Manager

Coleman Community Health Center Community Care Center Crenshaw Family Practice

La Grange Riverdale Columbus

in Georgia. These materials will be available on Brian Palmer, MD the GDPH website at http://health.state.ga.us/. Barry Froranelli, MD

DeKalb County Board of Health, Ryan White Clinic DeKalb County Board of Health
Vinson Health Center Adult Health Services

Decatur Decatur

Susan Reines, MD, Lalitha Chikkala, MD

DeKalb County Board of Health

Decatur

2004-2005 Influenza Vaccine

Michael Huey, MD

Both the inactivated and live, attenuated vaccines Joel Fine, MD

Vinson Health Center Child Health Services Emory University Student Health Services Fine & Associates

Atlanta Snellville

for 2004-2005 will contain: A/Fujian/411/2002 (H3N2)-like, A/New Caledonia/20/99 (H1N1)like, and B/Shanghai/361/2002-like antigens. An estimated 100 million doses of vaccine should be available during the 2004-2005 season. A lim-

Donna Nolan, RN William Manns, MD Jo Middlebrooks, RN Robin Dretler, MD David McCann, MD William Yang, MD, MPH

Forber Student Health at Valdosta State University Georgia Tech University Henry Medical Center Infectious Disease Specialists of Atlanta Infomedix Professional Corporation Medical Services Dept, Coca-Cola Company Newton Medical Associates

Valdosta Atlanta Stockbridge Decatur Colquitt Atlanta Covington

ited supply of a live, attenuated intranasal influenza vaccine will again be available for the 20042005 season. This intranasal vaccine is licensed

Herman Spivey, MD Philip Saleeby, MD Lea Hicks, RN Jean Chin, MD

Northwest Georgia Family Practice Philip R. Saleeby MDPC Tanner Medical Center/Villa Rica University Health Center

Summerville Brunswick Villa Rica Athens

for use in healthy persons 5-49 years of age.

Tura Anthony, RN Glenda van Houten, RN

University of West Georgia Health Services Upson Regional Medical Center

Carrollton Thomaston

Jill Goggans, MD

Waycross Internal Medicine

Waycross

Glenn Carter MD, William Roberson, DO

Hinesville

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
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Division of Public Health Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588 Fax: (404) 657-7517

Georgia Department of Human Resources

Please send comments to: Gaepinfo@dhr.state.ga.us

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 2004

Volume 20 Number 09

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for June 2004

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 June 2004
2004 57 2940 13 1 81 1227 7 27 46 5 1 2 0 1 0 204 61 0 6 8 12 0 24

Previous 3 Months Total

Ending June

2002

2003 2004

176

174

145

8544

9050

8243

24

26

29

18

8

13

218

190

212

4650

4414

3436

18

18

37

127

131

91

112

152

162

4

12

20

2

6

2

10

7

5

2

1

0

8

12

6

0

0

0

384

388

394

355

405

181

25

31

15

82

132

48

161

219

44

169

217

76

5

5

0

141

142

102

Previous 12 Months Total

Ending in June

2002

2003

2004

618

665

587

33929

35874

34312

152

125

145

56

35

31

904

905

858

18846

18625

15944

105

76

114

758

511

707

466

553

708

11

30

41

4

11

8

42

32

28

4

1

2

22

34

28

0

0

1

1763

1940

2064

1237

1980

742

110

112

116

296

432

362

696

794

463

798

838

605

21

13

3

578

553

538

* 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: 09/03-08/04 Five Years Ago: 09/99-08/00 Cumulative: 07/81-08/04

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

8

1,797 1,805

8

1,314 1,322

219

28,586 28,805

Percent Female
27.8
27.2
18.7

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

34.1

6.4

1.8

15.3

1.1

41.3

32.2

12.3

3.3

20.3

2.0

29.9

46.4

16.3

5.2

14.3

1.9

15.9

Race Distribution (%) White Black Other

20.7 75.8

3.5

20.1 76.9

3.0

32.6 64.8

2.6

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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