Georgia epidemiology report, Vol. 21, no. 10 (Oct. 2005)

October 2005

volume 21 number 10

Influenza

Epidemics of influenza usually occur during the winter, causing an average of 226,000 hospitalizations for influenza-related complications and 36,000 deaths per year in the United States. While influenza infects persons of all ages, rates of influenza complications requiring hospitalization are highest among children under two years of age, the elderly, and persons with certain chronic medical conditions. Most influenza-related deaths occur among the elderly. Prevention strategies are designed to prevent disease in these high-risk populations.
Preventing Influenza Annual influenza vaccination is the most effective way to prevent influenza and its complications. New for the 2005-06 season, the Advisory Committee on Immunization Practices (ACIP) now recommends annual influenza vaccination for persons with any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration (1). ACIP also emphasizes that health-care workers should be vaccinated against influenza annually. For this season, CDC is recommending that certain groups defer vaccination with trivalent inactivated influenza vaccine (TIV) until

October 24, 2005 due to uncertainties related to vaccine supply (2, 3). Live attenuated influenza vaccine (LAIV) may be administered at any time to persons aged 5-49 years. Healthcare providers who will have vaccine available may register at http:// www.immunizeadultga.org so that Georgians seeking vaccine can find providers in their community. The Georgia Division of Public Health (GDPH) will monitor the website during influenza season to know where influenza vaccine may be available.
Vaccine Supply Disruptions in vaccine supply during recent influenza seasons have required modifications in ACIP recommendations. Supplemental recommendations for the prioritization of inactivated influenza vaccine in times of shortage have been issued (2). Four vaccine manufacturers are expected to produce vaccine for the U.S. market this season. While 89-97 million doses are projected, the precise number and timing of doses remains unknown. On September 2, 2005, CDC recommended that TIV be given to certain priority groups as described in Table 1 until October 24, 2005. Beginning October 24, 2005, all persons will be eligible to receive TIV (3). State and local public health staff will work closely with private health care providers in the event of a vaccine shortfall in Georgia

Table 1. Target Groups for Annual Influenza Vaccination*
Priority Groups for TIV until Octobor 24, 2005 Persons at High Risk for Influenza-Related Complications: 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 (not including hypertension) 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) Adults and children with any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or
the handling of respiratory secretions or that can increase the risk for aspiration 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 Children aged 6-23 months Health-care Workers 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 Persons Who Can Transmit Influenza to Those at High Risk: Household contacts and out-of-home caregivers of children aged <6 months
Additional Priority Groups for TIV Vaccination beginning October 24, 2005 Healthy 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: 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 6-23 months of age
Use of LAIV May be administered at any time for vaccination of nonpregnant healthy persons aged 5--49 years, including most health-care personnel, other persons in close contact with groups at high risk for influenza-related complications, and others desiring protection against influenza.
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*
* For complete references see 1, 2, 3.

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to assess the local vaccine supply and to augment vaccine availability for members of vaccine priority groups wherever possible. Updated information as the season progresses will be available on the GDPH website http://health.state.ga.us/ epi/flu/index.asp.

Figure 1. Percent of Visits for Influenza-like illness Reported by Sentinel Provider Network in Georgia.

Overview of Influenza Surveillance in Georgia GDPH monitors influenza activity via a sentinel provider network, part of a nationwide surveillance network coordinated by the CDC. Weekly during influenza season, volunteer sentinel healthcare providers report the total number of patient visits and the number of those patient visits with influenza-like illness (ILI), defined as fever >100 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). The sentinel network is not used to determine the precise number of influenza illnesses during a given season. However, the illness data coupled with the results of virology testing help estimate influenza disease activity and distribution, and provide specimens for virology surveillance and strain selection for next year's influenza vaccine. During the 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.
Georgia Influenza Activity, 2004-2005 The 2004-2005 influenza season began with notification that the vaccine, Fluvirin, manufactured by Chiron Corporation, would not be available for distribution in the U.S., leaving only 1 of 2 manufacturers of injectable influenza vaccine for the season. Therefore, ACIP recommended that certain groups at high risk for complications from influenza be given priority. GDPH collaborated with CDC and vaccine manufacturer Aventis to determine where inactivated vaccine had been distributed. Local public health staff contacted the healthcare community to assess vaccine needs. A coordinated effort communicated vaccine priority guidelines, delivered vaccine to areas in need, alleviated disparities in vaccine supply, and maximized vaccination of priority groups. By the end of the season, approximately 1.3 million doses of influenza vaccine were distributed in Georgia. This report summarizes influenza activity in Georgia for the 20042005 season.

9 of the 35 influenza B isolates; six of the influenza B viruses isolated last season belong to the B/Yamagata lineage and were characterized as similar to B/Shanghai/361/2002 (the influenza B component in the 2004-05 and the 2005-06 influenza vaccine), and 3 influenza B viruses belong to the B/Victoria lineage.
Influenza activity peaked in Georgia during February. Influenza has peaked in January or February during the last 4 of 5 influenza seasons in Georgia. The proportion of visits to Georgia Influenza Sentinel Providers for ILI increased from 2.2% in mid- January to a peak of 5.0% during the second week of February, decreased to 2.4% in late March, and then steadily decreased to approximately 1.0% in April (Figure 1). Influenza activity in Georgia was characterized as local or regional from January 16-February 5, 2005, and widespread from February 6-March 5, 2005. "Widespread" designation was based on reports of ILI activity from Sentinel Providers and hospitals, lab-confirmed influenza in more than half of Georgia's designated regions, high rates of school absenteeism, and outbreaks in long-term care facilities. Influenza activity in Georgia was characterized as regional or local from March 6-April 2, 2005, and sporadic from March 3-9, 2005 based on reports of decreasing influenza activity from Sentinel Providers and District Health Offices.
Reports of Deaths among Children In August 2004, an influenza-associated death in a child <18 years of age was made a reportable condition in Georgia. During 20042005, four influenza-associated deaths among children <18 years of age were reported to GDPH. All were laboratory-confirmed by rapid antigen testing, viral culture, PCR, or immunohistochemistry.

Influenza Surveillance
On December 17, 2004, GPHL identified the season's first influenza virus isolate from a Georgia resident whose onset of illness was in mid-December. During the 2004-2005 season, GPHL identified a total of 135 influenza viruses; 100 influenza A and 35 influenza B. Of the 100 influenza A isolates, 97 were subtyped as influenza A (H3N2) and 3 were not subtyped. CDC antigenically characterized 11 of the 100 influenza A isolates; 3 were antigenically similar to A/ Wyoming/3/2003 (the A/Fujian/411/2002-like (H3N2) component of the 2004-05 influenza vaccine) and 8 were similar to A/California/7/2004 (the H3N2 component of the 2005-06 influenza vaccine). CDC antigenically characterized

Influenza Outbreaks During 2004-2005, 17 ILI outbreaks in institutional settings were reported to GDPH, including 10 in long-term care facilities, 1 in a hospital, 2 in correctional facilities, and 4 in schools. Of the 11 outbreaks that were confirmed as influenza, 9 were associated with Influenza A and 2 with Influenza B.
Avian Influenza Since December 2003, the World Health Organization (WHO) has continued to receive reports of confirmed human cases and poultry outbreaks of avian influenza A (H5N1) in Asia and other countries. The exposure of humans to ongoing poultry outbreaks is of grave concern. It enhances the potential for avian influenza

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(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. Healthcare providers are asked to report to Public Health any 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 The Behavioral Risk Factor Surveillance System (BRFSS) conducted a nationwide special study during October 2004-February 2005 to assess influenza vaccination uptake (4). Through January 2005, vaccine coverage levels among priority groups reached levels similar to prior years, whereas coverage levels among adults not in priority groups were approximately half of levels in 2003. Among non-high-risk adults 9.3% reported "saving vaccine for people who need it more". Last season was the first year that children aged 6 through 23 months were included in the vaccine target group, and 48.4% of those children were estimated to have received at least one dose. Data from the BRFSS indicate that influenza and pneumococcal vaccination rates have improved in recent years among Georgians aged > 65 years (Figure 2). Overall vaccination rates were minimally affected by the vaccine shortage, but are still far below the Healthy People 2010 goal of 90% vaccination coverage for both vaccines among people aged > 65 years. BRFSS also assessed vaccine uptake by race in the context of the 2004 vaccine shortage. Among the elderly, disparity by race has existed in Georgia for influenza vaccination rates. This

disparity widened in 2004 (Figure 3). Greater efforts should be made to vaccinate older black persons in Georgia.
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. 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, billing Medicare for immunizations, and important contact and reference information. These materials are available at http:// health.state.ga.us/epi/flu/outbreakcontrol.asp. GDPH is also developing materials to promote influenza vaccination among healthcare workers in Georgia. These materials will be available on the GDPH website at http://health.state.ga.us/.
Thank you Georgia influenza Sentinel Providers: GDPH would like to thank the 2004-05 Influenza Sentinel Providers, especially those who continued to report through the summer . The reports provide essential information that permits Public Health to follow statewide disease trends and circulating influenza strains. If you are a healthcare provider interested in volunteering as a sentinel physician please contact James Cope, Influenza Surveillance Coordinator, at 404-463-4625.
This article was written by James R. Cope, M.P.H., Kathryn E. Arnold, M.D., Pauline Terebuh, M.D., M.P.H., Shani Thompson, MPH, and Alison Han, M.S.

Figure 2. Influenza and Pneumococcal Vaccination Rates among Persons Aged>=65 Years, Georgia, 1995-2003

Vaccination rate (%)

100 80 60 40 20 0 1995

1997

1999

2000

2001

2002

2003

Influenza Pneumococcal

2004

Healthy Healthy People People
2000 2010 Goal Goal

Figure 3. Influenza Vaccination Rates by Race among Persons Aged>=65 Years, Georgia, 2003-2004

Percent Vaccinated

100

80

68.8 58.9

60

40

20

0

2003

71.7 36.0
2004

Ye ar

Black s White s

References: 1. CDC. Prevention and Control of Influenza. MMWR 2005;
54(No. RR-8); 1-40.
2. CDC. Tiered use of inactivated influenza vaccine in the event of a vaccine shortage. MMWR 2005; 54(30); 749-750.
3. CDC. Update: Influenza Vaccine Supply and Recommendations for Prioritization During the 2005--06 Influenza Season. MMWR 2005; 54(34);850.
4. CDC. Estimated influenza vaccination coverage among adults and children -- United States, September 1, 2004--January 31, 2005. MMWR 2005; 54(12); 304-307.

Division of Public Health http://health.state.ga.us
Stuart T. Brown, M.D. Director
State Health Officer

Epidemiology Branch http://health.state.ga.us/epi
Susan Lance, D.V.M., Ph.D. Director
State Epidemiologist

Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. Editor Kathryn E. Arnold, M.D.
Cherie Drenzek, D.V.M., M.S. Susan Lance, D.V.M., Ph.D.
Stuart T. Brown, M.D. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer

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

Georgia Department of Human Resources
Division of Public Health

Please send comments 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

October 2005

Volume 21 Number 10

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for July 2005

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 July 2005
2005 71
2501 10 2 46
1228 4 10 6 2 2 2 0 1 0
240 33 1 5 8 24 0 34

Previous 3 Months Total

Ending in July

2003

2004

2005

237

187

210

9004

9018

7802

35

36

24

10

5

8

210

243

138

4545

4198

3687

18

31

15

120

69

33

200

125

26

11

23

10

6

6

2

5

3

7

0

0

0

6

7

13

0

0

0

636

660

557

395

196

132

30

27

11

132

122

46

210

69

38

209

207

122

5

1

0

137

154

118

Previous 12 Months Total

Ending in July

2003

2004

2005

706

567

608

36065

35024

32638

125

139

155

31

26

23

896

878

773

18387

16494

15376

75

117

104

518

663

179

581

582

290

33

44

28

12

11

4

30

25

21

1

2

3

31

31

39

0

1

0

1977

2089

1869

1943

733

531

113

140

80

450

479

358

801

506

248

836

822

723

14

4

4

528

546

467

* 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: 10/04-09/05 Five Years Ago: 10/00-09/01 Cumulative: 07/81-09/05

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

4

1,606 1,610

8

1,186 1,194

224

28,877 29,101

Percent Female
25.2
26.4
19.4

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

31.9

5.4

2.1

11.4

1.5

30.5

10.3

2.4

17.5

1.7

45.3

15.8

4.9

14.4

1.9

Unknown
47.7 37.6 17.7

Race Distribution (%) White Black Other

23.2 74.8

2.0

19.3 76.2

4.4

31.9 65.6

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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