Georgia epidemiology report, Vol. 22, no. 10 (Oct. 2006)

October 2006

volume 22 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-related complications requiring hospitalization are highest among young 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. 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. Annual influenza vaccination is recommended for persons at high risk of developing complications from influenza as well as their contacts (1) (Table 1). New for the 2006-07 season, the Advisory Committee on Immunization Practices (ACIP) now recommends annual influenza vaccination for healthy children aged 24--59 months and their household contacts and that outof-home caregivers be vaccinated against influenza. (1) This change extends the recommendations for vaccination of children so that all children aged 6-<59 months receive annual vaccination. Children aged 6 months-<9 years who have not been previously vaccinated at any time should receive 2 doses of influenza vaccine. ACIP also emphasizes that health-care workers should be vaccinated against influenza annually. The optimal time to receive influenza vaccine is October-November; however, if uncertainties arise related to vaccine supply, CDC may recommend that certain groups defer vaccination with trivalent inactivated influenza vaccine (TIV). Live attenuated influenza vaccine (LAIV) may be administered at any time. In Georgia, influenza activity typically peaks after December, so influenza vaccination should continue throughout the influenza season as long as vaccine is available.
Four antiviral agents are approved for treatment or prophylaxis of influenza. Due to recent data indicating widespread resistance of circulating influenza viruses to these medications, ACIP recommends that neither amantadine nor rimantadine be used for treatment or chemoprophylaxis. Until susceptibility to adamantanes has been reestablished among circulating influenza A viruses, oseltamivir or zanamivir may be prescribed if antiviral treatment or chemoprophylaxis of influenza is indicated (1).
2006-07 Influenza Vaccine Both the inactivated and live, attenuated vaccines prepared for the 200607 season will include A/New Caledonia/20/1999 (H1N1)-like, A/ Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens. A supply of LAIV will again be available for the 2006-07 season, and is licensed for use in healthy persons 5-49 years of age. If you are providing influenza vaccine and would like to get the word out, go to http://www.immunizeadultga.org/. Healthcare providers who will have vaccine available may sign up on the website 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 National disruptions in vaccine supply during recent influenza seasons have required modifications in ACIP recommendations or in the traditional mechanisms for vaccine distribution during the course of the season. ACIP has issued supplemental recommendations for the prioritization of use of inactivated influenza vaccine in times of shortage. To ensure optimal use of available doses of influenza vaccine, health-care providers, those planning organized vaccine campaigns, and local public health agencies should:
1) develop plans for expanding outreach and infrastructure to vaccinate more persons than last year and;
2) develop contingency plans for the timing and prioritization of administering influenza vaccine, if the supply of vaccine is delayed and/or reduced.
Four vaccine manufacturers are expected to produce influenza vaccine for the U.S. market this season. While 100 million doses are projected (16% more doses than were available for the 2005-06 season), the precise number and timing of doses remains unknown due to uncertainties in vaccine production. While an adequate supply is anticipated for this season, state and local public health staff will work closely with private health care providers in the event of a vaccine shortfall in Georgia 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 at http://health.state.ga.us/epi/flu/index.asp.
Overview of Influenza Surveillance in Georgia Each year, 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 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 >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). 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 virology testing from GPHL and from a network of hospital laboratories throughout the state help estimate influenza disease activity and distribution, and provide specimens for influenza virus surveillance and strain selection for next year's influenza vaccine. GDPH requires reporting of pediatric influenza-related deaths and influenza outbreaks in schools, health care facilities, and other institutions. During

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. If yes, please send your name and e-mail address to Gaepinfo@dhr.state.ga.us. | Please visit, http://health.state.ga.us/epi/manuals/ger.asp for all current and past pdf issues of the GER.

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.
GDPH also utilizes the syndromic surveillance component of the State Electronic Notifiable Diseases Surveillance System (SendSS) to monitor influenza-like illness (ILI). Every week the District Health Offices can monitor the weekly adherence of their sentinel healthcare providers for reporting their data to the CDC, the ILI trends by District and State (aggregate) and ILI trends by four age groups (state aggregate). Also, respiratory and fever plus flu symptoms can be monitored among patients visiting a growing number of hospital-based emergency departments throughout the state (currently, in 7 of the 18 Health Districts). These symptoms are analyzed daily and increases beyond expected counts prompt automatic alerts to key public health and hospital staff. The number of patients admitted or who die with these symptoms is also available to public health and hospital staff.
Table 1. Target Groups for Annual Influenza Vaccination (1)
Children aged 659 months Women who will be pregnant during the influenza season Persons aged >50 years Children and adolescents (aged 6 months18 years) who are
receiving long-term aspirin therapy and, therefore, might be at risk for experiencing Reye syndrome after influenza infection Adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma (hypertension is not considered a high-risk condition) Adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunodeficiency (including immunodeficiency caused by medications or by human immunodeficiency virus) Adults and children who have 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 Residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions Persons who live with or care for persons at high risk for influenza-related complications, including healthy household contacts and caregivers of children aged 059 months Health-care workers

% of Visits

Healthcare providers are asked to report to public health patients with respiratory symptoms who have recently traveled to a country with poultry outbreaks and had recent close contact with potentially infected poultry or a human case of avian influenza. Close contact includes visiting a poultry farm, households where poultry are raised, or a live bird market in an affected country. It does NOT include exposure to cooked or processed poultry. Please go to http:// www.health.state.ga.us/index.asp for more information.
Georgia Influenza Activity - 2005-2006 Season
Influenza Surveillance The Georgia Public Health Laboratory (GPHL) confirmed last season's first influenza virus isolate from a Georgia resident whose illness began on December 5, 2005. During the 2005-2006 season, GPHL identified 83 influenza viruses; 100% were influenza A. Of the 83 influenza A isolates, 75 were subtyped as influenza A H3 and 8 were not subtyped. CDC antigenically characterized 19 of the 83 influenza A isolates: 16 were antigenically similar to the H3N2 equivalent component of the 2005-06 influenza vaccine and 3 were similar to A/Wisconsin/67/2005 (H3N2), the H3N2 component of the 2006-07 influenza vaccine. Influenza activity peaked in Georgia in late February. Influenza in Georgia has peaked in January or February during 4 of the last 5 influenza seasons. The proportion of ILI visits to Georgia Influenza sentinel providers peaked at 4.6% during the last week of February and decreased to less than 1% by late March. (Figure 1) Influenza activity in Georgia was characterized as local or regional from December 25 2005-February 4, 2006, and widespread from February 5-March 4, 2006. "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, and outbreaks in long-term care facilities. Influenza activity in Georgia was characterized as regional or local from March 5-April 15, 2006, and sporadic from April 16-May 20, 2006 based on reports of decreasing influenza activity from sentinel providers and district health offices.

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

10.0 8.0 6.0 4.0 2.0 0.0
Oct weOekct1weNeokv3weNeokv1weNeokv3weDeekc5weDeekc2weJeakn4weJeakn2weFeekb4weFeekb2weMeakr4weMeakr2weAepkr4weAepkr1weMeaky3weMeaky1weMeaky3weJeukn5weJeukn2weeJkul4weeJkul2weAeukg4weAeukg2weSeekp4weSeekp1week 3 Month and week

2003-2004

2004-2005

2005-2006

Avian Influenza
Since December 2003, the World Health Organization (WHO) has been receiving reports of human infections with avian influenza A (H5N1) in association with the expanding outbreaks among wild birds and poultry throughout Asia, Africa, the Middle East, and Europe. Although most human cases are thought to have resulted from direct exposure to infected poultry or their contaminated environment, limited human-tohuman transmission may have occurred in some instances. Human infections with other avian influenza subtypes have also occurred in recent years, but the associated wild bird or poultry outbreaks have been geographically more limited in scope. The ongoing exposure of humans to poultry outbreaks is a concern. It enhances the potential for avian influenza (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.

Reports of Deaths among Children In August 2004, influenza-associated deaths in children <18 years of age was made a reportable condition in Georgia. During the 2005-2006 season, the influenza-associated death of one child was reported to GDPH.
Influenza Outbreaks During 2005-2006, 6 influenza outbreaks were reported to GDPH from institutional settings (4 long-term care facilities, 1 hospital, 1 correctional facility). Of the 6 confirmed influenza outbreaks, 4 were associated with Influenza A, and the influenza type for the others was undetermined.
Georgia shows improvement, but vaccination among those at high risk remains low Data from the Behavioral Risk Factors Surveillance System (BRFSS) indicate that influenza and pneumococcal vaccination rates have improved overall during the past decade among Georgians aged >65

-2-

years (Figure 2), although vaccine coverage decreased slightly during the past two seasons when influenza vaccine supply was constrained. However, the vaccination rates are still far below the Healthy People 2010 goal of 90% vaccination for both vaccines among people aged > 65 years. A disparity by race has existed in Georgia for influenza vaccination among the elderly, but narrowed in 2005 (Figure 3). Greater efforts should be made to vaccinate older black persons in Georgia.
While most influenza vaccine is purchased directly by private providers, Public Health also distributes influenza vaccine. During the 2005-06 season, the Vaccines for Children program distributed 248,500 doses of vaccine to Georgia providers for administration to uninsured and underinsured children. County and District Health Departments distributed 266,915 doses of vaccine. Sanofi Pasteur donated 850 doses for Katrina evacuees staying in shelters in Georgia and donated 5,650 doses for other evacuees in Georgia with certain high-risk conditions.

Figure 2. Influenza and Pneumococcal Vaccination Rates among Persons Aged >=65 Years, Georgia, 1995-2005

100

Influenza

Pneumococcal

Healthy People 2010 Goal

90

80

Vaccination rate (%)

70 60 50

40

30

20 10
0 1995 1996 1997 1999 2000 2001 2002 2003 2004 2005

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

Percent Vaccinated

100

58.9 68.8

50

0 2003

71.7 36.0
2004 Year

64.5 45.2
2005

Blacks Whites

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 sends periodic email 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, 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 2005-06 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 James Cope, Influenza Surveillance Coordinator, at 404463-4625.

Table 2. Georgia Inf luenza Sentinel Provider Network

participants who submitted reports for at least half of the 34

weeks in the 2005-06 influenza season

Newnan Hospital Dalton Family Practice Wellstar Urgent Care Wellstar Urgent Care Wellstar Urgent Care Sandy Springs Pediatrics Coleman Community Health Center Tanner Medical Center The Pediatric Center Mountain Medical Cobb Pediatrics Lawrence Joel Army Health Clinic Lawrence Joel Army Health Clinic Lawrence Joel Army Health Clinic Valdosta State University Immediate Medical Care University of West Georgia Kennesaw State University Columbus State University Colquitt Complete Care Lakeside Pediatrics, LLC Catherine L. Bray MD Georgia Institute of Technology Child and Adolescent Medical Providers Northeast Georgia Medical Center Medical College of Georgia Fine and Assocaites Internal Medicine LaVista Primary Care Athens Neighborhood Health Center Upson Regional Medical Center Newton Medical Associates Northwest Georgia Family Practice Jafar Tabatabai MD Gilbert Health Center, University of Georgia Henry Medical Center Archibald Urgent Care Lisa Miller Pediatrics Gwinnett Medical Center Merinda Herron MD Emory University Student Health Services Owasa Family Medicine Tracy Middlebrooks, Jr. MD Community Care Center Philip Saleeby MD SE Georgia Physician Associates Ronny Sayers MD Emory Eastside Medical Center Lee Medical Arts Center Affinity Health Group Trojan Battery Co. W. A. Snyder, Jr. MD FAAFP Waycross Internal Medicine Group Medical Services Dept, Coca-Cola Company

Amna Khan-Hickman, RN Cathy Mincey P.C. J. Dorland Brown MD Sherri Barton MD Warren Falo MD Kytia Balcarek MD L. Kitty Price, RN Lea Hicks, RN Patty Hopkins Raymond Tidman MD Susan Staviss MD Sonja Foote Sonja Foote Sonja Foote Sonya Twomey, RN Stephanie Carol Tura Anthony, RN Ann Nichols FNP Becky Tew, RN, MSN Bill Swafford, MD Bob Bagheri, MD Catherine L. Bray, MD William Manns MD David Martin MD David Westfall MD James Wilde MD Joel Fine MD Dich Van Nguyen MD Gail Hurley MD Glenda van Houten RN Henry Patton PA Herman Spivey MD Jafar Tabatabai, MD Jean Chin MD Jo Middlebrooks RN Julia Weeks MD Lisa Miller MD Marcia Postal-Ranney RN Merinda Herron, MD Michael Huey MD Morris Jenkins MD Tracy Middlebrooks, Jr., MD Nancy Rowell MD, FNP Philip R. Saleeby MDPC Richard Ceniza MD Ronny Sayers, MD Rosalie Whisenant RN, CIC Susan Green RN Tibisay Villalobos-Fry MD, FAAP Michelle Haney RN W. A. Snyder, Jr., MD FAAFP Jill Goggans MD William Yang MD, MPH

Newnan Dalton Kennesaw Woodstock Marietta Atlanta La Grange Villa Rica Thomasville Blue Ridge Marietta Atlanta Atlanta Atlanta Valdosta Morrow Carrollton Kennesaw Columbus Colquitt Cumming Decatur Atlanta Lavonia Gainesville Augusta Snellville Tucker Athens Thomaston Covington Summerville Stone Mountain Athens Stockbridge Thomasville Covington Lawrenceville Atlanta Atlanta Calhoun Augusta Riverdale Brunswick Kingsland Sardis Snellville Leesburg Tifton Lithonia Brunswick Waycross Atlanta

This article was written by James R. Cope, M.P.H., Pauline Terebuh, M.D., M.P.H., Shani Thompson, MPH

References: 1. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2006;55(No. RR-10).

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
-3 -

Georgia Department of Human Resources
Division of Public Health

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 Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

October 2006

Volume 22 Number 10

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for July 2006

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 2006
2006
65 2936
14 6 55 1671 8 13 13 5 0 0 0 4 0 263 91 2 17 16 42 0 48

Previous 3 Months Total

Ending in July

2004

2005 2006

187

215

164

9014

8080

9348

36

27

56

5

7

17

242

175

145

4197

3873

4844

31

18

25

69

40

25

122

38

44

23

13

11

6

3

3

3

7

1

0

0

3

7

19

8

0

0

0

661

562

560

197

130

291

29

29

21

122

134

81

79

104

72

238

260

173

1

0

0

154

130

119

Previous 12 Months Total

Ending in July

2004 2005

2006

566 35034
138 26 877 16502 117 662 495 44 11 25 2 31 1 2091 735 143 484 521 874 4 546

611 32976
164 21 829 15605 111 188 304 31 5 20 3 46 0 1854 526 110 504 358 952 4 489

562 36121
206 43 672 17574 112 91 175 34 5 14 5 31 0 1945 956 124 428 347 875 5 491

* 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: 09/05-08/06 Five Years Ago: 09/01-08/02 Cumulative: 07/81-08/06

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

Percent Female

AIDS Profile Update
Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood

Unknown

Race Distribution (%) White Black Other

4

1,577 1,581

26.5

31.7

6.8

1.8

8.2

1.1

50.4

1

1,623 1,624

26.8

39.1

8.0

3.0

19.0

2.1

28.8

22.3 75.9

1.8

18.3 76.9

4.8

228

30,229 30,457

19.7

44.7

15.5

4.9

14.1

1.8

19.1

31.6 66.2

2.3

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 -